Benefit Plan Summaries Effective July 1, 2016

Benefit Plan Summaries
For groups with 2 to 50 employees
Effective July 1, 2016
Network options
UPMC Health Plan offers the following network options for our 2-50 market portfolio.
Erie
Warren
McKean
Tioga
Potter
Crawford
Bradford
Wayne
Forest
Elk
Venango
Mercer
Clarion
Butler
Sullivan
Cameron
Clinton
Clearfield
Centre
Indiana
Mifflin
Cambria
Allegheny
Blair
Westmoreland
Greene
Columbia
Montour
Northumberland
Snyder
Juniata
Dauphin
Lebanon
Fayette
Bedford
Fulton
Franklin
Adams
Carbon
Northampton
Lehigh
Berks
Perry
Cumberland
Somerset
Pike
Monroe
Schuylkill
Huntingdon
Washington
Lackawanna
Luzerne
Union
Armstrong
Beaver
Wyoming
Lycoming
Jefferson
Lawrence
Susquehanna
Lancaster
York
Bucks
Montgomery
Chester
Philadelphia
Delaware
Standard Network
Only employer groups domiciled within the 28 counties in our service area are able to purchase this plan.
Members will be covered for services when they seek care from participating providers within the
UPMC Standard Network.
These include all UPMC-owned facilities and providers in addition to other network facilities.
Erie
Warren
McKean
Tioga
Potter
Crawford
Wayne
Forest
Elk
Venango
Mercer
Clarion
Butler
Indiana
Allegheny
Cambria
Mifflin
Blair
Westmoreland
Snyder
Juniata
Columbia
Montour
Fayette
Somerset
Monroe
Carbon
Northumberland
Dauphin
Perry
Lebanon
Fulton
Franklin
Adams
Lehigh
Berks
Huntingdon
Bedford
Northampton
Schuylkill
Bucks
Montgomery
Cumberland
Washington
Greene
Luzerne
Union
Centre
Armstrong
Pike
Lycoming
Clinton
Clearfield
Beaver
Wyoming
Lackawanna
Sullivan
Cameron
Jefferson
Lawrence
Susquehanna
Bradford
Lancaster
York
Chester
Philadelphia
Delaware
Premium Network
Only employer groups domiciled within the 29 counties in our service area are able to purchase this plan.
Members will be covered for services when they seek care from participating providers within the
UPMC Premium Network.
These include all UPMC-owned facilities and providers in addition to other network facilities.
Medical plan descriptions
UPMC Small Business Advantage
UPMC Small Business Advantage includes plans that
use our Standard and Premium networks.
UPMC Consumer Advantage
UPMC Consumer Advantage® qualifies your employees
for a health savings account (HSA). An HSA is an account
for current and future health care expenses. The employer
may contribute to it along with the employee, but the
employee owns the HSA, keeps it year after year as it
grows, and can take it along when he or she retires or
leaves the company.
UPMC HealthyU
UPMC HealthyU is an innovative plan that rewards your
employees for making healthy choices. By completing
healthy activities, members earn reward dollars in a
health incentive account (HIA) that helps to pay for
their health care expenses. UPMC HealthyU recommends
healthy activities that are uniquely customized to the
individual, each with a reward dollar value to help them
focus on what’s most important to understanding and
improving their own health. Every time they complete
a recommended activity, UPMC Health Plan deposits
those reward dollars into their HIA. The reward
dollars they earn can help pay for out-of-pocket
medical expenses, such as deductible, coinsurance,
and pharmacy copayments.
UPMC Inside Advantage
UPMC Inside Advantage™ is a tiered network plan that
provides your employees with the same type of coverage
as other UPMC Health Plan offerings but with lower
out-of-pocket costs when they receive care at these
select facilities: Grove City Medical Center, Kane
Community Hospital, Warren General Hospital,
UPMC Hamot, UPMC Horizon, UPMC Northwest, and
all other UPMC-owned facilities.
