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Plan Overview - 2019 Standard Option HMO

With the Standard Option HMO you have:

  • Preventive care covered at 100 percent with no deductible applied.
  • A deductible of $800 for Self Only, or $1,600 for Self Plus One and Self and Family.
  • Twenty percent coinsurance for services that go toward your deductible until your out-of-pocket maximum is reached.
  • An out-of-pocket maximum of $6,000 for an individual, or $12,000 for Self Plus One and Self and Family.
  • Eligible prescription drugs only require a copayment. There's no need to meet the deductible first.
Service Copayment (no deductible applies)
UPMC AnywhereCare virtual urgent care visit$5
PCP office visit>$20
Physical, speech, occupational, or habilitative services visit$20
Chiropractic office visit$20
Specialist office visit$50
Urgent care center visit$75
Emergency room*$150

*Copayment waived if admitted; deductible and coinsurance then apply.
†HIA funds cannot be used for medical services copayments.

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.


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HealthyU Checklist - Standard Option HMO

To get the most from your HealthyU plan, follow these important steps:

  • Click on the "Sign Up" link below the user login at the top of this page and create your MyHealth OnLine account. You'll need your member ID card to register.
  • For those enrolled in Self Plus One and Self and Family coverage, your adult family members older than age 18 should also register and create their own MyHealth OnLine accounts.
  • Complete the MyHealth Questionnaire within the first 90 days of the new plan year (or within 90 days of your coverage effective date, if later). This will customize your MyHealth OnLine experience and you earn reward dollars in your health incentive account (HIA) for completing this activity.
  • Begin completing healthy activities to earn reward dollars. Track your reward dollars and monitor your HIA balance on MyHealth OnLine. Log in and view the Spending Accounts tab under the Spending and Claims menu.
  • Earn your maximum reward dollars to get the most value from your plan—up to $250 for Self Only coverage or $500 for Self Plus One and Self Plus Family coverage.
  • Take advantage of all the programs offered through UPMC Health Plan to improve and maintain your health!

Remember that any unused reward dollars in your HIA carry over to the following plan year up to two times your annual deductible.

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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 $800. 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.

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Using MyHealth OnLine – Standard Option HMO

MyHealth OnLine is where you can go every day for practical tips, tools, and strategies for better health. You can also find a doctor, view your medical history, and get information on your health plan benefits. The site keeps all your health information, all in one place. At MyHealth OnLine, you can:

  • Earn and track your reward dollars, so you know exactly how much you have in your account to spend on health care. (Remember, with HealthyU, you earn reward dollars when you do healthy activities throughout the year.)
  • Enjoy discounts and savings. Through MyHealth Community, you'll receive discounts at health-related businesses such as gyms, spas, salons, health food stores, sporting goods stores, and more.
  • Manage your health care information. Access your doctor's contact information, plan benefits, research prescription and treatment options savings information, and view your spending summary and claims. You can even order a new member ID card if you lose it.
  • Get connected to your health. Chat online with a Health Care Concierge or health coach, read blogs from health experts, get advice on medical screenings and healthy activities, and set personal goals for managing your health.

Don't forget to complete your MyHealth Questionnaire! Not only will you earn reward dollars, but your answers will generate a simple summary of your current health status and customize MyHealth OnLine with activities that can benefit you most.

Getting started is easy

  • Create your MyHealth OnLine account.
    Create one here. It's quick and easy. And once you've signed up, you'll have secure, 24/7 access to your health information. You'll need the number on your member ID card for this. Once you've created your account, you can simply enter your user name into the login field located in the top right corner of this page. Then click the "Log in" button to access MyHealth OnLine.
  • Choose your PCP.
    Find one here. We all get sick. Sometimes it's a minor illness. Sometimes it's more serious. That's why it's important to have your own primary care physician, or PCP. Your PCP's goal is to keep you healthy as well as treat you when you are sick or injured. Your PCP knows you and your health history. He or she is the best person to treat you and direct your care.

    Call a Health Care Concierge at 1-877-648-9641 if you need help finding a PCP near you.
  • Take your MyHealth Questionnaire.
    When you log in to your MyHealth OnLine account click on Better Health and Wellness Then click on Resources for Healthier Living. Go to Browse by Resource Type And finally Online Activities. In just 20 minutes or less, you can get a completely confidential overview of your health and a personalized plan to help you feel your best.

All enrolled employees and spouses can register and complete their own MyHealth Questionnaire for reward dollars.

HealthyU Checklist Plan Cost Scenarios Using MyHealth OnLine Your Plan Options Plan Overview HealthyU Checklist Plan Cost Scenarios
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Attention

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 upmchealthplan.com