Important Information about Medicare and the UPMC for Life Medicare Advantage Program

Medicare Eligibility: Our Medicare Advantage plans are available to persons entitled to Medicare Part A and enrolled in Part B. You must continue to pay Medicare premiums, reside in the service area, and not have end-stage renal disease (ESRD). UPMC for Life is a Medicare Advantage organization with a Medicare contract. Our contract with CMS is renewed annually and availability of coverage beyond the end of the current contract year is not guaranteed. UPMC for Life is a product of and operated by UPMC Health Plan, Inc., UPMC Health Network, Inc., and UPMC Health Benefits, Inc.

Premium Withhold Information: After you are enrolled in UPMC for Life, if you decide to switch your payment election to premium withhold or move from premium withhold to direct bill, it could take up to three months for it to take effect and you will ultimately remain held responsible for the premiums that occur in between.

Help for Prescription Drug Costs: People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY/TDD users should call 1-877-486-2048.

Pharmacy Network Limitations: UPMC for Life offers eligible individuals the following types of pharmacies in our network: retail, mail order, long-term care, home infusion, and Indian Health Service, Tribes, or Urban Indian (I/T/U). Benefits are only available at pharmacies that are contracted with UPMC for Life. For more information regarding our pharmacy network or mail-order prescription drug services, please call us at the number below.

Online Enrollment Information: Medicare beneficiaries may enroll in UPMC for Life through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at . For more information, call UPMC for Life at the number on .

Alternative Format Request: You have the right to get your questions answered. Our plan has individuals and translation services available to answer questions from non-English speaking beneficiaries, and must provide information about our benefits that is accessible and appropriate for persons eligible for Medicare because of disability. If you need plan documents in other formats, please contact UPMC for Life at the number below.

Medicare Advantage Enrollment Information: You may apply for enrollment in a Medicare Advantage Plan during the Annual Election Period from November 15, 2009 to December 31, 2009. You can only make one enrollment election during this time. Your coverage will be effective January 1, 2010 (subject to Medicare approval. You may also apply for enrollment in a Medicare Advantage Plan during the Open Enrollment Period from January 1, 2010 to March 31, 2010. You may make one election to the same type of plan you have currently. If you enroll during this time period, your coverage will become effective the first of the month after your completed election is received (subject to Medicare approval). After March 31, 2010, you cannot make a plan change unless you qualify for a special election Period (e.g. you move our of the plan’s service area) or have Medical Assistance coverage. If you have questions about your Medicare eligibility, call us at the number on .

Medical services that are not covered by UPMC for Life HMO and PPO plans.

1. Services that are not covered under Original Medicare.
2. UPMC for Life HMO plans: Services that you get from non-plan providers, except for care for a medical emergency and urgently needed care, renal (kidney) dialysis services that you get when you are temporarily outside the plan’s service area, and care from non-plan providers that is arranged or approved by a plan provider. UPMC for Life PPO plans: If you obtain services from a provider who contracts with your plan, the service will be treated as an in-network covered service unless the provider advises you otherwise. If you obtain a service from a non-plan provider, you may want to confirm in advance with your plan that the service you obtain is medically necessary and a plan-covered service.
3. UPMC for Life HMO plans: Services that you get without prior authorization, when prior authorization is required for getting that service. UPMC for Life PPO plans: Even though you are not required to get prior authorization for services from non-plan providers, you can ask us for prior authorization to make sure that we agree that the service are covered and medically necessary. You may also obtain cost sharing reductions if you choose to obtain prior authorization for certain services that you obtain from non-plan providers.
4. Services that are not reasonable and necessary according to Original Medicare Plan standards, unless these services are otherwise listed by UPMC for Life.
5. Emergency facility services for non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency.
6. Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under an approved clinical trial. Experimental procedures and items are those items and procedures determined by UPMC Health Plan and Original Medicare to not be generally accepted by the medical community.
7. Surgical treatment of morbid obesity unless medically necessary and covered under Original Medicare.
8. Private room in a hospital, unless medically necessary.
9. Private duty nurses.
10. Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility.
11. Nursing care on a full-time basis in your home.
12. Custodial care is not covered unless it is provided in conjunction with skilled nursing care and/or skilled rehabilitation services. “Custodial care” includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
13. Homemaker services.
14. Charges imposed by immediate relatives or members of your household.
15. Meals delivered to your home.
16. Unless medically necessary, elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance.
17. Cosmetic surgery or procedures, unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Breast surgery and all stages of reconstruction for the breast on which a mastectomy was performed and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected breast, is covered.
18. The following dental services (complex extractions, dentures, full mouth x-rays, orthodontics) are excluded. Certain dental services that you get when you are in the hospital will be covered.
19. Chiropractic care is generally not covered under the plan, (with the exception of the routine visits for manual manipulation of the spine) and is limited according to Medicare guidelines.
20. Routine foot care is generally not covered under the plan, (with the exception of the routine visits) and is limited according to Medicare guidelines.
21. Orthopedic shoes, unless they are part of a leg brace and are included in the cost of the leg brace. There is an exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease.
22. Supportive devices for the feet. There is an exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease.
23. Hearing aid batteries are not covered under the plan.
24. Radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services.
25. Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.
26. Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices.
27. Acupuncture.
28. Naturopaths' services.
29. Services provided to veterans in Veteran's Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost sharing is more than the cost sharing required under UPMC for Life, we will reimburse veterans for the difference.

UPMC for Life Contact Information: For full information on UPMC for Life benefits, call us toll-free at 1-866-400-5077, seven days a week, from 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-361-2629. From March 2 through November 14, you may receive a messaging service on weekends and holidays. Please leave a message and your call will be returned the next business day.