UPMC Health Options Schedule of Benefits

UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 1 of 9 UPMC Business Advantage MCA EPO Deductible $4,000 /$8,000 Coinsurance You pay $0 after Deductible Total Annual Out-of-Pocket $9,200 /$18,400 Primary care provider You pay $30 Copayment per visit Specialist office visit You pay $75 Copayment per visit Emergency Department You pay $350 Copayment per visit Urgent Care Facility You pay $100 Copayment per visit Rx $0 /$15 /$75 /$125 /$250 This Schedule of Benefits will be an important part of your Certificate of Coverage (COC) or your Summary Plan Description (SPD). If your plan has an SPD, it is issued by your employer or labor trust fund. It is not issued by UPMC Health Plan. It is important that you review and understand your COC and/or SPD because they describe in detail the services your plan covers. The Schedule of Benefits describes what you pay for those services. For Covered Services to be paid at the level described in your Schedule of Benefits, they must be Medically Necessary. They must also meet all other criteria described in your COC. Criteria may include Prior Authorization requirements. Please note that your plan may not cover all of your health care expenses, such as Copayments and Coinsurance. To understand what your plan covers, review your COC. You may also have Riders and Amendments that expand or restrict your benefits. Please note that UPMC Health Plan reserves the right to reduce or waive your cost-sharing for certain services, if necessary for compliance with the Mental Health Parity and Addiction Equity Act. If you have any questions about your benefits, or would like to find a Participating Provider near you, visit www.upmchealthplan.com. You can also call UPMC Health Plan Member Services at the phone number on your member ID card. For more information on your plan, please refer to the final page of this document. Plan Information UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Benefit Period Plan Year Primary Care Provider (PCP) Required Encouraged, but not required Prior Authorization Requirements Provider Responsibility Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Level 1 means you receive the highest level of benefits and have the lowest Out-of-Pocket costs. Level 1 includes all UPMC providers and UPMC-owned facilities along with many community based providers and facilities. At Level 2 your Out-of-Pocket costs may increase. If you have questions regarding your Benefit Levels, contact Member Services at the phone number on your member ID card.

UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 2 of 9 Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Annual Deductible Individual $3,750 if Take a Healthy Step met $7,750 if Take a Healthy Step met $4,000 if Take a Healthy Step not met $8,000 if Take a Healthy Step not met Family $7,500 if Take a Healthy Step met $15,500 if Take a Healthy Step met $8,000 if Take a Healthy Step not met $16,000 if Take a Healthy Step not met Your plan has an embedded Deductible, which means the plan pays for Covered Services in these two scenarios - whichever comes first: *When an individual within a family reaches his or her individual Deductible. At this point, only that person is considered to have met the Deductible; OR *When a combination of family members’ expenses reaches the family Deductible. At this point, all covered family members are considered to have met the Deductible. If you receive services at Benefit Level 1 providers or facilities, amounts applied to the Deductible listed at Benefit Level 1 will also apply to the Deductible listed at Benefit Level 2. If you receive services at Benefit Level 2 providers or facilities, amounts applied to the Deductible listed at Benefit Level 2 will also apply to Benefit Level 1. Deductible applies to all Covered Services you receive during the Benefit Period, unless the service is specifically excluded. Coinsurance You pay $0 after Deductible You pay 35% after Deductible Copayments may apply to certain Participating Provider services. Any Covered Services for which cost-sharing is not specified in the “Covered Services” table below will pay subject to the applicable Deductible and Coinsurance identified above. Total Annual Out-of-Pocket Limit Individual $9,200 Family $18,400

UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 3 of 9 Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Your plan has an embedded Out-of-Pocket Limit, which means the Out-of-Pocket Limit per Benefit Level is satisfied in one of two ways-whichever comes first: *When an individual within a family reaches his or her individual Out-of-Pocket Limit for a Benefit Level. At this point, only that person will have Covered Services paid at 100% for the remainder of the Benefit Period for that Benefit Level; OR *When a combination of a family member’s expenses reaches the family Out-of-Pocket Limit for a Benefit Level. At this point, all covered family members are considered to have met the Out-of-Pocket Limit and Covered Services will be paid at 100% for the remainder of the Benefit Period for that Benefit Level. If you receive services at Benefit Level 1 providers or facilities, amounts applied to the Out-of-Pocket listed at Benefit Level 1 will also apply to the Out-of-Pocket listed at Benefit Level 2. If you receive services at Benefit Level 2 providers or facilities, amounts applied to the Out-of-Pocket listed at Benefit Level 2 will also apply to Benefit Level 1. Out-of-Pocket costs (Copayments, Coinsurance, and Deductibles) for Covered Services apply toward satisfaction of the Out-of-Pocket Limit specified in this Schedule of Benefits. Member Cost Sharing UPMC MyCare Advantage Benefit Level 1 Other Participating Providers Benefit Level 2 Preventive Services Preventive Services will be covered in compliance with requirements under the Affordable Care Act (ACA). Please refer to the Preventive Services Reference Guide for additional details. Pediatric preventive/health screening examination Covered at 100%; you pay $0. Pediatric immunizations Covered at 100%; you pay $0. Well-baby visits Covered at 100%; you pay $0. Adult preventive/health screening examination Covered at 100%; you pay $0. Adult immunizations required by the ACA to be covered at no cost- sharing Covered at 100%; you pay $0. Screening gynecological exam Covered at 100%; you pay $0. Breast cancer and cervical cancer screening Covered at 100%; you pay $0. Screening services and procedures required by the ACA Covered at 100%; you pay $0. Hospital Services Hospital inpatient You pay $0 after Deductible. You pay 35% after Deductible. Outpatient/Ambulatory surgery You pay $0 after Deductible. You pay 35% after Deductible. Observation stay You pay $0 after Deductible. You pay $0 after Deductible. Maternity - facility services associated with delivery You pay $0 after Deductible. You pay 35% after Deductible. Emergency Services Emergency department You pay $350 Copayment per visit.

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.

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.

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.

UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 7 of 9 Prescription Medication Coverage For additional information on your pharmacy benefits, refer to your Prescription Medication Schedule of Benefits. Tier names describe the most common type(s) of medication (such as brands and generics) within that tier. The Your Choice pharmacy program will apply (mandatory generic). Not subject to Plan Deductible Retail prescription medication • Prescriptions must be dispensed by a participating pharmacy. • 30-day supply. Select Generic Medications Tier You pay $0 Copayment for select generic medications. Preferred Generic Medications Tier You pay $15 Copayment for preferred generic medications. Preferred Brand Medications and Generic Medications (Brand and Generic) Tier You pay $75 Copayment for preferred brand medications and generic medications (brand and generic). Nonpreferred Medications (Brand and Generic) Tier You pay $125 Copayment for nonpreferred medications (brand and generic). 90-day maximum retail supply available for three copayments Specialty prescription medication • Specialty medications are limited to a 30-day supply. See Prescription Medication Schedule of Benefits for additional information. • Most specialty medications must be filled at our contracted specialty pharmacy provider (list available upon request). • Your prescription medication benefit includes coverage of certain specialty medications in the SaveOnSP program. See Prescription Medication Schedule of Benefits for additional information. Specialty Medications (Brand and Generic) Tier You pay $250 Copayment for specialty medications (brand and generic). Oral Chemotherapy Medications (Brand and Generic) You pay $0 Copayment for oral chemotherapy medications (brand and generic). 30-day maximum supply Mail-order prescription medication • A three-month supply (up to 90 days) of medication may be dispensed through the contracted mail-service pharmacy. Select Generic Medications Tier You pay $0 Copayment for select generic medications. Preferred Generic Medications Tier You pay $30 Copayment for preferred generic medications. Preferred Brand Medications and Generic Medications (Brand and Generic) Tier You pay $150 Copayment for preferred brand medications and generic medications (brand and generic). Nonpreferred Medications (Brand and Generic) Tier You pay $250 Copayment for nonpreferred medications (brand and generic).

UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 8 of 9 Prescription Medication Coverage For additional information on your pharmacy benefits, refer to your Prescription Medication Schedule of Benefits. Tier names describe the most common type(s) of medication (such as brands and generics) within that tier. The Your Choice pharmacy program will apply (mandatory generic). Not subject to Plan Deductible 90-day maximum mail-order supply If the brand-name medication is dispensed instead of the generic equivalent, you must pay the Copayment associated with the brand-name medication as well as the price difference between the brand-name medication and the generic medication.

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