UPMC for Life HMO Rx (HMO) 2025 Plan Details for Sullivan County, Pennsylvania Residents
UPMC for Life HMO Rx (HMO) 2025 Plan Details for Sullivan County, Pennsylvania Residents
Navigating your Medicare Advantage options in Sullivan County for 2025 can be overwhelming, but we're here to help. With UPMC for Life HMO Rx (HMO) included in your plan options, you can evaluate it alongside other plans to make an informed decision. Enroll online quickly, or consult with a licensed agent if you need assistance.
Based on May, 2025 CMS enrollment data, an estimated 31,394 Medicare beneficiaries are enrolled in this plan, with 0 members in Sullivan County, PA.
UPMC for Life HMO Rx Overview
| Plan ID H3907-058-1 Overview | |
|---|---|
| Health Plan ID: | H3907-058-1 |
| Medicare Advantage Plan Type: | HMO |
| Plan Year: | 2025 |
| Monthly Premium: | $90.00 Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Annual Out-of-Pocket Maximum: | $4,500.00 (In-Network) |
| Part B Give Back: | $0.00/mo |
| Part D Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Availability: | Sullivan County, PA |
| Insured By: | UPMC for Life |
Explore the Benefits of UPMC for Life HMO Rx
UPMC for Life HMO Rx is a Medicare Advantage Prescription Drug (MAPD) Health Maintenance Organization (HMO) plan that combines hospital, medical, and drug coverage into one streamlined option. With a monthly premium of $90.00, it includes all benefits under Medicare Part A and Part B, along with built-in prescription drug coverage. The annual Part D deductible is $0.00. You’ll typically need to use doctors and providers in the plan’s network, except for emergency situations.
Primary care visits have a not covered, specialist visits come with a $25 copay, urgent care services carry a $55 copay, and ambulance transportation is $270 copay. These costs all apply toward the plan’s maximum out-of-pocket (MOOP) limit of $4,500.00 . Once that limit is met, all in-network healthcare services are fully covered for the rest of the year. That’s a major plus for those who want both medical and drug coverage bundled into one predictable package.
This plan is listed by CMS as H3907-058-1. You’ll find a summary of its cost sharing below, including what you can expect to pay for primary care, specialists, urgent care, and more. Still have questions? Check the FAQ section for more details.
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Cost-Sharing Overview
With UPMC for Life HMO Rx , you'll have cost-sharing expenses, which are the out-of-pocket costs for approved healthcare services. The table below provides a summary of the typical in-network out-of-pocket costs associated with plan H3907-058-1.
Find out the costs for visiting your primary care doctor and specialists, as well as coverage for wellness and preventive programs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $25 Copay |
Review the costs for emergency services, urgent care, ambulance services, inpatient hospital stays, and skilled nursing facility care.
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $125 Copay |
| Urgent care: | $55 Copay |
| Ground ambulance: | $270 Copay |
| Inpatient hospital care: | $295.00 per stay |
| Skilled Nursing Facility: | $10.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
This section covers Medicare-approved foot care services, including exams and routine foot care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $25 Copay |
| Routine Foot Care: | $25 Copay |
Understand the coverage for Medicare-approved chiropractic services and routine chiropractic care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $18 Copay Prior Authorization Required |
| Routine chiropractic: | Not Covered |
This section explains the costs for mental health services, including individual and group therapy, and inpatient care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $25 Copay |
| Outpatient group therapy: | $25 Copay |
| Inpatient psychiatric hospital care: | $295.00 per stay |
See the cost details for rehabilitation services, including physical therapy, speech therapy, and occupational therapy.
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $25 Copay Prior Authorization Required |
| Occupational therapy: | $25 Copay Prior Authorization Required |
Learn about the costs associated with medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | 20% Coinsurance Prior Authorization Required |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
This section outlines the costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $175 Copay Prior Authorization Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | $25 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | Not Covered |
Review the cost-sharing details for chemotherapy and other Medicare Part B-covered drugs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
This section details the dental services covered under your plan including, Medicare-covered preventive dental, oral exams, x-rays, dental cleanings, and comprehensive dental.
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $25 Copay |
| Oral exam | |
| Dental x-rays | |
| Cleaning | |
| Periodontics | |
| Endodontics | |
| Restorative Services |
This section outlines the coverage for hearing-related services, including exams, fittings, and hearing aids.
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Covered Limits may apply |
| Hearing exam | Covered Limits may apply |
Learn about the costs for vision-related services, including eye exams, eyeglasses, and contact lenses.
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | $25 Copay |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | Eyeglasses: Yes Contact Lenses: Yes Eyeglass Lenses: No Eyeglass Frames: No Eyewear Upgrades: No |
Maximum eyewear benefit: | $225.00 Every year |
Certain preventive services are covered 100% by UPMC for Life HMO Rx as a Part B benefit.
Part D Prescription Drug Costs & Benefits
UPMC for Life HMO Rx includes an enhanced benefit Medicare Part D plan (PDP), which offers greater coverage than basic plans. An enhanced benefit plan has a higher actuarial value, meaning it covers a larger percentage of your healthcare costs.
