Covered Services

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.

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)

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 the brand-name drug is dispensed instead of the generic equivalent, you must pay the copayment associated with the brand-name drug as well as the retail price different between the brand-name drug and the generic drug.

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.

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