UPMC for Life PPO Rx Choice (PPO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: UPMC for Life
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $30 copay
Out-of-network: 30% coinsurance
Emergency Room
$130 copay
Ambulance Coverage
In-network: $50-$340 copay
Out-of-network: 30% coinsurance
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0 copay
Out-of-network: $50 copay
Lab services:
In-network: $0-$30 copay
Out-of-network: $50 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $125 copay
Out-of-network: $250 copay
Outpatient x-rays:
In-network: $15 copay
Out-of-network: $20 copay
Hospital Services
Inpatient hospital coverage:
In-network:
Tier 1
$250 per stay
Tier 2
$275 per stay
Out-of-network:
$350 per stay
Outpatient hospital coverage:
In-network: $200-$250 copay
Out-of-network: $350 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $20 copay
Out-of-network: $30 copay
Urgent Care Coverage
$130 copay
Skilled Nursing Facility (SNF)
In-network:
Tier 1
$10 per day for days 1-20
$210 per day for days 21-100
Out-of-network:
30% per stay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $20 copay
Out-of-network: $30 copay
Outpatient individual therapy with a psychiatrist:
In-network: $20 copay
Out-of-network: $30 copay
Outpatient group therapy visits:
In-network: $20 copay
Out-of-network: $30 copay
Outpatient individual therapy visit:
In-network: $20 copay
Out-of-network: $30 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: 30% coinsurance
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: 30% coinsurance
Dental x-rays:
In-network: $0 copay
Out-of-network: 30% coinsurance
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: 30% coinsurance
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: 30% coinsurance
Fitting/evaluation:
In-network: $0 copay
Out-of-network: 30% coinsurance
Hearing aids - prescription:
In-network: $690-$1890 copay
Out-of-network: $690-$1890 copay
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
37% coinsurance (30-day supply)
37% coinsurance (90-day supply)
Tier 5: Specialty Tier
28% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$15.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$40.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
37% coinsurance (30-day supply)
37% coinsurance (90-day supply)
Tier 5: Specialty Tier
28% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$15.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$40.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
37% coinsurance (30-day supply)
37% coinsurance (90-day supply)
Tier 5: Specialty Tier
28% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
37% coinsurance (30-day supply)
37% coinsurance (90-day supply)
Tier 5: Specialty Tier
28% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
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