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UPMC for Life PPO Premier Rx (PPO)

H5533 - 011 - 0
4.5 out of 5 stars (4.5 / 5)

UPMC for Life PPO Premier Rx (PPO) is a Medicare Advantage Plan by UPMC for Life.

This page features plan details for 2025 UPMC for Life PPO Premier Rx (PPO) H5533 – 011 – 0 available in North Central and Central Pennsylvania.

Locations

UPMC for Life PPO Premier Rx (PPO) is offered in the following locations.

Adams County, Pennsylvania
Centre County, Pennsylvania
Clinton County, Pennsylvania

Click to see more locations

Plan Overview

UPMC for Life PPO Premier Rx (PPO) offers the following coverage and cost-sharing.

Insurer:UPMC for Life
Health Plan Deductible:$0
MOOP:$10,000 In and Out-of-network
$6,700 In-network
Drugs Covered:Yes

Ready to sign up for UPMC for Life PPO Premier Rx (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

UPMC for Life PPO Premier Rx (PPO) qualifies for a monthly Medicare Give Back Benefit of $54.00.

Premium Reduction:$54.00

Premium Breakdown

UPMC for Life PPO Premier Rx (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $54.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

UPMC for Life PPO Premier Rx (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $350.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $350.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

UPMC for Life PPO Premier Rx (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: Yes, contact plan for further details

Comprehensive Dental

  • Endodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • Out-of-Network: $10 copay (Authorization Required)
  • Lab services
    • In-Network: $10 copay (Authorization Required)
    • Out-of-Network: $10 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $225 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $10 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $350 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $30 copay (Authorization Required)
    • Out-of-Network: $30 copay (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $30 copay per visit
  • Primary
    • Out-of-Network: $0 copay
  • Specialist
    • Out-of-Network: $30 copay per visit

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $55 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $35 copay
    • Out-of-Network: $35 copay
  • Routine foot care
    • In-Network: $35 copay (Limits Apply)

Ground ambulance

    • Out-of-Network: 30% coinsurance
    • In-Network: $50-280 copay

Health plan deductible

    • $0

Hearing

  • Medicare-Covered Hearing Exam
    • In-Network: $35 copay
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $35 copay
  • Fitting/evaluation
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Hearing aids
    • Out-of-Network: $690-1,890 copay (Limits Apply)
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
  • Hearing aids
    • In-Network: $690-1,890 copay (Limits Apply)

Inpatient hospital coverage

    • Out-of-Network: $250 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)
    • In-Network: $170 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $10,000 In and Out-of-network
      $6,700 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 30% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $170 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)
    • Out-of-Network: $250 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $35 copay
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $35 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $35 copay
  • Outpatient individual therapy visit
    • In-Network: $35 copay
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $35 copay
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $35 copay
  • Outpatient group therapy visit
    • In-Network: $35 copay
  • Outpatient individual therapy visit
    • Out-of-Network: $35 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $325 copay per visit (Authorization Required)
    • Out-of-Network: $400 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: 30% coinsurance

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $35 copay (Authorization Required)
    • Out-of-Network: $35 copay (Authorization Required)
  • Occupational therapy visit
    • In-Network: $35 copay (Authorization Required)
    • Out-of-Network: $35 copay (Authorization Required)

Skilled Nursing Facility

    • In-Network: $10 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: 30% per stay (Authorization Required)

Transportation

    • Not covered

Vision

  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Other
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Routine eye exam
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for UPMC for Life PPO Premier Rx (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on UPMC for Life PPO Premier Rx (PPO)? See 2025 UPMC for Life PPO Premier Rx (PPO) at MedicareAdvantageRX.com.

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Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

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