2022 UPMC for Life PPO High Deductible Rx (PPO)


UPMC for Life PPO High Deductible Rx (PPO) H5533-003 is a 2022 Medicare Advantage Plan or Part-C by UPMC for Life available to residents in Pennsylvania. This plan includes additional prescription drug (Part-D) coverage. The UPMC for Life PPO High Deductible Rx (PPO) has a monthly premium of $35.00 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be a extremely nice safety net.

UPMC for Life PPO High Deductible Rx (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

UPMC for Life works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for UPMC for Life PPO High Deductible Rx (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from UPMC for Life and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from UPMC for Life except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 UPMC for Life Medicare Advantage Plan Costs

Name:
UPMC for Life PPO High Deductible Rx (PPO)
Plan ID:
H5533-003
Provider:UPMC for Life
Year:2022
Type: Local PPO
Monthly Premium C+D: $35.00
Part C Premium:$0.00
MOOP: $7,550
Part D (Drug) Premium:$35.00
Part D Supplemental Premium$0.00
Total Part D Premium:$35.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:No
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H5533-005
New Plan: 2023 H5533-005




UPMC for Life PPO High Deductible Rx (PPO) Part-C Premium

UPMC for Life charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



H5533-003 Part-D Deductible and Premium

UPMC for Life PPO High Deductible Rx (PPO) has a monthly drug premium of $35.00 and a $0.00 drug deductible. This UPMC for Life plan offers a $35.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by UPMC for Life above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $35.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.



UPMC for Life Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This UPMC for Life plan does not offer additional coverage through the gap.



Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The UPMC for Life PPO High Deductible Rx (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $8.70 for 75% low income subsidy $17.50 for 50% and $26.20 for 25%.



Full LIS Premium:$0.00
75% LIS Premium:$8.70
50% LIS Premium:$17.50
25% LIS Premium:$26.20


H5533-003 Formulary or Drug Coverage

UPMC for Life PPO High Deductible Rx (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 UPMC for Life PPO High Deductible Rx (PPO) H5533-003 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $0 $15
Tier 2 $10 $20
Tier 3 $47 $47
Tier 4 $100 $100
Tier 5 33% 33%
*Initial Coverage Phase and 30 day supply





2021 UPMC for Life PPO High Deductible Rx (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services Not covered
Endodontics Not covered
Extractions $0 copay (Out-of-Network)
Extractions $0 copay
Non-routine services $0 copay (Out-of-Network)
Non-routine services $0 copay
Periodontics Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered
Restorative services $0 copay (Out-of-Network)
Restorative services $0 copay



Deductible


$1,250 annual deductible



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) 30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI) $100 copay
Diagnostic tests and procedures 30% coinsurance (Out-of-Network)
Diagnostic tests and procedures $10 copay
Lab services 30% coinsurance (Out-of-Network)
Lab services $10 copay
Outpatient x-rays $10 copay
Outpatient x-rays 30% coinsurance (Out-of-Network)



Doctor Visits


Primary $10 copay per visit
Primary $40 copay per visit (Out-of-Network)
Specialist $60 copay per visit (Out-of-Network)
Specialist $50 copay per visit



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $65 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment 30% coinsurance (Out-of-Network)
Foot exams and treatment $50 copay
Routine foot care 30% coinsurance (Out-of-Network)
Routine foot care $50 copay



Ground Ambulance


$0 copay
30% coinsurance (Out-of-Network)



Hearing


Fitting/evaluation Not covered
Hearing aids - inner ear Not covered
Hearing aids - outer ear Not covered
Hearing aids - over the ear Not covered
Hearing exam 30% coinsurance (Out-of-Network)
Hearing exam $50 copay



Inpatient Hospital Coverage


$300 per stay
30% per stay (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies 20% coinsurance per item
Diabetes supplies 50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 18% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 50% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs) 18% coinsurance per item



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Chemotherapy 50% coinsurance (Out-of-Network)
Other Part B drugs 50% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $300 per stay
Inpatient hospital - psychiatric 30% per stay (Out-of-Network)
Outpatient group therapy visit $40 copay
Outpatient group therapy visit 30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $40 copay
Outpatient group therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)
Outpatient individual therapy visit $40 copay
Outpatient individual therapy visit 30% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)



MOOP


$11,300 In and Out-of-network
$7,550 In-network



Option


Yes, contact plan for further details



Optional supplemental benefits


No



Outpatient Hospital Coverage


$175 copay per visit
30% coinsurance per visit (Out-of-Network)



Preventive Care


30% coinsurance (Out-of-Network)
$0 copay



Preventive Dental


Cleaning 50% coinsurance (Out-of-Network)
Cleaning $0 copay
Dental x-ray(s) $15 copay
Dental x-ray(s) 50% coinsurance (Out-of-Network)
Fluoride treatment Not covered
Oral exam $15 copay
Oral exam 50% coinsurance (Out-of-Network)



Rehabilitation Services


Occupational therapy visit $40 copay
Occupational therapy visit 30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit $40 copay
Physical therapy and speech and language therapy visit 30% coinsurance (Out-of-Network)



Skilled Nursing Facility


$0 per day for days 1 through 20
$160 per day for days 21 through 100
30% per stay (Out-of-Network)



Transportation


Not covered



Vision


Contact lenses $0 copay
Contact lenses $0 copay (Out-of-Network)
Eyeglass frames Not covered
Eyeglass lenses Not covered
Eyeglasses (frames and lenses) $0 copay
Eyeglasses (frames and lenses) $0 copay (Out-of-Network)
Other Not covered
Routine eye exam $0 copay
Routine eye exam $60 copay (Out-of-Network)
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for UPMC for Life PPO High Deductible Rx (PPO) H5533



2021 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in UPMC for Life PPO High Deductible Rx (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for UPMC for Life PPO High Deductible Rx (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


UPMC for Life PPO High Deductible Rx (PPO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST




Coverage Area for UPMC for Life PPO High Deductible Rx (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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