2022 Lycoming Tioga MA Kit

UPMC for Life HMO Rx Premium, Deductible, and Out-of-Pocket Limit $81 per month Monthly plan premium No deductible 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 $295 per stay Inpatient hospital coverage* $225 per service Outpatient hospital and ambulatory surgery center coverage* $0 per visit; $0 per telehealth visit Primary Care Provider (PCP) $35 per visit; $30 per telehealth visit 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 UPMC AnywhereCare (virtual visit with a UPMC provider) $0 per service; for your annual wellness visit, flu, and pneumonia vaccines and preventive screenings Preventive care $35 per visit Physical therapy* $50 for treat and no transport; Ambulance* $250 per one-way trip 20% of the cost Medicare Part B drugs* 20% of the cost per item Durable medical equipment* 20% of the cost per item (limited to specific suppliers, products, and brands. Quantity limits apply.) Diabetes supplies Medicare-covered: Chiropractic care* 2 Tier 1: $18 per service Tier 2: $20 per service; Routine (6 visits per year): Tier 1: $18 per service Tier 2: $20 per service upmchealthplan.com/medicare 12 HMO Summary of Benefits 65 * Services with an asterisk (*) may require prior authorization.