Benefit Plan Summaries - USI Affinity · Benefit Plan Summaries ... Indiana Jefferson Juniata...

Benefit Plan SummariesFor groups with 2 to 50 employees

Effective January 1, 2017

Last Updated: November 15, 2016

UPMC Standard NetworkOnly employer groups domiciled within the 28 counties in our service area are able to purchase plans that include the UPMC Standard Network.

The UPMC Standard Network includes all UPMC-owned hospitals, providers, and facilities in addition to other community-based hospitals, providers, and facilities. Members will be covered for services when they seek care from participating providers within the UPMC Standard Network.

Adams

Allegheny

Armstrong

Beaver

Bedford

BerksBlair

Bradford

Bucks

Butler

Cambria

Cameron

CarbonCentre

Chester

Clarion

Clearfield

Clinton

Columbia

Crawford

Cumberland

Dauphin

Delaware

Elk

Erie

Fayette

Forest

FranklinFultonGreene

Huntingdon

Indiana

Jefferson

Juniata

Lackawanna

Lancaster

Lebanon

Lehigh

Luzerne

Lycoming

McKean

Mercer

Mifflin

Monroe

Montgomery

Montour

NorthamptonNorthumberland

Perry

Philadelphia

Pike

Potter

SchuylkillSnyder

Somerset

Sullivan

SusquehannaTioga

Union

Venango

Warren

Washington

Wayne

Westmoreland

Wyoming

kroY kroY

Lawrence

Network optionsUPMC Health Plan offers the following network options for our 2-50 market portfolio.

Allegheny

Armstrong

Beaver

Bedford

BerksBlair

Bradford

Bucks

Butler

Cambria

Cameron

CarbonCentre

Chester

Clarion

Clearfield

Clinton

Columbia

Crawford

Cumberland

Dauphin

Delaware

Elk

Erie

Fayette

Forest

FranklinFulton

Greene

Huntingdon

Indiana

Jefferson

Juniata

Lackawanna

Lancaster

Lawrence

Lebanon

Lehigh

Luzerne

Lycoming

McKean

Mercer

Mifflin

Monroe

Montgomery

Montour

NorthamptonNorthumberland

Perry

Philadelphia

Pike

Potter

SchuylkillSnyder

Somerset

Sullivan

SusquehannaTioga

Union

Venango

Warren

Washington

Wayne

Westmoreland

Wyoming

kroY kroYAdams

UPMC Premium NetworkOnly employer groups domiciled within the 29 counties in our service area are able to purchase plans that include the UPMC Premium Network.

The UPMC Premium Network includes all UPMC-owned hospitals, providers, and facilities in addition to other community-based hospitals, providers, and facilities. Members will be covered for services when they seek care from participating providers within the UPMC Premium Network.

UPMC Small Business AdvantageWith that in mind, we created UPMC Small Business Advantage, a unique portfolio of medical plan options for companies with less than 50 employees. UPMC Small Business Advantage comes standard with every small group plan. This unique plan design gives smaller businesses the opportunity to offer their employees a robust benefit package that addresses their total health and well-being.

LifeSolutions® employee assistance program is included with UPMC Small Business Advantage plans. Your employees can have three over-the-phone sessions per issue, and managers can receive consulting services. All employees are granted access to the WorkLife resource center, which contains online materials on a variety of topics.

UPMC Small Business Advantage plans also come with vision and dental discounts, including discounts on LASIK procedures and hearing aids.

UPMC Small Business Advantage plans can include the UPMC Standard Network or UPMC Premium Network. UPMC Small Business Advantage is available in EPO, PPO, and HMO plan types.

UPMC MyCare AdvantageUPMC MyCare Advantage is a tiered benefit plan that focuses on patient-centered care to improve the health outcomes of its members. It offers the same type of coverage as other UPMC Health Plan products, but maximizes in-network savings with lower cost sharing when members receive care from level 1 providers, which includes all UPMC-owned facilities and practices. Level 1 providers also include these valued community-based partners: Excela Health — Frick, Latrobe, Westmoreland; Grove City Medical Center; Heritage Valley Health System — Beaver and Sewickley; Jameson Hospital; Monongahela Valley Hospital; St. Clair Hospital; and Washington Health System Greene and Washington Hospital.

