Benefit Plan Summaries

Transcription

1 Benefit Plan Summaries For groups with 2-50 employees Effective January 1, 2018

2 Benefit Plan Summaries for groups with 2-50 employees

3 What s inside Network options... 2 Medical plan descriptions Standard Medical Plan Portfolio... 8 Pharmacy UPMC Vision Care UPMC Dental Advantage...20 UPMC Dental Advantage Discount Plan Dental Essential Health Benefits Schedule of Benefits for members under age Value-added benefits and services...24 Other services...24 The Affordable Care Act...26 Effective January 1, 2018 UPMC Health Plan

4 Network options UPMC Health Plan offers the following network options for our 2-50 market portfolio. Benefit Plan Summaries for groups with 2-50 employees Mercer Lawrence Beaver Greene Erie Crawford Washington Butler Allegheny Venango Fayette Warren Clarion Armstrong Forest Westmoreland Jefferson Indiana Somerset Elk Cambria McKean Clearfield Bedford Cameron Blair Fulton Potter Clinton Centre Huntingdon Mifflin Franklin Juniata Tioga Lycoming Union Snyder Perry Cumberland Adams Dauphin York Bradford Columbia Montour Northumberland Sullivan Lebanon Schuylkill Lancaster Wyoming Plan offered to employer groups located in these counties Access to care Out of area Susquehanna Luzerne Berks Lackawanna Carbon Chester Wayne Northampton Lehigh Monroe Delaware Bucks Montgomery Philadelphia Pike UPMC Partner Network The UPMC Partner Network consists of UPMC-owned hospitals, physician practices, and medical facilities as well as community-based doctors, hospitals, and other medical providers located within the counties in our service area, shown above. Members can obtain services as outlined in their plan documents when seeking care from participating providers within the Partner Network. To be eligible for the UPMC Partner Network, you, as the employer, must be located in Lycoming or Tioga counties. 2 UPMC Health Plan 2018

5 Erie Crawford Warren McKean Potter Tioga Bradford Susquehanna Wayne Mercer Venango Forest Clarion Jefferson Elk Cameron Clinton Lycoming Sullivan Columbia Wyoming Luzerne Lackawanna Pike Lawrence Butler Armstrong Clearfield Centre Union Snyder Montour Northumberland Carbon Monroe Beaver Indiana Schuylkill Northampton Mifflin Juniata Allegheny Cambria Blair Perry Dauphin Westmoreland Huntingdon Washington Cumberland Bedford Somerset Fayette Fulton Franklin York Greene Adams Plan offered to employer groups located in these counties Out of area Lebanon Lancaster Lehigh Berks Bucks Montgomery Chester Philadelphia Delaware Effective January 1, 2018 UPMC Standard Network The UPMC Standard Network consists of UPMC-owned hospitals, physician practices, and medical facilities as well as community-based doctors, hospitals, and other medical providers located within the counties in our service area, shown above. Members can obtain services as outlined in their plan documents when seeking care from participating providers within the Standard Network. UPMC Health Plan

6 Network Options (cont.) Benefit Plan Summaries for groups with 2-50 employees Mercer Lawrence Beaver Greene Erie Crawford Washington Butler Allegheny Venango Fayette Warren Clarion Armstrong Forest Westmoreland Jefferson Indiana Somerset Elk Cambria McKean Clearfield Bedford Cameron Blair Fulton Potter Clinton Centre Huntingdon Plan offered to employer groups located in these counties Mifflin Franklin Juniata Tioga Lycoming Union Snyder Perry Cumberland Adams Dauphin York Access to Care Bradford Columbia Montour Northumberland Sullivan Lebanon Schuylkill Lancaster Wyoming Susquehanna Luzerne Out of Area Berks Lackawanna Carbon Chester Wayne Northampton Lehigh Monroe Delaware Bucks Montgomery Philadelphia Pike UPMC Premium Network The UPMC Premium Network consists of UPMC-owned hospitals, physician practices, and medical facilities as well as community-based doctors, hospitals, and other medical providers located within the counties in our service area, shown above. Members can obtain services as outlined in their plan documents when seeking care from participating providers within the Premium Network. 4 UPMC Health Plan 2018

