UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_TAHS_LRG Med: K-11 Rx: $0/$15/$50/$100/$150 Page 2 of 8 Member Cost Sharing Participating Provider 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. Deductible applies to all Covered Services you receive during the Benefit Period, unless the service is specifically excluded. Coinsurance You pay $0 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 Your plan has an embedded Out-of-Pocket Limit, which means the Out-of-Pocket Limit is satisfied in one of two ways-whichever comes first: *When an individual within a family reaches his or her individual Out-of-Pocket Limit. At this point, only that person will have Covered Services paid at 100% for the remainder of the Benefit Period; OR *When a combination of a family member’s expenses reaches the family Out-of-Pocket Limit. At this point, all covered family members are considered to have met the Out-of-Pocket Limit and Covered Services will be paid at 100% for the remainder of the Benefit Period. Out-of-Pocket costs (Copayments, Coinsurance, and Deductibles) for Covered Services apply toward satisfaction of the Out-of-Pocket Limit specified in this Schedule of Benefits. Member Cost Sharing Participating Provider Preventive Services Preventive Services will be covered in compliance with requirements under the Affordable Care Act (ACA). Please refer to the Preventive Services Reference Guide for additional details. Pediatric preventive/health screening examination Covered at 100%; you pay $0. Pediatric immunizations Covered at 100%; you pay $0. Adult preventive/health screening examination Covered at 100%; you pay $0. Adult immunizations required by the ACA to be covered at no cost- sharing Covered at 100%; you pay $0. Screening gynecological exam Covered at 100%; you pay $0. Breast cancer and cervical cancer screening Covered at 100%; you pay $0. Screening services and procedures required by the ACA Covered at 100%; you pay $0.