UPMC for Life PPO Rx Enhanced (PPO) for Ohio

Monthly Plan Premium

$223.50

Annual Maximum Out-of-Pocket Limit

In-network: $3,200
Out-of-network: n/a

Annual Out-of-Pocket Deductible

In-network: n/a
Out-of-network: $250

Primary Care Doctor Visit Copay

In-network: $5
Out-of-network: $45

Specialist Doctor Visit Copay

In-network: $30
Out-of-network: $45

Inpatient Hospital Copay

In-network: $100 per stay; $200 maximum
Out-of-network: 20% of the cost per stay

Inpatient Mental Health Copay

In-network: $100 per stay; $200 maximum
Out-of-network: 20% of the cost per stay

Outpatient Services/Surgery

In-network: $60 per stay; $120 maximum
Out-of-network: 20% of the cost per stay

Outpatient Rehabilitation Services (speech, occupational, and physical therapy)

In-network: $20
Out-of-network: 20% of the cost per visit

Mental Health Services

In-network: $30
Out-of-network: $45

Emergency and Urgent Care

In-network: $50
Out-of-network: $50

Ambulance

In-network: $100 per stay
Out-of-network: 20% of the cost

Routine Vision

You receive: $250 toward the cost of one routine eye exam and eyewear every 2 years

Routine Hearing

In-network: $30 for one routine hearing exam per year
Out-of-network: No routine hearing

Routine Chiropractic

In-network: $30; limit 8 visits
Out-of-network: Not covered

Routine Podiatry

In-network: $30; limit 8 visits
Out-of-network: Not covered

Durable Medical Equipment

In-network: 20% of the cost per item
Out-of-network: 50% of the cost per item

Diagnostic Tests, X-rays, and Lab Services

In-network: $0 for clinical/diagnostic lab services and radiation; $20 for general x-rays; $50 for CT scans, MRIs, MRAs, and PET scans; $200 maximum
Out-of-network: 20% of the cost

Preventive Screenings

In-network: $0 for preventive screenings
$0-60 for a colonoscopy
Out-of-network: 20% of the cost
A separate office visit copay may apply

Skilled Nursing Facility

In-network: $25 each day, day 1-10
$60 each day, days 11-60
$0 each day, days 61-100
$3,200 maximum
Out-of-network: 20% of the cost per stay

Health and Fitness Program

Silver&Fit^® fitness program which provides membership to a participating fitness club at no additional cost

Worldwide Emergency Travel Assistance

Assist America^® provides emergency travel assistance when you're 100 miles from home or in another country

In-Network Retail Pharmacy (1 month - 31-day supply)

$5 Generics
$30 Preferred Brand
$85 Non-Preferred Brand
33% of the cost for Specialty drugs

In-Network Retail Pharmacy (3 months - 90-day supply)

$15 Generics
$90 Preferred Brand
$255 Non-Preferred Brand

Mail Order Pharmacy (3 months - 90-day supply)

$12.50 Generics
$75 Preferred Brand
$212.50 Non-Preferred Brand
33% of the cost for Specialty drugs (31-day supply)

Coverage After You Reach Your Initial Coverage Limit

After the total yearly drug costs (paid by both you and our plan) reach $2,830, you pay 100% of your prescription drug costs until your yearly out-of-pocket costs reach $4,550..

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: $2.50 for Generics and $6.30 for all other drugs, or 5% coinsurance.

Health Care Concierge⁺

A special team of Health Care Concierges who can help you understand your benefits and answer your questions.

UPMC Resources for Life⁺

Resources for managing life issues, like: legal guidance, financial counseling, household budgeting, and short-term telephone counseling.

Dental Discount Card⁺

Savings starting at 15% on dental services, such as routine cleanings and exams, x-rays and fillings, root canals and crowns, and dentures and bridges.

Brain Health and Fitness Program⁺

The InSight™ software program to load on your computer with exercises to help you keep your brain healthy and fit.

MyHealth Advice Line

24/7 health advice from experienced, registered nurses with one phone call.

MyHealth OnLine⁺

An Internet-based resource that gives you access to information about your health care visits, prescription refills, membership claims, and information on your benefits.

Care Management Programs

One-on-one support from health coaches who can help you live with chronic medical conditions, such as heart failure, asthma, diabetes, high blood pressure, depression, and more.