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UPMC for Life PPO Rx Choice (PPO)is a Medicare Advantage (Part C) Plan by UPMC for Life.
This page features plan details for 2024 UPMC for Life PPO Rx Choice (PPO)H5533 – 015 – 1 available in Allegheny County.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
UPMC for Life PPO Rx Choice (PPO)is offered in the following locations.
Allegheny County, Pennsylvania
Pennsylvania
Click to see more locations
Plan Overview
UPMC for Life PPO Rx Choice (PPO)offers the following coverage and cost-sharing.
| Insurer: | UPMC for Life |
| Health Plan Deductible: | $0.00 |
| MOOP: | $9,550 In and Out-of-network $5,500 In-network |
| Drugs Covered: | Yes |
Ready to sign up for UPMC for Life PPO Rx Choice (PPO)?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
8am – 11pm EST. 7 days a week
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 Rx Choice (PPO)qualifies for a monthly Medicare Give Back Benefit of $2.00.
| Premium Reduction: | $2.00 |
Premium Breakdown
UPMC for Life PPO Rx Choice (PPO)has a monthly premium of $19.00. 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 |
|---|---|---|---|---|
| $174.70 | $0.00 | $19.00 | $2.00 | $191.70 |
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 Choice (PPO)provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | |
| Formulary Link: | Formulary Link |
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 D | LIS Full |
|---|---|
| $19.00 | $ |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, 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 Choice (PPO)also provides the following benefits.
| $0 |
| In-network | No |
| $9,550 In and Out-of-network $5,500 In-network |
| No |
| In-network | Yes, contact plan for further details |
| In-network | $175 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $275 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $10 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $20 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $45 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $5 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $5 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $250 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $15 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $10 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $20 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $690-1,890 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $690-1,890 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | 30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | 30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | 30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Non-routine services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Non-routine services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Restorative services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Restorative services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Endodontics | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Endodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Periodontics | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Extractions | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Extractions | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Other | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Other | 30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $5 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $5 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network | $50-290 copay (Not applicable.) (Not applicable.) |
| out-of-network | 30% coinsurance (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $5 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $20 copay (Authorization is not required.) (Referral is not required.) |
| In-network Routine foot care | $5 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $225 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | $325 per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $225 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $325 per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $10 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $20 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $10 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $20 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $5 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $5 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $196 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for UPMC for Life PPO Rx Choice (PPO)?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
8am – 11pm EST. 7 days a week
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