Employers in these counties are eligible: Clarion,
Crawford, Elk, Erie, Forest, McKean, Mercer, Potter,
Venango, and Warren.
Here are descriptions of
each plan type:
EPO
With UPMC Health Plan’s EPO (Exclusive Provider
Organization) health benefit plan, your employees
must receive care from network physicians and facilities
(except in the case of emergency services). Preventive
care is always covered at 100 percent, and your
employees do not need a referral to see a specialist.
PPO
UPMC Health Plan’s PPO (Preferred Provider
Organization) health benefit plan allows your employees
to go out of the network to receive care; however, your
employees’ out-of-pocket expense may be lower if
they receive care from a network physician or facility.
Preventive care is always covered at 100 percent, and
your employees do not need a referral to see a specialist.
HMO
With UPMC Health Plan’s HMO (Health Maintenance
Organization) health benefit plan, your employees must
receive care from network physicians and facilities
(except in the case of emergency services). Your
employees must select a PCP who will help coordinate
their care. A PCP referral is required for most specialty
care. Preventive care is always covered at 100 percent.
Plan details
All plans are SHOP Marketplace eligible.
This document is meant to assist in comparing benefit plans. It is not a contract. If differences exist between this
summary and a group’s contract or a member’s Certificate of Coverage, the contract or Certificate of Coverage will prevail.
UPMC Small Business Advantage
Gold HMO $1,000
$10/$25
$1,000/
Platinum HMO
$20/$40
1
Waived if admitted.
After deductible.
2
$6,000
$2,000
$0/$0
$3002
$300
$40
$40
$3,750/
$7,500
0%
$10
$5
$25
$25
$1751
$02
$02
$30
$30
0%
$20
$10
$40
$40
$1751
$500
$150
$30
$30
$1,500/
$3,000
Lab and Other Services
$1751
Inpatient Hospital Care
$40
Emergency Department
$40
Urgent Care
$5
Specialist Office Visit
$10
E-visit
0%
PCP Visit
$6,850/
$13,700
Coinsurance
Other Imaging
(x-ray, etc.)
$3,000/
Advanced Imaging (PET,
MRI, etc.)
Silver HMO $3,000
$10/$40
Out-of-Pocket Maximum
(I/F)
Deductible (I/F)
Plan Name
Network: Standard
UPMC Inside Advantage™
Inpatient
Hospital Care
Advanced Imaging
(PET, MRI, etc.)
Other Imaging
(x-ray, etc.)
Lab and Other
Services
$40
$40
$1001
$02
$02
$30
$30
Level 2
$6,350/
$12,700
$6,350/
$12,700
35%
$20
$10
$40
$40
$1001
35%2
35%2
$30
$30
Non-Participating
Provider
$6,850/
$13,700
$10,000/
$20,000
40%
40%2
40%2
40%2
40%2
$1001
40%2
40%2
40%2
40%2
Out-of-Pocket
Maximum (I/F)
Urgent Care
$10
Specialist
Office Visit
$20
E-visit
0%
PCP Visit
$6,350/
$12,700
Coinsurance
$5,000/
$10,000
Deductible (I/F)
Level 1
Plan Name
Emergency
Department
Network: Premium
Silver PPO $5,000 $20/$40
Silver PPO $3,000 $20/$40
Level 1
$3,000/
$6,000
$6,850/
$13,700
0%
$20
$10
$40
$40
$1751
$02
$02
$30
$30
Level 2
$6,000/
$12,000
$6,850/
$13,700
35%
$20
$10
$40
$40
$1751
35%2
35%2
$30
$30
Non-Participating
Provider
$6,850/
$13,700
$10,000/
$20,000
40%
40%2
40%2
40%2
40%2
$1751
40%2
40%2
40%2
40%2
Gold PPO $1,250 $20/$40
Level 1
$1,250/
$2,500
$3,000/
$6,000
0%
$20
$10
$40
$40
$1001
$02
$02
$30
$30
Level 2
$2,500/
$5,000
$3,000/
$6,000
35%
$20
$10
$40
$40
$1001
35%2
35%2
$30
$30
Non-Participating
Provider
$5,000/
$10,000
$10,000/
$20,000
40%
40%2
40%2
40%2
40%2
$1001
40%2
40%2
40%2
40%2
Platinum PPO $250 $20/$40
Level 1
$250/
$500
$1,000/
$2,000
0%
$20
$10
$40
$40
$1751
$02
$02
$30
$30
Level 2
$500/
$1,000
$1,000/
$2,000
35%
$20
$10
$40
$40
$1751
35%2
35%2
$30
$30
$6,000/
$12,000
$10,000/
$20,000
40%
40%2
40%2
40%2
40%2
$1751
40%2
40%2
40%2
40%2
Non-Participating
Provider
Waived if admitted.
