HDHP Option PPO
The High-Deductible Health Plan (HDHP) Option comes with a health savings account (HSA). An HSA is a savings account that you can only use for qualified health care expenses. If you are not eligible for an HSA, let us know and we can set up a health reimbursement arrangement (HRA) for you. The funds in your HSA belong to you. You can keep them year after year, watch them grow, and take them with you if you change jobs or retire. There's no “use it or lose it” restriction, and eligible contributions to your HSA are tax-free.
It's important to know that with an HSA, your health incentive account (HIA) funds can only be used after you meet your deductible. It's your choice whether you use money in your HSA to pay for medical costs before reaching that point. You must pay all medical expenses until you reach your deductible. Once you meet your deductible, your available HIA funds will automatically be applied to your out-of-pocket expenses. If you do not have HIA funds to use, you may use your HSA funds for out-of-pocket expenses.
| Annual deductible |
| Self Only |
$2000 |
| Self Plus One/Self Plus Family |
$4000 |
| Cost share after deductible |
| Coinsurance (member pays) |
15% |
| Preventive care |
Member pays nothing |
| Provider services |
| PCP office visit |
15% after the deductible is met |
| Specialist office visit |
15% after the deductible is met |
| Virtual urgent care visit |
15% after the deductible is met |
| Urgent care visit |
15% after the deductible is met |
| Emergency room visit |
15% after the deductible is met |
| Prescription drug copayments – after deductible is met |
30-day supply |
90-day supply (mail order only) |
| Tier 1 Preferred Generic |
$20 |
$40 |
| Tier 2 Preferred Brand and Generic |
$50 |
$100 |
| Tier 3 Nonpreferred Brand and Generic |
$100 |
$200 |
| Tier 4 Specialty prescription drug |
50% of the discounted cost of the drug (max $250) |
N/A |
| Tier 5 preventive medications (per ACA) |
$0 |
$0 |
| Tier 6 oral chemotherapy (brand and generic) |
20% after deductible |
N/A |
| Safe Harbor preventive medications – 30 days |
$20, deductible does not apply |
Please note that with the HDHP Option PPO, prescriptions from out-of-network providers will not be covered by UPMC Health Plan.
Subscribers can earn up to $250 in their health incentive account every plan year, while enrolled employees and spouses can earn up to $500. The reward dollars you earn will carry over from year to year. You can use these reward dollars to pay for pharmacy copayments and coinsurance once your deductible is met. And remember, all qualified medical expenses can be paid using your tax-free dollars from your HSA.
High-Deductible Health Plan (HDHP) Summary of Coverage and Benefits
Reasons to Choose the High-Deductible Health Plan (HDHP) Option
2023 Safe Harbor Drug List
Plan Cost Scenario—HDHP Option PPO (Self Only)
Let's look at how you can use your health savings account (HSA) and health incentive account (HIA) to pay for medical expenses during your plan year. For this example, let's assume you've chosen the Self Only option.
Your deductible is $2,000. You and your employer contribute $900 to your HSA, and there's $250 in your health incentive account because you completed several healthy activities. You have a medically necessary procedure that costs $2,250. You can use the $900 in your HSA to help pay for this expense, then pay $1,100 out-of-pocket. This gets you to your $2,000 deductible. At this point, the final $250 can come from your HIA.
With the HDHP Option PPO, prescription drug expenses are subject to the deductible. This means you will pay the full discounted rate for your prescriptions until you meet the deductible. In this example, your HSA funds will help pay these expenses. After you meet the deductible, only copayments will apply to prescriptions.
If you use up your HIA funds, you will only be responsible for copayments and 15 percent coinsurance until you reach your out-of-pocket maximum. This is the most you'll have to pay in a plan year. At this point your coverage will pay 100 percent of your eligible medical expenses, including prescriptions.