UPMC for Life HMO No Rx (HMO)


Medicare Plan Details

2021 Plan
Monthly Premium
(select county for price)

 

by UPMC for Life
Additional Coverage
Hearing Vision Dental
Overall Government Star Rating
 4.0
out of 5 stars

State: Pennsylvania

Select your county to view the price for this plan

 


Plan Type

Medicare Advantage (Part C)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B

 

$0
$0
$0
$0
$7,550 In-network
No
Yes
Yes
Yes

Medical Benefits

Doctor Services

$0 copay
$45 copay per visit

Tests, labs, & imaging

$5 copay
$5 copay
$110 copay
$30 copay
$90 copay per visit (always covered)
$65 copay per visit (always covered)

Hospital Services

$300 per stay
$225 copay per visit

Skilled nursing facility

$0 per day for days 1 through 20
$80 per day for days 21 through 100

Preventive services

$0 copay

Ambulance

$50-125 copay

Therapy services

$40 copay
$40 copay

Mental health services

$40 copay
$40 copay
$40 copay
$40 copay

Opioid treatment services

Covered

Other services

20% coinsurance per item
20% coinsurance per item
20% coinsurance per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Part B Drugs

20% coinsurance
20% coinsurance

Extra Benefits

Hearing

$45 copay
$0 copay
$0 copay

Preventive Dental

$0 copay
$0 copay
Not covered
$0 copay

Comprehensive dental

$0 copay
Not covered
$0 copay
Not covered
Not covered
$0 copay
Not covered

Vision

$0 copay
$0 copay
$0 copay
Not covered
Not covered
Not covered

Other benefits

Limited coverage
Limited coverage
Not covered
Limited coverage
Limited coverage
Limited coverage
Limited coverage
 4
 3
 4
 5
 4
 5

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