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What's New for 2016

For all UPMC Health Plan Options

These changes apply to all options offered by UPMC Health Plan:

  • A Self Plus One enrollment type is now available.
  • Enrolled dependent children (up to age 26) residing or attending school outside of our western Pennsylvania service area will be covered at the highest level of benefits for covered services when they use providers that participate in our national network through Private Healthcare Systems (PHCS) or Medical Mutual of Ohio (MMO), or obtain services at a student health center. Members can search our online provider directory at www.upmchealthplan.com/find. Enter the city or ZIP code where care is needed, then select “Coverage through your employer” under “Coverage Type.” Scroll down to see the buttons “Care in Ohio” or “Care Outside of Western Pa. and Ohio.”

    Note that certain services require a prior authorization, and those requirements remain in force.

    As always, true emergencies are covered at the highest level of benefits for all UPMC Health Plan members.

  • Prescription Drug copayments are as follows:

    Formulary Status Copayment (after the annual deductible is met)
    Generic retail $10 up to a 30-day supply
    Generic mail order $20 up to a 90-day supply
    Preferred brand retail $40 up to a 30-day supply
    Preferred brand mail order $80 up to a 90-day supply
    Non-preferred brand retail $100 up to a 30-day supply
    Non-preferred brand mail order $200 up to a 90-day supply
    Specialty medications $100 up to a 30-day supply

High Option HMO

These additional changes apply to the High Option HMO:

  • The annual deductible is $650 for an individual and $1,300 for a family.
  • The coinsurance is 15 percent. This means that you pay 15 percent of the allowable expense and the plan pays 85 percent. Coinsurance is paid after the annual deductible is met.
  • The annual out-of-pocket maximum is $4,000 for an individual and $8,000 for a family.

Standard Option HMO

These additional changes apply to the Standard Option HMO:

  • The annual deductible is $800 for an individual and $1,600 for a family.
  • The annual out-of-pocket maximum is $5,000 for an individual and $10,000 for a family.
  • For retired members enrolled in Medicare Parts A and B, the annual deductible will be $650 for an individual. Coinsurance will continue to be 100 percent after the annual deductible is met.

High Deductible Health Plan

These additional changes apply to the High Deductible Health Plan:

  • The annual in-network out-of-pocket maximum is $5,000 for an individual and $10,000 for a family.
  • The out-of-network coinsurance is 40 percent. This means that you pay 40 percent of the allowable expense and the plan pays 60 percent when you utilize non-participating providers. Coinsurance is paid after the annual deductible is met.
  • The annual out of-network out-of-pocket maximum is $8,000 for an individual and $16,000 for a family.

HealthyU. Live Healthy. Earn Rewards.

HealthyU is an innovative plan that rewards you for making healthy choices. HealthyU now offers a more personalized approach that keeps you focused on healthy activities that are important to helping you understand and improve your health. You can now choose from a customized list of healthy activities that are important for your specific health and wellness goals, in addition to choosing from a standard list of healthy activities.

How easy is it to earn rewards?
Activity HealthyU reward dollars
Complete MyHealth Questionnaire (online health assessment) $50
Preventive Lab Screening $25
Preventive Screening (mammogram or colonoscopy) $50
Well Visit $50

The reward dollars you earn automatically help pay your out-of-pocket medical expenses, such as copayments and coinsurance. In one plan year, you can earn up to $250 for Self-Only coverage or $500 for Self Plus One and Self and Family coverage. Any unused reward dollars — at a value up to two times your annual deductible — automatically roll over to the next year.

2016 Plan Details

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See the details of the 2016 plans for Federal Employees.

 

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2016 Plans for Federal Employees

There are three HealthyU plan options available to federal employees:

Standard Option HMO

  • A deductible of $800 for Self-Only or $1,600 for Self Plus One and Self and Family.
  • 20 percent coinsurance after you reach your deductible for services other than preventive care until your out-of-pocket maximum is reached.
  • An out-of-pocket maximum of $5,000 for an individual or $10,000 for Self Plus One and Self and Family.

High Option HMO

  • A deductible of $650 for Self-Only and a $1,300 for Self Plus One and Self and Family.
  • 15 percent coinsurance after you reach your deductible for services other than preventive care until your out-of-pocket maximum is reached.
  • An out-of-pocket maximum of $4,000 for an individual or $8,000 for Self Plus One and Self and Family.

