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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 $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 $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 Rx Enhanced (PPO) plan has a $175 deductible for prescription drugs. After meeting the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you'll pay no copay at preferred pharmacies and preferred mail, but $20 at standard pharmacies and standard mail. Standard generic drugs have a $47 copay, and preferred brand drugs have 45% coinsurance. Non-preferred drugs have 31% coinsurance.
Additional Benefits
The UPMC for Life PPO Rx Enhanced (PPO) plan offers a range of benefits, including inpatient hospital stays with a $275 copay for days 1-5, and no copay for days 6-90. Outpatient services have varying copays, while services like partial hospitalization, home health, and skilled nursing facilities have no copay or specific copays. This plan also covers primary care, hearing, vision, and dental services with copays ranging from $15 to $40. Diagnostic and radiological services have their own copay structures, and ambulance services have copays depending on the type of service.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you'll pay a $275 copay for days 1-5, and no copay for days 6-90; additional days are covered with no copay. For Inpatient Hospital Psychiatric, you'll pay a $275 copay for days 1-5, and no copay for days 6-90; additional days and non-medicare covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services, observation services, and ambulatory surgical center services each have a $250 copay. Individual and group sessions for outpatient substance abuse each have a copay between $40.00 and $40.00.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life PPO Rx Enhanced (PPO) plan. There is no copay or coinsurance for this benefit.
Ambulance and Transportation Services See details
The UPMC for Life PPO Rx Enhanced (PPO) plan covers ambulance services with no coinsurance, but has copays for Medicare-covered ground ambulance services ($50-$280) and air ambulance services ($280). 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 Rx Enhanced (PPO). For Emergency Services, the copay is $110, and for Urgently Needed Services, the copay is $45. Worldwide Emergency Coverage and Worldwide Urgent Coverage have copays of $110 and $45, respectively, while Worldwide Emergency Transportation has a $280 copay.
Primary Care See details
The UPMC for Life PPO Rx Enhanced (PPO) plan covers a range of primary care benefits, including primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, and specialist services with a $40 copay. Also covered are mental health services with a $40 copay, podiatry services with a $40 copay, other health care professional services with a $40 copay, psychiatric services with a $40 copay, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a copay ranging from $0 to $40, and opioid treatment program services with a $40 copay.
Preventive Services See details
Preventive services are 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, enhanced disease management, telemonitoring services, are not covered. In-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling (4 sessions), fitness benefit (memory fitness), remote access technologies, home and bathroom safety devices, counseling services (6 sessions), glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit are covered.
Hearing Services See details
Hearing services include routine hearing exams with a $40 copay, fitting/evaluation for hearing aids, and prescription hearing aids with a copay between $690 and $1890. This plan does not cover prescription hearing aids for the inner ear, outer ear, or over the ear, nor does it cover OTC hearing aids.
Vision Services See details
Vision Services includes coverage for eye exams with a $40 copay. Eyewear is covered, including contact lenses (1 pair per year) and eyeglasses (lenses and frames, 1 pair per year) with a combined maximum benefit of $250 per year for both in-network and out-of-network services.
Dental Services See details
The UPMC for Life PPO Rx Enhanced (PPO) plan covers dental services including oral exams with a $15 copay, dental x-rays with a $15 copay, and prophylaxis (cleaning) with no copay. Orthodontic services are covered up to a maximum of $2900 per year, and restorative, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery services are covered with 50% coinsurance. Fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life PPO Rx Enhanced (PPO) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has an 18% coinsurance, and Prosthetics/Medical Supplies has an 18% coinsurance. Diabetic Supplies have a coinsurance between 0-20%, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic and radiological services, are covered, but Lab Services are not covered. Diagnostic Procedures/Tests have a $5 copay, Diagnostic Radiological Services have a copay of $200, Therapeutic Radiological Services have a $65 copay, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life PPO Rx Enhanced (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. This plan does not have any cost information available for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by UPMC for Life PPO Rx Enhanced (PPO), but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Other Services includes a Meal Benefit, but 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. The plan provides a Meal Benefit for a chronic illness or a medical condition that requires the enrollee to remain at home for a period of time.
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