Coverage under the plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, disability leave, pensions, etc. you must also contact your employing or retiring office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members.  Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office.  Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family.  You may change your enrollment 31 days before to 60 days after that event.  The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.  When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. 

Contact your carrier to add a family member when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a family member if you currently have a Self Only plan.  

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we.  Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.  

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) – such as marriage, divorce, or the birth of a child – outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live, or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or 
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2022 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment
• You are a family member no longer eligible for coverage

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage, or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional-information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information/ . A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26, regardless of marital status, etc.  Under TCC, you no longer receive a government contribution, but instead pay the entirety of your premium plus an administration service charge.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a  tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days after you are no longer eligible for coverage. 

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside and outside of the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage please contact us at 877-648-9641 or visit our website at www.upmchealthplan.com/FEHB.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll.  You should carry your ID card with you at all times.  You must show it whenever you receive services from a Plan provider, or fill a prescription at a participating pharmacy.  Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. 

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 877-648-9641 or write to us at UPMC Health Plan Member Services, U.S. Steel Tower, 600 Grant Street, Pittsburgh, PA 15219. You may also request replacement cards through our website at www.upmchealthplan.com/FEHB.

You may also access your ID card by downloading the UPMC Health Plan Mobile App for free onto your smartphone.

You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/or coinsurance. You can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network. If you enroll in the HDHP, you can also get care from non-Plan providers but it will cost you more.

FEHB Carriers must have clauses in their in-network (participating) providers agreements.  These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount.  If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website: www.upmchealthplan.com/FEHB.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be at reached 877-648-9641 or www.upmchealthplan.com/FEHB for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website. Plan facilities are also referred to as participating providers, plan providers, and in-network providers in this brochure.

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your healthcare.

Your primary care physician can be an internist, pediatrician, family practitioner, or general practitioner. Your primary care physician will provide most of your healthcare, or refer you to a specialist. Women may select an ob/gyn to provide or coordinate all covered gynecological/obstetrical care. However, women are not required to see the same ob/gyn on a regular basis.

If you are enrolled in the Standard Option, you must register your selected primary care physician with us. If you want to change your primary care physician, you may do so at any time by contacting Member Services at 877-648-9641 or by visiting the website at www.upmchealthplan.com/FEHB. If your primary care physician leaves the Plan, call us and we will help you select a new one.

Your primary care physician will refer you to a specialist for needed care. However, a referral is not required to see a specialist.

Here are some other things you should know about specialty care:

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who can recommend another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause; or
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Program plan; or
  • reduce our service area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services Department immediately at 877-648-9641.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.  If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply.  In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

Your primary care physician has authority to refer you for most services.  For certain services, however, your physician must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.  For the most up-to-date source of information on which procedures require your physician to obtain prior authorization, refer to https://www.upmchealthplan.com/providers/medical/resources/manuals/policies-procedures.aspx.

If you are considering an artificial insemination procedure, see requirements on page 36 or 93.

First, your physician, your hospital, you, or your representative, must call us at 877-648-9641 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number, and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization.  We will make our decision within 15 days of receipt of the pre-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know that information we need to complete our review of the claim.  You will then have up to 48 hours from to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) to end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 877-648-9641. You may also call OPM's Health Insurance at 202-606-0727 between 8 a.m. and 5 p.m. Eastern Standard Time to ask for a simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you do not indicate that your claim was a claim for urgent care, call us at 877-648-9641.  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. 

You do not need to pre-certify a vaginal delivery at a network facility. Further, if your baby stays after you are discharged, then your physician must contact us for precertification of additional days for your baby.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you are enrolled in the Standard HMO, you are responsible for the cost of any admission to a non-participating facility, except for emergency care and specialized care that has been precertified by UPMC Health Plan because the necessary care is not available from a participating provider.

If you enrolled in the HDHP, you may not be eligible for reimbursement under your plan when you use a non-participating facility that has not been precertified, except for emergency care or highly specialized care that has been precertified by UPMC Health Plan because the necessary care is not available from a participating provider.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.  If your claim is in reference to a contraceptive, call 877-648-9641

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within six months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   
   You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
   
   If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have.  We will write to you with our decision.
3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

A copayment is a fixed amount of money you pay to the participating provider, facility, pharmacy, etc., when you receive certain services.

Example: Under the Standard Option, when you visit a participating primary care physician you pay a $20 copayment.

A deductible is a fixed expense you must incur for covered services and supplies before we start paying benefits under this plan. 

• The calendar year deductible under the Standard Option is $850 for a Self Only. Under Self Plus One or Self and Family enrollment, the deductible under the Standard Option is $1,700. For a Self Plus One or Self and Family enrollment, if one member meets the individual deductible, the deductible is satisfied for that member and the Plan will begin to pay benefits.
• The calendar year deductible under the HDHP is $2,000 for a Self Only enrollment.  Under Self Plus One or Self and Family enrollment, the deductible under the HDHP is $4,000.  Under Self Plus One or Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reaches $4,000. The deductible is combined for services received from both Plan and non-Plan providers.
• The calendar year deductible will be prorated for any mid-year member enrollment.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan.  If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option. 

Coinsurance is the percentage of our allowance that you must pay for your care. With the exception of preventive care services, coinsurance does not begin until you have met your calendar year deductible.

• Under the Standard Option, you pay 20% of our allowance for covered services.
• Under the HDHP, you pay 15% of our allowance for services received from participating providers; 40% for non-participating providers.

Under the HDHP, if you receive care from non-Plan providers, benefits are paid at the out-of-network level. Except for in-network preventive care, the deductible must be satisfied before benefits are paid. If you receive services from a non-Plan provider, you may also have to pay the difference between the provider’s charge and UPMC Health Plan’s allowance (reasonable and customary charge).

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

Under the Standard Option, after your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $6,000 for Self Only, or $12,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. 

Under the HDHP, after your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance for In Network total $6,000 for Self Only, or $12,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for In Network covered services. For Out of Network, after your out-of-pocket expenses total $8,000 for Self Only or $16,000 for Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for Out of Network covered services.

Example Scenario:  Your plan has a $6,000 Self Only maximum out-of-pocket limit and a $12,000 Self Plus One or Self and Family maximum out-of-pocket limit. Under a Self Plus One enrollment, each enrollee will have an out of pocket maximum of $6,000 each calendar year. With a Self and Family enrollment, the out-of-pocket maximum is $12,000. One individual would have a $6,000 out-of-pocket limit, and a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified expenses up to a maximum of $12,000 for the calendar year before their qualified medical expenses begin to be covered in full.

However, costs for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay for these services:

• Dental Discount benefits
• Eyeglasses or contact lenses
• Expenses for services and supplies that exceed the stated maximum dollar or day limit
• Expenses for non-covered medical services
• Expenses from utilizing out-of-network providers
• Expenses for non-formulary medications

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the plan’s calculation of your out-of-pocket maximum is reflected accurately.

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Services are entitled to seek reimbursement for certain services and supplies they provide to you or a family member.  They may not seek more than their governing laws allow.  You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills. 

In addition, your health plan adopts and complies with the surprise billing laws of Pennsylvania/NSA. 

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to https://bit.ly/upmchpNSAFEHB or contact the health plan at 877-648-9641.

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).

• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians

• In physician's office

$20 per office visit for a PCP (No deductible)

$50 per office visit for a specialist (No deductible)

Professional services of physicians

• During a hospital stay
• In a skilled nursing  facility. Limited to 100 days per calendar year combined with Extended care facility admissions. 
• Office medical consultations
• Second surgical opinion
• Advance care planning
• Professional interpretation of diagnostic testing results

$50 per office visit for a specialist (No deductible)

20% of the Plan allowance for other covered services

Professional services of physicians

• At a convenience care clinic  

20% of the Plan allowance

$5 per visit (No Deductible)

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammogram
• CT/CAT Scans
• MRI
• Ultrasound
• Electrocardiogram and EEG
• Professional interpretation of diagnostic testing results

20% of the Plan allowance

Routine physical every 12 months by your PCP.

The following preventive services are covered at the time interval recommended at each of the links below:

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/index.html
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for woman such as Pap smears, gonorrhea prophylactic medication to protect newborns, counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventative care benefits for woman go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://www.health.gov/myhealthfinder

Tobacco cessation counseling

Nothing (No deductible)

Nothing (No deductible)

Routine mammogram - covered.

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing (No deductible)

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel
• Immunizations, boosters, and medications for travel or work-related exposure.

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org/Pages/default.aspx 
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org
• To build your personalized list of preventive services go to https://www.health.gov/myhealthfinder

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel
• Immunizations, boosters, and medications for travel or work-related exposure

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes 
• Delivery
• Postnatal care

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.  Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Contraceptive counseling as prescribed

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Tubal ligation

Note: We cover oral contraceptives and diaphragms under the prescription drug benefit.

Nothing (No deductible)

Nothing (No deductible)

Voluntary sterilization (See Surgical Procedures Section 5 (b)

Note: We cover oral contraceptives, Injectable, Vaginal, Patch, Diaphragm, Sponge, Cervical cap, Female condom and Spermidine under the prescription drug benefit.

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Infertility is the documented inability of a person under the age of 35 years to conceive a child within a 12 month period or a person 35 years or older to conceive a child within a six month period: (a) of unprotected coitus (sexual intercourse); or (b) after at least six episodes of artificial insemination.

Medical Description

Infertility is the documented inability of a woman to conceive a child. Infertility may be caused by female factors (e.g. pelvic adhesions, ovarian dysfunction, function or transport, or prior ligation); male factors (e.g. abnormalities in sperm production, function or transport or prior vasectomy), a combination of both male and female factors, and unknown causes. Once infertility is diagnosed, treatments for infertility may begin. The focus of this policy is the diagnosis of infertility. Treatment of the causes of infertility is not addressed in this policy. Refer to MP.018 – Infertility – Treatment policy found via the following link: https://www.upmchealthplan.com/providers/hcbs/resources/manuals/policies-procedures.aspx#I.

 Specific Indications for Diagnosis

• Member must fit the definition for infertility (as indicated in Section II Definitions)
• Members must be pre-menopausal and reasonably expect fertility as a natural state; or if menopausal, should have experienced it at an early age

Diagnosis and treatment  of Infertility

Depending on the member’s unique medical situation, the following diagnostic tests to diagnose fertility in males and females may be considered medically necessary:

• History & Physical
• Sperm function tests
• Hysterosalpingogram
• Hysteroscopy
• Sonohysterogram
• Prediction of Ovarian Reserve Hormone Evaluation
• Evaluation of folliculogenesis
• Endometrial biopsy
• Diagnostic laparoscopy
• Follow-up Conference
• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intrauterine insemination (IUI)
  • Intracervical insemination (ICI)
• Artificial reproduction:
  • Assisted Reproductive Technologies (ART)- all clinical and laboratory treatments in which both human oocytes and sperm, or embryos, are manipulated outside of the body with the intent of establishing pregnancy.
• Iatrogenic infertility (Fertility Preservation) - Coverage includes cryopreservation of embryos, eggs, sperm, and ovarian and testicular tissues in the case of medically necessary chemotherapy, radiation or pharmacological treatment with a likely side effect of infertility. 
• Infertility prescription drugs
• Lifetime maximum benefit per member is $25,000 and includes all of the above except artificial insemination which is exempt from the lifetime maximum of $25,000. Coverage of member’s preserved specimen is only available while the member is enrolled in UPMC Health Plan. Member is responsible for the cost once the member’s enrollment terminates or reaches the $25,000 maximum lifetime benefit.

