We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this 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.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See https://health-benefits.opm.gov/PSHB/ for enrollment information as well as:

• Information on the PSHB Program and plans available to you
• A health plan comparison tool

Note: Contact the USPS for information on how to enroll in a PSHB Program Plan through the PSHB System.

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 PSHB 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. You will be responsible for making changes to your enrollment status through the PSHB System.  In some cases, your employing or retirement office may need to submit documentation. For information on your premium deductions, you must also contact your employing or retirement office. 

Once enrolled in your PSHB 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.

You enroll in a PSHB Program Plan and make enrollment changes in the PSHB System located at https://health-benefits.opm.gov/PSHB/. For assistance with the PSHB System, call the PSHBP Helpline at (844) 451-1261. 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 request. 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 PSHB enrollment.

Use the PSHB System if you want to change from Self Only to Self Plus One or Self and Family, and to add or remove a family member. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please, report changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26 through the PSHB System. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one PSHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another PSHB or 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 PSHB Program, change your enrollment, or cancel coverage using the PSHB System. For a complete list of QLEs, visit the PSHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, 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.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

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 PSHB 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 PSHB 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 PSHB 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 PSHB coverage, you must continue your PSHB 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.

For annuitants who are required to be enrolled in Medicare Part B as a condition to continue PSHB coverage in retirement: If you enroll in Medicare Part B and continue PSHB coverage in retirement, the child equity law applies to you and you cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your child(ren) live as long as the court/administrative order is in effect. You cannot be compelled to enroll or remain enrolled in Medicare Part B to maintain your PSHB enrollment as a condition to satisfy a court/administrative order. However, if you do not enroll (or remain enrolled) in Medicare Part B as required to continue your PSHB coverage in retirement (notwithstanding an existing court/administrative order), you will not be able to continue your PSHB coverage in retirement.

Our PDP EGWP is only available to Postal Service annuitants who are Medicare Part D-eligible and their covered Medicare Part D-eligible family members. Our PDP EGWP is not an open market Medicare Part D Plan.  If you are an active Postal Service employee, or covered family member, and become eligible to enroll in Medicare Part D, you are not eligible to enroll in our PDP EGWP.  Please, contact CMS for assistance (833)-288-6901 or our UPMC for Life Medicare sales team at 844-761-0083. Our hours of operation are Oct. 1 – March 31 seven days a week from 8 a.m. to 8 p.m. and April 1 – Sept. 30 Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 3 p.m. TTY users should call 711. 

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage and premiums begin on January 1. If you joined at any other time during the year, your employing or retirement 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 PSHB Program. Generally, you must have been enrolled in the FEHB and/or PSHB 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; or
• 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 31st 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 60th day after the end of the 31-day temporary extension.

If you are eligible for coverage under spouse equity, you are only eligible to enroll in the FEHB Program. If you are not eligible for coverage under spouse equity and you are otherwise eligible for Temporary Continuation of Coverage (TCC), then you could enroll in TCC under the PSHB Program.

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must enter the date of the divorce or annulment and remove your ex-spouse in the PSHB System. We may ask for a copy of the divorce decree as proof. If you need to change your enrollment type, you must use the PSHB System. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member 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 coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). Former spouses eligible for coverage under the spouse equity law are not eligible to enroll in the PSHB Program. However, former spouses eligible for coverage under the spouse equity law may enroll in the FEHB Program. (Former Spouses seeking but not yet adjudicated as eligible for Spouse Equity may be entitled to TCC under a PSHB plan in the interim).

Former spouses not meeting the spouse equity requirements may be eligible for TCC under the PSHB Program provided you otherwise meet the eligibility requirements for TCC. If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website at https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s PSHB enrollment.

When a Postal Service annuitant who is Medicare Part D-eligible or their covered Medicare-eligible family member opts out of or disenrolls from our PDP EGWP, they will not have our prescription drug coverage under this plan. If you do not maintain creditable coverage, re-enrollment in our PDP EGWP may be subject to a late enrollment penalty. Contact us for additional information at (833)-288-6901.

If you leave Federal service, 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 PSHB enrollment after you retire, if you lose your Federal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal 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 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 PSHB Program coverage.

You may convert to a non-PSHB 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 service, your employing office will notify you of your right to convert. You must contact us in writing 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 contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the PSHB 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 or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 833-288-6901 or visit our website at www.upmchealthplan.com/PSHB.

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 Plan pharmacy. Until you receive your ID card, use your copy of the PSHB System enrollment confirmation.

Note: If you are enrolled in our Medicare Part D PDP EGWP, you may receive a second ID card for your prescription drug benefits.

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 833-288-6901 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:
www.upmchealthplan.com/PSHB.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance, if you use our point-of-service program, you can also get care from non-Plan providers, but it will cost you more. If you use our Open Access program, you can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.

PSHB Carriers must have clauses in their in-network (participating) provider 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. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

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

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 reached 833-288-6901 or www.upmchealthplan.com/PSHB 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 provider. This decision is important since your primary care provider provides or arranges for most of your health care.

Your primary care provider can be an internist, pediatrician, family practitioner, or general practitioner. Your primary care provider will provide most of your healthcare, or refer you to a specialist. Individuals may select an ob/gyn to provide or coordinate all covered gynecological/obstetrical care. However, individuals 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 provider with us. If you want to change your primary care provider, you may do so at any time by contacting Member Services at 833-288-6901 or by visiting the website at
www. upmchealthplan.com/PSHB. If your primary care provider leaves the Plan, call us and we will help you select a new one.

Your primary care provider 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 provider, 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:
  • Lose access to your specialist because your coverage changed from the FEHB to the PSHB and your health plan does not participate in the PSHB; or
  • Lose access to your specialist because we drop out of the Postal Service Employees Health Benefits (PSHB) Program and you enroll in another PSHB program plan; or
  • Lose access to your specialist because terminate our contract with your specialist for other than cause;
  • Lose access to your specialist because we reduce our service area and you enroll in another PSHB 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.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

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 customer service department immediately at 833-288-6901. If you are new to the PSHB 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 this PSHB plan, 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 92nd 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 PSHB 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.

Since your primary care provider arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

Your primary care provider 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
www.upmchealthplan.com/providers/medical/resources/manuals/policies-procedures.aspx.

If you are considering an artificial insemination procedure, see requirements on page 39 or 105.

First, your physician, your hospital, you, or your representative, must call us at 833-288-6901 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 what information we need to complete our review of the claim. You will then have up to 48 hours to provide information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the 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 833-288-6901. You may also call Postal Service Insurance Operations (PSIO) at (202) 936-0002 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 833-288-6901. 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 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 telephone 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 precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, 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.

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.

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

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 833-288-6901.

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 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.

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.
3. 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.

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 telephone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Note: If you are enrolled in our Medicare PDP EGWP and do not agree with our benefit coverage decision you have the right to appeal.  See Section. 8(a) for information about the PDP EGWP appeal process. 

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive. Available funds in your Health Incentive Account will reduce your cost-sharing.