After deductible.
1
2
$3002
$3002
$40
$40
Silver EPO
$3,000 $10/$40
$3,000/
$6,000
$6,850/
$13,700
0%
$10
$5
$40
$40
$1751
$3002
$3002
$40
$40
Silver EPO
$2,500 $20/$40
$2,500/
$5,000
$6,850/
$13,700
0%
$20
$10
$40
$40
$3001
$02
$300
$40
$40
Silver EPO
$1,750 20%
$1,750/
$3,500
$6,350/
$12,700
20%2
20%2
20%2
20%2
20%2
20%2
20%2
20%2
20%2
20%2
Gold EPO
$1,500 $10/$40
$1,500/
$3,000
$3,500/
$7,000
0%
$10
$5
$40
$40
$1751
$02
$02
$40
$40
Platinum EPO
$500 $20/$40
$500/
$1,000
$1,000/
$2,000
0%
$20
$10
$40
$40
$1001
$02
$125
$20
$20
Platinum EPO
$10/$25
$0/$0
$1,250/
$2,500
0%
$10
$5
$25
$25
$1751
$0
$150
$25
$25
Silver PPO
$5,000 $10/$40
$5,000/
$10,000
$6,850/
$13,700
0%
$10
$5
$40
$40
$1751
$3002
$3002
$40
$40
Gold PPO
$2,000/10%
$20/$40
$2,000/
$4,000
$3,000/
$6,000
10%
$20
$10
$40
$40
$1001
10%2
10%2
$40
$40
Gold PPO
$1,000 $20/$40
$1,000/
$2,000
$3,500/
$7,000
0%
$20
$10
$40
$40
$1751
$02
$02
$40
$40
$0/$0
$1,250/
$2,500
0%
$10
$5
$25
$25
$1751
$0
$150
$25
$25
Platinum PPO
$10/$25
Waived if admitted.
After deductible.
1
2
Lab and Other Services
Other Imaging
(x-ray, etc.)
$1751
Inpatient Hospital Care
$40
Emergency Department
$40
Urgent Care
$5
Specialist Office Visit
$10
E-visit
0%
PCP Visit
$6,850/
$13,700
Coinsurance
$5,000/
$10,000
Deductible (I/F)
Silver EPO
$5,000 $10/$40
Plan Name
Advanced Imaging (PET,
MRI, etc.)
Out-of-Pocket Maximum
(I/F)
Network: Premium
UPMC Consumer Advantage®
$02
$02
$02
$02
Gold HSA PPO
$1,350/10%
$1,350/
$2,700
$3,425/
$6,850
10%2
10%2
10%2
10%2
10%2
10%2
10%2
10%2
10%2
10%2
Gold HSA PPO
$1,400
$1,400/
$2,800
$3,425/
$6,850
0%2
$02
$02
$02
$02
$02
$02
$02
$02
$02
Gold HSA PPO
$1,750
$1,750/
$3,500
$3,425/
$6,850
0%2
$02
$02
$02
$02
$02
$02
$02
$02
$02
Lab and Other Services
Other Imaging (x-ray,
etc.)
