A non-government entity
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 $97.00. 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)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The UPMC for Life HMO Rx (HMO) plan features a $0 drug deductible, meaning your prescription coverage begins immediately. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay when using a preferred pharmacy or preferred mail order service for up to a three-month supply. 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 depending on the supply duration. For higher-tier medications, costs transition to a percentage-based coinsurance across all pharmacy and mail order options. You will pay 25% coinsurance for Tier 3 preferred brand drugs and 50% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 33% coinsurance and are limited to a one-month supply.
Additional Benefits
The UPMC for Life HMO Rx (HMO) plan offers comprehensive coverage with no copays and no coinsurance for primary care visits, preventive services, and home health care. Inpatient hospital stays require a $200 copay for acute care and a $295 copay for psychiatric stays, with no coinsurance for either. Emergency care is available with a $130 copay, which is waived upon admission, while specialist visits require a $25 copay. For ancillary care, members enjoy preventive dental services and over-the-counter benefits with no copays. Routine vision and hearing exams require a $25 copay, while comprehensive dental services are covered with a 30% coinsurance. Durable medical equipment and dialysis services are also covered with no copays and a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital care under UPMC for Life HMO Rx (HMO) is partially covered and requires prior authorization, featuring no coinsurance, a $200 annual copay for acute stays with unlimited additional days at no copay, and a $295 annual copay for psychiatric stays. Under this benefit, hospital upgrades, non-Medicare-covered stays, and additional days for psychiatric care are not covered.
Outpatient Services See details
Outpatient services are covered by UPMC for Life HMO Rx (HMO) with no coinsurance, featuring copays of $130 to $200 for outpatient hospital and observation services, and $130 for ambulatory surgical center services. Outpatient substance abuse sessions require a $25 copay, while outpatient blood services are covered with no copay 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 prior authorization and a copay of $50 to $335 for ground transport and $335 for air transport. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services are covered by UPMC for Life HMO Rx (HMO) with a $130 copay (waived if admitted to the hospital within 3 days) and no coinsurance, while urgently needed services require a $50 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $50, and $335 respectively.
Primary Care See details
UPMC for Life HMO Rx (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits, therapies, mental health, and podiatry require a $25 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, and telehealth is available with a $0 to $25 copay and no coinsurance.
Preventive Services See details
UPMC for Life HMO Rx (HMO) provides partially covered preventive services with no copay and no coinsurance for all covered services. While Medicare-covered preventive screenings, kidney disease education, and select benefits like counseling and in-home safety assessments are covered, several options including annual physical exams, health education, and weight management programs are not covered.
Hearing Services See details
Hearing services are partially covered by UPMC for Life HMO Rx (HMO), offering one annual routine hearing exam and fitting evaluation for a $25 copay and no coinsurance. Up to two prescription hearing aids are covered per year with no coinsurance and a copay between $690 and $1,890, though OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
UPMC for Life HMO Rx (HMO) provides partially covered vision services, which include annual routine eye exams and contact lens fittings for a $25 copay and no coinsurance. Eyewear is covered with no copay and no coinsurance up to a $225 annual limit, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life HMO Rx (HMO) dental services are partially covered, featuring preventive care such as exams and cleanings with no copay and no coinsurance, and Medicare-covered dental services for a $25 copay and no coinsurance. Comprehensive options like restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and 30% coinsurance up to a $5,000 yearly maximum, while fluoride, implants, orthodontics, adjunctive general, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by UPMC for Life HMO Rx (HMO) with no copay, no coinsurance, and required prior authorization. Associated Medicare Part B insulin drugs require a $35 copay and 0% to 20% coinsurance, while chemotherapy and other Part B drugs carry no copay and 0% to 20% coinsurance.
Dialysis Services See details
UPMC for Life HMO Rx (HMO) covers dialysis services 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 equipment, with no copays and a 20% coinsurance for most items. Prior authorization is required for these services, and diabetic supplies feature a coinsurance ranging from no coinsurance up to 20%.
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. While diagnostic services have no copay, diagnostic procedures, tests, and lab services are not covered; radiological services require copays including $25 for outpatient X-rays, a $55 minimum for therapeutic radiology, and a $175 minimum for diagnostic radiology.
Home Health Services See details
Home health services are covered by UPMC for Life HMO Rx (HMO) 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 (HMO) plan. This includes cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services, which are all excluded from coverage.
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, a prior three-day inpatient hospital stay is not required before admission, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by UPMC for Life HMO Rx (HMO), including over-the-counter (OTC) items and meal benefits with no copay and no coinsurance, while acupuncture is not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved