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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:
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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 pharmacy. For preferred generic drugs, there is no copay at preferred pharmacies or preferred mail order. Standard generic drugs have a $47 copay, and preferred and standard brand drugs have 40% coinsurance.
Additional Benefits
The UPMC for Life HMO Rx Choice (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and no copay for partial hospitalization. Emergency, urgent, and worldwide emergency services are covered with copays. Primary care, specialist visits, and mental health services also have copays. Preventive services have no copay for Medicare-covered services. The plan covers hearing exams with a copay, and hearing aids with a copay. Vision services include eye exams with a copay and eyewear coverage. Dental services include a copay for Medicare dental services, and coinsurance for other dental services. Home health services are covered with no copay.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization; for days 1-5, there is a $195 copay, and for days 6-90, there is no copay. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute are not covered; Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services are covered by UPMC for Life HMO Rx Choice (HMO), including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. For outpatient hospital services, observation services, and ambulatory surgical center services, there is a $300 copay. For individual and group sessions for outpatient substance abuse, the copay is $35.
Partial Hospitalization See details
Partial Hospitalization is covered by this plan. There is no cost sharing for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with no coinsurance for any services. Ground ambulance services have a copay between $50 and $270, while air ambulance services have a copay of $270; however, 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 the UPMC for Life HMO Rx Choice (HMO) plan. Emergency Services has a $125 copay, Urgently Needed Services has a $55 copay, and Worldwide Emergency Services has a $125 copay for Worldwide Emergency Coverage, a $55 copay for Worldwide Urgent Coverage, and a $270 copay for Worldwide Emergency Transportation.
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, and mental health specialty services with a $35 copay for individual and group sessions. The plan also covers podiatry services with a $35 copay, other health care professional visits with a $35 copay, psychiatric services with a $35 copay for individual and group sessions, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a copay between $0 and $35, and opioid treatment program services with a $35 copay.
Preventive Services See details
Preventive Services are covered by the UPMC for Life HMO Rx Choice (HMO) plan, with Medicare-covered preventive services offered with no copay. Additional preventive services are also covered, although annual physical exams, health education, personal emergency response systems, 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 benefits, home-based palliative care, in-home support services, enhanced disease management, telemonitoring services, are not covered. Other covered services include in-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling (4 visits), fitness benefit (memory fitness), 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 EKGs following a welcome visit.
Hearing Services See details
Hearing exams are covered with a $35 copay, and the plan covers routine hearing exams and fitting/evaluation for hearing aids with a limit of one visit per year. 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, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a $35 copay, and routine eye exams and other eye exam services are covered once per year, including contact lens fitting. Eyewear is covered with a combined maximum of $200 per year, and contact lenses and eyeglasses (lenses and frames) are covered once per year. Eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
The UPMC for Life HMO Rx Choice (HMO) plan covers Medicare Dental Services with a $35 copay, and other dental services, including oral exams (2 visits per year), dental x-rays (bitewing every 12 months, panoramic 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, while fluoride treatment, adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic services have a maximum plan benefit coverage of $5,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including insulin and other Medicare Part B drugs, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 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 under 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 under the UPMC for Life HMO Rx Choice (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, and Prosthetic Devices have a 20% coinsurance. Medical Supplies have a 20% coinsurance, while Diabetic Supplies have between 0% and 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services. Diagnostic Procedures/Tests and Lab Services have a $5 copay, while Diagnostic Radiological Services have a minimum copay of $220, Therapeutic Radiological Services have a minimum copay of $55, 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 by the UPMC for Life HMO Rx Choice (HMO) plan, 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 UPMC for Life HMO Rx Choice (HMO), 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 for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items and a Meal Benefit. 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.
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