Coverage Comparison Chart-HR @ Carnegie Mellon University - Carnegie Mellon University

Coverage Comparison Chart

View a PDF version of the Coverage Comparison Chart [pdf].

Plan Feature PPO Option 1
PPO option 2 High Deductible
PPO w/ HRA

HMO

Carrier Options
Highmark, UPMC
Highmark, UPMC
Highmark, UPMC HealthAmerica
Annual Deductible (Individual/Family)

In-Network Providers

$250/$500

$350 /$700

$1,000/$2,000

$0/$0

Out-of Network Providers $500/$1,000 $500/$1,000 $2,000/$4,000 Not covered
Annual Out-of-Pocket Maximum (Individual/Family)1,2

In-Network Providers

$1,500/$3,000

$2,500/$5,000

$4,500 / $9,000

$1,000 / $2,000

Out-of-Network Providers $3,000/$6,000 $3,000/$6,000 Unlimited Not covered
Plan Coinsurance Responsibility (After deductible)
In-Network Providers
90% 80% 80% 100%
Out-of-Network Providers
60% of UCR3
60% of UCR3 60% of UCR3 Not covered
Carnegie Mellon HRA Contribution
Individual / Family N/A N/A $250 / $500 N/A

Physician Visit (Copay/Coinsurance)

In-Network
Primary Care Office Visit $20 $20 80% $15
Specialist Office Visit $35
$35 80% $30
Preventive Care (per schedule)1 $0 $0 $0 $0
ER Visit (waived if admitted) $100 $100 80% $50
Out-of-Network
Primary and Specialist Office Visit 60% of UCR3 60% of UCR3 60% of UCR3 Not covered
Preventive Care 60% of UCR3 60% of UCR3 60% of UCR3 Not covered
ER Visit (waived if admitted) $100 $100 80% $50
Primary Care Physician Required? No No No Yes
1 The deductible and copay do not apply when adult or pediatric preventive care is performed according to the plan's schedule. If tests or lab work that are not on the plan's preventive care schedules are performed, the individual's portion of the cost will be applied to the deductible. For more information, see Preventive Health Care.
2 The deductible and out-of-pocket maximum are tracked separately for in- and out-of-network services under all plans. The annual out-of-pocket maximum includes deductible, copays, and coinsurance.
3 UCR = usual, customary, and reasonable charges the carrier has established for medical services. Out-of-network providers may bill you for their charges in excess of the UCR. Expenses in excess of the UCR do not count toward the out-of-pocket maximum.