UPMC for Life HMO No Rx (HMO)
H3907 - 002 - 0
(5 / 5)
UPMC for Life HMO No Rx (HMO) is a Medicare Advantage (Part C) Plan by UPMC for Life.
This page features plan details for 2024 UPMC for Life HMO No Rx (HMO) H3907 – 002 – 0 available in Western, Central, and North Eastern Pennsylvania.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
UPMC for Life HMO No Rx (HMO) is offered in the following locations.
Plan Overview
UPMC for Life HMO No Rx (HMO) offers the following coverage and cost-sharing.
| Insurer: | UPMC for Life |
| Health Plan Deductible: | $0.00 |
| MOOP: | $5,000 In-network |
| Drugs Covered: | No |
Ready to sign up for UPMC for Life HMO No Rx (HMO) ?
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 HMO No Rx (HMO) qualifies for a monthly Medicare Give Back Benefit of $39.00.
| Premium Reduction: | $39.00 |
Premium Breakdown
UPMC for Life HMO No Rx (HMO) 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 |
|---|---|---|---|
| $174.70 | $0.00 | $39.00 | $135.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
UPMC for Life HMO No Rx (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $5,000 In-network |
| No |
| In-network | Yes, contact plan for further details |
| $225 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $45 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (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.) |
| Diagnostic tests and procedures | $5 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $5 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $110 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $30 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $45 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $690-1,890 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Diagnostic services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Restorative services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| 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.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| $50-290 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $45 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $45 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| $300 per stay (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $300 per stay (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $80 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for UPMC for Life HMO No Rx (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
Factsonmedicare.com is a free-to-use informational website by Dog Media Solutions LLC. All insurance agents and enrollment platforms linked to this site have their own terms and conditions.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B Premium give-back is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do feature in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
HealthCompare Insurance Services does not offer every plan available in your area. Currently we represent 18 organizations, which offers 52,101 products in your area.
We do not feature every plan available in your area. Any information we provide is limited to those plans we do feature in your area. Enrollment is offered through our partners including HealthCompare Insurance Services Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
HealthCompare Insurance Services represents Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.
Medicare has neither approved nor endorsed any information on this site.