UPMC for Life HMO Rx Choice (HMO)
H3907 - 049 - 0
(5 / 5)
UPMC for Life HMO Rx Choice (HMO) is a Medicare Advantage (Part C) Plan by UPMC for Life.
This page features plan details for 2023 UPMC for Life HMO Rx Choice (HMO) H3907 – 049 – 0 available in Western, Central, and North Eastern Pennsylvania.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
UPMC for Life HMO Rx Choice (HMO) is offered in the following locations.
Plan Overview
UPMC for Life HMO Rx Choice (HMO) offers the following coverage and cost-sharing.
| Insurer: | UPMC for Life |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,500 In-network |
| Drugs Covered: | Yes |
Ready to sign up for UPMC for Life HMO Rx Choice (HMO) ?
Premium Breakdown
UPMC for Life HMO Rx Choice (HMO) has a monthly premium of $36.00. 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 |
|---|---|---|---|---|
| $164.90 | $0.00 | $36.00 | $0.00 | $200.90 |
- 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 HMO Rx Choice (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| 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 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $36.00 | $43.40 | $34.80 | $26.30 | $17.70 |
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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $15.00 copay | ||
| 2 (Generic) | $10.00 copay | $20.00 copay | ||
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 33% | 33% | 33% | 33% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $30.00 copay | $0.00 copay | $30.00 copay |
| 2 (Generic) | $20.00 copay | $40.00 copay | $20.00 copay | $40.00 copay |
| 3 (Preferred Brand) | $129.50 copay | $141.00 copay | $117.50 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $300.00 copay | $300.00 copay | $300.00 copay | $300.00 copay |
| 5 (Specialty Tier) |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
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 $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
UPMC for Life HMO Rx Choice (HMO) 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 |
Dental (comprehensive)
| Diagnostic services: | 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Endodontics: | 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Extractions: | 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Non-routine services: | 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Periodontics: | 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Restorative services: | 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $220 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | $5 copay (authorization required) (referral not required) |
| Lab services: | $5 copay (authorization required) (referral not required) |
| Outpatient x-rays: | $25 copay (authorization required) (referral not required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $35 copay per visit (authorization not required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $45 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $35 copay (authorization not required) (referral not required) |
| Routine foot care: | $35 copay (limits may apply) (authorization not required) (referral not required) |
Ground ambulance
| $50-300 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | $690-1,890 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | $35 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| $395 per stay (authorization required) (referral not required) |
Hospital coverage (outpatient)
| $250 copay per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $4,500 In-network |
Medical equipment/supplies
| Diabetes supplies: | 0-20% coinsurance per item (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $395 per stay (authorization required) (referral not required) |
| Outpatient group therapy visit: | $35 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $35 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | $35 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $35 copay (authorization not required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $35 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | $35 copay (authorization required) (referral not required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for UPMC for Life HMO Rx Choice (HMO) ?