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Plan H3907-002-0: UPMC for Life HMO No Rx (HMO) – 2025 Coverage Details for Snyder County, PA

This page provides coverage, cost, and availability details for UPMC for Life’s H3907-002-0 Medicare Advantage plan for 2025.

See more Medicare Advantage Plans in Snyder County, Pennsylvania.

CMS 2025 Rating: ☆☆☆☆☆*

*CMS rated this UPMC for Life plan (H3907-002-0) 4.5 (Good+) out of 5 stars.

Best Insurance Company Ranking
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The UPMC for Life logo is a registered trademark.[2] Its use by MedicareWire is strictly for editorial purposes. This is not a solicitation of insurance.

UPMC for Life HMO No Rx Basic Plan Details

Plan ID
H3907-002-0
Plan Type
HMO
Plan Year
2025
Premium
$0.00/mo
Plus your Medicare Part B premium.
Health Plan Deductible
$0.00
Out-of-Pocket Maximum
5,000.00 /yr (in-network)
Part B Reduction
$0.00/mo
Drug Plan Benefit
Not Included
Supplemental Benefits
Vision, Hearing
Availability
Snyder County, PA
Insured By
UPMC for Life
Summary of Benefits

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Health Plan Out-of-Pocket Costs

This UPMC for Life Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H3907-002-0.

NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.

Doctor's Office Visits

Primary
Not Covered
Specialist
$25 Copay

Emergency, Urgent, and Inpatient Hospital Coverage

Emergency room care
$125 Copay
Urgent care
$55 Copay
Ground ambulance
$290 Copay
Inpatient hospital care
$300.00 per stay
Skilled Nursing Facility
$0.00 per day for days 1 through 20
$80.00 per day for days 21 and beyond

Foot Care

Foot Exams and Treatments (Medicare-covered)
$25 Copay
Routine Foot Care
$25 Copay

Chiropractic Care

Medicare-covered chiropractic
$18 Copay
Prior Authorization Required
Routine chiropractic
Not Covered

Mental Health Services

Outpatient individual therapy
$25 Copay
Outpatient group therapy
$25 Copay
Inpatient psychiatric hospital care
$300.00 per stay

Rehabilitation Services

Physical therapy and speech and language therapy
$25 Copay
Prior Authorization Required
Occupational therapy
$25 Copay
Prior Authorization Required

Medical Equipment and Supplies

Diabetes supplies
20% Coinsurance
Prior Authorization Required
Durable medical equipment
20% Coinsurance
Prior Authorization Required
Prosthetics
20% Coinsurance

Diagnostics, Lab Services, and Imaging

Diagnostic radiology services
$110 Copay
Prior Authorization Required
Lab services
Not Covered
Outpatient x-rays
Not Covered
Diagnostic tests and procedures
Not Covered

Medicare Part B Drugs

Chemotherapy
20% Coinsurance
Other Part B drugs (Medicare-covered)
20% Coinsurance

Dental Services

Medicare Covered Preventive Dental
$25 Copay
Oral exam
$0
Dental x-rays
$0
Cleaning
$0
Periodontics
Not Covered
Endodontics
Not Covered
Restorative Services
Not Covered

Hearing Aids and Services

Fitting/evaluation
Covered
Limits may apply
Hearing aids
Not Covered
Hearing exam
Covered
Limits may apply

Vision Services

Medicare-covered eye exam
$ to $25 Copay
Routine eye exam
Covered
Limits may apply
Eyewear benefits
None

Get a copy of the UPMC for Life HMO No Rx Summary of Benefits.

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Do you have questions about costs in this plan? Call 1-855-728-0510 (TTY 711) to speak with a licensed insurance agent and learn more about this plan and other plans on this site (Mon-Fri 5am-6pm, Sat 6am-5pm PT).

Prescription Drug Costs & Benefits

This plan does not include a Medicare Part D plan for prescriptions.

Citations & References

Research Note: This content is based on independent analysis of CMS data by David Bynon, Medicare analyst and founder of MedicareWire.

For details on how this plan was analyzed and constructed using CMS data, see our Medicare Plan Research Methodology.

Disclaimer: MedicareWire does not endorse or rank Medicare plans. Plan information is provided for educational and research purposes only and may not reflect the most current data available from CMS or the plan provider.