UPMC for Life HMO Rx Choice (HMO) Medicare Advantage Plan H3907-057-4 • 2027 • Potter County, PA
- Monthly Premium
- $40.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $6000.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $700.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- Potter County, PA
- Local Enrollment
- 70 beneficiaries in Potter County
UPMC for Life HMO Rx Choice (HMO) Introduction
This Medicare Advantage HMO plan, UPMC for Life HMO Rx Choice, is offered by UPMC for Life and uses a Health Maintenance Organization (HMO) provider network. It comes with prescription drug coverage. For the 2027 plan year, the monthly premium is $40.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $6000.00. The plan is identified by CMS Plan ID H3907-057-4. The 2027 Part D prescription drug deductible is $700.00.
Enrollment in this plan requires residence in Potter County, Pennsylvania. CMS enrollment data reports 70 plan members in Potter County. New members can call the plan directly at (877)381-3765 (TTY 711) for assistance.
Compare Similar Plans in Potter County
Compare this plan with the two most-enrolled HMO plans available in Potter County, Pennsylvania. Enrollment is based on CMS local enrollment data.
| Plan Detail | UPMC for Life HMO Rx Choice | Community Blue Medicare HMO Signature | UPMC for Life HMO No Rx |
|---|---|---|---|
| CMS Plan ID | H3907-057-4 |
H3957-047-4 |
H3907-002-0 |
| Local Enrollment | 70 | 44 | 24 |
| Monthly Premium | $40.00 | $0.00 | $0.00 |
| Medical Deductible | $0.00 | $0.00 | $0.00 |
| Maximum Out-of-Pocket | $6,000.00 | $6,950.00 | $6,500.00 |
| Part B Giveback | Not offered | Not offered | −$140.00 reduction |
| Primary Care | $0 copay | $0 copay | $0 copay |
| Specialist | $35 copay | $40 copay | $40 copay |
| Part D Deductible | $700.00 | $700.00 | Not Applicable |
| CMS Star Rating | 4.5 | 4.5 | 4.5 |
| Dental | $0 copay | $0 copay | $0 copay |
| Vision | $0 copay | $0 copay | $0 copay |
| Hearing | $0 copay | $10 copay | $0 copay |
Want to explore more options? Browse all Medicare Advantage plans in Potter County, or compare Medicare Advantage plans across Pennsylvania, including premiums, out-of-pocket costs, CMS ratings, and enrollment.
Plan Benefits
UPMC for Life HMO Rx Choice includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The tables below outline the most common in-network out-of-pocket costs associated with plan H3907-057-4.
You can also compare 2027 costs and coverage with last year, side-by-side: Plan H3907-057-4 Cost Compare.
Office Visits
- Primary care
- In-network: $0 copay
- Specialist
- In-network: $35 copay
Preventive and Wellness Services
- Annual wellness exam
- Not covered
- Telehealth benefit
- In-network: $0-$35 copay
- Routine chiropractic
- Not covered
- Fitness benefits
- Coming soon
- Health education
- Not covered
- Counseling services
- In-network: $0 copay
- Over-the-counter drug benefits
- In-network: $0 copay
- Health transportation (non-emergency)
- Coming soon
Diagnostic, Lab, and Imaging Services
- Diagnostic radiology services
- In-network: $220 copay
- Lab services
- In-network: $5 copay
- Outpatient x-rays
- In-network: $25 copay
- Diagnostic tests and procedures
- In-network: $5 copay
Emergency and Urgent Care Services
- Emergency room care
- $130 copay
- Worldwide emergency care
- Coming soon
- Urgent care
- $50 copay
- Inpatient hospital care
- Tier 1
$400 per stay - Skilled Nursing Facility
- Tier 1
$10 per day for days 1-20
$221 per day for days 21-100 - Ground ambulance
- In-network: $50-$270 copay
Mental Health Services
- Outpatient individual therapy
- In-network: $35 copay
- Outpatient group therapy
- In-network: $35 copay
- Inpatient psychiatric hospital care
- Tier 1
$400 per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- In-network: $35 copay
- Occupational therapy
- In-network: $35 copay
Medical Equipment and Supplies
- Diabetes supplies
- In-network: 0%-20% coinsurance
- Durable medical equipment
- In-network: 20% coinsurance
- Prosthetics
- In-network: 20% coinsurance
Medicare Part B Drugs
- Chemotherapy
- In-network: 0%-20% coinsurance
- Other Part B drugs (Medicare-covered)
- In-network: 0%-20% coinsurance
Dental Services
- Oral exam
- In-network: $0 copay
- Dental x-rays
- In-network: $0 copay
- Cleaning
- In-network: $0 copay
- Periodontics
- In-network: 50% coinsurance
- Endodontics
- In-network: 50% coinsurance
- Restorative services
- In-network: 50% coinsurance
- Implant services
- Not covered
- Orthodontics
- Not covered
- Oral/Maxillofacial surgery
- In-network: 50% coinsurance
Vision Services
- Routine eye exam
- In-network: $0 copay
- Contact lenses
- In-network: $0 copay
- Eyeglass frames only
- Not covered
- Eyeglass lenses only
- Not covered
- Eyeglasses (frames & lenses)
- In-network: $0 copay
- Upgrades
- In-network: $0 copay
Hearing Services
- Hearing exam
- In-network: $0 copay
- Fitting/evaluation
- In-network: $0 copay
- Prescription hearing aids
- In-network: $690-$1890 copay
- OTC hearing aids
- Not covered
Additional and Special Needs Services
- Adult day health services
- Not covered
- Home-based palliative care
- Not covered
- Personal emergency response system
- Coming soon
- Weight management programs
- Not covered
- Wigs for chemotherapy-related hair loss
- Coming soon
- Alternative therapies
- Not covered
- Massage therapy
- Not covered
- Home/bathroom safety devices
- In-network: $0 copay
Certain preventive services are covered 100% by UPMC for Life HMO Rx Choice as a Part B benefit.
Prescription Drug Coverage
UPMC for Life HMO Rx Choice includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $28.30 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $28.30 |
| Low-Income Premium Subsidy: | $12.80 |
| Low-Income Premium Subsidy Paid by CMS: | $12.80 |
| Low-Income Subsidy Premium: | $15.50 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $700.00 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 Choice 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 copay | Coming soon |
| Generic | $0.00 copay | Coming soon |
| Preferred Brand | 25% coinsurance | Coming soon |
| Non-Preferred Drug | 28% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H3907)
Medicare Advantage (Part C) and Part D plans are rated each year by CMS on a 5-star scale. Ratings summarize plan performance across clinical care and member experience measures.
| CMS Measure | Star Rating |
|---|---|
| 2027 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 |
Contact Information for 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
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Medicare Advantage Plan Availability
UPMC for Life HMO Rx Choice is available to eligible Medicare beneficiaries residing in Potter County, Pennsylvania, including communities such as Shinglehouse, Coudersport, Galeton, Ulysses, and other areas throughout the county. Enrollment eligibility is based on county of residence, not city.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| UPMC for Life (official source) | https://www.upmchealthplan.com/medicare/ | October 4, 2026 |
| Medicare.gov | Compare types of Medicare Advantage Plans | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
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Provenance documentation for this data is maintained under the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.