Employers with two or more employees in these counties are eligible: Allegheny, Beaver, Bedford, Blair, Butler, Erie, Lawrence, Mercer, Venango, Washington, and Westmoreland. UPMC MyCare Advantage is available in the PPO plan type.

Medical plan descriptionsWe understand that employers of all sizes want to control health care costs while keeping their employees healthy.

UPMC HealthyUUPMC HealthyU is an innovative plan that rewards members for making healthy choices. By completing healthy activities, members earn reward dollars in a health incentive account (HIA) that helps 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 encourage members to focus on what’s most important in understanding and improving their own health. UPMC Health Plan deposits reward dollars into the member’s HIA every time he or she completes a recommended activity. The reward dollars then help pay for out-of-pocket medical expenses, such as deductible, coinsurance, and pharmacy copayments. UPMC HealthyU is available in the PPO plan type.

UPMC Consumer AdvantageUPMC Consumer Advantage® offers many plan options for groups looking to add a qualified high-deductible health plan (QHDHP) to their medical plan offerings. A QHDHP qualifies members for a health savings account or flexible spending account. These accounts help them pay for current and future health care expenses. Depending on the account selected, the employer and employee may contribute to the account, and employees may be able to take the funds with them at retirement or when they change employers. UPMC Consumer Advantage is available in the PPO plan type.

Here are descriptions of each plan type:EPOWith UPMC Health Plan’s EPO (exclusive provider organization) health benefit plan, members must receive care from network physicians and facilities (except in the case of emergency services). Preventive care is always covered at 100 percent, and members do not need a referral to see a specialist.

PPOUPMC Health Plan’s PPO (preferred provider organization) health benefit plan allows members to go out of the network to receive care; however, out-of-pocket expenses may be lower if they receive care from a network physician or facility. Preventive care is always covered at 100 percent, and members do not need a referral to see a specialist.

HMOWith UPMC Health Plan’s HMO (health maintenance organization) health benefit plan, members must receive care from network physicians and facilities (except in the case of emergency services). Members must select a primary care physician (PCP) to help coordinate their care. A PCP referral is required for most specialty care. Preventive care is always covered at 100 percent.

Plan detailsAll plans are SHOP Marketplace eligible.

Plan Type Plan Name Deductible (Individual/Family)

Out-of-Pocket Maximum

(Individual/Family)Network Coinsurance PCP Visit Specialist

Visit

UPMC AnywhereCare Visit

(PCP/Specialist)

Urgent Care Facility

Emergency Department

Inpatient Hospital Care

Advanced Imaging (PET, MRI, etc.)

Other Imaging (x-ray, etc.)

Lab and Other Services

EPO

Platinum EPO $10/$25 $0/$0 $1,250/$2,500 Premium $0 $10 $25 $5/$25 $25 $1751 $0 $150 $25 $25

Platinum EPO $500 $20/$40 $500/$1,000 $1,000/$2,000 Premium $02 $20 $40 $10/$40 $40 $1001 $02 $125 $20 $20

Gold EPO $1,000 $20/$45 $1,000/$2,000 $3,500/$7,000 Premium $02 $20 $45 $10/$45 $45 $1751 $02 $02 $45 $45

Gold EPO $1,500 $10/$40 $1,500/$3,000 $3,500/$7,000 Premium $02 $10 $40 $5/$40 $40 $1751 $02 $02 $40 $40

Gold EPO $2,000 $20/$40 $2,000/$4,000 $3,000/$6,000 Premium $02 $20 $40 $10/$40 $40 $1001 $02 $02 $40 $40

Silver EPO $3,000 $20/$50 $3,000/$6,000 $7,150/$14,300 Premium $02 $20 $50 $10/$50 $50 $2003 $3002 $3002 $50 $50

Bronze EPO $6,850 $6,850/$13,700 $7,150/$14,300 Premium $02 $02† $02 $02/$02 $02 $02 $02 $02 $02 $02

PPO

Platinum PPO $10/$25 $0/$0 $1,250/$2,500 Premium $0 $10 $25 $5/$25 $25 $1751 $0 $150 $25 $25

Platinum PPO $500 $20/$40 $500/$1,000 $1,000/$2,000 Premium $02 $20 $40 $10/$40 $40 $1001 $02 $125 $20 $20

Gold PPO $1,000 $20/$45 $1,000/$2,000 $3,500/$7,000 Premium $02 $20 $45 $10/$45 $45 $1751 $02 $02 $45 $45