Limitations/Contraindications

Normal physiological causes of infertility such as menopause

• Infertility resulting from voluntary sterilization
• The following diagnostic tests are considered investigational:

-         Tests to assess/improve sperm movement, or computer-assisted sperm analysis (CASA)

-         Analysis of adenosine triphosphate (ATP) in ejaculation

-         Tubaloscopy

-         Anti-zona pellucida antibodies

-         Hyaluronan binding assay (HBA)

-         Sperm washing and swim-up when performed as part of insemination

In order to assess medical necessity for infertility services, adequate information must be furnished by the treating physician. Necessary documentation includes, but is not limited to the following:

• Member’s age, clinical history, physical and functional status;
• Documentation of infertility, testing if done, and treatment history
• Documentation of any history of substance abuse, including smoking;
• Social Service evaluation
• Lab results: HIV antibody

Diagnostic tests for infertility may be ordered by a participating provider. However, most anti-retroviral therapy drugs and procedures should only be ordered or performed by credentialed Reproductive Endocrinologists.

If a member lives in an out-of-network area, then the credentials of the nearest Reproductive Endocrinologist or OB/Gynecologist must be reviewed by the Credentials Specialist prior to approval for coverage. Refer to plan-specific infertility riders. 

The procedure regarding a member acting as a surrogate mother is only covered if the couple has a relationship under which the FEHB Program recognizes each partner as a spouse of the other.

20% of the Plan allowance

Not covered:

• Member acting as a surrogate mother and all services and supplies associated with surrogate motherhood are not covered by the UPMC Insurance Services Division, nor are supplies and services related to the following:
  • Pre-pregnancy evaluations
  • Prenatal care
  • Perinatal care
  • Postnatal care

• Testing and treatment

• Allergy injections

20% of the Plan allowance

20% of the Plan allowance

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 105.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following a qualifying event/condition is provided for up to 12 weeks of sessions.
• Dialysis - hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy
• Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder
• Medical nutrition therapy to treat a chronic illness or condition; includes nutrition assessment and nutritional counseling by a dietitian or facility-based program which is ordered by a participating physician
  • Chronic Renal Disease, Diabetes Mellitus, and High Risk Obstetrical Symptomatic Conditions: unlimited number of visits when medically necessary
  • Morbid Obesity: limited to an initial assessment and five follow-up visits for a total of six visits per calendar year
  • Heart Disease, Symptomatic HIV/AIDS, and Celiac Disease: limited to two visits per calendar year
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services in Section 3.

• Pain management

Note: Pain management is covered if you are diagnosed with refractory chronic pain of at least six months duration. The provider must demonstrate that they anticipate these services to result in substantial improvement to your medical condition.

20% of the Plan allowance

Nutritional products that are specialty food products are covered when Medically Necessary and when under the direction of a physician on an outpatient basis, for the treatment of inborn errors of metabolism and some hereditary metabolic disorders in accordance with state law. Coverage is independent of whether the product is administered orally or enterally. These disorders include:

• Phenylketonuria (PKU)
• Branch-chain ketonuria
• Galactosemia 
• Homocysteinuria
• Allergic reaction or malabsorption syndromes, specifically hemorrhagic colitis

20% of the Plan allowance (no deductible)

Rehabilitation services are limited to the greater of 60 consecutive days of coverage or 25 visits per outpatient condition, per calendar year. 

Habilitation services are also limited to the greater of 60 consecutive days of coverage or 25 visits per outpatient condition, per calendar year. 

• Qualified physical therapists
• Occupational  therapists

Note:  We only cover therapy when a physician:

• orders the care
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

$20 per outpatient visit (No deductible)

For therapy received during a covered inpatient admission - 20% of the Plan allowance

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

Limited to the greater of 60 consecutive days of coverage or 25 outpatient visits per condition, per calendar year for Rehabilitaton.

Limited to the greater of 60 consecutive days of coverage or 25 outpatient visits per condition, per calendar year for Habilitation.

$20 per outpatient visit (No Deductible)

For therapy received during a covered inpatient admission - 20% of the Plan allowance 

Not covered:

• Speech therapy provided for developmental delays

• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices.

20% of the Plan allowance

• Hearing allowance of $1,325 per ear in each 36 month period, for adults aged 21 and over. You must use a participating provider in Amplifon Hearing Healthcare’s Network. To find a participating provider please visit https://www.amplifonusa.com/find-a-hearing-aid-clinic. Deductible and Coinsurance do not apply.

Note: To obtain services from Amplifon Hearing Healthcare, you must schedule an appointment with an Amplifon Hearing Healthcare participating provider by calling the Amplifon Hearing Healthcare toll free number at 888-487-5449.

Note: For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children. 

Nothing (No deductible)

Not covered:

• Hearing services that are not shown as covered

• One pair of standard eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

20% of the Plan allowance 

• Annual eye examination once every 24 months for adults and children

To use your eye examination benefit, call us at 877-648-9641 or visit www.upmchealthplan.com/FEHB/ to locate a vision care provider.

Not covered:

• Eyeglasses or contact lenses, except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

20% of the Plan allowance

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants.
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy. 

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and Ambulance services.

20% of the Plan allowance

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads, and heel cups (covered only with a diagnosis of diabetes or peripheral vascular disease)
• Hearing aids for children under age 21
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices (gradient compression stockings may be covered for certain diagnoses)
• Prosthetic replacements when it is determined by us that a repair costs less than 50% of a replacement

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Speech generating devices
• Blood glucose monitors
• Insulin pumps

877-648-9641

20% of the Plan allowance

Not covered: 

• Audible prescription reading devices
• Replacement or duplication except when necessitated due to a change in the patient’s medical condition or the cost to repair the item exceeds 50% of the price of a new item
• Comfort or convenience items, for your comfort or convenience or the comfort or convenience of your caretaker, including, but not limited to, fitness club memberships, air conditioners, televisions, phones, dehumidifiers, air purifiers, food blenders, exercise equipment, orthopedic mattresses, home or automobile modifications, whirlpools, barber or beauty services, guest service or similar items, even if recommended by a professional provider.
• Medical equipment and supplies that are:
  • expendable in nature (i.e. disposable items such as incontinent pads, catheters, irrigation kits, disposable electrodes, ace bandages, elastic stockings, and dressings) and
  • primarily used for non-medical purposes, regardless of whether recommended by a professional provider 

• Home healthcare ordered by a Plan physician and provided by a registered nurse (RN), licensed practical nurse (LPN), licensed vocational nurse (LVN), or home health aide
• Services include oxygen therapy, intravenous therapy, and medications

20% of the Plan allowance

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

All charges

• Manipulation of the spine and extremities.  Limited to 25 visits per calendar year

• Must be medically necessary

• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application. Children under the age of 13 must receive prior authorization for chiropractic care. 

$20 per office visit (No deductible)

Coverage is limited to acupuncture for the following conditions. Acupuncture is limited to 12 visits per calendar year.

• Nausea and vomiting of pregnancy (hyperemesis gravidarum)
• Post-operative nausea and vomiting
• Post-chemotherapy nausea and vomiting
• Migraines
• Chronic low back pain
• Chronic neck pain
• Knee osteoarthritis

20% of the Plan allowance

Not covered:

• Naturopathic services


• Hypnotherapy


• Biofeedback


• Acupuncture, other than listed above

Diabetic Self-Management Education (DSME) - Outpatient diabetes self-management training and education program is a program of self-management, training, and education, for the treatment of diabetes.  You do not need a physician prescription and no referral is required. You must have a chronic condition and your care must be medically necessary. There is no visit limit for this service.

Nothing (No deductible)

Nutritional Counseling - the assessment of a person's overall nutritional status followed by the assignment of an individualized diet, counseling, and/or nutritional therapies to treat a chronic illness or condition. Services must be delivered by a dietitian or facility-based program, ordered by a participating physician and offered by a participating provider. Coverage is limited to two visits per calendar year. Also see Medical nutrition therapy under Treatment therapies on page 39.

20% of the Plan allowance

Tobacco Cessation - individual, group, phone counseling provided by UPMC Health Plan, call 800-807-0751, and over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence. You must have a written prescription from your doctor for all medications, including OTC, in order to obtain coverage. See Prescription drug benefits.

Childhood obesity screening programs and treatment interventions

20% of the Plan allowance

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy  procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery )
• Surgical treatment of morbid obesity (bariatric surgery)
• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done.  For example, we pay Hospital  benefits for a pacemaker and Surgery  benefits for insertion of the pacemaker. 

20% of the Plan allowance

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)
• Gender Affirming Surgery
  • Surgical treatment for gender affirmation requires prior authorization and is limited to the following:
  • For female to male surgery: mastectomy, oophorectomy, salpingoophorectomy, hysterectomy, vaginectomy, metoidioplasty, phalloplasty, and scrotoplasty.
  • For male to female surgery: orchiectomy, penectomy, penile inversion vaginoplasty, breast augmentation and labiaplasty.

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

20% of the Plan allowance

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplasia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Surgery for TMJ disorder. 

Note: In order for surgery to be covered, documentation in the medical record must support that treatment of TMJ disorder with conventional non-surgical therapy has not resulted in adequate improvement.

• Other surgical procedures that do not involve the teeth or their supporting structures

20% of the Plan allowance

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

20% of the Plan allowance

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologus tandem transplants for
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

20% of the Plan allowance

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi's Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucupolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia 
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma  with recurrence (relapsed)
  • Amyloidosis
  • Breast cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

20% of the Plan allowance

Mini-transplants performed in a clinical trial setting (non-myeloblative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e. Fanconi's Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

20% of the Plan allowance

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial. 

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma 
  • Multiple sclerosis 
  • Sickle cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myeloproliferative disorders (MDDs)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

UPMC Health Plan utilizes the top transplant centers in Pennsylvania. Should care not be available in Pennsylvania, UPMC Health Plan will arrange for services out of the area.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

20% of the Plan allowance

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility. Limited to 100 days per calendar year combined with Extended care facility admissions. 
• Ambulatory surgical center
• Office

20% of the Plan allowance

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

20% of the Plan allowance

Other hospital services and supplies, such as:

• Operating, recovery and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen

20% of the Plan allowance

• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

20% of the Plan allowance

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals, and beds
• Private nursing care

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Observation level of care

Note: Observation is a level of care in an acute care hospital setting that is appropriate when a patient is receiving ongoing short-term treatment and assessments and it is not clear if inpatient level of care is needed. Reassessments are made during this time to determine if the patient requires inpatient admission, or may be discharged and receive follow-up in the outpatient setting.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

20% of the Plan allowance

Extended care benefit:

Limited to 100 days per calendar year combined with Skilled nursing facility admissions

20% of the Plan allowance

Skilled nursing facility (SNF):

Limited to 100 days per calendar year combined with Extended care facility admissions

20% of the Plan allowance

20% of the Plan allowance

• Advance directive information and forms are available to all members upon request. End of life care also includes face-to-face services with a patient, family member or surrogate in counseling and discussing advance directives.

