UPMC Health Options: Schedule of Benefits

UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-6 Rx: $0/$15/$50/$100/$150 Page 1 of 9 UPMC Business Advantage MCA EPO Deductible $2,000 /$4,000 Coinsurance You pay $0 after Deductible Total Annual Out-of-Pocket $5,000 /$10,000 Primary care provider You pay $25 Copayment per visit Specialist office visit You pay $45 Copayment per visit Emergency Department You pay $250 Copayment per visit Urgent Care Facility You pay $75 Copayment per visit Rx $0 /$15 /$50 /$100 /$150 This Schedule of Benefits will be an important part of your Certificate of Coverage (COC) or your Summary Plan Description (SPD). If your plan has an SPD, it is issued by your employer or labor trust fund. It is not issued by UPMC Health Plan. It is important that you review and understand your COC and/or SPD because they describe in detail the services your plan covers. The Schedule of Benefits describes what you pay for those services. For Covered Services to be paid at the level described in your Schedule of Benefits, they must be Medically Necessary. They must also meet all other criteria described in your COC. Criteria may include Prior Authorization requirements. Please note that your plan may not cover all of your health care expenses, such as Copayments and Coinsurance. To understand what your plan covers, review your COC. You may also have Riders and Amendments that expand or restrict your benefits. Please note that UPMC Health Plan reserves the right to reduce or waive your cost-sharing for certain services, if necessary for compliance with the Mental Health Parity and Addiction Equity Act. If you have any questions about your benefits, or would like to find a Participating Provider near you, visit www.upmchealthplan.com. You can also call UPMC Health Plan Member Services at the phone number on your member ID card. For more information on your plan, please refer to the final page of this document. Plan Information UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Benefit Period Plan Year Primary Care Provider (PCP) Required Encouraged, but not required Prior Authorization Requirements Provider Responsibility Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Level 1 means you receive the highest level of benefits and have the lowest Out-of-Pocket costs. Level 1 includes all UPMC providers and UPMC-owned facilities along with many community based providers and facilities. At Level 2 your Out-of-Pocket costs may increase. If you have questions regarding your Benefit Levels, contact Member Services at the phone number on your member ID card.