MEDICAL & PRESCRIPTION

UPMC Options

XPER offers 4 different medical options: EPO LOW, EPO HIGH, PPO LOW and PPO HIGH.  The EPO plans do not have non-network coverage but do not require you to select a Primary Care Physician or seek a referral to see a Specialist.  The PPO options do offer non-network benefits, although it is always in your best interest to stay within the network to minimize your expenses when you seek care.  The PPO options may be best for those of you who reside outside of PA where the network is broader.  To find a in network providers, please click here.

Preventive Care: All plans pay 100% for in-network preventive care.

Due to Healthcare Reform, your UPMC medical plan options cover all in-network age and gender appropriate testing at 100% with no patient responsibility.  This includes all well baby visits for newborns, child and adult vaccinations, annual physicals, and other testing such as mammograms for women over the age of 40.  Please note the provider must code these services as preventive for UPMC to apply your claim as preventive.  If you have a prior history or they are evaluating a symptom or condition, likely the visit will not be coded as preventive and you will have a patient responsibility to the cost of the claim.

All 4 plan options have some additional similarities.

Annual Deductible:  The annual deductible is $5,000 for Individual coverage and $10,000 for Family coverage (Employee + 1 or more Dependents) when you use in-network providers.

Coinsurance: Once you have met the deductible, you will pay coinsurance for services received. When you use in-network providers, your coinsurance cost will be 0% for individual and family.

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. The medical and prescription drug deductible, copayments and coinsurance all apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum, then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.  The plans have an Out of Pocket Maximum of $6,450 for Individual coverage and $12,900 for Family coverage.

Embedded Deductible and Out of Pocket Maximums:  Your plan has an embedded Deductible, which means the plan pays for Covered Services in these two scenarios — whichever comes first: *When an individual family member reaches his or her individual Deductible. At this point, only that person is considered to have met the Deductible; OR *When a combination of family members’ expenses reaches the family Deductible. At this point, all covered family members are considered to have met the Deductible.

Virtual Visits:  UPMC lets you get the care you need – including most prescriptions (when appropriate) – for a wide range of minor conditions. You can connect with a board certified provider via video chat or phone, when, where and how it works best for you. The cost for a virtual visit is less than or equal to the cost of an in person visit.

Health Reimbursement Arrangement (HRA): XPER funds a significant portion of the plans’ deductibles if you incur claims.  A claim is submitted to UPMC by your provider.  If it applies to the deductible, as a single, you will be responsible for the first $500 of services and then as you continue to incur claims towards the deductible, the XPER HRA will cover the remaining charges up to a maximum of $4,500.  For those covering dependents, you will be responsible for the first $1,000 of services and then the XPER funded HRA will cover up to $9,000.  You will be responsible for any plan copays while working towards the plan’s Out of Pocket Maximum.  You will pay up to $1,950 for services annually as a single or no more than $3,900 for those covering dependents. once you satisfy the plan’s Out of Pocket Maximum, all eligible services are covered by the plan at 100% with no patient responsibility.