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 provider you pay a $20 copayment.

A deductible is a fixed expense you must incur for certain 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 PSHB plans during Open Season, the effective date of your new PSHB plan is January 1 of the next year, and a new deductible starts on January 1. 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
• 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

For members enrolled in our Plan's associated MA-PD or PDP EGWP, we are required to accumulate all members’ actual out-of-pocket costs for Medicare-covered drugs, services and supplies toward the PSHB catastrophic maximum(s), unless specifically excluded below. 

If you are enrolled in our Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP), the prescription drug out-of-pocket maximum is $2,000.  After this maximum is met, we pay 100% of all eligible covered prescription drug benefits.

If you changed to this PSHB Plan during Open Season from a plan with a catastrophic protection benefit the effective date of the change is January 1, and covered expenses that apply to this plan’s catastrophic protection benefit starts on January 1.

Note: If you change PSHB plans during Open Season the effective date of your new PSHB plan is January 1 of the next year, and a new catastrophic protection accumulation starts on January 1. If you change plans at another time during the year, you must begin a new catastrophic protection accumulation under your new plan.  

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 from us 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” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services. 

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

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 surprise bills.

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 833-288-6901.

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 test

$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 copayment per visit (No deductible)

• Physician services for a Virtual Visit

$5 per visit (No deductible)

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• X-ray
• Non-routine mammogram
• CT/CAT Scan
• MRI
• Ultrasound
• Electrocardiogram and EEG
• Professional interpretation of diagnostic testing r

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:

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the website at 
  www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at 
  www.hrsa.gov/womens-guidelines.
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder.

Nothing (No deductible)

Tobacco cessation counseling

Nothing (No deductible)

Routine Prostate Specific Antigen (PSA) test - one annually age 40 and older

Nothing (No deductible)

• Routine mammogram 

Nothing (No deductible)

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at Vaccines & Immunizations | CDC

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)

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
  • Examination, referral, and Counseling: obesity prevention for midlife members (ages 40-60); annual counseling for those with normal or overweight body mass index (18-29.9 kg/m2) to main weight or limit weight gain, and screening/referral for those with a BMI > 30 for intense, multicomponent behavioral interventions. Counseling may include an individualized discussion of healthy eating and physical activity.
  • Obesity screening annually through 18 years
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
  • Lifestyle health coaching: Through virtual (Anywhere Care), telephonic, and digital (RxWell mobile app) modalities, health coaches may address lifestyle health needs.
  • Support and care during pregnancy - maternity care management supporting members through pregnancy along with counseling for healthy weight gain in pregnancy
  • Condition management coaching: A medical-behavioral approach to help manage chronic conditions and improve your health.
  • Case management: Case management coaches are licensed nurses, social workers, and other clinical professionals who help you manage your health by coordinating with your providers and providing access to resources.

See also Section 5(h) for Wellness and Special Features.

Nothing (No deductible)

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) or 5(f)(a) for cost share requirements for anti-obesity medications.

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See section 5(b) for Surgery requirements and cost share.

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.

All charges

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

Children’s immunization’s endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at Vaccines & Immunizations | CDC

Nothing (No deductible)

• You can also find a complete list of U.S. Preventive Services Task Force (USPSTF) online at
  www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

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)

Obesity counseling, screening, and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
  • Examination, referral, and Counseling: obesity prevention for midlife members (ages 40-60); annual counseling for those with normal or overweight body mass index (18-29.9 kg/m2) to main weight or limit weight gain, and screening/referral for those with a BMI > 30 for intense, multicomponent behavioral interventions. Counseling may include an individualized discussion of healthy eating and physical activity.
  • Obesity screening annually through 18 years
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
  • Lifestyle health coaching: Through virtual (Anywhere Care), telephonic, and digital (RxWell mobile app) modalities, health coaches may address lifestyle health needs.
  • Support and care during pregnancy - maternity care management supporting members through pregnancy along with counseling for healthy weight gain in pregnancy
  • Condition management coaching: A medical-behavioral approach to help manage chronic conditions and improve your health.
  • Case management: Case management coaches are licensed nurses, social workers, and other clinical professionals who help you manage your health by coordinating with your providers and providing access to resources.

See also Section 5(h) for Wellness and Special Features.

Nothing (No deductible)

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) or 5(f)(a) for cost share requirements for anti-obesity medications.

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

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

All charges

Complete maternity (obstetrical) care, such as:

• Prenatal and Postpartum care
• Screening for gestational diabetes
• Delivery
• Screening and counseling for prenatal and postpartum depression

Nothing (No deductible)

Breastfeeding and lactation support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

You do not need to precertify your vaginal delivery; see page 37 for other circumstances, such as extended stays for you or your baby.

Nothing (No deductible)

• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period.

Nothing (No deductible)

• 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. 
• 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 hospital stay, 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 addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

Nothing (no deductible)

Baby Steps is a maternity program available to all UPMC Health Plan members. This program connects you with maternity health coaches who provide support, education, and resources. Some examples of what you can talk about include prenatal vitamins, a birthing plan, breastfeeding, and signs of postpartum depression. We want to help increase your chances of having a healthy pregnancy, baby, and postpartum recovery. This program is provided to you at no-cost as part of your benefits. How frequently you communicate with your coach is up to you, with both phone and in-person options available.

Contact us to learn more about the Baby Steps program and get in touch with a health coach. Coaches are available Monday through Friday from 8 a.m. to 6 p.m.

• Phone: 1-866-778-6073 (TTY:711)
• Chat via UPMC Health Plan member site: Sign in to UPMC Health Plan member site | Register for UPMC Health Plan member site
• Email: maternitycoaches@upmc.edu (Coaches will schedule a phone call based on your availability.)
• UPMC Health Plan Maternity Program

Any member who is identified as having active or a history of chronic hypertension or PIH is stratified as high risk and targeted for active Case Management outreach for program participation. If one of the Case Managers is working with a member that develops hypertension during pregnancy, they can help facilitate receipt of a blood pressure cuff and work with the member and her provider to ensure the member is comfortable with self-monitoring BP at home and notifying their provider with signs/symptoms of worsening symptoms. Member can receive a blood pressure

• Provider Directory | Find Care | UPMC Health Plan

Nothing (No deductible)

Contraceptive counseling on an annual basis

Nothing (No deductible)

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:

• Voluntary female sterilization
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: See additional Family Planning and Prescription drug coverage Section 5(f) or 5(f)(a).

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov. 

Nothing (No deductible)

Voluntary male sterilization 

Nothing (No deductible)

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

All charges

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) egg- sperm contact through artificial insemination. Infertility may also be established through evidence of medical history and diagnostic testing.

Medical Description

Refer to MP.017 – Infertility – Treatment policy. Note that treatment of the causes of infertility is not addressed in this policy.

Specific Indications for Diagnosis

• Member must fit the definition for infertility (as indicated in Section 10 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.

