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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 2026, 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 2026.
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. Additionally, this plan comes with a Part B Premium reduction of $1.00. 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 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:
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Drug Coverage
The UPMC for Life HMO Deductible Rx (HMO) plan features an annual drug deductible of $175. You can avoid copays entirely on Tier 1 preferred generics and Tier 2 generics by using preferred pharmacies or preferred mail order services. For those who use standard pharmacies or standard mail order, Tier 1 copays start at $15 and Tier 2 copays start at $20. For brand-name and specialty medications, your costs will be calculated as a percentage of the drug cost rather than a flat copayment. Tier 3 preferred brands require a 25% coinsurance, and Tier 4 non-preferred drugs carry a 49% coinsurance regardless of the pharmacy type. Tier 5 specialty drugs require a 31% coinsurance for a one-month supply at both standard and preferred locations.
Additional Benefits
The UPMC for Life HMO Deductible Rx (HMO) plan offers affordable access to essential medical care, featuring no copay or coinsurance for primary care visits and preventive services. Specialist visits and routine outpatient diagnostic tests require a low copay of $25 or less, while inpatient hospital stays carry a $300 annual copay with no coinsurance. Emergency services are covered with a $130 copay, which is waived if you are admitted to the hospital within three days. For extra wellness support, the plan provides preventive dental cleanings and exams with no copay, alongside a $250 annual allowance for eyewear with no copay or coinsurance. Routine hearing and vision exams require a $25 copay, while durable medical equipment is covered with a 20% coinsurance and no copay. Additional perks like home health services, over-the-counter items, and meal benefits are also fully covered with no copay or coinsurance.
Inpatient Hospital See details
UPMC for Life HMO Deductible Rx (HMO) inpatient hospital services are partially covered, featuring a $300 annual copayment and no coinsurance for Medicare-covered acute and psychiatric stays, subject to prior authorization. Unlimited additional days for acute stays are covered with no copay, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
UPMC for Life HMO Deductible Rx (HMO) covers outpatient hospital, observation, and ambulatory surgical center services with a $125 copay and no coinsurance, subject to prior authorization. Outpatient substance abuse services require a $25 copay per session with no coinsurance, and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by UPMC for Life HMO Deductible Rx (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life HMO Deductible Rx (HMO) covers ambulance services with no coinsurance, requiring a copay of $50.00 to $240.00 for ground transport and $240.00 for air transport, both of which require prior authorization. Transportation services to health-related locations are not covered by this plan.
Emergency Services See details
Emergency services are covered by UPMC for Life HMO Deductible Rx (HMO) with a $130 copay (waived if admitted to the hospital within 3 days) and no coinsurance, while urgently needed services require a $50 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $50, and $240, respectively.
Primary Care See details
UPMC for Life HMO Deductible Rx (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits, therapy services, and mental health sessions require a $25 copay and no coinsurance. Additional telehealth services are offered with a $0 to $25 copay and no coinsurance, but chiropractic services are not covered.
Preventive Services See details
UPMC for Life HMO Deductible Rx (HMO) partially covers preventive services with no copay and no coinsurance for covered care, which includes Medicare-covered zero-dollar services, kidney disease education, and select counseling. However, several services are not covered under this benefit, including annual physical exams, health education, personal emergency response systems, and weight management programs.
Hearing Services See details
Hearing services are partially covered by UPMC for Life HMO Deductible Rx (HMO), which offers annual routine exams with a $25 copay and no coinsurance, and one fitting evaluation per year. Prescription hearing aids are covered with no coinsurance and copays ranging from $690.00 to $1,890.00, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by UPMC for Life HMO Deductible Rx (HMO), featuring a $25 copay and no coinsurance for annual eye exams with no deductible. Covered eyewear has no copay, no coinsurance, and a $250 annual allowance with no deductible, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life HMO Deductible Rx (HMO) offers partially covered dental services, featuring preventive cleanings, exams, and x-rays with no copay and no coinsurance, and Medicare-covered dental for a $25 copay and no coinsurance. Comprehensive services like restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and 50% coinsurance up to a $3,225 annual maximum, while fluoride, implants, orthodontics, and adjunctive general services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by UPMC for Life HMO Deductible Rx (HMO) with no copay and no coinsurance, although prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry 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
Dialysis services are covered by UPMC for Life HMO Deductible Rx (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment benefits under UPMC for Life HMO Deductible Rx (HMO) are covered with no copays, though prior authorization is required. Covered items—including durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes—carry a 20% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance. Brand and manufacturer limitations apply to both durable medical equipment and diabetic supplies.
Diagnostic and Radiological Services See details
UPMC for Life HMO Deductible Rx (HMO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Outpatient diagnostic procedures, tests, and lab services carry a $5 copay, while outpatient X-rays cost $15, therapeutic radiological services start at a $55 copay, and diagnostic radiological services start at a $180 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life HMO Deductible Rx (HMO) plan with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the UPMC for Life HMO Deductible Rx (HMO) plan with no copay and no coinsurance, but in practice only some services are covered. Under this plan, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by UPMC for Life HMO Deductible Rx (HMO) with no coinsurance, requiring a daily copay of $10 for days 1 to 20 and $218 for days 21 to 100. Prior authorization is required, prior hospital stays of less than three days are allowed, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
UPMC for Life HMO Deductible Rx (HMO) partially covers other services, providing over-the-counter (OTC) items and meal benefits with no copay and no coinsurance. Acupuncture and naloxone are not covered under these benefits.
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