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2022 Medicare Advantage Plan Benefit Details for the UPMC for Life HMO Salute (HMO) - H3907-053-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2022 Medicare Advantage Plan Details
Medicare Plan Name:UPMC for Life HMO Salute (HMO)
Location:Allegheny, Pennsylvania     Click to see other locations
Plan ID:H3907 - 053 - 0     Click to see other plans
Member Services:1-877-539-3080 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the UPMC for Life HMO Salute (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Medicare Part B Premium Reduction:This plan has a $50 Part B monthly premium rebate (or giveback). However, you must continue to pay your Medicare Part B premium.
Annual Deductible:no drug coverage
Health Plan Type:Local HMO *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Number of Members enrolled in this plan in Allegheny, Pennsylvania:106 members
Number of Members enrolled in this plan in Pennsylvania:441 members
Number of Members enrolled in this plan in (H3907 - 053):514 members
Plan’s Summary Star Rating: 5 out of 5 Stars.  
This plan qualifies for the 5-star rating Special Enrollment period. Read more.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 5 out of 5 Stars.
• Drug Cost Accuracy Rating: 5 out of 5 Stars.
— Plan Premium Details —
Monthly Premium with Extra Help Low-Income Subsidy (LIS):data not available
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: $50
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: Yes
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $6
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: Yes
Doctor visits
• Primary: $20 copay per visit
• Specialist: $50 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $5 copay (authorization required)
• Lab services: $5 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $250 copay (authorization required)
• Outpatient x-rays: $30 copay (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $50 copay per visit (always covered)
Inpatient hospital coverage
• $250 per day for days 1 through 7
$0 per day for days 8 through 90 (authorization required)
Outpatient hospital coverage
• $275 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$184 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $50-285 copay
Rehabilitation services
• Occupational therapy visit: $40 copay (authorization required)
• Physical therapy and speech and language therapy visit: $40 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $250 per day for days 1 through 7
$0 per day for days 8 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $40 copay
• Outpatient individual therapy visit with a psychiatrist: $40 copay
• Outpatient group therapy visit: $40 copay
• Outpatient individual therapy visit: $40 copay
Opioid treatment program services
• In-network: $50.00 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: 20% coinsurance per item
Dialysis
• 20% coinsurance
Hearing
• Hearing exam: $50 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0 copay (limits apply)
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: 50% coinsurance (limits apply)
• Diagnostic services: 50% coinsurance (limits apply)
• Restorative services: 50% coinsurance (limits apply)
• Endodontics: 50% coinsurance (limits apply)
• Periodontics: 50% coinsurance (limits apply)
• Extractions: 50% coinsurance (limits apply)
• Prosthodontics, other oral/maxillofacial surgery, other services: 50% coinsurance (limits apply)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: $0 copay (limits apply)
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Some coverage
• Transportation services for non-emergency care: Plan-approved locations: Not covered
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Some coverage
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Some coverage
• Support for Caregivers of Enrollees: Some coverage
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Some coverage
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Some coverage
Wellness programs (e.g., fitness, nursing hotline)
• Covered (authorization required)
Transportation
• $0 copay (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $50 copay
• Routine foot care: $50 copay (limits apply)
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)




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