20% of the plan allowance

20% of the Plan allowance

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

$20 per doctor's office visit (No deductible)

$50 per office visit for a specialist (No deductible)

$75 per urgent care center visit (No deductible)

$150 per hospital emergency room visit (No deductible)

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

$20 per doctor's office visit (No deductible)

$50 per office visit for a specialist (No deductible)

$75 per urgent care center visit (No deductible)

$150 per hospital emergency room visit (No deductible)

Not covered:

• Elective care, non-emergency care, and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Professional ambulance service when medically appropriate

20% of the Plan allowance

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

In order to ensure compliance with the Mental Health Parity and Addiction Equity Act, member cost-sharing may be reduced for certain services when received for the diagnosis or treatment of a mental health or substance use disorder or condition.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management  (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

$20 per outpatient office visit (No Deductible)

20% of the Plan allowance for other covered services

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

20% of the Plan allowance

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, residential treatment, and other hospital services

20% of the Plan allowance

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization, half-way house, full-day hospitalization, or facility-based intensive outpatient treatment

20% of the Plan allowance

• Services related to disorders that are not diagnoses listed in the most recent edition of the diagnostic and Statistical manual of Mental Disorders
• Treatment for organic disorders, including, but not limited, to organic brain disease
• Marriage or family counseling, except when rendered in connection with services provided for a treatable mental disorder
• Aversion therapy, bioenergetic therapy, carbon dioxide therapy, confrontation therapy, crystal healing therapy, cult deprogramming, electrical aversion therapy for alcoholism, narcotherapy, orthomolecular therapy, primal therapy, expressive therapies such as art or psychodrama, and hyperbaric or other therapy
• Sex therapy, listed in the most recent edition of the diagnostic and Statistical manual of Mental Disorders and treatment for sexual addiction
• Sedative action electrostimulation therapy
• Sensitivity training
• Twelve-step model programs as sole therapy for conditions, including, but not limited to, addictive gambling

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail-order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered
• Insulin
• Diabetic supplies limited to disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
• Tobacco cessation drugs, including over-the-counter (OTC) drugs approved by the FDA to treat tobacco dependence (See page 46)
• Drugs to treat gender dysphoria for gender-affirming services are covered under your prescription benefit plan and include testosterone, estrogen, and Luteinizing Hormone Releasing Hormone (LHRH) agents. Some of these medications may require prior authorization prior to approval. 

Retail (up to a 30-day supply)

$20 copayment for generic drugs

$50 copayment for preferred brand-name drugs

$100 copayment for non-preferred generic or brand-name drugs

90-day maximum retail supply available at certain retail outlets for three copayments

Specialty Prescription Drugs (up to a 30-day supply)

50% coinsurance up to a maximum of $250

Mail Order (up to a 90-day supply)

$40 copayment for generic drugs

$100 copayment for preferred brand-name drugs

$200 copayment for non-preferred brand-name drugs

Specialty prescription drugs are not covered through Mail Order

Notes:

• If there is no generic equivalent available, you will still have to pay the brand name copayments
• Deductible and Copayments are waived for tobacco cessation drugs

Contraceptive drugs and devices as listed in the ACA/HRSA site.  Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below. 

• UPMC Health Plan offers the full range of contraceptive methods. At this time, the only products that are not readily available without cost share are multi-source brand drugs. In order to get a multi-source brand contraceptive covered at $0, your provider will need to complete and submit a Cost Sharing Exception request form. This form is included with the Preventive Services Resource Guide as part of your plan documents, or may be downloaded from the Pharmacy Prior Authorization section of our website (upmchealthplan.com). Your provider can also directly submit an electronic version of the exception request through UPMC’s PromptPA Portal. In order to be approved for a cost-sharing exception, your provider must attest that the prescribed medication is medically necessary, and explain why it is a necessary form of contraception for you.
• Reimbursement for over-the-counter contraceptives can be submitted if you paid out-of-pocket for an OTC contraceptive product with a prescription from your provider and were not assessed $0 cost share, you can submit a claim for reimbursement. You can request a Pharmacy Direct Reimbursement Claim Form by calling our Health Care Concierge team at the phone number listed on the back of your member ID card or by logging into MyHealth OnLine. You must submit the completed form and your pharmacy label to UPMC Health Plan for review.

Generic versions of contraceptives are available with no copayment or deductible

Preferred and non-preferred brand name drugs will follow the plan payment level listed in the above section

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Vitamins, nutrients, and food supplements not listed as a covered benefit even if a physician prescribes or administers them are not covered except medically necessary formulas that are equivalent to a prescription drug for the treatment of phenylketonuria (PKU) branched-chain ketonuria, galactosemia, and homocystinuria as administered under the direction of a physician or listed as a covered benefit
• Nonprescription medications, unless specifically indicated elsewhere
• Medications prescribed for foreign travel 

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco cessation benefit. (See page 46)

The pharmacy benefit plan includes coverage for some preventive medications at no cost share when certain criteria in accordance with
the Patient Protection and Affordable Care Act of 2010 (PPACA) are met. The following drugs are eligible for ACA coverage. Generic products are required when available.

• Bowel preps for members age 45-75. Coverage is for generic products limited to 2 prescriptions per year.

• Smoking cessation products for all members age 18 and older

• Aspirin (81 mg – 325 mg) for members of child-bearing potential and adults through age 69

• Contraceptives for members of child - bearing potential through age 51.

• Breast cancer medications (generic tamoxifen, raloxifene, aromatase inhibitors) used for prevention in members age 35 and older who are at increased risk for breast cancer.

• Statins for members age 40-75. Statin must be low to moderate intensity and the member must have no history of cardiovascular disease, with at least one cardiovascular risk factor.

• Pre-Exposure Prophylaxis (PrEP) for members who are not infected with HIV who are at high risk for HIV infection.

• Folic acid supplements for members of childbearing age 400 & 800 mcg.

• Fluoride tablets, solution (not toothpaste, rinses) for children age 6 months through 16 years.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Note: To receive this benefit a prescription from a doctor must be presented to pharmacy.

20% of the Plan allowance

You and your family members can call Member Services with questions or concerns. Our Healthcare Concierge team delivers fast, personal service, and strives to answer your question on the first call. To speak with a Healthcare Concierge, call 877-648-9641. Our Healthcare Concierge team is available Monday through Friday from 7 a.m. to 7 p.m. and Saturday from 8 a.m. to 3 p.m. TTY/TDD users should call 711.

You and your family can earn reward dollars in a health incentive account by completing healthy activities throughout the year. These activities have been specially designed by our team of doctors, nurses, nutritionists, exercise physiologists, and behavioral health experts. They will alert you to potential health issues and provide tools to help you address the issues. Activities include:

• MyHealth Questionnaire: The confidential health risk assessment, powered by WebMD®, is a 20-minute online survey you take once a year. The results can help you understand your health status and suggest ways to make improvements. You can earn 50 reward dollars if completed within the 90 days of your effective date. You will earn 25 reward dollars if completed after 90 days.
• Biometric Screening: This health screening measures your total cholesterol level and glucose level. Your doctor will also check your blood pressure, height, weight, and body mass index (BMI). It is a simple assessment that can be done at your doctor’s office, a lab, or some convenience care clinics. Biometric screenings are recommended once every three years. You will earn 15 reward dollars for completing the LDL screening and 15 reward dollars for completing the glucose screening.
• Condition or Lifestyle Management Coaching: A health coach for condition management will help you manage a chronic condition so you can live your healthiest life possible. Health coaches can help with heart disease, diabetes, asthma, COPD, depression, and much more. Lifestyle programs include smoking cessation, stress management, physician activity, weight management, and nutrition. You can earn up to 150 reward dollars for completing a condition management program, and up to 110 reward dollars for completing a lifestyle management program.
• You will also receive reward dollars for completing activities uniquely customized just for you.

You will find a full list of eligible activities by logging in to MyHealth OnLine, the website that powers HealthyU, UPMC Health Plan’s member website.

The reward dollars you earn apply to your deductible, prescription copayments and coinsurance. In one plan year, you can earn up to $250 for Self Only coverage or $500 for Self Plus One or Self and Family coverage. Any unused reward dollars — at a value up to two times your annual deductible —automatically roll over to the next year.

The Plan will prorate any mid-year member enrollment deductibles, out-of-pocket costs and Health Incentive Account funds.

To learn more about HealthyU, visit www.upmchealthplan.com/FEHB or call a Healthcare Concierge at 877-648-9641.

HealthyU is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "health questionnaire" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a health screening (routine blood work), which will include a blood test for glucose screening and lipid panel .You are not required to complete the health questionnaire or to participate in the blood test or other medical examinations.

However, employees who choose to participate in the wellness program can receive an incentive of up to $250 for self, $500 for self plus one, and $500 for self plus family for completing healthy activities that are customized for each member. Although you are not required to complete the health questionnaire or participate in the health screening (routine blood work), only employees who do so will receive the selected reward.

Additional incentives as noted above may be available for employees who participate in certain health-related customized activities If you are unable to participate in any of the health-related activities, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting UPMC Health Plan at 877-648-9641.

The information from your health questionnaire and the results from your health screening (routine blood work) will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as recommended healthy activities. You also are encouraged to share your results or concerns with your own doctor.

Members receiving the COVID-19 vaccination are eligible to receive a $25 Health Incentive reward. You must provide a Centers for Disease Control and Prevention COVID-19 Vaccination Card as proof of attestation for receiving the vaccination. The annual maximum Health Incentive reward dollars per year remains $250 for Self Only coverage and $500 for Self and Family and Self Plus One coverage.

You and your family members have access to MyHealth, A nationally acclaimed health and wellness program. MyHealth guides and motivates you to live your healthiest life possible through online programs, tools, and over-the-phone advice. MyHealth was developed by UPMC, one of the nation's top hospital systems. This gives us in-house expertise in condition management and lifestyle behavior change that no other health plan can match.

MyHealth includes:

• MyHealth OnLine
• MyHealth Questionnaire
• MyHealth Community
• Health Coaching
• MyHealth Advice Line

For detailed descriptions, see below.

MyHealth OnLine is where you can go every day for practical tips, tools, and strategies for better health. You can also find a doctor, view your medical history, and get information on your health plan benefits. The site keeps all your health information, all in one place. At MyHealth OnLine, you can:

Earn and track your reward dollars, so you know exactly how much you have in your account to spend on healthcare. (Remember, with HealthyU, you earn reward dollars when you do healthy activities throughout the year.)

Enjoy discounts and savings: Health and Wellness Discounts focuses on great discounts at health- and wellness-related retailers such as gyms, spas, salons, health food stores, sporting goods stores, and more.

Manage your healthcare information: Access your doctor’s contact information, plan benefits, research prescription and treatment options, savings information, and view your spending summary and claims. You can even order a new member ID card if you lose it.

You can also chat online with a Healthcare Concierge or Health Coach, read blogs from health experts, get advice on medical screenings and healthy activities, and set personal goals for managing your health.

To get the most out of your benefits, log in to MyHealth OnLine at www.upmchealthplan.com/FEHB. To create an account click on Sign Up and use the number on your member ID card to register.

Once you log in to MyHealth OnLine, complete your MyHealth Questionnaire. Not only will you earn reward dollars in your Health Incentive Account, but your answers generate a simple summary of your current health status and customize MyHealth OnLine with activities that benefit you the most.

You and your family can receive discounts through Health and Wellness Discounts.

Visit MyHealth OnLine and log in or register to find great discounts near you, including Active&Fit. The Active&Fit Direct program allows you to choose from 10,000+ participating fitness centers nationwide for $25 a month (plus a $25 enrollment fee and applicable taxes). Learn more: act.fit/upmc. The Active&Fit Direct program is offered through American Specialty Health Fitness, Inc., one of the nation's leading fitness networks serving millions of members. Plus, you'll have access to your health information and tools that can help you get or stay healthy!

Log in to MyHealth OnLine, click on Better Health and Wellness in the left-hand navigation, and then click on Health and Wellness Discounts to find great discounts near you. 

A UPMC Health Plan health coach can get you started on a healthy living plan today.

Enroll in one of our proven six-week or eight-week lifestyle or chronic condition coaching programs and earn reward dollars in your Health Incentive Account. A health coach can help you manage a variety of conditions, including asthma, diabetes, hypertension and low back pain. They can also help you lose weight, quit smoking, eat healthier, reduce stress, and make other lifestyle changes to improve your health. You can also choose to do a one-time visit by phone or connect via live chat. Participating in these programs also give you the opportunity to earn reward dollars in your Health Incentive Account.

To get started, call a health coach at 800-807-0751.

For immediate access to free healthcare advice 24 hours a day, seven days a week call the MyHealth 24/7 Nurse Line at 866-918-1591. From general health information to help with a specific sickness or injury, an experienced registered nurse will provide you with prompt and efficient service.

