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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. Additionally, this plan comes with a Part B Premium reduction of $1.00. 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 $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) plan features a $400 annual drug deductible. For Tier 1 preferred generics and Tier 2 generics, there is no copay when you use a preferred pharmacy or preferred mail-order service for up to a three-month supply. If you choose a standard pharmacy or standard mail-order service, copays range from $15 to $30 for Tier 1 and $20 to $40 for Tier 2. For higher-tier medications, cost-sharing transitions to coinsurance regardless of the pharmacy type you use. You will pay a 25% coinsurance for Tier 3 preferred brand drugs, a 37% coinsurance for Tier 4 non-preferred drugs, and a 28% coinsurance for a one-month supply of Tier 5 specialty drugs. These coinsurance rates apply consistently across all preferred and standard pharmacy and mail-order options.
Additional Benefits
The UPMC for Life PPO Rx Choice (PPO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay a $325 copay per stay with no coinsurance, while emergency room visits require a $130 copay that is waived if admitted. Specialist visits, physical therapy, and outpatient mental health services are also accessible with a $30 copay and no coinsurance. This plan also includes valuable supplemental benefits, such as preventive dental care with no copay and comprehensive dental services covered at 50% coinsurance up to a $5,000 annual limit. Routine vision exams require a $30 copay, while annual eyewear is covered up to $300 with no copay. Additionally, hearing exams have a $30 copay, and select over-the-counter items and meal benefits are provided with no copay or coinsurance.
Inpatient Hospital See details
UPMC for Life PPO Rx Choice (PPO) covers inpatient acute and psychiatric hospital stays with a $325 copay per Medicare-covered stay and no coinsurance, subject to prior authorization. Unlimited additional days are covered for acute stays with no copay, but non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
UPMC for Life PPO Rx Choice (PPO) covers outpatient hospital and observation services with a $300 copay per stay and no coinsurance, and ambulatory surgical center services with a $250 copay and no coinsurance. Outpatient substance abuse sessions require a $30 copay with no coinsurance, while outpatient blood services are covered with no copay and 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
UPMC for Life PPO Rx Choice (PPO) covers ambulance services with no coinsurance, requiring a copayment of $50.00 to $345.00 for ground ambulance services and $345.00 for air ambulance services. For transportation, some services are covered, but transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
UPMC for Life PPO Rx Choice (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 3 days. Urgently needed services have a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $50, and $345 respectively.
Primary Care See details
UPMC for Life PPO Rx Choice (PPO) features primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, occupational therapy, and mental health services require a $30 copay and no coinsurance. Chiropractic services have a $15 copay and no coinsurance, though routine chiropractic care is not covered, and telehealth benefits are available with a $0 to $30 copay and no coinsurance.
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 like kidney disease education, smoking cessation, and home safety assessments. However, several sub-services are not covered, including annual physical exams, health education, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
UPMC for Life PPO Rx Choice (PPO) provides partial coverage for hearing services, which includes one annual routine hearing exam and fitting 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 inner ear, outer ear, over-the-ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are covered under the UPMC for Life PPO Rx Choice (PPO) plan with no deductibles, featuring a $30 copay and no coinsurance for annual eye exams. Eyewear is partially covered with no copay and no coinsurance up to a $300 annual limit, although individual eyeglass lenses and individual eyeglass frames are not covered.
Dental Services See details
Dental services are partially covered by UPMC for Life PPO Rx Choice (PPO), offering Medicare-covered dental for a $30 copay and no coinsurance, alongside preventive exams, cleanings, and x-rays with no copay and no coinsurance. Comprehensive services including restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and a 50% coinsurance up to a $5,000 annual maximum. Fluoride, implants, orthodontics, maxillofacial prosthetics, other diagnostic, other preventive, and adjunctive general 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 and no coinsurance, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, require no coinsurance to 20% coinsurance, with insulin also carrying a $35 copay.
Dialysis Services See details
Dialysis services are covered by the UPMC for Life PPO Rx Choice (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by UPMC for Life PPO Rx Choice (PPO) with no copay and 20% coinsurance, except for diabetic supplies which range from no coinsurance to 20% coinsurance. Prior authorization is required for durable medical equipment, prosthetics, and diabetic equipment, and some items may be limited to preferred manufacturers.
Diagnostic and Radiological Services See details
UPMC for Life PPO Rx Choice (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. There is no copay for lab services, but outpatient X-rays require a $20 copay, therapeutic radiology has an $80 minimum copay, diagnostic radiology has a $220 minimum copay, and diagnostic procedures and tests are not covered.
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 and a $15 copay. While some services are covered, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
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 three-day prior hospital stay is not required, and additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
UPMC for Life PPO Rx Choice (PPO) partially covers other services, providing over-the-counter (OTC) items and meal benefits with no copay and no coinsurance, while acupuncture is not covered. Covered OTC items are eligible for reimbursement, and the meal benefit is available for members with qualifying chronic or medical conditions requiring them to stay home.
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