Gold PPO $1,500 $10/$40 $1,500/$3,000 $3,500/$7,000 Premium $02 $10 $40 $5/$40 $40 $1751 $02 $02 $40 $40

Gold PPO $2,000 $20/$40 $2,000/$4,000 $3,000/$6,000 Premium $02 $20 $40 $10/$40 $40 $1001 $02 $02 $40 $40

Silver PPO $3,000 $20/$50 $3,000/$6,000 $7,150/$14,300 Premium $02 $20 $50 $10/$50 $50 $2003 $3002 $3002 $50 $50

Bronze PPO $6,850 $6,850/$13,700 $7,150/$14,300 Premium $02 $02 † $02 $02/$02 $02 $02 $02 $02 $02 $02

HM

O

Platinum HMO $10/$25 $0/$0 $1,250/$2,500 Standard $0 $10 $25 $5/$25 $25 $1751 $0 $150 $25 $25

Platinum HMO $500 $20/$40 $500/$1,000 $1,000/$2,000 Standard $02 $20 $40 $10/$40 $40 $1001 $02 $125 $20 $20

Gold HMO $1,000 $20/$45 $1,000/$2,000 $3,500/$7,000 Standard $02 $20 $45 $10/$45 $45 $1751 $02 $02 $45 $45



Silver HMO $3,000 $20/$50 $3,000/$6,000 $7,150/$14,300 Standard $02 $20 $50 $10/$50 $50 $2003 $3002 $3002 $50 $50

Bronze HMO $6,850 $6,850/$13,700 $7,150/$14,300 Standard $02 $02† $02 $02/$02 $02 $02 $02 $02 $02 $02

UPMC Small Business Advantage

1 Waived if admitted2 After deductible3 After deductible, copay waived if admitted4 Aggregate/Aggregate† First three PCP visits are $35 copayment per visit, not subject to deductible

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.

Plan Type Plan Name Deductible (Individual/Family)


(Individual/Family)Network Coinsurance PCP Visit Specialist

Visit


(PCP/Specialist)





Other Imaging (x-ray, etc.)

Lab and Other Services

EPO

Platinum EPO $10/$25 $0/$0 $1,250/$2,500 Premium $0 $10 $25 $5/$25 $25 $1751 $0 $150 $25 $25

Platinum EPO $500 $20/$40 $500/$1,000 $1,000/$2,000 Premium $02 $20 $40 $10/$40 $40 $1001 $02 $125 $20 $20

Gold EPO $1,000 $20/$45 $1,000/$2,000 $3,500/$7,000 Premium $02 $20 $45 $10/$45 $45 $1751 $02 $02 $45 $45

Gold EPO $1,500 $10/$40 $1,500/$3,000 $3,500/$7,000 Premium $02 $10 $40 $5/$40 $40 $1751 $02 $02 $40 $40

Gold EPO $2,000 $20/$40 $2,000/$4,000 $3,000/$6,000 Premium $02 $20 $40 $10/$40 $40 $1001 $02 $02 $40 $40

Silver EPO $3,000 $20/$50 $3,000/$6,000 $7,150/$14,300 Premium $02 $20 $50 $10/$50 $50 $2003 $3002 $3002 $50 $50

Bronze EPO $6,850 $6,850/$13,700 $7,150/$14,300 Premium $02 $02† $02 $02/$02 $02 $02 $02 $02 $02 $02

PPO

Platinum PPO $10/$25 $0/$0 $1,250/$2,500 Premium $0 $10 $25 $5/$25 $25 $1751 $0 $150 $25 $25

Platinum PPO $500 $20/$40 $500/$1,000 $1,000/$2,000 Premium $02 $20 $40 $10/$40 $40 $1001 $02 $125 $20 $20

Gold PPO $1,000 $20/$45 $1,000/$2,000 $3,500/$7,000 Premium $02 $20 $45 $10/$45 $45 $1751 $02 $02 $45 $45

Gold PPO $1,500 $10/$40 $1,500/$3,000 $3,500/$7,000 Premium $02 $10 $40 $5/$40 $40 $1751 $02 $02 $40 $40

Gold PPO $2,000 $20/$40 $2,000/$4,000 $3,000/$6,000 Premium $02 $20 $40 $10/$40 $40 $1001 $02 $02 $40 $40


Bronze PPO $6,850 $6,850/$13,700 $7,150/$14,300 Premium $02 $02 † $02 $02/$02 $02 $02 $02 $02 $02 $02