  • In vitro fertilization, embryo transfer, gamete intra-fallopian transfer (GIFT), zygote intra- fallopian transfer (ZIFT), services, IVF drugs and supplies related to covered ART procedures, cost of donor sperm and cost of donor egg. All included within the lifetime maximum of $25,000 per member. There are no annual cycle limits.

• 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 - subject to cost sharing shown in Section 5(f) Prescription Drug Benefits in UPMC Health Plan 2025 postal brochure RI 73-933 and included in the Lifetime maximum benefit per member.
• 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 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 PSHB Program recognizes each partner as a spouse of the other.

20% of the Plan allowance

• Fertility drugs (See Section 5f or 5(f)(a), if applicable page 67 or 73)

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

All charges

• Testing and treatment
• Allergy injections

20% of the Plan allowance

Allergy serum

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 51.

• 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 on page x.

• 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
• Homocystinuria
• 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

All charges

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

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

All charges

• 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 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 844-336-8951.

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

Nothing (No deductible)

Not covered:

Hearing services that are not shown as covered

All charges

• One pair of 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 833-288-6901 or visit www.upmchealthplan.com/PSHB to locate a vision care provider.

Nothing (No deductible)

Not covered:

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

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

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)

All charges

• 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.

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

All charges

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
• Audible prescription reading devices
• Speech generating devices
• Blood glucose monitors
• Insulin pumps

Note: Call us at 833-288-6901 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

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

All charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), 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)

Acupuncture – by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner

Dry Needling – by a licensed or certified practitioner [if still covered]

20% of the Plan allowance

Not covered:

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

All charges

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 43.

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.

Nothing (No deductible)

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 severe obesity (bariatric surgery) See criteria: MP.PA.040
• 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

Note: For female surgical family planning procedures see Family Planning Section 5(a)

Note: For male surgical family planning procedures see Family Planning Section 5(a)

Not covered:

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

All charges

• 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; birthmarks; 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
    • All medically necessary gender-affirming care surgeries are covered, including facial surgeries with prior authorization.
    • 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 and facial feminization surgeries.

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

All charges

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 leukoplakia 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)

All charges

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.

• Autologous 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)
  • Mucopolysaccharidosis (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
  • Aggressive non-Hodgkin's lymphoma
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Multiple myeloma
  • Medulloblastoma
  • Multiple myeloma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
• Hematopoietic Stem Cell Transplant (HSCT)

20% of the Plan allowance

Mini-transplants performed in a clinical trial setting (non-myeloablative, 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, PNH, 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 approved by the Plan’s medical director in accordance with the Plan’s protocols.

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
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • 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 lymphoma/small lymphocytic lymphoma (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.

20% of the Plan allowance

National Transplant Program (NTP) - 

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

All charges

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient de[artment
• 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

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

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
• 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

All charges

• 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

Not covered:  Blood and blood derivatives not replaced by the member

All charges

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

Not covered: Custodial care

All charges

Supportive and palliative care is covered for terminally ill patients, either in the home or in a hospice facility. Services include inpatient and outpatient care and family counseling. These services are provided under the direction of a physician who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

20% of the Plan allowance

Not covered: Independent nursing, homemaker services

All charges

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

Local professional ambulance service when medically appropriate

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

All charges

• 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

All charges

Professional ambulance service when medically appropriate

Note: See 5(c) for non-emergency service.

20% of the Plan allowance

Not covered: Air ambulance 

All charges

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 disordertreatment 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, 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, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

20% of the Plan allowance

Not covered:

• 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

All charges

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 medicines 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 the treatment of infertility including IVF, Artificial Insemination and cryopreservation
  • We cover injectable fertility drugs under the prescription drug and medical benefits and oral fertility drugs under the prescription 
• Drugs for sexual dysfunction
• Tobacco cessation drugs, including over-the- counter (OTC) drugs approved by the FDA to treat tobacco dependence (See page 48)
• 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.
• Medications prescribed to treat obesity

Retail (up to a 30-day supply)

$0 copayment for select generic medications

$20 copayment for preferred generic drugs

$50 copayment for preferred brand medications and generic medications

$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)

$0 copayment for select generic medications

$40 copayment for preferred generic drugs

$100 copayment for preferred brand medications and generic medications.

$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 Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines. Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories 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.

• If you have difficulty accessing contraceptive coverage or other reproductive healthcare you can contact contraception@opm.gov.
• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• 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 covered over-the-counter contraceptives can be submitted in accordance with Section 7.

• 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 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 UPMC Health Plan member site. You must submit the completed form and your pharmacy label to UPMC Health Plan for review. Please note, a prescription is not required for reimbursement for Opill.

Note: For additional Family Planning benefits see Section 5(a)

Generic and brand name drugs covered on the formulary are available at no copayment.

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a)

See Tobacco Cessation Educational Classes and Programs in Section 5(a)

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

All charges

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

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. Coverage is limited to 24 weeks of therapy per year.
• Aspirin (81 mg) for members of child- bearing potential
• Contraceptives coverage includes a full range of generic and single-source brand Food and Drug Administration (FDA) approved classes.
• 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 and at a low risk for adverse medication effects.
• 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 (400 and 800 mcg) for members of childbearing age.
• Fluoride tablets, solution (not toothpaste, rinses) for children age 6 months through 16 years.

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

Nothing (No deductible)

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a participating pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.

Nothing (No deductible)

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

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 medicines 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 the treatment of infertility including IVF, Artificial Insemination and cryopreservation
  • We cover injectable fertility drugs under the prescription drug and medical benefits and oral fertility drugs under the prescription
• Drugs for sexual dysfunction
• Tobacco cessation drugs, including over-the- counter (OTC) drugs approved by the FDA to treat tobacco dependence (See page 48)
• 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.
• Medications prescribed to treat obesity
• Medical Foods

Retail (up to a 30-day supply)

Preferred generic medications: $0 copayment at a preferred pharmacy; $15 at a standard pharmacy

Generic medications: $10 copayment at a preferred pharmacy; $20 at a standard pharmacy

Preferred brand medications: $47 copayment at both preferred and standard pharmacies

Non-Preferred brand medications: $100 copayment at both preferred and standard pharmacies

Covered Insulins: $35 copayment at both preferred and standard pharmacies

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

33% coinsurance 

Retail (up to a 100-day supply)

Preferred generic medications: $0 copayment at a preferred pharmacy; $30 at a standard pharmacy

Generic medications: $20 copayment at a preferred pharmacy; $40 at a standard pharmacy

Preferred brand medications: $129.50 copayment at a preferred pharmacy; $141 at a standard pharmacy

Non-preferred medications: $300 copayment at both preferred and standard pharmacies

Covered insulins: $96.25 copayment at a preferred pharmacy, $105 at a standard pharmacy

Mail Order (up to a 100-day supply)

Preferred generic medications: $0 copayment at a preferred pharmacy; $30 at a standard pharmacy

Generic medications: $20 copayment at a preferred pharmacy; $40 at a standard pharmacy

Preferred brand medications: $117.50 copayment at a preferred pharmacy; $141 at a standard pharmacy

Non-preferred medications: $300 copayment at both preferred and standard pharmacies

Covered insulins: $87.50 copayment at a preferred pharmacy, $105 at a standard pharmacy

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories 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.

