UPMC for Life Plan Documents

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To access your Annual Notice of Changes, Evidence of Coverage, Summary of Benefits, provider directory, or prescription drug formulary, visit our UPMC for Life shop page or UPMC for Life Complete Care (HMO D-SNP) shop page and enter your ZIP code. You can also log in to MyHealth OnLine (your secure member website) or download the UPMC Health Plan mobile app.

• Important Plan Information
• Appeals and Grievances

Request a Provider Directory or Plan Materials

Use our online form below to request a hard copy provider directory or other plan material. You can also send us a plan document or ask to be contacted by a member of our Health Care Concierge team.

Medical Coverage Decision (Organization Determination)

• If you are not getting certain medical care you want, and you believe that this care is covered by our plan.
• Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan.
• You are being told that coverage for certain medical care you have been getting that was previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.
• To learn more about medical coverage decisions for UPMC for Life, view your plan's Evidence of Coverage.

Mail: UPMC for Life
Clinical Operations, 37th Floor
600 Grant Street
Pittsburgh, PA 15219

• Member Organization Determination Form
• Provider Organization Determination Form
• Language Assistance

UPMC for Life uses clinical criteria to make coverage determinations. All of these clinical criteria are publicly available in our Policies & Procedures Manual.

Designate a Personal Representative

If you would like another person to act on your behalf when discussing your health care coverage and benefit information, you will need to fill out the form below and fax or mail it back to us. Once you return this completed, signed, and dated form to us, we can verify your request, adjust our records accordingly, and speak to your personal representative.

Fax to: 412-454-7829
Mail to:
UPMC Health Plan
PO Box 2965
Pittsburgh, Pennsylvania 15230-2965

Medical Claim Reimbursement Form

If you are a UPMC for Life member and have paid out-of-pocket for covered medical services, you can submit the form below to apply for reimbursement. Please follow these steps to submit a medical care claim reimbursement form to us.

Vision Claim Reimbursement Form

If you are a UPMC for Life member who has paid out-of-pocket for seeing a non-network vision provider, you can fill out the Vision Claim Form and fax or mail it to the address below for reimbursement. You will be reimbursed for your out-of-pocket costs up to the vision allowance amount for your plan. Please refer to your Summary of Benefits or Evidence of Coverage for your routine vision allowance.

Fax: 1-844-201-4655
Mail: UPMC Vision Care
P.O. Box 106039
Pittsburgh, PA 15230-6039

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

Dental Claim Reimbursement Form

If you are a UPMC for Life member who has paid out-of-pocket for seeing a non-network dental provider, you can fill out the Dental Claim Form and fax or mail it to the address below for reimbursement. You will be reimbursed for your out-of-pocket costs according to your plan benefits up to the dental allowance amount for your plan. Please refer to your Summary of Benefits or Evidence of Coverage for your comprehensive dental allowance.

Fax: 412-454-8519
Mail: UPMC Dental Advantage
Claims Department
PO Box 1600
Pittsburgh, PA 15230-1600

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

University of Pittsburgh Retirees Vision Claim Reimbursement Form

If you are a University of Pittsburgh retiree who has received vision services from a provider outside of the Envolve provider network, you can fill out the Vision Claim Form below and mail it to the following address:

Envolve Vision
Attn: Claims
PO Box 7548
Rocky Mount, NC 27804

UPMC for Life Prescription Drug Transition Policy

• For members in the first 90 days of enrollment—transition process
• For members currently residing in a long-term care facility—transition process
• For members moving from home to a long-term care facility or from a long-term care facility to home—transition process

Please follow these steps to submit prescription drug determination forms to us.

The forms linked below can be used to request prior authorization, coverage determination and redetermination, or an exception for prescription drugs.

1. Select and open the appropriate form:
   • Use this link to submit a request for a drug not currently covered under your plan:
     UPMC for Life Prescription Drug Coverage Determination/Exception Request Form (PDF)
   • Use this link to submit a request or redetermination of a drug coverage request denied within the past 60 days:
     UPMC for Life Medicare Prescription Drug Coverage Redetermination Request Form (PDF)
2. Fill out the form and save it to your computer's hard drive.
3. Submit your request form using our online submission tool.

Please note:
If you upload this file to us, it will remain on your computer.
If you are using a public or shared computer and you do not want to save your personal health information on that computer, you should consider calling Member Services or print and mail the form.

