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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:
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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, you'll 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 and preferred mail order, but a $20 copay at standard pharmacies and standard mail order. For preferred brand drugs and non-preferred drugs, you will pay 37% and 31% coinsurance, respectively. 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 wide array of benefits, including coverage for inpatient and outpatient services, with varying copays depending on the specific service. Emergency and ambulance services are covered, as are primary care, preventive, and home health services, often with no copay. Dental, vision, and hearing services are also included, with copays and limits on certain services. This plan provides coverage for home infusion, dialysis, and medical equipment, along with skilled nursing facility care. Additional benefits include OTC items and a meal benefit, while services such as cardiac rehabilitation and certain other therapies are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, each with a $325 copay for a Medicare-covered stay. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services, observation services, and ASC services have a $250 copay. Individual and group sessions for outpatient substance abuse have a copay between $30 and $30.
Partial Hospitalization See details
Partial Hospitalization is covered under the UPMC for Life PPO Rx Choice (PPO) plan. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with no coinsurance for any services. Ground ambulance services have a copay of $50-$345, while air ambulance services have a copay of $345. 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 by the UPMC for Life PPO Rx Choice (PPO) plan. Emergency Services has a $125 copay, Urgently Needed Services has a $55 copay, Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $345 copay; all services have 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 partially covered with an $18 copay, while routine chiropractic care is not covered. Individual and group mental health and psychiatric sessions have a $30 copay, and physical therapy and speech-language pathology services have a $30 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, and additional services such as In-Home Safety Assessment, Additional Sessions of Smoking and Tobacco Cessation Counseling (4 visits), Fitness Benefit (Memory Fitness), Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services (6 sessions). Annual physical exams, health education, Personal Emergency Response System (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 Benefit, Home-Based Palliative Care, Telemonitoring Services, Enhanced Disease Management, and In-Home Support Services are not covered.
Hearing Services See details
Hearing exams are covered with a $30 copay; routine hearing exams and fitting/evaluation for hearing aids are also covered, with a limit of 1 visit per year for each. Prescription hearing aids are covered, with a copay between $690 and $1890, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $30 copay, contact lenses, and eyeglasses (lenses and frames), each covered once per year. Eyeglass lenses and frames are not covered. There is a combined maximum of $300 per year for eyewear.
Dental Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers dental services, including Medicare dental services with a $30 copay, and other dental services. Other dental services include oral exams, dental x-rays, and cleaning, with a limit of 2 oral exams and cleanings per year, and 1 dental x-ray per year, and a 50% coinsurance for restorative services, endodontics, periodontics, prosthodontics, fixed, prosthodontics, removable, and oral and maxillofacial surgery. Fluoride treatments, adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under 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, Prosthetic Devices with 20% coinsurance, and Medical Supplies with 20% coinsurance. Diabetic Supplies have a coinsurance between 0-20%, and Diabetic Therapeutic Shoes/Inserts have 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, but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $225.00, Therapeutic Radiological Services have a copay of at most $80.00, and Outpatient X-Ray Services have a $20.00 copay.
Home Health Services See details
Home Health Services are covered by UPMC for Life PPO Rx Choice (PPO) with no copay and no coinsurance, but prior 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 Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the UPMC for Life PPO Rx Choice (PPO) plan. For days 1-20, there is a $10 copay, and for days 21-100, there is a $214 copay.
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. The plan offers OTC items as a supplemental benefit under Part C, and offers a limited duration meal benefit for chronic illness or for a medical condition that requires the enrollee to remain at home. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and more are not covered.
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