UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 5 of 9 Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Covered up to 30 visits per Benefit Period. Cardiac rehabilitation You pay $0 after Deductible. You pay 35% after Deductible. Covered up to 36 visits per Benefit Period. Pulmonary rehabilitation You pay $50 Copayment per visit. You pay $100 Copayment per visit. Covered up to 36 visits per Benefit Period. Habilitation Therapy Services Note: See the Behavioral Health Services section below for Habilitation 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. Covered up to 30 visits per Benefit Period. Medical Therapy Services Chemotherapy, radiation therapy, dialysis therapy You pay $0 after Deductible. You pay 35% after Deductible. Medical Therapy Services- Injectable, infusion therapy, or other drugs administered or provided by a medical professional in an outpatient or office setting You pay $0 after Deductible. You pay 35% after Deductible. Pain management Pain management program You pay $75 Copayment per visit. You pay $150 Copayment per visit. Behavioral Health (Mental Health and Substance Use Disorder) Services (Rehabilitative or Habilitative) Contact UPMC Health Plan Behavioral Health Services at 1-888-251-0083. Inpatient services (including inpatient hospital services, inpatient rehabilitation, detoxification, non-hospital residential treatment) You pay $0 after Deductible. You pay $0 after Deductible. Office visits, including psychotherapy, counseling, and urgent care You pay $30 Copayment per visit. You pay $30 Copayment per visit. Outpatient Services (includes intensive outpatient, partial hospitalization, and other medically necessary outpatient services) You pay $0 after Deductible. You pay $0 after Deductible. Laboratory services related to a Behavioral Health condition You pay $0 after Deductible. You pay $0 after Deductible.