UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 9 of 9 Services that require Prior Authorization Certain services and items must be Prior Authorized in order to be eligible for reimbursement under your plan. This means you must contact UPMC Health Plan and obtain Prior Authorization before receiving services. A list of services that must be Prior Authorized is available 24/7 on our website at www.upmchealthplan.com. You can also contact Member Services by calling the phone number on your member ID card. Your provider may also access this list at www.upmchealthplan.com or your provider may call Provider Services at 1-866-918- 1595 to initiate the Prior Authorization process on your behalf. Regardless, you must confirm that Prior Authorization has been given in advance of your receiving services in order for those services to be eligible for reimbursement in accordance with your plan. Please note, the list of services that require Prior Authorization is subject to change throughout the year. You are responsible for verifying you have the most current information as of your date of service. The capitalized words and phrases in this Schedule of Benefits mean the same as they do in your COC. Also, the headings under the Covered Services section are the same as those in your COC. At all times, UPMC Health Plan administers the coverage described in this document in full compliance with applicable laws and regulations, and, if applicable, subject to approval by the Pennsylvania Insurance Department. If any part of this Schedule of Benefits conflicts with any applicable law, regulation, or other controlling authority, the requirements of that authority will prevail and UPMC Health Plan reserves the right to update this document accordingly. Your plan documents will always include the Schedule of Benefits, the COC, and the Summary of Benefits and Coverage. You can log into the UPMC Health Plan member site to view these documents. If you have questions, call Member Services. UPMC Health Plan is the marketing name used to refer to the following companies, which are licensed to issue individual and group health insurance products or which provide third party administration services for group health plans: UPMC Health Network Inc., UPMC Health Options Inc., UPMC Health Coverage Inc., UPMC Health Plan Inc., UPMC Health Benefits Inc., UPMC for You Inc., Community Care Behavioral Health Organization, and/or UPMC Benefit Management Services Inc. UPMC Health Plan U.S. Steel Tower 600 Grant Street Pittsburgh, PA 15219 www.upmchealthplan.com