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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 a $175 annual drug deductible. You can save significantly on generic medications, as Tier 1 (Preferred Generic) and Tier 2 (Generic) drugs have no copay when filled for any supply length through a preferred pharmacy or preferred mail order. If you use standard pharmacies or standard mail order, Tier 1 drugs require a $15 to $30 copay, while Tier 2 drugs carry a $20 to $40 copay depending on the supply duration. For higher-tier medications, costs shift to coinsurance across all pharmacy and mail order options. Tier 3 (Preferred Brand) drugs require a 25% coinsurance, and Tier 4 (Non-Preferred Drug) medications have a 49% coinsurance for all supply lengths. Specialty drugs in Tier 5 are covered with a 31% coinsurance for a 1-month supply.
Additional Benefits
The UPMC for Life HMO Rx Choice (HMO) plan offers comprehensive coverage for essential medical services with predictable out-of-pocket costs. Primary care visits, select telehealth, and preventive services feature no copay and no coinsurance, while specialist visits and routine exams carry a $35 copay. For more intensive care, inpatient hospital stays require a $250 copay with no coinsurance, and emergency room visits are covered with a $130 copay. This plan also provides valuable supplemental benefits, including routine dental, home health, and partial hospitalization services with no copay and no coinsurance. Vision and hearing services are covered with a $35 copay for routine exams, alongside allowances for eyewear and hearing aids. Additionally, diagnostic tests and X-rays are available with low copays and no coinsurance, while medical equipment and dialysis require a 20% coinsurance with no copay.
Inpatient Hospital See details
UPMC for Life HMO Rx Choice (HMO) provides partially covered inpatient hospital benefits, requiring prior authorization but no coinsurance. Medicare-covered acute stays carry a $250 copay with unlimited additional days, while psychiatric stays require a $395 copay; however, upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by UPMC for Life HMO Rx Choice (HMO) with no coinsurance, featuring a $180 to $250 copay for outpatient hospital services and a $180 copay for ambulatory surgical center services. Additionally, observation services require a $250 copay per stay, outpatient substance abuse sessions have a $35 copay, and outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
UPMC for Life HMO Rx Choice (HMO) covers partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life HMO Rx Choice (HMO) covers emergency ambulance services with no coinsurance, requiring a copay of $50 to $270 for ground transport and $270 for air transport, with prior authorization required. Routine transportation services to health-related locations are not covered under this plan.
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 three days, and urgently needed services with a $50 copay, with no coinsurance required for either service. Worldwide emergency, urgent, and emergency transportation services 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) features primary care physician services and select telehealth benefits with no copay and no coinsurance. Most other primary care benefits—including specialist visits, physical therapy, mental health services, and up to four routine podiatry visits per year—have a $35 copay and no coinsurance, though chiropractic services are not covered in practice as routine and other chiropractic services are excluded.
Preventive Services See details
Preventive services are partially covered under the UPMC for Life HMO Rx Choice (HMO) plan, offering covered options like Medicare-covered zero-dollar preventive services and kidney disease education with no copay and no coinsurance. However, the plan does not cover an annual physical exam, health education, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, home-based palliative care, in-home support, enhanced disease management, or telemonitoring.
Hearing Services See details
Hearing services covered by the UPMC for Life HMO Rx Choice (HMO) include an annual routine hearing exam and fitting for a $35 copay and no coinsurance. Prescription hearing aids are partially covered with a copay ranging from $690 to $1,890 and no coinsurance for up to two aids per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services are covered by UPMC for Life HMO Rx Choice (HMO), featuring a $35 copay and no coinsurance for annual routine eye exams and contact lens fittings. Eyewear is partially covered with no copay or coinsurance up to a $200 yearly limit, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life HMO Rx Choice (HMO) partially covers dental services, providing Medicare-covered dental for a $35 copay and no coinsurance, alongside routine exams, cleanings, and x-rays with no copay and no coinsurance. Comprehensive options like restorative work and oral surgery are covered with no copay and 50% coinsurance up to a $5,000 annual limit, while fluoride, implants, and orthodontics 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, but require prior authorization. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin requires a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by UPMC for Life HMO Rx Choice (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life HMO Rx Choice (HMO) covers medical equipment, including durable medical equipment (DME), prosthetics, and diabetic equipment, with no copays and a 20% coinsurance for most items. Diabetic supplies range from no coinsurance to 20% coinsurance, and prior authorization is required across all covered categories.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by UPMC for Life HMO Rx Choice (HMO) with no coinsurance, though prior authorization is required. Diagnostic procedures, tests, and lab services carry a $5 copay, while radiological services incur copays of $25 for X-rays, $55 for therapeutic radiology, and $220 for diagnostic radiology.
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
Cardiac Rehabilitation Services are not covered under the UPMC for Life HMO Rx Choice (HMO) plan, which includes no coverage for cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services.
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 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
UPMC for Life HMO Rx Choice (HMO) partially covers other services, providing over-the-counter (OTC) items and a meal benefit with no copay and no coinsurance. However, acupuncture is not covered under this plan.
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