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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 2026, 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 2026.
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 $5.70. 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 features a $0 drug deductible, meaning your prescription coverage begins immediately. For Tier 1 preferred generic and Tier 2 generic medications, you will pay no copay when using a preferred pharmacy or preferred mail-order service. If you use a standard pharmacy or standard mail order, Tier 1 drugs require a $15 to $30 copay, and Tier 2 drugs require a $20 to $40 copay. For higher-tier medications, costs transition to coinsurance percentages across all pharmacy and mail-order options. Tier 3 preferred brand drugs require a 25% coinsurance, and Tier 4 non-preferred drugs have a 50% coinsurance. Specialty Tier 5 drugs are available for a one-month supply with a 33% coinsurance.
Additional Benefits
The UPMC for Life HMO Rx Enhanced (HMO) plan features predictable, low-cost options for core medical services, including no copays and no coinsurance for primary care visits, preventive care, and home health services. Specialist visits, mental health services, and physical therapy require a low $10 copay, while inpatient hospital stays cost a $125 copay per stay with no coinsurance. Outpatient hospital services require an $80 copay, and emergency room visits are covered with a $115 copay that is waived if you are admitted. For additional health needs, routine dental cleanings are available with no copay, while comprehensive dental services are covered with a 50% coinsurance up to a $5,500 annual limit. Routine vision and hearing exams both feature a $10 copay, with additional coverage of up to $450 yearly for eyewear and prescription hearing aid copays ranging from $690 to $1,890. Durable medical equipment and dialysis services generally require a 20% coinsurance with no copay, and skilled nursing facility stays have no copay for the first 20 days.
Inpatient Hospital See details
UPMC for Life HMO Rx Enhanced (HMO) partially covers inpatient hospital services with a $125.00 copayment per Medicare-covered stay and no coinsurance, requiring prior authorization. Unlimited additional acute care days are covered with no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UPMC for Life HMO Rx Enhanced (HMO) covers outpatient hospital, observation, and ambulatory surgical center services with an $80 copay and no coinsurance, subject to prior authorization. Outpatient substance abuse services require a $10 copay per individual or group session with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by UPMC for Life HMO Rx Enhanced (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life HMO Rx Enhanced (HMO) covers ambulance services with no coinsurance, requiring a copay of $50 to $100 for ground ambulance and $100 for air ambulance, both of which require prior authorization. Although some transportation services are covered, transportation to plan-approved or any other health-related locations is not covered.
Emergency Services See details
UPMC for Life HMO Rx Enhanced (HMO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed services are covered with a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $115, $40, and $100 respectively.
Primary Care See details
UPMC for Life HMO Rx Enhanced (HMO) offers primary care physician services with no copay and no coinsurance, while specialist visits, physical, occupational, and speech therapies, mental health, and podiatry services require a $10 copay and no coinsurance. Telehealth services feature a $0 to $10 copay and no coinsurance, but chiropractic services are not covered under this plan.
Preventive Services See details
UPMC for Life HMO Rx Enhanced (HMO) covers preventive services with no copay and no coinsurance, including kidney disease education, caregiver support, and fitness benefits. This benefit is partially covered, as annual physical exams, health education, personal emergency response systems, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, disease management, and telemonitoring are not covered.
Hearing Services See details
Hearing services are partially covered by UPMC for Life HMO Rx Enhanced (HMO) with no deductible, offering one routine hearing exam and fitting evaluation per year for a $10 copay and no coinsurance. Up to two prescription hearing aids are covered annually with no coinsurance and a copay ranging from $690.00 to $1,890.00, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
UPMC for Life HMO Rx Enhanced (HMO) offers partially covered vision services with no deductibles, featuring a $10 copay and no coinsurance for annual routine eye exams. Eyewear is covered with no copay and no coinsurance up to a $450 yearly limit, although individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life HMO Rx Enhanced (HMO) partially covers dental services, featuring cleanings with no copay and no coinsurance, oral exams and x-rays for a $15 copay and no coinsurance, and Medicare dental for a $10 copay and no coinsurance. Restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and 50% coinsurance up to a $5,500 annual limit, while fluoride, implants, orthodontics, other diagnostic, other preventive, adjunctive general, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
UPMC for Life HMO Rx Enhanced (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
UPMC for Life HMO Rx Enhanced (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life HMO Rx Enhanced (HMO) covers durable medical equipment, prosthetics, and diabetic supplies with no copay and generally a 20% coinsurance, though some diabetic supplies have no coinsurance. Prior authorization is required for these medical equipment benefits, and coverage may be limited to preferred manufacturers or vendors.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by UPMC for Life HMO Rx Enhanced (HMO) with no coinsurance, though prior authorization is required. While diagnostic procedures, tests, and lab services are not covered under this benefit, radiological services are covered with no coinsurance and copays of $10 for outpatient x-rays, a minimum of $55 for therapeutic radiology, and a minimum of $75 for diagnostic radiology.
Home Health Services See details
Home health services are covered by UPMC for Life HMO Rx Enhanced (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the UPMC for Life HMO Rx Enhanced (HMO) plan with no copay and no coinsurance. While some services are covered, specific programs including Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
UPMC for Life HMO Rx Enhanced (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. Stays feature no copay for days 1 through 20 and a $60 copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
UPMC for Life HMO Rx Enhanced (HMO) partially covers Other Services, featuring a home meal benefit with no copay and no coinsurance for members with qualifying chronic illnesses or medical conditions. Acupuncture and over-the-counter (OTC) items are not covered under this benefit.
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