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Standard Option HMO

With the Standard Option HMO, you have:

Annual deductible
Self Only $850
Self Plus One, Self Plus Family $1700 per family; $850 per member
Cost share after deductible
Coinsurance (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 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
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 in your health incentive account (HIA) to pay for your coinsurance, pharmacy copayments, and deductible. Subscribers can earn up to $250 in their HIA every plan year, while enrolled employees and their 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 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. 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):

You have earned $250 in your incentive account, but your procedure costs $500. In this case, the full $250 in your HIA is applied to the procedure cost, and you must cover the remaining $250.

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.

Once you meet your deductible, you will only be responsible for 20 percent coinsurance until you reach your out-of-pocket maximum of $6,000. This is the most you'll have to pay in a plan year. At this point, UPMC Health Plan will pay 100 percent of your eligible medical expenses, including for prescriptions.

Medicare Parts A and B for Annuitants

Annuitants can save 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, you can choose between two options.

UPMC Health Plan has designed the Standard Option HMO to assist you with your Medicare Part B payment.

Here are two options:

Option #1

  1. Choose to enroll in the Standard Option HMO.
  2. Choose to enroll in the Medicare Parts A and B.
  3. Choose to enroll in UPMC for Life FEHB Retirees by calling 1-844-383-1819 (TTY: 711).
  4. Most services will have a $0 copay or lower out-of-pocket costs with $0 deductible.

Option #2

  1. Choose to enroll in the Medicare Parts A and B.
  2. Your deductible will be reduced to $700 for Self Only coverage.
  3. Your coinsurance will be reduced to 0 percent.
  4. PCP visits will have a $20 copay and specialist visits will have a $50 copay.

With both options, you are eligible to receive up to $800 in premium reimbursement through a health reimbursement arrangement (HRA).

Set up your reimbursement by mail or online using these forms:

Remember, the Standard Option HMO includes a health incentive account (HIA) that enables you to earn up to $250 for Self Only coverage. 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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