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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 2026 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 an annual drug deductible of $175. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic medications when using a preferred pharmacy or preferred mail-order service. If you choose standard pharmacies or standard mail order, Tier 1 drugs require a copay of $15 to $30, while Tier 2 drugs carry a copay of $20 to $40 depending on the supply duration. For brand-name and specialty medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brands require a 25% coinsurance, Tier 4 non-preferred drugs require a 49% coinsurance, and Tier 5 specialty drugs carry a 31% coinsurance for a one-month supply. These coinsurance rates apply across all preferred and standard pharmacy or mail-order options.
Additional Benefits
The UPMC for Life HMO Rx Choice (HMO) plan offers comprehensive coverage with no copay and no coinsurance for primary care visits, home health services, and preventive care. Routine dental cleanings, select diagnostic services, and over-the-counter benefits also feature no copayments. For specialist visits, diagnostic procedures, and routine eye or hearing exams, members will pay affordable copays ranging from $5 to $35 with no coinsurance. For more intensive care, inpatient hospital acute stays require a $250 annual copay and emergency room visits have a $130 copay, both with no coinsurance. Skilled nursing facility stays feature a $10 daily copay for the first 20 days, while services like dialysis and durable medical equipment require a 20% coinsurance with no copay. Comprehensive dental services are also covered with a 50% coinsurance up to a $5,000 annual maximum.
Inpatient Hospital See details
Inpatient hospital services are covered by UPMC for Life HMO Rx Choice (HMO) with a $250 annual copay and no coinsurance for acute stays, and a $395 annual copay and no coinsurance for psychiatric stays. Prior authorization is required for these services, while upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
UPMC for Life HMO Rx Choice (HMO) covers outpatient services with no coinsurance, though prior authorization is required for outpatient hospital services (copay of $180 to $250), observation services ($250 copay per stay), and ambulatory surgical center services ($180 copay). Outpatient substance abuse services are covered with a $35 copay per session and no coinsurance, while outpatient blood services require no copay, coinsurance, or deductible.
Partial Hospitalization See details
Partial hospitalization services are covered by UPMC for Life HMO Rx Choice (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life HMO Rx Choice (HMO) partially covers ambulance and transportation services, offering ground ambulance services with a $50.00 to $270.00 copay and air ambulance services with a $270.00 copay, both with no coinsurance. Prior authorization is required for ambulance services, and transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
UPMC for Life HMO Rx Choice (HMO) covers emergency services with a $130 copay (waived if admitted to the hospital within 3 days) and urgently needed services with a $50 copay, both with 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
Primary care benefits under UPMC for Life HMO Rx Choice (HMO) feature no copay and no coinsurance for primary care visits, while specialist, 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 and other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered under UPMC for Life HMO Rx Choice (HMO) with no copay and no coinsurance for covered services like kidney disease education, diabetes self-management training, and glaucoma screenings. However, several sub-services are not covered, including annual physical exams, health education, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, home-based 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 routine exams and fittings for a $35 copay and no coinsurance, alongside up to two prescription hearing aids per year with a copay of $690 to $1,890 and no coinsurance. Over-the-counter hearing aids and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
UPMC for Life HMO Rx Choice (HMO) partially covers vision services, as individual eyeglass lenses and eyeglass frames are not covered. Covered eye exams require a $35 copay and no coinsurance, while covered eyewear has no copay and no coinsurance up to a $200 annual maximum, with no deductibles for either service.
Dental Services See details
Dental services are partially covered by UPMC for Life HMO Rx Choice (HMO), featuring Medicare-covered dental with a $35 copay and no coinsurance, and preventive care like exams and cleanings with no copay and no coinsurance. Comprehensive benefits like periodontics and oral surgery have no copay and a 50% coinsurance up to a $5,000 annual maximum, while fluoride, implants, orthodontics, other diagnostic services, and maxillofacial prosthetics 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 and no coinsurance, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy and other drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs require a $35 copay and a coinsurance ranging from no coinsurance to 20%.
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
Medical Equipment is covered under the UPMC for Life HMO Rx Choice (HMO) plan with no copays, though prior authorization is required. Members will pay a 20% coinsurance for durable medical equipment, prosthetics, and diabetic therapeutic shoes, while diabetic supplies carry a coinsurance ranging from 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. Covered diagnostic procedures and lab services have a $5 copay, outpatient x-rays carry a $25 copay, and therapeutic and diagnostic radiological services require minimum copays of $55 and $220, respectively.
Home Health Services See details
Home health services are covered by UPMC for Life HMO Rx Choice (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
UPMC for Life HMO Rx Choice (HMO) indicates that some services are covered for Cardiac Rehabilitation Services with no copay and no coinsurance, but specific sub-services like cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered.
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 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not 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, offering over-the-counter (OTC) items and meal benefits with no copay and no coinsurance, while acupuncture is not covered.
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