UPMC VirtualCare + Select Network + Bronze $4,400 + EPO – EPO

Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $80 copay
Specialist visit: $100 copay after deductible
Urgent care visit: $100 copay after deductible

SKU: 16322PA0050139 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type EPO
Deductible $4,400 per person $4,400 per person
Out-of-pocket max $9,450 per person $18,900 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit $80 copay
Specialist visit $100 copay after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $100 copay after deductible
Emergency room 40% after deductible
Ambulance 40% after deductible
Hospital stay (facility) 40% after deductible
Hospital stay (physician) 40% after deductible
Outpatient procedure (facility) 40% after deductible
Outpatient procedure (physician) 40% after deductible
Physical rehabilitation 40% after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay 40% after deductible

Pharmacy, Drugs, and Medication

Generic $30 copay
Brand 30% after deductible
Non-preferred Brand 50% after deductible
Specialty 50% after deductible, up to $500 copay, 50% after deductible, up to $500

Lab Tests and Diagnostic Procedures

X-rays 40% after deductible
Imaging (CT/PET/MRI) 40% after deductible
Blood work 40% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services 40% after deductible
Psychiatric hospital stay 40% after deductible

Health Plan Provider Information