$02
Inpatient Hospital Care
$02
Emergency Department
$02
Urgent Care
$02
Specialist Office Visit
$02
E-visit
0%2
PCP Visit
$6,450/
$12,900
Coinsurance
$3,000/
$6,000
Deductible (I/F)
Silver HSA PPO
$3,000
Plan Name
Advanced Imaging (PET,
MRI, etc.)
Out-of-Pocket Maximum
(I/F)
Network: Premium
UPMC HealthyU
10%2
10%2
10%2
10%2
10%2
Platinum HIA PPO
$1,350/10%
$1,350/
$2,700
$2,000/
$4,000
10%2
10%2
10%2
10%2
10%2
10%2
10%2
10%2
10%2
10%2
Waived if admitted.
After deductible.
1
2
Lab and Other Services
Other Imaging (x-ray,
etc.)
10%2
Inpatient Hospital Care
10%2
Emergency Department
10%2
Urgent Care
10%2
Specialist Office Visit
10%2
E-visit
$3,425/
$6,850
PCP Visit
$5,000
Coinsurance
$2,500/
Deductible (I/F)
Gold HIA PPO
$2,500/10%
Plan Name
Advanced Imaging (PET,
MRI, etc.)
Out-of-Pocket Maximum
(I/F)
Network: Premium
Pharmacy
UPMC Health Plan features a pharmacy network of more than 30,000 pharmacies nationwide, including Giant Eagle,
Kmart, Rite Aid, Target, CVS, Walmart, Sam’s Club, and Wegmans (Erie locations). UPMC Health Plan produces the
Advantage Choice formulary for our small market groups. We offer this formulary in searchable format at
www.upmchealthplan.com.
UPMC Health Plan contracts with Express Scripts Inc. to provide your employees with convenient home delivery of
certain maintenance medications. With home delivery, your employees will:
• Receive up to a 90-day supply of most drugs, plus refills.
• Enjoy strict quality and safety controls on all prescriptions.
For more information, visit www.upmchealthplan.com.
UPMC Small Business Advantage and
UPMC Inside Advantage™ Options
During deductible period and after the deductible has been met
Generic
Preferred Brand
Non-Preferred Brand
Specialty
$10
$40
$75
$95
$15
$30
$50
$95
Copayment (generic/preferred/non-preferred and/or specialty)
Retail (30-day supply)
Mail Order (90-day supply)
$10/$40/$75/$95
$20/$80/$150
$15/$30/$50/$95
$30/$60/$100
UPMC HealthyU Options: Integrated
During deductible period
Actual drug cost
After the deductible has been met
Generic
Preferred Brand
Non-Preferred Brand
Specialty
$10
$40
$75
$95
$15
$30
$50
$95
Copayment (generic/preferred/non-preferred and/or specialty) - after the deductible has been met
Retail (30-day supply)
Mail Order (90-day supply)
$10/$40/$75/$95
$20/$80/$150
$15/$30/$50/$95
$30/$60/$100
UPMC Consumer Advantage® Options: Integrated
During deductible period
Actual drug cost
After the deductible has been met
Generic
Preferred Brand
Non-Preferred Brand
Specialty
$10
$15
$40
$75
$95
$30
$50
$95
Copayment (generic/preferred/non-preferred and/or specialty) - after the deductible has been met
Retail (30-day supply)*
Mail Order (90-day supply)*
$10/$40/$75/$95
$20/$80/$150
$15/$30/$50/$95
$30/$60/$100
*If the brand-name drug is dispensed instead of the generic equivalent, member must pay the copayment associated with the brand-name drug as well as
the price difference between the brand-name drug and the generic drug.
Vision plan options
By offering UPMC Vision Advantage or UPMC Vision
Care to your employees, you allow them to receive more
integrated services from UPMC Health Plan. Our Health
Care Concierge team can answer questions about all
benefits purchased through UPMC Health Plan — at one
number or during one online chat session. Plus, your
employees will have access to benefits and information
for all products through MyHealth OnLine, our secure
member website.
