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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 $21.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $4.00. 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 $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 $9000.00 (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 $9000.00 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 will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you'll have no copay at preferred pharmacies or through mail order, and a $20 copay at standard pharmacies. For standard generic drugs, the copay is $47 regardless of the pharmacy.
Additional Benefits
The UPMC for Life PPO Rx Choice (PPO) plan offers a wide array of benefits, including coverage for inpatient hospital stays with a copay, outpatient services, and partial hospitalization. The plan also covers primary care visits with a copay, hearing and vision services, dental services, and home infusion services. You will also have coverage for ambulance and emergency services, and diagnostic and radiological services.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered by the UPMC for Life PPO Rx Choice (PPO) plan. For days 1-5 of inpatient hospital stays, there is a $185 copay, with no copay for days 6-90, and there is no coinsurance.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and ambulatory surgical center services, require a $300 copay, while outpatient substance abuse services have a $35 copay for both individual and group sessions. Outpatient blood services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial Hospitalization is covered by UPMC for Life PPO Rx Choice (PPO) with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by UPMC for Life PPO Rx Choice (PPO), with no coinsurance. Ground ambulance services have a copay of $50.00 - $340.00, and air ambulance services have a copay of $340.00. 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 UPMC for Life PPO Rx Choice (PPO). Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $340 copay.
Primary Care See details
The UPMC for Life PPO Rx Choice (PPO) plan covers primary care physician services, chiropractic services with an $18 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, mental health specialty services with a $35 copay, podiatry services with a $35 copay, other health care professional services with a $35 copay, psychiatric services with a $35 copay, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a $0-$35 copay, and opioid treatment program services with a $35 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services are covered, but the annual physical exam, health education, personal emergency response system, 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, enhanced disease management, telemonitoring services, and in-home support services are not covered. This plan covers 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, Counseling Services (6 sessions), and Kidney Disease Education Services.
Hearing Services See details
Hearing services are covered, including hearing exams with a $35 copay, as well as coverage for fitting/evaluation for hearing aids and prescription hearing aids. Prescription hearing aids have a copay between $690 and $1890, while inner ear, outer ear, and over-the-ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $35 copay, and routine eye exams and other eye exam services are covered once per year. Eyewear is covered, with a combined maximum of $300 per year for both in-network and out-of-network services, and you can get one pair of contact lenses and eyeglasses annually. Eyeglass lenses and frames are not covered.
Dental Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers dental services, including oral exams with a $35 copay, dental x-rays, and prophylaxis (cleaning). Orthodontic services are covered up to a $5000 maximum. Restorative, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery services are covered with 50% coinsurance. Fluoride treatment, adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the UPMC for Life PPO Rx Choice (PPO) plan, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%, and 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. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment. Durable Medical Equipment for use outside the home is not covered, while Diabetic Supplies have no coinsurance up to 20% and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including Diagnostic Procedures/Tests and Lab Services, have a $5 copay, while Diagnostic Radiological Services have a copay of at least $225, Therapeutic Radiological Services have a copay of at least $80, and Outpatient X-Ray Services have a $20 copay. Prior authorization is required for all services.
Home Health Services See details
Home Health Services are covered by the UPMC for Life PPO Rx Choice (PPO) plan with no copay or 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 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 with prior authorization required. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The UPMC for Life PPO Rx Choice (PPO) plan covers Over-the-Counter (OTC) Items, including Nicotine Replacement Therapy (NRT) as a Part C OTC benefit, and a Meal Benefit for chronic illnesses or medical conditions, but Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services are not covered. Additionally, 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.
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