2022 South Central MA Kit

UPMC for Life PPO Rx Choice Additional Benefits Out-of-Network (OUT) In-Network (IN) Medicare-covered: 20% of the cost per visit after deductible; Medicare-covered: $30 per visit; $0 for two cleanings per year; Dental services 3 20% of the cost for two cleanings per year (deductible does not apply); $0 for two oral exams per year; $0 for one bitewing x-ray per year; $0 for one comprehensive oral exam every 36 months; 20% of the cost for two oral exams per year (deductible does not apply); $0 for one panoramic x-ray every 36 months; 20% of the cost for one bitewing x-ray per year (deductible does not apply); 20% of the cost for one comprehensive oral exam every 36 months (deductible does not apply); 20% of the cost for one panoramic x-ray every 36 months (deductible does not apply); IN/OUT: $3,000 allowance with 50% coinsurance for comprehensive dental services per year with a $50 dental deductible (out-of-network deductible does not apply) Medicare-covered: 20% of the cost after deductible; Medicare-covered: $30 per visit; $0 for one routine vision examevery year Vision services 4 20% of the cost for one routine vision exam every year (deductible does not apply) IN/OUT: $300 allowance for routine contact lenses or eyewear, including lens options, every year (deductible does not apply) Medicare-covered: 20% of the cost after deductible; Medicare-covered: $30 per visit; $0 for one hearing exam per year; Hearing services 5 20% of the cost for one hearing exam per year (deductible does not apply); $0 for one hearing aid fitting every year 20% of the cost for one hearing aid fitting every year (deductible does not apply) IN/OUT: $500 allowance for hearing aids every year (deductible does not apply) Not covered $40 allowance per quarter to buy health care products Over-the-counter (mail order catalog) upmchealthplan.com/medicare 12 PPO Summary of Benefits 33