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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 2025, 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 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 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 $5.00. 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 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 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 pharmacy used. For preferred generic drugs, you will pay no copay at a preferred pharmacy or through preferred mail order. Standard generic drugs have a $47 copay, while preferred and non-preferred brands have 47% and 28% coinsurance respectively.
Additional Benefits
The UPMC for Life PPO Premier Rx (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services, including substance abuse treatment, have copays. Emergency and urgent care services have copays, and primary care services have copays for specialist visits and therapies. Preventive services have no copay, and vision services include eye exams and eyewear coverage. Hearing services cover routine exams and hearing aids, while dental services cover exams and cleanings with coinsurance for other services. The plan also covers ambulance services with copays, and durable medical equipment with coinsurance.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $165 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 for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, and Ambulatory Surgical Center (ASC) Services, each with a $325 copay. Outpatient substance abuse services cover individual and group sessions, with a copay between $35 and $35 per session, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the UPMC for Life PPO Premier Rx (PPO) plan with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the UPMC for Life PPO Premier Rx (PPO) plan, with no coinsurance for any ambulance services. Ground ambulance services have a copay of $50.00 - $280.00, and air ambulance services have a copay of $280.00, while transportation services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the UPMC for Life PPO Premier Rx (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $280 copay. There is no coinsurance for any of these services.
Primary Care See details
The UPMC for Life PPO Premier Rx (PPO) plan covers primary care physician services, chiropractic services (with a $15 copay), occupational therapy services (with a $35 copay), physician specialist services (with a $30 copay), mental health specialty services (with a $35 copay for individual and group sessions), podiatry services (with a $35 copay), other health care professional services (with a $35 copay), psychiatric services (with a $35 copay for individual and group sessions), physical therapy and speech-language pathology services (with a $35 copay), additional telehealth benefits (with a $0-$35 copay), and opioid treatment program services (with a $35 copay). Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with no copay, and additional services like In-Home Safety Assessment, 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). Annual physical exams, health education, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 benefit, home-based palliative care, in-home support services, telemonitoring services, and enhanced disease management are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $35 copay. Prescription hearing aids are covered with a copay between $690 and $1890, depending on the type.
Vision Services See details
Vision services include eye exams with a $35 copay. Eyewear is covered, with a combined maximum of $250 per year for both in-network and out-of-network services, and includes one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year; however, eyeglass lenses and frames are not covered.
Dental Services See details
The UPMC for Life PPO Premier Rx (PPO) plan covers Medicare Dental Services with a $35 copay. Other dental services include oral exams, dental x-rays, and prophylaxis (cleaning). Fluoride treatment, implant services, and orthodontics are not covered. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with 50% coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by UPMC for Life PPO Premier Rx (PPO), and prior authorization is required. Medicare Part B Insulin Drugs have a $35 copay and coinsurance between 0-20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered by the UPMC for Life PPO Premier Rx (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with a 20% coinsurance, as well as Prosthetic Devices and Medical Supplies with a 20% coinsurance. Diabetic Supplies have a coinsurance between 0% and 20%, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The UPMC for Life PPO Premier Rx (PPO) plan covers diagnostic and radiological services, including diagnostic procedures/tests with a $5 copay and lab services with a $5 copay. Diagnostic radiological services have a minimum copay of $225, therapeutic radiological services have a minimum copay of $65, and outpatient X-ray services have a $30 copay.
Home Health Services See details
Home Health Services are covered by the UPMC for Life PPO Premier Rx (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by UPMC for Life PPO Premier Rx (PPO), but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. The plan has a copay for some Cardiac and Pulmonary Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
The UPMC for Life PPO Premier Rx (PPO) plan covers Skilled Nursing Facility (SNF) services, but requires prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; additional and non-Medicare-covered SNF days are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and Meal Benefits, but does not cover Acupuncture, Dual Eligible SNPs with Highly Integrated Services, 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. The plan provides Over-the-Counter (OTC) Items as a supplemental benefit under Part C, including Nicotine Replacement Therapy (NRT).
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