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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 $6700.00 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 generic and Tier 2 generic medications, you will enjoy no copay for one, two, or three-month supplies when using a preferred pharmacy or preferred mail-order service. If you use standard pharmacies or standard mail order, copays range from $15 to $30 for Tier 1 drugs and $20 to $40 for Tier 2 drugs. For brand-name and specialty drugs, the plan transitions to coinsurance, requiring a 24% coinsurance for Tier 3 preferred brand drugs and 31% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 29% coinsurance for a one-month supply across all pharmacy and mail-order options. This structure makes the UPMC for Life HMO Premier Rx plan exceptionally cost-effective for members who primarily rely on generic medications.
Additional Benefits
The UPMC for Life HMO Premier Rx (HMO) plan offers robust coverage with no copay and no coinsurance for primary care visits, home health care, and preventive services. For specialists and physical therapy, you will pay a $35 copay per visit, while emergency care carries a $130 copay with no coinsurance. Inpatient hospital stays require a $170 daily copay for the first 7 days, after which there is no copay for days 8 through 90. This plan also includes essential lifestyle benefits, featuring no copay and no coinsurance for routine dental cleanings, exams, and select eyewear up to a $270 limit. Comprehensive dental services are covered with no copay and a 50% coinsurance up to $4,500, while diagnostic radiological services and durable medical equipment involve a 20% coinsurance or specific copays. Additionally, members can access over-the-counter items and meal benefits with no copay and no coinsurance.
Inpatient Hospital See details
UPMC for Life HMO Premier Rx (HMO) partially covers inpatient hospital acute and psychiatric stays with no coinsurance, requiring prior authorization and a copay of $170 per day for days 1 to 7, followed by no copay for days 8 to 90. While unlimited additional acute care days are covered at no copay, 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 $325 copay and no coinsurance, and ambulatory surgical center services with a $275 copay and no coinsurance. Outpatient substance abuse services are covered with a $35 copay per individual or group session and no coinsurance, while outpatient blood services are available with no copay and no coinsurance.
Partial Hospitalization See details
UPMC for Life HMO Premier Rx (HMO) covers partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance 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 transport and $270.00 for air transport. Prior authorization is required for ambulance services, while transportation services to plan-approved or 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, with the copay waived if admitted to the hospital within three days, and urgently needed services with a $50 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $50, and $270 respectively.
Primary Care See details
UPMC for Life HMO Premier Rx (HMO) features primary care physician visits with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services carry a $35 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, though routine chiropractic care is not covered.
Preventive Services See details
Preventive services are partially covered by UPMC for Life HMO Premier Rx (HMO) with no copay and no coinsurance for covered benefits like Medicare-covered preventive care, kidney disease education, and in-home safety assessments. However, several services are not covered under this plan, including annual physical exams, health education, personal emergency response systems, and medical nutrition therapy.
Hearing Services See details
UPMC for Life HMO Premier Rx (HMO) covers annual routine hearing exams and fitting evaluations for a $35 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $690 to $1,890 for up to two devices per year, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
UPMC for Life HMO Premier Rx (HMO) covers eye exams with a $35 copay and no coinsurance, while eyewear is partially covered with no copay and no coinsurance up to a $270 annual maximum. Under this eyewear benefit, individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
UPMC for Life HMO Premier Rx (HMO) covers Medicare dental services with a $35 copay and no coinsurance, and preventive services like exams, cleanings, and x-rays with no copay and no coinsurance. Comprehensive benefits, including restorative, endodontics, periodontics, prosthodontics, and oral surgery, are covered with no copay and 50% coinsurance up to a $4,500 annual limit. The plan's dental benefits are partially covered, as fluoride, implants, orthodontics, maxillofacial prosthetics, adjunctive general, and other diagnostic or preventive 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 and no coinsurance, though prior authorization is required. Covered Medicare Part B drugs, including chemotherapy and radiation, have no copay and a 0% to 20% coinsurance, while Part B insulin is subject to a $35 copay and a 0% to 20% coinsurance.
Dialysis Services See details
UPMC for Life HMO Premier Rx (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life HMO Premier Rx (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic therapeutic shoes, with no copays and a 20% coinsurance. Diabetic supplies are also covered with no copay and coinsurance ranging from no coinsurance up to 20%, with prior authorization required for these benefits.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by UPMC for Life HMO Premier Rx (HMO) with no coinsurance, though prior authorization is required. While some diagnostic services are covered, diagnostic procedures, tests, and lab services are not covered. Covered radiological services feature no coinsurance, carrying a $25 copay for outpatient X-rays, a minimum $55 copay for therapeutic services, and a minimum $225 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, though prior authorization is required.
Cardiac Rehabilitation Services See details
UPMC for Life HMO Premier Rx (HMO) covers Cardiac Rehabilitation Services with no copay and no coinsurance. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered under this plan.
Skilled Nursing Facility (SNF) See details
UPMC for Life HMO Premier Rx (HMO) covers Skilled Nursing Facility (SNF) services 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 inpatient hospital stay is not needed, and additional days beyond the standard 100-day Medicare benefit 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
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