HM

O

Platinum HMO $10/$25 $0/$0 $1,250/$2,500 Standard $0 $10 $25 $5/$25 $25 $1751 $0 $150 $25 $25

Platinum HMO $500 $20/$40 $500/$1,000 $1,000/$2,000 Standard $02 $20 $40 $10/$40 $40 $1001 $02 $125 $20 $20




Silver HMO $3,000 $20/$50 $3,000/$6,000 $7,150/$14,300 Standard $02 $20 $50 $10/$50 $50 $2003 $3002 $3002 $50 $50

Bronze HMO $6,850 $6,850/$13,700 $7,150/$14,300 Standard $02 $02† $02 $02/$02 $02 $02 $02 $02 $02 $02

What do aggregate and embedded mean?

Aggregate Deductible means that for family coverage, the entire family deductible must be met by one or a combination of the covered family members before covered services are paid for any member on the plan.Aggregate Out-of-Pocket Limit means that for family coverage, the entire family out-of-pocket limit must be met by one or a combination of the covered family members before the plan pays at 100 percent for covered services for the remainder of the benefit period.Embedded Deductible means the plan pays for covered services in these two scenarios (whichever comes first):1. When an individual within a family reaches his or her

individual deductible. At this point, only that person on the plan is considered to have met the deductible; OR

2. When a combination of family members' expenses reaches the family deductible. At this point, all covered family members are considered to have met the deductible.

Embedded Out-of-Pocket Limit means the out-of-pocket limit is satisfied in one of two ways (whichever comes first):1. When an individual within a family reaches the out-of-

pocket limit. At this point, only that person will have covered services paid at 100 percent for the remainder of the benefit period; OR

2. When a combination of family members' expenses reaches the family out-of-pocket limit. At this point, all covered family members are considered to have met the out-of-pocket limit and will have covered services paid at 100 percent for the remainder of the benefit period.

Note: All standard medical plans offered within this document are embedded, unless marked aggregate.

Plan Name Deductible (Individual/Family)


(Individual/Family)Network Coinsurance PCP Visit Specialist Visit


(PCP/Specialist)





Other Imaging (x-ray, etc.) Lab and Other Services

Gold HSA PPO $1,350/10%4 $1,350/$2,700 $3,425/$6,850 Premium 10%2 10%2 10%2 10%2/10%2 10%2 10%2 10%2 10%2 10%2 10%2

Gold HSA PPO $2,0004 $2,000/$4,000 $3,425/$6,850 Premium $02 $02 $02 $02/$02 $02 $02 $02 $02 $02 $02

Silver HSA PPO $3,250 $3,250/$6,500 $6,450/$12,900 Premium $02 $02 $02 $02/$02 $02 $02 $02 $02 $02 $02

UPMC HealthyU

Platinum HIA PPO $1,350/10% $1,350/$2,700 $2,000/$4,000 Premium 10%2 10%2 10%2 10%2/10%2 10%2 10%2 10%2 10%2 10%2 10%2

Gold HIA PPO $2,500/10% $2,500/$5,000 $3,425/$6,850 Premium 10%2 10%2 10%2 10%2/10%2 10%2 10%2 10%2 10%2 10%2 10%2

UPMC MyCare Advantage

Platinum PPO $250 $20/$40 $250/$500 $1,000/$2,000 Premium $02 $20 $40 $10/$40 $40 $1751 $02 $02 $30 $30

Tier 2 $500/$1,000 $1,000/$2,000 Premium 35%2 $40 $80 $10/$80 $80 $175 35%2 35%2 35%2 35%2

Gold PPO $1,250 $20/$40 $1,250/$2,500 $3,500/$7,000 Premium $02 $20 $40 $10/$40 $40 $1751 $02 $02 $35 $35

Tier 2 $2,500/$5,000 $3,500/$7,000 Premium 35%2 $40 $80 $10/$80 $80 $175 35%2 35%2 35%2 35%2


Tier 2 $6,600/$13,200 $7,150/$14,300 Premium 35%2 $50 $110 $13/$110 $110 $1753 35%2 35%2 35%2 35%2


Tier 2 $6,350/$12,700 $6,500/$13,000 Premium 35%2 $40 $80 $10/$80 $80 $1751 35%2 35%2 35%2 35%2

UPMC Consumer Advantage

1 Waived if admitted2 After deductible3 After deductible, copay waived if admitted4 Aggregate/Aggregate† First three PCP visits are $35 copayment per visit, not subject to deductible

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.