High Deductible Health Plan (HDHP)

  • A deductible of $2,000 for Self-Only or $4,000 for Self Plus One and Self and Family.
  • For the health savings account (HSA), members receive $83.33 per month for Self-Only coverage or $166.67 for Self Plus One and Self and Family enrollment. These funds can be used toward your deductible.
  • 10 percent coinsurance after you reach your deductible for services other than preventive care until your out-of-pocket maximum is reached.
  • An out-of-pocket maximum of $5,000 for Self-Only and $10,000 for Self Plus One and Self and Family (in-network); or $8,000 for Self-Only and $16,000 for Self Plus One and Self and Family (out-of-network).

2016 Plan Details

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See the details of the 2016 plans for Federal employees.

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2016 Rate Information for UPMC Health Plan

Non-postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

Postal rates apply to Postal Service employees. They are shown in special Guides published for APWU (including Material Distribution Center and Operating Services) NALC, NPMHU, and NRLCA Career Postal Employees (see RI 70-2A); Information Technology/Accounting Services employees (see RI 70-2IT); Nurses (see RI 70-2N); Postal Service Inspectors and Office of Inspector General (OIG) law enforcement employees and Postal Career Executive Service employees (see RI 70-2IN); and non-career employees (see RI 70-8PS).

Postal Category 1 rates apply to career bargaining unit employees covered by the Postal Police contract.

Postal Category 2 rates apply to career non-bargaining unit, non-executive, non-law enforcement employees, and non-law enforcement Inspection Service and Forensics employees.

For further assistance, Postal Service employees should call:

Human Resources Shared Service Center
1-877-477-3273, option 5
TTY: 1-866-260-7507

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee organization who are not career postal employees. Refer to the applicable Guide to Federal Benefits.

Type of Enrollment Enrollment Code Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Gov't Share Your Share Gov't Share Your Share Category 1 Your Share Category 2 Your Share
High Option Self Only 8W1 $213.37 $142.98 $462.30 $309.79 $131.12 $142.98
High Option Self Plus One 8W3 $461.02 $340.76 $998.88 $738.31 $315.15 $340.76
High Option Self and Family 8W2 $488.50 $348.89 $1058.42 $755.93 $321.75 $348.89
Standard Option Self Only UW4 $200.63 $66.87 $434.69 $144.89 $55.51 $66.87
Standard Option Self and Family UW5 $471.44 $157.14 $1021.44 $340.48 $130.43 $157.14
HDHP Option Self Only 8W4 $177.58 $59.19 $384.75 $128.25 $49.13 $59.19
HDHP Option Self Plus One 8W6 $393.65 $131.22 $852.92 $284.30 $108.91 $131.22
HDHP Option Self and Family 8W5 $409.36 $136.45 $886.94 $295.65 $113.26 $136.45

These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to your special Guide to Federal Benefits. Or contact the agency or tribal employer that maintains your health benefits enrollment.

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Dental Benefits

Limited dental coverage is included as part of your UPMC Health Plan enrollment, The following preventive dental services are covered at no cost to you:

  • Most diagnostic x-rays
  • Two oral exams per year
  • Two teeth cleanings per year
  • Topical fluoride

Discounts are provided for other dental services.

Note: Select "Federal & Postal Employee Health Benefit" under the "Program" drop-down menu.

You may also contact Avesis Dental by calling 1-888-729-7949 for more information. Representatives are available Monday through Friday from 7 a.m. to 8 p,m.

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Vision Benefits

Routine vision examination benefits through UPMC Vision Advantage are included as part of your UPMC Health Plan enrollment at no cost to you.

  • Adults are covered for one eye exam every 24 months. Children 18 years old and younger are covered for one eye exam every 12 months.
  • A 20 percent discount for prescription eyewear (excluding contact lenses) is available at participating providers.

Dental and vision benefits are neither offered nor guaranteed under contract with the FEHB program, but they are available to all members enrolled with UPMC Health Plan.

To use your eye examination benefit, call us at 1-877-648-9641 to locate a vision care provider or click on the Find a Provider link above.

These benefits are neither offered nor guaranteed under contract with the FEHB program, but are made available to all enrollees and family members who become members of UPMC Health Plan.

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Summary of Benefits and Coverage

View the summary of benefits and coverage documents for the 2016 benefit year:

2016 Plans for Federal Employees 2016 Rates Dental Benefits Vision Benefits 2016 Summary of Benefits What's New for 2016 2016 Plans for Federal Employees 2016 Rates Dental Benefits Vision Benefits
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Attention

It is important to know 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