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UPMC for Life PPO Essential Care Rx (PPO)

H5533 - 017 - 1
4.5 out of 5 stars (4.5 / 5)

UPMC for Life PPO Essential Care Rx (PPO) is a Medicare Advantage Plan by UPMC for Life.

This page features plan details for 2025 UPMC for Life PPO Essential Care Rx (PPO) H5533 – 017 – 1 available in Western, Central, and Northeastern Pennsylvania.

Locations

UPMC for Life PPO Essential Care Rx (PPO) is offered in the following locations.

Adams County, Pennsylvania
Allegheny County, Pennsylvania
Armstrong County, Pennsylvania

Click to see more locations

Plan Overview

UPMC for Life PPO Essential Care Rx (PPO) offers the following coverage and cost-sharing.

Insurer:UPMC for Life
Health Plan Deductible:$500 annual deductible
MOOP:$11,500 In and Out-of-network
$8,000 In-network
Drugs Covered:Yes

Ready to sign up for UPMC for Life PPO Essential Care Rx (PPO) ?

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 PPO Essential Care Rx (PPO) qualifies for a monthly Medicare Give Back Benefit of $101.00.

Premium Reduction:$101.00

Premium Breakdown

UPMC for Life PPO Essential Care Rx (PPO) has a monthly premium of $0.00. 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 $0.00 $0.00 $101.00 $
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 PPO Essential Care Rx (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $350.00
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
$0.00$0.00

Initial Coverage Phase

After you pay your $350.00 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 PPO Essential Care Rx (PPO) 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: 50 Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: 40% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: 40% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: 40% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $10 copay (Authorization Required)
  • Lab services
    • In-Network: $10 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $50 copay (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $275 copay (Authorization Required)
  • Lab services
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: 40% coinsurance (Authorization Required)

Doctor visits

  • Specialist
    • In-Network: $45 copay per visit
  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $0 copay
  • Specialist
    • Out-of-Network: 40% coinsurance per visit

Emergency care/Urgent care

  • Urgent care
    • $45 copay per visit (always covered)
  • Emergency
    • $110 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • In-Network: $45 copay (Limits Apply)
  • Foot exams and treatment
    • In-Network: $45 copay
    • Out-of-Network: 40% coinsurance

Ground ambulance

    • Out-of-Network: 40% coinsurance
    • In-Network: $50-280 copay

Health plan deductible

    • $500 annual deductible

Hearing

  • Hearing aids
    • Out-of-Network: $690-1,890 copay (Limits Apply)
  • Fitting/evaluation
    • Out-of-Network: 40% coinsurance (Limits Apply)
  • Hearing aids
    • In-Network: $690-1,890 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $45 copay
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 40% coinsurance

Inpatient hospital coverage

    • In-Network: $380 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • Out-of-Network: 40% per stay (Authorization Required)

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

    • $11,500 In and Out-of-network
      $8,000 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 40% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: 40% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)

Mental health services

  • Outpatient individual therapy visit
    • In-Network: $45 copay
  • Inpatient hospital – psychiatric
    • In-Network: $380 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 40% coinsurance
  • Outpatient individual therapy visit
    • Out-of-Network: 40% coinsurance
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 40% coinsurance
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $45 copay
  • Inpatient hospital – psychiatric
    • Out-of-Network: 40% per stay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $45 copay
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $45 copay
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 40% coinsurance

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $380 copay per visit (Authorization Required)
    • Out-of-Network: 40% coinsurance per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: 40% coinsurance

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $35 copay (Authorization Required)
  • Occupational therapy visit
    • In-Network: $35 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 40% coinsurance (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: 40% per stay (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: 40% coinsurance (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Not covered
  • Other
    • Out-of-Network: 40% coinsurance (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Out-of-Network: $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for UPMC for Life PPO Essential Care Rx (PPO) ?

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 PPO Essential Care Rx (PPO)? See 2025 UPMC for Life PPO Essential Care Rx (PPO) at MedicareAdvantageRX.com.

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