2022 Lycoming Tioga MA Kit

UPMC for Life HMO Rx (HMO) UPMC for Life HMO Rx Choice (HMO) $81 per month $38 per month Yes, Formulary 2 Yes, Formulary 2 $0 per visit $0 per visit $35 per visit $35 per visit PCP: $0 per visit; PCP: $0 per visit; Specialist: $30 per visit Specialist: $30 per visit $295 per stay $325 per stay $225 per surgery $200 per surgery $0 per day (days 1-20); $0 per day (days 1-20); $100 per day (days 21-100) $160 per day (days 21-100) $90 per visit $90 per visit $65 per visit $50 per visit $35 per visit $35 per visit $5 per day per facility $5 per day per facility $35 per service $20 per service $200 per service $180 per service 20% of the cost per item 20% of the cost per item 20% of the cost per item 20% of the cost per item No deductible No deductible $7,550 for Medicare-covered services, including $7,550 for Medicare-covered services, including copays and coinsurance copays and coinsurance No routine hearing benefits $0 for one hearing exam per year; $0 for one hearing aid fitting per year; $500 allowance for hearing aids per year $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; $3,000 maximum comprehensive dental allowance with 50% coinsurance per year $3,000 maximum comprehensive dental allowance with $50 deductible and 50% coinsurance per year $0 for one routine vision exam every two years; $0 for one routine vision exam per year; $200 allowance for contact lenses or eyewear (all lens types) e very two years $175 allowance for contact lenses or eyewear (all lens types) per year $50 allowance per quarter $40 allowance per quarter