Carnegie Mellon University

Medical Coverage Comparison

Plan Feature

PPO Option 1

PPO Option 2


High Deductible
PPO with HSA

Carrier Options Highmark, UPMC Highmark, UPMC Highmark/UPMC Highmark, UPMC
Annual Deductible (Individual/Family)1
In-Network Providers $250/$500 $500/$1,000 $0/$0 $1,600/$3,200
Out-of Network Providers $500/$1,000 $750/$1,500 Not covered $3,200/$6,400
Annual Out-of-Pocket Maximum (Individual/Family)2
In-Network Providers $1,500/$3,000 $3,000/$6,000 $1,000/$2,000 $3,200/$6,400
Out-of-Network Providers $3,000/$6,000 $3,500/$7,000 Not covered $6,400/$12,800
Plan Coinsurance Responsibility (After deductible)
In-Network Providers 90% 75% 100% 80%
Out-of-Network Providers 60% of UCR3 60% of UCR3 Not covered 60% of UCR3
Physician Visit (Copay/Coinsurance)
Primary Care Office Visit $20 $25 $20 20%4
Specialist Office Visit $35 $40 $35 20%4
Preventive Care (per schedule)1 $0 $0 $0 $0
Emergency Room Visit (waived if admitted) $100 $100 $100 20%4
Primary and Specialist Office Visit 60% of UCR3 60% of UCR3 Not covered 60% of UCR3
Preventive Care 60% of UCR3 60% of UCR3 Not covered 60% of UCR3
Emergency Room Visit (waived if admitted) $100 $100 $100 20%4

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.

4 Member coinsurance responsibility after the deductible is met.