A non-government entity
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 $20.00. 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 $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 $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:
Sign up for UPMC for Life PPO Rx Choice (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The UPMC for Life PPO Rx Choice (PPO) plan has a $175 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions, depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies and preferred mail order, but have a $20 copay at standard pharmacies and standard mail order. For preferred brand drugs, you pay 37% coinsurance, and for non-preferred drugs, you pay 31% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The UPMC for Life PPO Rx Choice (PPO) plan offers a range of benefits with varying cost-sharing. You'll have a $350 copay for inpatient hospital stays, and outpatient services have copays ranging from $30 to $275. The plan covers primary care with no copay, but specialist visits and other services like vision and dental have copays. This plan also includes coverage for emergency services, hearing and vision care, and dental services. The plan covers ambulance services with a copay, as well as home health services and skilled nursing facility stays with copays. The plan has additional benefits like OTC items and meal benefits.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered, with a $350 copay for a Medicare-covered stay. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay 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 $275 copay, while individual and group sessions for outpatient substance abuse have a $30 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the UPMC for Life PPO Rx Choice (PPO) plan, with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with no coinsurance for ambulance services. Ground ambulance services have a copay of $50.00 - $340.00, and air ambulance services have a copay of $340.00, while 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 under the UPMC for Life PPO Rx Choice (PPO) plan. Emergency Services have a $125 copay with no coinsurance, Urgently Needed Services have a $55 copay with no coinsurance, and Worldwide Emergency Services have a $125 copay for Worldwide Emergency Coverage, a $55 copay for Worldwide Urgent Coverage, and a $340 copay for Worldwide Emergency Transportation.
Primary Care See details
The UPMC for Life PPO Rx Choice (PPO) plan covers primary care physician services with no copay, and covers chiropractic services with an $18 copay. Occupational therapy services have a $30 copay, physician specialist services have a $30 copay, and physical therapy and speech-language pathology services have a $30 copay. Individual and group sessions for mental health and psychiatric services have a $30 copay. Podiatry services and other health care professional services have a $30 copay. Additional telehealth benefits have a copay between $0 and $30, and opioid treatment program services have a $30 copay.
Preventive Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers preventive services, including Medicare-covered services with no copay, and additional services like in-home safety assessments, support for caregivers, smoking cessation counseling (4 sessions), fitness benefits (memory fitness), remote access technologies, home and bathroom safety devices, and counseling services (6 sessions). The plan does not cover 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, and home and bathroom safety devices.
Hearing Services See details
Hearing services include hearing exams with a $30 copay, routine hearing exams, and fitting/evaluation for hearing aids, both of which are covered annually. Prescription hearing aids are covered with a copay between $690 and $1890, but prescription hearing aids for the inner, outer, and over the ear are not covered, and neither are OTC hearing aids.
Vision Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers vision services, including routine eye exams with a $30 copay. Eyewear is covered up to a combined maximum of $300 every year for both in-network and out-of-network services; contact lenses and eyeglasses (lenses and frames) are each limited to one per year, while eyeglass lenses and frames are not covered.
Dental Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers Medicare dental services with a $30 copay, and other dental services are also covered, including oral exams, dental x-rays, and teeth cleanings. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery have a 50% coinsurance. Orthodontic services have a $5,000 annual maximum benefit.
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 a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the UPMC for Life PPO Rx Choice (PPO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have no coinsurance and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and tests with a $5 copay, lab services with a $5 copay, diagnostic radiological services with a copay of at most $225, therapeutic radiological services with a copay of at most $80, and outpatient X-ray services with a $20 copay. Prior authorization is required for all diagnostic and radiological services.
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, though authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but specific services including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. There is a copay for covered services, but the specific amount is not detailed in this summary.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by UPMC for Life PPO Rx Choice (PPO), but require prior authorization. The copay is $10 for days 1-20, and $214 for days 21-100, while additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items and Meal Benefits, but 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, and Self-Directed Personal Assistance Services are not covered. This plan offers OTC items as a supplemental benefit and provides a limited duration meal benefit for a chronic illness or medical condition.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved