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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 2026, 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 2026.
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 $25.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $2.00. 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 $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 $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) Medicare plan features an annual drug deductible of $400. For Tier 1 preferred generics and Tier 2 generics, members enjoy no copay for any supply length when using preferred pharmacies or preferred mail order. If you choose to use standard pharmacies or standard mail order, copays for these generic tiers range from $15 to $40 depending on the drug tier and supply duration. For brand-name and specialty medications, the plan utilizes coinsurance instead of flat copays. Tier 3 preferred brands require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 37% coinsurance across all pharmacy options. Specialty drugs in Tier 5 incur a 28% coinsurance for a 1-month supply at both preferred and standard pharmacies and mail-order services.
Additional Benefits
The UPMC for Life PPO Rx Choice (PPO) plan offers robust coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits, physical therapy, and mental health services require a low $20 copay with no coinsurance. For major medical needs, inpatient hospital stays carry a $250 copay, while emergency room visits have a $130 copay, both with no coinsurance. This plan also includes coverage for dental, vision, and hearing services, featuring no copay for preventive dental care and routine eyewear up to a $300 annual limit. Diagnostic lab work and home infusion services are available with no copay, while durable medical equipment and dialysis require 20% coinsurance. Additionally, members can take advantage of over-the-counter benefits and home-delivered meals with no copay and no coinsurance.
Inpatient Hospital See details
UPMC for Life PPO Rx Choice (PPO) covers inpatient acute hospital stays with a $250 copay and no coinsurance, and inpatient psychiatric stays with a $275 copay and no coinsurance, both requiring prior authorization. While unlimited additional days for acute stays 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 Choice (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $200 to $250 copay, ambulatory surgical center services for a $200 copay, and outpatient substance abuse sessions for a $20 copay. Outpatient blood services are covered with no copay and no coinsurance, while observation services carry a $250 copay per stay with no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by UPMC for Life PPO Rx Choice (PPO) with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance services are covered by UPMC for Life PPO Rx Choice (PPO) with prior authorization and no coinsurance, requiring a copay of $50 to $340 for ground ambulance and $340 for air ambulance. Routine transportation services to plan-approved or any other health-related locations are not covered.
Emergency Services See details
Emergency services are covered by UPMC for Life PPO Rx Choice (PPO) with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed services require a $50 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with copays of $130, $50, and $340, respectively, and no coinsurance.
Primary Care See details
UPMC for Life PPO Rx Choice (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $20 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, but routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by UPMC for Life PPO Rx Choice (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
Hearing services are partially covered by UPMC for Life PPO Rx Choice (PPO), featuring a $20 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 copays ranging from $690 to $1,890, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
UPMC for Life PPO Rx Choice (PPO) provides partially covered vision services, as individual eyeglass lenses and eyeglass frames are not covered. Eye exams are available for a $20 copay and no coinsurance, while covered eyewear has no copay and no coinsurance up to a $300 annual maximum.
Dental Services See details
UPMC for Life PPO Rx Choice (PPO) offers partially covered dental services, with Medicare-covered dental requiring a $20 copay and no coinsurance, and preventive care like exams and cleanings available with no copay and no coinsurance. Comprehensive services like restorative work, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and 50% coinsurance up to a $6,000 annual limit, while fluoride, implants, orthodontics, maxillofacial prosthetics, other diagnostic, and adjunctive general services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by UPMC for Life PPO Rx Choice (PPO) with no copay, although prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life PPO Rx Choice (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life PPO Rx Choice (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and 20% coinsurance for most items. Diabetic supplies feature a coinsurance ranging from no coinsurance to 20%, and prior authorization is required for all covered equipment.
Diagnostic and Radiological Services See details
UPMC for Life PPO Rx Choice (PPO) partially covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Lab services are covered with no copay, but diagnostic procedures and tests are not covered, while covered radiological services require copays of $125 for diagnostic radiology, $80 for therapeutic radiology, and $15 for outpatient X-rays.
Home Health Services See details
Home health services are covered by UPMC for Life PPO Rx Choice (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by UPMC for Life PPO Rx Choice (PPO) with no coinsurance, though some services are covered while standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered and require a $15 copay.
Skilled Nursing Facility (SNF) See details
UPMC for Life PPO Rx Choice (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $210 daily copay for days 21 to 100. Prior authorization is required and a prior three-day hospital stay is not needed, though additional days beyond the standard 100 days are not covered.
Other Services See details
UPMC for Life PPO Rx Choice (PPO) partially covers other services, offering over-the-counter (OTC) items and meal benefits with no copay and no coinsurance. Acupuncture and other additional services are not covered under this benefit.
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