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UPMC for Life HMO Premier Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life HMO Premier Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on UPMC for Life HMO Premier Rx (HMO) in 2026, please refer to our full plan details page.
UPMC for Life HMO Premier Rx (HMO) is a HMO plan offered by UPMC Health System available for enrollment in 2025 to people living in Western Pennsylvania. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that UPMC for Life HMO Premier Rx (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about UPMC for Life HMO Premier Rx (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For UPMC for Life HMO Premier Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $350.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for UPMC for Life HMO Premier Rx (HMO)
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Drug Coverage
The UPMC for Life HMO Premier Rx (HMO) plan features an annual drug deductible of $350. For Tier 1 preferred generics and Tier 2 generics, members pay no copay for 1, 2, or 3-month supplies when using a preferred pharmacy or preferred mail order. Standard pharmacies and standard mail order require copays ranging from $15 to $30 for Tier 1 and $20 to $40 for Tier 2 medications. For brand-name and specialty medications, costs are structured as coinsurance across all pharmacy and mail-order networks. Tier 3 preferred brands require 24% coinsurance, and Tier 4 non-preferred drugs require 31% coinsurance for 1, 2, or 3-month supplies. Tier 5 specialty drugs require 29% coinsurance for a 1-month supply.
Additional Benefits
The UPMC for Life HMO Premier Rx (HMO) plan offers cost-effective healthcare coverage with no copay for primary care provider visits, preventive services, and home health care. For specialist consultations, routine eye exams, and annual hearing tests, members pay a predictable $35 copay with no coinsurance. Inpatient hospital stays require a $140 daily copay for the first seven days, and emergency room care features a $130 copay, both with no coinsurance. For specialized needs, durable medical equipment and dialysis services require a 20% coinsurance with no copay. Comprehensive dental care is covered with no copay and a 50% coinsurance up to a $4,500 annual limit, while prescription hearing aids require copays ranging from $690 to $1,890. Additionally, the plan delivers extra value by offering over-the-counter items and home-delivered meals with no copay and no coinsurance.
Inpatient Hospital See details
UPMC for Life HMO Premier Rx (HMO) covers inpatient acute hospital stays with no coinsurance, requiring a $140 daily copay for days 1 through 7 and no copay for days 8 and beyond. Inpatient psychiatric care is also covered with no coinsurance at a $165 daily copay for days 1 through 7 and no copay for days 8 through 90, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by UPMC for Life HMO Premier Rx (HMO) with no coinsurance, featuring copays of $210 to $325 for outpatient hospital services, $325 per stay for observation services, and $210 for ambulatory surgical center services, which require prior authorization. Outpatient substance abuse services have a $35 copay per individual or group session with no coinsurance, while outpatient blood services are available with no copay, coinsurance, or deductible.
Partial Hospitalization See details
Partial hospitalization is covered under the UPMC for Life HMO Premier Rx (HMO) plan with no copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life HMO Premier Rx (HMO) covers ground ambulance services with a copay of $50 to $270 and air ambulance services with a $270 copay, both with no coinsurance. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
UPMC for Life HMO Premier Rx (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within three days. Urgently needed services have a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $50, and $270 respectively.
Primary Care See details
Primary care benefits offered by UPMC for Life HMO Premier Rx (HMO) feature no copay and no coinsurance for primary care provider visits, while specialist visits, physical therapy, and mental health services require a $35 copay and no coinsurance. Chiropractic services are partially covered, with routine and other chiropractic services not covered under this plan. Routine podiatry is covered for up to four visits per year with a $35 copay and no coinsurance.
Preventive Services See details
UPMC for Life HMO Premier Rx (HMO) preventive services are partially covered with no copay and no coinsurance. Excluded services include annual physical exams, health education, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, enhanced disease management, and telemonitoring.
Hearing Services See details
UPMC for Life HMO Premier Rx (HMO) partially covers hearing services, offering annual routine hearing exams and fittings for a $35 copay and no coinsurance. Up to two prescription hearing aids are covered per year with a copay between $690 and $1,890 and no coinsurance, while OTC hearing aids and inner ear, outer ear, and over the ear prescription aids are not covered.
Vision Services See details
Vision services are covered by UPMC for Life HMO Premier Rx (HMO) with no deductibles, featuring routine eye exams and contact lens fittings for a $35 copay and no coinsurance. Eyewear is partially covered with no copay and no coinsurance up to a $270 annual maximum, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
Dental services are partially covered by UPMC for Life HMO Premier Rx (HMO), offering Medicare-covered dental for a $35 copay and no coinsurance, and preventive cleanings, exams, and x-rays with no copay and no coinsurance. Comprehensive benefits like restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and 50% coinsurance up to a $4,500 annual limit, while fluoride, implants, orthodontics, and other diagnostic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by UPMC for Life HMO Premier Rx (HMO) with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs have no copay and ranging from no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by UPMC for Life HMO Premier Rx (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by UPMC for Life HMO Premier Rx (HMO) with no copays, though a 20% coinsurance applies to durable medical equipment, prosthetics, and diabetic therapeutic shoes. Diabetic supplies carry no coinsurance to 20% coinsurance, and prior authorization is required for all covered equipment.
Diagnostic and Radiological Services See details
UPMC for Life HMO Premier Rx (HMO) diagnostic services are partially covered with no copay and no coinsurance, though diagnostic procedures, tests, and lab services are not covered. Radiological services are covered with no coinsurance and require prior authorization, with a $25 copay for outpatient X-rays, a minimum $55 copay for therapeutic radiological services, and a minimum $180 copay for diagnostic radiological services.
Home Health Services See details
UPMC for Life HMO Premier Rx (HMO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the UPMC for Life HMO Premier Rx (HMO) plan, as all associated sub-services, including intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services, are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) care is covered by UPMC for Life HMO Premier Rx (HMO) with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard 100 days are not covered.
Other Services See details
UPMC for Life HMO Premier Rx (HMO) partially covers other services, offering over-the-counter (OTC) items and meal benefits with no copay and no coinsurance. However, acupuncture is not covered under this plan.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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