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UPMC for Life HMO Rx Choice (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life HMO Rx Choice (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 Choice (HMO) in 2025, please refer to our full plan details page.
UPMC for Life HMO Rx Choice (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 Choice (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 Choice (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 Choice (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $34.00. 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 $5000.00 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 Rx Choice (HMO)
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Drug Coverage
The UPMC for Life HMO Rx Choice (HMO) plan has a $175 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and the pharmacy you use. For preferred generic drugs, you'll pay no copay at preferred pharmacies and $20 at standard pharmacies. For standard generic drugs, the copay is $47 regardless of the pharmacy. Brand name drugs have a 40% coinsurance, and non-preferred drugs have a 31% coinsurance.
Additional Benefits
The UPMC for Life HMO Rx Choice (HMO) plan offers a range of benefits, including inpatient hospital stays with a $395 copay, outpatient services with copays ranging from $35 to $250, and no copay for partial hospitalization. Emergency and urgent care services are covered, with copays varying by the type of service. Primary care visits have an $18 copay, and specialist visits are $35. This plan includes coverage for preventive services with no copay for Medicare-covered services, hearing exams with a $35 copay, and hearing aids with copays between $690 and $1890. Vision services have a $35 copay for eye exams, and up to $200 per year for eyewear. Dental services have a $35 copay for Medicare dental services, with 50% coinsurance for other dental procedures. Other benefits include home infusion services, dialysis services, medical equipment, and diagnostic services, all with varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered. For inpatient hospital stays, you will pay a $395 copay annually, and additional days for inpatient hospital acute are covered with 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 ASC Services each have a $250 copay, while Individual and Group Sessions for Outpatient Substance Abuse have a copay of $35.00.
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, with no coinsurance for any services. Ground ambulance services have a copay between $50 and $270, while air ambulance services have a copay of $270; however, 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 by UPMC for Life HMO Rx Choice (HMO). Emergency Services have a $125 copay with no coinsurance, while Urgently Needed Services have a $55 copay with no coinsurance. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $270 copay, and all have no coinsurance.
Primary Care See details
The UPMC for Life HMO Rx Choice (HMO) plan covers primary care physician services, chiropractic services with a $18 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, mental health and psychiatric services with a $35 copay for individual and group sessions, podiatry services with a $35 copay, other health care professional services with a $35 copay, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a $0-$35 copay, and opioid treatment program services with a $35 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services are covered by UPMC for Life HMO Rx Choice (HMO), with no copay for Medicare-covered services. Additional services include in-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling (4 visits), fitness benefits, remote access technologies, home and bathroom safety devices, and counseling services (6 sessions). Other preventive services covered include glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Annual physical exams, health education, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, enhanced disease management, and telemonitoring services are not covered.
Hearing Services See details
Hearing exams and prescription hearing aids are covered by the UPMC for Life HMO Rx Choice (HMO) plan, with a $35 copay for hearing exams. Routine hearing exams and fitting/evaluation for hearing aids are covered once per year, and prescription hearing aids (all types) are covered with a copay between $690 and $1890. Prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $35 copay, with coverage for routine eye exams and other eye exam services like contact lens fitting, each limited to one visit per year. Eyewear benefits include a combined maximum of $200 per year for contact lenses and eyeglasses (lenses and frames), while eyeglass lenses and frames are not covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $35 copay, and other dental services, including oral exams, dental x-rays, prophylaxis (cleaning), restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with 50% coinsurance. Fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life HMO Rx Choice (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical equipment benefits include durable medical equipment, prosthetics/medical supplies, and diabetic equipment. Durable medical equipment has a 20% coinsurance, and does not have a copay. Prosthetics/medical supplies and diabetic supplies and services are covered with a 20% coinsurance, and have no copay. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the UPMC for Life HMO Rx Choice (HMO) plan. Diagnostic Procedures/Tests and Lab Services have a $5 copay. Diagnostic Radiological Services have a copay of at least $220, Therapeutic Radiological Services have a copay of at least $55, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by UPMC for Life HMO Rx Choice (HMO) with no copay and no 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 generally covered, but this plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is no information about the cost of services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the UPMC for Life HMO Rx Choice (HMO) plan, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items and Meal Benefits. Acupuncture, 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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