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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 is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will pay no copay at preferred pharmacies or through mail order and a $20 copay at standard pharmacies. Standard generic drugs have a $47 copay, while preferred brand drugs have 50% coinsurance. Non-preferred drugs have 28% coinsurance.
Additional Benefits
The UPMC for Life PPO Essential Care Rx (PPO) plan offers a wide range of benefits, including inpatient and outpatient hospital services, with varying copays. You'll have a copay for services like primary care, specialist visits, and hearing exams, while preventive services and home health services have no copay. Additional benefits include coverage for dental, vision, and hearing services, with specific copays and coverage limits. The plan also covers ambulance, emergency, and skilled nursing facility services, with associated copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered with prior authorization. For days 1-5, there is a $380 copay, and for days 6-90, there is no copay. Additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, and ambulatory surgical center (ASC) services with a $380 copay. Outpatient substance abuse services, including individual and group sessions, have a copay between $45 and $45. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the UPMC for Life PPO Essential Care Rx (PPO) plan. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the UPMC for Life PPO Essential Care Rx (PPO) plan. Ground ambulance services have a copay of $50 to $280, while air ambulance services have a copay of $280, and there is no coinsurance for either. 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. Emergency Services have a $110 copay with no coinsurance, Urgently Needed Services have a $45 copay with no coinsurance, and Worldwide Emergency Coverage has a $110 copay with no coinsurance, Worldwide Urgent Coverage has a $45 copay with no coinsurance, and Worldwide Emergency Transportation has a $280 copay with no coinsurance.
Primary Care See details
The UPMC for Life PPO Essential Care Rx (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 covered with a $15 copay, while routine chiropractic care is not covered, and other services have a $35-$45 copay.
Preventive Services See details
The UPMC for Life PPO Essential Care Rx (PPO) plan covers Medicare-covered preventive services with no copay, but does not cover annual physical exams. Additional preventive services are partially covered, including in-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefits, remote access technologies, home and bathroom safety devices and modifications, and counseling services.
Hearing Services See details
Hearing services are covered, including routine hearing exams with a $45 copay. Prescription hearing aids are covered, but inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
The UPMC for Life PPO Essential Care Rx (PPO) plan covers vision services, including routine eye exams with a $45 copay, and eyewear with a combined maximum of $200 every year. Contact lenses and eyeglasses are covered, but eyeglass lenses and frames are not covered.
Dental Services See details
The UPMC for Life PPO Essential Care Rx (PPO) plan covers Medicare dental services with a $45 copay, and other dental services including oral exams (2 visits per year) and dental x-rays (1 bitewing x-ray every 12 months, 1 panoramic x-ray every 36 months). The plan has a $2,600 maximum benefit for orthodontic services, but does not cover fluoride treatment, adjunctive general services, implant services, or orthodontics. Restorative, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery have 50% coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the UPMC for Life PPO Essential Care Rx (PPO) plan, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0-20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life PPO Essential Care Rx (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by UPMC for Life PPO Essential Care Rx (PPO). Durable Medical Equipment (DME) has a 20% coinsurance, and Prosthetics/Medical Supplies - Non-Medicare benefit has a 20% coinsurance. Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests and Lab Services, both with a $10 copay. Diagnostic Radiological Services have a copay of at most $275, while Therapeutic Radiological Services have a copay of at most $65, and Outpatient X-Ray Services have a $50 copay.
Home Health Services See details
Home Health Services are covered by UPMC for Life PPO Essential Care Rx (PPO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the UPMC for Life PPO Essential Care Rx (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 UPMC for Life PPO Essential Care Rx (PPO), requiring prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100; additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Other Services benefit covers Over-the-Counter (OTC) Items and Meal Benefits, but does not cover 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, or Self-Directed Personal Assistance Services. This plan provides OTC items as a supplemental Part C benefit and offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit.
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