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UPMC for Life PPO Premier Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UPMC for Life PPO Premier Rx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on UPMC for Life PPO Premier Rx (PPO) in 2026, please refer to our full plan details page.
UPMC for Life PPO Premier Rx (PPO) is a PPO plan offered by UPMC Health System available for enrollment in 2025 to people living in North Central and Central 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 PPO Premier Rx (PPO) 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 PPO Premier Rx (PPO).
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 PPO Premier Rx (PPO), 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 $52.00. 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 $500.00 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 combined Maximum Out-Of-Pocket cost of $10000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 PPO Premier Rx (PPO)
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Drug Coverage
The UPMC for Life PPO Premier Rx (PPO) plan features an annual drug deductible of $500. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay when using preferred pharmacies or preferred mail-order services. Standard pharmacies and standard mail-order services charge copays ranging from $15 to $30 for Tier 1 and $20 to $40 for Tier 2, depending on the supply length. For higher-tier medications, costs are based on coinsurance across all pharmacy and mail-order options. Tier 3 preferred brands have a 24% coinsurance, Tier 4 non-preferred drugs carry a 30% coinsurance, and Tier 5 specialty drugs require a 27% coinsurance for a one-month supply.
Additional Benefits
The UPMC for Life PPO Premier Rx (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, home health services, and preventive care. For inpatient hospital stays, members pay a daily copay of $170 for days 1 through 6 and no copay for days 7 through 90, with no coinsurance required. Outpatient hospital services require a $375 copay, while emergency room visits carry a $130 copay and specialist visits require a $35 copay. This plan also features excellent supplemental benefits, including no copay and no coinsurance for preventive dental cleanings, exams, and over-the-counter items. Covered eyewear is available with no copay and no deductible up to a $250 annual maximum, while routine hearing exams require a $35 copay. For specialized needs, durable medical equipment and dialysis services are covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
UPMC for Life PPO Premier Rx (PPO) partially covers inpatient hospital services with no coinsurance, requiring a daily copay of $170 for days 1 to 6 and no copay for days 7 to 90 for both acute and psychiatric stays. Unlimited additional acute care days are covered at no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UPMC for Life PPO Premier Rx (PPO) covers outpatient hospital and observation services with a $375 copay and no coinsurance, and ambulatory surgical center services with a $325 copay and no coinsurance. 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 PPO Premier Rx (PPO) with a $55 copay and no coinsurance.
Ambulance and Transportation Services See details
UPMC for Life PPO Premier Rx (PPO) covers ambulance services with no coinsurance, requiring a copay of $50.00 to $280.00 for ground ambulance and $280.00 for air ambulance. Prior authorization is required for ambulance services, and transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Emergency services are covered by UPMC for Life PPO Premier Rx (PPO) with a $130 copay (waived if admitted within three days) and no coinsurance, while urgently needed services require a $50 copay and no coinsurance. Worldwide emergency coverage is also available with no coinsurance, featuring a $130 copay for emergency care, a $50 copay for urgent care, and a $280 copay for emergency transportation.
Primary Care See details
UPMC for Life PPO Premier Rx (PPO) offers primary care physician visits with no copay and no coinsurance, while specialist, therapy, and mental health services require a $35 copay and no coinsurance. Telehealth benefits are covered with a $0 to $35 copay and no coinsurance, though chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered under the UPMC for Life PPO Premier Rx (PPO) plan, offering covered services like Medicare-covered zero-dollar preventive care, kidney disease education, and select counseling with no copay and no coinsurance. However, several services are not covered under this benefit, including annual physical exams, health education, personal emergency response systems, and medical nutrition therapy.
Hearing Services See details
Hearing services covered by UPMC for Life PPO Premier Rx (PPO) include one annual routine hearing exam and fitting evaluation 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, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
UPMC for Life PPO Premier Rx (PPO) partially covers vision services, 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, no coinsurance, and no deductible up to a $250 annual maximum.
Dental Services See details
Dental services offered by UPMC for Life PPO Premier Rx (PPO) are partially covered, featuring no copay and no coinsurance for preventive exams, cleanings, and x-rays, and a $35 copay and no coinsurance for Medicare-covered dental. Comprehensive services like restorative care and oral surgery have no copay and 50% coinsurance up to a $5,000 annual maximum, though fluoride, implants, orthodontics, maxillofacial prosthetics, adjunctive general, and other diagnostic services are not covered.
Home Infusion bundled Services See details
UPMC for Life PPO Premier Rx (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the UPMC for Life PPO Premier Rx (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
UPMC for Life PPO Premier Rx (PPO) covers durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes with no copay and a 20% coinsurance. Diabetic supplies are also covered with no copay and coinsurance ranging from no coinsurance up to 20%, subject to prior authorization and vendor limitations.
Diagnostic and Radiological Services See details
UPMC for Life PPO Premier Rx (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Diagnostic tests, procedures, and lab services require a $10 copay, while outpatient x-rays have a $30 copay, therapeutic radiological services have a minimum $65 copay, and diagnostic radiological services have a minimum $200 copay.
Home Health Services See details
UPMC for Life PPO Premier Rx (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by UPMC for Life PPO Premier Rx (PPO) with a $15 copay and no coinsurance per session. This coverage includes intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
UPMC for Life PPO Premier Rx (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior three-day inpatient hospital stay. Covered stays require a $10 daily copay for days 1 through 20 and a $214 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by UPMC for Life PPO Premier Rx (PPO), which offers over-the-counter (OTC) items and a meal benefit with no copay and no coinsurance. Acupuncture and Naloxone are not covered under these services.
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