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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 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 (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) Medicare plan features a $0 drug deductible, allowing your prescription coverage to begin 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. If you choose a standard pharmacy or standard mail-order, Tier 1 drugs carry a copay of $15 for a one-month supply, while Tier 2 drugs carry a $20 copay. For higher-tier prescriptions, cost-sharing is based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 25% coinsurance, and Tier 4 non-preferred drugs have a 50% coinsurance across all pharmacy and mail-order options. Specialty drugs in Tier 5 require a 33% coinsurance for a one-month supply.
Additional Benefits
The UPMC for Life HMO Rx (HMO) plan offers affordable healthcare coverage with no copay and no coinsurance for primary care physician visits, select telehealth services, and home health care. Specialist visits, routine eye exams, and outpatient x-rays require a budget-friendly $25 copay with no coinsurance. For more intensive care, inpatient hospital stays require a $200 copay per stay, and emergency room services carry a $130 copay, both with no coinsurance. Preventive dental exams, partial hospitalization, and home infusion services are covered with no copay and no coinsurance, while comprehensive dental care requires a 30% coinsurance. Durable medical equipment, dialysis, and Medicare Part B drugs typically require a 20% coinsurance. Additionally, members can take advantage of an annual eyewear allowance of up to $225 and over-the-counter benefits with no copay or coinsurance.
Inpatient Hospital See details
UPMC for Life HMO Rx (HMO) covers inpatient acute hospital stays with a $200 copay per stay and no coinsurance, while inpatient psychiatric care requires a $295 copay per stay and no coinsurance, with prior authorization needed for both. Acute care includes unlimited additional days at no copay, but psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UPMC for Life HMO Rx (HMO) covers outpatient services with no coinsurance, requiring a $130 to $200 copay for outpatient hospital services, a $200 copay per stay for observation services, and a $130 copay for ambulatory surgical center services, with prior authorization needed for these options. Outpatient substance abuse sessions require a $25 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
UPMC for Life HMO Rx (HMO) covers partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by UPMC for Life HMO Rx (HMO), as transportation services to plan-approved or health-related locations are not covered. Covered ground ambulance services require a $50 to $335 copay, while air ambulance services have a $335 copay, both with no coinsurance and requiring prior authorization.
Emergency Services See details
Emergency services are covered by UPMC for Life HMO Rx (HMO) with a $130 copay, which is waived if admitted to the hospital within 3 days, and no coinsurance. Urgently needed services require a $50 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are 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 and select telehealth visits with no copay and no coinsurance. Specialist visits, mental health, therapy, and podiatry services require a $25 copay and no coinsurance, while chiropractic services are partially covered with a $15 copay and no coinsurance, excluding routine chiropractic care.
Preventive Services See details
Preventive services are partially covered by UPMC for Life HMO Rx (HMO) with no copay and no coinsurance for covered benefits like Medicare-covered preventive care, kidney disease education, and in-home safety assessments. However, several services are not covered under this plan, including annual physical exams, health education, personal emergency response systems (PERS), medical nutrition therapy, and weight management programs.
Hearing Services See details
UPMC for Life HMO Rx (HMO) hearing services are partially covered, offering annual routine hearing exams and fittings for a $25 copay and no coinsurance with no deductible. Up to two prescription hearing aids are covered per year with no coinsurance and a copay ranging from $690 to $1,890, though inner ear, outer ear, over the ear, and over-the-counter (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 partially covered with no copay or coinsurance up to a $225 annual maximum for contact lenses and complete eyeglasses, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life HMO Rx (HMO) offers partially covered dental services, including Medicare-covered dental care for a $25 copay and no coinsurance, and preventive exams and cleanings with no copay and no coinsurance. Comprehensive services like restorative care, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and 30% coinsurance up to a $5,000 annual maximum, while fluoride, implants, orthodontics, and adjunctive general 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, though prior authorization is required. Medicare Part B chemotherapy, radiation, insulin, and other drugs have coinsurance ranging from no coinsurance to 20% coinsurance, with insulin also requiring a $35 copay.
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 services, with no copay and prior authorization required. Members will pay a 20% coinsurance for most items, including medical supplies and therapeutic shoes, while diabetic supplies range from no coinsurance up to 20% coinsurance.
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. Lab services feature no copay, outpatient x-rays require a $25 copay, therapeutic radiology has a minimum $55 copay, and diagnostic radiology has a minimum $175 copay, while diagnostic procedures and tests are not covered.
Home Health Services See details
UPMC for Life HMO Rx (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 technically covered by UPMC for Life HMO Rx (HMO) with no copay and no coinsurance, but the benefit is not covered in practice as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded.
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 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a 3-day prior hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
UPMC for Life HMO Rx (HMO) offers partial coverage for other services, featuring over-the-counter (OTC) items and meal benefits with no copay and no coinsurance. Acupuncture is not covered under this benefit.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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