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UPMC for Life PPO Essential Care Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life PPO Essential Care Rx (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 Essential Care Rx (PPO) in 2025, please refer to our full plan details page.
UPMC for Life PPO Essential Care Rx (PPO) is a PPO plan offered by UPMC Health System available for enrollment in 2025 to people living in Western, Central, and Northeastern 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 Essential Care Rx (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 Essential Care Rx (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 Essential Care Rx (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $101.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $350.00 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 $11500.00 (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 $11500.00 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 Essential Care Rx (PPO) plan has a $350 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 will pay no copay at a preferred pharmacy or via mail order, and a $20 copay at a standard pharmacy or via standard mail order. For standard generic drugs, the copay is $47 regardless of pharmacy. Brand name drugs have a 50% coinsurance, and non-preferred drugs have a 28% coinsurance.
Additional Benefits
The UPMC for Life PPO Essential Care Rx (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient services, with varying copays depending on the service. Emergency, urgent, and worldwide emergency services are covered, with copays ranging from $45 to $110. The plan also covers primary care, preventive, hearing, vision, and dental services, each with specific copays or coinsurance requirements. Additional benefits include coverage for ambulance, home health, dialysis, and home infusion services, as well as medical equipment and diagnostic services, with varying cost-sharing structures. The plan also offers coverage for skilled nursing facilities, cardiac rehabilitation, and other services, such as over-the-counter items and meal benefits. However, the plan does not cover certain services, such as private duty nursing, acupuncture, and additional hours of care.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for acute and psychiatric stays, but non-Medicare-covered stays and upgrades for inpatient hospital acute are not covered. For days 1-5, the copay is $380, and there is no copay for days 6-90.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center Services have a $380 copay. Individual and Group Sessions for Outpatient Substance Abuse have a copay between $45 and $45.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life PPO Essential Care Rx (PPO) plan. You will pay a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a copay for Medicare-covered ground ambulance services ($50-$280) and air ambulance services ($280), and no coinsurance. 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 Essential Care Rx (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a $45 copay; both have no coinsurance. Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $280 copay; all have no coinsurance.
Primary Care See details
The UPMC for Life PPO Essential Care Rx (PPO) plan covers primary care physician services, occupational therapy, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are covered with a $15 copay, while routine chiropractic care is not covered; other services have a copay ranging from $35 to $45.
Preventive Services See details
Preventive Services includes coverage for Medicare-covered preventive services with no copay, but does not cover annual physical exams. Additional preventive services such as in-home safety assessments, smoking cessation counseling (4 visits), fitness benefits, remote access technologies, home and bathroom safety devices, and counseling services (6 sessions) are covered.
Hearing Services See details
Hearing services are covered, including routine hearing exams with a $45 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, with a copay between $690 and $1890 for all types of prescription hearing aids, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $45 copay and coverage for routine eye exams, other eye exam services, contact lenses (1 pair per year), eyeglasses (lenses and frames - 1 pair per year), and upgrades. Eyeglass lenses and frames are not covered. A combined maximum of $200 is covered per year for eyewear.
Dental Services See details
The UPMC for Life PPO Essential Care Rx (PPO) plan covers Medicare Dental Services with a $45 copay, and covers other dental services including oral exams, dental x-rays, prophylaxis (cleaning), restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with 50% coinsurance. Fluoride treatment, adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic Services have a maximum benefit of $2600 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by UPMC for Life PPO Essential Care Rx (PPO). For Medicare Part B Insulin Drugs, you will pay a $35 copay and between 0% and 20% coinsurance. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are covered with between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the UPMC for Life PPO Essential Care Rx (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance, but Durable Medical Equipment for use outside the home is not covered. Diabetic Equipment is covered, with a 0-20% coinsurance for Diabetic Supplies and a 20% coinsurance for Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests and lab services, are covered by UPMC for Life PPO Essential Care Rx (PPO) with a $10 copay. Diagnostic Radiological Services have a copay of at least $275, while Therapeutic Radiological Services have a copay of at least $65. Outpatient X-Ray Services have a $50 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life PPO Essential Care Rx (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. The cost sharing includes a copay, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the UPMC for Life PPO Essential Care Rx (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100, while additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items and Meal Benefits, but 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, and Self-Directed Personal Assistance Services are not covered. OTC items are covered, and the plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit, while meal benefits are provided for chronic illness or a medical condition that requires the enrollee to remain at home.
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