UPMC Vision Care
UPMC Vision Advantage
UPMC Vision Advantage offers Basic, Standard,
and Premium plan models, plus a vast network of
vision providers.
Features:
•Members are eligible for discounts on LASIK
procedures at UPMC Eye Center, QualSight, and
TLC Vision.
•Members receive a 20 percent discount on exams
and lenses purchased through a participating
UPMC Vision Advantage provider before their
next eligibility period. Discount does not apply to
contact lenses.
UPMC Vision Care, administered by National Vision
Administrators (NVA), offers Exam Only, Classic, Deluxe,
Prime, Premier, and Elite plan models, plus a national
network of vision providers.
Features:
• Discounts through the NVA EYEESSENTIAL® Plan.
• Mail-order contact lens service.
•Members are eligible for discounts on LASIK
procedures at UPMC Eye Center, QualSight, TLC
Vision, and LASIK Centers of America (LCA).
Product
Frequency
Copayment
Exam Only
24 months
$0
Exam Only 2
24 months
$15
Classic
24 months
$0
Classic 2
24 months
$15
Deluxe*
24 months
$0
Deluxe 2*
24 months
$15
Prime
12 months
$0
Prime 2
12 months
$15
Premier
12 months
$0
Premier 2
12 months
$15
Product
Frequency
Copayment
Basic (exam only)
24 months
$15
Elite
12 months
$0
Standard*
24 months
$15
Elite 2
12 months
$15
Premium
12 months
$15
Standard 2*
24 months
$0
Premium 2
12 months
$0
*For dependents through age 18, frequency for exams and lenses is 12 months.
Out-of-network reimbursement is based on Usual, Customary, and Reasonable as determined by UPMC Vision Advantage and UPMC Vision Care.
For further lens selections, refer to the Additional Lens Options document included in your Welcome Kit.
Pediatric Vision Services are covered in compliance with requirements under the Affordable Care Act (ACA) for members of group plans. Find eligibility and benefit details in your Certificate of Insurance and Pediatric
Vision EHB Rider at MyHealth OnLine or call Member Services.
Essential Health Benefits Rider for Members Under Age 19
Benefit
Examination
Lenses (for glasses)
In-Network1
Out-of-Network2
Frequency
100%
$30
12 months
3
Single Vision
100%
$25
12 months
Bifocal
100%
$35
12 months
Trifocal
100%
$45
12 months
Progressive
100%
$45
12 months
100%
$30
12 months
Frames
Frames
Contact lenses (in lieu of glasses) if deemed medically necessary
Contact lens fitting and follow-up reimbursement is separate from contact lens material.
Contact Lens Fitting
and Follow-up
100%
$35
12 months
Contact Lens Material
100%
$75
12 months
1
In-network reimbursement is based on the percentage of provider reimbursement. The provider is not permitted to bill the member for the difference for any services unless otherwise stated. The provider may charge
the member a copayment for optional lenses and treatments as described below.
Out-of-network reimbursement is based on Usual, Customary, and Reasonable rates as determined by UPMC Vision Advantage.
2
Lens reimbursement includes reimbursements for polycarbonate lenses.
3
Members are eligible for a 20% discount on additional examinations, frames, and lenses for glasses received from a participating provider prior to their next eligibility period. The 20% discount does not apply to
contact lenses.
UPMC Vision Advantage members are eligible for discounts on LASIK surgery when it is received by one of the following preferred providers: UPMC Eye Center, TLC Vision, and QualSight.
Members may purchase elective, nonmedical contacts (including evaluation and fitting) at their own expense. Participating vision providers are to discount the contact lens evaluation and fitting by 20%.
Discount does not apply to contact lens material.
Optional lenses and treatments are available in-network only for
additional copayment and may be billed by the provider.
Optional Lenses and Treatments
Copayment
Anti-Reflective Coating
$20
Hi-Index Lenses
$25
Tint Photochromatic
$25
Polarized Lenses
$20
Premium Progressives
$90
UPMC Dental Advantage
UPMC Dental Advantage
Discount Dental Program
UPMC Dental Advantage offers Basic, Standard, and
Premium plan models, plus a vast network of dentists.
