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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.
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 $6000.00 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. Beneficiaries can enjoy no copay for Tier 1 preferred generic and Tier 2 generic drugs when using a preferred pharmacy or preferred mail order. Standard pharmacies and standard mail-order options charge copays ranging from $15 to $30 for Tier 1 and $20 to $40 for Tier 2. Brand-name and specialty medications under this plan are subject to coinsurance rather than flat copays. Tier 3 preferred brands have a 24% coinsurance, Tier 4 non-preferred drugs carry a 31% coinsurance, and Tier 5 specialty drugs require a 29% coinsurance for a one-month supply. These coinsurance rates apply equally across both preferred and standard pharmacies as well as mail-order services.
Additional Benefits
The UPMC for Life HMO Premier Rx (HMO) plan offers affordable healthcare coverage with no copay or coinsurance for primary care visits, home health services, and routine preventive care. For specialist visits, physical therapy, and routine eye or hearing exams, members pay a predictable $35 copay with no coinsurance. Inpatient hospital stays require a daily copay of $140 for the first seven days, while emergency room visits have a $130 copay, both with no coinsurance. Preventive dental cleanings and exams feature no copay, while comprehensive dental services are covered with no copay and a 50% coinsurance up to a $4,500 annual limit. Durable medical equipment, diabetic shoes, and dialysis services require no copay and a 20% coinsurance. Additionally, members benefit from covered over-the-counter items and up to a $270 annual allowance for eyewear with no copay or coinsurance.
Inpatient Hospital See details
UPMC for Life HMO Premier Rx (HMO) covers inpatient hospital services with no coinsurance, though prior authorization is required. Acute care requires a $140 daily copay for days 1-7 and no copay for day 8 and beyond, while psychiatric stays require a $165 daily copay for days 1-7 and no copay for days 8-90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
UPMC for Life HMO Premier Rx (HMO) covers outpatient services with no coinsurance, including outpatient hospital services with a $210 to $325 copay, observation services at a $325 copay per stay, and ambulatory surgical center services for a $210 copay. Outpatient substance abuse sessions require a $35 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by UPMC for Life HMO Premier Rx (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life HMO Premier Rx (HMO) partially covers ambulance and transportation services, as transportation services to health-related locations are not covered. Covered ground ambulance services require a $50 to $270 copay, and air ambulance services require a $270 copay, with no coinsurance and prior authorization required for both.
Emergency Services See details
UPMC for Life HMO Premier Rx (HMO) covers emergency services with a $130 copay (waived if admitted to the hospital within 3 days) and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency services are also 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) offers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $35 copay and no coinsurance. Routine podiatry is covered for up to four visits per year with a $35 copay and no coinsurance, but 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 services, which include Medicare-covered zero-dollar preventive services, caregiver support, and select counseling. However, several sub-services are not covered under this plan, such as the annual physical exam, health education, and personal emergency response systems.
Hearing Services See details
Hearing services are partially covered by UPMC for Life HMO Premier Rx (HMO), which offers one routine hearing exam and fitting 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 hearing aids and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by UPMC for Life HMO Premier Rx (HMO), as individual eyeglass lenses and eyeglass frames are not covered. Covered eye exams require a $35 copay and no coinsurance, while covered eyewear has no copay and no coinsurance up to a $270 annual limit, with no deductibles for either service.
Dental Services See details
UPMC for Life HMO Premier Rx (HMO) offers partially covered dental services, featuring Medicare-covered dental for a $35 copay and no coinsurance. Preventive services like cleanings and exams have no copay and no coinsurance, while covered comprehensive services have no copay and 50% coinsurance up to a $4,500 annual maximum. 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. Associated Medicare Part B chemotherapy and other drugs have no copay and 0% (no coinsurance) to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% (no coinsurance) to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the UPMC for Life HMO Premier Rx (HMO) plan 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 shoes, with no copay and a 20% coinsurance. Diabetic supplies are also covered with no copay and range from no coinsurance to 20% coinsurance, with prior authorization required for all medical equipment.
Diagnostic and Radiological Services See details
UPMC for Life HMO Premier Rx (HMO) partially covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Lab services have no copay, outpatient X-rays have a $25 copay, therapeutic radiological services have a minimum $55 copay, and diagnostic radiological services have a minimum $225 copay, while diagnostic procedures and tests are not covered.
Home Health Services See details
Home Health Services are covered under the UPMC for Life HMO Premier Rx (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by UPMC for Life HMO Premier Rx (HMO) 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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by UPMC for Life HMO Premier Rx (HMO) with no coinsurance, requiring prior authorization and no prior three-day hospital stay. Covered days 1 through 20 require a $10 daily copay, while days 21 through 100 require a $218 daily copay; additional days beyond the Medicare-covered limit are not covered.
Other Services See details
UPMC for Life HMO Premier Rx (HMO) partially covers other services, providing over-the-counter (OTC) items and limited-duration meal benefits with no copay and no coinsurance. Acupuncture is not covered under this plan.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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