UPMC First Care + Premium Network + Gold $0 + PPO – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $7,500 per person $15,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $300 copay |
| Ambulance | 30% coinsurance |
| Hospital stay (facility) | $500 copay |
| Hospital stay (physician) | $250 copay |
| Outpatient procedure (facility) | $250 copay |
| Outpatient procedure (physician) | $250 copay |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $500 copay |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $50 copay |
| Non-preferred Brand | $100 copay |
| Specialty | 50%, up to $500 copay, 50%, up to $500 coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance |
| Imaging (CT/PET/MRI) | $400 copay |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | $500 copay |
