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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 2026, 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 2026.
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.
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 $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:
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Drug Coverage
The UPMC for Life PPO Rx Enhanced (PPO) plan features a $0 prescription drug deductible, allowing your coverage to begin immediately. For Tier 1 preferred generics and Tier 2 generics, there is no copay when using a preferred pharmacy or preferred mail order. If you choose a standard pharmacy or standard mail order, Tier 1 drugs require a $15 copay for a one-month supply, while Tier 2 drugs require a $20 copay. For brand-name and specialty medications, costs are based on coinsurance rather than flat copayments. Tier 3 preferred brands have a 25% coinsurance, while Tier 4 non-preferred drugs carry a 46% coinsurance across all pharmacy types. Tier 5 specialty drugs require a 33% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The UPMC for Life PPO Rx Enhanced (PPO) plan offers strong medical coverage, featuring no copay and no coinsurance for primary care doctor visits. Specialist visits require a $40 copay, while inpatient hospital stays carry a $250 copay and outpatient hospital services require a $150 copay. Emergency room visits are covered with a $115 copay, which is waived if you are admitted to the hospital. For supplemental benefits, the plan features no copay and no coinsurance for preventive dental cleanings, home health care, and home infusion services. Routine hearing and vision exams are available for a $40 copay, and eyewear is covered with no copay up to a $250 annual maximum. Additionally, skilled nursing facility care has no copay for the first 20 days, helping you manage recovery costs effectively.
Inpatient Hospital See details
UPMC for Life PPO Rx Enhanced (PPO) partially covers inpatient hospital services with an annual copayment of $250 and no coinsurance for Medicare-covered acute and psychiatric stays. Prior authorization is required, and while unlimited additional acute days are covered with no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers outpatient hospital, observation, and ambulatory surgical center services with a $150 copay and no coinsurance, though prior authorization is required. Outpatient substance abuse services have a $40 copay and no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by UPMC for Life PPO Rx Enhanced (PPO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers ambulance services with no coinsurance, requiring prior authorization and a copay of $50 to $315 for ground transport and $315 for air transport. While some transportation services are covered, transport to plan-approved or any health-related locations is not covered.
Emergency Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed care requires a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $115, $40, and $315 respectively.
Primary Care See details
Primary Care services are covered by UPMC for Life PPO Rx Enhanced (PPO) with no copay and no coinsurance for primary care physician visits, and a $40 copay with no coinsurance for specialists. Physical, occupational, and speech therapy services are also covered with a $35 copay and no coinsurance.
Preventive Services See details
Preventive Services are partially covered by UPMC for Life PPO Rx Enhanced (PPO) with no copay and no coinsurance for covered care. Sub-services that are not covered under this plan include annual physical exams, health education, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, enhanced disease management, and telemonitoring.
Hearing Services See details
UPMC for Life PPO Rx Enhanced (PPO) hearing services feature a $40 copay, no deductible, and no coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $690 to $1,890, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
UPMC for Life PPO Rx Enhanced (PPO) vision services are partially covered, featuring routine eye exams and contact lens fittings for a $40 copay and no coinsurance. Eyewear is covered with no copay and no coinsurance up to a $250 annual maximum, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
Dental services are partially covered by UPMC for Life PPO Rx Enhanced (PPO), featuring a $40 copay and no coinsurance for Medicare-covered dental, no copay and no coinsurance for preventive cleanings, and a $15 copay and no coinsurance for exams and x-rays. Covered comprehensive services—including restorative, endodontics, periodontics, prosthodontics, and oral surgery—have no copay and 50% coinsurance up to a $1,000 annual limit, while fluoride, implants, orthodontics, maxillofacial prosthetics, adjunctive general, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers home infusion bundled services with no copay, while associated Medicare Part B chemotherapy, radiation, and other drugs require a 0% to 20% coinsurance with no copay. Medicare Part B insulin is covered with a $35 copay and 0% to 20% coinsurance, and prior authorization or step therapy may be required.
Dialysis Services See details
Dialysis services are covered by the UPMC for Life PPO Rx Enhanced (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life PPO Rx Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay. These covered services require prior authorization and carry an 18% coinsurance for DME and prosthetics, while diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Diagnostic procedures, tests, and lab services carry a $5 copay, while radiological services require a copay of $10 for X-rays, $65 for therapeutic radiology, and $100 for diagnostic radiology.
Home Health Services See details
Home health services are covered by UPMC for Life PPO Rx Enhanced (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the UPMC for Life PPO Rx Enhanced (PPO) plan, as standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered.
Skilled Nursing Facility (SNF) See details
UPMC for Life PPO Rx Enhanced (PPO) covers skilled nursing facility (SNF) care with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
UPMC for Life PPO Rx Enhanced (PPO) partially covers other services, offering a meal benefit for qualifying chronic or recuperative medical conditions with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under this benefit.
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