Plan Name Deductible (Individual/Family)


(Individual/Family)Network Coinsurance PCP Visit Specialist Visit


(PCP/Specialist)





Other Imaging (x-ray, etc.) Lab and Other Services

Gold HSA PPO $1,350/10%4 $1,350/$2,700 $3,425/$6,850 Premium 10%2 10%2 10%2 10%2/10%2 10%2 10%2 10%2 10%2 10%2 10%2

Gold HSA PPO $2,0004 $2,000/$4,000 $3,425/$6,850 Premium $02 $02 $02 $02/$02 $02 $02 $02 $02 $02 $02

Silver HSA PPO $3,250 $3,250/$6,500 $6,450/$12,900 Premium $02 $02 $02 $02/$02 $02 $02 $02 $02 $02 $02

UPMC HealthyU

Platinum HIA PPO $1,350/10% $1,350/$2,700 $2,000/$4,000 Premium 10%2 10%2 10%2 10%2/10%2 10%2 10%2 10%2 10%2 10%2 10%2

Gold HIA PPO $2,500/10% $2,500/$5,000 $3,425/$6,850 Premium 10%2 10%2 10%2 10%2/10%2 10%2 10%2 10%2 10%2 10%2 10%2

UPMC MyCare Advantage

Platinum PPO $250 $20/$40 $250/$500 $1,000/$2,000 Premium $02 $20 $40 $10/$40 $40 $1751 $02 $02 $30 $30

Tier 2 $500/$1,000 $1,000/$2,000 Premium 35%2 $40 $80 $10/$80 $80 $175 35%2 35%2 35%2 35%2

Gold PPO $1,250 $20/$40 $1,250/$2,500 $3,500/$7,000 Premium $02 $20 $40 $10/$40 $40 $1751 $02 $02 $35 $35

Tier 2 $2,500/$5,000 $3,500/$7,000 Premium 35%2 $40 $80 $10/$80 $80 $175 35%2 35%2 35%2 35%2


Tier 2 $6,600/$13,200 $7,150/$14,300 Premium 35%2 $50 $110 $13/$110 $110 $1753 35%2 35%2 35%2 35%2


Tier 2 $6,350/$12,700 $6,500/$13,000 Premium 35%2 $40 $80 $10/$80 $80 $1751 35%2 35%2 35%2 35%2

PharmacyUPMC Health Plan’s pharmacy network includes more than 30,000 pharmacies nationwide, including Giant Eagle, Kmart, Rite Aid, Target, CVS, Walmart, Sam’s Club, and Wegmans (Erie locations).

During deductible period and after the deductible has been met

Generic Preferred Brand Non-Preferred Brand Specialty

$10 $40 $75 $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

UPMC HealthyU and UPMC Consumer Advantage Options: IntegratedDuring deductible period After the deductible has been met

Actual Drug CostGeneric Preferred Brand Non-Preferred Brand Specialty

$10 $40 $75 $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

UPMC Small Business Advantage and UPMC MyCare Advantage Options

UPMC Health Plan produces the Advantage Choice formulary for our small market groups. We offer this formulary at http://upmchp.us/pharmacybenefits or in searchable format at http://upmchp.us/medication.

UPMC Health Plan contracts with Express Scripts Inc. to provide convenient home delivery of certain maintenance medications. With home delivery, members can:

• 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 http://upmchp.us/pharmacybenefits.

UPMC Vision CareBy offering UPMC Vision Care to your employees, you allow them to receive more integrated services from UPMC Health Plan.

UPMC Vision Care, administered by National Vision Administrators (NVA), offers Exam Only, Classic, Deluxe, Prime, Premier, and Elite plan models, with both copay and no copay options, plus a national network of vision providers.

Features: • Discounts through the NVA EYEESSENTIAL® Plan

• Mail-order contact lens service

• Fixed copayments for lens add-ons

• Discounts on LASIK procedures at UPMC Eye Center, QualSight, TLC Vision, and LASIK Centers of America

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

Elite 12 months $0

Elite 2 12 months $15

*For dependents through age 18, frequency for exams and lenses is 12 months.

For further lens selections, request the "Additional Lens Options" document from your account representative.