When you're not feeling well, you can have a face-to-face conversation with a UPMC provider over live video straight from your smart phone, tablet or computer. See a UPMC provider in 30 minutes or less to discuss your symptoms and get a treatment plan. And if you need a prescription, the provider can call it in to your local pharmacy. Download the mobile app from the iTunes App Store or Google Play by searching for "AnywhereCare" or you can register at upmcanywherecare.com from your computer.

When you download this free app to your smartphone, you can:

• Search for participating providers.
• Chat with a Healthcare Concierge.
• Access your member ID card.
• Contact your providers.
• Check the status of your claims.
• Take the MyHealth Questionnaire.

UPMC Health Plan offers the MyHealth Ready to Quit™ health coaching program. The program will help you to quit using tobacco with a personal action plan that includes behavior modification strategies and tools based on the latest research. You will also receive reward dollars in your HIA by participating in the program.

Get prescription-strength health help with RXWell. Whether you’re feeling anxious, stressed, or sad, RXWell has a path for you. This app is designed to help you become emotionally and physically healthy by combining health coaching support and proven techniques.

• Manage anxiety, stress, or depression. Choose from three effective programs based on your needs.
• Relax using helpful practices. Learn calming techniques that can help you feel more centered in 10 minutes or less.
• Get support from a real health coach. Receive a personalized plan, set up goals, and message your health coach to get help along the way.
• Track your progress. Identify behavioral, mood, and emotional patterns over time.

UPMC Health Plan offers a travel assistance plan through Assist America, a global emergency assistance program for members who are traveling more than 100 miles from home. Assist America can help locate qualified doctors and hospitals, replace forgotten prescriptions, provide emergency medical evacuation and arrange for transportation so family members can be with injured relatives. Support is accessible 24 hours a day, 365 days a year. For a complete list of Assist America services visit www.assistamerica.com.

To receive services, contact Assist America at 800-872-1414 in the USA, or at 1-609-986-1234 outside of the USA. The Assist America reference number for UPMC Health Plan members is 01-AA-UP-156243.

You may also download the Health Plan Mobile App for free to your smartphone.

UPMC Health Plan offers Myhealthfinder tool @ https://www.upmchealthplan.com/members/learn/benefits-and-services/preventive-health.aspx. This tool will provide personalized recommendations to help you take charge of your health.

UPMC Health Plan communicates by phone with our members who have a hearing impairment through TTY. If you have a hearing impairment, call our TTY number at 711.

Under the flexible benefits option, we determine the most effective way to provide services.

• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed- upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Standard Option Members enrolled in Medicare Part A and B are eligible for reimbursement of Medicare Part B premiums up to $800 per calendar year. See page 144.  This applies to annuitants who chose to enroll in UPMC for Life FEHB Retirees Medicare Advantage plan as well.  

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations, tobacco cessation programs, obesity weight loss programs, disease management and wellness programs. These services are covered at 100%. Note that some services require you to use a Plan provider in order for the preventive care to be covered. The coverage is fully described in Section 5, Preventive care. You do not have to meet the deductible before using these services.

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5.  The Plan typically pays 85% for in-network and 60% for out-of-network care.

Covered services include:

• Medical services and supplies provided by physicians and other healthcare professionals
• Surgical and anesthesia services provided by physicians and other healthcare professionals
• Hospital services; other facility or ambulance services
• Emergency services/accidents
• Mental health and substance abuse benefits
• Prescription drug benefits
• Dental benefits

Reward dollars earned in your health incentive account are automatically applied to pharmacy copayments and coinsurance once your plan deductible is met. The reward dollars you earn carry over from year to year, up to two times the annual deductible. See page 127 for more details on earning reward dollars in your Health Incentive Account.

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see page 78 for more details).

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan. In 2023, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $75 per month for a Self Only enrollment or $150 per month for a Self Plus One or Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,600 for an individual and $7,200 for a family. See maximum contribution information on page 84. You can use funds in your HSA to help pay your coinsurance, copayments, and other qualified expenses. You own your HSA, so the funds can go with you if you change plans or employment. The Plan will establish an HSA for you with Healthcare Bank, a division of Bell State Bank and Trust, this HDHP’s fiduciary (an administrator, trustee, or custodian as defined by Federal tax code and approved by the IRS.)

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

• Your HSA is administered by UPMC Benefit Management Services 
• Your contributions to the HSA are tax deductible
• Your HSA earns tax-free interest
• You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS publication 502 for a complete list of eligible expenses)
• Your unused HSA funds and interest accumulate from year to year
• It’s portable - the HSA is owned by you and is yours to keep, even when you leave federal employment or retire
• When you need it, funds up to the actual HSA balance are available

Important consideration if you want to participate in a Healthcare Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a HCFSA (such as FSAFEDS offers – see Section 11), this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA Health Care Flexible Spending Account, we will establish an HRA for you.

If you are not eligible for an HSA, for example you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA.

In 2023, we will give you an HRA credit of $900 per calendar year for a Self Only enrollment or $1,800 per calendar year for a Self Plus One or Self and Family enrollment. You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible. 

HRA features include:

• For our HDHP option, the HRA is administered by UPMC Health Plan
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP
• Unused credits carryover from year to year
• HRA credit does not earn interest
• HRA credit is forfeited if you leave federal employment or switch health insurance plans.
• An HRA does not affect your ability to participate in an FSAFEDS Healthcare Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements.

When you use participating providers, your annual limit for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $6,000 for Self Only or $12,000 for Self Plus One or Self and Family enrollment. When you use out-of-network providers, your annual limit for out-of-pocket expenses (deductibles and coinsurance) for covered services is limited to $8,000 for Self Only or $16,000 for Self Plus One or Self and Family enrollment. Certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum). Also, the family out-of-pocket maximum must be met by one or more members of the family before benefits are payable at 100%. Refer to Section 4, Your catastrophic protection out-of-pocket maximum, and HDHP Section 5, Traditional medical coverage subject to the deductible, for more details.

HDHP Section 5(i) describes the health education resources and account management tools available to you to help you manage your healthcare and your healthcare dollars.

UPMC Health Plan is the HRA fiduciary for this Plan.

You must:

• Enroll in this HDHP
• Have no other health insurance coverage, including an FSA (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage)
• Not be enrolled in Medicare
• Not be claimed as a dependent on someone else’s tax return
• Not have received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits in the last three months
• Complete and return all banking paperwork.

Eligibility for contributions is determined on the first day of the month following your effective date of enrollment and will be prorated for length of enrollment.

You must enroll in this HDHP.

Eligibility is determined on the first day of the month following your effective day of enrollment and will be prorated for length of enrollment.

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month. Premium pass-through contributions are based on the effective date of your enrollment in the HDHP.

Note: If your effective date in the HDHP is after the 1^st of the month, the earliest your HSA will be established is the 1^st of the following month.

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for length of enrollment. The entire amount of your HRA will be available to you upon your enrollment.

For 2023, a monthly premium pass-through of $75 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $900 (prorated for midyear enrollment).

For 2023, a monthly premium pass-through of $150 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $1,800 (prorated for midyear enrollment).

The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass-through and enrollee contribution funds, which when combined do not exceed the maximum contribution amount set by the IRS, $3,600 for an individual and $7,200 for a family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution.

You are eligible to contribute up to the IRS limit for partial-year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12-month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA. If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Catch-up contributions are discussed on page 84.

The full HRA credit will be available, subject to proration, on the effective date of enrollment. The HRA does not earn interest.

You may make an annual maximum contribution of $2,700.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $5,400.

You cannot contribute to the HRA.

You can access your HSA by debit card.

For qualified medical expenses under your HDHP, you will be automatically reimbursed when claims are submitted through the HDHP for deductible, coinsurance, and pharmacy copayments. For expenses not covered by the HDHP, such as orthodontia, a reimbursement form must also be submitted.

You can pay the out-of-pocket expenses for yourself, your spouse, or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA.

See IRS Publication 502 for a list of eligible medical expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a list of eligible medical expenses. Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable. Most other types of medical insurance premiums are not reimbursable.

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty; however they will be subject to ordinary income tax.

Not applicable – distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Funds are not available for withdrawal until all the following steps are completed:

• Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).
• The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA.
• The fiduciary sends HSA paperwork for you to complete and the fiduciary receives the completed paperwork back from you.

The entire amount of your HRA will be available to you upon your enrollment in the HDHP.

FEHB enrollee

HDHP

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA. See page 78 for HSA eligibility.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

Reward dollars earned in your health incentive account are automatically applied to pharmacy copayments and coinsurance once your plan deductible is met. The reward dollars you earn carry over from year to year, up to two times the annual deductible. For the HDHP option, you must meet your deductible first, before you can use HIA dollars.

Reward dollars earned in your health incentive account are automatically applied to pharmacy copayments and coinsurance once your plan deductible is met. The reward dollars you earn carry over from year to year, up to two times the annual deductible. For the HDHP option, you must meet your deductible first, before you can use HIA dollars.

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS.  You may contribute your own money to your account.  If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes.  Your own HSA contributions are tax-deductible.  To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

If you are newly enrolled in a HDHP during Open Season and your effective date is after January 1st or you otherwise have partial-year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS, as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death or disability.

If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your HSA.  The allowable catch-up contribution will be $1,000.  Contributions must stop once an individual is enrolled in Medicare.  Additional details are available on the U.S. Department of Treasury Website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase any health insurance other than a Medigap policy. You can no longer contribute to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 800-829-3676, or visit the IRS Website at www.irs.gov and click on “Forms and Publications.” Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimburseable under limited circumstances.

You will receive a periodic statement that shows the “premium pass-through,” withdrawals, and interest earned on your account. In addition, you will receive an Explanation of Payment statement when you withdraw money from your HSA. Balances can also be viewed through UPMC MyHealth OnLine and the UPMC Consumer Advantage mobile app.

Please review the chart on page 80 which details the differences between an HRA and an HSA. The major differences are:

• you cannot make contributions to an HRA
• funds are forfeited if you leave the HDHP
• an HRA does not earn interest
• HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP. 
• FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

Professional services, such as:

• Routine physicals
• Routine screenings
• Routine immunizations endorsed by the Centers for Disease control and Prevention (CDC)
• Routine prenatal care
• Tobacco Cessation programs
• Obesity weight loss programs

Disease management programs

In-Network: Nothing

Out-of-Network Colonoscopy screening: All charges

Other Out-of-Network services: 40%

Routine physical every 12 months by your PCP.

The following preventive services are covered at the time interval recommended at each of the links below:

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/index.html
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
• Individual counseling on prevention and reducing health risks
• Preventative care benefits for woman such as Pap smears, gonorrhea prophylactic medication to protect newborns, counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventative care benefits for women go to Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• Routine mammograms - covered

Tobacco cessation counseling

In-Network: Nothing

Out-of-Network: 40%

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the USPSTF recommendations.

Routine physicals which include:

• One exam every 24 months up to age 65
• One exam every 12 months age 65 and older

Routine exams limited to:

• One routine OB/GYN exam every 12 months, including 1 Pap smear and related services
• One routine hearing exam every 24 months
• One routine eye exam every 12 months

Note: Any procedure, injection, diagnostic services, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance and deductible.

In-Network: Nothing

Out-of-Network routine physicals: All charges

Other Out-of-Network services: 40%

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.
• Routine physical exams by an out-of-network provider

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org/Pages/default.aspx 
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org
• To build your personalized list of preventive
  services go to https://www.health.gov/
  myhealthfinder

Note: Any procedure, injection, diagnostic services, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-Network: Nothing

Out-of-Network well child visits: All charges

Other Out-of-Network services: 40%

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.
• Well-child visits for routine examinations by an out-of-network provider

The deductible applies to almost all benefits in this Section. In the You pay column, we say “No deductible” when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

After you met the deductible, if you have available funds in your Health Incentive Account, your HIA will pay your out-of-pocket expenses to extent that funds are available.

