2013 Additional Documents

• Summary of Benefits
• Evidence of Coverage
• UPMC for Life Service Area Maps
• UPMC for Life Exclusions and Limitations Information
• Plan Ratings Information
• Notice of Privacy Practices
• HIPAA Notice of Privacy Practices
• Helpful Websites About Medicare

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Summary of Benefits

Please select the state in which you reside to see the Summary of Benefits for your region. These documents show a list of the benefits covered under our plans.

Pennsylvania		UPMC for Life		Select a plan: HMO Summary of Benefits PPO Summary of Benefits
West Virginia		UPMC for Life		PPO Summary of Benefits

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Evidence of Coverage

Please select the state in which you reside and the UPMC for Life plan name for the Evidence of Coverage you would like to view. These documents provide detailed plan benefits information and member rights and responsibilities.

Pennsylvania		UPMC for Life		Select a plan: HMO HMO Deductible with Rx (HMO) HMO Rx (HMO) HMO Rx Enhanced (HMO) PPO High Deductible with Rx (PPO) PPO Rx (PPO)
West Virginia		UPMC for Life		PPO High Deductible with Rx (PPO)

UPMC for Life has free interpreter services to answer any questions you may have about our plan. Click here for more information.

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UPMC for Life Service Area Maps

Click the link below to see a map of states and counties included in the UPMC for Life service area.

UPMC for Life HMO/PPO Service Area Map

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UPMC for Life Exclusions and Limitations Information

There are some services that are not covered and will not be paid for by UPMC for Life. The link below provides a detailed listing of these services.

Exclusions and Limitations of UPMC for Life Plans

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Plan Ratings Information

Please select the state in which you reside to see the UPMC for Life plan ratings information for your region. These documents show how the Medicare program has rated our plans on quality of care and service to our members.

Pennsylvania		UPMC for Life		Select a plan: HMO plans PPO plans
West Virginia		UPMC for Life		PPO plan

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Privacy Information

Your personal information is private and confidential. At UPMC for Life we take your privacy seriously. Whether you are a prospective, current, or former member, living or deceased, we respect and safeguard the privacy and confidentiality of the information that we have about you on file.

The information provided below outlines the steps UPMC for Life takes to safeguard your privacy.

Privacy Statement

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HIPAA Notice of Privacy Practices

Please select the plan in which you are enrolled to see the applicable Notice of Privacy Practices.

Notice of Privacy Practices HMO/PPO Members

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Helpful Websites About Medicare

• Medicare.gov
• Social Security Administration
• Medicare Ombudsman

 

• Prescription Drug Formulary Information
• Participating Pharmacy Information
• UPMC for Life Mail-Order Pharmacy
• Help for Prescription Drug Costs (LIS Premium Summary Table)
• Prescription Drug Authorizations, Exceptions, Redeterminations, and Grievances to the UPMC for Life Prescription Drug Formulary
• Medicare Prescription Drug Determination Request Forms
• UPMC for Life Medication Transition Process
• UPMC for Life Medication Management Program
• Pharmacy Claim Reimbursement Form
• Other Important Information

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Prescription Drug Formulary Information

A prescription drug formulary is a list of medications UPMC for Life covers.
UPMC for Life Prescription Drug Formulary

UPMC for Life may add or remove prescription drugs from our formulary during the year. The document below will advise you of these changes.
60-day Formulary Change Information

Some of the drugs that UPMC for Life covers may require you and your doctor to get prior approval from UPMC for Life. The document below will advise you of which drugs require prior authorization.
Prior Authorization Requirements

In some cases, UPMC for Life requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. The document below will advise you of which drugs require step therapy.
Step Therapy Requirements

The document below contains a list of select Part B drugs that UPMC for Life covers.
Covered Select Part B Drugs and Supplies

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Participating Pharmacy Information

UPMC for Life has over 60,000 participating pharmacies. The document below allows you to search for pharmacies in our network. Members must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. For more information regarding the UPMC for Life pharmacy network or mail-order prescription drug services, please call us at the phone number listed in the directory below.

UPMC for Life Pharmacy Directory

How many pharmacies participate in the UPMC for Life pharmacy network?
Does UPMC for Life meet Medicare requirements for pharmacy access?

