MedicareCommons™

Neutral. Transparent. Retrieval-first.

array(20) { ["plan_name"]=> string(41) "UPMC for Life PPO Essential Care Rx (PPO)" ["plan_id"]=> string(9) "H5533-017" ["org_name"]=> string(13) "UPMC for Life" ["plan_type"]=> string(9) "Local PPO" ["region"]=> string(47) "Western, Central, and Northeastern Pennsylvania" ["moop"]=> string(12) "Data missing" ["deductible"]=> string(12) "Data missing" ["inpatient_hospital"]=> string(106) "$380.00 (days 1–5), $0.00 (days 6–90), $0.00 (days –)
Prior Authorization Required" ["snf"]=> string(109) "$0.00 (days 1–20), $214.00 (days 21–100), $0.00 (days –)
Prior Authorization Required" ["pcp"]=> string(11) "Not Covered" ["specialist"]=> string(59) "$15.00 Copay
Prior Authorization Required" ["urgent_care"]=> string(59) "$35.00 Copay
Prior Authorization Required" ["er"]=> string(60) "$380.00 Copay
Prior Authorization Required" ["ambulance_ground"]=> string(69) "$50.00 - $280.00 Copay
Prior Authorization Required" ["ambulance_air"]=> string(60) "$280.00 Copay
Prior Authorization Required" ["dental"]=> string(37) "$0.00 max
$0.00 max" ["vision"]=> string(48) "Not Covered
$200.00/yr eyewear" ["hearing"]=> string(11) "Not Covered" ["rx"]=> array(2) { ["deductible"]=> string(7) "$350.00" ["tiers"]=> array(5) { [0]=> array(11) { ["order"]=> int(1) ["name"]=> string(29) "Preferred Generic*" ["deductible"]=> string(8) "Excluded" ["deductible_flag"]=> string(8) "Excluded" ["retail_30"]=> string(12) "$15.00 Copay" ["retail_90"]=> string(12) "$30.00 Copay" ["mail_30"]=> string(12) "$15.00 Copay" ["mail_90"]=> string(12) "$30.00 Copay" ["ltc_30"]=> string(11) "$0.00 Copay" ["out_network"]=> string(12) "$15.00 Copay" ["post_oop"]=> string(11) "$0.00 Copay" } [1]=> array(11) { ["order"]=> int(2) ["name"]=> string(19) "Generic*" ["deductible"]=> string(8) "Excluded" ["deductible_flag"]=> string(8) "Excluded" ["retail_30"]=> string(12) "$20.00 Copay" ["retail_90"]=> string(12) "$40.00 Copay" ["mail_30"]=> string(12) "$20.00 Copay" ["mail_90"]=> string(12) "$40.00 Copay" ["ltc_30"]=> string(11) "$0.00 Copay" ["out_network"]=> string(12) "$20.00 Copay" ["post_oop"]=> string(11) "$0.00 Copay" } [2]=> array(11) { ["order"]=> int(3) ["name"]=> string(15) "Preferred Brand" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(12) "$47.00 Copay" ["retail_90"]=> string(13) "$141.00 Copay" ["mail_30"]=> string(12) "$47.00 Copay" ["mail_90"]=> string(13) "$141.00 Copay" ["ltc_30"]=> string(12) "$47.00 Copay" ["out_network"]=> string(12) "$47.00 Copay" ["post_oop"]=> string(11) "$0.00 Copay" } [3]=> array(11) { ["order"]=> int(4) ["name"]=> string(18) "Non-Preferred Drug" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(15) "50% Coinsurance" ["retail_90"]=> string(15) "50% Coinsurance" ["mail_30"]=> string(15) "50% Coinsurance" ["mail_90"]=> string(15) "50% Coinsurance" ["ltc_30"]=> string(15) "50% Coinsurance" ["out_network"]=> string(15) "50% Coinsurance" ["post_oop"]=> string(11) "$0.00 Copay" } [4]=> array(11) { ["order"]=> int(5) ["name"]=> string(9) "Specialty" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(15) "28% Coinsurance" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(15) "28% Coinsurance" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(15) "28% Coinsurance" ["out_network"]=> string(15) "28% Coinsurance" ["post_oop"]=> string(11) "$0.00 Copay" } } } ["data_status"]=> string(2) "ok" }
🩺 Doctor’s Office Visits
Service 2026 2025
PrimaryComing soonNot Covered
SpecialistComing soon$15.00 Copay
Prior Authorization Required
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
Service 2026 2025
Emergency room careComing soon$380.00 Copay
Prior Authorization Required
Urgent careComing soon$35.00 Copay
Prior Authorization Required
Ground ambulanceComing soon$50.00 - $280.00 Copay
Prior Authorization Required
Inpatient hospital careComing soon$380.00 (days 1–5), $0.00 (days 6–90), $0.00 (days –)
Prior Authorization Required
Skilled Nursing FacilityComing soon$0.00 (days 1–20), $214.00 (days 21–100), $0.00 (days –)
Prior Authorization Required
🦶 Foot Care
Service 2026 2025
Foot Exams and Treatments (Medicare-covered)Coming soon20% Coinsurance
Routine Foot CareComing soon0% - 20% Coinsurance
Prior Authorization Required
💆 Chiropractic Care
Service 2026 2025
Medicare-covered chiropracticComing soon20% Coinsurance
Prior Authorization Required
Routine chiropracticComing soon20% Coinsurance
Prior Authorization Required
🧠 Mental Health Services
Service 2026 2025
Outpatient individual therapyComing soon$15.00 Copay
Outpatient group therapyComing soon$15.00 Copay
Inpatient psychiatric hospital careComing soon$380.00 (days 1–5), $0.00 (days 6–90), $0.00 (days –)
Prior Authorization Required
🏋️ Rehabilitation Services
Service 2026 2025
Physical therapy and speech/language therapyComing soon$45.00 Copay
Occupational therapyComing soon$45.00 Copay
🧰 Medical Equipment and Supplies
Service 2026 2025
Diabetes suppliesComing soonNot Covered
Prior Authorization Required
Durable medical equipmentComing soon$45.00 Copay
4 visits/yr
ProstheticsComing soon$45.00 Copay
🔬 Diagnostics, Lab Services, and Imaging
Service 2026 2025
Diagnostic radiology servicesComing soon$45.00 Copay
Lab servicesComing soon$35.00 Copay
Prior Authorization Required
Outpatient x-raysComing soon$0.00 - $45.00 Copay
Diagnostic tests and proceduresComing soon$45.00 Copay
💉 Medicare Part B Drugs
Service 2026 2025
ChemotherapyComing soon0% - 20% Coinsurance
Prior Authorization Required
Other Part B drugs (Medicare-covered)Coming soon20% Coinsurance

