Page 186 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 15206
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 1859577088
and more coverage and star ratings.
Password Date: 02/05/2019
Important Coverage Information

Symbols

A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage

* Estimated

UPMC for Life HMO 600 Grant Street Overall Star Rating: Enroll
Premier Rx (HMO) Pittsburgh, PA 15219 Members: [?]
1-877-539-3080 711 (TTY/TDD)
(H3907-046-0) Non Members: 1-877-381-3765 4 out of 5 stars
711 (TTY/TDD)
Organization: UPMC for Life
Plan Type: HMO

Benefits Highlights

Monthly health plan premium $0.00

Health plan deductible $0

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $6,000 In-network
responsibility (does not include
prescription drugs)
Optional supplemental benefits [?] No

Additional benefits and/or reduced cost-
sharing for enrollees with certain health In-Network: Yes, contact plan for further details
conditions?
Inpatient hospital coverage $275 per stay

Outpatient hospital coverage $350 per visit

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3907&plnid=046&sgmntid=0#plan_benefits 1/4