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UPMC for Life Mail-Order Pharmacy

UPMC for Life's mail-order pharmacy, Express Scripts, Inc., can mail medications directly to your home or any address that you specify. Members can use the form below to mail in prescription orders.
Express Scripts, Inc. Mail-Order Form

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Help for prescription drug costs (LIS Premium Summary Table)

People with limited incomes may qualify for extra help to pay their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or late enrollment penalty. Many people are eligible for these savings and don?t even know it. Please select the state in which you reside to receive the low income subsidy information for your region.

Select State: Pennsylvania West Virginia

For eligibility information, to sign-up for extra help, or to inquire about your low-income subsidy status contact:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, 7 days a week.
• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778.
  You can also visit their website at www.socialsecurity.gov/prescriptionhelp/.
• Your state Medicaid or Medical Assistance Office.

In some cases Medicare may not give UPMC for Life the correct low-income subsidy information for an eligible individual. Medicare created the Best Available Evidence policy so that plan sponsors could readdress cost-sharing for those beneficiaries once the original information was found to be incorrect.
Best Available Evidence (BAE) Policy

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Prescription Drug Authorizations, Exceptions, Redeterminations, and Grievances to the UPMC for Life Prescription Drug Formulary

UPMC for Life members may ask for a coverage determination, redetermination, or appeal for a Part D prescription drug. Use the links below to learn more.

What should I do before talking to my doctor about changing my prescription drugs or requesting an exception to the UPMC for Life prescription drug formulary?

UPMC for Life Evidence of Coverage — Appeals and Grievances and Coverage Determination Information


Part D Prescription Drug Appeals and Grievances Information

Members can request a coverage determination, exception, redetermination or appeal by completing and signing one of the forms below and mailing or faxing it to UPMC Health Plan, or by calling our Member Services department. Please contact us using one of the methods listed. You may also call our Member Services Department to get information about this process, to check on the status of your request, or to obtain an aggregate number of appeals and grievances for our plan.

• Fax: 412-454-7920
• Phone: Call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 1-800-361-2629.
• Mail: UPMC Health Plan
  ATTN: Appeals and Grievances
  PO BOX 2939
  Pittsburgh, PA 15230-2939

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Medicare Prescription Drug Determination Request Forms

UPMC for Life members should have their prescribing physician fill-out the following forms.

UPMC for Life Prescription Drug Coverage Determination/Exception Request Form
Medicare Prescription Drug Coverage Redetermination Request Form

The Medicare program also offers forms to Medicare beneficiaries and providers for prescription drug determination or appeal requests. Use the links below to view this information on the Medicare website.

• For Medicare Enrollees: Medicare Prescription Drug Determination Request Form
• For Medicare Providers: Medicare Part D Coverage Determination Request Form

A UPMC for Life member can appoint a person to act on his/her behalf. Print the form below, complete the required fields, and fax or mail it to us. Once we receive this completed request we will verify it, adjust our records accordingly, and speak to your appointed representative. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 1-800-361-2629.

• Fax: 412-454-7829
• Mail: UPMC for Life
  PO BOX 2965
  Pittsburgh, PA 15230-2965

Appointment of Representative Form

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UPMC for Life Prescription Drug Transition Policy

During the first 90 days that you are a member of UPMC for Life, we may cover a limited amount of your current non-formulary drug therapy in certain cases while you talk to your doctor to determine the right course of action for you. Click on the links below for more information.

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

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UPMC for Life Medication Therapy Management (MTM) Program

UPMC Health Plan has developed a unique medication therapy management program for members who take many medications. Use the links below to learn more.

How does UPMC for Life manage drug utilization?
How does UPMC for Life help members who take many medications?
Who is eligible for UPMC for Life's medication management program?

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Pharmacy Claim Reimbursement

If you are a UPMC for Life member, complete the form below to apply for reimbursement for Part D prescription drugs.
Prescription Drug Reimbursement Claim Form

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Other Important Information

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

UPMC for Life renews our contract with the Medicare program each year. If we plan to leave a service area, we must notify members accordingly.
Contract Termination Information

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.
UPMC for Life Out-of-Network Coverage

• Provider and Pharmacy Directories
• Pharmacy Directory
• Prescription Drug Formulary Information
• Out-of-Network Coverage
• Vision Provider Directory
• Dental Discount Program
• Silver&Fit Fitness Provider Directory

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Provider and Pharmacy Directories

The UPMC for Life provider network includes over 8,300 providers and 71 hospitals. Please select the state and the county in which you reside to see a directory for the participating providers in your region. You can also use our searchable directory to search for a specific provider or hospital.