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

Medication Therapy Management (MTM) program

UPMC Health Plan has developed a unique medication therapy management program for members who take many medications and meet certain criteria.

Use the links below to learn more.

• How does UPMC for Life help make sure I’m safe on my prescription medications?
• How does UPMC for Life help members who take many medications?
• Who is eligible for UPMC for Life's medication management program?

Pharmacy Claim Reimbursement

If you are a UPMC for Life member, complete the form below to apply for reimbursement for Part D prescription drugs. Please follow these steps to submit a prescription drug claim reimbursement form to us.

1. Open this form:
   • UPMC for Life Prescription Drug Claim Reimbursement Form
   • UPMC for Life Complete Care (HMO SNP) Prescription Drug Claim Reimbursement Form
2. Print the form. Follow the instructions on the form and fill out as completely as possible.
3. For your claim to be processed, you will need to get your prescription receipts or patient history printout from your pharmacy.
4. Mail the form and your receipts to us at the address below. Please do not staple or attach your receipts to another piece of paper.

Service Area Map

• 2024 UPMC for Life HMO/PPO Service Area Map
• 2024 UPMC for Life Complete Care (HMO SNP) Service Area Map

Privacy Information

We take your privacy seriously at UPMC for Life. The documents below show the steps we take to protect your personal information.

• Privacy Statement
• Notice of Privacy Practices

Fraud, Waste, and Abuse

The Centers for Medicare & Medicaid Services has information about how to protect yourself against various types of fraud and identity theft.

• Identity Theft
• Reducing Fraud
• Home Health Services
• Fake Discount Cards
• Telemarketing Scams
• Medicare and the Health Insurance Marketplace
• Medical Supplies
• Medical Services

Disaster and Catastrophic Events

In the event of a presidential emergency declaration, a presidential (major) disaster declaration, a declaration of emergency or disaster by a governor, or an announcement of a public health emergency by the secretary of Health and Human Services, UPMC for Life benefits will temporarily change to allow members access to out-of-network Medicare-certified facilities with reduced cost sharing. To learn more, click on the link below.

Monthly Premium Payments

Use the UPMC for Life premium invoice tutorial for help understanding your UPMC for Life premium invoice.

1. Download or log in to the UPMC Health Plan app, then select Account and Manage Premium Payments.
2. Log in to UPMC Health Plan Member Site. Under the Your Insurance section on the homepage, click on Premium Payments.

Use our 24/7 secure automated payment system
Call 1-877-539-3080 (TTY: 711) and press 1 to make premium payments, check your current premium balance, or verify if your most recent payment has been received.

Helpful Websites About Medicare

• Medicare Website
• Social Security Administration Website
• The Medicare Beneficiary Ombudsman

Other Important Information

UPMC for Life members have rights and responsibilities when disenrolling from a UPMC for Life plan. Use the links below to learn more.

• UPMC for Life Member Rights and Responsibilities
• UPMC for Life Member Disenrollment Rights and Responsibilities

If a member must seek care or pharmacy access outside the UPMC for Life network or service area, the member must take steps to ensure the care provided will be covered by our plan. Use the link below to learn more.

Find

• Doctors or Health Care Professional
• Hospital, Facility, or Urgent Care
• Pharmacy
• Medications

Contact Us

UPMC Health Plan
Attn: UPMC for Life
U.S. Steel Tower, 9th Floor
600 Grant Street
Pittsburgh, PA 15219

Medicare Resources

This information is not a complete description of benefits. Call 1-866-400-5077 (TTY: 711) for more information. Out-of-network/Noncontracted providers are under no obligation to treat UPMC for Life members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services. Other physicians/providers are available in the UPMC for Life network.

This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711).

UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., UPMC Health Benefits Inc., and UPMC Health Coverage Inc.

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UPMC for Life Members
Call us toll-free: 1-877-539-3080
TTY: 711

Oct. 1 – March 31:
Seven days a week from 8 a.m. to 8 p.m.

April 1 – Sept. 30:
Monday through Friday from 8 a.m. to 8 p.m., Saturday from 8 a.m. to 3 p.m.

UPMC for Life Prospective Members
Call us toll-free: 1-866-400-5077
TTY: 711

Jan. 1 – Sept. 30:
Seven days a week from 8 a.m. to 8 p.m.

Oct. 1 – Dec. 31:
Seven days a week from 7 a.m. to 9 p.m.

Last Updated: 01/11/2024