2022 Lycoming Tioga MA Kit

* Services with an asterisk (*) may require prior authorization. 1 UPMC nurses who answer calls are licensed to assist members located in Pennsylvania, West Virginia, and Ohio. Members must be located in one of those states when calling the UPMC My Health 24/7 Nurse Line. The UPMC My Health 24/7 Nurse Line is not a substitute for medical care. If an emergency arises, call 911 or go to the emergency department. Nurses cannot answer plan or benefit questions. Please call the Member Services phone number on the back of your member ID card for nonclinical inquiries. 2 The tiering structure for chiropractic care services is based on provider. 3 Members must use a participating dental provider. Go to www.upmchealthplan.com/medicare to find participating dental providers. You are responsible for all other charges beyond preventive dental care. Preventive care copays and the comprehensive dental allowance do not count toward the annual out-of-pocket maximum. A bitewing x-ray shows the upper and lower back teeth and how the teeth touch each other. 4 The routine vision allowance does not apply to glasses after cataract surgery. It does not count toward your annual out-of-pocket maximum. 5 Routine hearing copays and the hearing aid allowance do not count toward your annual out-of-pocket maximum. 6 UPMC for Life does not install bathroom safety devices or reimburse for costs associated with the installation of bathroom safety devices. UPMC for Life is not liable for improper installation, repairs, or other modifications. Members are responsible for any and all costs associated with installation. UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc. and/or its subsidiaries and/or affiliates in the USA and/or other countries. upmchealthplan.com/medicare 12 HMO Summary of Benefits 49