Pennsylvania Health Insurance

Affordable Pennsylvania Health Insurance Quotes

(888) 513-6446
Get Free Quotes
Compare
& Save

UPMC individual Health Plan insurance provides affordable medical coverage to Western Pennsylvania individuals and Seniors. 2022 Pa health Exchange Marketplace plans are offered to individuals, families, and the self-employed. As one of the top non-profit providers in the US, several different personal plan choices are available for individuals, families, and students, including the self-employed. Policies are also available to larger businesses in the area with many flexible options for employees.

Senior Medigap coverage, and plans not subsidized by the federal government are also offered. UPMC offers under-65 plans in 53 of the 67 counties, and the average increase this year was only 1.3%. Highmark members are often accepted at network providers, along with many additional carriers, including Cigna, and UnitedHealthcare. The out-of-pocket cost is also equal to Allegheny Health Network physicians and hospitals.

Senior private plans also feature Medicare-related options along with special needs plans and coverage for persons eligible for medical assistance. Medicare-eligible policies include the “UPMC For Life” HMO Advantage plan that offers a very low premium. Office visit copays are $5 for primary-care physicians, and $45 for specialists. Pa Advantage plans replace original Medicare benefits and should be appropriately reviewed prior to enrollment. Additional Senior plan information, including Part D prescription drug coverage, is discussed further below.

If you are a business-owner (large and small companies), employer-sponsored programs will help you offer your workers multiple benefit choices, including dental and vision. The SHOP Exchange (administered through the federal government) can also make it easy for your employees to review group benefits. Many additional benefits can be offered to employees, including dental, vision, life, and disability. Last year, during the beginning of the COVID-19 virus pandemic, cost-sharing and copays were eliminated for doctor-ordered tests. Early prescription refills were also provided.

More than 29,000 doctors and 140 hospitals are “in-network” throughout the state. If Urgent Care coverage is needed, an extended network provides out-of-area options through PHCS (Private Healthcare Systems), SuperMed PPO, and MultiPlan. Student Health Centers are also available from many Universities. UPMC expanded into Western Maryland by acquiring WMHS (Western Maryland Health System). The UPMC Premium Network is one of the most popular options, and is the largest available network, covering 53 counties. Carrier-owned facilities are included along with  many community-based hospitals and physicians.

Available 2022 Plans (Under Age 65)

There are eight available plans, and we help match the policy that provides the most needed benefits for you. UPMC  continues to update and offer their portfolio by offering “guaranteed issue” coverage which began when the Affordable Care Act legislation was passed. Currently, discounts are offered for hearing aids and LASIK eye procedures along with the mandatory “essential” benefits (mental illness, pediatric wellness, ER, office visits, prescription drugs, maternity etc…)

Some of the most popular individual and family plans are the Advantage Silver-tier options. These policies are eligible for considerable “cost-sharing” provisions that only Silver contracts enjoy, if you receive the federal subsidy. The entire portfolio of plans get a boost since UPMC is again rated “A-” from A.M.Best Company, one of the leading financial rating services. In most situations, Highmark plan rates are higher. NOTE: Additional policies may be offered in 2022, when Administration changes continue to be implemented. More

UPMC Provider Networks

UPMC Partner Network – Included counties are Allegheny, Bedford, Blair, Clinton, Erie, Lawrence, Lycoming, Mercer, Somerset, Tioga, and Venango. Considered an EPO (Exclusive Provider Organization), treatment outside of the area is not covered, unless it is considered an emergency. A partial list of hospitals and facilities include UPMC facilities, Penn State Health Milton S. Hershey Medical Center, Children’s Hospital, Magee-Womens, Eye And Ear Institute, Western Psychiatric Institute And Clinic, Corry Memorial, AHN Grove City Medical Center, Kane Community,  Select Speciality Hospital, and Jameson Hospitals.

UPMC Select Network – Included counties are Allegheny, Beaver, Butler, Fayette, Washington, and Westmoreland. A partial list of hospitals include Grove City Medical Center, UPMC facilities, Heritage Valley Health System, Children’s Home Of Pittsburgh, Butler Memorial, Penn State Health Milton S. Hershey Medical Center, Monongahela Valley, and many community hospitals. Also an EPO. 

UPMC Standard Network – Included counties are Crawford and Clearfield. A partial list of hospitals include UPMC facilities, Heritage Valley Health System, St. Clair, Children’s Home Of Pittsburgh, Armstrong County Memorial, Butler Memorial, Meadville Medical Center, Penn State Health Milton S. Hershey Medical Center, Penn Highlands Elk, Millcreek Community, Washington Health System, Indiana Regional Medical Center, Sharon Regional Health System, and Guthrie Corning (NY). This is an HMO network.

UPMC Premium Network – Pictured above, the largest and most expensive of the three Networks, the “Premium” option covers all of Western Pennsylvania, and extends towards the Central and Eastern portion of the state. As a PPO (Preferred Provider Organization), out-of-network benefits are more extensive than the previous two options. Flexible cost-sharing is also offered. During an emergency, any hospital, including facilities not in-network, can be utilized and the in-network benefit level will apply.

Included counties are Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Butler, Cambria, Cameron, Centre, Clarion, Clinton, Clearfield, Columbia, Cumberland, Crawford, Dauphin, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lackawanna, Lancaster, Lawrence, Lebanon, Luzerne, Lycoming, McKean, Mercer, Northumberland, Perry, Potter, Snyder, Somerset, Sullivan, Tioga, Union, Vernango, Warren, Washington, Westmoreland, Wyoming, and York.

Out-of-state providers include Cleveland Clinic System (Akron, Avon, Euclid, Fairview, Hillcrest, Lutheran, Marymount, Medina, South Pointe, and Union Hospitals), Wheeling Hospital, UPMC Hanover, UPMC Memorial, UPMC Chautauqua, Olean General, and Guthrie Corning Hospital.