• If you have difficulty accessing contraceptive coverage or other reproductive healthcare you can contact contraception@opm.gov.
• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• 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 covered over-the-counter contraceptives can be submitted in accordance with Section 7.

• 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 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 UPMC Health Plan member site. You must submit the completed form and your pharmacy label to UPMC Health Plan for review. Please note, a prescription is not required for reimbursement for Opill.

Note: For additional Family Planning benefits see Section 5(a)

Nothing for generic and brand name drugs and devices

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a)

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
• Nonprescription medications

All charges

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

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. Coverage is limited to 24 weeks of therapy per year.
• Aspirin (81 mg) for members of child- bearing potential
• Contraceptives coverage includes a full range of generic and single-source brand Food and Drug Administration (FDA) approved classes.
• 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 and at a low risk for adverse medication effects.
• 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 (400 and 800 mcg) for members of childbearing age.
• Fluoride tablets, solution (not toothpaste, rinses) for children age 6 months through 16 years.

Nothing (No deductible)

• Preventive Medications with USPSTF A and B recommendations. 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

Nothing (No deductible)

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a participating pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

Nothing (No deductible)

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

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

20% of the Plan allowance

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 833-288-6901. Our Healthcare Concierge team is available Monday through Friday from 8 a.m. to 6 p.m. TTY/TDD users should call 711.

You and your covered spouse, if applicable, can earn reward dollars 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, is a 10–12-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 points by completing the well-being assessment.
• Biometric Screening: This health screening measures your total cholesterol level and glucose 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 50 points for a biometric 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 25 points for per coaching session
• You will also receive points for completing activities uniquely customized just for you.

You will find a full list of eligible activities by logging in to UPMC Health Plan member site, the website that powers Take a Healthy Step, UPMC Health Plan’s member website.

The reward dollars you earn will be placed on a debit card that you can use toward your deductible, 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.

To learn more about Take a Healthy Step, visit www.upmchealthplan.com/PSHB or call a Healthcare Concierge at 833-288-6901.

Take a Healthy Step 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 well-being 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 are not required to complete the health questionnaire or other medical examinations.

However, employees who choose to participate in the wellness program can receive an incentive of up to $250 for Self Only and $500 for Self plus One or Self and 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 833-288-6901.

The information from your health questionnaire 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 50 points. The annual maximum reward dollars per year remains $250 for Self Only and $500 Self plus One and Self and Family.

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:

• UPMC Health Plan member site
• MyHealth Questionnaire
• MyHealth Community
• Health Coaching
• MyHealth Advice Line

For detailed descriptions, see below.

UPMC Health Plan member site 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 UPMC Health Plan member site, 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 Take a Healthy Step, you earn points when you do healthy activities throughout the year.) The points you earn will help you complete levels. Each level you complete will earn your reward dollars.

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 UPMC Health Plan member site at www.upmchealthplan.com/PSHB. To create an account click on Sign Up and use the number on your member ID card to register.

Once you log in to UPMC Health Plan member site, 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 UPMC Health Plan member site with activities that benefit you the most.

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

Visit UPMC Health Plan member site and log in or register to find great discounts near you, including Active&Fit. The Active&Fit Direct program allows you to choose from 16,000+ participating fitness centers nationwide for $28 a month (plus a $28 enrollment fee and applicable taxes). Learn more: https://www.activeandfitnow.com/. 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 UPMC Health Plan member site, 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 lifestyle or chronic condition coaching programs and earn points toward reward dollars. 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 points toward your reward dollars.

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 https://anywherecare.upmc.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 earn points 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. You can also earn points by completing an RxWell program.

• Manage anxiety, stress, or 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 162. This applies to annuitants who chose to enroll in UPMC for Life PSHB Retirees Medicare Advantage plan as well.

Baby Steps is a maternity program available to all UPMC Health Plan members. This program connects you with maternity health coaches who provide support, education, and resources. Some examples of what you can talk about include prenatal vitamins, a birthing plan, breastfeeding, and signs of postpartum depression. We want to help increase your chances of having a healthy pregnancy, baby, and postpartum recovery. This program is provided to you at no-cost as part of your benefits. How frequently you communicate with your coach is up to you, with both phone and in-person options available.

Contact us to learn more about the Baby Steps program and get in touch with a health coach. Coaches are available Monday through Friday from 8 a.m. to 6 p.m.

• Phone: 1-866-778-6073 (TTY:711)
• Chat via UPMC Health Plan member site: Sign in to UPMC Health Plan member site | Register for UPMC Health Plan member site
• Email: maternitycoaches@upmc.edu (Coaches will schedule a phone call based on your availability.)
• UPMC Health Plan Maternity Program

Any member who is identified as having active or a history of chronic hypertension or PIH is stratified as high risk and targeted for active Case Management outreach for program participation. If one of the Case Managers is working with a member that develops hypertension during pregnancy, they can help facilitate receipt of a blood pressure cuff and work with the member and her provider to ensure the member is comfortable with self- monitoring BP at home and notifying their provider with signs/ symptoms of worsening symptoms. Member can receive a blood pressure cuff from a DME provider with a physician’s order.

• Provider Directory | Find Care | UPMC Health Plan

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% if you use a network provider and the services are 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 use disorder benefits
• Prescription drug benefits
• Dental benefits

If you earn 250 points you will receive a $75 deposit into your HSA account debit card. See page 145 for more details on earning reward dollars. If you are not eligible for an HSA and earn 250 points you will receive $75 on a debit card that will be linked to your HRA to use toward deductible, copayments, and coinsurance that are incurred by anyone enrolled in your plan.

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see 88 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 Services (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan. In 2025, 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 enrollment or $150 per month for a 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 $4,300 for an individual and $8,550 for a family. See maximum contribution information on page 89. 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.

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
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.)
• 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 healthcare flexible spending account, 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, 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 2025, we will give you an HRA credit of $900 per year for a Self Only enrollment or $1,800 per month for a Self Plus One enrollment or $1,800 per year for a Self and Family enrollment. You can use the funds in your HRA debit card to help pay your health plan deductible, copayments and coinsurance incurred by anyone enrolled in your plan. Any reward dollars you earn will also be added to this debit card. If you disenroll, the funds on the card will be forfeited.

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 a Healthcare Flexible Spending Account (HCFSA). However, you must meet HCFSA 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. If you are enrolled in our PDP EGWP, see page 137 for additional information about your out-of-pocket maximum. 

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.

The Plan will establish an HSA for you with WEX, Inc., this HDHP’s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS.)

UPMC Health Plan is the HRA fiduciary for this Plan.

Set-up and monthly service fee is paid by the HDHP

None.

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 1st of the month, the earliest your HSA will be established is the 1st of the following month.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).

