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 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. Additionally, this plan comes with a Part B Premium reduction of $2.00. 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)
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 features a $350 annual drug deductible. You can enjoy no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) medications when using a preferred pharmacy or preferred mail order service. Standard pharmacies and standard mail order options are also available, with copays starting at $15 for Tier 1 and $20 for Tier 2 drugs. For brand-name and specialty medications, costs are covered through a percentage-based coinsurance. Tier 3 (Preferred Brand) drugs require a 24% coinsurance, and Tier 4 (Non-Preferred) drugs carry a 31% coinsurance at all pharmacy types. Tier 5 specialty drugs are limited to a one-month supply and require a 29% coinsurance.
Additional Benefits
The UPMC for Life HMO Premier Rx (HMO) plan offers affordable coverage for core medical services, including primary care doctor visits with no copay and specialist visits for a $35 copay. Inpatient hospital stays require a $100 daily copay for days 1 through 5 and no copay for days 6 through 90, while outpatient hospital services carry a $300 copay. Emergency room visits are covered with a $130 copay, which is waived if you are admitted to the hospital within three days. This plan also features valuable supplemental coverage, including preventive dental exams and cleanings with no copay, and routine vision and hearing exams for a $35 copay. Comprehensive dental services are covered up to a $4,500 annual limit with a 50% coinsurance, while eyewear is covered up to a $270 annual maximum with no copay. Additionally, durable medical equipment and dialysis services are covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
UPMC for Life HMO Premier Rx (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $100 daily copay for days 1 through 5 and no copay for days 6 through 90. Unlimited additional days for acute stays are covered with no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UPMC for Life HMO Premier Rx (HMO) covers outpatient hospital and observation services with a $300 copay and no coinsurance, and ambulatory surgical center services with a $275 copay and no coinsurance. Outpatient substance abuse services require a $35 copay with no coinsurance, while outpatient blood services are fully covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by UPMC for Life HMO Premier Rx (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by UPMC for Life HMO Premier Rx (HMO) with no coinsurance, requiring a copay of $50.00 to $270.00 for ground ambulance and $270.00 for air ambulance. While transportation is technically covered, only some services are covered as transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Emergency services are covered by UPMC for Life HMO Premier Rx (HMO) with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency services are covered with no coinsurance and copays of $130 for emergency care, $50 for urgent care, and $270 for emergency transportation.
Primary Care See details
UPMC for Life HMO Premier Rx (HMO) features primary care physician services with no copay and no coinsurance, while specialist, therapy, and mental health services require a $35 copay and no coinsurance. Some chiropractic services are covered with a $15 copay and no coinsurance, but routine and other chiropractic services are not covered. Routine podiatry is covered for up to four annual visits with a $35 copay and no coinsurance, and telehealth benefits range from no copay to a $35 copay with no coinsurance.
Preventive Services See details
UPMC for Life HMO Premier Rx (HMO) preventive services are partially covered with no copay and no coinsurance for covered benefits like kidney disease education, counseling, and home safety assessments. However, several sub-services are not covered, including the annual physical exam, health education, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy 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, featuring a $35 copay and no coinsurance for annual routine hearing exams and fittings. Up to two prescription hearing aids are covered per year with no coinsurance and a copay ranging from $690 to $1,890, while OTC hearing aids and inner, outer, or over-the-ear prescription hearing aid types are not covered.
Vision Services See details
UPMC for Life HMO Premier Rx (HMO) vision services are partially covered, offering routine eye exams and contact lens fittings for a $35 copay and no coinsurance. Eyewear is covered with no copay or coinsurance under a $270 annual maximum, which includes contact lenses and eyeglasses, though individual eyeglass lenses and frames are not covered.
Dental Services See details
UPMC for Life HMO Premier Rx (HMO) offers partially covered dental services, including preventive exams, cleanings, and x-rays with no copay and no coinsurance, and Medicare-covered dental for a $35 copay and no coinsurance. Comprehensive care like restorative services, endodontics, periodontics, prosthodontics, and oral surgery is covered up to a $4,500 annual maximum with no copay and a 50% coinsurance. Fluoride, implants, orthodontics, maxillofacial prosthetics, adjunctive general services, and other diagnostic or preventive dental services are not covered.
Home Infusion bundled Services See details
UPMC for Life HMO Premier Rx (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs have a coinsurance ranging from no coinsurance to 20%, while Part B insulin has a $35 copay and a coinsurance ranging from no coinsurance to 20%.
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 and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic shoes. Diabetic supplies are also covered with no copay and feature a coinsurance ranging from no coinsurance to 20%, with prior authorization required for these benefits.
Diagnostic and Radiological Services See details
UPMC for Life HMO Premier Rx (HMO) covers diagnostic and radiological services with no coinsurance, although diagnostic procedures, tests, and lab services are not covered. Covered radiological services require prior authorization and feature copays of $20 for outpatient X-rays, $55 for therapeutic radiology, and $200 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
UPMC for Life HMO Premier Rx (HMO) covers some cardiac rehabilitation services with no copay and no coinsurance; however, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
UPMC for Life HMO Premier Rx (HMO) covers skilled nursing facility (SNF) care with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $214 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 a meal benefit with no copay and no coinsurance. Acupuncture is not covered under this plan.
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