Eleven Urgent Care facilities are also conveniently located throughout the region. Locations are: Shadyside (Centre Avenue), McCandless (McKnight Road), Monroeville (William Penn Highway), Robinson (Steubenville Pike), Wexford (Perry Highway), Natrona Heights (Broadview Boulevard), North Huntingdon (Route 30), Hermitage (North Hermitage Road), Franklin (Allegheny Boulevard), Erie South (Peach Street), and Erie West (West 26th Street).

In the Pittsburgh area, more than 10 hospitals and 2,000 physicians are available. Five of the major hospitals include UPMC Shadyside, Children’s Hospital of Pittsburgh, Magee-Womens Hospital, UPMC Mercy, and UPMC Presbyterian/Montefiore.

UPMC Tower Network PPO – Available in Carbon, Lehigh, Berks, Northampton, and Schuylkill Counties as a PPO.

UPMC Tower Network EPO – Available in Berks County as an EPO. All Tower Health and UPMC providers are included.

Individual And Family Plans (Under Age 65)

On and off Marketplace policies are separated into five tier classifications: Catastrophic, Bronze, Silver, Gold, and Platinum. Premiums, out-of-pocket-expenses, copays, coinsurance, and deductibles, will vary, depending on the specific policy. Three different provider network options are available and discussed later in the article.

 

Catastrophic Tier

(Must be under age 30 or prove “financial hardship”)

Advantage Catastrophic $8,700/$0 – Deductible is $8,700 with 0% coinsurance. The concept of this policy is simple. Once you meet the deductible, there are no out-of-pocket expenses for covered benefits. However, you can not utilize a federal tax credit (subsidy) for this type of contract. Thus, Bronze-tier options should always be considered. Applicants of this plan must be under age 30, unless proof of financial hardship is provided. Applicants with major pre-existing conditions that have frequent specialist visits and non-generic prescriptions should also consider other available plans.

Bronze Tier

Advantage Bronze $6,700/$0 – Least expensive subsidized plan features unlimited pcp office visits (no cost after the deductible) for every family member. Specialist visits are subject to the deductible but receive generous network-negotiated repricing to reduce cost. The deductible is $6,700 with a maximum out-of-pocket cost of $8,700 and 40% coinsurance. Generic drugs are subject to only a $30 copay, while all other Tiers must meet a deductible and coinsurance.

Silver Tier

Advantage Silver $3,000/$50 – $3,000 deductible with $6,000 maximum out-of-pocket expenses and 30% coinsurance. Office visit copays are $50 and $80 (not subject to a deductible). $75 copay for Laboratory services. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $10, $50, and $100. The Urgent Care copay is $80. Mental health, behavioral, and substance abuse outpatient services are subject to an $50 copay, and ER visits are subject to 30% coinsurance after the deductible.

Advantage Silver $1,500/$75 – $1,500 deductible with $8,700 maximum out-of-pocket expenses and 40% coinsurance. Office visit copays are $75 and $100 (not subject to a deductible). $80 copay for Laboratory services. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $10, $50, and $100. The Urgent Care copay is $100. Mental health, behavioral, and substance abuse outpatient services are subject to an $75 copay, and ER visits are subject to 40% coinsurance after the deductible.

Advantage Silver $3,500/$40 – $3,500 deductible with $8,700 maximum out-of-pocket expenses and 30% coinsurance. Office visit copays are $40 and $75 (not subject to a deductible). $60 copay for Laboratory services. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $10, $50, and $100. The Urgent Care copay is $75. Mental health, behavioral, and substance abuse outpatient services are subject to an $40 copay, and ER visits are subject to $1,000 copay after the deductible.

Advantage Silver $6,800/$0 – $6,800 deductible with $8,700 maximum out-of-pocket expenses and 40% coinsurance. Office visit copays are $0 and $40 (not subject to a deductible). $25 copay for Laboratory services. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $10, $50, and $100. The Urgent Care copay is $40. Mental health, behavioral, and substance abuse outpatient services are subject to an $0 copay, and ER visits are subject to 40% coinsurance copay after the deductible.

Advantage Silver HSA – $3,100 deductible with $5,300 maximum out-of-pocket expenses and 20% coinsurance. Policy is HSA-eligible.

Gold Tier 

Advantage Gold $1000/$10 – $1,000 deductible with $7,000 maximum out-of-pocket expenses and 20% coinsurance. Office visit copays are $10 and $70 (not subject to a deductible). X-rays and blood tests are subject to a $50 copay, and imaging (MRIs, PET scans and CT scans) is also subject to 20% coinsurance. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $10, $50, and $100 ($20, $125, and $300 mail order). The Urgent Care copay is $70 and the ER coinsurance is 20%. Mental health, behavioral, and substance abuse outpatient services are subject to a $10 copay, and rehabilitation services are subject to a $50 copay.

Advantage Gold HSA $3,100/$0 – $3,100 deductible with $4,000 maximum out-of-pocket expenses and 10% coinsurance. Policy is HSA-eligible.

Platinum Tier

No plans available

Current UPMC Monthly Rates (Under Age-65)

25-Year-Old With $33,000 Household Income (Allegheny County)

$32 – Advantage Bronze $6,700/$0

$76 – Advantage Gold HSA $3,100/$0

$105 – VirtualCare Silver $4,500/$0

$109 – Advantage Gold $1,000/$10

40-Year-Old Married Couple (2 Persons) With $54,000 Household Income (Allegheny County)

$67 – Advantage Bronze $6,700/$0

$181 – Advantage Gold HSA $3,100/$0

$254 – VirtualCare Silver $4,500/$0

$262 – Advantage Gold $1,000/$10

55-Year-Old Married Couple (2 Persons) With $68,000 Household Income (Allegheny County)

$93 – Advantage Bronze $6,700/$0

$291 – Advantage Gold HSA $3,100/$0

$420 – VirtualCare Silver $4,500/$0

$434 – Advantage Gold $1,000/$10

35-Year-Old With $36,000 Household Income (Westmoreland County)