Part D Plan Premium
The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.
| Basic Part D Premium: | $21.40 |
|---|---|
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $21.40 |
| Low-Income Premium Subsidy: | ${part_d_lips_amount} |
| Low-Income Premium Subsidy Paid by CMS: | $21.40 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a $0.00 annual Part D deductible. You'll pay this deductible at the pharmacy before UPMC for Life starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, UPMC for Life HMO Rx may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 | $15.00 |
| Generic | $0.00 | $20.00 |
| Preferred Brand | $47.00 | $47.00 |
| Non-Preferred Drug | 49.00% | 49.00% |
| Specialty Tier | 33.00% | 33.00% |
| *Deductible does not apply. | ||
CMS 5-Star Rating Overview
The Centers for Medicare & Medicaid Services (CMS) reviews and rates Medicare Advantage (Part C) and drug plans (Part D) annually, using a 5-star system to measure aspects such as member satisfaction, preventive services, and management of chronic conditions.
Higher star ratings generally indicate better plan performance, which can be a useful factor to consider when deciding on a plan that aligns with your healthcare goals and preferences.
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall 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 |
If you are new to Medicare or Medicare Advantage plans, the following information will help you understand the enrollment process and restrictions.
Who Can Enroll in UPMC for Life HMO Rx ?
To enroll in UPMC for Life HMO Rx , you must meet the following criteria:
- Be eligible for Medicare Part A and Part B.
- Reside in the plan’s service area.
If you meet these requirements, you are eligible to enroll in UPMC for Life HMO Rx and benefit from its comprehensive coverage options.
Enrollment Periods for UPMC for Life HMO Rx
Knowing when you can enroll in UPMC for Life HMO Rx is essential. Here are the main enrollment periods:
- Initial Enrollment Period (IEP): Your IEP starts three months before your 65th birthday and ends three months after, giving you a seven-month window to enroll in Medicare.
- Annual Enrollment Period (AEP): The AEP, from October 15 to December 7, allows you to make changes to your Medicare Advantage plan if you are currently enrolled in a Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (MA OEP): Running from January 1 to March 31, the MA OEP lets you switch plans or return to Original Medicare if you are currently enrolled in a Medicare Advantage plan.
- Special Enrollment Periods (SEPs): Life events such as moving or losing coverage may qualify you for a SEP, enabling you to enroll or make changes outside the usual periods.
If you're uncertain about the right time to enroll, Call HealthCompare (our trusted enrollment partner) at 1-833-748-3201 (TTY 711) for guidance from a licensed insurance agent.
Steps to Enroll in UPMC for Life HMO Rx
Enrolling in UPMC for Life HMO Rx is easy. Choose the option that works best for you:
- Online through MedicareEnrollment.com: Visit the enrollment page and complete your enrollment through their Secure Online Enrollment Form.
- By Phone: Call HealthCompare (our trusted enrollment partner) at 1-833-748-3201 (TTY 711). A licensed insurance agent can assist you with the enrollment process and provide answers to any questions.
- Through Medicare.gov: Go to Medicare.gov, log in or create an account, and follow the instructions to join UPMC for Life HMO Rx through the official Medicare website.
- Directly with UPMC for Life HMO Rx : You can also enroll directly with the plan. The necessary contact details are provided below in the "Contact" section.
Remember to enroll during the correct enrollment period to ensure your coverage starts on time.
Here are some of the most frequently asked questions people have about plan ID H3907-058-1:
What’s the monthly premium for UPMC for Life HMO Rx (HMO)?
The 2025 premium is $90.00 each month, and you must continue to pay your Part B premium.
How high can my costs go in a worst-case year?
For 2025, the maximum you’d spend out-of-pocket in-network is $4,500.00 .
What’s the prescription-drug deductible for 2025?
Yes. The Part D deductible is $0.00. The plan does not have a drug tier without a deductible.
What’s the CMS star score for UPMC for Life HMO Rx ?
CMS rates it ★4.5 out of 5 stars for 2025.
How many members does UPMC for Life HMO Rx have?
Enrollment stands at roughly 31,394 members.
Contact UPMC for Life
| Website: | UPMC for Life Plan Page |
|---|---|
| Providers: | UPMC for Life Providers Page |
| Formulary: | UPMC for Life Formulary Page |
| Pharmacy: | UPMC for Life Pharmacy Page |
| New Member Health Plan Help: | (877)381-3765 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (877)381-3765 |
| New Member Part D TTY Users: | 711 |
If you're eligible for Medicare but haven't enrolled or need to verify your enrollment status, visit the Social Security Administration website. For more information about Medicare Advantage, visit medicare.gov.
- UPMC for Life, https://www.upmchealthplan.com/medicare/, Last Accessed June 1, 2025
- Medicare.gov, "Compare types of Medicare Advantage Plans", Last Accessed 25 May, 2025
- AARP.org, "The Big Choice: Original Medicare vs. Medicare Advantage", Last Accessed 25 May, 2025
- Medicare.gov, "Your coverage options", Last Accessed 25 May, 2025
- CMS.gov, Landscape Source Files, Last Accessed October 15, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 15, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 15, 2024
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County, Last Accessed June 6, 2025
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