UPMC Health Plan - UPMC Advantage Gold $1,000/$10 - Premium Network
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$10 Copay
50% Coinsurance after deductible
Specialist Visit
$70 Copay
50% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
$10 Copay
50% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
50% Coinsurance after deductible
Laboratory Outpatient and Professional Services
$50 Copay
50% Coinsurance after deductible
X-rays and Diagnostic Imaging
20% Coinsurance after deductible
50% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
20% Coinsurance after deductible
50% Coinsurance after deductible
Generic Drugs
$10 Copay
100% Coinsurance
Preferred Brand Drugs
$50 Copay
100% Coinsurance
Non-Preferred Brand Drugs
$100 Copay
100% Coinsurance
Specialty drugs
50% Coinsurance
100% Coinsurance
Outpatient Facility Fee
20% Coinsurance after deductible
50% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
20% Coinsurance after deductible
50% Coinsurance after deductible
Emergency Room Services
20% Coinsurance after deductible
20% Coinsurance after deductible
Emergency Transportation/Ambulance
20% Coinsurance after deductible
20% Coinsurance after deductible
Urgent Care
$70 Copay
50% Coinsurance after deductible
Inpatient Hospital Services
20% Coinsurance after deductible
50% Coinsurance after deductible
Inpatient Physician and Surgical Services
20% Coinsurance after deductible
50% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
$10 Copay
50% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
20% Coinsurance after deductible
50% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
$10 Copay
50% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
20% Coinsurance after deductible
50% Coinsurance after deductible
Prenatal and postnatal care
No Charge
50% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
20% Coinsurance after deductible
50% Coinsurance after deductible
Home Healthcare Services
20% Coinsurance after deductible
50% Coinsurance after deductible
Outpatient Rehabilitation Services
$50 Copay
50% Coinsurance after deductible
Habilitation Services
$50 Copay
50% Coinsurance after deductible
Skilled Nursing Facility
20% Coinsurance after deductible
50% Coinsurance after deductible
Durable Medical Equipment
50% Coinsurance after deductible
50% Coinsurance after deductible
Hospice Services
20% Coinsurance after deductible
50% Coinsurance after deductible
Chiropractic Care
$50 Copay
50% Coinsurance after deductible
Acupuncture
$70 Copay
50% Coinsurance after deductible
Rehabilitative Speech Therapy
$50 Copay
50% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
$50 Copay
50% Coinsurance after deductible
Well Baby Visits and Care
No Charge
50% Coinsurance after deductible
Allergy Testing
20% Coinsurance after deductible
50% Coinsurance after deductible
Diabetes Education
No Charge
50% Coinsurance after deductible
Nutritional Counseling
20% Coinsurance after deductible
50% Coinsurance after deductible
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Accidental Dental
20% Coinsurance after deductible
50% Coinsurance after deductible
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
20% Coinsurance after deductible
40% Coinsurance after deductible
Dental Check Up (Child)
No Charge
20% Coinsurance after deductible
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
50% Coinsurance after deductible
70% Coinsurance after deductible
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
50% Coinsurance after deductible
100% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered