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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.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
UPMC for Life PPO Rx Choice (PPO) is a PPO plan offered by Upmc Health Network, Inc. available for the 2026 plan year 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.
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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $5500.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $5500.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $9550.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $9550.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
Drug Coverage
The UPMC for Life PPO Rx Choice (PPO) plan features a $400 annual drug deductible. For Tier 1 preferred generics and Tier 2 generics, members pay no copay when using a preferred pharmacy or preferred mail-order service. Standard pharmacies and standard mail-order options require a copay, starting at $15 for Tier 1 and $20 for Tier 2 for a one-month supply. For higher-tier medications, costs are based on a percentage of the drug cost rather than flat copays. Tier 3 preferred brands require 25% coinsurance, and Tier 4 non-preferred drugs require 37% coinsurance at all pharmacy and mail-order locations. Tier 5 specialty drugs carry a 28% coinsurance for a one-month supply across all filling options.
Additional Benefits
The UPMC for Life PPO Rx Choice (PPO) plan offers robust coverage for essential medical services, often featuring no coinsurance and predictable copayments. Members enjoy no copays or coinsurance for primary care visits, home health services, and covered preventive care, while specialist visits and diagnostic lab tests require low copays. Inpatient hospital stays require a $250 copay per acute care stay with no coinsurance, and emergency room visits have a $130 copay that is waived if admitted. For dental care, routine preventive services feature no copay, while comprehensive dental services are covered with no copay and a 50% coinsurance up to a $4,000 annual limit. Vision and hearing benefits include a $30 copay for routine exams, with additional allowances up to $200 for eyewear and partial coverage for hearing aids. Additionally, over-the-counter items and meals are covered with no copay, while durable medical equipment and dialysis require a 20% coinsurance.
Inpatient Hospital See details
UPMC for Life PPO Rx Choice (PPO) offers partially covered inpatient hospital benefits with no coinsurance, requiring a $250 copay per acute care stay and a $350 copay per psychiatric stay. Unlimited additional acute care days are covered with no copay, but upgrades, additional psychiatric days, 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, featuring copays of $200 to $300 for outpatient hospital and observation services, $200 for ambulatory surgical center visits, and $30 for substance abuse sessions. Outpatient blood services are fully covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by UPMC for Life PPO Rx Choice (PPO) with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life PPO Rx Choice (PPO) covers ambulance services with no coinsurance, requiring a copay of $50.00 to $340.00 for ground ambulance and $340.00 for air ambulance, with prior authorization required. Transportation services to plan-approved or other health-related locations are not covered under this plan.
Emergency Services See details
Emergency services under UPMC for Life PPO Rx Choice (PPO) are covered with a $130 copay and no coinsurance, with the copay waived if admitted to the hospital within three days. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are 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 telehealth benefits range from a $0 to $30 copay with no coinsurance. Specialist visits, therapies, mental health, and podiatry services require a $30 copay and no coinsurance, whereas 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 benefits, including kidney disease education, glaucoma screenings, and diabetes self-management training. However, several sub-services are not covered under this plan, such as annual physical exams, health education, personal emergency response systems, and weight management programs.
Hearing Services See details
UPMC for Life PPO Rx Choice (PPO) covers annual routine hearing exams and fittings for a $30 copay and no coinsurance, with no deductible. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $690 to $1,890 for up to two aids per year, though OTC hearing aids and inner ear, outer ear, and over the ear prescription aids are not covered.
Vision Services See details
Vision services are covered by UPMC for Life PPO Rx Choice (PPO) with no deductibles, offering routine eye exams and contact lens fittings for a $30 copay and no coinsurance. Eyewear is partially covered with no copay or coinsurance up to a $200 annual limit, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life PPO Rx Choice (PPO) partially covers dental services, offering preventive care such as exams, cleanings, and x-rays with no copay and no coinsurance, and Medicare-covered dental services with a $30 copay and no coinsurance. Comprehensive services like restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and a 50% coinsurance up to a $4,000 annual maximum, but fluoride, implants, orthodontics, maxillofacial prosthetics, adjunctive general services, 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 is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry between no coinsurance and 20% coinsurance, while Part B insulin drugs require a $35 copay and between no coinsurance and 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 equipment, with no copays. These services require prior authorization and carry a 20% coinsurance, though diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by UPMC for Life PPO Rx Choice (PPO) with no coinsurance, though prior authorization is required. Members pay a $5 copay for diagnostic procedures, tests, and lab services, a $20 copay for outpatient X-rays, a minimum $80 copay for therapeutic radiological services, and a minimum $250 copay for diagnostic radiological services.
Home Health Services See details
UPMC for Life PPO Rx Choice (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
UPMC for Life PPO Rx Choice (PPO) covers Cardiac Rehabilitation Services with no coinsurance, though only some services are covered. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, 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 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
UPMC for Life PPO Rx Choice (PPO) provides partial coverage for other services, offering 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 plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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* 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.
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