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 2025, a monthly premium pass through of $75 will be made by the HDHP directly into your HSA each month.

For 2025, your HRA annual credit is $900 (prorated for mid-year enrollment).

For 2025, a monthly premium pass through of $150 will be made by the HDHP directly into your HSA each month.

For 2025, your HRA annual credit is $1,800 (prorated for mid-year enrollment). This will be placed on your HRA debit card.

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 of $4,300 for an individual and $8,550 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).

Additional contribution discussed on page 92.

The full HRA credit on the debit card 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 $3,250.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $6,500.

You cannot contribute to the HRA.

You can access your HSA by debit card.

You can access your HRA by debit card.

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 and 969 for information on eligible medical expenses. 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 you 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.

PSHB 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 88 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.

Yes, accumulates without a maximum cap.

Yes, accumulates without a maximum cap.

If you earn 250 points you will receive a $75 contribution to your HSA debit card. If you have a covered spouse and they earn 250 points you will earn an additional $75 contribution to your HSA debit card.

If you are not eligible for HSA and have HRA, you will receive a $75 contribution to your HRA debit card. If you have a covered spouse and they earn 250 points you will earn an additional $75 contribution to your HRA debit card.

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. 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 either tax-deductible or pre-tax (if made by payroll deduction). You receive tax advantages in any case. 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 newly enroll in an HDHP during Open Season your effective date is January 1st, or if you enroll at any other time and 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 contributions to your HSA. The allowable additional contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS website at www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676. www.ustreas.gov/offices/public-affairs/hsa/

If you have not named beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA becomes part of your taxable estate.

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, 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 health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For detailed information of IRS-allowable expenses, request a copy of IRS Publication 502 and 969 by calling 1-800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.” Note: Although over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

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 UPMC Health Plan member site and the UPMC Consumer Advantage mobile app.

You can request reimbursement in any amount.

If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you become ineligible to contribute to an HSA.

Please review the chart on page 88 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. PSHB 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.

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:

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the website at
  www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines

In-Network: Nothing

Out-of-Network Colonoscopy screening: All charges

Other Out-of-Network services: 40%

• Routine mammogram

In-Network: Nothing

Out-of-Network: 40%

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 Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at Vaccines & Immunizations | CDC

In-Network: Nothing

Out-of-Network routine physicals: All charges

Other Out-of-Network services: 40%

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%

Obesity counseling, screening, and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
  • Examination, referral, and Counseling: obesity prevention for midlife members (ages 40-60); annual counseling for those with normal or overweight body mass index (18-29.9 kg/m2) to main weight or limit weight gain, and screening/referral for those with a BMI > 30 for intense, multicomponent behavioral interventions. Counseling may include an individualized discussion of healthy eating and physical activity.
  • Obesity screening annually through 18 years
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
  • Lifestyle health coaching: Through virtual (Anywhere Care), telephonic, and digital (RxWell mobile app) modalities, health coaches may address lifestyle health needs.
  • Support and care during pregnancy - maternity care management supporting members through pregnancy along with counseling for healthy weight gain in pregnancy
  • Condition management coaching: A medical-behavioral approach to help manage chronic conditions and improve your health.
  • Case management: Case management coaches are licensed nurses, social workers, and other clinical professionals who help you manage your health by coordinating with your providers and providing access to resources.

See also Section 5(h) for Wellness and Special Features.

In-Network: Nothing

Out-of-Network: 40%

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) or 5(f)(a) for cost share requirements for anti-obesity medications.

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

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.

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to www.brightfutures.aap.org/Pages/default.aspx
• Immunizations such as DtaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and For a complete list of immunizations go to the Centers for Disease Control (CDC) website at Vaccines & Immunizations | CDC
• Note: You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at: 
  www.uspreventiveservicestaskforce.org
• To build your personalized list of preventive services go to https://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 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%

Obesity counseling, screening, and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
  • Examination, referral, and Counseling: obesity prevention for midlife members (ages 40-60); annual counseling for those with normal or overweight body mass index (18-29.9 kg/m2) to main weight or limit weight gain, and screening/referral for those with a BMI > 30 for intense, multicomponent behavioral interventions. Counseling may include an individualized discussion of healthy eating and physical activity.
  • Obesity screening annually through 18 years
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
  • Lifestyle health coaching: Through virtual (Anywhere Care), telephonic, and digital (RxWell mobile app) modalities, health coaches may address lifestyle health needs.
  • Support and care during pregnancy - maternity care management supporting members through pregnancy along with counseling for healthy weight gain in pregnancy
  • Condition management coaching: A medical-behavioral approach to help manage chronic conditions and improve your health.
  • Case management: Case management coaches are licensed nurses, social workers, and other clinical professionals who help you manage your health by coordinating with your providers and providing access to resources.

See also Section 5(h) for Wellness and Special Features.

In-network: Nothing

Out-of-network: 40%

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) or 5(f)(a) for cost share requirements for anti-obesity medications.

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

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

All charges

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. You are permitted to use the HSA or HRA debit card to cover the deductible.

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. You may choose to pay the coinsurance or pharmacy copayment from your HSA or HRA debit card. If you have earned 250 points then $75 will be deposited into your HSA debit card. If you have a covered spouse and they earn 250 points you will receive an additional $75 deposit into your HSA debit card. If you are not eligible for HSA and have an HRA and earned 250 points $75 will be deposited onto your HRA debit card.

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., you may choose to pay the coinsurance or pharmacy copayment from your HSA. If you have earned 250 points then $75 will be deposited into your HSA debit card. If you have a covered spouse and they earn 250 points an additional $75 will be deposited into your HSA debit card. If you are not eligible for HSA and have an HRA and earned 250 points you will earn $75 on a HRA debit card to use toward out-of-pocket costs. If you have a covered spouse and they earn 250 points an additional $75 will be added to the HRA debit card.

After you meet the deductible, we pay the allowable charge (less your coinsurance or copayment) until you meet the annual catastrophic out-of-pocket maximum.

In-network: After you meet the deductible, you pay only the coinsurance or pharmacy copayment for covered services. You may choose to pay the coinsurance or pharmacy copayment from your HSA or HRA debit card. If you have earned 250 points then $75 will be deposited into your HSA debit card. If you have a covered spouse and they earn 250 points you will receive an additional $75 deposit into your HSA debit card. If you are not eligible for HSA and have an HRA and earned 250 points $75 will be deposited onto your HRA debit card.

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., you may choose to pay the coinsurance or pharmacy copayment from your HSA. If you have earned 250 points then $75 will be deposited into your HSA debit card. If you have a covered spouse and they earn 250 points an additional $75 will be deposited into your HSA debit card. If you are not eligible for HSA and have an HRA and earned 250 points you will earn $75 on a HRA debit card to use toward out-of-pocket costs. If you have a covered spouse and they earn 250 points an additional $75 will be added to the HRA debit card.

