UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_TAHS_LRG Med: K-11 Rx: $0/$15/$50/$100/$150 Page 3 of 8 Member Cost Sharing Participating Provider Hospital Services Hospital inpatient You pay $0 after Deductible. Outpatient/Ambulatory surgery You pay $0 after Deductible. Observation stay You pay $0 after Deductible. Maternity - facility services associated with delivery You pay $0 after Deductible. Emergency Services Emergency department You pay $250 Copayment per visit. Copayment waived if you are admitted to hospital. Emergency transportation You pay $0 after Deductible. Surgical Services Surgical services (professional provider services) You pay $0 after Deductible. Provider Medical Services Inpatient medical care visits, intensive medical care, and consultation You pay $0 after Deductible. Adult immunizations not required to be covered by the ACA You pay $0 after Deductible. Primary care provider office visit You pay $25 Copayment per visit. Specialist office visit You pay $45 Copayment per visit. Convenience care visit You pay $25 Copayment per visit. Urgent care facility You pay $75 Copayment per visit. Virtual Visits UPMC AnywhereCare - Virtual Urgent Care and Children’s AnywhereCare Covered at 100%; you pay $0. Virtual visit - Primary Care You pay $13 Copayment per visit. Virtual visit – Specialist You pay $23 Copayment per visit. Virtual visit – Behavioral Health You pay $13 Copayment per visit. UPMC MyHealth 24/7 Nurse Line If you would like to speak to a registered nurse about a specific health concern or when to seek treatment, call our UPMC MyHealth 24/7 Nurse Line at 1-866-918-1591(TTY:711) 365 days/year. You may also send an email for non-urgent issues using the web nurse request system at www.upmchealthplan.com and a nurse will respond within 24 hours. Allergy Services Treatment, injections, and serum You pay $0 after Deductible. Diagnostic Services Advanced imaging (e.g., PET, MRI) You pay $0 after Deductible. Other imaging (e.g., x-ray, sonogram,) You pay $0 after Deductible. Laboratory services You pay $0 after Deductible.