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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 $58.00. 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 a $400.00 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 Rx Enhanced (PPO) plan features an annual drug deductible of $400. You can maximize your savings on generic medications by using preferred pharmacies or preferred mail-order services, which offer no copay for Tier 1 preferred generics and Tier 2 generics. Standard pharmacies and standard mail-order services carry a copay of $15 to $30 for Tier 1 drugs and $20 to $40 for Tier 2 drugs depending on the supply size. For brand-name and specialty medications, your cost-sharing is based on coinsurance regardless of the pharmacy or mail-order option you choose. Tier 3 preferred brands require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 38% coinsurance. Tier 5 specialty drugs are covered with a 28% coinsurance for a 1-month supply.
Additional Benefits
The UPMC for Life PPO Rx Enhanced (PPO) plan offers comprehensive medical coverage with no copay or coinsurance for primary care visits and covered preventive services. For specialized care, members pay a $40 copay for specialist visits, while inpatient hospital stays require a $275 copay for days 1 through 5 and no copay for days 6 through 90. Outpatient hospital services are covered with a $250 copay and no coinsurance, ensuring predictable costs for major medical needs. This plan also features valuable dental, vision, and hearing benefits to help manage your everyday health costs. Routine dental cleanings and home health services are available with no copay, while comprehensive dental services are covered with a 50% coinsurance up to a $2,900 annual limit. Additionally, routine vision exams carry a $40 copay, and eyewear is covered with no copay or coinsurance up to a $250 yearly allowance.
Inpatient Hospital See details
UPMC for Life PPO Rx Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $275 copay for days 1 through 5 and no copay for days 6 through 90. Non-Medicare-covered stays, upgrades, and additional psychiatric hospital days are not covered.
Outpatient Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers outpatient hospital and observation services with a $250 copay and no coinsurance, and ambulatory surgical center services with a $200 copay and no coinsurance. Outpatient substance abuse sessions require a $40 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
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
Ambulance and transportation services are covered by UPMC for Life PPO Rx Enhanced (PPO), though transportation services to plan-approved or any health-related locations are not covered. Medicare-covered ground ambulance services have a copay of $50.00 to $280.00 and air ambulance services have a $280.00 copay, both with no coinsurance and requiring prior authorization.
Emergency Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within three days. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency care, urgent care, and emergency transportation are covered with no coinsurance and copays of $115, $40, and $280, respectively.
Primary Care See details
UPMC for Life PPO Rx Enhanced (PPO) covers primary care physician services with no copay and no coinsurance, while physical, occupational, and speech therapies require a $35 copay and no coinsurance. Specialist visits, mental health sessions, and podiatry services have a $40 copay and no coinsurance, but chiropractic services are not covered in practice.
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 benefits, such as Medicare-covered preventive care, glaucoma screenings, and diabetes self-management. However, several services are not covered under this benefit, including annual physical exams, health education, personal emergency response systems, weight management programs, and nutritional or dietary benefits.
Hearing Services See details
UPMC for Life PPO Rx Enhanced (PPO) partially covers hearing services, featuring a $40 copay and no coinsurance for annual routine exams and fitting evaluations. Up to two prescription hearing aids are covered per year with no coinsurance and a copay ranging from $690 to $1,890, though OTC hearing aids and inner-ear, outer-ear, or over-the-ear prescription models are not covered.
Vision Services See details
Vision Services under UPMC for Life PPO Rx Enhanced (PPO) feature covered routine eye exams and contact lens fittings for a $40 copay, no coinsurance, and no deductible. Eyewear is partially covered with no copay, no coinsurance, and no deductible up to a $250 annual limit, which covers contact lenses and complete eyeglasses but excludes individual eyeglass lenses and frames.
Dental Services See details
UPMC for Life PPO Rx Enhanced (PPO) dental services are partially covered, featuring Medicare-covered dental for a $40 copay and no coinsurance, alongside cleanings with no copay or coinsurance. Comprehensive benefits like restorative care and endodontics require no copay and 50% coinsurance up to a $2,900 annual limit, though fluoride, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs carry coinsurance ranging from no coinsurance to 20%, while Part B insulin has a $35 copay and up to 20% coinsurance.
Dialysis Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers Dialysis Services 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 (DME), prosthetics, medical supplies, and diabetic equipment, with no copay for all covered services. Members will pay an 18% coinsurance for DME, prosthetics, and medical supplies, and between no coinsurance and 20% coinsurance for diabetic supplies and therapeutic shoes.
Diagnostic and Radiological Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers diagnostic and radiological services with no coinsurance, requiring a $5 copay for diagnostic procedures and lab services, and a $20 copay for outpatient X-rays. Therapeutic radiological services require a $65 copay and diagnostic radiological services require a $200 copay, with prior authorization required for all of these services.
Home Health Services See details
UPMC for Life PPO Rx Enhanced (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
UPMC for Life PPO Rx Enhanced (PPO) does not cover Cardiac Rehabilitation Services, as cardiac, intensive cardiac, pulmonary, and SET for PAD services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
UPMC for Life PPO Rx Enhanced (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the 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 medical conditions or chronic illnesses with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under this benefit.
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