Coverage Comparison Chart - Human Resources - Carnegie Mellon University

Coverage Comparison Chart

Plan Feature PPO 1
PPO 2 PPO 3

High Deductible
PPO w/ HRA

HMO Comprehensive
Carrier Options
Highmark and UPMC
Highmark and UPMC
Highmark and UPMC
Highmark and UPMC
HealthAmerica
Highmark
Annual Deductible (Individual/Family)

In-Network Providers

$250/$500

$250 /$500

$500/$1000

$1000/$2000

$0/$0

 

$500/$1000

Out-of Network Providers $500/$1000 $500/$1000 $1000/$2000 $2000/$4000 Not Covered
Annual Out-of-Pocket Maximum (Individual/Family)

In-Network Providers

$1,000/$2,000

$2,000/$4,000

$3,500 / $7,000

$4,500 / $9,000

$1,000/$2,000

 

$2,500/$5,000

Out-of-Network Providers $3,000/$6,000 $3,000/$6,000 $4,500 / $9,000 Unlimited Not Covered
Plan Coinsurance Responsibility
In-Network Providers
100% 80% 80% 80% 100% 80%
Out-of-Network Providers
60% of UCR
60% of UCR 60% of UCR 60% of UCR
Not Covered
80% of UCR
Carnegie Mellon HRA Contribution
Individual / Family N/A N/A N/A $250 / $500 N/A N/A

Physician Visit (Copay/Coinsurance)

In-Network
Primary Care Office Visit $20 $20 $20 80% $15 80%
Specialist Office Visit $35
$35 $35 80% $30
80%
Preventive Care (per schedule) $0 $0 $0 $0 $0 $0
ER Visit (waived if admitted) $50 $50 $50 80% $50
80%
Out-of-Network
Primary and Specialist Office Visit 60% of UCR 60% of UCR 60% of UCR 60% of UCR Not Covered
80% of UCR
Preventive Care 60% of UCR 60% of UCR 60% of UCR 60% of UCR Not Covered
80% of UCR
ER Visit (waived if admitted) $50 $50 $50 80% $50 80% of UCR
Primary Care Physician Required? No No No No Yes No