2022 Lycoming Tioga MA Kit

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 StateMedical Assistance program. Enrollment in UPMC for Life depends on contract renewal. Out-of-network/Noncontracted providers are under no obligation to treat UPMC for Life members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services. *You can call us Oct. 1 – Dec. 7 seven days a week from 7 a.m. to 9 p.m., Dec. 8 – Dec. 31 seven days a week from 8 a.m. to 8 p.m., and Jan. 1 – Sept. 30 Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 3 p.m. **J.D. Power 2020 Certified Customer Service Program SM recognition is based on successful completion of an evaluation and exceeding a customer satisfaction benchmark through a survey of recent servicing interactions. For more information, visit www.jdpower.com/ccc. 1 The Travel Concierge Program is applicable only in the states of Arizona, Florida, Georgia, North Carolina, South Carolina, and Tennessee. HMO members will be charged in-network cost sharing for covered services received from any provider that accepts Medicare. PPO plan members will be charged out-of-network cost sharing as applicable for covered services received from nonparticipating providers. All members are charged the applicable cost sharing for emergency and urgent care as listed in the Evidence of Coverage. 2 Members must use a participating hearing provider. Go to upmchealthplan.com/find to find participating hearing providers. Routine hearing copays and the hearing aid allowance are excluded from the yearly deductible, if applicable, and do not count toward your annual maximum out-of-pocket. 3 Members must use a participating dental provider. Go to upmchealthplan.com/find to find participating dental providers. You are responsible for all other charges beyond preventive dental care. Preventive care copays and the dental allowance are excluded from the yearly medical deductible, if applicable, and do not count toward the annual maximum out-of-pocket. 4 The routine vision allowance does not apply to glasses after cataract surgery. It is excluded from the yearly deductible, if applicable, and does not count toward your annual maximum out-of-pocket. 5 The over-the-counter (OTC) allowance cannot be used to pay for your Part B or Part D prescription drug costs. 6 Lower copays for non-insulin brand-name diabetic medications (Tier 2) apply only to the initial coverage stage and do not apply to plans that use Formulary 1. Members who receive Low Income Subsidy (extra help paying for Part D prescriptions) will not have reduced copays or reduced insulin costs. These benefits do not apply to all plans. See your plan formulary for more information. 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. Y0069_221187_M Copyright 2021 UPMC Health Plan Inc. All rights reserved. 2022_LTROLFLD_21MCID2165