UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-6 Rx: $0/$15/$50/$100/$150 Page 2 of 9 Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Annual Deductible Individual $1,750 if Take a Healthy Step met $3,750 if Take a Healthy Step met $2,000 if Take a Healthy Step not met $4,000 if Take a Healthy Step not met Family $3,500 if Take a Healthy Step met $7,500 if Take a Healthy Step met $4,000 if Take a Healthy Step not met $8,000 if Take a Healthy Step not met Your plan has an embedded Deductible, which means the plan pays for Covered Services in these two scenarios - whichever comes first: *When an individual within a family reaches his or her individual Deductible. At this point, only that person is considered to have met the Deductible; OR *When a combination of family members’ expenses reaches the family Deductible. At this point, all covered family members are considered to have met the Deductible. If you receive services at Benefit Level 1 providers or facilities, amounts applied to the Deductible listed at Benefit Level 1 will also apply to the Deductible listed at Benefit Level 2. If you receive services at Benefit Level 2 providers or facilities, amounts applied to the Deductible listed at Benefit Level 2 will also apply to Benefit Level 1. Deductible applies to all Covered Services you receive during the Benefit Period, unless the service is specifically excluded. Coinsurance You pay $0 after Deductible You pay 35% after Deductible Copayments may apply to certain Participating Provider services. Any Covered Services for which cost-sharing is not specified in the “Covered Services” table below will pay subject to the applicable Deductible and Coinsurance identified above. Total Annual Out-of-Pocket Limit Individual $5,000 Family $10,000