SCHEDULE OF BENEFITS FOR THE UPMC HEALTH SYSTEM ADVANTAGE by rek77289

VIEWS: 20 PAGES: 5

									SCHEDULE OF BENEFITS ADVANTAGE PANTHER GOLD PLAN – Applies to Oakland, Johnstown
and Titusville campuses
The following Schedule of Benefits is part of your Certificate of Coverage. It sets forth benefit limits and cost-sharing amounts for
specific Covered Services during a Benefit Period. A Benefit Period is the 12-month period that begins on the effective date of your
coverage. Capitalized words and phrases used in this Schedule of Benefits have the same meaning as set forth in the Certificate of
Coverage. The headings under the Covered Services set forth below correspond with sections of your Certificate of Coverage that further
describe the terms and conditions of coverage for each class of services. Remember, in order to be covered at the level set forth in this
Schedule of Benefits, all services must be Medically Necessary and meet all other criteria set forth in your Certificate of Coverage,
including, but not limited to, Prior Authorization, when applicable. This managed care plan may not cover all your health care expenses.
Please read your Certificate of Coverage carefully for complete information about benefits and exclusions. If you have questions,
please contact UPMC Health Plan Member Services at 1-888-499-6885.


    BENEFIT PERIOD
    Contract Year – July 1 to June 30

                                  UPMC ADVANTAGE NETWORK                         OTHER PARTICIPATING FACILITIES
    LIFETIME BENEFIT
    LIMIT
                                  No Limit                                     $2,000,000

                                  UPMC ADVANTAGE NETWORK                       OTHER PARTICIPATING FACILITIES
    ANNUAL OUT-OF-
    POCKET LIMIT
    Individual                    None                                         $1,500
    Family                        None                                         $3,000

    ANNUAL                        UPMC ADVANTAGE NETWORK                       OTHER PARTICIPATING FACILITIES
    DEDUCTIBLE
    Individual                    None                                         $300 per Benefit Period
    Family                        None                                         $600 per Benefit Period
    Deductible applies to all Covered Services furnished to a member per Benefit Period, unless specifically excluded. The
    Deductible does not apply towards satisfaction of the Out-of-Pocket Limit specified in this Schedule of Benefits.

     PLAN PAYMENT                 UPMC ADVANTAGE NETWORK                       OTHER PARTICIPATING FACILITIES
     LEVEL
                                  100%                                         80% after deductible

    PREEXISTING                   UPMC ADVANTAGE NETWORK                       OTHER PARTICIPATING FACILITIES
    CONDITION
    LIMITATIONS
                                  None                                         None

    PRIMARY CARE                  UPMC ADVANTAGE NETWORK                       OTHER PARTICIPATING FACILITIES
    PROVIDER (PCP)
    REQUIRED
                                  Yes                                          Yes

    PRECERTIFICATION              UPMC ADVANTAGE NETWORK                       OTHER PARTICIPATING FACILITIES
    REQUIREMENTS
                                  Provider responsibility                      Provider responsibility

                                                                                                                             B83
                                                                                                              ATTACHMENT TO COC
                                                                                                                            2009
COVERED SERVICES                                     UPMC ADVANTAGE                         OTHER PARTICIPATING
                                                     NETWORK                                FACILITIES
HOSPITAL SERVICES
 Semi-Private Room, Private Room (if                                                       80% after Deductible
                                                100% after $100 Copayment per inpatient
 Medically Necessary), Surgery, Pre-
                                                                 stay
 Admission Testing
                                                  Limit of four Copayment per Benefit
                                                   Period; 100% coverage thereafter
  Outpatient surgery
                                                 100% after $100 Copayment per visit;
                                                 Limit of four Copayments per Benefit
                                                   Period; 100% coverage thereafter
 Outpatient care, medical services, ancillary
                                                100%
 services, colonoscopy and supplies
EMERGENCY SERVICES
Emergency Care Coverage
                                                 100% after $30 Copayment per visit for members 18 years old and under

                                                  100% after $50 Copayment per visit for members 19 years old and over

                                                                Copayment waived if admitted as inpatient
DIAGNOSTIC SERVICES
Inpatient & outpatient hospital services        100%                                       80% after Deductible
Hospital Outpatient Mammogram (based on         100%                                       80% (Deductible does not
age guidelines)                                                                            apply)
Non-hospital Outpatient Facility                100%                                       80% after Deductible
Non-hospital Outpatient Facility                100%                                       80% (Deductible does not
Mammogram (based on age guidelines)                                                        apply)
Advanced Imaging (e.g., PET, MRI, etc.)         100% after $25 Copayment per visit         80% after Deductible
                                                (limit four Copayments per Benefit
                                                Period; 100% coverage thereafter)
Other Imaging (e.g., X-ray, Sonogram, etc.)     100% after $5 Copayment per visit (limit   80% after Deductible
                                                four Copayments per Benefit Period;
                                                100% coverage thereafter)
Diagnostics billed by Physician Office                                             100%
PHYSICIAN SERVICES
Preventive Care
Pediatric Care and Immunizations
  Routine Physical Exam                                                           100%
  Pediatric Immunizations                                                         100%
  Well-Baby Visits                                                                100%
Adult Routine Physical Examination
  Routine Physical Exam                                                           100%
  Age Specific Preventative Care screenings                                       100%
  (colonoscopy, prostate cancer screenings,
  etc.)
  Adult Immunizations                                                            100%
PCP Office Visit - for treatment of medical                        100% after $15 Copayment per visit
disease or injury
Specialist Office Visit; including ob-gyn                          100% after $25 Copayment per visit




