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UPMC for Life HMO Deductible Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life HMO Deductible Rx (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 Deductible Rx (HMO) in 2025, please refer to our full plan details page.
UPMC for Life HMO Deductible Rx (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 Deductible Rx (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 Deductible Rx (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 Deductible Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $22.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 a $175.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6000.00 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:
Sign up for UPMC for Life HMO Deductible Rx (HMO)
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Drug Coverage
The UPMC for Life HMO Deductible Rx (HMO) plan has a $175 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and the pharmacy used. For preferred generic drugs, you will have no copay at preferred pharmacies and preferred mail order, but pay a $20 copay at standard pharmacies and standard mail order. Standard generic drugs have a $47 copay, while preferred brand drugs have a 42% coinsurance.
Additional Benefits
The UPMC for Life HMO Deductible Rx (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $300 copay, while outpatient services have a $125 copay, and emergency services have a $125 copay. Many primary care services, such as specialist visits and physical therapy, have copays between $18 and $35. Preventive services are covered, with no copay for Medicare-covered services. The plan includes coverage for hearing, vision, and dental services, with copays for exams and varying costs for hearing aids, eyewear, and dental procedures. The plan also offers home infusion, dialysis, medical equipment, and diagnostic services with copays or coinsurance, and skilled nursing facility stays have copays.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For Inpatient Hospital-Acute, there is a $300 copay for a Medicare-covered stay, and no copay for additional days. Inpatient Hospital Psychiatric has a $300 copay for a Medicare-covered stay.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center Services have a $125 copay, while Individual and Group Sessions for Outpatient Substance Abuse have a copay between $30 and $30.
Partial Hospitalization See details
Partial Hospitalization is covered by this plan. There is no copay or coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the UPMC for Life HMO Deductible Rx (HMO) plan. Ground Ambulance Services have a copay of $50.00 - $270.00, while Air Ambulance Services have a copay of $270.00; there is no coinsurance for either. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered by UPMC for Life HMO Deductible Rx (HMO), with a $125 copay and no coinsurance. Urgently needed services have a $55 copay and no coinsurance. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $270 copay, with no coinsurance for any of these services.
Primary Care See details
The UPMC for Life HMO Deductible Rx (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have an $18 copay, physician specialist services have a $30 copay, and physical therapy and speech-language pathology services have a $30 copay, while individual and group sessions for mental health and psychiatric services have a minimum copay of $35 and a maximum copay of $35; other services have varying copays.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with no copay. Additional services like in-home safety assessments, support for caregivers, additional smoking cessation counseling, fitness benefits, remote access technologies, home and bathroom safety devices, and counseling services (6 sessions) are also covered. Kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs after the welcome visit are also covered. Annual physical exams, health education, personal emergency response systems, medical nutrition therapy, and several other services are not covered.
Hearing Services See details
Hearing services are covered, including routine hearing exams with a $30 copay, and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $690 and $1890, but inner ear, outer ear, and over the ear prescription hearing aids, as well as OTC hearing aids, are not covered.
Vision Services See details
Vision services include eye exams with a $30 copay, with one routine eye exam and one other eye exam service covered per year. Eyewear is covered with a combined maximum benefit of $150 per year, and contact lenses and eyeglasses (lenses and frames) are covered, with one pair of each covered per year; eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
Dental Services include Medicare dental services with a $30 copay, oral exams (2 per year), dental x-rays, and prophylaxis (cleaning, 2 per year); however, fluoride treatment, adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with 50% coinsurance, and orthodontic services have a maximum benefit of $3225 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the UPMC for Life HMO Deductible Rx (HMO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment are covered. Durable Medical Equipment has a 20% coinsurance with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance with no copay. Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including Diagnostic Procedures/Tests and Lab Services, require a copay of $5. Diagnostic Radiological Services have a copay of at most $200, Therapeutic Radiological Services have a copay of at most $55, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life HMO Deductible Rx (HMO) plan with no copay or coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the UPMC for Life HMO Deductible Rx (HMO) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214.
Other Services See details
Other Services include Over-the-Counter (OTC) Items and Meal Benefits, while acupuncture, Dual Eligible SNPs with Highly Integrated Services, and many other services are not covered. The OTC benefit includes Nicotine Replacement Therapy (NRT) as a Part C OTC benefit, and covers all drugs on the CMS OTC list.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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