2022 South Central MA Kit

UPMC for Life PPO Rx Enhanced (PPO) UPMC for Life PPO Rx Choice (PPO) $60 per month $29 per month Yes, Formulary 2 Yes, Formulary 1 IN: $5 per visit; IN: $0 per visit; OUT: 40% per visit after deductible OUT: 20% per visit after deductible IN: $40 per visit; IN: $30 per visit; OUT: 40% per visit after deductible OUT: 20% per visit after deductible IN: PCP: $0 per visit; IN: PCP: $0 per visit; Specialist: $35 per visit; Specialist: $25 per visit; OUT: Not covered OUT: Not covered IN: $275 per day (days 1-5); $0 per day (days 6-90); IN: $330 per stay; OUT: 40% per stay after deductible OUT: 20% per stay after deductible IN: $250 per surgery; IN: $200 per surgery; OUT: 40% per surgery after deductible OUT: 20% per surgery after deductible IN: $0 per day (days 1-20) and $160 per day (days 21-100); IN: $0 per day (days 1-20) and $184 per day (days 21-100); OUT: 40% of the cost per stay after deductible OUT: 20% of the cost per stay after deductible IN/OUT: $90 per visit (deductible does not apply) IN/OUT: $90 per visit (deductible does not apply) IN/OUT: $65 per visit (deductible does not apply) IN/OUT: $65 per visit (deductible does not apply) IN: $40 per visit; IN: $30 per visit; OUT: 40% of the cost after deductible OUT: 20% of the cost after deductible IN: $5 per day per facility; IN: $0 per day per facility; OUT: 40% of the cost after deductible OUT: 20% of the cost after deductible IN: $20 per service; IN: $25 per service; OUT: 40% of the cost after deductible OUT: 20% of the cost after deductible IN: $200 per service; IN: $245 per service; OUT: 40% of the cost after deductible OUT: 20% of the cost after deductible IN: 18% of the cost per item; IN: 20% of the cost per item; OUT: 50% of the cost (deductible does not apply) OUT: 20% of the cost (deductible does not apply) IN: 20% of the cost per item; IN: 20% of the cost per item; OUT: 50% of the cost after deductible OUT: 20% of the cost after deductible IN: No deductible; IN: No deductible; OUT: $500 for applicable services OUT: $250 for applicable services IN: $7,550 for Medicare-covered services, including copays and coinsurance; IN/OUT: $11,300 for Medicare-covered services, including copays and coinsurance IN: $7,550 for Medicare-covered services, including copays and coinsurance; IN/OUT: $11,300 for Medicare-covered services, including copays and coinsurance IN: $40 for one hearing exam per year and IN: $0 for one hearing exam per year and $40 for one hearing aid fitting every three years; $0 for one hearing aid fitting per year; OUT: 50% of the cost; OUT: 20% of the cost; IN/OUT: $1,500 allowance for hearing aids every three years IN/OUT: $500 allowance for hearing aids per year (deductible does not apply) (deductible does not apply) IN: $0 per cleaning and $15 per oral exam twice per year; IN: $0 for two oral exams and cleanings per year; $15 for one bitewing x-ray per year; $0 for one bitewing x-ray per year; $15 for one panoramic x-ray every 36 months; $0 for one panoramic x-ray every 36 months; OUT: 50% of the cost; IN/OUT: $1,000 maximum comprehensive dental allowance OUT: 20% of the cost (deductible does not apply); IN/OUT: $3,000 maximum comprehensive dental allowance e with 50% coinsurance per year with $50 deductible and 50% coinsurance per year (deductible does not apply) IN: $0 for one routine vision exam per year; IN: $0 for one routine vision exam per year; OUT: 50% of the cost for one routine vision exam per year; IN/OUT: $200 allowance for contact lenses or eyewear (all lens types) per year (deductible does not apply) OUT: 20% of the cost for one routine vision exam per year; IN/OUT: $300 allowance for contact lenses or eyewear (all lens types) per year (deductible does not apply) $25 allowance per quarter $40 allowance per quarter