                                                                                                                       B83
                                                                                                        ATTACHMENT TO COC
                                                                                                                      2009
COVERED SERVICES                                   UPMC ADVANTAGE                          OTHER PARTICIPATING
                                                   NETWORK                                 FACILITIES
PHYSICIAN SURGICAL SERVICES
                                                                           100%
PHYSICIAN MEDICAL SERVICES
                                                                           100%
   Inpatient Medical Care Visits
   and Intensive Medical Care,
   Consultation, Newborn Care
WOMEN’S CARE
Annual Gynecologic Exam, Breast Exam, and Pap Test, Prenatal Visits, Diagnostic Tests and Surgical Services
  Care provided/coordinated                                              100%
  through PCP or network
  OB/GYN
ALLERGY SERVICES
   Diagnostic Testing                                                    100%
   Treatment Including Injections                                        100%
   and Serum
REHABILITATION THERAPY SERVICES
Physical, Speech, and Occupational Therapy
   Hospital and Non-hospital      100% after $10 Copayment per visit            80% after Deductible
   Outpatient
                                       Covered up to 60 visits per Benefit Period for all three therapies combined
Cardiac Rehabilitation
  Hospital Outpatient              100%                                          80% after Deductible
                                                         Covered up to 12 weeks per Benefit Period
Pulmonary Rehabilitation
   Hospital Outpatient            100% after $10 Copayment per visit             80% after Deductible
                                                        Covered up to 24 visits per Benefit Period
MEDICAL THERAPY SERVICES
Chemotherapy, Radiation Therapy, Infusion Therapy, Dialysis Treatment
  Inpatient & Outpatient          100%                                           80% after Deductible
  Hospital Services
  Non-Hospital Outpatient                                                 100%
  Services
PAIN MANAGEMENT PROGRAMS
  Hospital Outpatient             100% after $25 Copayment per visit             80% after Deductible
  Professional Services                                     100% after $25 Copayment per visit
BEHAVIORAL HEALTH SERVICES - Contact UPMC Health Plan Behavioral Health Services at 1-877-461-8610
General Mental Illness
Inpatient                          100%
                                              Up to 30 days per Benefit Period; Lifetime Maximum of 90 days
Outpatient                         100% after $20 Copayment per visit
                                                           Up to 25 visits per Benefit Period




                                                                                                                       B83
                                                                                                        ATTACHMENT TO COC
                                                                                                                      2009
COVERED SERVICES                    UPMC ADVANTAGE                               OTHER PARTICIPATING FACILITIES
                                    NETWORK
Serious Mental Illness Services
Inpatient
                                    100%

                                                     Up to 30 days per Benefit Period; No Lifetime Maximum

                                    The 30 inpatient days set forth above may be exchanged on a 1:2 basis to secure up to 60
                                                                    additional outpatient visits
Outpatient                          100% after $20 Copayment per visit
                                                            Benefit Limit of 60 visits per Benefit Period

SUBSTANCE ABUSE SERVICES - Contact UPMC Health Plan Behavioral Health Services at 1-877-461-8610
Inpatient Detoxification 100%
                                       Benefit Limit of seven days per admission; Lifetime Maximum of four admissions
                                    100%
Inpatient Non-hospital
Residential Alcohol or Other                Benefit Limit of 30 days per Benefit Period; Lifetime Maximum of 90 days
Drug Services
Outpatient Rehabilitation           100%
                                    Benefit Limit of 60 full-session visits (or equivalent partial visits) per Benefit Period, 30
                                    of which may be exchanged on a 2:1 basis to secure up to an additional 15 inpatient non-
                                                            hospital residential alcohol treatment days

                                           Benefit Limit of 120 full-session visits or equivalent partial visits per lifetime
OTHER MEDICAL SERVICES
Private Duty Nursing                                                         100%
Skilled Nursing Facility – Benefit Limit of 90 days per Benefit Period
   Hospital based facility           100%                                        80% after Deductible
   Non-hospital based facility                                               100%
Home Health Care                     100%                                        80% after Deductible
Hospice Care                                                                 100%
Therapeutic Manipulation –
                                          100% after $30 Copayment for initial evaluation; then $15 Copayment per visit
Chiropractic care                                                          thereafter

                                                             Covered up to 25 visits per Benefit Period
Acupuncture                                                                   100%
                                        Please reference your Certificate of Coverage or call Member Services for details

Podiatric Care                                                  100% after $25 Copayment per visit

Durable Medical Equipment
Facility and Ancillary Services     100%                                            80% after Deductible
Physician Office Services
                                                                                 100%




                                                                                                                              B83
                                                                                                               ATTACHMENT TO COC
                                                                                                                             2009
COVERED SERVICES                      UPMC ADVANTAGE                         OTHER PARTICIPATING FACILITIES
                                      NETWORK
Corrective Appliances
  Hospital based facility               100%                                   80% after Deductible
  Physician services                                                            100%
Ambulance Services                                                              100%
Fertility Testing                                                               100%
Nutritional Supplements                 100%                                   80% (Deductible does not apply)
Diabetic Education
   Hospital Related Services            100%                                   80% after Deductible
   Physician & Ancillary Services                                               100%
Diabetic Equipment and Supplies         Must be obtained at a participating pharmacy; 100% after Copayment, if applicable
(Glucometer, Test Strips, Lancets,
Insulin and Syringes)
Blood and Blood Products                100%                                   80% after Deductible
Clinical Trials                                                                 100%
 Dental Services - Related to Accidental Injury
   Physician Services                                                           100%
   Hospital related services            100%                                    80% after Deductible
Oral Surgical Services
   Physician Services                                                           100%
   Hospital related services            100%                                    80% after Deductible




                                                                                                                        B83
                                                                                                         ATTACHMENT TO COC
                                                                                                                       2009

								
To top