7 Effective January 1, 2018 UPMC Health Plan

8 Medical plan descriptions Benefit Plan Summaries for groups with 2-50 employees We understand that employers want to control health care costs while keeping their employees healthy. Our current portfolio offers a variety of plans to meet the needs of our diverse employer groups. With that in mind, we created UPMC Small Business Advantage, a unique portfolio of medical plan options for companies with fewer 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. hospitals and facilities, which include 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; Monongahela Valley Hospital; St. Clair Hospital; Washington Health System Greene; Uniontown Hospital; and Washington Hospital. Life Solutions employee assistance program is included with 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 Work-Life resource center, which contains online materials on a variety of topics. Employers in these counties are eligible: Allegheny, Beaver, Bedford, Blair, Butler, Fayette, Lawrence, Washington, and Westmoreland. UPMC MyCare Advantage is available in the PPO plan type. 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, UPMC Partner Network, or UPMC Premium Network. is available in EPO, PPO, and HMO plan types. UPMC MyCare Advantage UPMC 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 6 UPMC Health Plan 2018 UPMC HealthyU UPMC HealthyU is an innovative plan that rewards members for making healthy choices. By completing healthy activities, subscribers and their covered spouse or covered domestic partner can earn reward dollars in a health incentive account (HIA) that helps pay for their health care expenses. Dependent children (including adult children) are not eligible to earn reward dollars. 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.

9 Here are descriptions of each plan type: UPMC 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 (HSA) or flexible spending account (FSA). 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 the employee may be able to take the funds along when changing employers or at retirement. UPMC Consumer Advantage is available in the PPO plan type. Please see the Other Services section for more information. Preferred provider organization (PPO) UPMC 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. UPMC Inside Advantage UPMC Inside Advantage is a tiered benefit plan that provides lower out-of-pocket costs when employees receive care at Level 1 facilities. Level 1 includes all UPMC providers and UPMC-owned facilities along with many community-owned providers and facilities, such as Grove City Medical Center and Warren General Hospital. UPMC facilities in northwest Pennsylvania include UPMC Hamot, UPMC Horizon, UPMC Kane, UPMC Jameson, and UPMC Northwest. At Level 2, out-of-pocket costs may increase. Level 2 includes many UPMC-contracted facilities and the services affiliated with those contracted facilities, such as lab, x-ray, MRI therapy, and more. Exclusive provider organization (EPO) With 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. Health maintenance organization (HMO) With 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 provider (PCP) to help coordinate their care. A PCP referral is required for most specialty care. Preventive care is always covered at 100 percent. Employers in these counties are eligible: Clarion, Crawford, Elk, Erie, Forest, McKean, Mercer, Potter, Venango, and Warren. UPMC Health Plan Effective January 1, 2018 UPMC Consumer Advantage

10 Standard Medical Plan Portfolio Plan Type Plan Name Deductible (Individual/Family) Out-of-Pocket Maximum (Individual/ Family) Network Coinsurance PCP Benefit Plan Summaries for groups with 2-50 employees EPO PPO HMO UPMC Small Business Advantage Platinum $10/$25 Platinum $500 $20/$40 Gold $1,000 $25/$50 Gold $1,500 $25/$50 Gold $1,750 $30/$50 Gold $2,000 $20/$40 Gold $2,500 $20/$40 Silver $3,000 $30/$50 Bronze $6,850 $0/$0 $1,300/$2,600 $0 $10 $500/$1,000 $1,000/$2,000 $20 $1,000/$2,000 $5,000/$10,000 $25 $1,500/$3,000 $5,000/$10,000 $25 $1,750/$3,500 $4,000/$8,000 $30 $2,000/$4,000 $2,500/$5,000 $5,000/$10,000 $4,000/$8,000 Premium/ Standard (HMO) $0 1 $20 $20 $3,000/$6,000 $7,350/$14,700 $30 $6,850/$13,700 $7,150/$14,300 $0 1&5 Notes for all plans The emergency department copayment applies both in- and out-of-network. This document is meant to help members compare 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 prevails. A health reimbursement arrangement (HRA) can be added to any plan with a deductible of at least $1,000. ¹After deductible. ²Aggregate. ³Copayment waived if admitted to hospital. 4 UPMC HealthyU products are sold with $500/$1,000 HIA options. 5 First three PCP visits are $35. 6 Copayment per day for a maximum of 5 days. Copayment per visit not subject to deductible. 8 UPMC Health Plan 2018