Supplemental Benefits

🦷 Dental Services
Service 2026 2025
Medicare Covered Preventive DentalComing soon$0.00 max
$0.00 max
Oral examComing soonNot Covered
Dental x-raysComing soonNot Covered
CleaningComing soonNot Covered
PeriodonticsComing soon50% Coinsurance
EndodonticsComing soon50% Coinsurance
Restorative ServicesComing soon50% Coinsurance
Dental MaximumComing soonNot Covered
👂 Hearing Aids and Services
Service 2026 2025
Fitting/evaluationComing soonNot Covered
Hearing aidsComing soon$690.00 - $1,890.00 Copay
Hearing examComing soon$0.00 max
$0.00 max
Hearing MaximumComing soon$0.00 max
👓 Vision Services
Service 2026 2025
Medicare-covered eye examComing soon$0.00 max
$0.00 max
Routine eye examComing soonNot Covered
Eyewear benefitsComing soonNot Covered
Vision Eyewear MaximumComing soon$200.00/yr eyewear
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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.

{name} Prescription Drug Plan Premium Details
Basic Part D Premium: ${part_d_basic_premium}
Supplemental Part D Premium: ${part_d_supplemental_premium}
Total Part D Premium: ${part_d_total_premium}
Low-Income Premium Subsidy: ${part_d_lips_amount}
Low-Income Premium Subsidy Paid by CMS: ${part_d_lips_cms_pays}
Low-Income Subsidy Premium: ${part_d_lis_premium}

For more details, visit the Social Security Extra Help program.

Prescription Drug Plan Deductible

This plan has a ${deductible} annual Part D deductible. You'll pay this deductible at the pharmacy before {carrier} starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, {name} may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

{name} Pharmacy Out-of-Pocket Costs by Drug Tier
Drug Tier Retail Mail Order
Preferred Generic<sup>*</sup>30-day: $15.00 Copay
90-day: $30.00 Copay		30-day: $15.00 Copay
90-day: $30.00 Copay
Generic<sup>*</sup>30-day: $20.00 Copay
90-day: $40.00 Copay		30-day: $20.00 Copay
90-day: $40.00 Copay
Preferred Brand30-day: $47.00 Copay
90-day: $141.00 Copay		30-day: $47.00 Copay
90-day: $141.00 Copay
Non-Preferred Drug30-day: 50% Coinsurance
90-day: 50% Coinsurance		30-day: 50% Coinsurance
90-day: 50% Coinsurance
Specialty30-day: 28% Coinsurance
90-day: —		30-day: 28% Coinsurance
90-day: —
*Deductible does not apply.