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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 2026, 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 2026.
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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 features a yearly prescription drug deductible of $175. You will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when filling one, two, or three-month prescriptions at preferred pharmacies or through preferred mail order. If you use standard pharmacies or standard mail order, Tier 1 copays range from $15 to $30, and Tier 2 copays range from $20 to $40 depending on the supply duration. Higher-tier medications require coinsurance instead of copayments at all pharmacy types. You will pay a 25% coinsurance for Tier 3 preferred brand drugs and a 44% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 31% coinsurance for a one-month supply.
Additional Benefits
The UPMC for Life PPO High Deductible Rx (PPO) plan offers comprehensive coverage with many services featuring no copay and no coinsurance, including primary care visits, home health services, and partial hospitalization. For inpatient hospital stays, members pay a $300 annual copay with no coinsurance, while emergency room visits require a $115 copay. Outpatient hospital services carry a $175 copay, and specialist visits require a $40 copay. In addition, routine dental cleanings, restorative care, and home infusions are available with no copay, while routine vision and hearing exams require a $40 copay. Diagnostic lab services and X-rays are accessible with a $10 copay, and durable medical equipment requires an 18% coinsurance with no copay. Please note that cardiac rehabilitation, acupuncture, and over-the-counter items are not covered under this plan.
Inpatient Hospital See details
UPMC for Life PPO High Deductible Rx (PPO) partially covers inpatient hospital services, requiring a $300 annual copay and no coinsurance for Medicare-covered acute and psychiatric stays. Prior authorization is required, and non-Medicare-covered stays, upgrades, and additional days for psychiatric stays are not covered.
Outpatient Services See details
Outpatient services are covered by UPMC for Life PPO High Deductible Rx (PPO) with no coinsurance, featuring a $175 copay for outpatient hospital, observation, and ambulatory surgical center services, which require prior authorization. Outpatient substance abuse services have a $35 copay with no coinsurance, and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
UPMC for Life PPO High Deductible Rx (PPO) covers partial hospitalization services. There is no copay and no coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by UPMC for Life PPO High Deductible Rx (PPO) with no copay and no coinsurance, though only some services are covered because ground ambulance, air ambulance, and health-related transportation services are not covered.
Emergency Services See details
UPMC for Life PPO High Deductible Rx (PPO) covers emergency services with a $115 copay, which is waived if admitted to the hospital within three days, and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are also covered with no coinsurance at these same copay amounts, and worldwide emergency transportation is covered.
Primary Care See details
UPMC for Life PPO High Deductible Rx (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits, mental health, psychiatric, podiatry, and opioid treatment services for a $40 copay and no coinsurance. Therapy services require a $30 copay and no coinsurance, while some chiropractic services are covered for a $15 copay and no coinsurance, though routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by UPMC for Life PPO High Deductible Rx (PPO) with no copay and no coinsurance for covered benefits like kidney disease education and glaucoma screenings. However, some benefits are not covered, including annual physical exams, health education, weight management programs, and personal emergency response systems.
Hearing Services See details
UPMC for Life PPO High Deductible Rx (PPO) partially covers hearing services, offering one routine exam and fitting evaluation annually for a $40 copay, no deductible, and no coinsurance. Up to two prescription hearing aids are covered per year with no coinsurance and copayments between $690 and $1,890, though OTC hearing aids and inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
UPMC for Life PPO High Deductible Rx (PPO) covers routine eye exams and contact lens fittings with a $40 copay, no coinsurance, and no deductible. Eyewear is partially covered with no copay and no coinsurance up to a $125 annual combined maximum, although individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life PPO High Deductible Rx (PPO) partially covers dental services, offering cleanings, restorative care, and oral surgery with no copay and no coinsurance, exams and x-rays for a $15 copay and no coinsurance, and Medicare dental services for a $40 copay and no coinsurance. Non-covered services include fluoride, other diagnostic or preventive services, adjunctive general services, endodontics, periodontics, prosthodontics, implants, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by UPMC for Life PPO High Deductible Rx (PPO) with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and coinsurance ranging from no coinsurance to 20%, while chemotherapy and other Part B drugs carry no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered under the UPMC for Life PPO High Deductible Rx (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life PPO High Deductible Rx (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and diabetic equipment, with no copays and required prior authorization. DME, prosthetics, and medical supplies carry an 18% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance, and diabetic therapeutic shoes or inserts require a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by UPMC for Life PPO High Deductible Rx (PPO) with no coinsurance, though prior authorization is required. Outpatient lab services, diagnostic procedures, and X-rays have a $10 copay, while therapeutic radiology requires a minimum $65 copay and diagnostic radiology requires a minimum $100 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, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the UPMC for Life PPO High Deductible Rx (PPO) plan. This exclusion applies to cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services, which are all not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by UPMC for Life PPO High Deductible Rx (PPO) with no coinsurance, as additional days beyond the standard 100 days are not covered. Patients pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with prior authorization required but no preceding three-day hospital stay necessary.
Other Services See details
UPMC for Life PPO High Deductible Rx (PPO) partially covers other services, offering a limited-duration meal benefit for chronic or homebound medical conditions with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under this plan.
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