11 Specialist UPMC AnywhereCare (On-Demand/ PCP/Specialist) Urgent Care Emergency Department 3 Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging, (x-ray, etc.) Lab, and Other Services Pharmacy Option $25 $5/$10/ $25 $25 $175 $0 $150 $25 $40 $10/$20/$40 $40 $100 $0 1 $125 $20 $50 $13/$25/$50 $50 $175 1 $500 6 $200 1 $45 $50 $13/$25/$50 $50 $175 $0 1 $0 1 $50 $50 $15/$30/$50 $50 $200 $0 1 $0 1 $50 $40 $10/$20/$40 $40 $100 $0 1 $0 1 $40 $40 $10/$20/$40 $40 $100 $0 1 $0 1 $40 A or B $50 $15/$30/$50 $50 $250 1 $500 6 $300 1 $50 1 $0 1 $0 1 /$0 1 /$0 1 $0 1 $0 1 $0 1 $0 1 $0 1 Effective January 1, 2018 UPMC Health Plan

12 Standard Medical Plan Portfolio (continued) Plan Name Deductible (Individual/ Family) Out-of-Pocket Maximum (Individual/ Family) Network Coinsurance PCP Specialist Platinum EPO $10/$25 Partner Network $0/$0 $1,300/$2,600 $0 $10 $25 Benefit Plan Summaries for groups with 2-50 employees Partner Network Platinum EPO $500 $20/$40 Partner Network Gold EPO $1,000 $25/$50 Partner Network Gold EPO $1,500 $25/$50 Partner Network Gold EPO $1,750 $30/$50 Partner Network Gold EPO $2,000 $20/$40 Partner Network Gold EPO $2,500 $20/$40 Partner Network Silver EPO $3,000 $30/$50 Partner Network Bronze EPO $6,850 Partner Network $500/$1,000 $1,000/$2,000 $20 $40 $1,000/$2,000 $5,000/$10,000 $25 $50 $1,500/$3,000 $5,000/$10,000 $25 $50 $1,750/$3,500 $4,000/$8,000 $30 $50 $2,000/$4,000 $5,000/$10,000 Partner $20 $40 $0 1 $2,500/$5,000 $4,000/$8,000 $20 $40 $3,000/$6,000 $7,350 /$14,700 $30 $50 $6,850/$13,700 $7,150/$14,300 $0 1&5 $0 1 Plan Name Deductible (Individual/ Family) Out-of-Pocket Maximum (Individual/ Family) Network Coinsurance PCP UPMC Consumer Advantage UPMC Consumer Advantage Gold HSA PPO $1,350/10% Premium Network 2 $1,350/$2,700 $3,425/$6,850 UPMC Consumer Advantage Gold HSA PPO $2,000 Premium Network 2 $2,000/$4,000 $3,425/$6,850 UPMC Consumer Advantage Silver HSA PPO $3,250 Premium Network $3,250/$6,500 $6,450/$12,900 Premium 10% 1 10% 1 $0 1 $ UPMC Health Plan 2018

13 UPMC AnywhereCare (On-Demand/ PCP/Specialist) Urgent Care Emergency Department 3 Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.), Lab, and Other Services Pharmacy Option $5/$10/$25 $25 $175 $0 $150 $25 $10/$20/$40 $40 $100 $0 1 $125 $20 $13/$25/$50 $50 $175 1 $500 6 $200 1 $45 $13/$25/$50 $50 $175 $0 1 $0 1 $50 $15/$30/$50 $50 $200 $0 1 $0 1 $50 $10/$20/$40 $40 $100 $0 1 $0 1 $40 A or B $10/$20/$40 $40 $100 $0 1 $0 1 $40 $15/$30/$50 $50 $250 1 $500 6 $300 1 $50 1 $0 1 /$0 1 /$0 1 $0 1 $0 1 $0 1 $0 1 $0 1 Effective January 1, 2018 Specialist UPMC AnywhereCare (On-Demand/ PCP/Specialist) Urgent Care Emergency Department Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.), Lab, and Other Services Pharmacy Option 10% 1 10% 1 /10% 1 /10% 1 10% 1 10% 1 10% 1 10% 1 10% 1 A or B $0 1 0% 1 /0% 1 /0% 1 $0 1 $0 1 $0 1 $0 1 $0 1 UPMC Health Plan