$58 – Advantage Bronze $6,700/$0

$115 – Advantage Gold HSA $3,100/$0

$149 – VirtualCare Silver $4,500/$0

$157 – Advantage Gold $1,000/$10

48-Year-Old Married Couple (2 Persons) With $56,000 Household Income (Westmoreland County)

$45 – Advantage Bronze $6,700/$0

$199 – Advantage Gold HSA $3,100/$0

$289 – VirtualCare Silver $4,500/$0

$310 – Advantage Gold $1,000/$10

50-Year-Old Married Couple And Two Children (2 Persons) With $90,000 Household Income (Westmoreland County)

$119 – Advantage Bronze $6,700/$0

$359 – Advantage Gold HSA $3,100/$0

$499 – VirtualCare Silver $4,500/$0

$532 – Advantage Gold $1,000/$10

30-Year-Old With $33,000 Household Income (Northampton County)

$149 – Advantage Bronze $6,700/$0

$323 – Advantage Gold HSA $3,100/$0

$409 – Advantage Silver $3,500/$40 

30-Year-Old Married Couple (2 Persons) With $40,000 Household Income (Northampton County)

$170 – Advantage Bronze $6,700/$0

$517 – Advantage Gold HSA $3,100/$0

$197 – VirtualCare Silver $4,500/$0

60-Year-Old Married Couple (2 Persons) With $67,000 Household Income (Fayette County)

$2 – Advantage Bronze $6,700/$0

$49 – Advantage Gold HSA $3,100/$0

$451 – Advantage Silver $3,500/$25

$232 – Advantage Gold $1,000/$10

45-Year-Old Married Couple And One Child (3 Persons) With $70,000 Household Income (Fayette County)

$8 – Advantage Bronze $6,700/$0

$181 – Advantage Gold HSA $3,100/$0

$281 – VirtualCare Silver $4,500/$0

$304 – Advantage Gold $1,000/$10

 

Federal Employees Health Benefits

Three HealthyU options are available to Federal employees. They are:

High Deductible Health Plan (HDHP) – Deductibles are $2,000 for a single policy and $4,000 for a family policy. Monthly HSA contributions into the account are $75 for a single plan, and $150 for a family plan. The coinsurance is 15%, and maximum out-of-pocket expenses for one person is $6,000, and $12,000 for a family. Drug copays (after deductible is met) are $20 (generic), $50 (preferred brand), $100 (non-preferred brand), and 50% (specialty).

Standard Option HMO – Deductibles are $850 and $1,700 (single and family) with 20% coinsurance. Maximum out-of-pocket expenses are $6,000 and $12,000 for an individual and family. $20 and $50 office visit copays with $75 Urgent Care copay. The virtual urgent care copay is $5. Generic, preferred brand, and non-preferred brand drug copays are $20, $50, and $100 ($40, $100, and $200 mail order).

HealthyU provides 100% coverage (no copay, coinsurance, or deductible) for qualified preventative expenses. Also included is a “Health Incentive Account” (HIA) that provides the opportunity to earn $250 (single) or $500 (family) for making healthy choices. Several personalized activities will earn “reward dollars,” that can be utilized to pay out-of-pocket expenses, such as copays, coinsurance, and deductibles.

Biweekly share rates:

HDHP: $77.07 (self only), $170.71 (self plus one), $177.60 (self plus family)

Standard: $88.93 (self only), $225.92 (self plus one), $209.98 (self plus family)

Several popular reward include preventative lab screening ($25), preventative Colonoscopy or mammogram ($50), checkup or routine physical ($50), and completing the MyHealth assessment ($50). Additional savings and discounts are available for spas and fitness centers. The list of available facilities is annually updated.

Pittsburgh and the Western portion of the state are not the only areas where you can utilize benefits. If you travel abroad, you’ll still be in good hands. The Advanced Radiosurgery Center Of Excellence (San Pietro FBF Hospital) in Rome is one of the most respected resources in Italy for treating tumors. UPMC has another location in Sicily along with other facilities in Ireland, China, Singapore and Japan. Compared to other major regional carriers, the UPMC provider network is very large.

Health Plan Maternity Program

Both mother and baby receive special care and attention with this special program. A unique gift is also presented when all requirements are met. Both pre-delivery and post-delivery assistance is provided. Participation should begin before the 34th week of pregnancy. Several of the program requirements include 10 prenatal office visits, completion of required lab tests and x-rays, and signing of consent form. A visit with a provider within the first 13 weeks of pregnancy also must be completed.

“text4baby” is also offered to recent mothers and pregnant women. After signing up (it’s free!), periodic tips and assistance will be provided, with information based upon the expected delivery date.Texts are free and do not count against a maximum limit, if you use one of these carriers: Alltel, Assurance Wireless, AT&T, Bluegrass Cellular, Boost Mobile, Cellular South, Cellcom, Centenial Cellular, Cincinnati Bell, Cricket, Metro PCS, nTelos, Nex-Tech Wireless, Sprint Nextel, T-Mobile, US Cellular, Verizon, and Virgin Mobile USA.

Women’s health has always been a priority. Resources and information are always provided, and all plans feature the most comprehensive benefits. “MyHealth OnLine topics include women in business, domestic abuse and violence, pregnancy, health and wellness, breast and cervical cancer, depression, stress, and anxiety, and heart disease.

UPMC Medigap Information

“UPMC For Life” also offers four affordable HMO options for its Medicare Advantage portfolio. Some of the newer benefits include unlimited fitness, low $5 copay for doctor visits and a policy with no premium. The fitness benefit allows the customer to pick any fitness facility, and a portion of the cost will be reimbursed. Two PPO plans are also available along with vision and dental coverage (dental is a discount) and travel assistance. NOTE:Part B benefits should not be terminated.

