2022 Lycoming Tioga MA Kit

UPMC for Life HMO Deductible Rx (HMO) UPMC for Life HMO Premier Rx (HMO) $22 per month $0 per month Yes, Formulary 2 Yes, Formulary 1 $0 per visit (deductible does not apply) $0 per visit $35 per visit (deductible does not apply) $40 per visit PCP: $0 per visit; PCP: $0 per visit; Specialist: $30 per visit (deductible does not apply) Specialist: $35 per visit $300 per stay after deductible $190 per day (days 1-5); $0 per day (days 6-90) $125 per surgery after deductible $325 per surgery $0 per day (days 1-20); $0 per day (days 1-20); $172 per day (days 21-100) (deductible does not apply) $184 per day (days 21-100) $90 per visit (deductible does not apply) $90 per visit $65 per visit (deductible does not apply) $65 per visit $0 per visit after deductible $40 per visit $10 per day per facility (deductible does not apply) $5 per day per facility $20 per service after deductible $45 per service $200 per service after deductible $225 per service $0 per item (deductible does not apply) 20% of the cost per item 20% of the cost per item after deductible 20% of the cost per item $750 for applicable services No deductible $7,550 for Medicare-covered services, including $7,550 for Medicare-covered services, including copays and coinsurance copays and coinsurance $20 for one hearing exam per year; $0 for one hearing exam per year; $20 for one hearing aid fitting per year; $0 for one hearing aid fitting per year; $100 allowance for hearing aids per year $500 allowance for hearing aids per year (deductible does not apply) $0 for two oral exams and cleanings per year; $0 for two oral exams and cleanings per year; $0 for one bitewing x-ray per year; $0 for one bitewing x-ray per year; $0 for one panoramic x-ray every 36 months; $0 for one panoramic x-ray every 36 months; $1,250 maximum comprehensive dental allowance with 50% coinsurance per year $2,000 maximum comprehensive dental allowance with $50 deductible and 50% coinsurance per year (deductible does not apply) $0 for one routine vision exam every two years; $0 for one routine vision exam per year; $100 allowance for contact lenses or eyewear (all lens types) every two years (deductible does not apply) $200 allowance for contact lenses or eyewear (all lens types) per year $25 allowance per quarter $25 allowance per quarter