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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 $6000.00 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, you'll pay a copay or coinsurance for your medications depending on the drug tier and pharmacy. For preferred generic drugs, you'll pay no copay at preferred pharmacies or via mail order, and a $20 copay at standard pharmacies. Standard generic drugs have a $47 copay regardless of pharmacy. For preferred brand drugs, you pay 40% coinsurance, and for non-preferred drugs, you pay 31% coinsurance.
Additional Benefits
The UPMC for Life HMO Rx Choice (HMO) plan offers a range of benefits, including coverage for inpatient hospital stays with a $395 copay, outpatient services with a $250 copay, and emergency services with a $125 copay. Primary care physician visits, specialist visits, and mental health services have a $35 copay. This plan also covers preventive services, hearing exams with a $35 copay, and vision services like eye exams with a $35 copay, as well as contact lenses and eyeglasses. Dental services include Medicare Dental Services with a $35 copay, with 50% coinsurance for restorative services. The plan covers home health services with no copay, and offers skilled nursing facility care with a copay, and also provides coverage for home infusion, dialysis, medical equipment, and diagnostic services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. The plan has a copay of $395.00 for a Medicare-covered stay for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, and the Additional Days for Inpatient Hospital-Acute service is covered with no copay. 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.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and ambulatory surgical center (ASC) services, have a $250 copay. Outpatient substance abuse services have a $35 copay for individual and group sessions. Outpatient blood services are also covered.
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 by UPMC for Life HMO Rx Choice (HMO). Ground ambulance services have a copay between $50 and $270, while air ambulance services have a $270 copay; both have no coinsurance. 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, 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; all services have no coinsurance.
Primary Care See details
The UPMC for Life HMO Rx Choice (HMO) plan covers primary care physician services, chiropractic services with an $18 copay, 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 services 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 $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, including Medicare-covered zero-dollar preventive services. Annual physical exams, health education, personal emergency response systems (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 benefits, home-based palliative care, in-home support services, enhanced disease management, telemonitoring services are not covered. In-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefits, remote access technologies, home and bathroom safety devices and modifications, counseling services, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit are covered.
Hearing Services See details
Hearing services include routine hearing exams with a $35 copay, and fitting/evaluation for hearing aids, with a limit of one visit per year. Prescription hearing aids are partially covered; Prescription Hearing Aids (all types) are covered with a copay between $690 and $1890, while Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $35 copay, as well as coverage for contact lenses and eyeglasses (lenses and frames), both limited to one pair per year. Eyeglass lenses and frames are not covered. A combined maximum of $200.00 is provided for eyewear every year.
Dental Services See details
For UPMC for Life HMO Rx Choice (HMO), dental services include Medicare Dental Services with a $35 copay, and other services with no maximum plan benefit coverage. Oral exams and prophylaxis (cleaning) are covered with 2 visits per year, and dental x-rays are covered with bitewing x-rays offered every 12 months and panoramic x-rays offered every 36 months. Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with a 50% coinsurance, while 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, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by UPMC for Life HMO Rx Choice (HMO) with a 20% coinsurance.
Medical Equipment See details
The UPMC for Life HMO Rx Choice (HMO) plan covers Durable Medical Equipment (DME) with a 20% coinsurance and requires prior authorization, but does not cover Durable Medical Equipment for use outside the home. Prosthetic Devices and Medical Supplies are covered with a 20% coinsurance, and Diabetic Supplies are covered with a 0-20% coinsurance, while 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. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the UPMC for Life HMO Rx Choice (HMO) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. The copay is $10 for days 1-20, and $214 for days 21-100; additional days beyond Medicare-covered, and non-Medicare-covered stays are not covered.
Other Services See details
The "Other Services" benefit includes coverage for Over-the-Counter (OTC) Items and Meal Benefits, while Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and other services are not covered. This plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit.
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