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UPMC for Life PPO Rx Enhanced (PPO)

H5533 - 008 - 0
4.5 out of 5 stars (4.5 / 5)

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

This page features plan details for 2025 UPMC for Life PPO Rx Enhanced (PPO) H5533 – 008 – 0 available in Western and Central Pennsylvania.

Locations

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

Adams County, Pennsylvania
Berks County, Pennsylvania
Bradford County, Pennsylvania

Click to see more locations

Plan Overview

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

Insurer:UPMC for Life
Health Plan Deductible:$500 annual deductible
MOOP:$11,300 In and Out-of-network
$7,550 In-network
Drugs Covered:Yes

Ready to sign up for UPMC for Life PPO Rx Enhanced (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

Premium Breakdown

UPMC for Life PPO Rx Enhanced (PPO) has a monthly premium of $58.00. 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 $41.90 $16.10 $ $
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 Rx Enhanced (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $175.00
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
$16.10$0.00

Initial Coverage Phase

After you pay your $175.00 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 Rx Enhanced (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)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: 50 Coins – No Co pay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: 50 Coins – No Co pay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Restorative Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 15.00 Copay
    • Out-of-Network: 50% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – 15.00 Copay
    • Out-of-Network: 50% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Lab services
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $5 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $200 copay (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $20 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 40% coinsurance (Authorization Required)

Doctor visits

  • Specialist
    • Out-of-Network: 40% coinsurance per visit
  • Primary
    • Out-of-Network: $30 copay per visit
    • In-Network: $0 copay
  • Specialist
    • In-Network: $40 copay 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)

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

Ground ambulance

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

Health plan deductible

    • $500 annual deductible

Hearing

  • Hearing aids
    • In-Network: $690-1,890 copay (Limits Apply)
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $40 copay
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 40% coinsurance
  • Fitting/evaluation
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Hearing aids
    • Out-of-Network: $690-1,890 copay (Limits Apply)

Inpatient hospital coverage

    • Out-of-Network: 40% per stay (Authorization Required)
    • In-Network: $275 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)

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

    • $11,300 In and Out-of-network
      $7,550 In-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 18% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 18% coinsurance per item (Authorization Required)

Medicare Part B drugs

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

Mental health services

  • Inpatient hospital – psychiatric
    • Out-of-Network: 40% per stay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $40 copay
  • Inpatient hospital – psychiatric
    • In-Network: $275 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 40% coinsurance
  • Outpatient individual therapy visit
    • Out-of-Network: 40% coinsurance
  • Outpatient group therapy visit
    • In-Network: $40 copay
    • 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: $40 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $250 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)
    • In-Network: $35 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 40% coinsurance (Authorization Required)
    • In-Network: $35 copay (Authorization Required)

Skilled Nursing Facility

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

Transportation

    • Not covered

Vision

  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Eyeglass frames
    • Not covered
  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Other
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for UPMC for Life PPO Rx Enhanced (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 Rx Enhanced (PPO)? See 2025 UPMC for Life PPO Rx Enhanced (PPO) at MedicareAdvantageRX.com.

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