UPMC for Life HMO No Rx (HMO)
UPMC HEALTH PLAN, INC. · 2026 plan year
Plan ID H3907-002-000
Showing OH · also offered in: PA
HMO★ 4.5 CMS Stars
- MOOP (in-network)
- $6,000
- MOOP (combined)
- —
- Monthly premium
- $0/mo
- Prescription drugs
- Not included
This plan in 2027
Plan information
- Contract / Plan / Segment
- H3907-002-000
- Medical deductible
- $0 — no deductible
- Also owed
- Your Medicare Part B premium, paid separately
More UPMC HEALTH PLAN, INC. plans in OH
Benefits & cost sharing
Hospital
| Benefit | In-network |
|---|---|
| Inpatient Hospital — Acute | $495 per stay |
| Inpatient Hospital — Additional Days (Acute) | No charge |
| Inpatient Hospital — Psychiatric | $495 per stay |
| Worldwide Urgent Care Coverage | $50 |
Pharmacy
| Benefit | In-network |
|---|---|
| Part B Drugs | See plan details |
| Chemotherapy & Radiation Drugs (Part B) | 0%-20% coinsurance |
| Other Part B Drugs | 0%-20% coinsurance |
Mental Health
| Benefit | In-network |
|---|---|
| Mental Health Specialty Services | See plan details |
| Mental Health — Individual Sessions | $25 |
| Mental Health — Group Sessions | $25 |
| Supplemental Health Benefits | See plan details |
Other
| Benefit | In-network |
|---|---|
| Diabetic Supplies | 0%-20% coinsurance |
| Dental — Oral & Maxillofacial Surgery | 50% coinsurance |
| Primary Care Physician Services | No charge |
| Worldwide Emergency Transportation | $290 |
| Partial Hospitalization Program | No charge |
| Intensive Outpatient Program (IOP) | No charge |
| Home Health Services | No charge |
| Skilled Nursing Facility (SNF) | $0/day for days 1–20, $80/day for days 21–100 |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | No charge |
| Intensive Cardiac Rehabilitation — Additional Sessions | No charge |
| Pulmonary Rehabilitation — Additional Sessions | No charge |
| Supervised Exercise Therapy (SET) | No charge |
| Emergency Services | $130 |
| Urgently Needed Services | $50 |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Worldwide Emergency Coverage | $130 |
| Chiropractic Services | $15 |
| Occupational Therapy Services | $25 |
| Physician Specialist Services | $25 |
| Podiatry Services | $25 |
| Podiatry Services | $25 |
| Other Health Care Professional Services | $25 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | $25 |
| Psychiatric Services — Group Sessions | $25 |
| Physical Therapy & Speech-Language Pathology | $25 |
| Additional Telehealth Services (Part B) | $0-$25 |
| Opioid Treatment Program Services | $25 |
| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | No charge |
| Laboratory Services | No charge |
| Radiological Services | See plan details |
| Diagnostic Radiology | $110 |
| Therapeutic Radiology | $80 |
| X-Ray Services | No charge |
| Outpatient Hospital Services | $250 |
| Hospital Observation Services | $250 per stay |
| Ambulatory Surgical Center (ASC) | $250 |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | $25 |
| Substance Abuse — Group Sessions | $25 |
| Outpatient Blood Services | No charge |
| Ambulance Services | See plan details |
| Ground Ambulance | $50-$290 |
| Air Ambulance | $290 |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Prosthetics & Orthotics | See plan details |
| Prosthetic Devices | 20% coinsurance |
| Medical Supplies | 20% coinsurance |
| Diabetic Supplies & Services | See plan details |
| Diabetic Therapeutic Shoes & Inserts | 20% coinsurance |
| Dialysis Services | 20% coinsurance |
| Over-the-Counter (OTC) Items | No charge |
| Meal Benefit | No charge |
| Medicare-Covered Preventive Services | See plan details |
| Smoking & Tobacco Cessation Counseling | No charge |
| Fitness Benefit | No charge |
| Remote Access Technologies | No charge |
| Home & Bathroom Safety Devices | No charge |
| Counseling Services | No charge |
| In-Home Safety Assessment | No charge |
| Caregiver Support Services | No charge |
| Kidney Disease Education Services | No charge |
| Glaucoma Screening | No charge |
| Diabetes Self-Management Training | No charge |
| Digital Rectal Exams | No charge |
| Welcome to Medicare EKG | No charge |
| Insulin (Part B) | 0%-20% coinsurance (max $35) |
| Dental — Medicare-Covered Services | $25 |
| Dental — Preventive | See plan details |
| Dental — Oral Exams | No charge |
| Dental — X-Rays | No charge |
| Dental — Prophylaxis (Cleaning) | No charge |
| Dental — Comprehensive | See plan details |
| Dental — Restorative Services | 50% coinsurance |
| Dental — Endodontics (Root Canal) | 50% coinsurance |
| Dental — Periodontics (Gum Care) | 50% coinsurance |
| Dental — Removable Prosthodontics (Dentures) | 50% coinsurance |
| Dental — Fixed Prosthodontics (Bridges) | 50% coinsurance |
| Vision — Eye Exams | $25 |
| Vision — Eye Exams | See plan details |
| Vision — Routine Eye Exams | No charge |
| Vision — Other Eye Services | No charge |
| Vision — Eyewear | No charge |
| Vision — Eyewear | See plan details |
| Vision — Contact Lenses | No charge |
| Vision — Eyeglasses (Lenses & Frames) | No charge |
| Vision — Eyewear Upgrades | No charge |
| Hearing — Exams | $25 |
| Hearing — Exams | See plan details |
| Hearing — Routine Exams | No charge |
| Hearing — Fitting & Evaluation for Hearing Aid | No charge |
| Hearing — Prescription Hearing Aids | See plan details |
| Hearing — Hearing Aids (All Types) | $690-$1,890 |
Service area
- OH: 2 counties
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