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UPMC for Life HMO Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life HMO Rx (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 (HMO) in 2026, please refer to our full plan details page.
UPMC for Life HMO Rx (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 (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 (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 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $90.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 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 (HMO)
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Drug Coverage
The UPMC for Life HMO Rx (HMO) plan features a $0 prescription drug deductible, allowing your coverage to begin immediately. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay when filled through a preferred pharmacy or preferred mail-order service for one-, two-, or three-month supplies. If you use standard pharmacies or standard mail-order services, Tier 1 drugs have a $15 copay for one month and a $30 copay for two or three months, while Tier 2 drugs have a $20 copay for one month and a $40 copay for two or three months. For higher-tier medications, the plan utilizes coinsurance instead of copays across all pharmacy and mail-order options. You will pay a 25% coinsurance for Tier 3 preferred brand drugs and a 50% coinsurance for Tier 4 non-preferred drugs, regardless of the supply duration. Tier 5 specialty drugs require a 33% coinsurance for a one-month supply at both preferred and standard pharmacies or mail-order services.
Additional Benefits
The UPMC for Life HMO Rx (HMO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. For specialized medical care, members pay a $25 copay for specialists and therapy with no coinsurance, while inpatient hospital stays require a $295 annual copay. Outpatient hospital services require a $200 copay, and emergency room visits have a $130 copay that is waived upon admission. Essential dental, vision, and hearing benefits are widely covered, including no copay for preventive dental exams and cleanings. Routine vision and hearing exams require a $25 copay, while comprehensive dental care is covered with no copay and a 30% coinsurance. Durable medical equipment and dialysis services are also covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
UPMC for Life HMO Rx (HMO) partially covers inpatient hospital services with a $295 annual copay and no coinsurance for Medicare-covered acute and psychiatric stays, both of which require prior authorization. Unlimited additional acute care days are covered with no copay, but non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
UPMC for Life HMO Rx (HMO) outpatient services are covered with no coinsurance, featuring a $200 copay (prior authorization required) for ambulatory surgical center, outpatient hospital, and observation services. Outpatient substance abuse services have a $25 copay per individual or group session 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 (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life HMO Rx (HMO) covers ambulance services with no coinsurance, requiring a copay of $50 to $335 for ground transport and $335 for air transport. Prior authorization is required for these ambulance services, while plan-approved transportation services are not covered.
Emergency Services See details
UPMC for Life HMO Rx (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, with no coinsurance for either service. Worldwide emergency, urgent, and transportation services are also covered with copays of $130, $50, and $335 respectively, and no coinsurance.
Primary Care See details
UPMC for Life HMO Rx (HMO) covers primary care physician services with no copay and no coinsurance, and specialist, therapy, and mental health services with a $25 copay and no coinsurance. Telehealth options range from no copay to a $25 copay with no coinsurance, and while some chiropractic services are covered for a $15 copay and no coinsurance, routine chiropractic care and other chiropractic services are not covered.
Preventive Services See details
UPMC for Life HMO Rx (HMO) offers partial coverage for preventive services with no copay and no coinsurance for covered benefits, which include Medicare-covered preventive care, kidney disease education, and counseling. However, several benefits are not covered, such as annual physical exams, health education, personal emergency response systems (PERS), and medical nutrition therapy.
Hearing Services See details
Hearing services covered by UPMC for Life HMO Rx (HMO) include one annual routine exam and fitting evaluation for a $25 copay and no coinsurance. Prescription hearing aids are partially covered with copays ranging from $690 to $1,890 and no coinsurance, but inner ear, outer ear, over-the-ear, and OTC hearing aids are not covered.
Vision Services See details
UPMC for Life HMO Rx (HMO) covers routine eye exams and contact lens fittings with a $25 copay and no coinsurance. Eyewear is covered with no copay and no coinsurance up to a $225 annual maximum for contact lenses and complete eyeglasses, though individual eyeglass lenses and frames are not covered.
Dental Services See details
Dental services are partially covered by UPMC for Life HMO Rx (HMO), offering Medicare-covered dental with a $25 copay and no coinsurance, and preventive exams, cleanings, and x-rays with no copay and no coinsurance. Comprehensive services such as restorative, endodontics, periodontics, prosthodontics, and oral surgery require no copay and a 30% coinsurance up to a $5,000 annual maximum. Fluoride, implants, orthodontics, adjunctive general, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
UPMC for Life HMO Rx (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this plan, Medicare Part B chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Medicare Part B insulin drugs require a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life HMO Rx (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life HMO Rx (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay. A 20% coinsurance applies to durable medical equipment, prosthetics, and diabetic shoes, while diabetic supplies have a coinsurance ranging from 0% (no coinsurance) to 20%. Prior authorization is required for these benefits, and coverage may be limited to preferred manufacturers or vendors.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by UPMC for Life HMO Rx (HMO) with no coinsurance, though prior authorization is required. Covered diagnostic services feature no copay, but diagnostic procedures, tests, and lab services are not covered. Radiological services feature no coinsurance and require copays, including a $175 minimum copay for diagnostic radiological services, a $55 minimum copay for therapeutic radiological services, and a $25 copay for outpatient X-rays.
Home Health Services See details
UPMC for Life HMO Rx (HMO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no copay and no coinsurance under the UPMC for Life HMO Rx (HMO) plan, though only some services are covered since cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
UPMC for Life HMO Rx (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, but a three-day prior inpatient hospital stay is not, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
Other Services are partially covered by UPMC for Life HMO Rx (HMO), offering over-the-counter (OTC) items and meal benefits with no copay and no coinsurance. Acupuncture is not covered under these services.
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