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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 2026 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)
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Drug Coverage
The UPMC for Life HMO Premier Rx (HMO) plan features an annual drug deductible of $350. You will pay 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 services require copays ranging from $15 to $30 for Tier 1 and $20 to $40 for Tier 2, depending on the supply length. For brand-name and specialty drugs, costs are determined by a percentage of the drug cost rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs carry a 31% coinsurance across all pharmacy options. Specialty medications in Tier 5 are subject to a 29% coinsurance for a one-month supply.
Additional Benefits
The UPMC for Life HMO Premier Rx (HMO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care doctor visits and preventive care. Specialist visits, mental health therapies, and urgent care require a copay of $35 to $50, while emergency room care is covered with a $130 copay and no coinsurance. For hospital care, inpatient acute stays require a $100 daily copay for days one through five with no copay for subsequent days, and outpatient hospital services carry a $300 copay. Additional benefits include preventive dental exams with no copay and comprehensive dental covered up to $4,500 annually with a 50% coinsurance. Routine vision and hearing exams require a $35 copay, which includes up to a $270 annual eyewear allowance and coverage for up to two hearing aids per year. Members also receive home health care, over-the-counter items, and meal benefits with no copay, while durable medical equipment and dialysis require 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 acute care days are covered with no copay, though 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 are covered with a $35 copay and no coinsurance, while outpatient blood services are available with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
UPMC for Life HMO Premier Rx (HMO) covers partial hospitalization services with no copay and no coinsurance. This plan ensures you can receive necessary care without any out-of-pocket costs.
Ambulance and Transportation Services See details
UPMC for Life HMO Premier Rx (HMO) covers Medicare-covered ambulance services with no coinsurance, requiring a copay of $50 to $270 for ground ambulance services and $270 for air ambulance services, both of which require prior authorization. Transportation services to 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, which is waived if you are admitted to the hospital within three days. Urgently needed services require a $50 copay with no coinsurance, while worldwide emergency coverage is available 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) offers primary care physician services with no copay and no coinsurance, while specialist, mental health, and therapy services require a $35 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, though routine and other chiropractic services are not covered. Telehealth services are also available with a copay ranging from $0 to $35 and no coinsurance.
Preventive Services See details
UPMC for Life HMO Premier Rx (HMO) partially covers preventive services with no copay and no coinsurance for covered benefits like kidney disease education, glaucoma screenings, diabetes self-management, and in-home safety assessments. However, several sub-services are not covered under this plan, including annual physical exams, health education, personal emergency response systems (PERS), medical nutrition therapy, and weight management programs.
Hearing Services See details
UPMC for Life HMO Premier Rx (HMO) hearing services are partially covered, offering one routine hearing exam and one fitting evaluation per year for a $35 copay and no coinsurance. Up to two prescription hearing aids are covered annually with a copay ranging from $690 to $1,890 and no coinsurance, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are covered by UPMC for Life HMO Premier Rx (HMO), offering annual routine eye exams and contact lens fittings for a $35 copay and no coinsurance. Eyewear is partially covered with no copay or coinsurance up to a $270 yearly limit for contact lenses and complete eyeglasses, though individual eyeglass lenses and frames are not covered.
Dental Services See details
Dental services are partially covered by UPMC for Life HMO Premier Rx (HMO), offering Medicare-covered dental at a $35 copay with no coinsurance, and preventive exams, cleanings, and x-rays with no copay and no coinsurance. Comprehensive services such as restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered up to a $4,500 annual limit with no copay and 50% coinsurance; however, 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 and step therapy are required. Covered Medicare Part B chemotherapy and other drugs have no copay and a coinsurance of no coinsurance to 20%, while Part B insulin has a $35 copay and a coinsurance of 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 covered by UPMC for Life HMO Premier Rx (HMO), including durable medical equipment, prosthetics, and medical supplies, requires no copay and a 20% coinsurance. Diabetic equipment and supplies are also covered with no copay and coinsurance ranging from no coinsurance up to 20%, with prior authorization and manufacturer limitations applying to certain items.
Diagnostic and Radiological Services See details
UPMC for Life HMO Premier Rx (HMO) covers radiological services with no coinsurance, requiring a $20 copay for outpatient X-rays, a minimum $55 copay for therapeutic radiology, and a minimum $200 copay for diagnostic radiology. Diagnostic services, including diagnostic procedures, tests, and lab services, are not covered under this plan, and prior authorization is required for all covered 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) cardiac rehabilitation services feature no copay and no coinsurance, and although some services are covered, standard 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) services 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 required, and additional days beyond the standard Medicare-covered 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 meal benefits with no copay and no coinsurance. Acupuncture is not covered under this plan.
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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.
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