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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 2026, 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 2026.
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 $30.00. 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 features an annual drug deductible of $175. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay when using a preferred pharmacy or preferred mail-order service for up to a 3-month supply. If you choose standard pharmacy or standard mail-order options, Tier 1 copays range from $15 to $30, while Tier 2 copays range from $20 to $40 depending on the supply duration. For brand-name and specialty medications, your costs are structured as coinsurance across all pharmacy and mail-order options. Tier 3 preferred brands carry a 25% coinsurance, Tier 4 non-preferred drugs carry a 49% coinsurance, and Tier 5 specialty drugs require a 31% coinsurance for a 1-month supply.
Additional Benefits
UPMC for Life HMO Rx Choice (HMO) offers robust medical coverage with no copay and no coinsurance for primary care visits, home health services, and preventive dental care. For specialized care, members benefit from predictable flat-rate copayments and no coinsurance, such as a $35 copay for specialist visits, a $130 copay for emergency room visits, and a $250 copay for acute inpatient hospital stays. Outpatient hospital procedures and diagnostic services are also covered with fixed copays and no coinsurance. To support overall wellness, this plan covers routine eye exams, hearing exams, and Medicare-covered dental services for a $35 copay. Additional benefits like home-delivered meals and eyewear up to a $200 annual limit are available with no copay and no coinsurance. For medical supplies, durable medical equipment, and dialysis, members will pay no copay and a standard 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are covered by UPMC for Life HMO Rx Choice (HMO) with a $250 copayment for acute care and a $400 copayment for psychiatric stays, both requiring prior authorization and featuring no coinsurance. While unlimited additional acute care days are covered with no copayment, psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UPMC for Life HMO Rx Choice (HMO) covers outpatient services with no coinsurance, including outpatient hospital services with a $180 to $300 copay and observation services with a $300 copay per stay. Ambulatory surgical center services require a $180 copay, outpatient substance abuse sessions carry a $35 copay, 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 Rx Choice (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by UPMC for Life HMO Rx Choice (HMO), offering ground ambulance transfers for a $50 to $270 copay and air ambulance services for a $270 copay, both with no coinsurance. Prior authorization is required for ambulance services, and additional transportation services to health-related locations are not covered.
Emergency Services See details
UPMC for Life HMO Rx Choice (HMO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within 3 days, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency care, urgent care, and emergency transportation are also covered with no coinsurance and copays of $130, $50, and $270 respectively.
Primary Care See details
UPMC for Life HMO Rx Choice (HMO) covers primary care physician services and select telehealth benefits with no copay and no coinsurance. Specialist visits, therapy services, mental health care, and podiatry require a $35 copay and no coinsurance, while chiropractic services are not covered.
Preventive Services See details
UPMC for Life HMO Rx Choice (HMO) preventive services are partially covered with no copay and no coinsurance for covered benefits such as kidney disease education, counseling, and diabetes self-management training. However, several services are not covered under this plan, including annual physical exams, health education, personal emergency response systems (PERS), medical nutrition therapy, and weight management programs.
Hearing Services See details
UPMC for Life HMO Rx Choice (HMO) covers annual routine hearing exams and fittings with a $35 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $690 to $1,890 for up to two devices per year, while inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
UPMC for Life HMO Rx Choice (HMO) covers annual eye exams with a $35 copay, no coinsurance, and no deductible. Eyewear is partially covered with no copay, no coinsurance, and no deductible up to a $200 yearly limit for contact lenses and combined eyeglasses, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
Dental Services are partially covered by UPMC for Life HMO Rx Choice (HMO), offering preventive care like cleanings and exams with no copay and no coinsurance. Medicare-covered dental services require a $35 copay and no coinsurance, while covered comprehensive services have no copay and 50% coinsurance up to a $5,000 annual maximum. Fluoride, implants, orthodontics, adjunctive general, maxillofacial prosthetics, other diagnostic, and other preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by UPMC for Life HMO Rx Choice (HMO) with no copay, although prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and radiation, have no copay and a coinsurance ranging from no coinsurance to 20%, while Medicare Part B insulin has a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
UPMC for Life HMO Rx Choice (HMO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life HMO Rx Choice (HMO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes carry a 20% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic services are partially covered by UPMC for Life HMO Rx Choice (HMO) with no coinsurance and no copay for lab services, though diagnostic procedures and tests are not covered. Radiological services are covered with no coinsurance and require copays of $25 for X-rays, a minimum of $55 for therapeutic radiology, and a minimum of $220 for diagnostic radiology, with prior authorization required for both categories.
Home Health Services See details
UPMC for Life HMO Rx Choice (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
UPMC for Life HMO Rx Choice (HMO) provides coverage for cardiac rehabilitation services with no copay and no coinsurance. Although some services are covered, specific sub-services—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 Choice (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day hospital stay is not required, additional days beyond the standard 100 days are not covered.
Other Services See details
UPMC for Life HMO Rx Choice (HMO) partially covers other services, offering over-the-counter (OTC) items and meal benefits with no copay and no coinsurance, while acupuncture is not covered. Covered benefits include reimbursement for CMS-approved OTC items like nicotine replacement therapy, as well as home meal delivery for members with chronic or qualifying medical conditions.
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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