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UPMC for Life PPO Rx Choice (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life PPO Rx Choice (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 Choice (PPO) in 2025, please refer to our full plan details page.
UPMC for Life PPO Rx Choice (PPO) is a PPO plan offered by UPMC Health System available for enrollment in 2025 to people living in Northwestern 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 Choice (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 Choice (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 Choice (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $19.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $7.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
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 $9000.00 (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 $9000.00 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 Choice (PPO)
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Drug Coverage
The UPMC for Life PPO Rx Choice (PPO) plan has a $175 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, preferred generic drugs have no copay at preferred pharmacies and preferred mail order, but a $20 copay at standard pharmacies and standard mail order. For preferred brand drugs and non-preferred drugs, you'll pay 37% and 31% coinsurance, respectively, regardless of pharmacy type. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The UPMC for Life PPO Rx Choice (PPO) plan offers a variety of benefits, including coverage for inpatient and outpatient services, with varying copays. It also covers primary care, preventive, hearing, vision, and dental services with copays ranging from $0 to $20, and coinsurance for some dental procedures. Additional benefits include ambulance services, emergency services, home health services with no copay, and skilled nursing facility services with a copay for days 21-100. This plan also offers coverage for medical equipment, home infusion, and dialysis services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, each with a $250 copay per stay, and additional days for Inpatient Hospital-Acute with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and additional days, and non-Medicare stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center Services have a $200 copay, while individual and group outpatient substance abuse sessions have a $20 copay; outpatient blood services have a three-pint deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life PPO Rx Choice (PPO) plan, with a copay of $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by UPMC for Life PPO Rx Choice (PPO). Ground ambulance services have a copay of $50.00 - $340.00, and air ambulance services have a copay of $340.00, with no coinsurance for either. Transportation services to plan-approved and any health-related locations are not covered.
Emergency Services See details
Emergency Services under the UPMC for Life PPO Rx Choice (PPO) plan include a $125 copay, while Urgently Needed Services have a $55 copay, and Worldwide Emergency Services have varying copays depending on the service. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $340 copay.
Primary Care See details
The UPMC for Life PPO Rx Choice (PPO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional visits, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $15 copay, while other services have copays ranging from $0 to $20.
Preventive Services See details
Preventive Services are covered, but annual physical exams, health education, enhanced disease management, telemonitoring services, and wigs for hair loss related to chemotherapy are not covered. Additional services like in-home safety assessments, support for caregivers of enrollees, additional sessions of smoking cessation counseling (up to 4 visits), fitness benefits, remote access technologies, home and bathroom safety devices, and counseling services (up to 6 sessions) are covered. Other covered services include glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following welcome visits.
Hearing Services See details
Hearing services include hearing exams with a $20 copay, as well as fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, with a copay between $690 and $1890 for all types of hearing aids, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $20 copay, and coverage for contact lenses and eyeglasses (lenses and frames), with an annual combined maximum of $300 for eyewear. Eyeglass lenses and frames are not covered.
Dental Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers dental services, including oral exams with a $20 copay, dental x-rays, and prophylaxis (cleaning). Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with a 50% coinsurance. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the UPMC for Life PPO Rx Choice (PPO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay with 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the UPMC for Life PPO Rx Choice (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Diabetic Equipment, including Diabetic Supplies with 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance. Durable Medical Equipment for use outside the home is not covered, and there is also 20% coinsurance for Prosthetics/Medical Supplies.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under UPMC for Life PPO Rx Choice (PPO). Diagnostic procedures/tests and lab services are not covered, but diagnostic radiological services have a copay of at most $150, therapeutic radiological services have a copay of at most $80, and outpatient X-ray services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life PPO Rx Choice (PPO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the UPMC for Life PPO Rx Choice (PPO) plan. Specifically, Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are all not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, with a $0 copay for days 1-20 and a $196 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers Over-the-Counter (OTC) Items, and Meal Benefits, but does not cover Acupuncture, 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, or Self-Directed Personal Assistance Services. The plan offers OTC items as a supplemental benefit, and offers a limited duration meal benefit for a chronic illness or medical condition that requires the enrollee to remain at home for a period of time.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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