2022 Lycoming Tioga MA Kit

UPMC for Life PPO Flex Rx Out-of-Network (OUT) In-Network (IN) IN: $0 per service; for your annual wellness visit, preventive screenings, and flu and pneumonia vaccines Preventive care OUT: 30% of the cost per service (deductible does not apply) 30% of the cost after deductible $30 per visit Physical therapy* 30% of the cost after deductible $50 for treat and no transport; Ambulance* $295 per one-way trip 30% of the cost after deductible 20% of the cost Medicare Part B drugs* 30% of the cost per item (deductible does not apply) 20% of the cost per item Durable medical equipment* 30% of the cost per item after deductible 20% of the cost per item (limited to specific suppliers, products, and brands. Quantity limits apply.) Diabetes supplies Medicare-covered: 30% of the cost after deductible Medicare-covered: Tier 1: $18 per service Tier 2: $20 per service Chiropractic care* 2 No routine chiropractic care Medicare-covered: 30% of the cost after deductible; Medicare-covered: $30 per visit; Podiatry services Routine (4 visits per year): Routine (4 visits per year): 30% of the cost per routine visit (deductible does not apply) $30 per routine visit Facility and Testing Costs Out-of-Network (OUT) In-Network (IN) IN/OUT: $90 per visit (deductible does not apply) Emergency care IN/OUT: $65 per visit (deductible does not apply) Urgentlyneededservices 30% of the cost after deductible $10 per day per facility Diagnostic services/ labs* Advanced imaging (CT, MRI, and PET scans): 30% of the cost after deductible; Advanced imaging (CT, MRI, and PET scans): $275 per service; Basic imaging and X-rays: $30 per service Imaging* Basic imaging and X-rays: 30% of the cost after deductible Inpatient: 30% of the cost per stay after deductible; Inpatient: $400 per stay; Outpatient therapy: $30 per visit, $25 per telehealth visit Mental health services * Outpatient therapy: 30%of the cost after deductible 30% of the cost per stay after deductible $0 per day (days 1-20); $184 per day (days 21-100) Skilled nursing facility* * Services with an asterisk (*) may require prior authorization. upmchealthplan.com/medicare 7 28