Important Plan Information

Important Plan Information

• UPMC for You Advantage
• UPMC for You Advantage Information
• UPMC for You Advantage Member Rights and Responsibilities
• UPMC for Life Specialty Plan
• UPMC for Life Specialty Plan Information
• UPMC for Life Specialty Plan Member Rights and Responsibilities
• UPMC for Life Options
• UPMC for Life Options Information
• UPMC for Life Options Member Rights and Responsibilities

Plan Rating Information

Prescription Drug Formulary Information

• Prescription Drug Formulary*
• 60-day Formulary Change Information* — coming soon
• UPMC for Life Prior Authorization Information for Prescription Drugs*

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

Important Plan Forms

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

To ask for a coverage determination, redetermination, or appeal about a Part D drug, a signed, written request should be faxed to UPMC Health Plan or sent to the address listed below. Please click on the Prescription Drug Coverage Determination Form/Exception Request and the Prescription Drug Coverage Redetermination Forms above.

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 a coverage determination, redetermination, or appeal by calling our Member Services Department at 1-800-606-8648 from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 1-866-407-8762.

• 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:

If you have any questions about this form, please call our Member Services Department at 1-800-606-8648, from 8 a.m. to 8 p.m.,* seven days a week.TTY/TTD users should call 1-866-407-8762.

• 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*

Disenrollment Rights and Responsibilities

• Disenrollment Rights and Responsibilities Information
• Medicare Prescription Drug Plan Finder

HIPAA Notice of Privacy Practices

• Privacy Statement
• Notice of Privacy Practices SNP Members
• Exclusions and Limitations*

Contract Termination

• Contract Termination Information*

• UPMC for You Advantage
• UPMC for Life Specialty Plan
• UPMC for Life Options