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Plan Name 1 |
Plan Name 2 |
Plan Name 3 |
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| Plan Premium (per month) |
$0 |
$0 |
$40 |
| Annual Deductible |
No deductible |
No deductible |
No deductible |
| Annual Out-of-Pocket Maximum
Your out-of-pocket spending limit for the year
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$3,400 for Medicare-covered services, including copays and coinsurance |
$6,000 for Medicare-covered services, including copays and coinsurance |
$3,400 for Medicare-covered services, including copays and coinsurance |
| Prescription Drug |
Not included |
Included |
Not included |
| Primary Care Physician |
$0 per visit |
$0 per visit |
$40 per visit |
| Specialist |
$45 per visit |
$35 per visit |
$30 per visit |
| Preventative Services, Immunizations, and Screenings |
$0 per service (deductible does not apply).
This means you pay nothing for your annual wellness exam, immunizations such as the flu and pneumonia vaccines, and important preventive screenings for breast cancer, pap and pelvic, prostate cancer, osteoporosis, and colon cancer. |
$0 per service (deductible does not apply).
This means you pay nothing for your annual wellness exam, immunizations such as the flu and pneumonia vaccines, and important preventive screenings for breast cancer, pap and pelvic, prostate cancer, osteoporosis, and colon cancer. |
$0 per service (deductible does not apply).
This means you pay nothing for your annual wellness exam, immunizations such as the flu and pneumonia vaccines, and important preventive screenings for breast cancer, pap and pelvic, prostate cancer, osteoporosis, and colon cancer. |
| Inpatient Hospital and Inpatient Mental Health |
$350 per stay |
$375 per stay |
$400 per stay |
| Outpatient Surgery |
$225 per surgery |
$350 per surgery |
$200 per surgery |
| Skilled Nursing Facility |
$20 per day (days 1-20); $80 per day (days 21-100) |
$0 per day (days 1-20); $160 per day (days 21-100) |
$20 per day (days 1-20); $80 per day (days 21-100) |
| Emergency Care |
$120 per visit |
$90 per visit |
$120 per visit |
| Urgent Care |
$50 per visit |
$50 per visit |
$50 per visit |
| Lab Services |
$5 per day per facility |
$10 per day per facility |
$10 per day per facility |
| X-rays |
$30 per service |
$50 per service |
$10 per service |
| Advanced Imaging (CT, MRI, and PET scans) |
$1100 per service |
$140 per service |
$100 per service |
| Durable Medical Equipment |
20% of the cost per item |
20% of the cost per item |
20% of the cost per item |
| Diabetic Supplies |
20% of the cost per item |
20% of the cost per item |
20% of the cost per item |
| Routine Vision
The routine vision allowance does not apply to glasses after cataract surgery. It is excluded from the yearly deductible, if applicable, and does not count toward your annual out-of-pocket maximum.
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$0 for one routine vision exam every two years; $150 allowance for contact lenses and eyewear every two years |
$0 for one routine vision exam per year; $200 allowance for contact lenses and eyewearper year |
$0 for one routine vision exam per year; $200 allowance for contact lenses and eyewearper year |
| Preventive Dental
Members must use a participating dental provider. Find participating dental providers. You are responsible for all other charges beyond preventive dental care. Preventive care copays and the comprehensive dental allowance are excluded from the yearly deductible, if applicable, and do not count toward the annual out-of-pocket maximum.
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No preventive dental benefits |
$0 for one oral cleaning and exam every six months; $0 for one bitewing x-ray per year; $325 allowance for comprehensive dental services per year |
$0 for one oral cleaning and exam every six months; $0 for one bitewing x-ray per year; $325 allowance for comprehensive dental services per year |
| Routine Hearing
Members must use a participating hearing provider. Find participating hearing providers. Routine hearing copays and the hearing aid allowance are excluded from the yearly deductible, if applicable, and do not count toward your annual out-of-pocket maximum.
