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Standard Option HMO

With the Standard Option HMO, you have:

Annual deductible (embedded)
Self Only $850
Self Plus One, Self Plus Family $1700
Cost share after deductible
Coinsurance, which member pays 20%
Preventive care Member pays nothing
Provider services
PCP office visit $20
Specialist office visit $50
Virtual urgent care visit $5
Urgent care visit $75
Emergency room visit $150
Prescription Drug Copayments
Generic retail copayment – 30 days $20
Preferred brand retail copayment – 30 days $50
Non-Preferred brand retail copayment – 30 days $100
Specialty prescription drug copayment – 30 days 50% of the discounted cost of the drug up to a maximum of $250
Mail order (when applicable) is available for 90-day supply at twice the retail copayment.  

The deductible, coinsurance, and prescription drug copayments all apply to your out-of-pocket maximum with the Standard Option HMO. Once you reach your out-of-pocket maximum, you have 100 percent coverage, including prescription drugs, until the end of the year.

With this option, you can use the reward dollars earned in your health incentive account (HIA) to pay for coinsurance, pharmacy copayments, and deductible. Subscribers can earn up to $250 in their HIA every plan year, while enrolled employees and spouses can earn up to $500. Unused reward dollars carry over from year to year, up to two times the annual deductible.

Plan Cost Scenario – Standard Option HMO

Scenario 1 (Self Only):

Let's take a look at how you can use your health incentive account (HIA) to help pay for medical expenses during your plan year. For this example, let's assume you've chosen the Self Only option.

Your deductible is $850. You completed healthy activities and received $200 in your HIA. You have a medical test done that costs $150 and applies to your deductible. The $200 in your HIA applies first so you pay nothing out-of-pocket. Plus, you still have a balance of $50 in your HIA with the opportunity to earn another $50 to help offset future medical expenses.

Scenario 2 (Self Only):

Here's a second example: This time you have earned $250 in your incentive account—but your procedure costs $500. In this case, the full $250 in your HIA is applied and you must cover the remaining $250 out-of-pocket.

If you have not met your deductible, you will have out-of-pocket costs, but your HIA reward dollars will help you lower those costs until you've met your deductible.

For services that apply to your deductible, once you meet your deductible, you are only responsible for 20 percent coinsurance until you reach your out-of-pocket maximum of $6,000, which is the most you'll have to pay in one plan year. At that point your coverage pays 100 percent of your eligible medical expenses, including prescriptions.

Medicare Parts A and B for Annuitants

Annuitants can start saving with FEHB and Medicare Parts A and B. When you enroll in the Standard Option HMO and Medicare Parts A and B are the primary payer of benefits, the plan deductible is reduced and the plan coinsurance is waived. In addition, you and your covered spouse are eligible to receive an $800 MC Premium Reimbursement. For more information, visit our Medicare Parts A and B for Annuitants page.

HIA funds cannot be used for medical services copayments.



It is important to know that when you enroll in this plan, services are provided through UPMC Health Plan's participating providers as described in UPMC Health Plan's federal brochure — but the continued participation of any one doctor, hospital, or other provider cannot be guaranteed.

Continue to UPMC Health Plan online provider search


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