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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 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 $8.00. 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 $5000.00 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 has a $350 deductible for prescription drugs. Once the deductible is met, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies and preferred mail order, and a $20 copay at standard pharmacies and standard mail order. Standard generic drugs have a $47 copay regardless of the pharmacy. Brand name drugs have a 50% coinsurance, and non-preferred drugs have a 28% coinsurance.
Additional Benefits
The UPMC for Life HMO Premier Rx (HMO) plan offers comprehensive coverage, including inpatient hospital stays with a $100 copay for the first five days, and no copay for days 6-90. Outpatient services have varying copays, with $35 copays for many primary care and specialist visits, and no copay for partial hospitalization. The plan also includes coverage for ambulance services with copays, emergency services, and preventive services. Additionally, the plan provides benefits for hearing and vision services, including routine exams and eyewear, and covers dental services with copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a $100 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while the non-Medicare-covered stay and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services and observation services have a $300 copay, ambulatory surgical center services have a $275 copay, and both individual and group sessions for outpatient substance abuse have a $35 copay. Outpatient blood services are covered, and the plan waives the three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life HMO Premier Rx (HMO) plan. There is no cost for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay of $50 to $270, while air ambulance services have a copay of $270; there is no coinsurance for either. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage have a copay of $125, $55, and $55, respectively, with no coinsurance. Worldwide Emergency Transportation has a copay of $270 with no coinsurance.
Primary Care See details
The UPMC for Life HMO Premier Rx (HMO) plan covers primary care physician services, chiropractic services (with an $18 copay), occupational therapy (with a $35 copay), specialist services (with a $35 copay), mental health specialty services (with a $35 copay), podiatry services (with a $35 copay), and other health care professional services (with a $35 copay). The plan also covers psychiatric services (with a $35 copay), physical therapy and speech-language pathology services (with a $35 copay), additional telehealth benefits (with a copay between $0 and $35), and opioid treatment program services (with a $35 copay).
Preventive Services See details
Preventive Services are covered by the UPMC for Life HMO Premier Rx (HMO) plan, with specific benefits including Medicare-covered preventive services, in-home safety assessments, support for caregivers, additional sessions of smoking cessation counseling, fitness benefit (memory fitness), remote access technologies, home and bathroom safety devices, 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 due 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, and telemonitoring services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $35 copay, and fitting/evaluation for hearing aids. The plan covers prescription hearing aids (all types) with a copay between $690 and $1890, but does not cover prescription hearing aids for inner ear, outer ear, or over the ear. OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $35 copay, and eyewear with a combined maximum benefit of $200 every year. Contact lenses and eyeglasses (lenses and frames) are covered, with 1 pair allowed per year. Eyeglass lenses and frames are not covered.
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) with no copay, but fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with 50% coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by UPMC for Life HMO Premier Rx (HMO). For Medicare Part B Insulin Drugs, there is a $35 copay, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life HMO Premier Rx (HMO) plan. You are responsible for 20% coinsurance.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment, is covered by UPMC for Life HMO Premier Rx (HMO). Durable Medical Equipment has no copay and a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. Diabetic Supplies have no copay and a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the UPMC for Life HMO Premier Rx (HMO) plan, with no copay for all diagnostic services. Diagnostic Radiological Services have a maximum copay of $200, Therapeutic Radiological Services have a maximum copay of $55, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by UPMC for Life HMO Premier Rx (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services are covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by UPMC for Life HMO Premier Rx (HMO), but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and Meal Benefits. 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.
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