2022 Lycoming Tioga MA Kit

UPMC for Life HMO Deductible Rx Premium, Deductible, and Out-of-Pocket Limit $22 per month Monthly plan premium $750 Annual deductible $7,550 for Medicare-covered services, including copays and coinsurance; Your out-of-pocket spending limit for the year. This is not a deductible and does not include costs for Part D prescription drugs. Maximum out-of-pocket responsibility Covered. See prescription drug chart on page 15 Part DPrescription drugs Basic Medical Costs $300 per stay after deductible Inpatient hospital coverage* $125 per service after deductible Outpatient hospital and ambulatory surgery center coverage* $0 per visit (deductible does not apply); $0 per telehealth visit (deductible does not apply) Primary Care Provider (PCP) $35 per visit (deductible does not apply); $30 per telehealth visit (deductible does not apply) Specialist You can virtually visit with your doctor over the phone or online if your provider participates in telehealth. You'll pay the same copay or less for telehealth visits that you would pay if you were seeing your doctor in-person. Your provider must be in the same state as you during your visit. Talk to your doctor to see if using telehealth is right for you. Telehealth $0 per eVisit (deductible does not apply) UPMC AnywhereCare (virtual visit with a UPMC provider) $0 per service (deductible does not apply); for your annual wellness visit, flu, and pneumonia vaccines and preventive screenings Preventive care $0 per visit after deductible Physical therapy* $50 for treat and no transport after deductible; Ambulance* $100 per one-way trip after deductible 20% of the cost (deductible does not apply) Medicare Part B drugs* $0 per item (deductible does not apply) Durable medical equipment* 20% of the cost per item after deductible (limited to specific suppliers, products, and brands. Quantity limits apply.) Diabetes supplies Medicare-covered (deductible does not apply): Chiropractic care* 2 Tier 1: $18 per service Tier 2: $20 per service No routine chiropractic care upmchealthplan.com/medicare 6 HMO Summary of Benefits 59 * Services with an asterisk (*) may require prior authorization.