2022 South Central MA Kit

UPMC for Life PPO Rx Choice Premium, Deductible, and Out-of-Pocket Limit In-Network (IN)/Out-of-Network (OUT) $29 per month Monthly plan premium OUT: $250 Annual deductible IN: $7,550 for Medicare-covered services, including copays and coinsurance Maximum out-of-pocket responsibility COMBINED IN/OUT: $11,300 for Medicare-covered services, including copays, coinsurance, and the deductible. This is your out-of-pocket spending limit for the year, and does not include costs for Part D prescription drugs. Covered. See prescription drug chart on page 14 Part DPrescription drugs Basic Medical Costs Out-of-Network (OUT) In-Network (IN) 20% of the cost per stay after deductible $330 per stay Inpatient hospital coverage* 20% of the cost per service after deductible $200 per service Outpatient hospital and ambulatory surgery center coverage* 20% of the cost per in-person visit after deductible $0 per visit, $0 per telehealth visit Primary Care Provider (PCP) 20% of the cost per in-person visit after deductible $30 per visit, $25 per telehealth visit Specialists Not covered. 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 50% of the cost (deductible does not apply) $0 per eVisit UPMC AnywhereCare (virtual visit with a UPMC provider) *Services with an asterisk (*) may require prior authorization. upmchealthplan.com/medicare 10 PPO Summary of Benefits 31