UPMC Advantage Silver $1,500/$75 – Standard Network

62560PA0010125
Silver
HMO

UPMC Advantage Silver $1,500/$75 – Standard Network is a Silver HMO plan by UPMC Health Plan.

Locations

UPMC Advantage Silver $1,500/$75 – Standard Network is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of UPMC Advantage Silver $1,500/$75 – Standard Network 62560PA0010125.
Insurer: UPMC Health Plan
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 62560PA0010125

Cost-Sharing Overview

UPMC Advantage Silver $1,500/$75 – Standard Network offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for UPMC Advantage Silver $1,500/$75 - Standard Network?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

UPMC Advantage Silver $1,500/$75 – Standard Network offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: A PCP is required for specialist visits and services. Referrals are not required for Pediatric Specialist visits (children under 21), Ob-gyns, Mental Health or Substance Use Services, and Virtual Visits.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what UPMC Advantage Silver $1,500/$75 – Standard Network covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Services Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Dental Services and Emergency Medical Services Only
National Network: No

Additional Benefits and Cost-Sharing

UPMC Advantage Silver $1,500/$75 – Standard Network includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Diabetes Care Management
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No12 Visit(s) per Benefit Period Additional EHB Benefit
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No120 Days per Benefit Period Substantially Equal
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per Benefit Period You pay full cost Out of Network. Eligible for a $30 reimbursement.Substantially Equal
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Treatment(s) per Lifetime Substantially Equal
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Select generics available for $0. Visit the Formulary page to learn more.Additional EHB Benefit
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Certain Diagnostic Services may have additional cost sharing.
Hearing Aids
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Certain Diagnostic Services may have additional cost sharing.
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The Health Benefit Plan will provide coverage for surgical services provided: By a Participating Professional Provider, and/or a Participating Facility Provider; For the treatment of disease or injury.
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Certain Diagnostic Services may have additional cost sharing.
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Benefit Period Substantially Equal
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Office visit cost share applies to first visit only.
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No36 Visit(s) per Benefit Period Limit 36 visits per benefit period for Cardiac Rehabilitation Therapy, Pulmonary Rehabilitation Therapy, and Respiratory Therapy. Limit 30 visits per benefit period for speech therapy. Combined limit of 30 visits per benefit period for physical therapy and occupational therapy.Substantially Equal
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No6 Visit(s) per Benefit Period Additional EHB Benefit
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Benefit Period Substantially Equal
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Out-of-network pediatric immunizations are not subject to the deductible.
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Limited to artificial insemination.
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Substantially Equal
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No36 Visit(s) per Benefit Period Includes Cardiac Rehabilitation Therapy, Pulmonary Rehabilitation Therapy, Respiratory Therapy.Substantially Equal
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Foot Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Prior Authorization RequiredAdditional EHB Benefit
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inherited Metabolic Disorder – PKU
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Benefit Period You pay full cost Out of Network. Eligible for a $55-$75 reimbursement. You pay cost of In-Network, Non-Collection Frames.Substantially Equal
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Anesthesia
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Days per Benefit Period Substantially Equal
Treatment for Temporomandibular Joint Disorders
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Up to $500/30-day PrescriptionSubstantially Equal
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per 6 Months Substantially Equal
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Benefit Period Substantially Equal

Free Preventive Services

There is no copayment or coinsurance for any of the following UPMC Advantage Silver $1,500/$75 – Standard Network preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for UPMC Advantage Silver $1,500/$75 - Standard Network?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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