2023 UPMC for Life HMO Rx Choice (HMO)
UPMC for Life HMO Rx Choice (HMO) H3907-049 is a 2023 Medicare Advantage Plan or Part-C by UPMC for Life available to residents in Pennsylvania and Ohio. This plan includes additional prescription drug (Part-D) coverage. UPMC for Life UPMC for Life HMO Rx Choice (HMO) has a monthly premium of $36.00 and has an in-network maximum out-of-pocket limit of $4,500 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $4,500 out-of-pocket. This can be an extremely nice safety net.
UPMC for Life works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for UPMC for Life HMO Rx Choice (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from UPMC for Life and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from UPMC for Life except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Pennsylvania or Medicare Advantage in Ohio.
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2023 UPMC for Life Medicare Advantage Plan Overview
|Name:||UPMC for Life HMO Rx Choice (HMO)|
|Plan ID:||H3907 049 0|
|Provider:||UPMC for Life|
|Combined Premium (C+D):||$36.00/mo|
|Part C Premium:||$0/mo|
|Part D (Drug) Premium:||$36.00/mo|
|Part D Supplemental Premium||$0/mo|
|Total Part D Premium:||$36.00/mo|
|Tiers with No Deductible:||0|
|Benchmark:||Not below the regional benchmark|
|Type of Medicare Health:||Enhanced Alternative|
|Drug Benefit Type:||Enhanced|
What type of plan is UPMC for Life HMO Rx Choice (HMO)
UPMC for Life HMO Rx Choice (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your primary care physician will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.
How much does UPMC for Life HMO Rx Choice (HMO) cost?
A monthly premium is the fee you pay to the plan in exchange for coverage. UPMC for Life charges a $36.00 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. UPMC for Life HMO Rx Choice (HMO) has a monthly drug premium of $36.00 and a $0 drug deductible. This UPMC for Life plan offers a $36.00 Part-D Basic Premium that is Not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by UPMC for Life above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $36.00. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.
UPMC for Life Gap Coverage
In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This UPMC for Life plan does not offer additional coverage through the gap.
Extra Help Premium Assistance
The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The UPMC for Life HMO Rx Choice (HMO) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $9.00 for 75% low-income subsidy $18.00 for 50% and $27.00 for 25%.
|Full Assistance Premium:||$0|
|75% Assistance Premium:||$9.00|
|50% Assistance Premium:||$18.00|
|25% Assistance Premium:||$27.00|
The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. UPMC for Life HMO Rx Choice (HMO) by UPMC for Life MOOP is $4,500. Once you spend $4,500 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.
Formulary and Drug Coverage
UPMC for Life HMO Rx Choice (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
The complete UPMC for Life HMO Rx Choice (HMO) Formulary.
*Initial Coverage Phase and 30 day supply
Summary of Benefits*2021 data this will be updated with 2023 data when available.
The benefit information provided is a summary of what UPMC for Life HMO Rx Choice (HMO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from UPMC for Life helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.
|Diagnostic services||50% coinsurance|
|Non-routine services||50% coinsurance|
|Prosthodontics, other oral/maxillofacial surgery, other services||50% coinsurance|
|Restorative services||50% coinsurance|
Diagnostic Tests and Procedures
|Diagnostic radiology services (e.g., MRI)||$150 copay|
|Diagnostic tests and procedures||$10 copay|
|Lab services||$10 copay|
|Outpatient x-rays||$10 copay|
|Specialist||$35 copay per visit|
Emergency care/Urgent Care
|Emergency||$90 copay per visit (always covered)|
|Urgent care||$65 copay per visit (always covered)|
Foot Care (podiatry services)
|Foot exams and treatment||$35 copay|
|Routine foot care||Not covered|
|Hearing aids||$0 copay|
|Hearing exam||$35 copay|
Inpatient Hospital Coverage
|$325 per stay|
|Diabetes supplies||20% coinsurance per item|
|Durable medical equipment (e.g., wheelchairs, oxygen)||20% coinsurance per item|
|Prosthetics (e.g., braces, artificial limbs)||20% coinsurance per item|
Medicare Part B Drugs
|Other Part B drugs||20% coinsurance|
Mental Health Services
|Inpatient hospital - psychiatric||$325 per stay|
|Outpatient group therapy visit||$35 copay|
|Outpatient group therapy visit with a psychiatrist||$35 copay|
|Outpatient individual therapy visit||$35 copay|
|Outpatient individual therapy visit with a psychiatrist||$35 copay|
|Yes, contact plan for further details|
Optional supplemental benefits
Outpatient Hospital Coverage
|$200 copay per visit|
|Dental x-ray(s)||$0 copay|
|Fluoride treatment||Not covered|
|Oral exam||$0 copay|
|Occupational therapy visit||$35 copay|
|Physical therapy and speech and language therapy visit||$35 copay|
Skilled Nursing Facility
|$0 per day for days 1 through 20
$160 per day for days 21 through 100
|Contact lenses||$0 copay|
|Eyeglass frames||Not covered|
|Eyeglass lenses||Not covered|
|Eyeglasses (frames and lenses)||$0 copay|
|Routine eye exam||$0 copay|
Wellness Programs (e.g. fitness nursing hotline)
CMS Star Ratings
Is UPMC for Life HMO Rx Choice (HMO) a good plan? UPMC for Life HMO Rx Choice (HMO) received a 5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare UPMC for Life HMO Rx Choice (HMO) performance among several different plans.
