A non-government entity
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 2025, 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 2025.
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. Additionally, this plan comes with a Part B Premium reduction of $7.00. You must continue to pay paying your reduced 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)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The UPMC for Life HMO Premier Rx (HMO) plan has a $350 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies and mail order, and a $20 copay at standard pharmacies. Standard generic drugs have a $47 copay at all pharmacies. Preferred and non-preferred brand drugs have a 50% and 28% coinsurance respectively.
Additional Benefits
The UPMC for Life HMO Premier Rx (HMO) plan offers comprehensive coverage with a variety of benefits. This plan includes coverage for inpatient and outpatient hospital services, with copays ranging from $165 to $325. You'll also have access to primary care, specialist visits, and various therapies with a $35 copay, and chiropractic services for $18. Preventive services, emergency services, and hearing and vision care are covered, though some services may have copays. Dental services include oral exams, x-rays, and cleaning, as well as orthodontics. Additionally, the plan covers home health, skilled nursing, and dialysis services, along with medical equipment and home infusion services.
Inpatient Hospital See details
Inpatient Hospital services are covered by UPMC for Life HMO Premier Rx (HMO), with a copay of $165 per day for days 1-7, and no copay for days 8-90. Additional days for Inpatient Hospital-Acute are covered, and Inpatient Hospital Psychiatric services are covered, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services, observation services, and ambulatory surgical center services, each with a $325 copay. Outpatient substance abuse services, including individual and group sessions, have a copay between $35.00 and $35.00. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by this plan. There is no copay or coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a copay for both Ground Ambulance Services ($50-$270) and Air Ambulance Services ($270), and no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $270 copay.
Primary Care See details
The UPMC for Life HMO Premier Rx (HMO) plan covers Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic Services are covered with a $18 copay, while Routine Chiropractic Care is not covered, and all other services have a $35 copay.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with no copay, and additional services such as In-Home Safety Assessment, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services. Annual physical exams, health education, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, enhanced disease management, telemonitoring services, are not covered.
Hearing Services See details
Hearing exams are covered with a $35 copay, including routine hearing exams and fitting/evaluation for hearing aids, each limited to one visit per year. Prescription hearing aids are covered with a copay between $690 and $1890, but inner ear, outer ear, and over-the-ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with a $35 copay, and coverage for contact lenses and eyeglasses. Eyeglass lenses and frames are not covered. There is a $200 combined maximum plan benefit for all eyewear every year.
Dental Services See details
The UPMC for Life HMO Premier Rx (HMO) plan covers dental services, including oral exams with a $35 copay, dental x-rays, and prophylaxis (cleaning), and covers orthodontics up to a $4,500 maximum per year. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with a 50% coinsurance, while fluoride treatments, adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered with prior authorization. Medicare Part B Insulin Drugs have a $35 copay, with a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life HMO Premier Rx (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment is covered by UPMC for Life HMO Premier Rx (HMO), including Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic Supplies have a coinsurance between 0-20%, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic procedures/tests and lab services are not covered. For Diagnostic Radiological Services, there is a copay of at most $225, for Therapeutic Radiological Services, there is a copay of at most $55, and for Outpatient X-Ray Services, there is a $25 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life HMO Premier Rx (HMO) plan, with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but this plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is no copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; additional and non-Medicare-covered SNF days are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items and Meal Benefits, but Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. The plan offers OTC items and a limited duration meal benefit.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved