Medical Assistance

Our Benefits and Services

When you choose UPMC for You, you choose the #1 Medicaid Plan in PA for eight out of nine years in a row, and the #10 plan in the nation.* As a UPMC for You member, you can visit some of the best doctors and hospitals in Pennsylvania. The UPMC for You provider network includes both UPMC and community providers, totaling more than 86 hospitals and more than 10,000 physicians.

Use UPMC for You to help you stay healthy and get treatment for any health problems. Members can access these benefits:

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Pharmacy

Our members can count on us for prescription drug coverage. They get all of the same drugs that Medical Assistance covers, plus some over-the-counter drugs and vitamins with a prescription. Some medications may require a copayment, and depending on your category of aid, limits may apply.

Pharmacy Resources for Members
The UPMC for You Pharmacy Formulary is a list of Food and Drug Administration (FDA) approved medications. This list was developed by UPMC for You doctors and pharmacists and includes the most commonly used drugs. Medications on the formulary (drug list) that are prescribed by a doctor are paid for by UPMC for You. The list does not include every medication a doctor might prescribe. The drugs on the formulary have been selected because they are safe, work well, and cost less than other drugs that have the same level of effectiveness.

Find a participating pharmacy

Pharmacy guides:

Financial Responsibilities
Pharmacy Prior Authorization Criteria
View minutes from the Pharmacy & Therapeutics Committee meetings

Dental

A general dentist is a health professional who specializes in caring for teeth, gums, and other tissues in the mouth. A dental specialist treats children and people who need special care for their teeth or gums. The UPMC for You network includes general dentists and specialists. We cover exams, cleanings, and fillings for all UPMC for You members.

The UPMC for You network includes general dentists and dentists who provide special dental care. Members can call Dental Member Services at 1-888-257-0474 to get a dentist's name or to see what dental benefits they have. TTY users should call toll-free 1-800-201-7165.

Avesis manages UPMC for You Dental benefits.

Benefit Changes
Effective May 1, 2012

Vision

An optometrist performs eye examinations and fits you for glasses or contact lenses. An ophthalmologist treats eye problems, may perform surgery, and may write prescriptions. The ophthalmologist can also perform eye exams and fit you for glasses or contact lenses.

Our members can self-refer to participating ophthalmologists or optometrists for a routine eye exam. If a UPMC for You member needs to see an ophthalmologist for a problem, he or she must get a referral from their primary care practitioner (PCP).

UPMC for You vision benefits are administered through OptiCare Managed Vision.

Members who need help finding an eye care provider, or have questions about their vision benefit, can call OptiCare Member Services at 1-866-458-2138. TTY users should call toll-free 1-800-361-2629. Representatives are available Monday through Friday from 8 a.m. to 7 p.m.

A list of participating vision providers is available on the OptiCare vision provider search page.

Providers

UPMC for You covers doctor visits, with no copayments. (Some members may have a small copayment for chiropractors and podiatrists.)

Members choose a primary care practitioner (PCP). A PCP is a personal doctor or Certified Registered Nurse Practitioner (CRNP). He or she provides or arranges all of our members' health care needs.

If a member needs to see a specialist, our doctors help take care of the details. There is no paperwork to worry about.

Services that do not require a referral:

  • Well-woman visit
  • Pregnancy/birth services
  • Family planning
  • Vision exams
  • Substance abuse
  • Dental care
  • Behavioral health

A PCP can be a family and general practice doctor, a pediatrician, an internal medicine doctor, or a CRNP. Family and general practice doctors treat all family members. Most pediatricians treat children, and most internal medicine doctors treat adults. A CRNP is a registered nurse with advanced training in a specialty area, certified by the boards in that specialty area. A CRNP may diagnose a condition or prescribe medicine under the direction of a doctor.

The Find A Doctor search tool can help our members find and select a doctor that is conveniently located.

Special Care

Our programs help keep our members healthy. We have programs for asthma, diabetes, chronic obstructive pulmonary disease (COPD), depression, and heart disease.

Additional Benefits

UPMC for a New Beginning Maternity Program

Moms are important. We care about you and your children. Our UPMC for a New Beginning Maternity Program will help keep you and your baby healthy. If you meet program requirements, you could receive an infant car seat or a portable play yard. To get your infant car seat or portable play yard, you will need to:

  • Visit your maternity provider within 13 weeks of becoming pregnant.
  • Enroll in the UPMC for a New Beginning Maternity Program before you are 34 weeks pregnant.
  • Keep at least eight prenatal visits.
  • Get all of the routine lab tests ordered by your maternity provider.
  • Keep all of your scheduled telephone calls with the maternity program representative.
  • Return to UPMC for You the consent form signed by you and your maternity provider.

We help you find maternity providers who are close to your home.

If you have any questions about the UPMC for a New Beginning Maternity Program, please call 1-866-778-6073, Monday through Friday, from 8 a.m. to 4:30 p.m. TTY users should call 1-800-361-2629 toll-free.

text4baby

The text4baby program is available to pregnant women and new moms. You can get free tips on your cell phone to help you through your pregnancy and your baby’s first year.

Registration is easy. You can register online or from your cell phone. Your tips are timed to your due date or your baby’s birth date.

If you have service with one of the carriers listed below, text4baby is free. Even mothers without a text messaging plan can get these messages for free. If you have limited texts per month, text4baby won't reduce that limit.

  • Alltel
  • Assurance Wireless
  • AT&T
  • Bluegrass Cellular
  • Boost Mobile
  • Cellular South
  • Cellcom
  • Centennial Cellular
  • Cincinnati Bell
  • CricKet
  • Metro PCS
  • N-Telos
  • Nex-Tech Wireless
  • Sprint Nextel
  • T-Mobile
  • U.S. Cellular
  • Verizon Wireless
  • Virgin Mobile USA

If you have questions about text4baby, please call 1-866-778-6073, Monday through Friday, from 8 a.m. to 4:30 p.m. TTY users should call toll-free to 1-800-361-2629.

MyHealth Advice

MyHealth Advice Line

Immediate access to health care advice is available 24 hours a day/7days a week through the UPMC Health Plan MyHealth Advice Line. Whether you are seeking general health advice or information regarding a specific medical issue, experienced registered nurses are available around the clock to provide you with prompt and efficient services. Call the MyHealth Advice Line at 1-866-918-1591. TTY users should call toll-free 1-866-918-1593.

Note: The MyHealth Advice Line is not a substitute for medical care. If you need emergency care, go to the nearest emergency room, or call 911 or the local ambulance service.

Submit email inquiries 24 hours a day/7 days a week using the Web Nurse Request system available on the UPMC for You website at www.upmchealthplan.com/members. Log in and select Contact Us. Then click on Web Nurse from the list. Responses to email inquiries will be within 24 hours of receipt of the original message.

TTY users should call toll-free 1-800-361-2629.