Schedule of Benefits UPMC Consumer Advantage Primary Care Provider: 10% Deductible HSA PPO - Premium Network Specialist: 10% after Deductible Deductible: $1,500 / $3,000 Emergency Department: 10% after Deductible Coinsurance: 10% Total Annual Out-of-Pocket: $2,600 / $5,200 Health Savings Plan (Modified) Summary This Schedule of Benefits will be an important part your COC and/or SPD. Criteria may include Prior of your Certificate of Coverage (COC) or your Authorization requirements. Summary Plan Description (SPD). If your plan has an SPD, it is issued by your employer or labor trust Please note that your plan may not cover all of your fund. It is not issued by UPMC Health Plan. It is health care expenses, such as copayments and important that you review and understand your coinsurance. To understand what your plan covers, COC and/or SPD because they describe in detail review your COC and/or SPD. You may also have the services your plan covers. The Schedule of Riders and Amendments that expand or restrict Benefits describes what you pay for those services. your benefits. For Covered Services to be paid at the level If you have any questions about your benefits, or described in your Schedule of Benefits, they must would like to find a Participating Provider near you, be Medically Necessary. visit You can also call UPMC Health Plan Member Services at the phone number on the back of your They must also meet all criteria described in member ID card. For more information on your plan, please refer to the final page of this document. Plan Information Participating Provider Non-Participating Provider Benefit Period Plan Year Primary Care Provider (PCP) Encouraged, but not required Required Pre-Certification and Prior Provider Responsibility Member Responsibility Authorization Requirements If you fail to obtain Authorization for certain services, you may not be eligible for reimbursement under your plan. Please see additional information below. Member Cost Sharing Participating Provider Non-Participating Provider HSA: Health Savings Seed Money $650/Single $1,300/Family (Amount Prorated Based Upon Date of Enrollment) Annual Deductible Individual $1,500 $3,500 Family $3,000 $7,000
Schedule of Benefits UPMC Consumer Advantage Primary Care Provider: 10% Deductible HSA PPO - Premium Network Specialist: 10% after Deductible Deductible: $1,500 / $3,000 Coinsurance: 10% Total Annual Out-of-Pocket: $2,600 / $5,200 Emergency Department: 10% after Deductible Health Savings Plan (Modified) Summary 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 criteria described in your COC and/or SPD. 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 and/or SPD. You may also have Riders and Amendments that expand or restrict your benefits. If you have any questions about your benefits, or would like to find a Participating Provider near you, visit You can also call UPMC Health Plan Member Services at the phone number on the back of your member ID card. For more information on your plan, please refer to the final page of this document. Plan Information Participating Provider Non-Participating Provider Benefit Period Plan Year Primary Care Provider (PCP) Required Encouraged, but not required Pre-Certification and Prior Authorization Requirements Provider Responsibility Member Responsibility If you fail to obtain Authorization for certain services, you may not be eligible for reimbursement under your plan. Please see additional information below. Member Cost Sharing Participating Provider Non-Participating Provider HSA: Health Savings Seed Money (Amount Prorated Based Upon Date of Enrollment) $650/Single $1,300/Family Annual Deductible Individual $1,500 $3,500 Family $3,000 $7,000
2018%20UPMC%20Health%20Savings%20PPO%20Summary%20of%20Plan%20Benefits.docx