Summary Guide - Human Resources - University of Pittsburgh

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Upmc Medical Plans (continued)
Inpatient and Outpatient Facility Services
Member services: 1-888-499-6885
www.upmchealthplan.com
Medical Insurance Plans Comparative Summary of Key Provisions
How the Plan Works
Basic Plan Features
and Explanations
Panther Gold with Advantage
Network (HMO)
Panther Advocate
(New PPO/HIA)
Panther Premier (PPO) Panther Plus (PPO) Panther Basic (PPO)
Requires selection of a network doctor—
primary care physician (PCP) a May select any doctor b May select any doctor b May select any doctor b May select any doctor b
No coverage provided outside the UPMC Health
Plan network, except in the case of an emergency
UPMC
Advantage
Network:
Higher Benefit–UPMC
Owned Facilities c
UPMC
Affiliated
Network:
Lower Benefit–No
Out of Network
Benefit Coverage d
Provides coverage to any
doctor or hospital
FULL UPMC
IN NETWORK
OUT OF
NETWORK
Provides coverage to any
doctor or hospital
FULL UPMC
IN NETWORK
OUT OF
NETWORK
Provides coverage to any
doctor or hospital
FULL UPMC
IN NETWORK
OUT OF
NETWORK
Provides coverage to any
doctor or hospital
FULL UPMC
IN NETWORK
OUT OF
NETWORK
Deductible n/a $300/$600 $750 / $1,500 $1,500 / $3,000 $500 / $1,000 $1,000 / $2,000 $750 / $1,500 $1,500 / $3,000 $1,000 / $2,000 $2,000 / $4,000
Coinsurance n/a 20% 10% 30% 10% 30% 20% 40% 30% 50%
Plan Responsibility 100% 80% 90% 70% 90% 70% 80% 60% 70% 50%
Out of Pocket Max -INCLUDES
Deductible and Coinsurance
Amounts
Copayment
n/a $1,800 / $3,600 $1,250 / $2,500 $2,500 / $5,000 $1,500 / $3,000 $3,000 / $6,000 $2,250 / $4,500 $4,500 / $9,000 $5,000 / $10,000 $10,000 / $20,000
Copayments for various
services are listed below
n/a
n/a
Health Incentive Account (HIA)
$500 / $1,000
Earning Maximum
Reduced Deductible if
n/a
n/a n/a n/a n/a n/a n/a
100% HIA Earned Before Claims
$250 / $500 $1,000 / $2,000
n/a
are Incurred
Reduced Out of Pocket Max
if 100% HIA Earned Before
$750 / $1,500 $2,000 / $4,000
Claims are Incurred †
Health Plan Payments for Services are Noted Below; Copayments for the HMO and Deductibles and Coinsurance for PPO the Plans Apply as Stated Above
Inpatient Hospital Services
max. of 2 copayments per plan year
Outpatient Facility Services
and Observations
(e.g., same day surgery)
max. of 4 copayments per plan year
100% after
$500 copayment
100% after
$200 copayment
a b
To locate participating physicians and
facilities in the UPMC network if you reside in
Western Pennsylvania:
1. Go to www.upmchealthplan.com
2. Click on “Find a Doctor”
»»
To locate physicians for the Panther Gold plan, click on
“UPMC Advantage”
»»
To locate physicians for any of the PPO plans, click on
“UPMC Health Plan PPO”
b
To locate physicians and facilities if you reside
outside of Western Pennsylvania:
1. Go to www.upmchealthplan.com
2. Click on “Find a Doctor”
3. Click on “Out of Area Members Find a Doctor” to locate other
contracted networks of UPMC Health Plan
For Ohio residents, click on “The Ohio Portion of the Map”
»»
For all others, click on “The Out-of-Area Portion of the Map”
c
UPMC Advantage Network
Listed below is a sampling of the Advantage Network hospitals. To locate the full
listing of Advantage Network hospitals, please refer to the instructions above.
»»
Children’s Hospital of
UPMC Northwest
Pittsburgh of UPMC
UPMC Presbyterian
»»
Conemaugh Valley »»
UPMC Shadyside
Memorial Hospital
»»
Magee-Womens Hospital
of UPMC
»»
Memorial Medical Center
Downtown (Johnstown)
»»
Western Psychiatric
Institute and Clinic
»»
Windber Medical Center
d
Other Affiliated UPMC Facilities
Listed below is a sampling of the other affiliated UPMC facilities. To locate the full
listing of facilities, please refer to the instructions above.
Butler Memorial Hospital »»
St. Clair Memorial
»»
Jefferson Regional
Medical Center
Hospital
»»
The Washington Hospital
† HIA credits automatically apply to prescription copays at the pharmacy
however copays are not counted toward the Out of Pocket maximum.
Diagnostic Services:
Basic (e.g., x-ray, sonograms)
max. of 4 copayments per plan year
High-tech (e.g., MRI, CT, PET)
max. of 4 copayments per plan year
Medical Therapy Services
(e.g., dialysis, radiation, chemo)
100% after
$20 copayment
100% after
$80 copayment
100%
80% 90% 70% 90% 70% 80% 60% 70% 50%
*The Summary of Benefits and Coverage (SBC) and uniform glossary
of terms, developed by UPMC Health Plan as mandated by the Patient
Protection and Affordable Care Act (PPACA) are available online at
www.hr.pitt.edu/benefits. Hard copies are also available by contacting
the Benefits Department at 412-624-8160.
Physical, Speech, and
Occupational Therapy
(Limit 60 visits/plan year all therapies
combined)
100% after
$25 copayment