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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 2026 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 $34.00. 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. 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 features a $400 drug deductible. For Tier 1 (Preferred Generic) and Tier 2 (Generic) medications, there is no copay when using a preferred pharmacy or preferred mail order. If you use standard pharmacies or standard mail order, Tier 1 drugs carry a $15 to $30 copay, and Tier 2 drugs carry a $20 to $40 copay depending on the supply fill. Brand-name and specialty medications are subject to coinsurance rather than flat copays. Tier 3 (Preferred Brand) drugs require a 25% coinsurance, while Tier 4 (Non-Preferred) drugs have a 37% coinsurance across all pharmacy options. Specialty drugs in Tier 5 carry a 28% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The UPMC for Life PPO Rx Choice (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits and preventive services. For specialists and routine dental, vision, or hearing exams, members generally pay a $30 copay with no coinsurance. Inpatient hospital stays require a $250 annual copay with no coinsurance, while outpatient hospital services feature copays ranging from $230 to $325. Most diagnostic lab tests, home health services, and over-the-counter benefits are available with no copay and no coinsurance. For major medical needs, dialysis services and durable medical equipment require a 20% coinsurance and no copay. Additionally, comprehensive dental care is covered with a 50% coinsurance up to a $5,000 annual limit, helping you manage out-of-pocket costs for more complex procedures.
Inpatient Hospital See details
UPMC for Life PPO Rx Choice (PPO) covers inpatient acute hospital stays with a $250 annual copay and unlimited additional days at no copay, and inpatient psychiatric stays with a $350 annual copay, both with no coinsurance. Prior authorization is required for these services, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
UPMC for Life PPO Rx Choice (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $230 to $325 copay, ambulatory surgical center services with a $230 copay, and outpatient substance abuse sessions with a $30 copay. Outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
UPMC for Life PPO Rx Choice (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under UPMC for Life PPO Rx Choice (PPO) with no coinsurance, requiring a $50 to $340 copay for ground ambulance and a $340 copay for air ambulance. For transportation, some services are covered, but transportation to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
UPMC for Life PPO Rx Choice (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 3 days. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and emergency 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, and telehealth services with a $0 to $30 copay and no coinsurance. Specialist visits, therapies, mental health, psychiatric, and podiatry services require a $30 copay and no coinsurance, while chiropractic services are not covered.
Preventive Services See details
UPMC for Life PPO Rx Choice (PPO) covers preventive services with no copay and no coinsurance, including Medicare-covered zero-dollar preventive services, kidney disease education, and select screenings. While additional benefits like caregiver support and in-home safety assessments are included, some services such as annual physical exams, health education, and personal emergency response systems (PERS) are not covered.
Hearing Services See details
UPMC for Life PPO Rx Choice (PPO) hearing services are partially covered, offering one routine hearing exam and fitting evaluation per year for a $30 copay and no coinsurance. Up to two prescription hearing aids are covered annually with a copay ranging from $690 to $1,890 and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
UPMC for Life PPO Rx Choice (PPO) covers annual routine eye exams and contact lens fittings with no deductible, a $30 copay, and no coinsurance. Eyewear is partially covered with no copay, coinsurance, or deductible up to a $300 annual limit, though 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), featuring Medicare-covered dental services at a $30 copay and no coinsurance, and preventive care like cleanings and exams with no copay and no coinsurance. Comprehensive dental benefits, including restorative care and periodontics, have no copay and a 50% coinsurance up to a $5,000 annual maximum, while fluoride, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
UPMC for Life PPO Rx Choice (PPO) covers home infusion bundled services with no copay, while associated Medicare Part B chemotherapy and other drugs require between no coinsurance and 20% coinsurance. Covered Medicare 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 (DME), prosthetics, and diabetic supplies, with no copay and a 20% coinsurance, though diabetic supplies range from no coinsurance to 20% coinsurance. Prior authorization is required for these benefits, and coverage may be limited to preferred vendors or manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under UPMC for Life PPO Rx Choice (PPO) with no coinsurance, though prior authorization is required and diagnostic procedures and tests are not covered. Covered services feature no copay for lab services, a $25.00 copay for outpatient X-rays, a minimum $80.00 copay for therapeutic radiology, and a minimum $250.00 copay for diagnostic radiological services.
Home Health Services See details
Home Health Services are covered by UPMC for Life PPO Rx Choice (PPO) 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, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation services are not covered and require a $15 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by UPMC for Life PPO Rx Choice (PPO) with no coinsurance, requiring a $10 copay for days 1 through 20 and a $218 copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not needed, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by UPMC for Life PPO Rx Choice (PPO), which provides over-the-counter (OTC) items and health-related meal benefits with no copay and no coinsurance. Acupuncture is not covered under this plan.
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