MEDICAL Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Y O U R J O U R N E Y T O HEALTH MyCare Advantage EPO $750 MyCare Advantage EPO $2000 MyCare Advantage EPO $4,000 Level 1 Level 2 Level 1 Level 2 Level 1 Level 2 Deductible ( Ind/ Fam) $750 / $1,500 $2,500 / $5,000 $2,000 / $4,000 $4,000 / $8,000 $4,000 / $8,000 $8,000 / $16,000 Coinsurance 0% 35% 0% 35% 0% 35% Primary Care Visit $20 $40 $25 $50 $30 $60 Specialist Office Visit $40 $80 $45 $90 $75 $150 Urgent Care Visit $75 $150 $75 $150 $100 $200 Emergency Room $200 $250 $350 Procedures In-Patient & Out-Patient : 0% after deductible In-Patient & Out-Patient : 35% after deductible In-Patient & Out-Patient : 0% after deductible In-Patient & Out-Patient : 35% after deductible In-Patient & Out-Patient : 0% after deductible In-Patient & Out-Patient : 35% after deductible Prescriptions (Retail / Mail Order) $0/$15/$45/$90/$125 $0/$30/$90/$180/N/A $0/$15/$50/$100/$150 $0/$30/$100/$200/N/A $0/$15/$75/$125/$250 $0/$30/$150/$250/N/A Total Annual Out-of- Pocket Limit $4,000 / $8,000 $5,000 / $10,000 $9,200 / $18,400 Contributions Per Biweekly Pay Period Employee: $62.00 Employee + Spouse: $119.00 Employee + Children: $101.00 Family: $157.00 Employee: $47.00 Employee + Spouse: $99.00 Employee + Children: $85.00 Family: $132.00 Employee: $37.00 Employee + Spouse: $78.00 Employee + Children: $67.00 Family: $104.00 PLANS ARE AVAILABLE FOR EMPLOYEES OUTSIDE OF THE WESTERN PA/UPMC SERVICE REGION. BENEFIT SUMMARY AVAILABLE UPON REQUEST FROM HR. DEPENDENTS (UP TO AGE 26) WHO LIVE OUTSIDE THE SERVICE AREA HAVE COVERAGE THROUGH CIGNA’S PPO NETWORK. *Deductible applies first. The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits for specific benefits. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases. REVIEW PLAN SUMMARIES MyCare Advantage EPO $750 MyCare Advantage EPO $2000 MyCare Advantage EPO $4000 UPMC Health Plan Network Compare