2027 Medicare Advantage plan

UPMC for Life PPO Salute (PPO): 2027 benefits and costs

UPMC for Life PPO

CMS plan ID: H5533-016-1 · Plan year: 2027

UPMC for Life PPO Salute (PPO) is a 2027 Medicare Advantage plan offered by UPMC for Life. It is listed in Pennsylvania.

2027 plan costs at a glance

Monthly plan premium$0.00

In-network medical out-of-pocket maximum$9,850.00

Organization: UPMC for Life
Plan organization: UPMC HEALTH NETWORK, INC.
Parent company: UPMC Health System
Plan type: PPO
Part C premium: $0.00
Prescription drug coverage: No
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)
Monthly Part B premium after plan reduction: $159.50 (estimated)$209.50 standard premium less $50.00 plan reduction.

You must continue to pay your Medicare Part B premium.

Annual medical deductible: Medicare's Part A and Part B deductibles apply separately
Applies to out-of-network Medicare-covered services.
In-network medical maximum: $9,850.00
Combined in/out-of-network medical maximum: $14,800.00
Out-of-network medical maximum: Not applicable

Part B premium reduction: $50.00

2027 benefit summary

Doctor visits and medical care

Plan-level deductibles may still apply when a service-specific deductible is listed as No.

Common medical services and member costs
Service	In-network	Out-of-network	What to know
Primary care doctor	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No
Specialist visit	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Telehealth	0% to 20% coinsurance Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Emergency care	20% coinsurance	Not summarized. Check coverage with the plan.
Urgent care	20% coinsurance	Not summarized. Check coverage with the plan.
Home health	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Medicare-covered chiropractic	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Medicare-covered foot care	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Other health professionals	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required No Benefit period Original Medicare
Inpatient mental health care	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required No Benefit period Original Medicare
Skilled nursing facility	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	Out-of-network	What to know
Outpatient hospital care	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No
Hospital observation services	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No
Ambulatory surgical center	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes Referral required No
Outpatient blood	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	Out-of-network	What to know
Diagnostic procedures and tests	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes Referral required No
Laboratory services	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes Referral required No
Therapeutic radiology	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes Referral required No
X-rays	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	Out-of-network	What to know
Partial hospitalization	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Intensive outpatient program	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Substance use treatment, individual sessions	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Substance use treatment, group sessions	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Opioid treatment program	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Mental health, individual sessions	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Mental health, group sessions	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Psychiatry, individual sessions	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Psychiatry, group sessions	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	Out-of-network	What to know
Occupational therapy	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes Referral required No
Physical and speech therapy	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes Referral required No
Cardiac rehabilitation	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Intensive cardiac rehabilitation	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Pulmonary rehabilitation	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	Out-of-network	What to know
Ground ambulance	0% to 20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes
Air ambulance	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes
Diabetic supplies	0% to 20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes
Diabetic monitors	0% to 20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	Out-of-network
Medicare-covered dental	20% coinsurance	20% coinsurance Deductible applies No
Oral examsAdditional plan benefit	$0	50% coinsurance Deductible applies No
Dental X-raysAdditional plan benefit	$0	50% coinsurance Deductible applies No
Dental cleaningAdditional plan benefit	$0	50% coinsurance Deductible applies No
Restorative dental careAdditional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Root canal treatment (endodontics)Additional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Gum treatment (periodontics)Additional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Removable dentures (prosthodontics)Additional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Fixed dental restorations (prosthodontics)Additional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Oral surgeryAdditional plan benefit	50% coinsurance	50% coinsurance Deductible applies No

Additional network details

These costs apply to the listed service categories and networks.

Dental benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Diagnostic and preventive dental (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Comprehensive dental (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Vision benefits

Vision benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered eye exams	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	50% coinsurance Deductible applies No	Approval required No Referral required No
Medicare-covered eyewear	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Vision benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Eye exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Other Eye Exam ServicesAdditional plan benefit	Out-of-network	50% coinsurance Deductible applies No
Eyewear (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
UpgradesAdditional plan benefit	Out-of-network	$0 Deductible applies No

Hearing benefits

Hearing benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered hearing exams	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	50% coinsurance Deductible applies No	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	50% coinsurance Deductible applies No	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$690.00 to $1,890.00 copay Service-specific deductible No	$5,000.00 copay Deductible applies No	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Hearing benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Hearing exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Prescription hearing aids (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Extra benefits

Extra benefits and member costs
Service	In-network	Out-of-network	What to know
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies No
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	50% coinsurance Deductible applies Yes Deductible amount $500.00 Dollar benefit limit applies No	Approval required No Referral required No

Additional services and network costs

Additional network details

These costs apply to the listed service categories and networks.

Additional medical services: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Medicare-covered preventive servicesMedicare-covered care	Out-of-network	$0 Deductible applies No
Additional Sessions of Smoking and Tobacco Cessation CounselingAdditional plan benefit	Out-of-network	50% coinsurance Deductible applies Yes Deductible amount $500.00	Dollar benefit limit applies No
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)Additional plan benefit	Out-of-network	50% coinsurance Deductible applies Yes Deductible amount $500.00	Dollar benefit limit applies No
Home and Bathroom Safety Devices and ModificationsAdditional plan benefit	Out-of-network	$0 Deductible applies No	Dollar benefit limit applies No
In-Home Safety AssessmentAdditional plan benefit	Out-of-network	50% coinsurance Deductible applies Yes Deductible amount $500.00	Dollar benefit limit applies No
Glaucoma ScreeningMedicare-covered care	Out-of-network	20% coinsurance Deductible applies No
Diabetes Self-Management TrainingMedicare-covered care	Out-of-network	20% coinsurance Deductible applies No
Digital Rectal ExamsMedicare-covered care	Out-of-network	20% coinsurance Deductible applies No
EKG after a Welcome to Medicare visitMedicare-covered care	Out-of-network	20% coinsurance Deductible applies No
Medicare Part B insulinMedicare-covered care	Out-of-network	$35.00 copay; 0% to 20% coinsurance Deductible applies No

Allowances and optional benefits

FlexSpendCard-DVH

One shared limit covers the listed services, not a separate allowance for each service.

Services sharing this allowance: Oral Exams; Dental X-Rays; Dental cleaning; Restorative dental care; Root canal treatment (endodontics); Gum treatment (periodontics); Removable dentures (prosthodontics); Fixed dental restorations (prosthodontics); Oral and Maxillofacial Surgery; Routine Eye Exams; Other Eye Exam Services; Contact Lenses; Eyeglasses (lenses and frames); Upgrades; Routine Hearing Exams; Hearing aid fitting and evaluation; Prescription Hearing Aids (all types)
How benefits are provided: Debit Card
Advance choice of benefits required: No
Shared benefit limit: $200.00
How often this limit applies: Every year
Shared limit on visits or trips: No

FlexSpendCard-OTC/Copay/Fitness/HSD

One shared limit covers the listed services, not a separate allowance for each service.

Services sharing this allowance: Worldwide Emergency Coverage; Worldwide Urgent Coverage; Worldwide Emergency Transportation; Over-the-counter health items; Fitness Benefit; Home and Bathroom Safety Devices and Modifications
How benefits are provided: Debit Card
Advance choice of benefits required: No
Shared benefit limit: $200.00
How often this limit applies: Every year
Shared limit on visits or trips: No

Prescription drug coverage

This plan does not include a Part D prescription drug benefit.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 58 county listings across 1 state or territory