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 consultations
• Second surgical opinion
• Advance care planning

In-Network: 15%

Out-of-Network: 40%

• 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 mammograms
• CT (CAT) Scans/MRI
• Ultrasound
• Electrocardiogram and EEG

In-Network: 15%

Out-of-Network: 40%

Complete maternity (obstetrical) care, such as:

• Prenatal and Postpartum care
• Screening for gestational diabetes
• Delivery
• Professional interpretation of diagnostic testing results
• Screening and counseling for prenatal and postpartum depression

In-Network: 15%

Out-of-Network: 40%

Breastfeeding and lactation support, supplies and counseling for each birth

In-Network: 15%

Out-of-Network: 40%

Note: Here are some things to keep in mind:

• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period.
• You do not need to precertify your vaginal delivery; see page 103 for other circumstances, such as extended stays for you or your baby.
• 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 a Self and Family enrollment.
• 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 hospital stay, 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 addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, 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 addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

In-Network: 15%

Out-of-Network: 40%

Baby Steps is a maternity program available to all UPMC Health Plan members. This program connects you with maternity health coaches who provide support, education, and resources. Some examples of what you can talk about include prenatal vitamins, a birthing plan, breastfeeding, and signs of postpartum depression. We want to help increase your chances of having a healthy pregnancy, baby, and postpartum recovery. This program is provided to you at no-cost as part of your benefits. How frequently you communicate with your coach is up to you, with both phone and in-person options available.

Contact us to learn more about the Baby Steps program and get in touch with a health coach. Coaches are available Monday through Friday from 8 a.m. to 6 p.m.

• Phone: 1-866-778-6073 (TTY:711)
• Chat via UPMC Health Plan member site: Sign in to UPMC Health Plan member site | Register for UPMC Health Plan member site
• Email: maternitycoaches@upmc.edu (Coaches will schedule a phone call based on your )
• UPMC Health Plan Maternity Program

Any member who is identified as having active or a history of chronic hypertension or PIH is stratified as high risk and targeted for active Case Management outreach for program participation. If one of the Case Managers is working with a member that develops hypertension during pregnancy, they can help facilitate receipt of a blood pressure cuff and work with the member and her provider to ensure the member is comfortable with self-monitoring BP at home and notifying their provider with signs/ symptoms of worsening symptoms. Member can receive a blood pressure cuff from a DME provider with a physician’s order.

• Provider Directory | Find Care | UPMC Health Plan

In-Network: 15%

Out-of-Network: 40%

Contraceptive counseling as prescribed

In-Network: Nothing (No deductible)

Out-of-Network: 40%

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:

• Voluntary female sterilization
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: See additional Family Planning and Prescription drug coverage Section 5(f) or 5(f)(a).

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

In-Network: Nothing (No deductible)

Out-of-Network: 40%

Voluntary family planning services, limited to:

• Voluntary male sterilization

In-Network: 15% coinsurance after deductible is met

Out-of-Network: 40%

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing counseling

All charges

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) egg- sperm contact through artificial insemination. Infertility may also be established through evidence of medical history and diagnostic testing.

Medical Description

Refer to MP.017 – Infertility – Treatment policy. Note that treatment of the causes of infertility is not addressed in this policy.

Specific Indications for Diagnosis

• Member must fit the definition for infertility (as indicated in Section I0 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.
  • In vitro fertilization, embryo transfer, gamete intra-fallopian transfer (GIFT), zygote intra- fallopian transfer (ZIFT), services, IVF drugs and supplies related to covered ART procedures, cost of donor sperm and cost of donor egg. All included within the lifetime maximum of $25,000 per member.
• 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 
• Infertility prescription drugs - subject to cost sharing shown in Section 5(f) Prescription Drug Benefits in UPMC Health Plan 2025 Postal Brochure RI 73-933 and included in the Lifetime maximum benefit per member.
• 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 Member is responsible for the cost once the member’s enrollment terminates or reaches the $25,000 maximum lifetime benefit. There are no annual cycle limits.

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 PSHB Program recognizes each partner as a spouse of the other.

In-Network: 15%

Out-of-Network: 40%

• Fertility drugs (See Section 5f or 5(f)(a) and page 131 or 139)

Note: We cover Injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

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

All charges

• Testing and treatment
• Allergy injections

In-Network: 15%

Out-of-Network: 40%

Allergy serum

In-Network: 15%

Out-of-Network: 40%

• 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 117.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following 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 on page x.

• 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%

Out-of-Network: 40%

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
• Homocystinuria
• 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%

Out-of-Network: 40%

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges

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%

Out-of-Network: 40%

Not covered:

• Speech therapy for developmental delays

All charges

• 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%

Out-of-Network: 40%

• External hearing aids (see Section 5(a) Orthopedic and prosthetic devices, page 111.)
• 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%

Out-of-Network: 40%

Not covered:

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

All charges

• One pair of 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 833-288-6901 or visit www.upmchealthplan.com/PSHB/ 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

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

In-Network: 15%

Out-of-Network: 40%

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)

All charges

• 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 and anesthesia services. 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%

Out-of-Network: 40%

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

All charges

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 833-288-6901 as soon as your as soon as your physician prescribes this equipment. We can assist you in locating a participating supplier.

In-Network: 15%

Out-of-Network: 40%

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

All charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.

In-Network: 15%

Out-of-Network: 40%

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.

In-Network: 15%

Out-of-Network: 40%

Not covered:

All charges

Acupuncture – by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner

Dry Needling – by a licensed or certified practitioner

In-Network: 15%

Out-of-Network: 40%

Not covered:

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

All charges

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 108.

In-Network: 15%

Out-of-Network: 40%

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.

Nothing (No deductible)

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 severe obesity (bariatric surgery) See criteria: MP.PA.040
• 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.

Note: For female surgical family planning procedures see Family Planning Section 5(a)

Note: For male surgical family planning procedures see Family Planning Section 5(a)

In-Network: 15%

Out-of-Network: 40%

Not covered:

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

All charges

• 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; birthmarks; and webbed fingers and toes.
• Gender Affirming Surgery
  • All medically necessary gender-affirming care surgeries are covered, including facial surgeries with prior authorization.
  • 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 and facial feminization surgeries.

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.

• 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)

In-Network: 15%

Out-of-Network: 40%

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

All charges

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 leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Surgery for TMJ

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%

Out-of-Network: 40%

Not covered:

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

All charges

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

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.

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

In-Network: 15%

Out-of-Network: 40%

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)
  • Mucopolysaccharidosis (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
  • Aggressive non-Hodgkin's lymphoma
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

In-Network: 15%

Out-of-Network: 40%

Mini-transplants performed in a clinical trial setting (non-myeloablative, 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)
  • Amyloidosis Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, PNH, 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 are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols.

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
  • Myelodysplasia/Myelodysplastic Syndromes
  • Multiple sclerosis
  • Myeloproliferative disorders (MDDs)
  • 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 lymphoma/small lymphocytic lymphoma (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
• Hematopoietic Stem Cell Transplant (HSCT)

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.