14 Standard Medical Plan Portfolio (continued) Plan Name Deductible (Individual/ Family) Out-of-Pocket Maximum (Individual/ Family) Network Coinsurance PCP Benefit Plan Summaries for groups with 2-50 employees UPMC HealthyU UPMC Inside Advantage UPMC HealthyU Platinum HIA PPO $1,350/10% Premium Network UPMC HealthyU Gold HIA PPO $2,500/10% Premium Network Plan Name UPMC Inside Advantage Platinum PPO $250 $20/$40 Premium Network UPMC Inside Advantage Gold PPO $1,000 $25/$50 Premium Network UPMC Inside Advantage Gold PPO $1,250 $25/$50 Premium Network UPMC Inside Advantage Silver PPO $3,000 $30/$60 Premium Network Level Deductible (Individual/ Family) $1,350/$2,700 4 $2,000/$4,000 4 $2,500/$5,000 4 $3,425/$6,850 4 Out-of-Pocket Maximum (Individual/ Family) Level 1 $250/$500 $1,000/$2,000 Level 2 $500/$1,000 Level 3 Out-of-Network $6,000/ $12,000 Combined with benefit Level 1 out-of-pocket. Premium 10% 1 10% 1 Network Coinsurance PCP Specialist $0 1 $20 $40 35% 1 $10,000/$20,000 40% 1 40% 1 40% 1 Level 1 $1,000/$2,000 $6,000/$12,000 $0 1 $2,000/ Combined with benefit $25 $50 Level 2 35% $4,000 Level 1 out-of-pocket. 1 Level 3 Out-of-Network $4,000/ $8,000 $10,000/ $20,000 40% 1 40% 1 40% 1 Level 1 $1,250/$2,500 $4,000/$8,000 $0 1 $2,500/ Combined with benefit $25 $50 Level 2 35% $5,000 Level 1 out-of-pocket. Premium 1 Level 3 Out-of-Network $5,000/ $10,000 $10,000/ $20,000 40% 1 40% 1 40% 1 Level 1 $3,000/$6,000 $7,350/$14,700 $0 1 $6,600/ Combined with benefit $30 $60 Level 2 35% $13,200 Level 1 out-of-pocket. 1 Level 3 Out-of-Network $13,200/$20,000 $15,000/$30,000 40% 1 40% 1 40% 1 UPMC Inside Advantage Silver PPO $5,000 $30/$60 Premium Network Level 2 $6,350/$12,700 Combined with benefit Level 1 out-of-pocket. 35% 1 $30 $60 Level 1 $5,000/$10,000 $7,350/$14,700 $0 1 Level 3 Out-of-Network $12,700/$20,000 $15,000/$30,000 40% 1 40% 1 40% 1 12 UPMC Health Plan 2018

15 Specialist UPMC AnywhereCare (On-Demand/ PCP/Specialist) Urgent Care Emergency Department Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.), Lab, and Other Services Pharmacy Option 10% /10% 1 /10% 1 10% 1 10% 1 10% 1 10% 1 10% 1 A or B UPMC AnywhereCare (On-Demand/ PCP/Specialist) Urgent Care Emergency Department 3 Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.), Lab, and Other Services Pharmacy Option $0 1 $0 1 $30 $10/$20/$40 $40 $175 35% 1 35% 1 35% 1 40% 1 40% 1 40% 1 40% 1 40% 1 $400 6 $0 1 $50 $13/$25/$50 $50 $175 35% 1 35% 1 35% 1 40% 1 40% 1 40% 1 40% 1 40% 1 $0 1 $0 1 $50 $13/$25/$50 $50 $ % 1 35% 1 35% 1 A or B Effective January 1, % 1 40% 1 40% 1 40% 1 40% 1 $15/$30/$60 $60 $200 1 $600 6 $0 1 $60 35% 1 35% 1 40% 1 40% 1 40% 1 40% 1 40% 1 $15/$30/$60 $60 $450 $600 6 $0 1 $60 35% 1 35% 1 40% 1 40% 1 40% 1 40% 1 40% 1 UPMC Health Plan

