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Medicare Part B Reimbursement Request Form


  1. Information
  2. Reimbursement
  3. Reimbursement Distribution
  4. Signature/Authorization

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Participant Information

Please read the instructions before submitting your Medicare Part B Reimbursement Request form:

1. Please complete the following form. All fields are required.
2. If you are submitting for your spouse or disabled dependent, please complete another submission of this form.

*These fields are required to complete the above form.

Medicare Part B Reimbursement

  1. In the Coverage Period section, enter the first of the month in which you are eligible for Medicare Part B this year and enter the last day of the year. For example, if you are eligible for Medicare Part B on January 1, 2019, you will fill in 1/1/2019 to 12/31/2019.
  2. Submit a copy of your Social Security cost-of-living adjustment (COLA) statement as proof of your payment (usually mailed starting in November the year before the adjustment becomes effective) or any other documentation showing your annual Medicare Part B premiums.
  3. If Medicare Part B premiums are not deducted from your Social Security check, submit a copy (front and back) of the cleared check or a bank/credit card statement that indicates your Medicare Part B premium payment.

I am requesting reimbursement of the following paid Medicare Part B premiums:

Coverage Period

Upload Documents

Please attach documents showing your monthly Medicare Part B premium(s) paid. The documents must include the period for which you have paid, proof of the premium payment, the name of the insurance company, the type of expense (Medicare Part B premiums), and the covered participant’s name. If you are attaching a copy of a cleared check, please submit an attachment of the front of the check.

*These fields are required to complete the above form.

Reimbursement Distribution

Please select the method in which you would like to receive your Medicare Part B reimbursement.

I am electing to have my Medicare part B reimbursement made:




Address Verification

Please complete the fields with the mailing address in which you would like to receive your Medicare Part B reimbursement.





*These fields are required to complete the above form.

Bank Account Verification

To enroll in direct deposit, complete this authorization form to permit all parties to deposit your Medicare Part B reimbursement into your bank account. Please note that it is required to attach a voided check for verification of all financial institution information and that only one bank account will be accepted for your reimbursement.

Account Information

Account Type



Financial Institution Information





Upload Check

Please upload an image of the front of a voided check.


*These fields are required to complete the above form.

Participant Signature/Authorization

The information furnished by me in support of this application for reimbursement is true and correct to the best of my knowledge. I understand that Medicare Part B premiums submitted for reimbursement must qualify under the provisions of the plan.

I hereby authorize any individual or organization to release any information requested by UPMC Benefit Management Services with respect to this specific request.

I elect to have my Medicare Part B reimbursement made by direct deposit into the account indicated above (this process will remain in effect until I cancel it in writing). If I change accounts, I will inform UPMC Benefit Management Services by submitting a revised authorization form.

*These fields are required to complete the above form.

Thank you for your submission. If you have selected to receive your reimbursement by mail, you should expect to receive your reimbursement check in the next 3-5 business days. If you chose to receive your reimbursement by direct deposit into your bank account, you should expect your reimbursement deposit to be made in the next 2-3 business days.

If you have any questions or concerns, please call us at 1-877-648-9641.

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