Pennsylvania		Select a county: Allegheny Armstrong Beaver Bedford Blair Butler Cambria Cameron Clarion Clearfield Crawford Elk Erie Fayette Forest Greene Huntingdon Indiana Jefferson Lawrence McKean Mercer Potter Somerset Venango Warren Washington Westmoreland
Ohio/West Virginia (Group Only)		Select a county: Belmont Brooke Hancock Jefferson Marshall Monongalia Ohio Preston Wetzel
West Virginia		Select a county: Brooke Hancock Marshall Monongalia Ohio Preston Wetzel

Searchable Provider Directory

Important Information for HMO Members: When using an HMO plan, you must use plan providers, except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor UPMC for Life will be responsible for the costs.

Important Information for PPO Members: When using a PPO plan, accessing service out-of-network may cost more than using services in-network. With the exception of emergency and urgent care, it will cost more to get care from non-plan or non-preferred providers.

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Pharmacy Directory

UPMC for Life has over 60,000 participating pharmacies. The document below allows you to search for pharmacies in our network. Members must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. For more information regarding the UPMC for Life pharmacy network or mail-order prescription drug services, please call us at the phone number listed in the directory below.

UPMC for Life Pharmacy Directory

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Prescription Drug Formulary Information

A prescription drug formulary is a list of medications UPMC for Life covers.
UPMC for Life Prescription Drug Formulary

UPMC for Life may add or remove prescription drugs from our formulary during the year. The document below will advise you of these changes.
60-day Formulary Change Information

Some of the drugs that UPMC for Life covers may require you and your doctor to get prior approval from UPMC for Life. The document below will advise you of which drugs require prior authorization.
Prior Authorization Requirements

In some cases, UPMC for Life requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. The document below will advise you of which drugs require step therapy.
Step Therapy Requirements

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Out-of-Network Coverage

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.
UPMC for Life Out-of-Network Coverage

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Vision Provider Directory

To find a list of vision providers that are participating in the UPMC for Life vision provider network, please use the directory below. UPMC for Life HMO and PPO members receive a routine vision allowance toward the cost of one routine eye exam and eyewear, such as lenses, frames, or contact lenses, every two years. Please see the Summary of Benefits booklet for the routine vision allowance amount.

See any provider you like even if the provider is not in the vision provider network. If you get your routine vision services from a vision plan provider, the provider will bill the vision plan on your behalf. If you get your routine vision services from a non-plan provider, you may need to pay the cost at the time of the service and submit a claim form for reimbursement.

Routine Vision Provider Directory
Routine Vision Care Reimbursement Form for Out-of-Network Services

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Dental Discount Program

Take advantage of savings starting at 15% on routine and major dental services at a participating dental provider. No referrals or prior approvals are needed. Enjoy unlimited usage on services such as cleanings and exams, x-rays and fillings, root canals and crowns, and dentures and bridges.

To find a list of dental discount providers, please click on the link below. In the Groups section enter the number 7951 into the blank next to Group or Client Number. You can also contact New Benefits Member Services at 1-866-917-9730, Monday through Friday from 9 a.m. to 8 p.m. and Saturday from 10 a.m. to 5 p.m. TTY/TDD users should call 1-800-361-2629.
Dental Discount Locate Providers

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Silver&Fit^® Fitness Provider Directory

To find a list of fitness centers and facilities that are participating in the Silver&Fit health and wellness network, please use the directory below.
Silver&Fit Provider Directory

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Hearing Discount Program

Save up to 20% off hearing services at participating retail locations. This program includes a free annual hearing screening and exams, as well as discounts on hearing aid instruments. No referrals or prior approvals are needed.

To find a participating hearing discount provider, go to www.beltone.com or www.hearpo.com/upmc.

Please note: if you are enrolled in the UPMC for Life HMO Rx Enhanced (HMO) plan or UPMC for Life PPO Rx (PPO) plan you have routine hearing benefits and are not eligible to receive this discount.