Out-of-network reimbursement is based on usual, customary, and reasonable rates as determined by UPMC Vision Care.

Pediatric Vision Services are covered as required under the Affordable Care Act (ACA) for members enrolled in ACA-compliant group plans. Employees can find eligibility and benefit details in their Pediatric Vision Certificate of Insurance and Pediatric Vision Schedule of Benefits on MyHealth OnLine, or they can call Member Services once enrolled.

Vision Essential Health Benefits Schedule of Benefits for members under age 19

Optional Lens and Treatment Fixed Fee Optional Lens

and Treatment Fixed Fee

Plastic Dyes - Solid $8 Progressives (Tier 1) $50

Anti-Reflective Coating (Tier 1) $40 Progressives

(Tier 2) $80

Hi-Index Plastic 1.53-1.60/Trivex $40 Polarized

(Tier 1) $65

Hi-Index Plastic 1.66/1.67 $71 Transitions VII $70

Hi-Index Plastic 1.70 and above $80

1In-network reimbursement is based on the percentage of provider reimbursement. Participating vision providers are not permitted to bill the member for the difference for any services unless otherwise stated. Participating vision providers may charge a member a copayment for optional lenses and treatments listed below.2Out-of-network reimbursement is based on usual, customary, and reasonable rates as determined by UPMC Vision Care.3Lens reimbursement includes reimbursements for polycarbonate lenses.4Provider may make available non-collection frames. Non-collection frames are frames that are any amount over the retail allowance for collection frames. If non-collection frames are chosen, members are responsible for the difference in cost between the retail allowance amount for collection frames and the retail price of the frame, less a 20 percent discount.

Members are eligible for additional lens options at a fixed fee, in-network only. If members choose extra options, they are responsible for the additional cost of the options paid directly to the vision provider. For additional lens options, refer to the chart. Members receive a 20 percent courtesy discount on lens options not listed below.

Frequency

BenefitIn-

Network1Out-of-Network Reimbursement2

Children Under Age 19

Examination 100% $30 12 months

Lenses (for glasses)3 – All lenses must be provided by an NVA-contracted laboratory.

Single Vision 100% $25 12 months

Bifocal 100% $35 12 months

Trifocal 100% $45 12 months

Frames

Collection Frames 100%

$30 12 months

Non-Collection Frames4 Covered 12 months

Contact Lenses – If deemed medically necessary. Prior authorization is required. Contact lens fitting and follow-up reimbursement are separate from contact lens material.

Contact Lens Fitting and Follow-up 100% $225 12 months

Contact Lens Material 100% 12 months

UPMC Dental AdvantageUPMC Dental Advantage offers Basic, Standard, and Premium plan models, plus a vast network of dentists.

Our plans encourage regular preventive care and foster open communication between members and dentists regarding treatment plans.

Features: • Prior authorization is not required for major services.

• Enhanced benefits include: – One additional cleaning for members who are pregnant, during the course of the pregnancy. – Increased coverage for nonsurgical periodontal treatment, including topical application of fluoride for adults with a history of surgical periodontal treatment. – Coverage for microbial tests and brush biopsies.

Plan In-Network Covered Amount Class I/Class II/Class III Deductible/ Plan Year Maximum Ortho Lifetime Maximum

Service Class Deductible Annual

MaximumOrtho

Coverage

Ortho Lifetime

MaximumOut-of-

Network Coverage

Class I

Class II

Class III $0 $50 $75 $1,000 $1,500 $2,000 Yes No $1,000

BasicBasic 100/0/0/$01 3 — — 3 — — — — — — 3 — 80/0/0Basic 100/0/0/$501 3 — — — 3 — — — — — 3 — 80/0/0Basic 100/0/0/$751 3 — — — — 3 — — — — 3 — 80/0/0StandardStandard 100/50/50/ $0/$1,500/No Ortho 3 3 3 3 — — — 3 — — 3 — 80/40/20