As you approach age 65, and have not previously been covered by Medicare, a seven-month window is available to enroll in Parts A and B. This period begins three months prior to the month of your 65th birthday. If you are still receiving benefits through an employer, once you retire, approximately eight months is provided to enroll in Parts A and B. New HMO Premier Rx and HMO Rx Choice plans are available in Northwest counties.

Senior UPMC Medicare Advantage Health Plans

Medicare Open Enrollment is not related to the Health Exchange. Affordable Medicare Supplement rates in Pennsylvania are also offered by many large and reputable carriers. The previously-mentioned UPMC Advantage plan options that are available in Allegheny County and the surrounding area are very moderately-priced. “UPMC For Life” contracts have earned  4.0 stars (out of 5) from Medicare for the PPO and HMO plans. Most plans offer preventative dental benefits (exams and cleanings). More than 19,000 physicians and 3,000 facilities area available.

The available options are:

HMO No Rx – No deductible with $0 and $45 office visit copays. Telehealth copays are $0 and $40. Inpatient hospital charge is $300 per stay and maximum out-of-pocket expenses are $7,550.  $225 outpatient surgery copay with $90 and $50 copays for ER and Urgent Care visits. Skilled nursing facility daily copays are $20 for first 20 days and $80 for days 21-100. Out-of-pocket costs for lab services and x-rays are approximately $5 and $30. MRIs, PET scans, and CT scans are subject to $110 copay. The physical therapy visit copay is $40.

Diabetic supplies and durable medical equipment are subject to 20% coinsurance. One routine vision exam is provided every two years ($0 copay) with $150  available for eyewear expenses. Preventative dental visit copays are $0 for two cleanings and oral exams per year. One bitewing x-ray is covered ($0 copay) per year with an annual $2,00 dental services allowance. One panoramic x-ray ($0 copay) is provided every 36 months. One annual hearing exam and an additional hearing aid fitting exam is provided ($0 copay). A $500 annual hearing aid allowance is also available.

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line, RxWell,  Assist America (and worldwide emergency assistance (more than 100 miles from home) are also included. Every three months, a $50 allowance is provided for the purchase of daily health and wellness items.

Items must be used during the current quarter and can not be carried forward. Telehealth copays are $0 for pcp visits and $40 for specialist visits. UPMC AnywhereCare copays are $0 for medical visits. Six sessions of personal counseling (at no cost) are provided along with an annual free in-home safety assessment.

Part D prescription drug benefits are also not included.

 

HMO Premier RxNo deductible with $0 and $40 office visit copays. Inpatient hospital charge is $190 per day for five days. Maximum out-of-pocket expenses are $7,550.  $325 outpatient surgery copay with $90 and $65 copays for ER and Urgent Care visits. Skilled nursing facility daily copays are $0 for first 20 days and $184 for days 21-100. Out-of-pocket costs for lab services and x-rays are approximately $5 and $45. MRIs, PET scans, and CT scans are subject to $225 copay. The physical therapy visit copay is $40.

Diabetic supplies and durable medical equipment are subject to 20% coinsurance. One routine vision exam is provided every two years ($0 copay) with $200  available for eyewear expenses. Preventative dental visit copays are $0 for two cleanings and oral exams per year. One bitewing x-ray is covered ($0 copay) per year with an annual $2,000 dental services allowance. One panoramic x-ray ($0 copay) is provided every 36 months. One annual hearing exam and an additional hearing aid fitting exam is provided ($0 copay). A $500 annual hearing aid allowance is also available.

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line, RxWell,  Assist America (and worldwide emergency assistance (more than 100 miles from home) are also included. Every three months, a $50 allowance is provided for the purchase of daily health and wellness items.A free Fitbit is provided every two years. Three bathroom safety products are provided each year.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), and $100 (Tier 4). 90-day mail-order copays are $0 (Tier 1), $40 (Tier 2), $117.50 (Tier 3), and $300 (Tier 4).

 

HMO Deductible Rx – $750 deductible with $0 and $35 office visit copays. Inpatient hospital charge is $300 per stay. Maximum out-of-pocket expenses are $7,550.  $125 outpatient surgery copay with $90 and $65 copays for ER and Urgent Care visits. Skilled nursing facility daily copays are $0 for first 20 days and $172 for days 21-100. Out-of-pocket costs for lab services and x-rays are approximately $10 and $20. MRIs, PET scans, and CT scans are subject to $200 copay. The physical therapy visit copay is $0.

Diabetic supplies and durable medical equipment are subject to 20% coinsurance. One routine vision exam is provided every two years ($0 copay) with $100  available for eyewear expenses. Preventative dental visit copays are $0 for two cleanings and oral exams per year. One bitewing x-ray is covered ($0 copay) per year with an annual $1,250 dental services allowance. One panoramic x-ray ($0 copay) is provided every 36 months. One annual hearing exam and an additional hearing aid fitting exam is provided ($20 copay). A $100 annual hearing aid allowance is also available.

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line and worldwide emergency assistance (more than 100 miles from home) are also included. Every three months, a $25 allowance is provided for the purchase of daily health and wellness items. Items must be used during the current quarter and can not be carried forward. Telehealth copays are $0 for pcp visits and $30 for specialist visits. UPMC AnywhereCare copays are $0 for medical visits.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), and $100 (Tier 4). 90-day mail-order copays are $0 (Tier 1), $20 (Tier 2), $117.50 (Tier 3), and $300 (Tier 4).

 

HMO Rx Choice – $0 deductible with $0 and $35 office visit copays. Inpatient hospital charge is $325 per stay. Maximum out-of-pocket expenses are $7,550.  $200 outpatient surgery copay with $90 and $50 copays for ER and Urgent Care visits. Skilled nursing facility daily copays are $0 for first 20 days and $160 for days 21-100. Out-of-pocket costs for lab services and x-rays are approximately $5 and $10. MRIs, PET scans, and CT scans are subject to $180 copay. The physical therapy visit copay is $35.

