UPMC for Life PPO Salute (PPO)

Medicare Plan Details (2023 Plan)


Monthly Premium

 

by UPMC for Life
Additional Coverage
HearingVisionDental
Overall Government Star Rating
 5.0
out of 5 stars

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Plan Type

Medicare Advantage (Part C)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B

 

$0
$0
$0
$1,600 per year for inpatient hospital services and $226 for outpatient services with a total plan deductible of $1,826 per year from in-network and out-of-network providers.
$8,950 In and Out-of-network
$5,500 In-network
No
Yes
Yes
Yes

Doctor Services

In-network: 20% coinsurance per visit
Out-of-network: 20% coinsurance per visit
In-network: 20% coinsurance per visit
Out-of-network: 20% coinsurance per visit

Tests, labs, & imaging

In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
20% coinsurance per visit (always covered)
20% coinsurance per visit (always covered)

Hospital Services

In-network: In 2023 the amounts for each benefit period are:
$1,600 deductible for days 1 through 60
$400 copay per day for days 61 through 90
Out-of-network: In 2023 the amounts for each benefit period are:
$1,600 deductible for days 1 through 60
$400 copay per day for days 61 through 90
In-network: 20% coinsurance per visit
Out-of-network: 20% coinsurance per visit

Skilled nursing facility

In-network: In 2023 the amounts for each benefit period are:
$0 copay for days 1 through 20
$200 copay per day for days 21 through 100
Out-of-network: In 2023 the amounts for each benefit period are:
$0 copay for days 1 through 20
$200 copay per day for days 21 through 100

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: 0-20% coinsurance
Out-of-network: 20% coinsurance

Therapy services

In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Mental health services

In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: 0-20% coinsurance per item
Out-of-network: 20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Hearing

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $690-1,890 copay
Out-of-network: $690-1,890 copay

Preventive Dental

In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: 50% coinsurance
Not covered
In-network: $0 copay
Out-of-network: 50% coinsurance

Comprehensive dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Vision

In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Not covered
Not covered
In-network: $0 copay
Out-of-network: $0 copay

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Limited coverage
Not covered
Limited coverage
 5
 4
 4
 5
 5
 5

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