100% of allowable charges until you meet the deductible of $2,000 for Self Only enrollment or $4,000 for Self Plus One or Self and Family enrollment

In-network:  After you meet the deductible, you pay only the coinsurance or pharmacy copayment for covered services.  If you have available funds in your Health Incentive Account (HIA), the coinsurance or pharmacy copayment will be paid automatically from the funds available in your HIA.  If your HIA has been exhausted, you may choose to pay the coinsurance or pharmacy copayment from your HSA.  If your HIA has been exhausted, your HRA will pay the coinsurance or pharmacy copayment if funds are available. 

Out-of-network:  After you meet the deductible, you pay pharmacy copayments or coinsurance on our Plan allowance and any difference between our allowance and the billed amount.  If you have available funds in your Health Incentive Account (HIA), the coinsurance balance or pharmacy copayment will be paid automatically from the funds available in your HIA.  If your HIA has been exhausted, you may choose to pay the coinsurance or pharmacy copayment from your HSA.  If your HIA has been exhausted, your HRA will pay the coinsurance or pharmacy copayment if funds are available. 

In-network: After you meet the deductible, you pay only the coinsurance or pharmacy copayments for covered services. If your HIA has been exhausted, you may choose to pay the coinsurance or pharmacy copayments from your HSA.  If your HIA has been exhausted, your HRA will pay the coinsurance or pharmacy copayment if funds are available.  You may also pay for these expenses out-of-pocket, with your HSA.

Out-of-network:  After you meet the deductible, you pay pharmacy copayments or coinsurance on our Plan allowance and any difference between our allowance and the billed amount.  If you have available funds in your Health Incentive Account (HIA), the coinsurance balance or pharmacy copayment will be paid automatically from the funds available in your HIA.  If your HIA has been exhausted, you may choose to pay the coinsurance or pharmacy copayment from your HSA.  If your HIA has been exhausted, your HRA will pay the coinsurance or pharmacy copayment if funds are available. 

Professional services of physicians

• In physician's office
• In a convenience care clinic
• During a hospital stay
• In a skilled nursing facility. Limited to 100 days per calendar year combined with Extended care facility admissions 
• Office medical consultants
• Second surgical opinion
• Advance care planning

In-Network:  15%

• Physician services for a Virtual Visit
• Professional interpretation of diagnostic testing results

In-Network: 15%

Out-of-Network: 40%

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammogram
• CT (CAT) Scans/MRIs
• Ultrasound
• Electrocardiogram and EEG

In-Network: 15%

Complete maternity (obstetrical) care, including:

• Prenatal care
• Screening for gestational diabetes 
• Delivery
• Postnatal care
• Professional interpretation of diagnostic testing results

In-Network: 15%

Out-of-Network: 40%

In-Network: 15%

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery as long as an in-network providers are used.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

In-Network: 15%

In-Network: Nothing (No deductible)

Out-of-Network: 40%

Voluntary family planning services, limited to:

• Tubal ligation
• Injectable contraceptive drugs (such as Depo-Provera)
• Surgically implanted contraceptives
• Intrauterine devices (IUDs)
• Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit.

In-Network: Nothing (No deductible)

Out-of-Network: 40%

Voluntary family planning services, limited to:

• Vasectomy

In-Network: 15% coinsurance after deductible is met

Out-of-Network: 40%

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Infertility is the documented inability of a person under the age of 35 years to conceive a child within a 12 month period or a person 35 years or older to conceive a child within a six month period: (a) of unprotected coitus (sexual intercourse); or (b) after at least six episodes of artificial insemination.

Medical Description

Infertility is the documented inability of a woman to conceive a child. Infertility may be caused by female factors (e.g. pelvic adhesions, ovarian dysfunction, function or transport, or prior ligation); male factors (e.g. abnormalities in sperm production, function or transport or prior vasectomy), a combination of both male and female factors, and unknown causes. Once infertility is diagnosed, treatments for infertility may begin. The focus of this policy is the diagnosis of infertility. Treatment of the causes of infertility is not addressed in this policy. Refer to PAY.018 – Infertility – Treatment policy.

 Specific Indications for Diagnosis

• Member must fit the definition for infertility (as indicated in Section II Definitions)
• Members must be pre-menopausal and reasonably expect fertility as a natural state; or if menopausal, should have experienced it at an early age

Diagnosis and treatment of Infertility

Depending on the member’s unique medical situation, the following diagnostic tests to diagnose fertility in males and females may be considered medically necessary:

• History & Physical
• Sperm function tests
• Hysterosalpingogram
• Hysteroscopy
• Sonohysterogram
• Prediction of Ovarian Reserve Hormone Evaluation
• Evaluation of folliculogenesis
• Endometrial biopsy
• Diagnostic laparoscopy
• Follow-up Conference
• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intrauterine insemination (IUI)
  • Intracervical insemination (ICI)
• Artificial reproduction:
  • Assisted Reproductive Technologies (ART)- all clinical and laboratory treatments in which both human oocytes and sperm, or embryos, are manipulated outside of the body with the intent of establishing pregnancy.
• Iatrogenic infertility (Fertility Preservation) - Coverage includes cryopreservation of embryos, eggs, sperm, and ovarian and testicular tissues in the case of medically necessary chemotherapy, radiation or pharmacological treatment with a likely side effect of
• Infertility prescription drugs
• Lifetime maximum benefit per member is $25,000 and includes all of the above except artificial insemination which is exempt from the lifetime maximum of $25,000. Coverage of member’s preserved specimen is only available while the member is enrolled in UPMC Health Plan. Member is responsible for the cost once the member’s enrollment terminates or reaches the $25,000 maximum lifetime benefit.

Limitations/Contraindications

Normal physiological causes of infertility such as menopause

• Infertility resulting from voluntary sterilization
• The following diagnostic tests are considered investigational:

-         Tests to assess/improve sperm movement, or computer-assisted sperm analysis (CASA)

-         Analysis of adenosine triphosphate (ATP) in ejaculation

-         Tubaloscopy

-         Anti-zona pellucida antibodies

-         Hyaluronan binding assay (HBA)

-         Sperm washing and swim-up when performed as part of insemination

In order to assess medical necessity for infertility services, adequate information must be furnished by the treating physician. Necessary documentation includes, but is not limited to the following:

• Member’s age, clinical history, physical and functional status;
• Documentation of infertility, testing if done, and treatment history
• Documentation of any history of substance abuse, including smoking;
• Social Service evaluation
• Lab results: HIV antibody

Diagnostic tests for infertility may be ordered by a participating provider. However, most anti-retroviral therapy drugs and procedures should only be ordered or performed by credentialed Reproductive Endocrinologists.

If a member lives in an out-of-network area, then the credentials of the nearest Reproductive Endocrinologist or OB/Gynecologist must be reviewed by the Credentials Specialist prior to approval for coverage. Refer to plan-specific infertility riders. 

The procedure regarding a member acting as a surrogate mother is only covered if the couple has a relationship under which the FEHB Program recognizes each partner as a spouse of the other. 

In-Network: 15%

Out-of-Network: 40%

Not covered:

• Member acting as a surrogate mother and all services and supplies associated with surrogate motherhood are not covered by the UPMC Insurance Services Division, nor are supplies and services related to the following:
  • Pre-pregnancy evaluations
  • Prenatal care
  • Perinatal care
  • Postnatal care

• Testing and treatment
• Allergy injections

In-Network: 15%

In-Network: 15%

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 106.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following a qualifying event/condition is provided for up to 12 sessions.
• Dialysis - hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy
• Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder
• Medical nutrition therapy to treat a chronic illness or condition; includes nutrition assessment and nutritional counseling by a dietitian or facility-based program which is ordered by a physician.
• Chronic Renal Disease, Diabetes Mellitus, and High Risk Obstetrical Symptomatic Conditions: unlimited number of visits when medically necessary
• Morbid Obesity: limited to an initial assessment and five follow-up visits for a total of six visits per calendar year
  Heart Disease, Symptomatic HIV/AIDS, and Celiac Disease: limited to two visits per calendar year
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services in Section 3.

• Pain management

Note: Pain management is covered if you are diagnosed with refractory chronic pain of at least six months duration. The provider must demonstrate that they anticipates these services to result in substantial improvement to your medical condition.

In-Network: 15%

Nutritional products that are specialty food products are covered when Medically Necessary and when under the direction of a physician on an outpatient basis, for the treatment of inborn errors of metabolism and some hereditary metabolic disorders in accordance with state law. Coverage is independent of whether the product is administered orally or enterally. These disorders include:

• Phenylketonuria (PKU)
• Branch-chain ketonuria
• Galactosemia 
• Homocysteinuria
• Allergic reaction or malabsorption syndromes, specifically hemorrhagic colitis

In-Network: 15% (no deductible)

Out-of-Network: 40% (no deductible)

Rehabilitation services are limited to the greater of 60 consecutive days of coverage or 25 visits per condition, per calendar year.

Habilitation services are also limited to the greater of 60 consecutive days of coverage or 25 visits per condition, per calendar year.

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a physician:

• orders the care
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

In-Network: 15%

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

Limited to the greater of 60 consecutive days of coverage or 25 visits per condition, per calendar year for Rehabilitation.

Limited to the greater of 60 consecutive days of coverage or 25 visits per condition, per calendar year for Habilitation.

In-Network: 15%

Not covered:

• Speech therapy for developmental delays

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children.

In-Network: 15%

• External hearing aids (see Section 5(a) Orthopedic and prosthetic devices, page 98.)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices.

In-Network: 15%

Not covered:

• Hearing aid batteries
• Hearing services that are not shown as covered

• One pair of standard eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
  

In-Network: 15%

Out-of-Network: 40%

• Annual eye examination once every 24 months for adults and children

To use your eye examination benefit, call us at 877-648-9641 or visit www.upmchealthplan.com/FEHB/ to locate a vision care provider.

In-Network: 15%

Out-of-Network: 40%

Not covered:

• Eyeglasses or contact lenses, except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

In-Network: 15%

Not covered:

• Cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Hearing aids are covered at the applicable coinsurance level after the calendar year deductible is met for adults age 21 and over. The benefit limit is $1,500 per ear in each 36 month period.
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants.
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy. 

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and Ambulance services.

In-Network: 15%

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads, and heel cups (covered only with a diagnosis of diabetes or peripheral vascular disease)
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices (gradient compression stockings may be covered for certain diagnoses)
• Prosthetic replacements when it is determined by us that a repair costs less than 50% of a replacement
• Hearing aids for children up to age 21
• Hearing aid batteries

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Speech generating devices
• Blood glucose monitors
• Insulin pumps

Note: Call us at 877-648-9641 as soon as your physician prescribes this equipment. We can assist you in locating a participating supplier. 

In-Network: 15%

Not covered: 

• Audible prescription reading devices
• Replacement or duplication except when necessitated due to a change in the patient’s medical condition or the cost to repair the item exceeds 50% of the price of a new item
• Comfort or convenience items, for your comfort or convenience or the comfort or convenience of your caretaker, including, but not limited to, fitness club memberships, air conditioners, televisions, phones, dehumidifiers, air purifiers, food blenders, exercise equipment, orthopedic mattresses, home or automobile modifications, whirlpools, barber or beauty services, guest service or similar items, even if recommended by a professional provider.
• Medical equipment and supplies that are:
  -  expendable in nature (i.e. disposable items such as incontinent pads, catheters, irrigation kits, disposable electrodes, ace bandages, elastic stockings, and dressings) and
  -  primarily used for non-medical purposes, regardless of whether recommended by a professional provider

• Home healthcare ordered by a Plan physician and provided by a registered nurse (RN), licensed practical nurse (LPN), licensed vocational nurse (LVN), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications

In-Network: 15%

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

• Manipulation of the spine and extremities limited to 25 visits per calendar year
• Must be medically necessary
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Children under the age of 13 must receive prior authorization for chiropractic care.