• Authorized Representative Forms
• Routine Vision Care Reimbursement for Out-of-Network Services
• Express Scripts, Inc., Mail-Order Form
• Prescription Drug Authorizations, Exceptions, Redeterminations, and Grievances to the UPMC for Life Prescription Drug Formulary

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Authorized Representative Forms

A UPMC for Life member can appoint a person to act on his/her behalf or to view his/her protected health information (PHI). Choose the appropriate form below, complete the required fields, sign, print, and fax or mail it to us. Once we receive this completed request we will verify it, adjust our records accordingly, and speak to your appointed representative or share your PHI as needed. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 1-800-361-2629.

• Fax: 412-454-7829
• Mail: UPMC for Life
  PO BOX 2965
  Pittsburgh, PA 15230-2965

Appointment of Representative Form — Use this form to appoint a representative to make decisions for you and legally act on your behalf (e.g., make requests, present or get evidence, obtain appeals information, and receive notices regarding an appeal).

Personal Representative Designation Form — Use this form to appoint a representative to act on your behalf in discussing your health information and benefit coverage through UPMC Health Plan.

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Routine Vision Care Reimbursement for Out-of-Network Services

As a UPMC for Life member, you can receive routine vision care services from providers outside of the vision provider network. If you get your routine vision care services from a non-plan provider, you may need to pay the cost at the time of the service. You can submit the claim form below for reimbursement.
Routine Vision Care Reimbursement Form for Out-of-Network Services

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Express Scripts, Inc., Mail-Order Form

UPMC for Life's mail-order pharmacy, Express Scripts, Inc., can mail medications directly to your home or any address that you specify. Members can use the form below to mail in prescription orders.
Express Scripts, Inc., Mail-Order Form

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Prescription Drug Authorizations, Exceptions, Redeterminations, and Grievances to the UPMC for Life Prescription Drug Formulary

UPMC for Life members may ask for a coverage determination, redetermination, or appeal for a Part D prescription drug. Use the links below to learn more.

What should I do before talking to my doctor about changing my prescription drugs or requesting an exception to the UPMC for Life prescription drug formulary?

UPMC for Life Evidence of Coverage — Appeals and Grievances and Coverage Determination Information

Part D Prescription Drug Appeals and Grievances Information

Members can request a coverage determination, redetermination or appeal by completing and signing one of the forms below. Please contact us using one of the methods listed. You may also call our Member Services Department to get information about this process, to check on the status of your request, or to obtain an aggregate number of appeals and grievances for our plan.

• Fax: 412-454-7920
• Phone: Call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 1-800-361-2629.
• Mail: UPMC Health Plan
  ATTN: Appeals and Grievances
  PO BOX 2939
  Pittsburgh, PA 15230-2939

UPMC for Life Prescription Drug Coverage Determination/Exception Request Form
Medicare Prescription Drug Coverage Redetermination Request Form

The Medicare program also offers forms to Medicare beneficiaries and providers for prescription drug determination or appeal requests. Use the links below to view this information on the Medicare website.

For Medicare beneficiaries: Medicare Prescription Drug Coverage Determination Request Form
For Medicare providers: Medicare Part D Coverage Determination Request Form

• Filing an Appeal or Grievance
• How to obtain the aggregate number of grievances, appeals, and exceptions filed with UPMC for Life
• Member Rights and Responsibilities
• Medicare Contract Information

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Filing an Appeal or Grievance

At UPMC for Life, we continually work to improve the quality of care and service that you receive as a member. We encourage you to let us know right away if you have questions, concerns, or problems related to covered services or the care you receive while you are a member of UPMC for Life by calling our Member Services Department at 1-877-539-3080 from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 1-800-361-2629.

How to file an appeal or grievance

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How to obtain the aggregate number of grievances, appeals, and exceptions filed with UPMC for Life

To obtain the aggregate number of grievances, appeals, and exceptions filed with UPMC for Life, please call our Member Services Department at 1-877-539-3080 from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 1-800-361-2629.

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Member Rights and Responsibilities

UPMC for Life members have rights and responsibilities when participating in health management programs or disenrolling from a UPMC for Life plan. Use the links below to learn more.

UPMC for Life Member Rights and Responsibilities

Rights and Responsibilities of Members Participating in Health Management Programs

Disenrollment Rights and Responsibilities

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Medicare Contract Information

UPMC for Life renews our contract with the Medicare program each year. If we plan to leave a service area, we must notify members accordingly.

Contract Termination Information