Standard 100/50/50/ $0/$1,500/Ortho/$1,000 3 3 3 3 — — — 3 — 3 — 3 80/40/20

Standard 100/50/50/ $75/$2,000/No Ortho 3 3 3 — — 3 — — 3 — 3 — 80/40/20

PremiumPremium 100/80/50/ $0/$1,500/No Ortho 3 3 3 3 — — — 3 — — 3 — 80/60/40

Premium 100/80/50/ $0/$1,500/Ortho/$1,000 3 3 3 3 — — — 3 — 3 — 3 80/60/40

Premium 100/70/50/ $0/$1,000/No Ortho 3 3 3 3 — — 3 — — — 3 — 80/40/20

Premium 100/70/50/ $50/$1,000/No Ortho 3 3 3 — 3 — 3 — — — 3 — 80/40/20

Premium 100/70/50/ $0/$1,500/No Ortho 3 3 3 3 — — — 3 — — 3 — 80/40/20

Premium 100/70/50/ $50/$1,500/No Ortho 3 3 3 — 3 — — 3 — — 3 — 80/40/20

Premium 100/80/50/ $50/$1,000/No Ortho 3 3 3 — 3 — 3 — — — 3 — 100/80/50

Premium 100/80/50/ $50/$1,500/No Ortho 3 3 3 — 3 — — 3 — — 3 — 100/80/50

1 20% discount applies to Class II & III services when visiting participating providers.

See plan documents for additional information.

Members 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 may receive a 20 percent discount on eligible Class II and Class III services received by a participating provider. Members should review their plan documents for additional information.

UPMC Dental Advantage Discount PlanUPMC Dental Advantage offers a Discount Dental Plan to all new and current employers, either as a standalone plan option or as an added benefit to the existing Basic plan offerings.

Features: • 20 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 Discount Dental Plan may not be used in conjunction with other insurance, including other UPMC Dental Advantage plans.

The discount does not apply to orthodontic or cosmetic services.

Dental Essential Health Benefits Schedule of Benefits 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 your employees have been provided conflict with those set forth in this plan document, the terms and conditions of this plan document control.

1Out-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.2Orthodontic 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.

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. Coverage for members is administered in accordance with policies and procedures in effect on the date of service. Additional plan information can be found in the Pediatric Dental Certificate of Insurance.

Copayments, coinsurance, and deductibles for dental benefits apply toward satisfaction of the combined out-of-pocket maximum specified in the member’s Medical Schedule of Benefits. Services are covered at 100 percent after the out-of-pocket maximum is satisfied.

This Pediatric Dental Schedule of Benefits may expand or restrict the benefits set forth in the member’s UPMC Dental Advantage Pediatric Dental Certificate of Insurance. You may advise your employees to see the Pediatric Dental Certificate of Insurance for the details of the terms of coverage for their health benefit plan. In the event that the terms of the Pediatric Dental Certificate of Insurance conflict with this Pediatric Dental Schedule of Benefits, the terms of this Pediatric Dental Schedule of Benefits control.

In-Network Out-of-Network1

Plan Year Deductible: Class I (Out-of-Network Only), Class II, and Class III Services

$50 Individual/$150 Eligible Dependents (2+ Children)

$75 Individual/$200 Eligible Dependents (2+ Children)

Class I: Diagnostic/Preventive 100% 90%

Exams and Prophylaxis Payable for 2 services in a Benefit Period

BitewingsPayable for 2 services in a Benefit Period up to age 14; 1 service in a Benefit

Period for 14+ years

Complete Series and Panoramic FilmsPayable for 1 service in a 36-month period and is not covered for members

under the age of 5

Topical Fluoride Payable to age 19 for 2 services in a Benefit Period

Periodontal Scaling and Root Planing Payable for 1 service every 24 months

Sealants Payable to age 14 for 1 service per tooth (molar) every 36 months

Space Maintainers Payable to age 19

Class II: Basic Services 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 and Bridges Payable for 1 service per tooth in a 60-month period

Inlay/Onlay – Metallic/Porcelain/Resin up to 4 Surfaces Payable for 1 service per tooth in a 60-month period

Implants Payable for 1 service per tooth per lifetime

Dentures Complete and Partial Payable for 1 service in a 60-month period

Prefabricated Stainless Steel Crown/Primary Tooth Payable for 1 service per tooth in a 60-month period

Orthodontics: Subject to Medical Deductible2 50% Not Covered

UPMC Health Plan offers a robust benefit package for value-added benefits and services that focus on the total health and well-being of your employees. All UPMC Small Business Advantage medical plans come standard with this unique benefit package. The value-added benefits and services of UPMC Small Business Advantage include:

LifeSolutions employee assistance programWorkplace, personal, and family issues can be distracting, resulting in lost productivity and missed work. LifeSolutions® offers a host of resources to help our members feel better and stay focused and to help managers with workplace issues. Benefits include coaching and counseling over the phone and numerous online resources, such as financial calculators and self-assessments. Employees and managers do not need to be enrolled in a medical plan to receive employee assistance program (EAP) services. Also, EAP services are available to all members of the employee's and manager's household.