In-Network: 15%

Coverage is limited to acupuncture for the following conditions. Acupuncture is limited to 12 visits per calendar year.

• Nausea and vomiting of pregnancy (hyperemesis gravidarum)
• Post-operative nausea and vomiting
• Post-chemotherapy nausea and vomiting
• Migraines
• Chronic low back pain
• Chronic neck pain
• Knee osteoarthritis

In-Network: 15%

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback
• Acupuncture, other than listed above 

Diabetic Self-Management Education (DSME) - Outpatient diabetes self-management training and education program is a program of self-management, training, and education, for the treatment of diabetes.  You do not need a physician prescription and no referral is required. You must have a chronic condition and your care must be medically necessary. There is no visit limit for this service.

Nothing (No deductible) 

Nutritional Counseling - the assessment of a person's overall nutritional status followed by the assignment of an individualized diet, counseling, and/or nutrition therapies to treat a chronic illness or condition. Services must be delivered by a dietitian or facility-based program, ordered by a participating physician and offered by a participating provider. Coverage is limited to two visits per calendar year. Also see Medical nutrition therapy under Treatment therapies on page 96.

In-Network: 15%

Tobacco Cessation- individual, group, phone counseling provided by UPMC Health Plan, call 800-807-0751, and over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence. You must have a written prescription from your doctor for all medications, including OTC, in order to obtain coverage. See Prescription drug benefits.

Childhood obesity screening programs and treatment interventions

In-Network: 15%

Out-of-Network: 40%

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the
  surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery)
• Insertion of internal prosthetic devices . See 5(a) Orthopedic and prosthetic devices for device coverage information
• Voluntary sterilization (e.g., vasectomy)
• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

In-Network: 15%

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities, cleft lip, cleft palate, birth marks, and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedemas
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)
• Gender Affirming Surgery
  • Surgical treatment for gender affirmation requires prior authorization and is limited to the following:
  • For female to male surgery: mastectomy, oophorectomy, salpingoophorectomy, hysterectomy, vaginectomy, metoidioplasty, phalloplasty, and scrotoplasty.
  • For male to female surgery: orchiectomy, penectomy, penile inversion vaginoplasty, breast augmentation, and labiaplasty.
• Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

In-Network: 15%

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplasia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Surgery for TMJ disorder. 

Note: In order for surgery to be covered, documentation in the medical record must support that treatment of TMJ disorder with conventional non-surgical therapy has not resulted in adequate improvement.

• Other surgical procedures that do not involve the teeth or their supporting structures

In-Network: 15%

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

In-Network: 15%

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologus tandem transplants for
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

In-Network: 15%

Blood or marrow stem cell transplants

The plan extends coverage for the diagnoses as indicated below.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi's Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucupolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia 
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma  with recurrence (relapsed)
  • Amyloidosis
  • Breast cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

In-Network: 15%

Mini-transplants performed in a clinical trial setting (non-myeloblative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

In-Network: 15%

Out-of-Network: 40%

These blood or marrow stem cell transplants covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial. 

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma 
  • Multiple sclerosis 
  • Sickle cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myeloproliferative disorders (MDDs)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

UPMC Health Plan utilizes the top transplant centers in Pennsylvania. Should care not be available in Pennsylvania, UPMC Health Plan will arrange for services out of the area.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

In-Network: 15%

Out-of-Network: 40%

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility. Limited to 100 days per calendar year combined with Extended care facility admissions. 
• Ambulatory surgical center
• Office

In-Network: 15%

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

In-Network: 15%

Other hospital services and supplies, such as:

• Operating, recovery and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

In-Network: 15%

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Observation level of care

Note: Observation is a level of care in an acute care hospital setting that is appropriate when a patient is receiving ongoing short-term treatment and assessments and it is not clear if inpatient level of care is needed. Reassessments are made during this time to determine if the patient requires inpatient admission, or may be discharged and receive follow-up in the outpatient setting.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

In-Network: 15%

In-Network: 15%

In-Network: 15%

In-Network: 15%

In-Network: 15%

Out-of-Network: 40%

In-Network: 15%

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient in a hospital, including doctors’ services

Note: We do not waive ER coinsurance if you are admitted to the hospital.

• Emergency care at a doctor's office
• Emergency care at an urgent care center
• Emergency care as an outpatient in a hospital, including doctor's services

Note: We do not waive ER coinsurance if you are admitted to the hospital.

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Professional ambulance service when medically appropriate

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

In order to ensure compliance with the Mental Health Parity and Addiction Equity Act, member cost-sharing may be reduced for certain services when received for the diagnosis or treatment of a mental health or substance use disorder or condition.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management  (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

In-Network: 15%

Out-of-Network: 40%

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

In-Network: 15%

Out-of-Network: 40%

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, residential treatment, and other hospital services

In-Network: 15%

Out-of-Network: 40%

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization, half-way house, full-day hospitalization, or facility-based intensive outpatient treatment

In-Network: 15%

Out-of-Network: 40%

• Services related to disorders that are not diagnoses listed in the most recent edition of the diagnostic and Statistical manual of Mental Disorders
• Treatment for organic disorders, including, but not limited, to organic brain disease
• Marriage or family counseling, except when rendered in connection with services provided for a treatable mental disorder
• Aversion therapy, bioenergetic therapy, carbon dioxide therapy, confrontation therapy, crystal healing therapy, cult deprogramming, electrical aversion therapy for alcoholism, narcotherapy, orthomolecular therapy, primal therapy, expressive therapies such as art or psychodrama, and hyperbaric or other therapy
• Sex therapy, listed in the most recent edition of the diagnostic and Statistical manual of Mental Disorders and treatment for sexual addiction
• Sedative action electrostimulation therapy
• Sensitivity training
• Twelve-step model programs as sole therapy for conditions, including, but not limited to, addictive gambling

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail-order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered
• Insulin
• Diabetic supplies limited to disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
• Tobacco cessation drugs including over-the-counter (OTC) drugs approved by the FDA to treat tobacco dependence. (See page 103).
• Drugs to treat gender dysphoria

In-Network:

Retail (up to a 30-day supply)

$20 copayment for generic drugs

$50 copayment for preferred brand-name drugs

$100 copayment for non-preferred brand-name drugs

90-day maximum supply available at certain retail outlets for three copayments.

Specialty Prescription Drugs (up to a 30-day supply)

50% coinsurance up to a maximum of $250

Mail-Order (up to a 90-day supply)

$40 copayment for generic drugs

$100 copayment for preferred brand-name drugs

$200 copayment for non-preferred brand-name drugs

Specialty drugs are not covered through Mail-Order

Notes:

• If there is no generic equivalent available, you will pay the brand-name copayment.
• Copayments are waived for tobacco cessation drugs. (No deductible)

Out-of-Network:  All charges

Generic versions of contraceptives are available with no copayment and no deductible.

Preferred and non-preferred brand name drugs will follow the plan payment level listed in the above section.

Medications to promote better health as recommended by the ACA. 

The following medications are covered with the applicable copay prior to the deductible being met. Please see www.upmchealthplan.com/FEHB for the list of qualifying medications.

(No deductible) Applicable copay applies

Retail (up to a 30-day supply)

$20 copayment for generic drugs

Mail-Order (up to a 90-day supply)

$40 copayment for generic drugs

Out-of-Network:  All charges

The pharmacy benefit plan includes coverage for some preventive medications at no cost share when certain criteria in accordance with
the Patient Protection and Affordable Care Act of 2010 (PPACA) are met. The following drugs are eligible for ACA coverage. Generic products are required when available.

• Bowel preps for members age 45-75. Coverage is for generic products limited to 2 prescriptions per year.

• Smoking cessation products for all members age 18 and older

• Aspirin (81 mg – 325 mg) for members of child-bearing potential and adults through age 69

• Contraceptives for members of child - bearing potential through age 51.

• Breast cancer medications (generic tamoxifen, raloxifene, aromatase inhibitors) used for prevention in members age 35 and older who are at increased risk for breast cancer.

• Statins for members age 40-75. Statin must be low to moderate intensity and the member must have no history of cardiovascular disease, with at least one cardiovascular risk factor.

• Pre-Exposure Prophylaxis (PrEP) for members who are not infected with HIV who are at high risk for HIV infection.

• Folic acid supplements for members of childbearing age 400 & 800 mcg.

• Fluoride tablets, solution (not toothpaste, rinses) for children age 6 months through 16 years.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Note: To receive this benefit a prescription from a doctor must be presented to pharmacy.

Nothing (No deductible)

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy (after the plan deductible is met)
• Vitamins, nutrients, and food supplements not listed as a covered benefit even if a physician prescribes or administers them are not covered except medically necessary formulas that are equivalent to a prescription drug for the treatment of phenylketonuris (PKU) branched-chain ketonuris, galactosemia, and homocystinuria as administered under the direction of a physician or listed as a covered benefit.
• Non-prescription medications, except those listed on the Your Choice formulary
• Medications prescribed for foreign travel

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco cessation benefit. (See page 103)

All charges

In-Network: 15%

We have no other dental benefits.

You and your family members can call Member Services with questions or concerns. Our Healthcare Concierge team delivers fast, personal service, and strives to answer your question on the first call. To speak with a Healthcare Concierge, call 877-648-9641. Our Healthcare Concierge team is available Monday through Friday from 7 a.m. to 7 p.m. and Saturday from 8 a.m. to 3 p.m. TTY/TDD users should call 711.

You and your family can earn reward dollars in a health incentive account by completing healthy activities throughout the year. These activities have been specially designed by our team of doctors, nurses, nutritionists, exercise physiologists, and behavioral health experts. They will alert you to potential health issues and provide tools to help you address the issues. Activities include:

• MyHealth Questionnaire: The confidential health risk assessment, powered by WebMD®, is a 20-minute online survey you take once a year. The results can help you understand your health status and suggest ways to make improvements. You can earn 50 reward dollars if completed within the 90 days of your effective date. You will earn 25 reward dollars if completed after 90 days. 
• Biometric Screening: This health screening measures your total cholesterol level and glucose level. Your doctor will also check your blood pressure, height, weight, and body mass index (BMI). It is a simple assessment that can be done at your doctor’s office, a lab, or some convenience care clinics. Biometric screenings are recommended once every three years. You will earn 15 reward dollars for completing the LDL screening and 15 reward dollars for completing the glucose screening.
• Condition or Lifestyle Management Coaching: A health coach for condition management will help you manage a chronic condition so you can live your healthiest life possible. Health coaches can help with heart disease, diabetes, asthma, COPD, depression, and much more. Lifestyle programs include smoking cessation, stress management, physician activity, weight management, and nutrition. You can earn up to 150 reward dollars for completing a condition management program, and up to 110 reward dollars for completing a lifestyle management program.
• You will also receive reward dollars for completing activities uniquely customized just for you.

You will find a full list of eligible activities by logging in to MyHealth OnLine, the website that powers HealthyU, UPMC Health Plan’s member website.

The reward dollars you earn apply to your pharmacy copayments and coinsurance after your deductible is met. In one plan year, you can earn up to $250 for Self Only coverage or $500 for Self Plus One or Self and Family coverage. Any unused reward dollars — at a value up to two times your annual deductible —automatically roll over to the next year.

The Plan will prorate any mid-year member enrollment deductibles, out-of-pocket costs and Health Incentive Account funds.

To learn more about HealthyU, visit www.upmchealthplan.com/FEHB or call a Healthcare Concierge at 877-648-9641.

HealthyU is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "health questionnaire" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a health screening (routine blood work), which will include a blood test for glucose screening and lipid panel .You are not required to complete the health questionnaire or to participate in the blood test or other medical examinations.

