Medical Coverage Comparison
|
Plan Feature |
PPO Option 1 |
PPO Option 2 |
EPO/HMO |
High Deductible |
| 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) | ||||
| In-Network | ||||
| 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 |
| Out-of-Network | ||||
| 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.