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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 2025, 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 2025.
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. Additionally, this plan comes with a Part B Premium reduction of $1.00. You must continue to pay paying your reduced 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:
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Drug Coverage
The UPMC for Life HMO Rx (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay different copays or coinsurance amounts depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies and mail order, but a $20 copay at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The UPMC for Life HMO Rx (HMO) plan offers a wide range of benefits including inpatient and outpatient hospital services, with varying copays. It also covers primary care, specialist visits, and mental health services, each with a copay. Additionally, the plan includes coverage for emergency services, hearing, vision, and dental care, with specific copays and coinsurance amounts. The plan provides coverage for ambulance services, home infusion, dialysis, medical equipment, and diagnostic services, all with different cost-sharing structures. Preventive services and home health services are covered with no copay. The plan also has coverage for skilled nursing facilities, with copays for specific days.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, each with a copay of $295. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services, are covered. Outpatient Hospital Services, Observation Services, and ASC services have a $200 copay, while Individual and Group Sessions for Outpatient Substance Abuse have a copay between $25 and $25.
Partial Hospitalization See details
Partial Hospitalization is covered by this plan. There is no copay or coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $50 and $270, while air ambulance services have a $270 copay, and there is no coinsurance for any ambulance services. 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 under the UPMC for Life HMO Rx (HMO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $55 copay, while Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $270 copay. There is no coinsurance for any of these services.
Primary Care See details
The UPMC for Life HMO Rx (HMO) plan covers primary care physician services, chiropractic services with an $18 copay, occupational therapy services with a $25 copay, physician specialist services with a $25 copay, mental health specialty services with a $25 copay for individual and group sessions, podiatry services with a $25 copay for routine foot care, other health care professional services with a $25 copay, psychiatric services with a $25 copay for individual and group sessions, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a copay between $0 and $25, and opioid treatment program services with a $25 copay. Routine Chiropractic Care is limited to 6 visits per year.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, and additional preventive services like in-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefits, remote access technologies, home and bathroom safety devices and modifications, and counseling services. 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, enhanced disease management, telemonitoring services, and in-home support services are not covered. Other preventive services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit are covered.
Hearing Services See details
Hearing services include routine hearing exams with a $25 copay, as well as fitting/evaluation for hearing aids. Prescription hearing aids are covered, with a copay between $690 and $1890 for all types of prescription hearing aids, but inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $25 copay, and coverage for contact lenses and eyeglasses (lenses and frames). Eyeglass lenses and frames are not covered. The plan offers a combined maximum of $225 per year for eyewear.
Dental Services See details
Dental services include a $25 copay for Medicare dental services. Other dental services cover oral exams (2 visits per year) and dental x-rays, including bitewing x-rays (1 per year) and panoramic x-rays (1 every 36 months), and prophylaxis (cleaning) (2 visits per year); however, fluoride treatment is not covered. Orthodontic services have a $5,000 maximum plan benefit per year, and restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with a 30% coinsurance. Adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, 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 by UPMC for Life HMO Rx (HMO) with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by the UPMC for Life HMO Rx (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies have a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by UPMC for Life HMO Rx (HMO), but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $175, Therapeutic Radiological Services have a copay of at most $55, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by UPMC for Life HMO Rx (HMO), with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, 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) benefits are covered under the UPMC for Life HMO Rx (HMO) plan, with a $10 copay for days 1-20 and a $214 copay 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 Over-the-Counter (OTC) Items, and 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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