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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 $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 $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 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 the pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies or 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. Preferred brand drugs and non-preferred drugs have a 50% and 28% coinsurance, respectively.
Additional Benefits
The UPMC for Life HMO Premier Rx (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services and emergency services have copays ranging from $55 to $325. The plan also provides coverage for primary care, preventive services, hearing, vision, dental, and home health services, often with copays. Additional benefits include coverage for ambulance, partial hospitalization, and skilled nursing facilities, with specific copays. The plan also covers home infusion services, dialysis, medical equipment, and diagnostic services. However, it's important to note that certain services like cardiac rehabilitation, and some vision and dental procedures are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $170 copay for days 1-7 and no copay for days 8-90. Additional days for inpatient hospital-acute are covered with no copay, while non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services include outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services, observation services, and ASC services each have a $325 copay. Individual and group sessions for outpatient substance abuse have a copay between $35.00 and $35.00.
Partial Hospitalization See details
Partial Hospitalization is covered by the UPMC for Life HMO Premier Rx (HMO) plan. There is no copay or coinsurance for this benefit.
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 between $50 and $270, while air ambulance services have a $270 copay, but 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, and Worldwide Emergency Services are covered by UPMC for Life HMO Premier Rx (HMO). Emergency Services and Worldwide Emergency Coverage have a $125 copay, Urgently Needed Services and Worldwide Urgent Coverage have a $55 copay, and Worldwide Emergency Transportation has a $270 copay; all have no coinsurance.
Primary Care See details
The UPMC for Life HMO Premier Rx (HMO) plan covers primary care physician services, occupational therapy, physician specialist services, mental health specialty services, podiatry, other health care professionals, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services and physical therapy require prior authorization. Chiropractic services have a $15 copay, occupational therapy has a $35 copay, physician specialist services have a $35 copay, individual and group mental health sessions have a $35 copay, podiatry services have a $35 copay, other health care professionals have a $35 copay, individual and group psychiatric sessions have a $35 copay, physical therapy and speech-language pathology services have a $35 copay, additional telehealth benefits have a $0 - $35 copay, and opioid treatment program services have a $35 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive services are covered under the UPMC for Life HMO Premier Rx (HMO) plan, with no copay for Medicare-covered preventive services. Additional preventive services are covered, but 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. The plan offers coverage for in-home safety assessments, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling (4 visits), fitness benefit (memory fitness), remote access technologies, home and bathroom safety devices and modifications, and counseling services (6 sessions).
Hearing Services See details
Hearing Services includes coverage for routine hearing exams with a $35 copay, and for fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $690 and $1890, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with a $35 copay, and other eye exam services are covered. Eyewear benefits are covered, including contact lenses and eyeglasses (lenses and frames), with a combined maximum of $200. Eyeglass lenses and frames are not covered.
Dental Services See details
The UPMC for Life HMO Premier Rx (HMO) plan covers Medicare Dental Services with a $35 copay, and offers Oral Exams (2 visits per year), Dental X-Rays (1 bitewing x-ray every 12 months, and 1 panoramic x-ray every 36 months), and Prophylaxis (Cleaning) (2 visits per year). Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with 50% coinsurance, while Fluoride Treatment, Adjunctive General Services, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the UPMC for Life HMO Premier Rx (HMO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with a 20% coinsurance, Prosthetics/Medical Supplies with no copay and a coinsurance for Medicare-covered devices, and Diabetic Equipment, including Diabetic Supplies with 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with some services having a copay. Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $225, Therapeutic Radiological Services have a copay of at most $55, and Outpatient X-Ray Services have a copay of $25.
Home Health Services See details
Home Health Services are covered by the UPMC for Life HMO Premier Rx (HMO) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but not in practice, as Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered, but prior authorization is required. For days 1-20, the copay is $10, and for days 21-100, the copay is $214.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items and a Meal Benefit. Acupuncture and Dual Eligible SNPs with Highly Integrated Services are not covered. Additionally, 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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