Advantage Network - Specific network of UPMC facilities and services. Applies to
Panther Gold plan only. Click
here for a list of facilities.
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Coinsurance - The percentage of the cost of medical services paid by the member.
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Coordinated Care - Care is considered coordinated (in-network) when it is performed
or authorized by your PCP. If you choose to obtain medical care through another
physician, either in-or-out-of network, this care will be considered
self-referred because it is not coordinated through your PCP. Coordinated care
benefits apply if authorized by your PCP. If not authorized, then self-referred
care benefits apply. No benefit will be payable for self-referred care under
the Panther Gold plan outside the UPMC Health Plan Network.
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Co-payment - There is a fixed, upfront dollar amount you will pay for certain
covered services before the plan begins to provide benefits.
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Deductible - The deductible is the initial amount you must pay each year for
covered services before the plan begins to provide benefits.
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Out-of-Network Providers - Physicians and/or facilities that do not belong
to the UPMC Health Plan network of participating providers.
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Out-of-Pocket Maximum - This is the most you will have to pay each plan year before the
plan begins to pay 100 percent of reasonable and customary covered
expenses. Out-of-pocket maximums exclude deductibles, co-payments,
prescription drug expenses, precertification penalties and amounts over
reasonable and customary charges.
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Preferred/Non-Preferred Brand Prescription Drugs - The Prescription Drug Program now
includes Preferred Brand and Non-Preferred Brand medications. Please call UPMC Pharmacy Services at
1-800-396-4139 for details.
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Prenotification - This is the notification that must be given to UPMC Health Plan
prior to inpatient and certain outpatient services being obtained. If you
or your physician does not prenotify UPMC Health Plan, you may be subject to a
$500 penalty. Please see plan design grids to determine who is
responsible for prenotification, either you or the participating network
physician.
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Reasonable and Customary Charges - The amount determined to be a reasonable expense for
certain medical services. This amount is determined by UPMC Health Plan and is
based on regional and national data. Amounts above the reasonable and
customary charge are the financial responsibility of the member receiving such
services.
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UPMC Health Plan Network - Participating hospitals and physicians,
including the Advantage Network.
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