In-Network: 15%

Out-of-Network: 40%

National Transplant Program (NTP) –

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

All charges

Professional services provided in –

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

In-Network: 15%

Out-of-Network: 40%

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.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, 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%

Out-of-Network: 40%

Not covered:

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

All charges

• 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
• 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%

Out-of-Network: 40%

Not covered: Blood and blood derivatives not replaced by the member

All charges

Extended care benefit:

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

In-Network: 15%

Out-of-Network: 40%

Skilled nursing facility (SNF):

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

In-Network: 15%

Out-of-Network: 40%

Not covered: Custodial care

All charges

Supportive and palliative care is covered for terminally ill patients, either in the home or in a hospice facility. Services include inpatient and outpatient care and family counseling. These services are provided under the direction of a physician who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

In-Network: 15%

Out-of-Network: 40%

Not covered: Independent nursing, homemaker services

All charges

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.

In-Network: 15%

Out-of-Network: 40%

Local professional ambulance service when medically appropriate

In-Network: 15%

Out-of-Network: 40%

• 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 waive the ER copay if you are admitted to the hospital.

15%

Not covered: Elective care or non-emergency care

All charges

• 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 waive the ER copay if you are admitted to the hospital.

15%

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

All charges

Accidental injury

15%

Professional ambulance service when medically appropriate.

Note: See 5(c) for non-emergency service.

15%

Not covered: Air ambulance

All charges

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 alcoholism and drug use, 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, and other hospital services

In-Network: 15%

Out-of-Network: 40%

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

• Services such as partial hospitalization, half-way house, residential treatment, 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

All charges

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 medicines 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 the treatment of infertility including IVF, Artificial Insemination and cryopreservation
  • We cover injectable fertility drugs under the prescription drug and medical benefits and oral fertility drugs under the prescription drug benefit
• Drugs for sexual dysfunction
• Tobacco cessation drugs including over-the- counter (OTC) drugs approved by the FDA to treat tobacco dependence. (See page 114).
• Drugs to treat gender dysphoria
• Medications prescribed to treat obesity

In-Network:

Retail (up to a 30-day supply)

$0 copayment for select generic medications

$20 copayment for preferred generic drugs

$50 copayment for preferred brand medications and generic medications

$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)

$0 copayment for select generic medications

$40 copayment for preferred generic drugs

$100 copayment for preferred brand medications and generic medications

$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 (No deductible)

Out-of-Network: All charges

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.
Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories 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.

• If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• 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 covered over-the-counter contraceptives can be submitted using the process outlined below.

• 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 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 UPMC Health Plan member site. You must submit the completed form and your pharmacy label to UPMC Health Plan for review. Please note, a prescription is not required for reimbursement for Opill.

Note: For additional Family Planning benefits see Section 5(a)

Generic and brand name drugs covered on the formulary are available at no copayments.

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a)

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/PSHB 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

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

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. Coverage is limited to 24 weeks of therapy per year.
• Aspirin (81 mg) for members of child- bearing potential
• Contraceptives coverage includes a full range of generic and single-source brand Food and Drug Administration (FDA) approved classes.
• 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 and at low risk for adverse medication effects.
• 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 (400 and 800 mcg) for members of childbearing age.
• Fluoride tablets, solution (not toothpaste, rinses) for children age 6 months through 16 years.

Preventive Medications with USPSTF A and B recommendations. 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 prescriber must be presented to the pharmacy, with the exception of Opill.

Nothing (No deductible)

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a participating pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to
www.findtreatment.samhsa.gov/

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

All charges

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 (including those administered during a non-covered admission or in a non-covered facility) 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 the treatment of infertility including IVF, Artificial Insemination and cryopreservation
  • We cover injectable fertility drugs under the prescription drug and medical benefits and oral fertility drugs under the prescription drug benefit
• Drugs for sexual dysfunction
• Tobacco cessation drugs including over-the- counter (OTC) drugs approved by the FDA to treat tobacco dependence. (See page 114).
• 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.
• Medications prescribed to treat obesity
• Medical Foods

Retail (up to a 30-day supply)

Preferred generic medications: $0 copayment at a preferred pharmacy; $15 at a standard pharmacy

Generic medications: $10 copayment at a preferred pharmacy; $20 at a standard pharmacy

Preferred brand medications: $47 copayment at both preferred and standard pharmacies

Non-Preferred brand medications: $100 copayment at both preferred and standard pharmacies

Covered Insulins: $35 copayment at both preferred and standard pharmacies

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

33% coinsurance 

Retail (up to a 100-day supply)

Preferred generic medications: $0 copayment at a preferred pharmacy; $30 at a standard pharmacy

Generic medications: $20 copayment at a preferred pharmacy; $40 at a standard pharmacy

Preferred brand medications: $129.50 copayment at a preferred pharmacy; $141 at a standard pharmacy

Non-preferred medications: $300 copayment at both preferred and standard pharmacies

Covered insulins: $96.25 copayment at a preferred pharmacy, $105 at a standard pharmacy

Mail Order (up to a 100-day supply)

Preferred generic medications: $0 copayment at a preferred pharmacy; $30 at a standard pharmacy

Generic medications: $20 copayment at a preferred pharmacy; $40 at a standard pharmacy

Preferred brand medications: $117.50 copayment at a preferred pharmacy; $141 at a standard pharmacy

Non-preferred medications: $300 copayment at both preferred and standard pharmacies

Covered insulins: $87.50 copayment at a preferred pharmacy, $105 at a standard pharmacy

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines. Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories 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.

• If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• 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 covered over-the-counter contraceptives can be submitted using the process outlined below.

• 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 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 UPMC Health Plan member site. You must submit the completed form and your pharmacy label to UPMC Health Plan for review. Please note, a prescription is not required for reimbursement for Opill.

Note: For additional Family Planning benefits see Section 5(a)

Generic and brand name drugs covered on the formulary are available at no copayments.

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a)

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

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. Coverage is limited to 24 weeks of therapy per year.
• Aspirin (81 mg) for members of child- bearing potential
• Contraceptives coverage includes a full range of generic and single-source brand Food and Drug Administration (FDA) approved classes.
• 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 and at low risk for adverse medication effects.
• 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 (400 and 800 mcg) for members of childbearing age.
• Fluoride tablets, solution (not toothpaste, rinses) for children age 6 months through 16 years.

Nothing (No deductible)

• Preventive Medications with USPSTF A and B recommendations. 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 prescriber must be presented to the pharmacy, with the exception of Opill.

Nothing (No deductible)

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a network pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at: https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

Nothing (No deductible)

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugsobtainedatanon-Planpharmacy(afterthe 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

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

In-Network: 15%

Out-of-Network: 40%

Dental benefits

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 833-288-6901. Our Healthcare Concierge team is available Monday through Friday from 8 a.m. to 6 p.m. TTY/TDD users should call 711.