16 Standard Medical Plan Portfolio (continued) Plan Name Level Deductible (Individual/ Family) Out-of-Pocket Maximum (Individual/ Family) Network Coinsurance PCP Specialist Level 1 $250/$500 $1,000/$2,000 $0 1 $20 $40 Benefit Plan Summaries for groups with 2-50 employees UPMC MyCare Advantage UPMC MyCare Advantage Platinum PPO $250 $20/$40 Premium Network UPMC MyCare Advantage Gold PPO $1,000 $25/$50 Premium Network UPMC MyCare Advantage Gold PPO $1,500 $25/$50 Premium Network UPMC MyCare Advantage Silver PPO $4,500 $40/$65 Premium Network UPMC MyCare Advantage Silver PPO $6,500 $25/$50 Premium Network Level 2 $500/$1,000 Level 3 Out-of-Network $6,000/ $12,000 Combined with benefit Level 1 out-of-pocket. Premium 35% 1 $40 $80 $10,000/$20,000 40% 1 40% 1 40% 1 Level 1 $1,000/$2,000 $6,000/$12,000 $0 1 $25 $50 Level 2 Level 3 Out-of-Network $2,000/ $4,000 $4,000/ $8,000 Combined with benefit Level 1 out-of-pocket. $10,000/ $20,000 35% 1 $50 $100 40% 1 40% 1 40% 1 Level 1 $1,500/$3,000 $3,750/$7,500 $0 1 $25 $50 Level 2 $3,000/$6,000 Level 3 Out-of-Network $6,000/$12,000 Combined with benefit Level 1 out-of-pocket. $10,000/ $20,000 35% 1 $50 $100 40% 1 40% 1 40% 1 Level 1 $4,500/$7,000 $7,350/$14,700 $0 1 $40 $65 Level 2 $7,000/$14,000 Level 3 Out-of-Network Combined with benefit Level 1 out-of-pocket. 35% 1 $80 $130 $10,000/$20,000 $10,000/$20,000 40% 1 40% 1 40% 1 Level 1 $6,500/$7,000 $7,350/$14,700 $0 1 $25 $50 Level 2 $7,000/$14,000 Level 3 Out-of-Network Combined with benefit Level 1 out-of-pocket. 35% 1 $50 $100 $10,000/$20,000 $10,000/$20,000 40% 1 40% 1 40% 1 14 UPMC Health Plan 2018

17 UPMC AnywhereCare (On-Demand/ PCP/Specialist) Urgent Care Emergency Department 3 Inpatient Hospital Care Advanced Imaging (PET, MRI, etc.) Other Imaging (x-ray, etc.), Lab, and Other Services Pharmacy Option $10/$20/$40 $40 $0 1 $0 1 $30 $80 $175 35% 1 35% 1 35% 1 40% 1 40% 1 40% 1 40% 1 40% 1 $13/$25/$50 $50 $0 1 $0 1 $50 $100 $ % 1 35% 1 35% 1 40% 1 40% 1 40% 1 40% 1 40% 1 $13/$25/$50 $50 $0 1 $0 1 $35 $100 $ % 1 35% 1 35% 1 A or B 40% 1 40% 1 40% 1 40% 1 40% 1 $65 $0 1 $0 1 $0 1 $20/$40/$65 $130 $0 1 35% 1 35% 1 35% 1 40% 1 40% 1 40% 1 40% 1 40% 1 $50 $0 1 $0 1 $30 $13/$25/$50 $100 $ % 1 35% 1 35% 1 40% 1 40% 1 40% 1 40% 1 40% 1 Effective January 1, 2018 UPMC Health Plan

