Page 7 - Goodwill of SWPA 2022 Benefits Guide

Medical and pharmacy coverage

UPMC MyCare Advantage PPO HDHP UPMC MyCare Advantage PPO with HRA

Medical Plan Provisions Level 1 Level 2 Level 1 Level 2

Company contribution to HRA
(Employee/Employee +1 or Family) None $2,000/$4,000
Deductible per Benefit Period
(Individual/Family) $1,400/$2,800 $2,800/$5,600 $2,500/$5,000 $5,000/$10,000
Coinsurance 80%* 70%* 80%* 70%*

Out-of-Pocket Maximum $5,150/$10,300 $3,800/$7,000 $4,100/$8,200 $1,600/$3,200
(Includes Deductible)
Preventive Care Covered at 100% (no deductible) Covered at 100% (no deductible)
Primary Care Provider
Office Visit 80%* 70%* $20 copay $40 copay
Specialist Office Visit 80%* 70%* $35 copay $70 copay
Telemedicine 80%* (UPMC Anywhere Care) $5 copay (UPMC Anywhere Care)
Inpatient Hospital Services 80%* 70%* 80%* 70%*
Outpatient Hospital Services 80%* 70%* 80%* 70%*
Urgent Care 80%* 70%* $35 copay $70 copay

Emergency Room 80%* $100 copay
Non-Participating Providers Non-Participating Providers
Deductible per Benefit Period
(Individual/Family) $12,500/$25,000 $7,500/$15,000
Coinsurance 50%* 50%*
Out-of-Pocket Maximum $12,500/$25,000 $5,000/$10,000
(Includes Deductible)
Primary Care Provider 50%* 50%*
Office Visit
Specialist Office Visit 50%* 50%*

Inpatient Hospital Services 50%* 50%*
Outpatient Hospital Services 50%* 50%*
Urgent Care 50%* 50%*

Emergency Room 80% after Enhanced deductible 50%*
Retail Pharmacy (up to a 30-day supply)
Retail Pharmacy 80%* Generic: $10 | Formulary Brand: $35 |
(30-day supply) Non-Formulary Brand: $65
Mail Order Pharmacy 80%* Generic: $20 | Formulary Brand: $70 |
(90-day supply) Non-Formulary Brand: $130

*After deductible

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