You and your covered spouse, if applicable, can earn points 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 well-being assessment, is a 10-12-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 points by completing the MyHealth Questionnaire.
• Biometric Screening: This health screening measures your total cholesterol level and glucose 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 50 points for completing biometric 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 25 points per coaching session
• 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 UPMC Health Plan member site, the website that powers Take a Healthy Step, 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 $75 for Self Only coverage or $150 for Self Plus One or Self and Family coverage to your HSA/HRA. If you are eligible for HSA the funds can be used for any 213d medical expense prior to the deductible being met. If you are not HSA eligible it will be placed in an HRA and will be used after the deductible is met for coinsurance and pharmacy copayments via claim submission. Any unused reward dollars — at a value up to two times your annual deductible —automatically roll over to the next year.

To learn more about Take a Healthy Step, visit www.upmchealthplan.com/PSHB or call a Healthcare Concierge at 833-288-6901.

Take a Healthy Step 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 well-being 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 are not required to complete the health questionnaire or other medical examinations.

However, employees who choose to participate in the wellness program can receive an HSA contribution of $75 for self, $150 for self plus one, and $150 for self plus family for completing healthy activities that are customized. Although you are not required to complete the health questionnaire 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 833-288-6901.

The information from your health questionnaire 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.

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:

• UPMC Health Plan member site
• MyHealth Questionnaire
• MyHealth Community
• Health Coaching
• MyHealth Advice Line

For detailed descriptions, see below.

UPMC Health Plan member site 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 UPMC Health Plan member site, 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 Take a Healthy Step, 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 UPMC Health Plan member site at www.upmchealthplan.com/PSHB. To create an account click on Sign Up and use the number on your member ID card to register.

Once you log in to UPMC Health Plan member site, complete your MyHealth Questionnaire. Not only will you earn points, but your answers generate a simple summary of your current health status and customize UPMC Health Plan member site with activities that benefit you the most.

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

Visit UPMC Health Plan member site and log in or register to find great discounts near you, including Active&Fit. The Active&Fit Direct program allows you to choose from 16,000+ participating fitness centers nationwide for $28 a month (plus a $28 enrollment fee and applicable taxes). Learn more: https://www.activeandfitnow.com/. 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 UPMC Health Plan member site, 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 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 points toward reward dollars.

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 https://anywherecare.upmc.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. You can also earn points by completing an RxWell program.

• Manage anxiety, stress, or 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).

Baby Steps is a maternity program available to all UPMC Health Plan members. This program connects you with maternity health coaches who provide support, education, and resources. Some examples of what you can talk about include prenatal vitamins, a birthing plan, breastfeeding, and signs of postpartum depression. We want to help increase your chances of having a healthy pregnancy, baby, and postpartum recovery. This program is provided to you at no-cost as part of your benefits. How frequently you communicate with your coach is up to you, with both phone and in-person options available.

Contact us to learn more about the Baby Steps program and get in touch with a health coach. Coaches are available Monday through Friday from 8 a.m. to 6 p.m.

• Phone: 1-866-778-6073 (TTY:711)
• Chat via UPMC Health Plan member site: Sign in to UPMC Health Plan member site | Register for UPMC Health Plan member site
• Email: maternitycoaches@upmc.edu (Coaches will schedule a phone call based on your availability.)
• UPMC Health Plan Maternity Program

Any member who is identified as having active or a history of chronic hypertension or PIH is stratified as high risk and targeted for active Case Management outreach for program participation. If one of the Case Managers is working with a member that develops hypertension during pregnancy, they can help facilitate receipt of a blood pressure cuff and work with the member and her provider to ensure the member is comfortable with self- monitoring BP at home and notifying their provider with signs/ symptoms of worsening symptoms. Member can receive a blood pressure cuff from a DME provider with a physician’s order.

• Provider Directory | Find Care | UPMC Health Plan

Take a Healthy Step 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 UPMC Health Plan member site, 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, UPMC Health Plan member site, 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 UPMC Health Plan member site, complete your MyHealth Questionnaire and earn 50 points. Your answers generate a simple summary of your current health status and customize UPMC Health Plan member site 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 UPMC Health Plan member site at www.upmchealthplan.com/PSHB. 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 UPMC Health Plan member site. Visit www.upmchealthplan.com/PSHB and login to UPMC Health Plan member site using the member identification number on your member ID card.

If you have an HRA,

• Your HRA balance will be available through UPMC Health Plan member site. Visit www.upmchealthplan.com/PSHB and login to UPMC Health Plan member site 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/PSHB.

Pricing information for medical care is available at www.upmchealthplan.com/PSHB.  Pricing information for prescription drugs is available at www.upmchealthplan.com/PSHB.

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

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

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

Case Managers

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

Case managers may be contacted by calling Member Services at 833-288-6901 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 833-288-6901, or at our website at www.upmchealthplan.com/PSHB.

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 payor – 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

PDP EGWP- How to file a claim

If you recently paid cash for a covered medication, complete the form below to apply for reimbursement for Part D prescription drugs. Please follow these steps to submit a prescription drug claim reimbursement form to us.

1. Open this form:
• UPMC for Life Prescription Drug Claim Reimbursement Form
• UPMC for Life Complete Care (HMO D-SNP) Prescription Drug Claim Reimbursement Form
2. Print the form. Follow the instructions on the form and fill out as completely as possible.
3. For your claim to be processed, you will need to get your prescription receipts or patient history printout from your pharmacy.
4. Mail the form and your receipts to us at the address below. Please do not staple or attach your receipts to another piece of paper.
   
   UPMC for Life/UPMC for Life Complete Care Pharmacy Services Department
   U.S. Steel Tower, 12th Floor
   600 Grant Street
   Pittsburgh, PA 15219

Submit your claims to:

UPMC Health Plan

Claims Department

P.O. Box 2999

Pittsburgh, PA 15230-2999

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

We will notify you of our decision within 30 days after we receive 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 telephone customer assistance) and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions 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 procedure codes.

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

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at:

UPMC Health Plan

Complaints/Grievances/Appeals Department

P.O. Box 2939

Pittsburgh, PA 15230-2939

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 decision, 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, Postal Service Insurance Operations (PSIO), 1900 E Street, room 3443, NW, Washington, DC 20415

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 or notify you of the status of OPM’s review 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.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 833-288-6901. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s PSIO at 202-936-0002 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a family member is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers’ Compensation Programs if you are receiving Workers’ Compensation benefits.

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 payor and the other plan pays a reduced benefit as the secondary payor. 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 coordinating of benefits, visit our website at www.upmchealthplan.com/PSHB.

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

When we are the secondary payor, 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.

Please see Section 4, Your Costs for Covered Services, for more information about how we pay claims.

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 PSHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant, you can suspend your PSHB coverage to enroll in one of these programs, eliminating your PSHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your PSHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the PSHB 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 PSHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant, you can suspend your PSHB coverage to enroll in one of these state programs, eliminating your PSHB premium. For information on suspending your PSHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the PSHB 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 PSHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your PSHB 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 at 1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on your PSHB plan so that your plans can coordinate benefits. Providing your PSHB information may reduce your out-of-pocket cost.