2022 Lycoming Tioga MA Kit

UPMC for Life HMO Deductible Rx Medicare-covered: $35 per visit after deductible Podiatry services Routine (4 visits per year): $35 per routine visit (deductible does not apply) Facility and Testing Costs $90 per visit (deductible does not apply) Emergency care $65 per visit (deductible does not apply) Urgently needed services $10 per day per facility (deductible does not apply) Diagnostic services/ labs* Advanced imaging (CT, MRI, and PET scans): $200 per service after deductible; Imaging* Basic imaging and X-rays: $20 per service after deductible Inpatient: $300 per stay after deductible; Mental health services* Outpatient therapy: $35 per visit after deductible, $30 per telehealth visit after deductible $0 per day (days 1-20) (deductible does not apply); Skilled nursing facility* $172 per day (days 21-100) (deductible does not apply) Additional Benefits Medicare-covered: $35 per visit (deductible does not apply); Dental services 3 $0 for two cleanings per year (deductible does not apply); $0 for two oral exams per year (deductible does not apply); $0 for one bitewing x-ray per year (deductible does not apply); $0 for one comprehensive oral exam every 36 months (deductible does not apply); $0 for one panoramic x-ray every 36 months (deductible does not apply); $1,250 allowancewith 50%coinsurance for comprehensive dental services per year (deductible does not apply) Medicare-covered: $35 per visit (deductible does not apply); Vision services 4 $0 for one routine vision exam every 2 years (deductible does not apply); $100 allowance for routine contact lenses or eyewear, including lens options, every 2 years (deductible does not apply). Medicare-covered: $35 per visit (deductible does not apply); Hearing services 5 $20 for one hearing exam per year (deductible does not apply); $20 for one hearing aid fitting every year (deductible does not apply); $100 allowance for hearing aids every year (deductible does not apply) $25 allowance per quarter to buy health care products. Over-the-counter (mail order catalog) FREE unlimited gym memberships and one FREE personal training session each year at participating fitness facilities as well as the option to work out at home with fitness kits. SilverSneakers ® * Services with an asterisk (*) may require prior authorization. upmchealthplan.com/medicare 7 60