q1medicare.com
Powered by Q1Group LLC
A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu ☰
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2025
  • FAQs
  • Articles
  • Search ⌕
  • Contact
  • 2024
  • 2025
  • FAQs
  • Articles
  • Latest Medicare News
  • Search ⌕

2022 Medicare Advantage Plan Benefit Details for the UPMC for Life HMO Rx (HMO) - H3907-029-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2022 Medicare Advantage Plan Details
Medicare Plan Name:UPMC for Life HMO Rx (HMO)
Location:Allegheny, Pennsylvania 15238     Click to see other locations
Plan ID:H3907 - 029 - 0     Click to see other plans
Member Services:1-877-539-3080 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the UPMC for Life HMO Rx (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$81.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$4,430
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$7,550
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,769 drugsBrowse the UPMC for Life HMO Rx (HMO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
This plan offers select insulin at a $35 copay. Learn more.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$10.00$47.00$100.0033%
• Number of Drugs per
  Tier:		293972663899942
Plan's Pharmacy Search:https://www.upmchealthplan.com/medicare/documents-and-forms/
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 003858   PCN: MD   See BIN/PCNs for all plans
Number of Members enrolled in this plan in Allegheny, Pennsylvania:13,793 members
Number of Members enrolled in this plan in Pennsylvania:38,326 members
Number of Members enrolled in this plan in (H3907 - 029):38,455 members
Plan’s Summary Star Rating: 5 out of 5 Stars.  
This plan qualifies for the 5-star rating Special Enrollment period. Read more.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 5 out of 5 Stars.
• Drug Cost Accuracy Rating: 5 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Base
Premium		Part D Supplemental
Premium
$81.00$27.40$53.60$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$12.90$23.00$33.20$43.40
Total Monthly Premium with LIS (Parts C & D):$40.30$50.40$60.60$70.80
— Plan Health Benefits —
** Base Plan **
Premium
• Total monthly premium: $81.00
• Health plan premium: $27.40
• Drug plan premium: $53.60
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $7
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: Yes
Doctor visits
• Primary: $0 copay
• Specialist: $35 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $5 copay (authorization required)
• Lab services: $5 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $200 copay (authorization required)
• Outpatient x-rays: $35 copay (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $65 copay per visit (always covered)
Inpatient hospital coverage
• $295 per stay (authorization required)
Outpatient hospital coverage
• $225 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$100 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $50-250 copay
Rehabilitation services
• Occupational therapy visit: $35 copay (authorization required)
• Physical therapy and speech and language therapy visit: $35 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $295 per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist: $35 copay
• Outpatient individual therapy visit with a psychiatrist: $35 copay
• Outpatient group therapy visit: $35 copay
• Outpatient individual therapy visit: $35 copay
Opioid treatment program services
• In-network: $35.00 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: 20% coinsurance per item
Dialysis
• 20% coinsurance
Hearing
• Hearing exam: $35 copay
• Fitting/evaluation: Not covered
• Hearing aids - inner ear: Not covered
• Hearing aids - outer ear: Not covered
• Hearing aids - over the ear: Not covered
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: 50% coinsurance (limits apply)
• Diagnostic services: 50% coinsurance (limits apply)
• Restorative services: 50% coinsurance (limits apply)
• Endodontics: 50% coinsurance (limits apply)
• Periodontics: 50% coinsurance (limits apply)
• Extractions: 50% coinsurance (limits apply)
• Prosthodontics, other oral/maxillofacial surgery, other services: 50% coinsurance (limits apply)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: $0 copay (limits apply)
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Some coverage
• Health Education: Not covered
• In-Home Safety Assessment: Some coverage
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Some coverage
• Support for Caregivers of Enrollees: Some coverage
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Some coverage
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Some coverage
Wellness programs (e.g., fitness, nursing hotline)
• Covered (authorization required)
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment: $35 copay
• Routine foot care: $35 copay (limits apply)
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)




Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs




© Q1Group LLC 2005 - 2024  



Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
.