The plans are designed to encourage regular preventive
care and foster open communication between members
and dentists regarding recommended treatment plans.
UPMC Dental Advantage offers a Discount Dental Plan
to all new and current employer groups, either as a
standalone plan option or as an added benefit to the
existing Basic plan offerings. Employees who choose to
enroll in the standalone Discount Dental Plan will receive
a 20 percent discount on all eligible Class I, II, and III
services when visiting a participating provider. Members
enrolled in a UPMC Dental Advantage Basic plan are
eligible for a 20 percent discount on eligible Class II and
Class III services received by a participating provider.
The discount does not apply to orthodontic or cosmetic
services. Please review plan documents for
additional information.
Features:
•Prior authorization is not required for
major services.
•Enhanced benefits include one additional cleaning
for members who are pregnant during
the course of pregnancy; increased coverage for
nonsurgical periodontal treatment, including topical
application of fluoride for adults with a history of
surgical periodontal treatment; and coverage for
microbial tests and brush biopsies.
Features:
• 2
0 percent discount is applied to the provider’s usual
and customary charges.
• Claims do not need to be submitted for the
discount plan.
• ID cards are not required.
• The UPMC Dental Advantage Discount Dental Plan
may not be used in conjunction with other insurance.
Plan In-Network Covered
Amount/Class I/Class II/
Class III/Deductible/
Plan Year Maximum/
Ortho Lifetime Maximum
Service Class
Class I
Class II
Deductible
Class III
$0
$50
Annual Maximum
$75
$1,000
$1,500
Ortho
Coverage
$2,000
Yes
No
Ortho
Lifetime
Maximum
Out-ofNetwork
Coverage
$1,000
Basic
ü
Basic 100/0/0/$01
1
ü
1
ü
Basic 100/0/0/$50
Basic 100/0/0/$75
ü
ü
ü
ü
80/0/0
ü
80/0/0
ü
80/0/0
Standard
Standard 100/50/50/$0/
$1,500/No Ortho
ü
ü
ü
ü
ü
Standard 100/50/50/$0/
$1,500/Ortho/$1,000
ü
ü
ü
ü
ü
Standard 100/50/50/$75/
$2,000/No Ortho
ü
ü
ü
ü
80/40/20
ü
ü
ü
ü
ü
80/40/20
80/40/20
Premium
Premium 100/80/50/$0/
$1,500/No Ortho
ü
ü
ü
ü
ü
Premium 100/80/50/$0/
$1,500/Ortho/$1,000
ü
ü
ü
ü
ü
Premium 100/70/50/$0/
$1,000/No Ortho
ü
ü
ü
ü
Premium 100/70/50/$50/
$1,000/No Ortho
ü
ü
ü
Premium 100/70/50/$0/
$1,500/No Ortho
ü
ü
ü
Premium 100/70/50/$50/
$1,500/No Ortho
ü
ü
ü
ü
ü
ü
ü
ü
80/60/40
ü
80/60/40
ü
ü
80/40/20
ü
ü
80/40/20
ü
ü
80/40/20
ü
ü
80/40/20
A 20% discount applies to non-covered Class II and Class III services when received from a participating provider. Discount does not apply to orthodontic or cosmetic services.
1
Essential Health Benefits Rider for Members Under Age 19
UPMC Dental Advantage will cover the services set forth below, which are related to the dental benefits provided with UPMC Dental Advantage
policies and procedures. If the terms and conditions set forth in other dental benefit materials you have been provided conflict with those set
forth in this plan document, the terms and conditions of this plan document control.
