UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 4 of 9 Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 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. You pay 35% after Deductible. Provider Medical Services Inpatient medical care visits, intensive medical care, and consultation You pay $0 after Deductible. You pay 35% after Deductible. Adult immunizations not required to be covered by the ACA You pay $0 after Deductible. You pay 35% after Deductible. Primary care provider office visit You pay $30 Copayment per visit. You pay $60 Copayment per visit. Specialist office visit You pay $75 Copayment per visit. You pay $150 Copayment per visit. Convenience care visit You pay $30 Copayment per visit. You pay $30 Copayment per visit. Urgent care facility You pay $100 Copayment per visit. You pay $200 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 $15 Copayment per visit. You pay $30 Copayment per visit. Virtual visit – Specialist You pay $38 Copayment per visit. You pay $75 Copayment per visit. Virtual visit – Behavioral Health You pay $15 Copayment per visit. You pay $15 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. You pay 35% after Deductible. Diagnostic Services Advanced imaging (e.g., PET, MRI) You pay $0 after Deductible. You pay 35% after Deductible. Other imaging (e.g., x-ray, sonogram,) You pay $0 after Deductible. You pay 35% after Deductible. Laboratory services You pay $0 after Deductible. You pay 35% after Deductible. Diagnostic testing You pay $0 after Deductible. You pay 35% after Deductible. Rehabilitation Therapy Services Note: See the Behavioral Health Services section below for Rehabilitation Therapy services prescribed for the treatment of a Behavioral Health condition. Physical and occupational therapy You pay $50 Copayment per visit. You pay $100 Copayment per visit. Covered up to 30 visits per Benefit Period for both therapies combined. Speech therapy You pay $50 Copayment per visit. You pay $100 Copayment per visit.