Employees receive: • Three confidential telephone sessions with a licensed

professional per issue.

Value-added benefits and servicesUPMC Small Business Advantage

• Access to the WorkLife online resource website with information on a variety of topics, such as personal relationships, child care, elder care, adoption, legal matters, financial concerns, etc.

Employers receive: • Unlimited managerial telephone counseling

sessions with a licensed professional on topics such as improving effectiveness at work, addressing sensitive employee issues, and dealing with workplace stress concerns.

• Online education and training.

Other value-added benefits and services

Assist AmericaThe nation's largest provider of emergency medical services for travelers comes free of charge with UPMC Health Plan coverage. Members have access to care 24/7 — anytime, anywhere.

Health coachingWe offer lifestyle improvement and condition management programs at no cost to our members. Members work one-on-one with a health coach over the phone. Programs include nutrition, weight loss, physical activity, tobacco cessation, and stress reduction.

MyHealth OnLineMyHealth OnLine is a secure website where members can personalize their goals and needs. Here, they can take the MyHealth Questionnaire to find out their health risks. 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 AnywhereCareWith UPMC AnywhereCare, members can get treatment for colds and flu, strep throat, and other nonemergency conditions with an e-visit — anytime, day or night. The cost is less than or the same as a visit with their primary care physician.

UPMC Health Plan members located in Pennsylvania at the time of service will have a virtual visit with a UPMC-employed provider. If a member is located outside Pennsylvania, service will be delivered by a separate provider group – Online Care Group (OCG). UPMC AnywhereCare is currently not available in Texas or Arkansas.

UPMC eDermatologyMembers 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 during the eDermatology visit.

UPMC MyHealth 24/7 Nurse LineMembers 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.

Member must be in Pennsylvania, West Virginia, or Ohio when calling the UPMC MyHealth 24/7 Nurse Line.

Health Care ConciergeMembers receive fast, personal service from our UPMC Health Plan Health Care Concierge team. Our outstanding customer service team strives to resolve questions and concerns in one phone call or online chat session.

UPMC Consumer Advantage spending accounts

Flexible spending accountsFlexible spending accounts (FSAs) from UPMC Consumer Advantage help members save money using pretax dollars. We offer health care, dependent care, and limited purpose FSAs as well as commuter transportation accounts.

Health savings accountsHealth savings accounts (HSAs) from UPMC Consumer Advantage help members pay for out-of-pocket health care expenses. An HSA must be paired with a qualified high-deductible health plan. Both the employer and employee can contribute. The balance can be carried over from year to year. The employee owns the account and can take it when he or she changes employers.

Health reimbursement arrangementsHealth reimbursement arrangements (HRAs) from UPMC Consumer Advantage are employee spending accounts that employers fund. Your employees can use their HRAs to pay for health care deductible expenses. Funds that the employer contributes to the HRA are not considered wages and are not subject to income taxes, FICA (Social Security and Medicare), or workers’ compensation.

Qualified transportation accountsQualified transportation accounts from UPMC Consumer Advantage are member spending accounts that employees fund with pretax contributions. Funds can be used for eligible transit and parking expenses related to their commute to and from work.

Ancillary services

UPMC COBRA AdvantageWe administer monthly billing and collection from the COBRA or Mini-COBRA participant, monitor nonpayment, and provide late payment notices. We also handle open enrollment mailing, carrier updates, and other vital communications.

Retiree billingOur 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 information provided for these benefits is for informational purposes only. Actual benefits are subject to the terms and conditions of the Certificate of Coverage.

The Affordable Care ActTo remain in compliance with the Affordable Care Act (ACA), UPMC Health Plan has incorporated the following factors into our plan offerings for employer groups within our small market portfolio.

Actuarial valueThe Affordable Care Act 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 percent, respectively. Issuers must offer plans within +/- 2 percent of these values.

Community ratingUnder 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 & 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 children ages 0 to 20 years, the age-adjusted premiums must be the same for all individuals.

For adults 64 years of age or older, age-adjusted premiums must be the same for all individuals.

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.

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 Care. 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 eligible 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.

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