UPMC for Life HMO Rx (HMO)

$15 copayment for primary care doctor visits
Coordinates well with State Pharmacy Assistance Program (SPAP) prescription drug coverage, like PACE or PACENET
Low prescription drug copayments of $5 for generics and $38 for preferred-brand drugs for a 31-day supply
Vision coverage, including $150 toward the cost of the one routine eye exam and eyewear every 2 years
Membership to a participating fitness club with our Silver&Fit fitness program at no additional cost

Benefits:	You Pay:
High-Level Benefits:
Monthly Plan Premium	$119
Annual Maximum Out-of-Pocket Limit	In-network: $3,400 Out-of-network: n/a
Annual Out-of-Pocket Deductible	n/a
Primary Care Doctor Visit Copay	$15
Specialist Doctor Visit Copay	$40
Inpatient Hospital Copay	$300 per stay; $900 maximum
Detailed Benefits:
Inpatient Mental Health Copay	$300 per stay; $900 maximum
Outpatient Services/Surgery	$200 per visit; $400 maximum
Outpatient Rehabilitation Services (speech, occupational, and physical therapy)	$40
Mental Health Services	$40
Emergency and Urgent Care	$50
Ambulance	$100
Routine Vision	You receive: $150 toward the cost of one routine eye exam and eyewear every 2 years
Routine Hearing	No routine hearing
Routine Chiropractic	$40 per visit; limit 6 visits
Routine Podiatry	$40 per visit; limit 4 visits
Durable Medical Equipment	20% of the cost per item
Diagnostic Tests, X-rays, and Lab Services	$0 for clinical/diagnostic lab services $30 for general x-rays $90 for CT scans, MRIs, MRAs, and PET scans $25 for radiation therapy, up to $100 maximum
Preventive Screenings	$0 for routine physical exams and preventive screenings
Skilled Nursing Facility	$25 each day, days 1-10 $70 each day, days 11-55 $0 each day, days 56-100; $3,400 maximum
Health and Fitness Program	Silver&Fit^® fitness program which provides membership to a participating fitness club at no additional cost
Worldwide Emergency Travel Assistance	Assist America^® provides emergency travel assistance when you're 100 miles from home or in another country
Prescription Drug Coverage:
In-Network Retail Pharmacy (1 month - 31-day supply)	$5 Generics $38 Preferred Brand $86 Non-Preferred Brand 33% of the cost for Specialty Drugs
In-Network Retail Pharmacy (3 months - 90-day supply)	$10 Generics $95 Preferred Brand $258 Non-Preferred Brand
Coverage After You Reach Your Initial Coverage Limit	You pay a maximum of 93% of the costs for generic drugs and a discounted price for the total cost of brand-name drugs.
Catastrophic Coverage	After your yearly out-of-pocket drugs costs reach $4,550, you pay the greater of: $2.50 for generic and $6.30 for all other drugs, or 5% coinsurance.
Extra Services and Programs:
Health Care Concierge	A special team of Health Care Concierges who can help you understand your benefits and answer your questions.
UPMC Resources for Life⁺	We have specialists who can connect you to resources for: legal guidance, financial counseling, household budgeting, and short-term telephone counseling.
Dental Discount Card⁺	Savings starting at 15% on dental services, such as routine cleanings and exams, x-rays and fillings, root canals and crowns, and dentures and bridges.
Brain Health and Fitness Program⁺	The InSight™ software program to load on your computer with exercises to help you keep your brain healthy and fit.
MyHealth Advice Line	24/7 health advice from experienced, registered nurses with one phone call.
MyHealth OnLine⁺	An Internet-based resource that gives you access to information about your health care visits, prescription refills, membership claims, and information on your benefits.
Care Management Programs	One-on-one support from health coaches who can help you live with chronic medical conditions, such as heart failure, asthma, diabetes, high blood pressure, depression, and more.

Click here for a list of additional plan documents and forms.

Call us toll-free: 1-866-400-5077
TTY/TDD: 1-800-361-2629

Hours: 8 a.m. to 8 p.m.,*
seven days a week

⁺The products and services described are neither offered nor guaranteed under contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any dispute regarding these products and services may be subject to the UPMC for Life grievance process.

Limitations, copayments, and restrictions may apply to plan benefits. Plan benefits and cost-sharing may change from year-to-year.

You must continue to pay your Medicare Part B premium.

UPMC for Life is a Medicare Advantage organization with a Medicare contract. UPMC for Life is a product of and operated by UPMC Health Plan, Inc., UPMC Health Network, Inc., and UPMC Health Benefits, Inc.

Members may enroll in the plan only during specific times of the year. For questions about your Medicare eligiblity or more information, call us at the phone number above.

Beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this extra help, contact 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, 7 days a week; the Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday (TTY/TDD users should call 1-800-325-0778); or your State Medicaid Office.