Go Back

UPMC for Life PPO Salute (PPO)

H5533 - 016 - 1

(4.5 / 5)

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

This page features plan details for 2025 UPMC for Life PPO Salute (PPO) H5533 – 016 – 1 available in Western, Central, and Northeastern Pennsylvania.

Locations

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

Insurer:	UPMC for Life
Health Plan Deductible:	Coming soon
MOOP:	$10,100 In and Out-of-network $6,750 In-network
Drugs Covered:	No

Ready to sign up for UPMC for Life PPO Salute (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 Salute (PPO) qualifies for a monthly Medicare Give Back Benefit of $65.00.

Premium Reduction:

$65.00

Premium Breakdown

UPMC for Life PPO Salute (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.

Part B	Part C	Part B Give Back	Total
$185.00	$0.00	$65.00	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

UPMC for Life PPO Salute (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 – No Copay
- Out-of-Network: 50% Coins – No Copay
Oral Exams
- In-Network: No Coins – No 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
- In-Network: 20% coinsurance (Authorization Required)
- Out-of-Network: 20% coinsurance (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- Out-of-Network: 20% coinsurance (Authorization Required)
Lab services
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: $0 copay (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- In-Network: 20% coinsurance (Authorization Required)
Outpatient x-rays
- In-Network: 20% coinsurance (Authorization Required)
- Out-of-Network: 20% coinsurance (Authorization Required)

Doctor visits

Primary
- In-Network: 20% coinsurance per visit
- Out-of-Network: 20% coinsurance per visit
Specialist
- Out-of-Network: 20% coinsurance per visit
- In-Network: 20% coinsurance per visit

Emergency care/Urgent care

Urgent care
- 20% coinsurance per visit (always covered)
Emergency
- 20% coinsurance per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- In-Network: 20% coinsurance
Routine foot care
- Not covered
Foot exams and treatment
- Out-of-Network: 20% coinsurance

Ground ambulance

- In-Network: 0-20% coinsurance
- Out-of-Network: 20% coinsurance

Health plan deductible

- Coming soon

Hearing

Fitting/evaluation
- In-Network: $0 copay (Limits Apply)
Hearing aids
- In-Network: $690-1,890 copay (Limits Apply)
Medicare-Covered Hearing Exam
- In-Network: 20% coinsurance
Hearing aids
- Out-of-Network: $690-1,890 copay (Limits Apply)
Fitting/evaluation
- Out-of-Network: 50% coinsurance (Limits Apply)
Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- Out-of-Network: 20% coinsurance

Inpatient hospital coverage

- In-Network: Coming soon (Authorization Required)
- Out-of-Network: Coming soon (Authorization Required)

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

- $10,100 In and Out-of-network
  $6,750 In-network

Medical equipment/supplies

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

Medicare Part B drugs

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

Mental health services

Inpatient hospital – psychiatric
- Out-of-Network: Coming soon (Authorization Required)
Outpatient group therapy visit with a psychiatrist
- Out-of-Network: 20% coinsurance
Outpatient group therapy visit
- In-Network: 20% coinsurance
Outpatient individual therapy visit
- In-Network: 20% coinsurance
Inpatient hospital – psychiatric
- In-Network: Coming soon (Authorization Required)
Outpatient group therapy visit
- Out-of-Network: 20% coinsurance
Outpatient individual therapy visit with a psychiatrist
- In-Network: 20% coinsurance
- Out-of-Network: 20% coinsurance
Outpatient group therapy visit with a psychiatrist
- In-Network: 20% coinsurance
Outpatient individual therapy visit
- Out-of-Network: 20% coinsurance

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- In-Network: 20% coinsurance per visit (Authorization Required)
- Out-of-Network: 20% coinsurance per visit (Authorization Required)

Preventive care

- In-Network: $0 copay
- Out-of-Network: $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- In-Network: 20% coinsurance (Authorization Required)
- Out-of-Network: 20% coinsurance (Authorization Required)
Occupational therapy visit
- In-Network: 20% coinsurance (Authorization Required)
- Out-of-Network: 20% coinsurance (Authorization Required)

Skilled Nursing Facility

- In-Network: Coming soon (Authorization Required)
- Out-of-Network: Coming soon (Authorization Required)

Transportation

- Not covered
- In-Network: $0 copay (Limits Apply, Authorization Required)
- Out-of-Network: $0 copay (Limits Apply, Authorization Required)

Vision

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

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

- Covered