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Covered Services

Chart head

The Preferred Provider Organization (PPO) plan offers you the choice of two levels of health care benefits each time you need medical services. Members will have reduced cost-sharing if care is received from a participating provider. Coordination of service is not required.

Chart
Annual deductible

Individual

$100
$200
Annual out-of-pocket maximum

Individual

$5,000
$10,000

Family

$10,000
$20,000
Plan payment level
80% after deductible
60% after deductible1
Lifetime benefit level
$250,000
$50,000
Primary care provider
(PCP) required
No
No
Pre-existing condition limitations
None
None
Precertification
requirements
Provider responsibility
Member responsibility - $500
financial penalty per
incident for failure to precertify non-emergency admissions
Preventive Care
Adult    
Routine physical exam
100% after $25 copayment per visit
Not covered
Pediatric    
Routine physical exam
100% after $25 copayment per visit
Not covered
Pediatric immunizations
100% (deductible does not apply)
60% (deductible does not apply)1
Well-baby visits
100% after $25 copayment per visit
Not covered
Physician Services
Physician office visit
(for illness or injury)
100% after $25 copayment per visit
60% after deductible1
Medical/surgical services
(inpatient medical and surgical care,
outpatient surgeon's fees, anesthesia)
80% after deductible1
60% after deductible1
These dollar amounts apply to outpatient surgical services - 1) Covered up to $12,000 per Benefit Period for surgeon fees; 2) Covered up to $2,400 per Benefit Period for assistant surgeon fees; and 3) Covered up to $2,400 per Benefit Period for anesthetist
No dollar limits on medical services per Benefit Period
Women's Care
Routine gynecological exam,
Pap test, mammogram,
prenatal visit, diagnostic
tests, and surgical
services
100% after $25 copayment
(applies to routine gynecological exam only); 80% after
deductible for all other care; Pap test and mammogram
not subject to deductible
60% after deductible1
Routine gynecological exam, Pap test,
and mammogram
not subject to deductible
Abortion services covered up to $250 per Benefit Period
Hospital Services
Inpatient care,
medical/ancillary
services, diagnostics and supplies
100% after $500 copayment per inpatient stay
60% after deductible1
Outpatient care
80% after deductible for outpatient care
Emergency Services
Emergency Care Coverage
100% after $50 copayment
per visit (copayment
waived if admitted)
100% after $50 copayment
per visit (copayment
waived if admitted)
Covered up to $6,000 per Benefit Period (includes both physician and facility charges)
Diagnostic Services
Advanced imaging
(e.g., PET, MRI, etc.)
80% after deductible
60% after deductible1
Other imaging (e.g., x-ray,
sonogram, etc.)
80% after deductible
60% after deductible1
Lab and other diagnostic
services
80% after deductible
60% after deductible1
 
Outpatient lab and radiology services limited to $1,500 per Benefit Period
Medical Therapy Services
Chemotherapy, radiation,
infusion therapy,
dialysis treatment
80% after deductible
60% after deductible1
Rehabilitation Therapy Services
Physical and occupational
therapy
100% after $25 copayment per visit
60% after deductible1
Covered up to 60 visits per Benefit Period for all three therapies combined.
Other Medical Services
Home health care
80% after deductible
60% after deductible1
Hospice care
80% after deductible
60% after deductible1
Behavioral Health - Contact UPMC Health Plan Behavioral Health Services at
1-888-251-0083
Behavioral health    
Inpatient2
100% after $500 copayment per inpatient stay
60% after deductible1
Limit of 30 days per Benefit Period; lifetime maximum
of 90 days
Outpatient2
100% after $25 copayment per visit
50% after deductible1
Up to 20 visits per Benefit Period; Group visits and 15-minute medication visits count as 1/2 visit
Substance Abuse Services
100% after $500 copayment per inpatient stay
50% after deductible1
80% after deductible for outpatient care
Inpatient detoxification
Limit of 7 days per admission, lifetime maximum of 4 admissions
Inpatient rehabilitation
Limit of 30 days per Benefit Period, lifetime maximum of 90 days
Outpatient rehabilitation
Limit of 60 visits per Benefit Period, lifetime maximum of 120 visits
Prescription Drug Coverage - The Your Choice Pharmacy Program will apply (Mandatory Generic)

Retail prescription drug3

  • Prescriptions must be dispensed by a participating pharmacy
$10 copayment for generic drugs
$20 copayment for preferred brand drugs
$40 copayment for non-preferred brand drugs
30-day maximum retail supply
UPMC Health Plan pays up to a maximum of $500 per Benefit Period in combination with mail-order and specialty drugs

Specialty prescription drug3

  • Specialty medications are limited to a
    30-day supply
  • Most specialty medications must be filled at our contracted specialty pharmacy provider (list available upon request)

*Drugs in limited distribution may not be available from UPMC Health Plan's contracted specialty provider

$40 copayment for specialty drugs

30-day maximum specialty supply

UPMC Health Plan pays up to a maximum of $500 per Benefit Period in combination with mail-order and retail drugs

Mail-order prescription drug3

  • A three-month supply (up to 90 days) of medication may be dispensed through the contracted mail service pharmacy.
$20 copayment for generic drugs
$40 copayment for preferred brand drugs
$80 copayment for non-preferred brand drugs
90-day maximum mail-order supply
UPMC Health Plan pays up to a maximum of $500 per Benefit Period in combination with retail and specialty drugs


1 If care is out-of-network, benefits are paid at a lower level after your annual deductible is met. If you go to an out-of-network provider, you also may have to pay the difference between the provider's charge and the UPMC Health Plan payment (reasonable and customary amount).

2 Pennsylvania Act 1998-150 mandates 30 inpatient days per benefit period (no lifetime maximum) and 60 outpatient visits per Benefit Period for certain diagnoses based on medical necessity and appropriateness. For additional information concerning coverage and diagnosis requirements, call UPMC Health Plan Behavioral Services at 1-888-251-0083.

3 If a physician demonstrates that the brand name drug is medically necessary and appropriate, the member will pay only the non-preferred brand-name drug copayment.

This summary is meant to assist in comparing the benefit plans. It is not a contract. If differences exist between this and a group's contract or a member's certificate of coverage, the contract or certificate of coverage prevails.

In this document, the term "UPMC Health Plan" refers to benefit plans offered by UPMC Health Network, Inc., as well as plans offered by UPMC Health Plan, Inc.

This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered.

UPMC Health Plan Member Services: 1-888-876-2756.

TTY Services: 1-800-361-2629

 


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