Diabetic supplies and durable medical equipment are subject to 20% coinsurance. One routine vision exam is provided every two years ($0 copay) with $175  available for eyewear expenses. Preventative dental visit copays are $0 for two cleanings and oral exams per year. One bitewing x-ray is covered ($0 copay) per year with an annual $3,000 dental services allowance. One panoramic x-ray ($0 copay) is provided every 36 months. One annual hearing exam and an additional hearing aid fitting exam is provided ($0 copay). A $500 annual hearing aid allowance is also available.

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line and worldwide emergency assistance (more than 100 miles from home) are also included. Every three months, a $40 allowance is provided for the purchase of daily health and wellness items. Items must be used during the current quarter and can not be carried forward. Telehealth copays are $0 for pcp visits and $30 for specialist visits. UPMC AnywhereCare copays are $0 for medical visits.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), and $100 (Tier 4). 90-day mail-order copays are $0 (Tier 1), $20 (Tier 2), $117.50 (Tier 3), and $300 (Tier 4).

 

HMO Rx – $0 deductible with $0 and $35 office visit copays. Inpatient hospital charge is $295 per stay. Maximum out-of-pocket expenses are $7,550.  $225 outpatient surgery copay with $90 and $65 copays for ER and Urgent Care visits. Skilled nursing facility daily copays are $0 for first 20 days and $100 for days 21-100. Out-of-pocket costs for lab services and x-rays are approximately $5 and $35. MRIs, PET scans, and CT scans are subject to $200 copay. The physical therapy visit copay is $35.

Diabetic supplies and durable medical equipment are subject to 20% coinsurance. One routine vision exam is provided every two years ($0 copay) with $200  available for eyewear expenses. Preventative dental visit copays are $0 for two cleanings and oral exams per year. One bitewing x-ray is covered ($0 copay) per year with an annual $3,000 dental services allowance. One panoramic x-ray ($0 copay) is provided every 36 months. Routine hearing benefits are not included.

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line and worldwide emergency assistance (more than 100 miles from home) are also included. Every three months, a $50 allowance is provided for the purchase of daily health and wellness items. Items must be used during the current quarter and can not be carried forward. Telehealth copays are $0 for pcp visits and $30 for specialist visits. UPMC AnywhereCare copays are $0 for medical visits.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), and $100 (Tier 4). 90-day mail-order copays are $0 (Tier 1), $20 (Tier 2), $117.50 (Tier 3), and $300 (Tier 4).

 

HMO Rx Enhanced – $0 deductible with $5 and $25 office visit copays. Inpatient hospital charge is $125 per stay. Maximum out-of-pocket expenses are $7,550.  $225 outpatient surgery copay with $90 and $65 copays for ER and Urgent Care visits. Skilled nursing facility daily copays are $0 for first 20 days and $60 for days 21-100. Out-of-pocket costs for lab services and x-rays are approximately $0 and $20. MRIs, PET scans, and CT scans are subject to $75 copay. The physical therapy visit copay is $25.

Diabetic supplies and durable medical equipment are subject to 20% coinsurance. One routine vision exam is provided every two years ($0 copay) with $200  available for eyewear expenses. Preventative dental visit copays are $0 for two cleanings and $15 for oral exams per year. One bitewing x-ray is covered ($15 copay) per year. One panoramic x-ray ($15 copay) is provided every 36 months. One annual hearing exam and an additional hearing aid fitting exam is provided ($0 copay). A $1,500 hearing aid allowance every three years is also available.

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line and worldwide emergency assistance (more than 100 miles from home) are also included.  Telehealth copays are $0 for pcp visits and $20 for specialist visits. UPMC AnywhereCare copays are $5 for medical visits.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), and $100 (Tier 4). 90-day mail-order copays are $0 (Tier 1), $20 (Tier 2), $117.50 (Tier 3), and $300 (Tier 4).

 

PPO High Deductible Rx –  $1,250 deductible with $10 and $50 office visit copays. Inpatient hospital charge is $300 per stay after the deductible, and maximum out-of-pocket expenses are $7,550. Part D prescription drug benefits are included. $175 outpatient surgery copay after the deductible with $90 and $65 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $10. MRIs, PET scans, and CT scans are subject to $100 copay after the deductible.

Diabetic supplies and durable medical equipment are subject to 20% coinsurance after the deductible. Skilled nursing facility daily copays are $0 for first 20 days and $160 for days 21-100. The physical therapy visit copay is $40.

Preventative dental visit copays are $0 for two cleanings and $15 for two oral exams per year. One bitewing x-ray is covered ($15 copay) per year. Routine hearing benefits are not provided. $175 annual allowance for fillings and extractions.

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line and worldwide emergency assistance (more than 100 miles from home) are also included. 

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), and $100 (Tier 4). 90-day mail-order prescription drug preferred copays are $0 (Tier 1), $20 (Tier 2), $117.50 (Tier 3), and $300 (Tier 4).

PPO Rx Enhanced$0 deductible with $5 and $40 office visit copays. Inpatient hospital charge is $250 per stay, and maximum out-of-pocket expenses are $7,550. Part D prescription drug benefits are included. A $150 outpatient surgery copay applies with $90 and $65 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $5-$20. MRIs, PET scans, and CT scans are subject to a $100 copay.

Diabetic supplies and durable medical equipment are subject to 20% coinsurance. Skilled nursing facility daily copays are $0 for first 20 days and $160 for days 21-100. One routine vision exam is provided every year ($0 copay) with $175 available for eyewear expenses.

Preventative dental benefits include a $15 copay for an oral exam and $0 copay for cleaning every six months. Bitewing x-rays are covered annually with a $15 copay. Routine hearing benefits include one routine exam and hearing aid fitting every three years (subject to a $40 copay).

