UPMC Advantage + Partner Network + Silver $4,000 + EPO + HSA Eligible – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: No charge after deductible
Specialist visit: 30% after deductible
Urgent care visit: 30% after deductible
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | N/A N/A |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | No charge after deductible |
| Specialist visit | 30% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 30% after deductible |
| Emergency room | 30% after deductible |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | 30% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay after deductible |
| Brand | $50 copay after deductible |
| Non-preferred Brand | $100 copay after deductible |
| Specialty | 50% after deductible, up to $500 copay, 50% after deductible, up to $500 |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | 30% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge after deductible |
| Psychiatric hospital stay | 30% after deductible |
