Covered Services

The PPO plan offers you the choice of two levels of health care benefits each time you need medical services. You will have reduced cost-sharing if you receive care from a participating provider. Coordination of services is not required.

For More Information
This managed care plan may not cover all your health care expenses. Please read your Certificate of Coverage carefully for complete information about benefits and exclusions. If you have any questions, please contact UPMC Health Plan Member Services at
1-888-876-2756.

Annual deductible
Individual	$50	$50
Maximum per injury or illness
Individual	$100,000 per injury or sickness
Coinsurance	80% after deductible1	60% after deductible1
Lifetime maximum	Unlimited	Unlimited
Primary care provider (PCP) required	No	No
Pre-existing condition limitations	None	None
Precertification requirements	Provider responsibility	Member responsibility; required for select services; $500 financial penalty per incident for failure to comply
Preventive Care
Adult
Routine physical exam	80% after deductible1	Not covered
Pediatric
Routine physical exam	80% after deductible1	Not covered
Pediatric immunizations	100% (deductible does not apply)1	60% (deductible does not apply)1
Well-baby visits	80% after deductible1	Not covered
Physician Services
Physician office visit (for illness or injuy)	80% after deductible1	60% after deductible1
Medical/Surgical services (medical and surgical care, outpatient surgeon's fees, anesthesia)	80% after deductible1	60% after deductible1
Women's Care
Routine gynecological exam, Pap test, mammogram, prenatal visit, diagnostic tests, and surgical services	80% after deductible1 Routine gynecological exam, Pap test, and mammorgram not subject to deductible	60% after deductible1 Routine gynecological exam, Pap test, and mammorgram not subject to deductible
Hospital Services
Inpatient care, medical/ancillary services, diagnostics, and supplies	80% after deductible1	60% after deductible1
Outpatient care	80% after deductible1
Emergency Department Services
Must contact Member/Provider Services department within 24 hours or as soon as reasonably possible	100% after $50 copayment per visit (copayment waived if admitted)	100% after $50 copayment per visit (copayment waived if admitted)
Outpatient Diagnostic Services
Advanced imaging (e.g. PET, MRI, etc.)	80% after deductible1	60% after deductible1
Other imaging (e.g. x-ray, sonogram, etc.)	80% after deductible1	60% after deductible1
Lab and other diagnostic services	80% after deductible1	60% after deductible1
Medical Therapy Services
Chemotherapy, radiation infusion therapy, dialysis treatment	80% after deductible1	60% after deductible1
Rehabilitation Therapy Services
Physical and occupational therapy	80% after deductible1	60% after deductible1
Other Medical Services
Home health care	80% after deductible1	60% after deductible1
Hospice care	80% after deductible1	60% after deductible1
Allergy testing and serum	80% after deductible1	60% after deductible1
Behavioral Health - Contact Western Behavioral Health Care at 1-888-251-0083
Mental health
Inpatient	80% after deductible1	60% after deductible1
Outpatient	80% after deductible1	60% after deductible1
Chemical dependency treatment	80% after deductible1	60% after deductible1
	80% after deductible1
Inpatient detoxification	Limit of 7 days per admission, lifetime maximum of 4 admissions
Intpatient 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	Up to a maximum of $1,000 per benefit period in conjunction with retail prescription drugs, specialty prescription drugs, and mail-order prescription 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 Network, Inc., payment (reasonable and customary amount).

³ If you receive a brand-name drug instead of the generic equivalent, you must pay the brand-name copayment as well as the retail price difference between the brand and generic drug.

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