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UPMC for Life PPO Rx Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life PPO Rx Enhanced (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 Rx Enhanced (PPO) in 2025, please refer to our full plan details page.
UPMC for Life PPO Rx Enhanced (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 Rx Enhanced (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 Rx Enhanced (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 Rx Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $140.00. 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 has a $500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
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:
Sign up for UPMC for Life PPO Rx Enhanced (PPO)
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Drug Coverage
The UPMC for Life PPO Rx Enhanced (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have a $47 copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for Medicare Part D covered drugs. If you qualify for the low-income subsidy, your Part D premium will be reduced.
Additional Benefits
The UPMC for Life PPO Rx Enhanced (PPO) plan offers a variety of benefits. Inpatient hospital stays have a $250 copay, while outpatient services have a $150 copay. Primary care visits range from no copay to a $40 copay, and emergency services have a copay between $45 and $110. This plan includes coverage for hearing, vision, and dental services. Hearing exams have a $40 copay, and prescription hearing aids have a minimum copay of $690. Eye exams have a $40 copay, and eyewear is covered up to $250 per year. Dental services include a $40 copay for Medicare Dental Services, and a 50% coinsurance for restorative services, endodontics, and other services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both with a $250 copay per stay; additional days for Inpatient Hospital-Acute are also covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services, including outpatient hospital services, observation services, and ambulatory surgical center services, are covered with a $150 copay. Outpatient substance abuse services, including individual and group sessions, are covered with a $40 copay. Outpatient blood services are also covered, with a waived deductible for three pints of blood.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life PPO Rx Enhanced (PPO) plan. There is no information available about the cost of services, such as the copay or coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the UPMC for Life PPO Rx Enhanced (PPO) plan. Ground Ambulance Services have a copay of $50-$280, and Air Ambulance Services have a copay of $280; there is no coinsurance for either. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage have a copay of $110, $45, $110, and $45 respectively, with no coinsurance. Worldwide Emergency Transportation has a copay of $280 with no coinsurance.
Primary Care See details
The UPMC for Life PPO Rx Enhanced (PPO) plan covers primary care physician services, chiropractic services, occupational therapy, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic and routine foot care services have a $15 copay, individual and group mental health and psychiatric sessions have a $40 copay, and occupational therapy and physical therapy have a $35 copay. Physician specialist services have a $40 copay, and additional telehealth benefits have a copay between $0 and $40. Other health care professional services and opioid treatment program services have a $40 copay.
Preventive Services See details
The UPMC for Life PPO Rx Enhanced (PPO) plan covers preventive services, including Medicare-covered services with no copay. Additional preventive services are partially covered; annual physical exams, health education, personal emergency response systems (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, and in-home support services are not covered. The plan also covers in-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefits, remote access technologies, home and bathroom safety devices and modifications, counseling services (6 sessions), kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit.
Hearing Services See details
Hearing services include coverage for hearing exams with a $40 copay, and fitting/evaluation for hearing aids, with one visit covered every year. Prescription hearing aids are covered, with a minimum copay of $690 and a maximum copay of $1890, and up to two hearing aids covered every year; however, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $40 copay, and eyewear with a combined maximum benefit of $250 per year. This plan covers one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year. Eyeglass lenses and frames are not covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $40 copay. Oral exams and dental x-rays each have a $15 copay, while fluoride treatments, adjunctive general services, implant services, and orthodontics are not covered. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery have 50% coinsurance. The plan also offers a $1,000 annual maximum for orthodontic services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the UPMC for Life PPO Rx Enhanced (PPO) plan. The plan has a copay of $35 for Medicare Part B Insulin Drugs, with a coinsurance between 0% and 20% for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life PPO Rx Enhanced (PPO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics, Medical Supplies, and Diabetic Equipment, is covered under the UPMC for Life PPO Rx Enhanced (PPO) plan. DME has an 18% coinsurance with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetics and Medical Supplies have an 18% coinsurance with no copay. Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, with no copay for either.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the UPMC for Life PPO Rx Enhanced (PPO) plan. Diagnostic Procedures/Tests have a copay of $5.00, Diagnostic Radiological Services have a copay of at most $100.00, Therapeutic Radiological Services have a copay of at most $65.00, and Outpatient X-Ray Services have a copay of $10.00; however, Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by UPMC for Life PPO Rx Enhanced (PPO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the UPMC for Life PPO Rx Enhanced (PPO) plan, but require prior authorization. For days 1-20, there is no copay, while days 21-100 have a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, dual eligible SNPs with highly integrated services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, case management, institution for mental disease services, services in an intermediate care facility, case management, tobacco cessation counseling, 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. The Meal Benefit is covered, but the plan does not provide details on the cost.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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