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Standard Option HMO

With the Standard Option HMO, you have:

HMO Plan Comparison Standard Option HMO
Annual deductible (embedded)
Individual $850
PCP office visit $20
Specialist office visit $50
Virtual urgent care visit $5
Urgent care visit $75
Emergency room visit $150
Cost share after deductible
Coinsurance, which member pays 20%
Preventive care Member pays Nothing
Rx Copayments
Generic retail copayment – 30 days $20
Preferred brand and generic retail copayment- 30 days $50
Non-Preferred brand retail copayment – 30 days $100
Mail order (when applicable) is available for 90-day supply at twice the retail copayment.  

The Standard Option HMO offers a lower monthly premium. The deductible, coinsurance, and prescription drug copayments all apply to your out-of-pocket maximum. 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.

Standard Option HMO Summary of Benefits and Coverage

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 HealthyU pays 100 percent of your eligible medical expenses, including prescriptions.

FEHB and Medicare Part B

Medicare Part B is available if you need assistance with medical supplies and services medically necessary to treat a health condition. For more information, visit our FEHB and Medicare Part B 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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