However, employees who choose to participate in the wellness program can receive an incentive of up to  $250 for self, $500 for self plus one, and $500 for self plus family for completing healthy activities that are customized for each member. Although you are not required to complete the health questionnaire or participate in the health screening (routine blood work), only employees who do so will receive the selected reward.

Additional incentives as noted above may be available for employees who participate in certain health-related customized activities If you are unable to participate in any of the health-related activities, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting UPMC Health Plan at 877-648-9641.

The information from your health questionnaire and the results from your health screening (routine blood work) will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as recommended healthy activities. You also are encouraged to share your results or concerns with your own doctor.

Members receiving the COVID-19 vaccination are eligible to receive a $25 Health Incentive reward. You must provide a Centers for Disease Control and Prevention COVID-19 Vaccination Card as proof of attestation for receiving the vaccination. The annual maximum Health Incentive reward dollars per year remains $250 for Self Only coverage and $500 for Self and Family and Self Plus One coverage.

You and your family members have access to MyHealth, A nationally acclaimed health and wellness program.  MyHealth guides and motivates you to live your healthiest life possible through online programs, tools, and over-the-phone advice. MyHealth was developed by UPMC, one of the nation's top hospital systems. This gives us in-house expertise in condition management and lifestyle behavior change that no other health plan can match.

MyHealth includes:

• MyHealth OnLine
• MyHealth Questionnaire
• MyHealth Community
• Health Coaching
• MyHealth Advice Line

For detailed descriptions, see below.

MyHealth OnLine is where you can go every day for practical tips, tools, and strategies for better health. You can also find a doctor, view your medical history, and get information on your health plan benefits. The site keeps all your health information, all in one place. At MyHealth OnLine, you can:

Earn and track your reward dollars, so you know exactly how much you have in your account to spend on healthcare. (Remember, with HealthyU, you earn reward dollars when you do healthy activities throughout the year.)

Enjoy discounts and savings: Health and Wellness Discounts focuses on great discounts at health- and wellness-related retailers such as gyms, spas, salons, health food stores, sporting goods stores, and more.

Manage your healthcare information: Access your doctor’s contact information, plan benefits, research prescription and treatment options, savings information, and view your spending summary and claims. You can even order a new member ID card if you lose it.

You can also chat online with a Healthcare Concierge or Health Coach, read blogs from health experts, get advice on medical screenings and healthy activities, and set personal goals for managing your health.

To get the most out of your benefits, log in to MyHealth OnLine at www.upmchealthplan.com/FEHB. To create an account click on Sign Up and use the number on your member ID card to register.

You and your family can receive discounts through Health and Wellness Discounts.

Visit MyHealth OnLine and log in or register to find great discounts near you, including Active&Fit. The Active&Fit Direct program allows you to choose from 10,000+ participating fitness centers nationwide for $25 a month (plus a $25 enrollment fee and applicable taxes). Learn more: act.fit/upmc. The Active&Fit Direct program is offered through American Specialty Health Fitness, Inc., one of the nation's leading fitness networks serving millions of members. Plus, you'll have access to your health information and tools that can help you get or stay healthy!

Log in to MyHealth OnLine, click on Better Health and Wellness in the left-hand navigation, and then click on Health and Wellness Discounts to find great discounts near you. 

A UPMC Health Plan health coach can get you started on a healthy living plan today.

Enroll in one of our proven six-week or eight-week lifestyle or chronic condition coaching programs and earn reward dollars in your Health Incentive Account. A health coach can help you manage a variety of conditions, including asthma, diabetes, hypertension and low back pain. They can also help you lose weight, quit smoking, eat healthier, reduce stress, and make other lifestyle changes to improve your health. You can also choose to do a one-time visit by phone or connect via live chat. Participating in these programs also give you the opportunity to earn reward dollars in your Health Incentive Account.

To get started, call a health coach at 800-807-0751.

For immediate access to free healthcare advice 24 hours a day, seven days a week call the MyHealth 24/7 Nurse Line at 866-918-1591. From general health information to help with a specific sickness or injury, an experienced registered nurse will provide you with prompt and efficient service.

When you're not feeling well, you can have a face-to-face conversation with a UPMC provider over live video straight from your smart phone, tablet or computer. See a UPMC provider in 30 minutes or less to discuss your symptoms and get a treatment plan. And if you need a prescription, the provider can call it in to your local pharmacy. Download the mobile app from the iTunes App Store or Google Play by searching for "AnywhereCare" or you can register at upmcanywherecare.com from your computer.

When you download this free app to your smartphone, you can:

• Search for participating providers.
• Chat with a Healthcare Concierge.
• Access your member ID card.
• Contact your providers.
• Check the status of your claims.
• Take the MyHealth Questionnaire.

Get prescription-strength health help with RXWell. Whether you’re feeling anxious, stressed, or sad,  RXWell has a path for you. This app is designed to help you become emotionally and physically healthy by combining health coaching support and proven techniques.

• Manage anxiety, stress, or depression. Choose from three effective programs based on your needs.
• Relax using helpful practices. Learn calming techniques that can help you feel more centered in 10 minutes or less
• Get support from a real health coach. Receive a personalized plan, set up goals, and message your health coach to get help along the way.
• Track your progress. Identify behavioral, mood, and emotional patterns over time.

UPMC Health Plan offers a travel assistance plan through Assist America, a global emergency assistance program for members who are traveling more than 100 miles from home. Assist America can help locate qualified doctors and hospitals, replace forgotten prescriptions, provide emergency medical evacuation and arrange for transportation so family members can be with injured relatives. Support is accessible 24 hours a day, 365 days a year. For a complete list of Assist America services visit www.assistamerica.com.

To receive services, contact Assist America at 800-872-1414 in the USA, or at 1-609-986-1234 outside of the USA. The Assist America reference number for UPMC Health Plan members is 01-AA-UP-156243.

You may also download the Health Plan Mobile App for free to your smartphone.

UPMC Health Plan offers Myhealthfinder tool @ https://www.upmchealthplan.com/members/learn/benefits-and-services/preventive-health.aspx. This tool will provide personalized recommendations to help you take charge of your health.

UPMC Health Plan communicates by phone with our members who have a hearing impairment through TTY. If you have a hearing impairment, call our TTY number at 711.

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed- upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

HealthyU makes it easy to get information, knowledge, and resources to help you guide your healthcare needs and healthcare costs. You can earn reward dollars and save more money by picking the best healthcare options for you.

Educate yourself on your health by:

• Asking your doctor for generic drugs
• Reviewing treatment options for your condition on MyHealth OnLine, and possibly avoid costly procedures
• Working with a health coach to assist with your health decisions
• Calling the Nurse Advice Line if you have questions on any health issue

Our secure member portal, MyHealth OnLine, gives you instant access to tools and support. You can earn and track reward dollars, search for a doctor, review claims and spending account balances, chat with a Member Services Healthcare Concierge, and more.

Once you log in to MyHealth OnLine, complete your MyHealth Questionnaire and earn reward dollars in your health incentive account. Your answers generate a simple summary of your current health status and customize MyHealth OnLine with activities that benefit you the most.

UPMC Health Plan provides health education, decision-making, and price and quality comparison tools. You are able to access more than 200 health topics covering many common conditions, procedures, and alternative treatments. You’ll also find online health coaching, helpful videos, and downloadable educational materials.

Join our health discussion online. Visit the UPMC MyHealth Facebook page or follow @UPMCMyHealth on Twitter for health and wellness information. Or read the UPMC MyHealth Matters blog from our health and nutrition experts that cover a variety of topics that will inspire you to take an active role in your health.

To get the most out of your benefits, log in to MyHealth OnLine at www.upmchealthplan.com/FEHB. To create an account click on Sign Up and use the number on your member ID card to register.

If you have an HSA,

• You will receive a monthly statement outlining your account balance and activity.
• Your HSA balance will be available through MyHealth OnLine. Visit www.upmchealthplan.com/FEHB and login to MyHealth OnLine using the member identification number on your member ID card.

If you have an HRA,

• Your HRA balance will be available through MyHealth OnLine. Visit www.upmchealthplan.com/FEHB and login to MyHealth OnLine using the member identification number on your member ID card.
• Your balance will also be shown on your EOB form.

As a member of this HDHP, you may choose any provider. However, you will receive discounts when you see a network provider. Directories are available online at

www.upmchealthplan.com/FEHB.

Link to online pharmacy through www.upmchealthplan.com/FEHB.

Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.upmchealthplan.com/FEHB.

Patient safety information is available online at www.upmchealthplan.com/FEHB.

Case managers may be contacted by calling Member Services at 877-648-9641 and asking to be connected with our care management area.

In most cases, providers and facilities file claims for you. Provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 877-648-9641 or at our website at www.upmchealthplan.com/FEHB.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number, and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payer – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

UPMC Health Plan
Claims Department
P.O. Box 2999
Pittsburgh, PA 15230-2999

Submit your claims to:

UPMC Health Plan
Claims Department
P.O. Box 2999
Pittsburgh, PA 15230-2999

Submit your claims to:

UPMC Health Plan
Claims Department
P.O. Box 2999
Pittsburgh, PA 15230-2999

We will notify you of our decision within 30 days after we receive your post-service your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30 day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected. 

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

You may designate a representative of your choice, such as family member, friend, advocate, or attorney, to act on your behalf at any point during the Complaint or Grievance process.  For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent.   For the purposes of this section, we are also referring to your authorized representative when we refer to you.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English version of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and the procedure codes. 

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within six months from the date of our decision; and

b) Send your request to us at:

UPMC Health Plan
Complaints and Grievances Department
P.O. Box 2939
Pittsburgh, PA 15230-2999

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Include your email address (optional for member), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim; or

b) Write to you and maintain our denial; or

c) Ask you or your provider for more information,

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

If you do not agree with our decisions, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3610. 

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email.  Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note:  If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note:  You are the only person who has a right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct.  OPM will send you a final decision within 60 days.  There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue.  If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval.  This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision.  This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process.  Further, federal law governs your lawsuit, benefits, and payment of benefits.  The federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision.  You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines.  For more information on NAIC rules regarding the coordination of benefits, visit our website at www.upmchealthplan.com/FEHB.

When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

TRICARE is the healthcare program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or a similar agency pays its maximum benefits for your treatment, we will cover your care.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone 877-888-3337 (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

Your benefit plan covers routine clinical services that are part of a clinical trial or research study approved by an Institutional Review Board as well as medically necessary services to treat complications arising from participation in the clinical trials and studies. These services must be prior authorized by UPMC Health Plan and all plan limitations apply.

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan — You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 877-648-9641 or see our website at www.upmchealthplan.com/FEHB.

We offer two options designed to help retired Standard Option HMO members who are enrolled in Medicare Parts A and B with their Medicare Part B premium. The first option you may choose is to enroll in the new “ UPMC for Life FEHB Retirees”  Medicare Advantage plan; if you choose this option the benefits of the new plan will apply. In addition to partial reimbursement of your Medicare Part B premium, we will cover additional benefits, including several $0 cost services and hearing aids. The second option is to be covered by the Standard Option HMO and Medicare Parts A and B, and you choose not to enroll in the UPMC for Life FEHB Retirees, then your coinsurance will be reduced to 0% after the calendar year deductible is met. Whichever option you choose you will be eligible for up to a $800 Medicare Part B premium reimbursement. UPMC Health Plan will reimburse enrolled members up to $66.67 per month up to a maximum of $800 per year for Medicare Part B premium through a health reimbursement arrangement (HRA).  This reimbursement is available once per year and must be requested through our portal with proof of payment.

