UPMC for Life HMO Premier Rx (HMO)

Pennsylvania Medicare Advantage Plan (2025 Plan)


Monthly Premium

Your Cost
$0
by UPMC for Life

Additional Coverage

HearingVisionDental

Overall Government Star Rating

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Plan Name
UPMC for Life HMO Premier Rx (HMO)
Insurance Carrier
UPMC for Life
Plan Type
Medicare Advantage Plan With Part D Prescription Drug Coverage
Network Type
HMO

UPMC for Life HMO Premier Rx (HMO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in Pennsylvania and offered by the health insurance company UPMC for Life. This plan’s network type is HMO which determines in-network doctors who accept the health plan and whether a referral is needed.

Monthly Premium
$0
Annual Deductible
$0
Max Out-of-Pocket
$5,000
Primary doctor visit
$0 copay
Specialist visit
$35 copay per visit
ER visit
$125 copay per visit (always covered)
Ambulance
$50-270 copay

UPMC for Life HMO Premier Rx (HMO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $5,000 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for UPMC for Life HMO Premier Rx (HMO) are defined below.

Yes
Part D Prescription Drug Coverage
Yes
Dental
Yes
Vision
Yes
Hearing

UPMC for Life HMO Premier Rx (HMO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. UPMC for Life HMO Premier Rx (HMO) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. UPMC for Life HMO Premier Rx (HMO) includes coverage for the following additional benefits:

Other benefits

Fitness benefit
Limited coverage
Over the counter drug benefits
Limited coverage
In-home support services
Not covered
Home and bathroom safety devices
Limited coverage
Meals for short duration
Limited coverage
Annual physical exams
Not covered
Telehealth
Limited coverage

Monthly Premium
$0
Health Portion of Premium
$0
Drug Portion of Premium
$0
Health Plan Deductible
$0
Health Plan Max Out-of-Pocket
$5,000 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes

Doctor Services

Primary doctor visit
$0 copay
Specialist visit
$35 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures
$0 copay
Lab services
$0 copay
Diagnostic radiology services (like MRI)
$200 copay
Outpatient x-rays
$20 copay
Emergency care
$125 copay per visit (always covered)
Urgent care
$55 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
$100 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient hospital coverage
$300 copay per visit

Skilled nursing facility

Skilled nursing facility
$10 per day for days 1 through 20
$214 per day for days 21 through 100

Preventive services

Preventive services
$0 copay

Ambulance

Ground ambulance
$50-270 copay

Therapy services

Occupational therapy visit
$35 copay
Physical therapy & speech & language therapy visit
$35 copay

Mental health services

Outpatient group therapy with a psychiatrist
$35 copay
Outpatient individual therapy with a psychiatrist
$35 copay
Outpatient group therapy visit
$35 copay
Outpatient individual therapy visit
$35 copay

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
20% coinsurance per item
Prosthetics (like braces, artificial limbs)
20% coinsurance per item
Diabetes supplies
0-20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseCatastrophic coverage phase
Preferred Generic$15.00 copay$0 copay
Generic$20.00 copay$0 copay
Preferred Brand$47.00 copay$0 copay
Non-Preferred Drug50% coinsurance$0 copay
Specialty Tier28% coinsurance$0 copay

Part B Drugs

Chemotherapy drugs
0-20% coinsurance
Other Part B drugs
0-20% coinsurance

Hearing

Hearing exam
$35 copay
Fitting/evaluation
$0 copay
Hearing aids - All types
$690-1,890 copay

Preventive Dental

Oral exam
In-network: $0 copay
Out-of-network: $0 copay
Cleaning
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment
Not covered
Dental x-rays
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Endodontics
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Periodontics
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Prosthodontics, removable
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Prosthodontics, fixed
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Maxillofacial prosthetics
Not covered
Implant services
Not covered
Oral and maxillofacial surgery
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Orthodontics
Not covered
Adjunctive general services
Not covered

Vision

Routine eye exam
$0 copay
Contact lenses
$0 copay
Eyeglasses (frames & lenses)
$0 copay
Eyeglass frames (only)
Not covered
Eyeglass lenses (only)
Not covered
Upgrades
$0 copay

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