Provider and Pharmacy Directories

• Searchable Provider Directory (allows you to search for a specific provider or hospital to see if it is participating in the UPMC for Life network)

Provider Directories (please click on the link that applies to the state and county in which you reside)

Pharmacy Directories (please click on the link that applies to the state in which you reside)

• Pharmacy Directory – Pennsylvania and West Virginia
• Pharmacy Directory – Ohio
  
  

Prescription Drug Formulary Information

• UPMC for Life Prescription Drug Formulary
• 60-day Formulary Change Information
• Step Therapy Requirements Documents
• Prior Authorization Requirements Documents
  

   Additional Part D Prescription Drug Coverage Information

Important Plan Forms

• Personal Representative Designation Form
• Prescription Drug Coverage Determination Form/Exceptions Request Form
• Prescription Drug Coverage Redetermination Form
  

  To ask for an appeal about a Part D drug and/or Part C medical care or service, a signed, written appeal request must be faxed to UPMC for Life or sent to the address listed below.
  

  FAX:	412-454-7920
  WRITE:	UPMC Health Plan
  	Attn: Appeals and Grievances
  	P.O. Box 2939
  	Pittsburgh, PA 15230-2939

  
  You may also ask for an appeal by calling our Member Services Department seven days a week from 8 a.m. to 8 p.m.* at 1-877-539-3080. TTY/TDD users should call 1-800-361-2629.

• Member Authorization to Use/Disclose PHI
• Express Scripts, Inc., Mail-Order Form
• Appointment of Representative


Appointment of Representative Instructions:
In order to appoint a person to act on your behalf concerning your health care benefits, print the form above, complete the required fields, and fax or mail it 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 appointed representative.

Please return this completed form either by fax or by mail:

FAX:	412-454-7829
MAIL TO:	UPMC for Life
	P.O. Box 2965
	Pittsburgh, Pennsylvania 15230-2965




If you have any questions about this form, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m.,* seven days a week.TTY/TTD users should call 1-800-361-2629.

• Routine Vision Care Reimbursement Form for Out-of-Network Services
  

  This form is intended for use by members who receive services from providers outside of the OptiCare Managed Vision provider network. Please do not use this form to report services furnished by an OptiCare provider.

• Rights and Responsibilities for Members Participating in Health Management Programs

Plan Ratings Information

• UPMC for Life HMO plans in Pennsylvania
• UPMC for Life PPO plans in Pennsylvania
• UPMC for Life PDP plans in Pennsylvania and West Virginia

Filing an Appeal or Grievance

• Appeals & Grievances Information

	How to obtain the aggregate number of grievances, appeals, and exceptions filed with UPMC for Life:
	Please call our Member Services Department seven days a week from 8 a.m. to 8 p.m.* at 1-877-539-3080 if you need more information about the number of appeals and grievances filed by our members. TTY/TDD users should call 1-800-361-2629.

Disenrollment Rights and Responsibilities

• Disenrollment Rights and Responsibilities Information
• Medicare Beneficiary Rights

HIPPA Notice of Privacy Practices
Click on the Notice of Privacy Practices for the plan in which you are enrolled.

• Privacy Statement
• Notice of Privacy Practices HMO/PPO Members
• Notice of Privacy Practices Prescription Drug Plan Only Members
• Notice of Privacy Practices National Complementary Plan Members
• Notice of Privacy Practices Private Fee-for-Service Members

   Exclusions and Limitations of UPMC for Life Plans

   Contract Termination Information

   Out-of-Network Coverage

Helpful Websites About Medicare

• Medicare.gov Website
• Social Security Administration Website