Plan Year Deductible: Class I (Out-of-Network Only),
Class II, Class III
Class I: Diagnostic/Preventive
Exams and Prophylaxis
Bitewings
Complete Series and Panoramic Films
Topical Fluoride
Periodontal Scaling/Root Planing
Sealants
In-Network
Out-of-Network1
$50 Individual/
$150 Eligible Dependents (2+)
$75 Individual/$200 Eligible
Dependents (2+)
100%
90%
Payable for two services in a benefit year
Payable for two services in a benefit year up to age 14;
one service in a benefit year for 14+ years
Payable for one service in a 36-month period and is not
covered for members under the age of 5
Payable to age 19 for two services in a benefit year
Payable for one service every 24 months
Payable to age 14 for one service per tooth (molar) every 36 months
Space Maintainers
Class II: Basic Services
Payable to age 19
70%
60%
Amalgam and Composite Fillings
Payable
Pulpal Therapy/Anterior and Posterior
Payable
Endodontic Therapy
(Including treatment plan, clinical procedures, and follow-up care)
Payable
Extractions and Oral Surgery
Payable
Class III: Major Services
50%
40%
Crowns
Payable for one service per tooth in a 60-month period
Inlay/Onlay — metallic/porcelain/resin up to 4 surfaces
Payable for one service per tooth in a 60-month period
Implants
Payable for one service per tooth, per lifetime
Prosthodontics
Dentures Complete and Partial
Prefabricated Stainless Steel Crown/Primary Tooth
Orthodontics: Subject to Medical Deductible2
Payable
Payable for one service in a 60-month period
Payable for one service per tooth in a 60-month period
50%
Not covered
The services above are not all-inclusive — they include only the most common dental procedures in a class or service grouping. UPMC Dental
Advantage encourages, but does not require, members to seek predetermination for major services, such as crowns and bridges, to obtain the
most accurate payment estimate. Additional plan information can be found in the Certificate of Insurance.
Copayments, coinsurance, and deductibles for dental benefits apply toward satisfaction of the combined out-of-pocket maximum specified in
your Medical Schedule of Benefits. Services are covered at 100% after the out-of-pocket maximum is satisfied.
1
Out-of-network reimbursement is based on Usual, Customary, and Reasonable charges as determined by UPMC Dental Advantage. The
member is responsible for the difference between those charges and the provider’s fee.
Orthodontic coverage is subject to the Medical Deductible, which can be found in the Medical Schedule of Benefits. Orthodontic services are
payable only when deemed medically necessary by the plan.
2
Additional plan information can be found in the Certificate of Insurance.
This Rider may expand or restrict the benefits set forth in your UPMC Dental Advantage Pediatric Dental Certificate of Insurance. See the
Certificate of Insurance for the details of the terms of coverage for your health benefit plan. If the terms of your Certificate of Insurance conflict
with this Rider, the terms of this Rider prevail.
Value-added benefits
and services
Health coaching
UPMC MyHealth 24/7 Nurse Line
Your employees can speak to a registered nurse anytime,
day or night, when they have a health question or medical
concern by calling the UPMC 24/7 MyHealth Nurse Line.
We offer lifestyle improvement and condition
management programs at no cost to your employees.
Your employees work one-on-one with a health coach
over the phone.
Programs include:
•
MyHealth Less Stress
•
MyHealth Weigh to Wellness®
•
MyHealth Eating Well
•
MyHealth Step Up to Wellness®
•
MyHealth Ready to Quit®
MyHealth OnLine
MyHealth OnLine is a secure website that employees
can personalize for their goals and needs. Here, they
can take the MyHealth Questionnaire to find out what
their health risks are. In return, they get a list of activities
recommended just for them to reduce their risk for
chronic disease, feel better, and meet their goals. They
can also research health conditions, access treatment
cost and comparison tools, see their claims and coverage
information, and more.
UPMC AnywhereCare
With UPMC AnywhereCare, employees can get
treatment for colds and flu, strep throat, poison ivy,
and other nonemergency conditions right from their
computer. They receive a care plan and prescription
(if needed), usually within 30 minutes. The cost is
less than or the same as a visit with their primary care
physician. Your employees can also connect with leading
dermatologists and get treatment for skin conditions and
disorders. These services are available 24/7.