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line and worldwide emergency assistance (more than 100 miles from home) are also included.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), and $100 (Tier 4). 90-day mail-order prescription drug preferred copays are $0 (Tier 1), $20 (Tier 2), $117.50 (Tier 3), and $300 (Tier 4).

 

HMO Rx Enhanced$0 deductible with $5 and $25 office visit copays. Inpatient hospital charge is $125 per stay, and maximum out-of-pocket expenses are $7,550. Part D prescription drug benefits are included. A $80 outpatient surgery copay applies with $90 and $65 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $0-$20. MRIs, PET scans, and CT scans are subject to a $75 copay. Diabetic supplies and durable medical equipment are subject to 20% coinsurance. Skilled nursing facility daily copays are $10 for first 20 days and $60 for days 21-100.

Preventative dental benefits include a $15 copay for an oral exam and $0 copay for cleaning every six months. Bitewing x-rays are covered annually with a $15 copay. Routine hearing benefits include an annual routine exam and a hearing aid fitting every three years.

SilverSneakers Fitness Program (free gym membership to participating facilities) and Travel Concierge (pay same cost-sharing in other states) are included. The MyHealth 24/7 Nurse Line and worldwide emergency assistance (more than 100 miles from home) are also included. RxWell app is also provided to help with many health concerns.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), and $100 (Tier 4). 90-day mail-order prescription drug preferred copays are $0 (Tier 1), $20 (Tier 2), $117.50 (Tier 3), and $300 (Tier 4).

 

Estimated monthly rates for each plan are shown below. Not all plans are offered in each county. Medicare Part B premiums are not included.

Allegheny, Westmoreland, Butler, Cambria, Fayette, Blair, Crawford, Clearfield, Somerset, Bradford, Venango, Bedford, Jefferson, McKean, Warren, Beaver, Greene, and Washington Counties

$0 –  HMO No Rx

$0 – HMO Salute

$0 –  HMO Premier Rx 

$22 – HMO Deductible Rx

$25 – HMO Access Rx

$35 – PPO High Deductible Rx

$38 – HMO Rx Choice

$81 – HMO Rx

$136 – PPO Rx Enhanced

$302 – HMO Rx Enhanced

Lancaster, Lehigh, Adams, Dauphin, York, and Berks Counties

$0 –  HMO No Rx

$0 – PPO Flex

$0 –  HMO Premier Rx 

$22 – HMO Deductible Rx

$29 – PPO Rx Choice

$38 – HMO Rx Choice

$60 – PPO Rx Enhanced

$81 – HMO Rx

$302 – HMO Rx Enhanced

Fulton and Adams Counties

$0 –  HMO No Rx

$0 – PPO Flex

$22 – HMO Deductible Rx

$29 – PPO Rx Choice

$38 – HMO Rx Choice

$60– PPO Rx Enhanced

$81 – HMO Rx

$302 – HMO Rx Enhanced

Berks County

$0 –  HMO No Rx

$0 –  HMO Premier Rx

$62 – PPO Rx Enhanced

$302 – HMO Rx Enhanced

Union, Clinton, Tioga, Sullivan, Lycoming, and Snyder Counties

$0 –  HMO No Rx

$0 – PPO Flex

$22 – HMO Deductible Rx

$35 – PPO High Deductible Rx

$38 – HMO Rx Choice

$81 – HMO Rx

$136 – PPO Rx Enhanced

$302 – HMO Rx Enhanced

Potter, Lawrence, Indiana, Huntingdon, and Mercer Counties

$0 –  HMO No Rx

$0 – PPO Flex

$22 – HMO Deductible Rx

$35 – PPO High Deductible Rx

$38 – HMO Rx Choice

$81 – HMO Rx

$136 – PPO Rx Enhanced

$302 – HMO Rx Enhanced

Armstrong, Forest, Jefferson, And Clarion Counties

$0 – HMO No Rx

$0 – HMO Premier Rx

$0 – HMO Salute

$22 – HMO Deductible Rx

$25 – HMO Access Rx

$35 – PPO High Deductible Rx

$38 – HMO Rx Choice

$81 – HMO Rx

$136 – PPO Rx Enhanced

$302 – HMO Rx Enhanced

 

UPMC For Kids

This program is now the largest CHIP plan in Pennsylvania. Your child may qualify if they are under age 19, a US citizen (National or Qualified Alien may be considered), not presently covered or eligible for Medicaid, and a legal resident of the state. “Free,” “Low-Cost,” and “Full-Cost” benefits are provided, regardless of household income. The “Free” program waives copays for ER, Urgent Care and office visits. Regardless of income, benefits are identical. Only copays of certain services will vary.

A summary of some of the comprehensive benefits are listed below. A more detailed summary is available upon request.

Hospitalization Services – Surgical, medical, skilled nursing, mental health, and rehabilitation admissions. Transplants, physician services, blood, and anesthesia are included. Semiprivate room charges are covered.

Emergency Room Visits – Sudden onset of a medical condition, severe pain, or a situation that involves immediate attention is typically a reason to visit the ER.

Urgent Care – When a primary care physician (pcp) is not available, sickness and/or injuries can be treated at an Urgent Care facility. Typically, the condition, if untreated, can potentially result in a more serious or emergency situation. Visits outside of the service area are also covered.

Physician Visits – Primary care physician (pcp) and specialist visits are covered, along with immunizations, well-child visits, and all other qualified preventative expenses. Outpatient surgery and diagnostic tests performed in the office are also covered. Allergy services (testing, injections, and serum), and hearing services (routine annual hearing exam and hearing aids and fittings every two years) are covered.

OB/GYN – Preventative visits are covered, including family planning and counseling services, outpatient surgery, pap test, breast exam, maternity care, diagnostic tests in the office, and yearly gynecological exam.