18 Pharmacy UPMC Health Plan s pharmacy network includes more than 50,000 pharmacies nationwide, including Giant Eagle, Kmart, Rite Aid, CVS, Walmart, Sam s Club, and Wegmans (Erie locations). Benefit Plan Summaries for groups with 2-50 employees UPMC Health Plan produces multiple formularies, depending on your group plan. We offer our formularies at upmchp.us/pharmacybenefits or in searchable format at 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. Marketing Portfolio UPMC MyCare Advantage UPMC Inside Advantage UPMC Consumer Advantage Pharmacy Option Option A Rx Summary $10/$40/$75/$95 $10/$40/$75/$95 after deductible. Rx Integration Not subject to plan deductible. Subject to plan deductible. Retail 30-Day Supply Generic $10 Retail 30- Day Supply Preferred Pharmacy UPMC HealthyU UPMC MyCare Advantage UPMC Inside Advantage $10/$40/$75/$95 after deductible. $15/$40/$75/$95 Subject to plan deductible. Not subject to plan deductible. $40 UPMC Consumer Advantage Option B $15/$40/$75/$95 after deductible Subject to plan deductible. $15 UPMC HealthyU $15/$40/$75/$95 after deductible Subject to plan deductible. For more information, visit upmchp.us/pharmacybenefits. 16 UPMC Health Plan 2018

19 Retail 30- Day Supply Nonpreferred Retail 30-day Supply Specialty Mail-Order 90-Day Supply Generic $20 Mail-Order 90-Day Supply Preferred Mail-Order 90-Day Supply Nonpreferred Effective January 1, 2018 $75 $95 $80 $150 $30 UPMC Health Plan

20 UPMC Vision Care By offering UPMC Vision Care to your employees, you allow them to receive more integrated services from UPMC Health Plan. Benefit Plan Summaries for groups with 2-50 employees 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. Vision Essential Health Benefits Schedule of Benefits for members under age 19 Benefit In-Network 1 Reimbursement 2 Out-of-Network Frequency 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% 12 months $30 Non-Collection Frames 4 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% $ months Contact Lens Material 100% 12 months 18 UPMC Health Plan 2018

21 1 In-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. 2 Out-of-network reimbursement is based on usual, customary, and reasonable rates as determined by UPMC Vision Care. 3 Lens reimbursement includes reimbursements for polycarbonate lenses. 4 Provider 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. 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. Members 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. Optional Lens and Treatment Fixed Fee Plastic Dyes - Solid $8 Anti-Reflective Coating (Tier 1) Hi-Index Plastic /Trivex Hi-Index Plastic 1.66/1.67 Hi-Index Plastic 1.70 and above $40 $40 Optional Lens and Treatment Progressives (Tier 1) Progressives (Tier 2) Polarized (Tier 1) Fixed Fee $50 $80 $65 $71 Transitions VII $70 $80 Effective January 1, 2018 UPMC Health Plan

22 UPMC Dental Advantage UPMC Dental Advantage offers Basic, Standard, and Premium plan models, plus a vast network of dentists. Benefit Plan Summaries for groups with 2-50 employees 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. Plan In-Network Covered Amount Class I/Class II/ Class III Deductible/ Plan Year Maximum Ortho Lifetime Maximum Service Class Deductible Annual Maximum Ortho Coverage Ortho Lifetime Maximum Out-of- Network Coverage Class I Class II Class III $0 $50 $75 $1,000 $1,500 $2,000 Yes No $1,000 Basic Basic 100/0/0/$ /0/0 Basic 100/0/0/$ /0/0 Basic 100/0/0/$ /0/0 Standard Standard 100/50/50/ $0/$1,500/No Ortho Standard 100/50/50/ $0/$1,500/Ortho/$1,000 Standard 100/50/50/ $75/$2,000/No Ortho Premium Premium 100/80/50/ $0/$1,500/No Ortho Premium 100/80/50/ $0/$1,500/Ortho/$1,000 Premium 100/70/50/ $0/$1,000/No Ortho Premium 100/70/50/ $50/$1,000/No Ortho Premium 100/70/50/ $0/$1,500/No Ortho Premium 100/70/50/ $50/$1,500/No Ortho Premium 100/80/50/ $50/$1,000/No Ortho Premium 100/80/50/ $50/$1,500/No Ortho 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. 1 20% discount applies to Class II & III services when visiting participating providers. See plan documents for additional information /40/ /40/ /40/ /60/ /60/ /40/ /40/ /40/ /40/ /80/ /80/50 20 UPMC Health Plan 2018

