UPMC for Life HMO Rx (HMO)

H3907 - 058 - 1
4.5 out of 5 stars (4.5 / 5)

UPMC for Life HMO Rx (HMO) is a Medicare Advantage Plan by UPMC for Life.

This page features plan details for 2025 UPMC for Life HMO Rx (HMO) H3907 – 058 – 1 available in Western, Central, and Northeastern Pennsylvania.

Locations

UPMC for Life HMO Rx (HMO) is offered in the following locations.

Plan Overview

UPMC for Life HMO Rx (HMO) offers the following coverage and cost-sharing.

Insurer:UPMC for Life
Health Plan Deductible:$0
MOOP:$4,500 In-network
Drugs Covered:Yes

Ready to sign up for UPMC for Life HMO Rx (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

UPMC for Life HMO Rx (HMO) qualifies for a monthly Medicare Give Back Benefit of $1.00.

Premium Reduction:$1.00

Premium Breakdown

UPMC for Life HMO Rx (HMO) has a monthly premium of $90.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $68.60 $21.40 $1.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

UPMC for Life HMO Rx (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$21.40$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

UPMC for Life HMO Rx (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: Yes, contact plan for further details

Comprehensive Dental

  • Endodontics
    • In-Network: 30 Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: 30 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 30 Coins – No Co pay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: 30 Coins – No Co pay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: 30 Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: 30 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Outpatient x-rays
    • $25 copay (Authorization Required)
  • Diagnostic tests and procedures
    • $0 copay (Authorization Required)
  • Lab services
    • $0 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • $175 copay (Authorization Required)

Doctor visits

  • Primary
    • $0 copay
  • Specialist
    • $25 copay per visit

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $55 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • $25 copay (Limits Apply)
  • Foot exams and treatment
    • $25 copay

Ground ambulance

    • $50-270 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids OTC
    • Not covered
  • Fitting/evaluation
    • $0 copay (Limits Apply)
  • Hearing aids
    • $690-1,890 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • $25 copay

Inpatient hospital coverage

    • $295 per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $4,500 In-network

Medical equipment/supplies

  • Diabetes supplies
    • 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Other Part B drugs
    • 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • $25 copay
  • Inpatient hospital – psychiatric
    • $295 per stay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • $25 copay
  • Outpatient group therapy visit
    • $25 copay
  • Outpatient individual therapy visit
    • $25 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $200 copay per visit (Authorization Required)

Preventive care

    • $0 copay

Rehabilitation services

  • Occupational therapy visit
    • $25 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • $25 copay (Authorization Required)

Skilled Nursing Facility

    • $10 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • $0 copay (Limits Apply)
  • Routine eye exam
    • $0 copay (Limits Apply)
  • Upgrades
    • $0 copay (Limits Apply)
  • Eyeglass frames
    • Not covered
  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • $0 copay (Limits Apply)
  • Other
    • $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for UPMC for Life HMO Rx (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on UPMC for Life HMO Rx (HMO)? See 2025 UPMC for Life HMO Rx (HMO) at MedicareAdvantageRX.com.

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