UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 6 of 9 Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Physical, occupational, or speech therapy related to a Behavioral Health Condition You pay $30 Copayment per visit. You pay $30 Copayment per visit. Visit limits do not apply. Applied behavior analysis for the treatment of Autism Spectrum Disorder You pay $0 after Deductible. You pay $0 after Deductible. Other Medical Services Refer to the Certificate of Coverage (COC) for specific Benefit Limitations that may apply to the services listed below. Visit limits do not apply for medically necessary services provided for treatment of a Behavioral Health condition. Acupuncture You pay $75 Copayment per visit. You pay $150 Copayment per visit. Covered up to 12 visits per Benefit Period. Corrective appliances You pay $0 after Deductible. You pay 35% after Deductible. Dental services related to accidental injury You pay $0 after Deductible. You pay 35% after Deductible. Durable medical equipment You pay $0 after Deductible. You pay 35% after Deductible. Fertility testing You pay $0 after Deductible. You pay 35% after Deductible. Home health care You pay $0 after Deductible. You pay 35% after Deductible. Covered up to 60 days per Benefit Period. Hospice care You pay $0 after Deductible. You pay 35% after Deductible. Medical nutrition therapy You pay $0 after Deductible. You pay 35% after Deductible. Nutritional counseling You pay $0 after Deductible. You pay 35% after Deductible. Covered up to 6 visits per Benefit Period. Nutritional formulas Covered at 100%; you pay $0. You pay 35%. Deductible does not apply. Nutritional formulas for the treatment of PKU and related disorders are not subject to Deductible. Oral surgical services You pay $0 after Deductible. You pay 35% after Deductible. Podiatry services You pay $75 Copayment per visit. You pay $150 Copayment per visit. Skilled nursing facility You pay $0 after Deductible. You pay 35% after Deductible. Covered up to 120 days per Benefit Period. Therapeutic manipulation/chiropractic care You pay $75 Copayment per visit. You pay $150 Copayment per visit. Covered up to 20 visits per Benefit Period. Private duty nursing You pay $0 after Deductible. You pay 35% after Deductible. Diabetic Equipment, Supplies, and Education Diabetic equipment and supplies (NOTE: If you have prescription drug coverage through a program other than Express Scripts, Inc., that plan will pay for diabetic supplies and equipment first.) Glucometer, test strips, and lancets, insulin and syringes Must be obtained at a Participating Pharmacy. See applicable Prescription Schedule of Benefits for coverage information. Diabetic education Covered at 100%; you pay $0. You pay 35% after Deductible.