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No routine hearing benefits |
$0 for one hearing exam per year; $0 for one hearing aid fitting exam every three years; $1,500 allowance for hearing aids every three years |
$0 for one hearing exam per year; $0 for one hearing aid fitting exam every three years; $1,500 allowance for hearing aids every three years |
| SilverSneakers® Fitness Program |
FREE gym membership to a participating fitness facility or the option to work out at home; unlimited access to participating locations (if applicable); one FREE personal training session each year at a participating fitness facility. |
FREE gym membership to a participating fitness facility or the option to work out at home; unlimited access to participating locations (if applicable); one FREE personal training session each year at a participating fitness facility. |
FREE gym membership to a participating fitness facility or the option to work out at home; unlimited access to participating locations (if applicable); one FREE personal training session each year at a participating fitness facility. |
| Over-the-counter (OTC) mail order catalog |
$50 quarterly allowance to buy health and wellness items you use every day; this allowance must be used in full each quarter and does not roll over from quarter to quarter |
$50 quarterly allowance to buy health and wellness items you use every day; this allowance must be used in full each quarter and does not roll over from quarter to quarter |
$50 quarterly allowance to buy health and wellness items you use every day; this allowance must be used in full each quarter and does not roll over from quarter to quarter |
| Travel Concierge Program |
In-network coverage while traveling in Florida, Georgia, North Carolina, South Carolina, and Tennessee. Call the Health Care Concierge team before you see your provider so that we can help to coordinate your care. |
In-network coverage while traveling in Florida, Georgia, North Carolina, South Carolina, and Tennessee. Call the Health Care Concierge team before you see your provider so that we can help to coordinate your care. |
In-network coverage while traveling in Florida, Georgia, North Carolina, South Carolina, and Tennessee. Call the Health Care Concierge team before you see your provider so that we can help to coordinate your care. |
| Worldwide Emergency Assistance |
Assist America provides help 24/7 when you travel more than 100 miles from home or to another country. Assist America can help with: emergency medical evacuation, hospital admission, medical monitoring, round-trip transportation for a family member or friend, help replacing forgotten prescriptions (additional costs may apply), local language communications, and medically necessary transportation. |
Assist America provides help 24/7 when you travel more than 100 miles from home or to another country. Assist America can help with: emergency medical evacuation, hospital admission, medical monitoring, round-trip transportation for a family member or friend, help replacing forgotten prescriptions (additional costs may apply), local language communications, and medically necessary transportation. |
Assist America provides help 24/7 when you travel more than 100 miles from home or to another country. Assist America can help with: emergency medical evacuation, hospital admission, medical monitoring, round-trip transportation for a family member or friend, help replacing forgotten prescriptions (additional costs may apply), local language communications, and medically necessary transportation. |
| UPMC MyHealth 24/7 Nurse Line |
Call for general health information or facts about a specific medical issue at no additional cost. Experienced, registered nurses are on hand to provide you with prompt and efficient service. |
Call for general health information or facts about a specific medical issue at no additional cost. Experienced, registered nurses are on hand to provide you with prompt and efficient service. |
Call for general health information or facts about a specific medical issue at no additional cost. Experienced, registered nurses are on hand to provide you with prompt and efficient service. |
| UPMC AnywhereCare |
$0 for a medical visit; $35 for a dermatology visit |
$0 for a medical visit; $35 for a dermatology visit |
$0 for a medical visit; $35 for a dermatology visit |
| Telehealth |
You can virtually visit with your doctor over the phone or online if your provider participates in telehealth. You’ll have the same copay as if you were seeing your doctor in-person. Your provider must be in the same state as you during your visit. |
You can virtually visit with your doctor over the phone or online if your provider participates in telehealth. You’ll have the same copay as if you were seeing your doctor in-person. Your provider must be in the same state as you during your visit. |
You can virtually visit with your doctor over the phone or online if your provider participates in telehealth. You’ll have the same copay as if you were seeing your doctor in-person. Your provider must be in the same state as you during your visit. |
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Plan Name 1 |
Plan Name 2 |
Plan Name 3 |
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