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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 $30.00. 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 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 $9550.00 (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 $9550.00 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 Choice (PPO) Medicare plan features a $400 annual drug deductible. Beneficiaries enjoy no copay for Tier 1 preferred generics and Tier 2 generics when filled through a preferred pharmacy or preferred mail order. Standard pharmacies and standard mail order services carry a copay starting at $15 for Tier 1 and $20 for Tier 2 generic drugs. For brand-name and specialty medications, the plan charges a coinsurance percentage rather than a flat copayment. You will pay 25% coinsurance for Tier 3 preferred brands, 37% coinsurance for Tier 4 non-preferred drugs, and 28% coinsurance for Tier 5 specialty drugs. These coinsurance rates remain consistent across all preferred and standard pharmacy and mail-order options.
Additional Benefits
The UPMC for Life PPO Rx Choice (PPO) plan offers affordable healthcare access with no copay for primary care visits, preventive services, home health care, and over-the-counter items. For more intensive care, members pay fixed copays of $250 to $350 for inpatient hospital stays and $200 to $325 for outpatient services, with no coinsurance required. Specialist visits and mental health services are available for a $30 copay, while emergency room care carries a $130 copay. Additionally, the plan features comprehensive dental, vision, and hearing benefits, including no copay for preventive dental cleanings and a $200 annual eyewear allowance. Vision and hearing exams require a $30 copay, while comprehensive dental services are covered at a 50% coinsurance up to a $4,000 yearly limit. For medical equipment and dialysis services, members will pay no copay and a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are covered by UPMC for Life PPO Rx Choice (PPO) with no coinsurance, requiring a $250 copay for acute care and a $350 copay for psychiatric stays, both of which require prior authorization. While unlimited additional days are covered for acute care, psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UPMC for Life PPO Rx Choice (PPO) covers outpatient hospital services with a $200 to $325 copay and ambulatory surgical center services with a $200 copay, both featuring no coinsurance. Outpatient substance abuse sessions carry a $30 copay with no coinsurance, while outpatient blood services are available with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by UPMC for Life PPO Rx Choice (PPO) with a $55 copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life PPO Rx Choice (PPO) covers ground ambulance services with a $50.00 to $340.00 copay and air ambulance services with a $340.00 copay, both with no coinsurance. For transportation, some services are covered, but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
UPMC for Life PPO Rx Choice (PPO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within three days, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency, urgent, and emergency transportation services are also covered with no coinsurance and copays of $130, $50, and $340 respectively.
Primary Care See details
UPMC for Life PPO Rx Choice (PPO) covers primary care physician services with no copay and no coinsurance, while specialist, therapy, and mental health services require a $30 copay and no coinsurance. Some chiropractic services are covered, but routine and other chiropractic care are not covered.
Preventive Services See details
Preventive services are covered by UPMC for Life PPO Rx Choice (PPO) with no copay and no coinsurance, including Medicare-covered preventive services, kidney disease education, and select additional services like counseling and in-home safety assessments. However, this benefit is only partially covered, as annual physical exams, health education, personal emergency response systems, and medical nutrition therapy are not covered.
Hearing Services See details
UPMC for Life PPO Rx Choice (PPO) provides partial coverage for hearing services, offering one annual routine hearing exam for a $30 copay and no coinsurance. Up to two prescription hearing aids are covered per year with no coinsurance and copays ranging from $690 to $1,890, but 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) offers partially covered vision services with no deductibles, including eye exams and contact lens fittings for a $30 copay and no coinsurance. Eyewear is covered with no copay and no coinsurance up to a $200 annual limit, although individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life PPO Rx Choice (PPO) partially covers dental services, featuring Medicare-covered dental with a $30 copay and no coinsurance, plus preventive exams and cleanings with no copay and no coinsurance. Comprehensive benefits like restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and 50% coinsurance up to a $4,000 annual maximum, while fluoride, implants, orthodontics, adjunctive general, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
UPMC for Life PPO Rx Choice (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Covered Medicare Part B chemotherapy, radiation, and other drugs have no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs carry a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by UPMC for Life PPO Rx Choice (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life PPO Rx Choice (PPO) covers durable medical equipment, prosthetics, medical supplies, and diabetic equipment with no copay and a 20% coinsurance, though diabetic supplies range from no coinsurance to 20% coinsurance. Prior authorization is required for these benefits, and certain manufacturer or vendor limitations may apply.
Diagnostic and Radiological Services See details
UPMC for Life PPO Rx Choice (PPO) partially covers diagnostic services, providing lab services with no copay and no coinsurance, while diagnostic procedures and tests are not covered. Radiological services are covered with no coinsurance and require prior authorization, with copays of $250 for diagnostic, $80 for therapeutic, and $25 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, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under the UPMC for Life PPO Rx Choice (PPO) plan with no coinsurance, but some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered and require a $15 copay.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by UPMC for Life PPO Rx Choice (PPO) with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not necessary, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
Other services offered by UPMC for Life PPO Rx Choice (PPO) are partially covered, providing over-the-counter (OTC) items and meal benefits with no copay and no coinsurance. Acupuncture, Naloxone, and other additional services are not covered under this benefit.
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