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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.
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)
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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 is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have a $47 copay. The plan also has an initial coverage phase where you pay the costs for your drugs until your total drug costs reach $2000. Once you reach $2000 in out-of-pocket drug costs, 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 range of benefits, including inpatient and outpatient hospital services with varying copays. It covers services like primary care, preventive services, hearing, vision, and dental, each with specific copays and coverage details. The plan also provides coverage for emergency services, ambulance, and home health services, and includes additional benefits like OTC items and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered, each requiring prior authorization. Inpatient Hospital-Acute has a copay of $350 per stay, while Additional Days for Inpatient Hospital-Acute has no copay. 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, and outpatient substance abuse services, are covered by the UPMC for Life PPO Rx Choice (PPO) plan. Outpatient Hospital and Observation Services have a $250 copay, Ambulatory Surgical Center (ASC) Services have a $225 copay, and 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. There is no coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. 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 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 and no coinsurance, Urgently Needed Services have a $55 copay and no coinsurance, and Worldwide Emergency Services have a copay of $125 for Worldwide Emergency Coverage, $55 for Worldwide Urgent Coverage, and $340 for Worldwide Emergency Transportation, with no coinsurance.
Primary Care See details
The UPMC for Life PPO Rx Choice (PPO) plan covers primary care physician services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are covered with an $18 copay, while individual and group mental health and psychiatric sessions, and opioid treatment program services have a $30 copay.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with no copay, and additional preventive services like in-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefits, remote access technologies, home and bathroom safety devices and modifications, and counseling services. Annual physical exams, health education, personal emergency response systems (PERS), medical nutrition therapy (MNT), 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 In-Home Support Services are not covered.
Hearing Services See details
Hearing exams are covered with a $30 copay, and routine hearing exams and fitting/evaluation for hearing aids are also covered. Prescription hearing aids are covered, but inner ear, outer ear, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $30 copay and eyewear benefits with a combined maximum of $300 per year. Contact lenses and eyeglasses (lenses and frames) are covered with a limit of one per year, while eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, as well as Oral Exams, Dental X-Rays, and Prophylaxis (Cleaning), which are subject to limitations. Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with 50% coinsurance, while Fluoride Treatment, Adjunctive General Services, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered. The plan also offers orthodontic services with a $5,000 maximum benefit per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered with prior authorization. Medicare Part B Insulin Drugs have a $35 copay and 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 UPMC for Life PPO Rx Choice (PPO), with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance for Medicare-covered items, as well as Diabetic Equipment that includes Diabetic Supplies with a 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by UPMC for Life PPO Rx Choice (PPO). Diagnostic Procedures/Tests and Lab Services have a $5 copay, while Diagnostic Radiological Services have a $225 copay and Therapeutic Radiological Services have an $80 copay. Outpatient X-Ray Services have a $20 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 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. The plan does not cover any of the Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
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. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers Over-the-Counter (OTC) Items and a Meal Benefit, 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 provides OTC items as a supplemental benefit under Part C, and the meal benefit is offered for a chronic illness, or for a medical condition or potential medical condition that requires the enrollee to remain at home for a period of time.
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