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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:
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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, the plan covers medications with varying costs depending on the drug tier and pharmacy type. For example, preferred generic drugs have no copay at preferred pharmacies and preferred mail order, while standard generic drugs have a $47 copay. Brand-name and non-preferred drugs have coinsurance costs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs. If you qualify for the low-income subsidy, your monthly premium is $16.20.
Additional Benefits
The UPMC for Life HMO Rx Choice (HMO) plan offers a range of benefits, including inpatient and outpatient hospital services, with varying copays. The plan covers primary care, specialist visits, and mental health services, all with a $35 copay. Preventive services, hearing, vision, and dental services are also included, with specific copays and coverage limits for each. This plan provides coverage for ambulance services, emergency services, and home health services, as well as services such as home infusion, dialysis, and medical equipment. Diagnostic and radiological services are covered with varying copays. The plan also covers over-the-counter items and a meal benefit, with a copay, and skilled nursing facilities, but does not cover annual physical exams.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For a Medicare-covered stay, the copay is $395 annually. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services and outpatient substance abuse services, are covered. Outpatient hospital services and observation services have a $250 copay, Ambulatory Surgical Center (ASC) Services have a $225 copay, and individual and group sessions for outpatient substance abuse have a minimum and maximum copay of $35.00.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life HMO Rx Choice (HMO) plan. There is no cost to you for this benefit.
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 to $270, and air ambulance services have a copay of $270, but 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, and Urgently Needed Services have a $55 copay; both have no coinsurance. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $270 copay; all three have no coinsurance.
Primary Care See details
The UPMC for Life HMO Rx Choice (HMO) plan covers Primary Care Physician Services, Occupational Therapy Services (with a $35 copay), Physician Specialist Services (with a $35 copay), Mental Health Specialty Services (with a $35 copay), Podiatry Services (with a $35 copay), Other Health Care Professional (with a $35 copay), Psychiatric Services (with a $35 copay), Physical Therapy and Speech-Language Pathology Services (with a $35 copay), Additional Telehealth Benefits (with a copay between $0-$35), and Opioid Treatment Program Services (with a $35 copay). Chiropractic Services and Physical Therapy and Speech-Language Pathology Services require prior authorization.
Preventive Services See details
Preventive Services are covered by UPMC for Life HMO Rx Choice (HMO), including Medicare-covered zero-dollar preventive services. Annual physical exams are not covered, and additional preventive services include In-Home Safety Assessment, Additional Sessions of Smoking and Tobacco Cessation Counseling (4 sessions), Fitness Benefit, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, Counseling Services (6 sessions), Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Health Education, Personal Emergency Response System, Medical Nutrition Therapy, 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, Enhanced Disease Management, Telemonitoring Services, and other services are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $35 copay, and routine hearing exams and fitting/evaluation for hearing aids are covered once per year. Prescription hearing aids are partially covered, with a copay between $690 and $1890 for all types of hearing aids, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered; over-the-counter hearing aids are also not covered.
Vision Services See details
The UPMC for Life HMO Rx Choice (HMO) plan covers vision services, including eye exams with a $35 copay, and eyewear. Eyewear coverage includes a combined maximum of $200 per year for contact lenses, eyeglasses (lenses and frames), and upgrades, with 1 pair of contacts and 1 pair of eyeglasses (lenses and frames) covered each year. Eyeglass lenses and frames are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $35 copay, and other dental services. Other dental services include oral exams (2 visits per year), dental x-rays (1 bitewing x-ray every 12 months, and 1 panoramic x-ray every 36 months), and prophylaxis (cleaning) (2 visits per year). Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with 50% coinsurance. Fluoride treatment, adjunctive general services, implant services, and maxillofacial prosthetics are not covered. Orthodontic services have a maximum plan benefit of $5,000 per year, and orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the UPMC for Life HMO Rx Choice (HMO) plan. For Medicare Part B Insulin Drugs, there is a $35 copay, and coinsurance may apply.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life HMO Rx Choice (HMO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits are covered under the UPMC for Life HMO Rx Choice (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance for covered services. Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by UPMC for Life HMO Rx Choice (HMO). Diagnostic Procedures/Tests and Lab Services have a $5 copay, Diagnostic Radiological Services have a $220 copay, Therapeutic Radiological Services have a $55 copay, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life HMO Rx Choice (HMO) plan 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 technically covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the UPMC for Life HMO Rx Choice (HMO) plan, with a copay of $10 for days 1-20, and a copay of $214 for days 21-100. Additional days beyond Medicare-covered, and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The UPMC for Life HMO Rx Choice (HMO) plan covers Over-the-Counter (OTC) Items and a Meal Benefit, but Acupuncture is not covered. The plan offers OTC items as a supplemental benefit under Part C, and the Meal Benefit is offered for a chronic illness or medical condition. Other services, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and Private Duty Nursing Services, are not covered.
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