UPMC for Life HMO Rx Choice (HMO) H3907-049-000 is a 2021 Medicare Advantage plan with drug coverage provided by UPMC for Life.

In terms of networks, this plan is a Local HMO. HMO plans require you to choose an in-network primary care doctor who coordinates your care with other healthcare providers in your network. With HMOs, you must generally seek care in-network. If you seek care outside of the plan’s network, the plan will only cover emergency or urgent care in most cases. Local HMOs cover only a small service area or part of the country. If you want to have costs covered out of network, you may want to look for PPOs in your county. Meanwhile, if you need a wider area of coverage, you may want to look at Regional PPO plans specifically.

When it comes to cost-sharing, you’ll want to consider both monthly costs and out-of-pocket costs. This plan has a monthly premium of $40, which covers both the health and drug portions of the plan.

The drug plan portion of this plan provides Enhanced Alternative (EA) benefits, which are benefits that exceed the required standard.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $0.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H3907-049-000
Plan Organization UPMC for Life
Plan Type Local HMO
Plan Name UPMC for Life HMO Rx Choice (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 4
Plan Cost Sharing
Premium $40.00
Total Premium (Includes Part B) $175.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $40.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $40.00
Monthly Part D Premium Full Assistance $2.50
Monthly Part D Premium 75% Assistance $11.90
Monthly Part D Premium 50% Assistance $21.30
Monthly Part D Premium 25% Assistance $30.60
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $7550.00
Gap Coverage No

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - Yes, contact plan for further details
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes - No No 50% coinsurance
Endodontics Yes - No No 50% coinsurance
Extractions Yes - No No 50% coinsurance
Non-routine services Yes - No No 50% coinsurance
Periodontics Yes - No No 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services Yes - No No 50% coinsurance
Restorative services Yes - No No 50% coinsurance
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No $150 copay
Diagnostic tests and procedures - - Yes No $10 copay
Lab services - - Yes No $10 copay
Outpatient x-rays - - Yes No $10 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - Yes No $35 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $65 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No No $35 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $50-200 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - No No $0 copay
Hearing aids Yes - No No $0 copay
Hearing exam - - No No $35 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $325 per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $7,550 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - No - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20% coinsurance
Other Part B drugs - - Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes No $325 per stay
Outpatient group therapy visit - - No No $35 copay
Outpatient group therapy visit with a psychiatrist - - No No $35 copay
Outpatient individual therapy visit - - No No $35 copay
Outpatient individual therapy visit with a psychiatrist - - No No $35 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $200 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Dental x-ray(s) Yes - No No $0 copay
Fluoride treatment No - - - Not covered
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes No $35 copay
Physical therapy and speech and language therapy visit - - Yes No $35 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 per day for days 1 through 20$160 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes - No No $0 copay
Other No - - - Not covered
Routine eye exam Yes - No No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Adams County, Pennsylvania, Allegheny County, Pennsylvania, Armstrong County, Pennsylvania, Beaver County, Pennsylvania, Bedford County, Pennsylvania, Blair County, Pennsylvania, Bradford County, Pennsylvania, Butler County, Pennsylvania, Cambria County, Pennsylvania, Cameron County, Pennsylvania, Carbon County, Pennsylvania, Centre County, Pennsylvania, Clarion County, Pennsylvania, Clearfield County, Pennsylvania, Clinton County, Pennsylvania, Crawford County, Pennsylvania, Cumberland County, Pennsylvania, Dauphin County, Pennsylvania, Elk County, Pennsylvania, Erie County, Pennsylvania, Fayette County, Pennsylvania, Forest County, Pennsylvania, Fulton County, Pennsylvania, Greene County, Pennsylvania, Harrison County, Ohio, Huntingdon County, Pennsylvania, Indiana County, Pennsylvania, Jefferson County, Ohio, Jefferson County, Pennsylvania, Juniata County, Pennsylvania, Lancaster County, Pennsylvania, Lawrence County, Pennsylvania, Lebanon County, Pennsylvania, Lehigh County, Pennsylvania, Lycoming County, Pennsylvania, Mckean County, Pennsylvania, Mercer County, Pennsylvania, Mifflin County, Pennsylvania, Montour County, Pennsylvania, Northampton County, Pennsylvania, Perry County, Pennsylvania, Potter County, Pennsylvania, Snyder County, Pennsylvania, Somerset County, Pennsylvania, Sullivan County, Pennsylvania, Susquehanna County, Pennsylvania, Tioga County, Pennsylvania, Union County, Pennsylvania, Venango County, Pennsylvania, Warren County, Pennsylvania, Washington County, Pennsylvania, Wayne County, Pennsylvania, Westmoreland County, Pennsylvania, Wyoming County, Pennsylvania, York County, Pennsylvania

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