4

4 out of 5 stars* for plan year 2024

Plan ID: H3907-049

What You Need to Know:

  • UPMC for Life HMO Rx Choice (HMO) is a Medicare Advantage Health Maintenance Organization Local HMO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $40, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $7,550 per year (in-network).
  • UPMC for Life HMO Rx Choice (HMO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $40.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$40

Monthly Premium

Medicare Plan Features
Monthly Premium: $40.00
Part C Premium: $0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$40.00 $0 $40.00 $0 $40.00 $0 0.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local HMO
Similar Plan: H3907-050
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $7,550
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Armstrong, Pennsylvania: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
609 members 4 out of 5 Stars. 4 out of 5 Stars. 4 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,692 drugs
Number of Members Enrolled in this Plan in Armstrong, Pennsylvania: 43,986 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$0.00 $40.00 $0.00 $40.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$2.50 $30.60 $30.60 $21.30 $21.30 $11.90 $11.90
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
331 $0.00 1037 $10.00 559 $47.00 873 $100.00 892 33%

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3
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HumanaChoice R0923-002 (Regional PPO) (2023)Regional PPO$6,700$0
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UPMC for Life PPO High Deductible with Rx (PPO) (2023)Local PPO$7,550$0
3
Aetna Medicare Advantra Credit Value (PPO) (2023)Local PPO$7,550$250
5
UPMC for Life PPO Rx Enhanced (PPO) (2023)Local PPO$7,550$0
3
Humana Honor (PPO) (2023)Local PPO *$6,700$-
4
Aetna Medicare Gold Plan (PPO) (2023)Local PPO$7,550$0
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Security Blue HMO-POS Deluxe (HMO-POS) (2023)Local HMO$4,500$0
4
Community Blue Medicare HMO Signature (HMO) (2023)Local HMO$7,550$0
4
Aetna Medicare Value (PPO) (2023)Local PPO$7,550$0
5
HumanaChoice H5216-116 (PPO) (2023)Local PPO *$3,900$-
4
Aetna Medicare Advantra Gold (HMO) (2023)Local HMO$4,900$0
5
Security Blue HMO-POS ValueRx (HMO-POS) (2023)Local HMO$5,500$0
4
Aetna Medicare Advantra Silver (HMO) (2023)Local HMO$7,550$0
5
Community Blue Medicare HMO Prestige (HMO) (2023)Local HMO$6,700$0
4
Humana Value Plus H5216-117 (PPO) (2023)Local PPO$6,700$420
4
Security Blue HMO-POS Basic (HMO-POS) (2023)Local HMO *$5,900$-
4
Freedom Blue PPO Classic (PPO) (2023)Local PPO$4,500$0
4
AARP Medicare Advantage Patriot (HMO) (2023)Local HMO *$5,500$-
5
Aetna Medicare Advantra Eagle (HMO) (2023)Local HMO *$4,000$-
5
Allwell Medicare Complement (HMO) (2023)Local HMO$7,550$445
4
Security Blue HMO-POS Standard (HMO-POS) (2023)Local HMO$5,000$0
4
Allwell Medicare Boost (HMO) (2023)Local HMO$7,550$0
4
UPMC for Life HMO Rx (HMO) (2023)Local HMO$7,550$0
4
Complete Blue PPO Distinct (PPO) (2023)Local PPO$6,500$0
4
UPMC for Life HMO Deductible with Rx (HMO) (2023)Local HMO$7,550$0
4
Lasso Healthcare Growth (MSA) (2023)MSA *$-$-
4
AARP Medicare Advantage Choice (PPO) (2023)Local PPO$4,900$0
New plan - not yet rated.
Lasso Healthcare Growth Plus (MSA) (2023)MSA *$-$-
4
Allwell Medicare (HMO) (2023)Local HMO$6,700$0
4
Aetna Medicare Silver (HMO) (2023)Local HMO$7,550$0
5
UPMC for Life HMO No Rx (HMO) (2023)Local HMO *$7,550$-
4
Allwell Medicare Simple (HMO) (2023)Local HMO *$3,450$-
4
Freedom Blue PPO Select (PPO) (2023)Local PPO$5,000$0
4
AARP Medicare Advantage Plan 1 (HMO) (2023)Local HMO$6,700$0
5
UPMC for Life HMO Rx Enhanced (HMO) (2023)Local HMO$7,550$0
4
AARP Medicare Advantage Plan 2 (HMO) (2023)Local HMO$5,500$0
5
Freedom Blue PPO ValueRx (PPO) (2023)Local PPO$5,500$0
4
Medicare Advantage Plans by UPMC for Life
UPMC for Life PPO High Deductible with Rx (PPO) (2023)Local PPO$7,550$0
3
UPMC for Life PPO Rx Enhanced (PPO) (2023)Local PPO$7,550$0
3
UPMC for Life HMO Rx (HMO) (2023)Local HMO$7,550$0
4
UPMC for Life HMO Deductible with Rx (HMO) (2023)Local HMO$7,550$0
4
UPMC for Life HMO No Rx (HMO) (2023)Local HMO *$7,550$-
4
UPMC for Life HMO Rx Enhanced (HMO) (2023)Local HMO$7,550$0
4

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