Member must be in Pennsylvania or Maryland during the
online visit. For e-visits with a dermatologist, member must
be in Pennsylvania during the online visit.
The information provided for these benefits is for informational purposes
only. Actual benefits are subject to the terms and conditions of the
certificate of coverage.
Health Care Concierge
Your employees receive fast, personal service from our
UPMC Health Plan Health Care Concierge team. Our
customer service team strives to resolve questions and
concerns in one phone call.
LifeSolutions employee assistance program
Workplace, personal, and family issues can be distracting
to employees, resulting in lost productivity and missed
work. LifeSolutions® offers a host of resources to help
your employees feel better and stay focused. Benefits
include coaching and counseling over the phone and
numerous online resources, such as financial calculators
and self-assessments.
LifeSolutions is included as part of the UPMC Small
Business Advantage plan. Other standalone program
options are available.
Ancillary services
UPMC COBRA Advantage
We administer monthly billing and collection from the
COBRA participant, monitor nonpayment, and provide
late payment notices. We also handle open enrollment
mailing, carrier updates, and other vital communications.
Retiree billing
Our Web-based system allows you to coordinate
enrollment, billing, and reimbursement of retiree
benefits. Electronic payment of monthly premiums
eliminates the need to write checks. This information
can be accessed 24/7.
The Affordable Care Act
Note: To remain in compliance with the Affordable Care
Act (ACA), UPMC Health Plan has incorporated these
factors into our plan offerings for employer groups
within our small market portfolio:
For children ages 0 to 20 years, the age-adjusted
premiums must be the same for all individuals.
Actuarial Value
The premium charged at renewal or point of sale remains
as sold until the next renewal date, when rates will be
adjusted based on age bracket changes.
The ACA requires that all new small market products
meet specific actuarial values, which are the percentage
of medical expenses, on average, paid by the insurer.
The ACA uses metal levels of Platinum, Gold, Silver, and
Bronze to correspond with actuarial values of 90%, 80%,
70%, and 60%, respectively. Issuers must offer plans
within +/- 2% of these values.
Community Rating
Under community rating, premiums may vary based only
upon the following four factors:
1.Rating area — There are nine rating regions in the
state. A list of these regions by county is available
from the Centers for Medicare and Medicaid
Services.
2. Single vs. family coverage — Premiums for family
coverage will be based on premiums for each
individual in a family. Under this approach, we will
add the individual rate for each family member to
arrive at a family premium. All family members age
21 and older will be added. However, only the three
oldest covered children under age 21 will be counted.
3. Tobacco use — Premiums charged for tobacco users
may be up to 1.5 times higher than premiums charged
for non-tobacco users.
4. Age — Premiums based on age will work like this:
Adults (ages 21-63) may have different premiums
based on age. But the difference may not be more
than three-to-one. That is, the premium charged to
the oldest adult may not be more than three times
higher than the premium charged to the youngest
adult (age 21 or older).
For adults 64 years of age or older, age-adjusted
premiums must be the same for all individuals.
Essential Health Benefits (EHBs)
EHBs are a specific set of health benefits, items, and
services that must be covered by health plans in the
individual and small group markets. These benefits
include, among other things, pediatric dental and vision
services.
Our pediatric dental and vision services will be
administered by UPMC Dental Advantage and UPMC
Vision Advantage. UPMC Health Plan has embedded
these benefits into its medical plans, which makes it
easy for employers to administer and comply with ACA
mandates. Please refer to the Schedules of Benefits,
which define the coverage for dependents.
Please note that if a dependent turns 19 years of age
during a plan year, that dependent will continue to
have Essential Health Benefits coverage until the end of
the plan year.
U.S. Steel Tower, 600 Grant Street
Pittsburgh, PA 15219
www.upmchealthplan.com
Copyright 2016 UPMC Health Plan Inc. All rights reserved.
UPMCHP BPS 2-50 EFF 7-1-16 PROD KICKOFF 16SAM0111 (MJA) 3/31/16 1.5M CDI