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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 $97.00. 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:
Sign up for UPMC for Life HMO Rx (HMO)
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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 when using preferred mail order, but a $20 copay at a standard pharmacy. After your total drug costs reach $2000, 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 range of benefits, including inpatient hospital stays with a $295 copay, outpatient services with copays ranging from $25 to $200, and emergency services with a $125 copay. This plan also covers primary care physician services and specialist visits, both with a $25 copay, and covers preventative services with no copay. Additional benefits include coverage for hearing exams with a $25 copay, prescription hearing aids with copays between $690 and $1890, and vision services with a $25 copay for eye exams. Dental services include coverage for oral exams, x-rays, and cleanings with no copay, as well as restorative services, endodontics, periodontics, prosthodontics, and oral and maxillofacial surgery with 30% coinsurance. The plan also covers home health services with no copay, skilled nursing facility services with copays, and offers an OTC benefit.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered, but require prior authorization. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, there is a $295 copay for a Medicare-covered stay. 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
The UPMC for Life HMO Rx (HMO) plan covers outpatient services, including outpatient hospital services and observation services with a $200 copay, and ambulatory surgical center services with a $200 copay. The plan also covers outpatient substance abuse services, including individual and group sessions, with a copay between $25 and $25, and outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life HMO Rx (HMO) plan. The plan covers this benefit, but the specific costs associated with the benefit are not detailed in the provided information.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by UPMC for Life HMO Rx (HMO). Ground ambulance services have a copay between $50 and $270, and air ambulance services have a copay of $270, with no coinsurance for either. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered by UPMC for Life HMO Rx (HMO). Emergency Services have a $125 copay, while Urgently Needed Services have a $55 copay; both have no coinsurance. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $270 copay; these services also have no coinsurance.
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, podiatry services with a $25 copay, other health care professional services with a $25 copay, psychiatric services with a $25 copay, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a $0-$25 copay, 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 are covered, with no copay for Medicare-covered preventive services. Annual physical exams, health education, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 Benefit, Home-Based Palliative Care, Enhanced Disease Management, Telemonitoring Services are not covered. In-Home Safety Assessment, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, Counseling Services, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are all covered. Counseling Services are limited to 6 sessions.
Hearing Services See details
Hearing exams are covered with a $25 copay, including routine hearing exams and fitting/evaluation for hearing aids, each limited to one visit per year. Prescription hearing aids are covered with a copay between $690 and $1890, but not for inner ear, outer ear, or over-the-ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay. Eyewear includes coverage for contact lenses and eyeglasses, with a combined maximum benefit of $225 every year, but eyeglass lenses and frames are not covered.
Dental Services See details
Dental services include coverage for oral exams with a $25 copay, dental x-rays, and cleaning with no copay, as well as restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with 30% coinsurance. Fluoride treatment, 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. The plan covers Medicare Part B insulin drugs with a $35 copay and a coinsurance between 0% and 20%. Medicare Part B chemotherapy/radiation drugs and other Medicare Part B drugs are covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life HMO Rx (HMO) plan. You are responsible for a 20% coinsurance for these services.
Medical Equipment See details
The UPMC for Life HMO Rx (HMO) plan covers Durable Medical Equipment (DME) with a 20% coinsurance and requires prior authorization, but does not cover DME for use outside the home. Prosthetics and Medical Supplies are covered with a 20% coinsurance, and Diabetic Supplies are covered with 0-20% coinsurance. Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance.
Diagnostic and Radiological Services See details
For the UPMC for Life HMO Rx (HMO) plan, Diagnostic and Radiological Services are covered. Diagnostic procedures/tests and lab services are not covered. Diagnostic Radiological Services have a copay of at most $175.00, Therapeutic Radiological Services have a copay of at most $55.00, and Outpatient X-Ray Services have a copay of $25.00.
Home Health Services See details
Home Health Services are covered by UPMC for Life HMO Rx (HMO), with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but this 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 (HMO). For days 1-20, the copay is $10, and for days 21-100, the copay is $214; 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 a Meal Benefit, while acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services are not covered. The plan offers OTC items as a supplemental benefit, including nicotine replacement therapy, but does not cover Naloxone.
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