 You may enroll in this program if: 

• You enroll in the Plan’s Standard Option HMO
• You have Medicare Parts A and B
• The FEHB subscriber completes an additional application for enrollment in UPMC for Life FEHB Retirees

If, for any reason, you do not meet the enrollment requirements for UPMC for Life FEHB Retirees you will no longer be eligible to participate in the program.  Your reimbursements will end and your regular FEHB Standard Option HMO will resume.

 To learn more about “UPMC for Life FEHB Retirees” and how to enroll, call us at 1-844-383-1819.  Help is available seven days a week from 7 a.m. to 9 p.m,  or visit our website at Federal Employee Health Benefits (FEHB) | UPMC Health Plan TTY users should call 711.

 If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan.  These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.  To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227) (TTY: 877-486-2048) or at www.medicare.gov. If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan:  We offer a Medicare Advantage plan known as “UPMC for Life FEHB Retirees”. UPMC for Life FEHB Retirees enhances your FEHB coverage by lowering cost-sharing for many services and/or adding benefits.  If you have Medicare Parts A and B, or Medicare Part B only, and you reside in our Medicare Advantage plan area, you are able to enroll in UPMC for Life FEHB Retirees.  Enrolling in UPMC for Life FEHB Retirees does not change your FEHB premium.  Your enrollment is in addition to your FEHB Standard Option enrollment: however, your benefits will be provided under the UPMC for Life FEHB Retirees and are subject to Medicare rules. If you are considering enrolling in UPMC for Life FEHB Retirees , please call us at 1-844-383-1819.  Help is available seven days a week from 7 a.m. to 9 p.m.,  or visit our website at Federal Employee Health Benefits (FEHB) | UPMC Health Plan TTY users should call 711.

FEHB annuitants that are enrolled in the FEHB Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan receive additional benefits and cost savings.  

Annual Deductible

Standard Option HMO You pay without Medicare Part B: $850 per individual

Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan: You pay $0 per individual

Standard Option You pay with Medicare Part B: $700 per individual

Annual Out of Pocket Maximum

Standard Option You pay with or without Medicare Part B: $6,000 per individual

Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan: You pay $3,400 per individual

Medicare Part B Premium Reimbursement Offered

Standard Option You receive without Medicare Part B: None

Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan with Medicare Part B:

You receive up to $800 per calendar year submitted once per year with a proof of premium payment and reimbursement form

Primary Care Physician

Standard Option You pay with or without Medicare Part B: $20

Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan:

You pay $0

Specialist Physician

Standard Option You pay with or without Medicare Part B: $50

Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan:

You pay $25

Inpatient Hospital

Standard Option You pay without Medicare Part B: You pay 20% after deductible

Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan: You pay $0

Standard Option HMO with Medicare Part B: Deductible then 0%

Outpatient Hospital

Standard Option You pay without Medicare Part B: You pay 20% after deductible

Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan: You pay $0

Standard Option HMO with Medicare Part B: Deductible then 0%

Prescription Drugs

Retail (up to 30-day maximum supply) Standard Option You pay with or without Medicare Part B: $20 generic, $50 preferred brand, $100 non-preferred brand

Retail (up to 30-day maximum supply) Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan : $0/$15 generic, $10/$20 preferred brand, $47 non-preferred brand

Mail Order (90-day supply) Standard Option You pay with or without Medicare Part B: 2x retail copayment

Mail Order (90-day supply) Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan : $0/$30 generic, $20/$40 preferred brand, $117.50 -$141 non-preferred brand

Specialty Drugs (up to 30-day maximum supply) Standard Option You pay with or without Medicare Part B: 50% coinsurance with a maximum of $250

Specialty Drugs (up to 30-day maximum supply) Standard Option HMO and UPMC For Life FEHB Retirees Medicare Advantage Plan : $300

Medicare Part B Premium Reimbursement will be prorated if member is not enrolled in the Standard plan, retired and electing Part B for the entire calendar year.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov. 

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan: You may enroll in UPMC Health Plan’s Medicare Advantage plan (UPMC for Life) and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers), but we will not waive any of our copayments, coinsurance, or deductibles.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). 

However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

When you use participating providers, you are protected by an annual catastrophic limit for out-of-pocket expenses for covered services. After your coinsurance, copayments, and deductibles total the out-of-pocket limit, you do not have to pay any more for covered services. There are separate out-of-pocket limits for Self Only and family coverage, as well as network and out-of-network expenses. Certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s benefit maximum, or if you use out-of-network providers, or amounts in excess of the Plan allowance). The family out-of-pocket maximum must be met by one or more members of the family before benefits will be paid at 100%.

For all plans, the annual catastrophic limit for out-of-pocket expenses can be either embedded or aggregate. Embedded means the out-of-pocket maximum has an enrollee out-of-pocket maximum within the family maximum. It is met by either an enrollee reaching the maximum or a combination of family members reaching the maximum out-of-pocket limit. Individual plans have individual out-of-pocket maximums.

The aggregate out-of-pocket maximum means the plan has a single out-of-pocket maximum that the entire family must meet either by a combination of family members’ claims or by one person’s claims. Individual plans have an individual out-of-pocket maximum.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

See Section 4, page 26

See Section 4, page 26

See Section 4, page 26

Care that does not require the continuing services of a skilled medical facility or healthcare professional and which is furnished primarily to provide room and board, education, assistance with the activities of daily living, or other non-skilled care for mentally or physically disabled persons. 

See Section 4, page 26

For all plans, the annual deductible can be either embedded or aggregate. Embedded means the deductible has an individual deductible within the family deductible. It is met by either an individual reaching the deductible or a combination of family members reaching the deductible limit. Individual plans have individual deductibles.

The aggregate deductible means the plan has a single deductible that the entire family must meet either by a combination of family members’ claims or by one person’s claims. Individual plans have a individual deductibles.

Experimental/Investigative is the use of any treatment, service, procedure, facility, equipment, drug, device or supply (intervention), which is not determined by UPMC Health Plan or its designated agent to be medically effective for the condition (including diagnosis and stage of illness) being treated. UPMC Health Plan will consider an intervention to be Experimental/Investigative if, at the time of service:

1. The intervention does not have FDA approval to market for the specific relevant indication(s); or
2. Available scientific evidence and/or prevailing peer review medical literature do not indicate that the treatment is safe and effective for treating or diagnosing the relevant medical condition or illness; or
3. The intervention is not proven to be as safe or as effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or
4. The intervention does not improve health outcomes; or
5. The intervention is not proven to be able to be replicated outside the research setting.

If an intervention as defined above is determined to be Experimental/Investigative at the time of service, it will not receive retroactive coverage even if it is found to be in accordance with the above criteria at a later date.

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Medically necessary are services or supplies that are determined to be:

1. Commonly recognized throughout the physician’s specialty as appropriate for the diagnosis and/or treatment of the member’s condition, illness, disease or injury
2. Provided in accordance with standards of good medical practice and consistent with scientifically based guidelines of medical, research, or healthcare coverage organizations or governmental agencies that are accepted by UPMC Health Plan
3. Can reasonably be expected to improve an individual’s condition or level of functioning; and
4. Is in conformity, at the time of treatment, with medical management criteria/guidelines adopted by UPMC Health Plan or its designee
5. Not provided only as a convenience or comfort measure or to improve physical appearance; and
6. Rendered in the most cost-efficient manner and setting appropriate for the delivery of the health service.

UPMC Health Plan reserves the right to determine in its sole judgment whether a service meets these criteria and will be authorized for payment. Authorization for payment decisions shall be made by UPMC Health Plan with input from the member’s PCP, or other physician providing the service. Independent consultation with a physician other than the PCP or attending physician may be obtained at the discretion of UPMC Health Plan.

The fact that a physician or other healthcare provider may order, prescribe, recommend, or approve a service, supply, or therapeutic regime does not, of itself, determine Medical Necessity and Appropriateness or make such a service, supply, or treatment a Covered Service.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Participating providers accept our plan allowance, so you will be billed no more than the applicable cost-sharing amount when you utilize participating providers.

If you are enrolled in the HDHP, you may also obtain services from non-participating providers. If you utilize non-participating providers, you will be responsible for the out-of-network cost-sharing as well as any amounts in excess of the plan allowance. 

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Member Service Department at 877-648-9641. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

See Section 4, page 26

See Section 4, page 26

See Section 4, page 26

See Section 4, page 26

Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses. If you enroll in the HDHP option and you are not eligible for a Health Savings Account (HSA), an HRA will be provided instead. You can use funds in your HRA to help pay your health plan deductible, and/or for certain expenses that don’t count toward the deductible. 

HRA features include:

1. Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment
2. Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP
3. Unused credits carryover from year to year
4. HRA credit does not earn interest
5. HRA credit is forfeited if you leave Federal employment or switch health insurance plans

Health Savings Accounts provide a means to help you pay out-of-pocket expenses.

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA benefits within the last three months, or do not have other health insurance coverage other than another high deductible health plan. In addition to the monthly contribution the HDHP will make to your HSA, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after-tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

1. Your contributions to the HSA are tax deductible
2. Your HSA earns tax-free interest
3. You can make tax-free withdrawals for qualified medical expenses for you, your spouse, and dependents (see IRS publication 502 for a complete list of eligible expenses)
4. Your unused HSA funds and interest accumulate from year to year
5. It’s portable — the HSA is owned by you and is yours to keep, even when you leave federal employment or retire
6. When you need it, funds up to the actual HSA balance are available

Office visit copay: $20 primary care; $50 specialist

32

20% of the Plan allowance

56

20% of the Plan allowance

57

$150 copay per emergency room visit

60

$150 copay per emergency room visit

60

20% of the Plan allowance

62

$20 copay per outpatient visit

62

$20 generic

$50 preferred brand-name

$100 non-prefered brand-name

64

50% of the cost up to a maximum of $250

64

$40 generic

$100 preferred brand-name

$200 non-preferred brand-name

Specialty prescription drugs are not covered through mail-order

64

Limited Dental benefits and discounts under a non-FEHB benefit program

68

Nothing for routine eye exam. Once every 24 months for adults and children. 

42

• HealthCare Concierge Team
• Health Incentive Account
• MyHealth Health and Wellness
• MyHealth OnLine
• MyHealth Questionnaire
• MyHealth Community
• Health Coaching
• MyHealth Advice Line
• UPMC Anywhere Care
• Health Plan Mobile App
• Tobacco Cessation
• RXWell
• Assist America
• Services for Members who have a Hearing Impairment
• Flexible Benefits Option

69

$6,000 Self Only or $12,000 Self Plus One or Self and Family per year.

27

Nothing

85

In-Network: 15%

Out-of-Network: 40%

90

In-Network: 15%

Out-of-Network: 40%

90

In-Network: 15%

Out-of-Network: 40%

111

In-Network: 15%

Out-of-Network: 40%

112

In-Network: 15%

Out-of-Network: 15%

115

In-Network: 15%

Out-of-Network: 15%

115

In-Network: 15%

Out-of-Network: 40%

116

$20 generic drugs

$50 preferred brand-name drugs

$100 non-preferred brand-name drugs

121

50% of the cost up to a maximum of $250

121

$40 generic drugs

$100 preferred brand-name drugs

$200 non-preferred brand-name drugs

Specialty prescription drugs are not covered through mail-order

121

Limited Dental benefits and discounts under a non-FEHB benefit program.

124

Nothing for routine eye exam.  Once every 24 months for adults and children.

98

• HealthCare Concierge Team
• Health Incentive Account
• MyHealth Health and Wellness
• MyHealth OnLine
• MyHealth Questionnaire
• MyHealth Community
• Health Coaching
• MyHealth Advice Line
• UPMC Anywhere Care
• Health Plan Mobile App
• Tobacco Cessation
• RXWell
• Assist America
• Services for Members who have a Hearing Impairment
• Flexible Benefits Option

125

In-Network: $6,000 Self Only or $12,000 Self Plus One or  Self and Family

Out-of-Network: $8,000 Self Only or $16,000 Self Plus One or Self and Family

27