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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 $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 $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) Medicare prescription drug plan features an annual drug deductible of $175. This plan offers excellent savings on generic medications, featuring no copay for Tier 1 preferred generics and Tier 2 generics when filled through a preferred pharmacy or preferred mail order service. If you choose a standard pharmacy or standard mail order, Tier 1 drugs carry a $15 to $30 copay, while Tier 2 drugs cost between $20 and $40. For higher-tier medications, cost-sharing is based on coinsurance across all pharmacy and mail-order options. You will pay 25% coinsurance for Tier 3 preferred brands, 49% coinsurance for Tier 4 non-preferred drugs, and 31% coinsurance for Tier 5 specialty drugs. Specialty tier medications are limited to a one-month supply.
Additional Benefits
The UPMC for Life HMO Rx Choice (HMO) plan offers affordable healthcare coverage with no copay for primary care doctor visits, home health services, and preventive dental cleanings. For specialized care, members pay a low $35 copay with no coinsurance for specialist visits, routine vision exams, and physical therapy. If you require hospital care, inpatient acute stays have a $250 copay, while outpatient hospital services range from a $180 to $300 copay, both with no coinsurance. Additional benefits include a $200 annual allowance for eyewear with no copay, as well as no copay or coinsurance for over-the-counter items and home meals. Emergency room visits require a $130 copay, which is waived if you are admitted to the hospital within three days. For durable medical equipment and dialysis services, you will pay no copay and a 20% coinsurance, helping keep your out-of-pocket costs predictable.
Inpatient Hospital See details
UPMC for Life HMO Rx Choice (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $250 copay per acute stay and a $400 copay per psychiatric stay, both requiring prior authorization. While unlimited additional acute days are covered with no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by UPMC for Life HMO Rx Choice (HMO) with no coinsurance, featuring a $180 to $300 copay for outpatient hospital and observation services and a $180 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $35 copay with 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), with ground ambulance requiring a $50.00 to $270.00 copay and air ambulance requiring a $270.00 copay, both with no coinsurance and requiring prior authorization. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
UPMC for Life HMO Rx Choice (HMO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within three days, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency and urgent services are also covered with no coinsurance, featuring copays of $130 for emergency care, $50 for urgent care, and $270 for emergency transportation.
Primary Care See details
UPMC for Life HMO Rx Choice (HMO) covers 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. Routine and other chiropractic services are not covered, but routine podiatry is covered for up to 4 visits per year with a $35 copay and no coinsurance.
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 benefits like kidney disease education, diabetes self-management training, and glaucoma screenings. While supplemental benefits such as in-home safety assessments and counseling are covered, several services—including annual physical exams, health education, and weight management programs—are not covered.
Hearing Services See details
Hearing services covered by UPMC for Life HMO Rx Choice (HMO) include annual routine exams and fitting evaluations for a $35 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $690 to $1,890, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
UPMC for Life HMO Rx Choice (HMO) covers vision services with no deductibles, featuring a $35 copay and no coinsurance for annual routine eye exams and contact lens fittings. Eyewear is partially covered with no copay or coinsurance 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, offering preventive cleanings, exams, and x-rays with no copay and no coinsurance, alongside Medicare-covered dental services for a $35 copay and no coinsurance. Comprehensive care, including restorative, endodontic, periodontic, prosthodontic, and oral surgery services, is covered with no copay and 50% coinsurance up to a $5,000 annual limit, while fluoride, implants, orthodontics, maxillofacial prosthetics, and adjunctive general services are not covered.
Home Infusion bundled Services See details
UPMC for Life HMO Rx Choice (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 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 durable medical equipment, prosthetics, and diabetic supplies with no copay and generally 20% coinsurance, though diabetic supplies range from no coinsurance to 20% coinsurance. Prior authorization is required for these services, and coverage may be limited to preferred vendors and specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by UPMC for Life HMO Rx Choice (HMO) with no coinsurance, as diagnostic procedures and tests are not covered. Covered lab services have no copay, while radiological services require prior authorization and copays of $25 for X-rays, a minimum of $55 for therapeutic radiology, and a minimum of $220 for diagnostic radiology.
Home Health Services See details
UPMC for Life HMO Rx Choice (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the UPMC for Life HMO Rx Choice (HMO) plan. This means that cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage, resulting in no plan-covered benefits or associated copays and coinsurance for these treatments.
Skilled Nursing Facility (SNF) See details
UPMC for Life HMO Rx Choice (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10.00 daily copay for days 1 to 20 and a $218.00 daily copay for days 21 to 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required, and additional days beyond the standard Medicare benefit are not covered.
Other Services See details
Other services are partially covered by UPMC for Life HMO Rx Choice (HMO), including over-the-counter (OTC) items and a meal benefit with no copay and no coinsurance, though acupuncture is not covered.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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