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2022 UPMC for Life HMO Deductible Rx (HMO) in Allegheny, Pennsylvania 15238

Medicare Advantage Plan Benefit Details in Plain Text

The following Medicare Advantage plan benefits apply to the UPMC for Life HMO Deductible Rx (HMO) (H3907 - 037) in Allegheny, Pennsylvania 15238.

This plan is administered by UPMC HEALTH PLAN, INC.. To switch to a different Medicare Advantage plan or to change your location, click here.

Click here to see the UPMC for Life HMO Deductible Rx (HMO) health and prescription benefit details in chart format

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Plan Premium

The UPMC for Life HMO Deductible Rx (HMO) has a monthly premium of $22.00. That is $264.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $22.00 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership and Plan Ratings

The UPMC for Life HMO Deductible Rx (HMO) (H3907 - 037) currently has 27,737 members. There are 8,130 members enrolled in this plan in Allegheny, Pennsylvania, and 27,632 members in Pennsylvania.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars.

Therefore, this plan qualifies for the 5-star rating Special Enrollment period ( Read more). The detail CMS plan carrier ratings are as follows:

Customer Service Rating of 5 out of 5 stars
Member Experience Rating of 5 out of 5 stars
Drug Cost Information Accuracy Rating of 5 out of 5 stars

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary

This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2022 is $480. This plan (UPMC for Life HMO Deductible Rx (HMO)) has no deductible.

The following information is about the UPMC for Life HMO Deductible Rx (HMO) formulary (or drug list). There are 3703 drugs on the UPMC for Life HMO Deductible Rx (HMO) formulary. Click here to browse the UPMC for Life HMO Deductible Rx (HMO) Formulary.

The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The UPMC for Life HMO Deductible Rx (HMO)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:

Tier 1 (Preferred Generic) contains 293 drugs and has a co-payment of $0.00.
Tier 2 (Generic) contains 972 drugs and has a co-payment of $10.00.
Tier 3 (Preferred Brand) contains 663 drugs and has a co-payment of $47.00.
Tier 4 (Non-Preferred Drug) contains 899 drugs and has a co-payment of $100.00.
Tier 5 (Specialty Tier) contains 942 drugs and has a co-insurance of 33% of the drug cost.

This plan offers some forms of insulin as part of the Senior Savings Model. The Senior Savings Model a copay of $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please see the plan formulary (drug list) for more details.

Click here to browse the UPMC for Life HMO Deductible Rx (HMO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (UPMC for Life HMO Deductible Rx (HMO)) offers No Coverage during the Coverage Gap phase.

The UPMC for Life HMO Deductible Rx (HMO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

Base Plan
Premium
• Health plan premium: $0
• Drug plan premium: $22
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $750 In-network
• 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: $10 copay (authorization required)
• Lab services: $10 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $200 copay (authorization required)
• Outpatient x-rays: $20 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
• $300 per stay (authorization required)
Outpatient hospital coverage
• $125 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20 $172 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $50-100 copay
Rehabilitation services
• Occupational therapy visit: $0 copay (authorization required)
• Physical therapy and speech and language therapy visit: $0 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $300 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): $0 copay (authorization required)
• Prosthetics (e.g., braces, artificial limbs): $0 copay (authorization required)
• Diabetes supplies: 20% coinsurance per item
Dialysis
• 20% coinsurance
Hearing
• Hearing exam: $35 copay
• Fitting/evaluation: $20 copay (limits apply)
• Hearing aids: $0 copay (limits apply)
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)

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