CHIP Monthly Rates In Most Pa Counties

$0 – Free CHIP

$47.06 – Low-cost 1 CHIP

$65.89 – Low-cost 2 CHIP

$75.30 – Low-cost 3 CHIP

$191.11- Full-cost CHIP

CHIP Monthly Rates In  Centre, Juniata, Perry, Fulton, Franklin, Adams, Cumberland, Lebanon, Snyder, Union, Schuylkill, Berks, Lehigh, Northampton, Lebanon, Chester, Lancaster, Dauphin, and Mifflin Counties

$0 – Free Chip

$59.57 – Low-cost 1 CHIP

$83.39 – Low-cost 2 CHIP

$95.31 – Low-cost 3 CHIP

$247.34 – Full-cost CHIP

 

Special Needs Plans

UPMC For Life Complete Care (HMO-SNP) provides coverage for persons that are enrolled in Medicare and also qualify for Medicaid. Referrals are not needed and a large network of providers is available. Prescriptions can be filled (and refilled) at nearby pharmacies, or mail-ordered. The cost of the plan is $0, although you still must pay your Part B premium. There is no deductible to meet and office visits (pcp and specialist) are covered without a copay. Inpatient hospital, outpatient surgery, ER, and Urgent Care visits are covered at 100%.

Diagnostic services have a $0 copay per day per facility. Basic and advanced imaging services are also provided with a $0 copay. Hearing exams and hearing aid fittings (one per year are fully covered, and a $1,500 hearing aid allowance is provided every three years. Dental cleanings have a $0 copay, and a $5,000 allowance (each year) for comprehensive benefits is available. Vision services have a $0 copay with an annual allowance of $400 for routine contact lenses and eyewear. Physical therapy, one-way ambulance trips, and one-way transportation trips (maximum 50) have a $0 copay.

The yearly maximum out-of-pocket maximum (expenses) is $3,400. Part D prescription drug copays range from $0-$3.30 for generic, $0-$8.25 for preferred brand,  non-preferred, and specialty, and $0 for select care drugs.  Additional benefits include healthy food card, health care concierge, SilverSneakers, In-home safety, and home-delivered meals. 

 

Employer Plans (Small And Large Businesses)

Medical, dental, and vision coverage is available for your employees. Flexible customized plans are offered with a large network that includes more than 11,000 physicians, 125 hospitals and related facilities, 30,000 pharmacies for your prescription and non-prescription drugs, and many Urgent Care centers. Flexible spending accounts are offered, along with high-deductible, and more conventional comprehensive Group plans.

Dental coverage can be bought privately, or through an employer-sponsored Group plan. The regional network of providers is very large, and a national network is available through DenteMax. Choosing a primary dentist is not required since PPO plans are utilized. Pre-existing conditions are generally covered, and major services do not require pre-authorization.

Available medical options include:

HealthyU – Comprehensive plan for two or more employees that pays “reward dollars” for primary insured and spouse/domestic partner (dependents not eligible). Funds can be accumulated to help pay out-of-pocket expenses (coinsurance, copays, and deductibles) by engaging in healthy activities that promote wellness. Once the activity is completed, funds are deposited into the account. 

The HIA (Health Incentive Account) keeps track of your funds and can be reviewed at any time. Spouses and domestic partners can also utilize the card and activities are customized to fit the member. Dependent children are not eligible to earn reward dollars. HIA dollars can be spent via a debit card or automatic application.

Inside Advantage – Workers are provided a choice of network facilities in Northwestern Pa. When a Level-1 hospital or provider is utilized, the out-of-pocket cost is less. Local facilities that also qualify for the savings include Meadville Medical Center, Warren General Hospital, Grove City Medical Center, and Titusville Area Hospital.

Exclusive and preferred provider organization plans are offered with the Premium Network, the most comprehensive option. The tiered-benefit design provides a unique approach to group coverage.

Qualified Groups must have at least 51 employees. Plans are offered in the following counties: Clarion, Crawford, Elk, Erie, Forest, McKean, Mercer, Potter, Venango, and Warren. Level-2 benefits are available, which includes selected services that ate affiliated with contracted lab, x-ray, and therapy facilities.

Small Business Advantage – Comprehensive healthcare options are available, along with  vision discount benefits and other options. Companies with less than 50 employees can qualify for coverage. Dental discounts, and worker-assistance programs are also included in the coverage package.

MyCare Advantage – Plans are similar to other Health Plan contracts, but by utilizing Level 1 medical facilities and hospitals in-network expenses are less. 15,000 additional Level 2 providers are also available, although out-of-pocket expenses will be higher.

Large Group employers can choose one of the following preferred networks:

Premium – Hospitals, physician practices and medical facilities are owned by UPMC. Additional community-based providers are also available.

Standard – Similar to Premium network, but there are less participating counties, especially in Central Pa.

Note: The UPMC Medical Commercial Group Rate Cap Program offers a 9.5% cap on the initial renewal (51 or more employees). A 12% cap on the second renewal is offered if the MER is equal or less than 88%.

 

UPMC AnywhereCare

UPMC AnywhereCare can be utilized to have face-to-face meetings with providers through your mobile device or home computer. Many conditions are treatable, including sore throats, flues, stomach ailments, urinary tract infections, and several additional ailments. Physicians, physician assistants, and certified registered nurse practitioners receive special training to help customers.

This feature is not appropriate for infants, although children ages three and older can use the service (with a parent or legal guardian, of course!). The cost is generally less than a primary-care physician would charge. A mobile app is available from Google Pay or the Apple App Store. Service is also available outside of Pennsylvania.

While traveling, if you suffer a life-threatening condition or illness, you should immediately go to the closest emergency treatment center. The highest level of coverage will be paid. UPMC should be contacted within 24 hours of admission to a medical facility. If not contacted, it is possible that non-emergency medical expenses will be the patient’s responsibility to pay.

