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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 $35.00. 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:
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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, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, you will have no copay at preferred pharmacies or preferred mail order, while standard pharmacies and standard mail order have a $20 copay. Standard generic drugs have a $47 copay regardless of the pharmacy. Preferred and non-preferred brand drugs have a 40% and 31% coinsurance, respectively.
Additional Benefits
The UPMC for Life HMO Rx Choice (HMO) plan offers a range of benefits with varying cost-sharing requirements. Inpatient hospital stays have a $400 copay per stay, while outpatient services such as hospital services and ambulatory surgical centers have a $300 copay. Emergency services have a $125 copay, and primary care physician services, as well as many other services, are covered with copays ranging from $18 to $55. Preventive services are covered, and the plan offers hearing and vision benefits, including hearing exams and eye exams with a $35 copay. Dental services include oral exams and dental x-rays with a $35 copay, and restorative services with 50% coinsurance. Durable medical equipment and prosthetic devices have 20% coinsurance, and home health services are covered with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both with a $400 copay per stay; however, Additional Days for Inpatient Hospital Psychiatric, Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered. Additional Days for Inpatient Hospital-Acute are covered with no copay.
Outpatient Services See details
Outpatient Services are covered, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services, observation services, and ambulatory surgical center services have a $300 copay, while individual and group sessions for outpatient substance abuse have a copay between $35 and $35.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life HMO Rx Choice (HMO) plan. There is no additional information about the cost of this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by UPMC for Life HMO Rx Choice (HMO). Ground ambulance services have a copay of $50-$270, and air ambulance services have a copay of $270, while 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. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $270 copay.
Primary Care See details
The UPMC for Life HMO Rx Choice (HMO) plan covers Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic Services are covered with a $18 copay, and the plan covers routine foot care with a $35 copay.
Preventive Services See details
Preventive Services are covered by UPMC for Life HMO Rx Choice (HMO), including Medicare-covered zero dollar services, In-Home Safety Assessment, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, Counseling Services (6 sessions), Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. The plan does not cover annual physical exams, health education, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, and Enhanced Disease Management, Telemonitoring Services.
Hearing Services See details
Hearing exams are covered under the UPMC for Life HMO Rx Choice (HMO) plan with a $35 copay, and fitting/evaluation for hearing aids are covered as well. Prescription hearing aids are covered with a copay between $690 and $1890, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $35 copay, routine eye exams once per year, and other eye exam services including contact lens fitting once per year. Eyewear includes contact lenses (one pair per year), eyeglasses (lenses and frames) (one pair per year), and upgrades. Eyeglass lenses and frames are not covered.
Dental Services See details
Dental services include Medicare dental services with a $35 copay, and other dental services. Other dental services cover oral exams (2 per year) and dental x-rays, including bitewing x-rays (1 every 12 months) and panoramic x-rays (1 every 36 months). Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with 50% coinsurance. Fluoride treatment, adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the UPMC for Life HMO Rx Choice (HMO) plan. For Medicare Part B insulin drugs, there is a $35 copay, with 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 by the UPMC for Life HMO Rx Choice (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered by UPMC for Life HMO Rx Choice (HMO). 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 with no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a $5 copay, Lab Services with a $5 copay, Diagnostic Radiological Services with a $220 copay, Therapeutic Radiological Services with a $55 copay, and Outpatient X-Ray Services with a $25 copay. Prior authorization is required for all diagnostic and radiological services.
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. 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 provided about cost-sharing (copay or coinsurance) for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by UPMC for Life HMO Rx Choice (HMO), 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 coverage and non-Medicare stays are not covered.
Other Services See details
Under the UPMC for Life HMO Rx Choice (HMO) plan, 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. Over-the-counter (OTC) items and meal benefits are covered.
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