|2022 Overall Rating|
|Part C Summary Rating|
|Part-D Summary Rating|
|Staying Healthy: Screenings, Tests, Vaccines|
|Managing Chronic (Long Term) Conditions|
|Member Experience with Health Plan|
|Complaints and Changes in Plans Performance|
|Health Plan Customer Service|
|Drug Plan Customer Service|
|Complaints and Changes in the Drug Plan|
|Member Experience with the Drug Plan|
|Drug Safety and Accuracy of Drug Pricing|
Staying Healthy, Screening, Testing, & Vaccines
|Total Preventative Rating|
|Breast Cancer Screening|
|Colorectal Cancer Screening|
|Annual Flu Vaccine|
|Monitoring Physical Activity|
Managing Chronic And Long Term Care for Older Adults
|SNP Care Management|
|Diabetes Care - Eye Exam|
|Diabetes Care - Kidney Disease|
|Diabetes Care - Blood Sugar|
|Controlling Blood Pressure|
|Reducing Risk of Falling|
|Improving Bladder Control|
Member Experience with H3907-049 Health Plan
|Total Experience Rating|
|Getting Needed Care|
|Health Care Quality|
|Rating of Health Plan|
Member Complaints and Changes in Plans Performance
|Complaints about Health Plan|
|Members Leaving the Plan|
|Health Plan Quality Improvement|
Health Plan Customer Service Rating for UPMC for Life
|Total Customer Service Rating|
|Timely Decisions About Appeals|
|Reviewing Appeals Decisions|
|Call Center, TTY, Foreign Language|
Drug Plan Customer Service Ratings
|Call Center, TTY, Foreign Language|
Ratings For Member Complaints and Changes in the Drug Plans Performance
|Complaints about the Drug Plan|
|Members Choosing to Leave the Plan|
|Drug Plan Quality Improvement|
Member Experience with the Drug Plan
|Rating of Drug Plan|
|Getting Needed Prescription Drugs|
Drug Safety and Accuracy of Drug Pricing
|MPF Price Accuracy|
|Drug Adherence for Diabetes Medications|
|Drug Adherence for Hypertension (RAS antagonists)|
|Drug Adherence for Cholesterol (Statins)|
|MTM Program Completion Rate for CMR|
|Statin with Diabetes|
Ready to Enroll?
Mon-Sun 8am-11pm EST
(Click county or state to compare all available Advantage plans)
The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for UPMC for Life HMO Rx Choice (HMO) requires you to live in that plan’s service area. The service area is listed below:
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How much does UPMC for Life HMO Rx Choice (HMO) cost?
UPMC for Life charges a $36.00 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
How much is UPMC for Life HMO Rx Choice (HMO) MOOP?
The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. UPMC for Life HMO Rx Choice (HMO) by UPMC for Life MOOP is $4,500. Once you spend $4,500 you will pay nothing for Part A or Part B covered services.
What type of plan is UPMC for Life HMO Rx Choice (HMO)?
UPMC for Life HMO Rx Choice (HMO) is a Local HMO. With a health maintenance organization you will be required to receive most of your health care from an in-network provider. HMOs require that you select a primary care physician (PCP).
Is UPMC for Life HMO Rx Choice (HMO) a good plan?
UPMC for Life HMO Rx Choice (HMO) received a 5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance.
Source:CMS. Data as of Oct 1, 2022.
Last updated on
Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit.
Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.