23 UPMC Dental Advantage UPMC Dental Advantage offers Basic, Standard, and Premium plan models, plus a vast network of dentists. UPMC Dental Advantage plans encourage regular preventive care and foster open communication between members and dentists regarding treatment plans. Features: Prior authorization not required for major services Enhanced benefits: One additional cleaning for members who are pregnant during the course of their 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 Product Deductible Orthodontics Annual Maximum Basic Basic 1a (100/0/0) 1 $0 None None Basic 1b (100/0/0) 1 $50 None None Basic 1c (100/0/0) 1 $75 None None Standard Standard 2a (100/50/50) $0 None $1,500 Standard (100/50/50) $0 Yes $1,000 max $1,500 Standard 2c (100/50/50) $75 None $2,000 Premium Premium 3a (100/80/50) $0 None $1,500 Premium (100/80/50) $0 Yes $1,000 max $1,500 Premium (100/70/50) $0 None $1,000 Premium (100/70/50) $50 None $1,000 Premium (100/70/50) $0 None $1,500 Premium (100/70/50) $50 None $1,500 Premium (100/80/50) $50 None $1,000 Premium (100/80/50) $50 None $1,500 Effective January 1, 2018 UPMC Health Plan

24 UPMC Dental Advantage Discount Plan Benefit Plan Summaries for groups with 2-50 employees UPMC 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. 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. 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. 22 UPMC Health Plan 2018

25 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 In-Network Out-of-Network 1 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 Bitewings Payable for 2 services in a benefit period Payable for 2 services in a benefit period up to age 14; 1 service in a benefit period for 14+ years Complete Series and Panoramic Films Payable for 1 service in a 36-month period and is not covered for members under the age of 5 Topical Fluoride Periodontal Scaling and Root Planing Sealants Payable to age 19 for 2 services in a benefit period Payable for 1 service every 24 months 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 Pulpal Therapy/Anterior and Posterior Endodontic Therapy (including treatment plan, clinical procedures, and follow-up care) Extractions and Oral Surgery Payable Payable Payable Payable Class III: Major Services 50% 40% Crowns and Bridges Inlay/Onlay Metallic/Porcelain/ Resin up to 4 Surfaces Implants Dentures Complete and Partial Prefabricated Stainless Steel Crown/Primary Tooth Payable for 1 service per tooth in a 60-month period Payable for 1 service per tooth in a 60-month period Payable for 1 service per tooth per lifetime Payable for 1 service in a 60-month period Payable for 1 service per tooth in a 60-month period Orthodontics: Subject to Medical Deductible 2 50% Not Covered Effective January 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. 2 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. 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. UPMC Health Plan

