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UPMC for Life HMO Rx Enhanced (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life HMO Rx Enhanced (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on UPMC for Life HMO Rx Enhanced (HMO) in 2025, please refer to our full plan details page.
UPMC for Life HMO Rx Enhanced (HMO) is a HMO plan offered by UPMC Health System available for enrollment in 2025 to people living in Western, Central, and Northeastern Pennsylvania. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that UPMC for Life HMO Rx Enhanced (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about UPMC for Life HMO Rx Enhanced (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For UPMC for Life HMO Rx Enhanced (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $295.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $13.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $7550.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The UPMC for Life HMO Rx Enhanced (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay different copays or coinsurance amounts depending on the drug tier and the pharmacy you use. For example, you will pay no copay for preferred generic drugs at preferred pharmacies and $20 at standard pharmacies. For preferred brand drugs, you pay 50% coinsurance, and for non-preferred drugs, you pay 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The UPMC for Life HMO Rx Enhanced (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $125 copay, while outpatient services like hospital visits and ambulatory surgical centers have an $80 copay. Emergency services have a $110 copay, and primary care visits are covered with no copay. This plan includes coverage for preventive services with no copay, along with hearing, vision, and dental services, each with their own copays. Additionally, you'll find coverage for ambulance, home health, and skilled nursing facility services. The plan also has coinsurance for dialysis and durable medical equipment, as well as other services.
Inpatient Hospital See details
Inpatient Hospital benefits with UPMC for Life HMO Rx Enhanced (HMO) include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric stays with a $125 copay per stay, but Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered. Additional Days for Inpatient Hospital-Acute have no copay.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services. Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center (ASC) Services have a $80 copay, while Individual and Group Sessions for Outpatient Substance Abuse have a $10 copay. Outpatient Blood Services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial Hospitalization is covered by this plan. There is no information about the cost of this service in the provided snippet.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground Ambulance Services have a copay of $50-$100, and Air Ambulance Services have a copay of $100; there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $100 copay.
Primary Care See details
The UPMC for Life HMO Rx Enhanced (HMO) plan covers primary care physician services with no copay, chiropractic services for a $15 copay, and occupational therapy services with a $10 copay. The plan also covers physician specialist services, mental health, podiatry, other health care professional, psychiatric services, physical therapy, speech-language pathology, additional telehealth benefits, and opioid treatment program services, each with a copay of $10.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, and additional preventive services including In-Home Safety Assessment, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, Counseling Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Annual physical exams, Health Education, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, Enhanced Disease Management, Telemonitoring Services, and In-Home Support Services are not covered.
Hearing Services See details
Hearing exams are covered with a $10 copay, with routine hearing exams and fitting/evaluation for hearing aids also covered once per year. Prescription hearing aids are covered with a copay between $690 and $1890, but inner ear, outer ear, and over-the-ear prescription hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $10 copay, one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year, and coverage for upgrades. The plan also offers a $350 combined maximum benefit for eyewear.
Dental Services See details
Dental services include coverage for Medicare Dental Services with a $10 copay, Oral Exams with a $15 copay, and Dental X-Rays with a $15 copay. Other services are covered with 50% coinsurance, including Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery. Fluoride Treatment, Adjunctive General Services, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. For Medicare Part B Insulin Drugs, you will pay a $35 copay and 0-20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, you will pay 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life HMO Rx Enhanced (HMO) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and no copay, Prosthetics/Medical Supplies with 20% coinsurance and no copay, and Diabetic Equipment. Diabetic Supplies have between 0% and 20% coinsurance and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
For UPMC for Life HMO Rx Enhanced (HMO), Diagnostic and Radiological Services are partially covered. Diagnostic services do not have a copay, but Diagnostic Procedures/Tests and Lab Services are not covered. Radiological Services have a copay, with Diagnostic Radiological Services having a maximum copay of $75, Therapeutic Radiological Services having a maximum copay of $55, and Outpatient X-Ray Services having a $10 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life HMO Rx Enhanced (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the UPMC for Life HMO Rx Enhanced (HMO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the UPMC for Life HMO Rx Enhanced (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $60. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered under the UPMC for Life HMO Rx Enhanced (HMO) plan. Acupuncture, Over-the-Counter (OTC) Items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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