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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 $40.00. 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 features an annual drug deductible of $175. For lower-tier medications, you can enjoy no copay on Tier 1 preferred generic and Tier 2 generic drugs when using a preferred pharmacy or preferred mail order. If you choose standard pharmacies or standard mail order, copays for these drugs range from $15 to $40 depending on the tier and supply length. Brand-name and specialty medications are subject to coinsurance rather than flat copayments. Tier 3 preferred brands require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 49% coinsurance. Specialty drugs in Tier 5 require a 31% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
UPMC for Life HMO Rx Choice (HMO) offers affordable healthcare coverage, featuring no copays for primary care visits and preventive services. For inpatient hospital stays, members pay a $395 annual copay with no coinsurance, while emergency room visits carry a $130 copay. Specialist visits and physical therapy are also highly accessible with a standard $35 copay and no coinsurance. This plan also includes essential dental, vision, and hearing benefits to support your overall well-being. Preventive dental care, home health services, and select over-the-counter items are covered with no copay and no coinsurance. Routine vision exams require a $35 copay, while members receive a $200 yearly limit for eyewear and coverage for prescription hearing aids with no coinsurance.
Inpatient Hospital See details
UPMC for Life HMO Rx Choice (HMO) covers inpatient acute and psychiatric hospital stays with a $395 annual copay, no coinsurance, and required prior authorization. Unlimited additional days for acute stays are covered with no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UPMC for Life HMO Rx Choice (HMO) covers outpatient hospital and observation services with a $250 copay and no coinsurance, and ambulatory surgical center services with a $200 copay and no coinsurance. Outpatient substance abuse sessions have a $35 copay and no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
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), featuring no coinsurance and copays of $50.00 to $270.00 for ground ambulance services and $270.00 for air ambulance services. Some transportation services are covered, but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Emergency services are covered by UPMC for Life HMO Rx Choice (HMO) with a $130 copay (waived if admitted within 3 days) and no coinsurance, while urgently needed services require a $50 copay and no coinsurance. Worldwide emergency, urgent, and 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) offers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $35 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, though routine chiropractic care is not covered.
Preventive Services See details
Preventive Services are partially covered by UPMC for Life HMO Rx Choice (HMO) with no copay and no coinsurance for covered services like diabetes training and glaucoma screenings. This benefit does not cover annual physical exams, health education, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, enhanced disease management, and telemonitoring.
Hearing Services See details
UPMC for Life HMO Rx Choice (HMO) partially covers hearing services, offering one routine exam and fitting annually for a $35 copay and no coinsurance. Up to two prescription hearing aids are covered per year with a copay ranging from $690 to $1,890 and no coinsurance, though OTC hearing aids as well as inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
UPMC for Life HMO Rx Choice (HMO) covers annual routine eye exams and contact lens fittings with a $35 copay and no coinsurance. Eyewear is partially covered with no copay, no coinsurance, and no deductible up to a $200 yearly limit for contact lenses or complete eyeglasses, 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, featuring Medicare-covered dental at a $35 copay and no coinsurance. Preventive care like exams, cleanings, and x-rays is available with no copay and no coinsurance, while comprehensive services like restorative, endodontics, periodontics, prosthodontics, and oral surgery require no copay and 50% coinsurance up to a $5,000 yearly limit. Fluoride, implants, orthodontics, adjunctive general services, maxillofacial prosthetics, and other diagnostic or 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, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs require between no coinsurance and 20% coinsurance, while Part B insulin has a $35 copay and between no coinsurance and 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 with no copays, though prior authorization is required and a 20% coinsurance applies to durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes. Diabetic supplies are also covered with no copay and a coinsurance ranging from 0% (no coinsurance) to 20%.
Diagnostic and Radiological Services See details
UPMC for Life HMO Rx Choice (HMO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Diagnostic procedures and lab services have a $5 copay, outpatient X-rays have a $25 copay, and therapeutic and diagnostic radiological services require minimum copays of $55 and $220, respectively.
Home Health Services See details
UPMC for Life HMO Rx Choice (HMO) covers home health services with no copay and no coinsurance. Prior authorization is required to receive these covered services.
Cardiac Rehabilitation Services See details
UPMC for Life HMO Rx Choice (HMO) covers some cardiac rehabilitation services with no copay and no coinsurance. However, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by UPMC for Life HMO Rx Choice (HMO) 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 needed, 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, providing over-the-counter (OTC) items and meal benefits with no copay and no coinsurance. Acupuncture is not covered under this benefit.
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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