UPMC Health Plan

UPMC Advantage Gold HSA $3,100/$0 - Premium Network

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Plan Overview

Medical Deductible	Individual: $3,100 Family: $6,200 Per Person: $3,100
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $4,000 Family: $8,000 Per Person: $4,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: No Charge after deductible
Specialist	Standard: 10% Coinsurance after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: $50 Copay after deductible
Non Preferred Brand Drugs	Standard: $100 Copay after deductible
Generic Drugs	Standard: $25 Copay after deductible
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 10% Coinsurance after deductible
Inpatient Services	Standard: 10% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: 10% Coinsurance after deductible

Rates shown are determined based on age, geographic region, and tobacco use and are dependent on information provided by or on behalf of the consumer. If changes are made to the determining factors, rates will change accordingly. UPMC Health Plan is not responsible for typographical errors, errors of fact, or any other error resulting from information provided by or on behalf of consumer. UPMC Health Plan is not responsible for the calculation of any financial assistance, including advance payments of the premium tax credit, provided through the Federally Facilitated Marketplace. This managed care plan may not cover all of your health care expenses and all benefits are subject to the terms and conditions set forth in your policy. Read your contract/policy carefully to determine which health care services are covered.

Nondiscrimination statement

UPMC Health Plan¹ complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

¹UPMC Health Plan is the marketing name used to refer to the following companies, which are licensed to issue individual and group health insurance products or which provide third party administration services for group health plans: UPMC Health Network Inc., UPMC Health Options Inc., UPMC Health Coverage Inc., UPMC Health Plan Inc., UPMC Health Benefits Inc., UPMC for You Inc., and/or UPMC Benefit Management Services Inc.

Translation Services"

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