26 Value-added benefits and services Benefit Plan Summaries for groups with 2-50 employees Value-added benefits and services at no additional charge UPMC Health Plan offers a robust package for valueadded benefits and services that focus on the total health and well-being of your employees. The valueadded benefits rider includes: Life Solutions employee assistance program Workplace, personal, and family issues can be distracting, resulting in lost productivity and missed work. Life Solutions offers a host of resources to help our members feel better and stay focused. 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 or manager's household. Health coaching We offer lifestyle improvement and condition management programs at no cost to our members. Members work one-on-one with a UPMC Health Plan health coach over the phone. Programs include nutrition, weight loss, physical activity, tobacco cessation, and stress reduction. MyHealth OnLine MyHealth OnLine is a secure website where members can personalize their goals and needs. Here, they can take the MyHealth Questionnaire to discover their health risks. In return, they get a personalized list of recommended activities aimed to reduce their risk for chronic disease, allow them to feel better, and help them meet their goals. They can also research health conditions, access treatment cost and comparison tools, see their claims and coverage information, and more. Other services UPMC Dental Advantage Discount Plan Employees and eligible dependents receive a 20 percent discount on eligible Class I, II, and III services when received by a participating dentist. The discount is applied to the dentist s usual and customary charges. No claims submission or member ID cards are required. This discount plan does not apply to orthodontic or cosmetic services. UPMC Vision Care (Exam Only with copayment) Members receive a vision exam for a $15 copayment when received by a participating vision provider. They also have access to a mail-order contact lens program and lens options at a fixed copayment. All other services, such as frames and lenses, are discounted through the NVA EYEESSENTIAL Plan. UPMC AnywhereCare UPMC AnywhereCare is a newly enhanced virtual visit platform that allows members to receive expert care from the comfort of their home using a computer, tablet, or smartphone. UPMC AnywhereCare connects a member to a provider using video technology. Nonemergency conditions, such as sinus infection, allergies, or pink eye, can be treated. This service is available 24/7 from anywhere in the United States. Coming soon, a member can use this video technology to see PCPs and specialists. Patients located in Pennsylvania at the time of the service will have a virtual visit with a UPMC-employed provider. If a patient is located outside Pennsylvania, the service will be delivered by a separate provider group Online Care Group (OCG). 24 UPMC Health Plan 2018

27 UPMC edermatology Members can also connect with a board-certified dermatologist for skin conditions. This service is available 24/7 and can be accessed through Simply describe the condition by answering a questionnaire and attach three photos of the affected area. A board-certified UPMC dermatologist will respond with a diagnosis and treatment plan and send a prescription to your pharmacy (if necessary). A patient must be in Pennsylvania at the time of the visit. UPMC MyHealth 24/7 Nurse Line Members can speak to a registered nurse anytime, day or night, at no charge, when they have a health question or medical concern by calling the UPMC MyHealth 24/7 Nurse Line. UPMC nurses who answer calls are licensed to assist members located in Pennsylvania, West Virginia, and Ohio. Members must be located in one of those states when calling the UPMC MyHealth 24/7 Nurse Line. Health Care Concierge Members receive fast, personal service from our UPMC Health Plan Health Care Concierges. Our outstanding customer service team strives to resolve questions and concerns in one phone call or online chat session. Assist America This travel assistance program is available to members when they travel more than 100 miles from home, both inside and outside the country. UPMC Consumer Advantage spending accounts Flexible spending account (FSA) UPMC Consumer Advantage FSAs help members save money using pretax dollars. We offer health care, dependent care, and limited purpose FSAs. Health reimbursement arrangement (HRA) HRAs from UPMC Consumer Advantage are employerfunded member spending accounts. Members can use their HRAs to pay for deductible health care 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 account (QTA) UPMC Consumer Advantage QTAs 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 Advantage We administer monthly billing and collection from COBRA or mini-cobra participants, monitor for nonpayment, and provide late payment notices. We also handle open enrollment mailings, carrier updates, and other vital communications. Retiree billing Our web-based system allows employers 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. Effective January 1, 2018 Health savings account (HSA) Also available from UPMC Consumer Advantage, HSAs help members pay for out-of-pocket health care expenses. HSAs must be paired with a QHDHP. 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. UPMC Health Plan

28 The Affordable Care Act To remain in compliance with the Affordable Care Act, UPMC Health Plan has incorporated the following factors into our plan offerings for employer groups within our small market portfolio. Benefit Plan Summaries for groups with 2-50 employees Actuarial value The Affordable Care Act (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 percent, respectively. Issuers must offer plans within -4/+2 for all metal types except Bronze. Certain Bronze plans allow -4/+5. 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 & 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 14 and 15 to 20 years, the age-adjusted premiums must be the same for all individuals. For adults and 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. 26 UPMC Health Plan 2018

29 NOTES Effective January 1, 2018 UPMC Health Plan

30 NOTES Benefit Plan Summaries for groups with 2-50 employees 28 UPMC Health Plan 2018

31 NOTES Effective January 1, 2018 UPMC Health Plan

32 U.S. Steel Tower, 600 Grant Street Pittsburgh, PA Copyright 2017 UPMC Health Plan Inc. All rights reserved SM GRP BPS 17SAM1408 (MJA) 10/19/17 12M CDI