 

HealthChoices (UPMC For You Medical Assistance)

“HealthChoices” is a managed medical assistance program. Eligibility details are provided by the Department of Human Services. Typically, there are several choices in every county. For example, in Allegheny County, the four offered plans are Aetna Better Health, Gateway Health Plan, UnitedHealthcare Community Plan, and UPMC For You. Each household member can choose the plan that best fits their situation. Prior to the effective date of coverage, you may be able to use your ACCESS or EBT card to receive benefits. Once the enrollment packet arrives in the mail, a pcp (primary care physician) should be selected.

A Health Care Concierge department is provided to help with your questions or concerns. Information can be given regarding coverage of over-the-counter and prescription drugs. Online chats ensure privacy. Medical advice is available 24/7 from the UPMC MyHealth Nurse Line. Registered nurses can assists with information and advice on various medical issues. If immediate treatment or consultation is needed, the caller will be referred to the appropriate physician or needed provider.

Copays for the HealthChoices plan include $0 for ambulance trips, $0 for dental care, $3 for inpatient hospital treatment, $2 for outpatient hospital treatment, $2 for independent surgical center, $0 for rental and purchase of authorized medical equipment, $0 for physician visits, $0 for optometrist visits, $1 for generic prescriptions, $3 for brand name prescriptions, and $1 for x-rays. The pharmacy forrmulary is available online and contains FDA-approved medications and drugs. You can also easily search for specific drugs.

 

Travel Coverage

If you are more than 100 miles away from home and need medical assistance, help is just a phone call away. “Assist America” partners with UPMC to provide access to physicians, specialists, hospitals, pharmacies, and other medical facilities where you are located. There is no cost for the benefit, and you may also utilize help in other countries 24/7. Experienced professionals can provide valuable help when traveling abroad.

Several of the most useful services include healthcare repatriation, communication of emergency information, prescription drug advice, hospital and ER admission help, and health evaluation. Toll-free phone numbers are provided for inside and outside the United States, along with an identification number.

 

UPMC Vs. Highmark

UPMC and Highmark have previously waged a war of the airwaves. UPMC had stated that Highmark patients could no longer use their facilities, beginning at the end of 2013. If they were willing to pay higher costs, then the usage could continue. However, a court-ruling extended the network coverage. Both companies should end their bitter war, or patients will continue to suffer.

However, UPMC continues to be recognized for their outstanding service. The National Committee For Quality Assurance (NCQA) rated the UPMC commercial and Medicaid HMOs the best in the state with the highest available marks for customer service and treatment. Past issues of “Consumer Reports” will provide additional details. NCQA ratings are based on quality, satisfaction and standards.

In the past, UPMC had alleged that Highmark was falsely advertising hospital admissions information about customers. A lawsuit was filed in the US District Court in Pittsburgh. Highmark stood by the commercials and provided information backing its claims. Previously, UPMC aired some commercials that Highmark felt were misleading.

You can easily compare specific policy rates and more specific details on our website when you request a quote. Along with Highmark, Western Pa is very well-represented with affordable medical plan options. Aetna and UnitedHealthcare also offer attractive priced policies.

 

Paying Your Healthcare Bill – Five Options

1. Check or money order through US mail. The address is PO Box 371842 Pittsburgh, Pa 15250-7842.

2. Submit your payment online. Payments are accepted from checking accounts, credit cards, and debit cards. The website link is secure. Please email us for the specific url.

3. Autopay. Your premium can be electronically deducted from your account the same day every month. There are no fees.

4. By phone. We provide a toll-free phone number that is open until 7 p.m. most evenings.

5. In-person. Visit a customer-service location during normal business hours. Mall locations can be found at the Ross Park Mall, Monroeville Mall, Mall at Robinson, Millcreek Mall, and South Hill Village.

About UPMC Health Plan

Company headquarters are in Pittsburgh, and the parent company is the University of Pittsburgh Medical Center. Products and services are offered to more than 3 million persons, and provided by 140 hospitals and more than 20,000 physicians in four states.

Recent awards to the parent company have been received from the Human Rights Campaign Foundation, National Business Group on Health, Stevie Awards, US News And World Report, International Customer Management Institute, and National Committee For Quality Assurance.

 

Updates From The Past

UPMC will be considering Highmark facilities “non-network” at the end of 2014, which could drastically increase the cost for many users. Legislation has now been introduced that will require UPMC to accept Highmark members as “in the network.” The bill (introduced by Reps Frankel and Christiana) is designed to protect consumers in the Western portion of the state.

The feud may be nearing an end. The antitrust lawsuits between UPMC and Highmark are over, according to their attorneys. Although the network-provider issue is still unresolved, it is a step in the right direction.

UPMC and Highmark have decided to dismiss their lawsuits against each other. A judge had also ruled last month for the dismissal. The original litigation between the two huge companies started in 2009. Both carriers offer healthcare coverage in Western Pa.

The National Football League (NFL) has awarded a grant to UPMC for concussion research. Brain imaging research is being used to help in the treatment and discovery of concussions. Football players, of course, are very prone to head injuries, despite recent rule changes.

UPMC might be terminating its Medicare Advantage plans with Highmark, and the Blue Cross company is not happy. Governor Tom Wolf would like the action reversed, and has threatened to take action to protect consumers. However, the main issue seems to be if the terms of an existing contract were broken when Highmark reduced its network payments for cancer-care.

Financially, this has been a good year. Operating revenues, income and margin have all increased, according to the most recent report (effective June 30). Enrollment revenues including insurance services increased, which should keep rates fairly stable, despite increases in many other costs, including patient care and drug prescription expenses.

More than 2.7 million person are now covered by UPMC for their individual or group medical benefits.This has helped expand local capital expenditures, including the Lemieux Sports Complex in Cranberry Township.

UPMC rates are still very attractive in the Pittsburgh area and Allegheny County. In surrounding counties (Westmoreland, for example), prices are typically very low compared to Highmark, Aetna, and other major companies. However, there are several provider network options, and it is very important to ensure your personal physician (or specialist) is approved for the specific plan you are considering.