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UPMC for Life PPO High Deductible Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life PPO High Deductible Rx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on UPMC for Life PPO High Deductible Rx (PPO) in 2025, please refer to our full plan details page.
UPMC for Life PPO High Deductible Rx (PPO) is a PPO plan offered by UPMC Health System available for enrollment in 2025 to people living in Western and Central 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 PPO High Deductible Rx (PPO) 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 PPO High Deductible Rx (PPO).
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 PPO High Deductible Rx (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $33.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $0.50. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $1250.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $175.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $11300.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $11300.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 PPO High Deductible Rx (PPO) plan has a $175 deductible for prescription drugs. After the deductible is met, you'll pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have no copay at preferred pharmacies and preferred mail order, but a $20 copay at standard pharmacies and standard mail order. For preferred brand drugs, you pay 50% coinsurance, and for non-preferred drugs, you pay 31% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The UPMC for Life PPO High Deductible Rx (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $300 copay, while outpatient services have a $175 copay. Emergency services have a $110 copay, and primary care visits range from no copay to a $40 copay depending on the service. Preventive services are covered with no copay, and hearing exams have a $40 copay. Vision services include eye exams with a $40 copay, and the plan covers eyewear. Dental services include oral exams with a $15 copay, and there is a $40 copay for Medicare dental services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered and require prior authorization. For Inpatient Hospital-Acute, there is a $300 copay for a Medicare-covered stay, and additional days are covered with no copay. For Inpatient Hospital Psychiatric, there is a $300 copay for a Medicare-covered stay, and additional days are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services, observation services, and ambulatory surgical center services with a $175 copay, as well as outpatient substance abuse services with a copay of $35 for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by the UPMC for Life PPO High Deductible Rx (PPO) plan. There is no information about the cost of this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by UPMC for Life PPO High Deductible Rx (PPO). All ambulance services are covered with prior authorization and no copay or coinsurance, but ground and air ambulance services are not covered. 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 by UPMC for Life PPO High Deductible Rx (PPO). Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services and Worldwide Urgent Coverage have a $45 copay; there is no coinsurance for any of these services. Worldwide Emergency Transportation has no copay or coinsurance.
Primary Care See details
Primary Care benefits with UPMC for Life PPO High Deductible Rx (PPO) include coverage for Primary Care Physician Services, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $30 copay, Physician Specialist Services with a $40 copay, Mental Health Specialty Services with a $40 copay for individual and group sessions, Podiatry Services with a $40 copay for Medicare-covered podiatry services and routine foot care, Other Health Care Professional with a $40 copay, Psychiatric Services with a $40 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with a $30 copay, Additional Telehealth Benefits with a $0-$40 copay, and Opioid Treatment Program Services with a $40 copay. Routine Chiropractic Care is limited to 8 visits per year.
Preventive Services See details
The UPMC for Life PPO High Deductible Rx (PPO) plan covers preventive services, including Medicare-covered preventive services with no copay. Additional preventive services are partially covered, but 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, telemonitoring services, and enhanced disease management are not covered.
Hearing Services See details
Hearing exams are covered with a $40 copay. Prescription hearing aids (all types) are covered with a copay between $690 and $1890, and fitting/evaluation for hearing aids are covered.
Vision Services See details
Vision services include eye exams with a $40 copay, and the plan covers one routine eye exam and one other eye exam service per year. Eyewear is covered with a combined maximum benefit of $125 per year for both in and out-of-network services, and contact lenses and eyeglasses (lenses and frames) are covered, with one pair allowed per year. However, eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $40 copay, Oral Exams with a $15 copay for up to two visits per year, and Dental X-Rays with a $15 copay, with bitewing x-rays offered once per year and panoramic x-rays offered once every 36 months. Fluoride Treatment is not covered, and Orthodontic Services are covered up to a $350 annual maximum.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life PPO High Deductible Rx (PPO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment is covered, with Durable Medical Equipment requiring an 18% coinsurance and Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts also requiring coinsurance. Durable Medical Equipment for use outside the home is not covered, and Diabetic Supplies have a 0-20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the UPMC for Life PPO High Deductible Rx (PPO) plan. Diagnostic Procedures/Tests and Lab Services have a $10 copay, while Diagnostic Radiological Services have a $100 copay and Therapeutic Radiological Services have a $65 copay. Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by UPMC for Life PPO High Deductible Rx (PPO) with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the UPMC for Life PPO High Deductible Rx (PPO) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100, and there is no coinsurance.
Other Services See details
Other Services are partially covered by the UPMC for Life PPO High Deductible Rx (PPO) plan. Acupuncture, Over-the-Counter (OTC) Items, 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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