Welcome to your plan!
Whether you are new or returning, thank you for being a member of UPMC Health Plan.
We’re committed to ensuring you have an exceptional health journey that’s tailored to you. Think of your health insurance plan as your safety net, not just a stack of paperwork. Take the time to explore it and you’ll uncover valuable benefits that can make a difference in your well-being.
The first step we encourage every member to take is to create a UPMC Health Plan Login.1 This will allow you to fully unlock the potential of your UPMC Health Plan experience. You’ll gain access to our suite of tools and medication management resources; learn more about participating providers in your area, copayments for covered services, how to submit claims, and other key plan information; and more.
It's quick and easy to create a UPMC Health Plan Login, which you can then use to access the UPMC Health Plan app, member site, and 24/7 video visits.2 Once you have a Login, you can use our app or member site to:
- Access to your personal health information 24/7.
- Find an in-network provider.
- Learn about your benefits.
- Print or request a member ID card.
- Select or change your primary care provider.
- Review your member guide.
- Watch health videos and get daily activity and healthy living tips.
- Receive virtual care through 24/7 video visits and more!
UPMC Health Plan covers different medications, and we call our list a formulary. We then sort the medicines in our formulary into groups. Your UPMC Health Plan prescription coverage might vary from that of your previous plan. It’s essential to stay informed. Here’s how:
- Health Care Concierge: Call the number on your member ID card to speak with a Health Care Concierge. They can talk with you about any coverage questions you have.
- Free medication review: Request a personalized medication review with one of our pharmacists. They can help you understand your options and any potential issues.
- Price a Prescription: Curious about a specific medication? Use our Price a Prescription tool to find out if it’s covered and its cost.
To find out your copayments and learn about your prescription coverage, check your member ID card. You can also look at your Schedule of Benefits. If you’re curious about covered medications, visit our Pharmacy page to review the pharmacy program.
It’s crucial to select a primary care provider (PCP) or confirm that your current one participates with UPMC Health Plan. PCPs offer essential preventive screenings at no cost.3 These screenings can help you stay healthy and catch potential issues early. PCPs work with other health care providers to ensure you receive top-notch care. If you have a chronic or complex health condition, your PCP will point you to participating specialists who specialize in addressing your needs. Some providers even offer virtual visits so you can have consultations from the comfort of your home.
Finding health care providers is easy with the help of our Health Care Concierge team.
Cost sharing is the portion of health care costs that you, as the insured, are responsible for paying out of your pocket. This means that you and UPMC Health Plan both pay for your care. You contribute a portion, and UPMC Health Plan covers the rest. Your deductible is a fixed amount that you must pay for covered medical services before the Health Plan will pay benefits. It’s like a health care threshold. Until you reach your deductible, you must pay for each covered service. After you meet your deductible, you and UPMC Health Plan will share your care costs through coinsurance. This is a percentage of the cost of covered medical services that you must pay. If your coinsurance is 20 percent, you must pay 20 percent toward the cost of your covered health care services. UPMC Health Plan will cover the remaining 80 percent.
Some plans also have copayments. This is a specified dollar amount or percentage that you are required to contribute toward the cost of covered medical services under your health care coverage. Copayments may vary by type of service and are specified in plan documents and on ID cards. You’ll pay these when you receive a service, and your deductible and coinsurance won’t apply.
Lastly, you have an out-of-pocket maximum. This is the most you’ll pay toward covered care in a plan year. Once you hit the out-of-pocket maximum, UPMC Health Plan will cover 100 percent of your care.
Stay informed and take charge of your health! You can view all your plan’s care costs by going to Coverage and Benefits.
You must notify UPMC Health Plan in writing within 20 days of the occurrence or beginning of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given either by you or on your behalf should be addressed to Claims Department, UPMC Health Plan Inc., [PO Box 2999, Pittsburgh, PA 15230-2999]. You may also call UPMC Health Plan at the phone number on your member ID card (or any authorized agent of UPMC Health Plan) and provide them with enough information for them to identify you.
If you receive care from a participating provider, you will not have to submit a claim to UPMC Health Plan. UPMC Health Plan will pay the provider directly. However, if you obtain medically necessary covered services from a nonparticipating provider, you may have to file a claim yourself.
Check out the Forms and Guides section of the UPMC Health Plan member site for a form to submit a claim.
The UPMC Health Plan member guide is a valuable resource. It is something you should reference for information on:
- Benefits and services.
- Care options.
- How the Health Plan may view or handle new technologies.
- How to obtain specialty or emergency care.
- Submitting complaints or filing grievances.
- Language services.
- Member rights and responsibilities and more.
Remember: The member guide is your compass for navigating your health plan!
As a UPMC Health Plan member, it’s important for you to understand the intricacies of your coverage. Having this understanding can help ensure you can make informed decisions.
Your UPMC Health Plan coverage offers a treasure trove of benefits—from preventive care to specialized treatments. Remember, it’s not just about insurance—it’s about your well-being.
If you’re traveling or seeking care elsewhere, it’s important to know your options. There are sometimes limitations when you venture outside your service area, but we’ll guide you on accessing quality services even beyond our borders. Study your plan to understand your restrictions—what’s covered, what’s not—and learn about exclusions and why certain procedures may not be covered.
If you have questions, you can call the Health Care Concierge team at 1-844-220-4785 (TTY: 711) or chat with them in the UPMC Health Plan member site or app.
Getting healthy results is easier when you have a team of experts to help. They can guide you, encourage you, and help you keep going. You can get support from the experts at UPMC Health Plan. This suite of services lets you work with nurses, dietitians, and other professionals to manage your health conditions and make healthy lifestyle changes. Together, you’ll create a customized plan to achieve your personal health goals and work through challenges along the way.
If you want to lose weight, be more active, or stop smoking, our health coaches can help. If you have a health condition and want to feel better by learning to manage it, our care managers have the experience to handle even your most complex needs.
Here’s the best part about our health and wellness services: they are FREE for all UPMC Health Plan members. You can opt in or out at any time.
Find out more about our health and wellness services
As a UPMC Health Plan member, you have several options for receiving high-quality care when and where you need it. Knowing your options will help you make the best choice based on your needs.
Specialty care focuses on specific health conditions or complex cases. Whether you have a rare disease, chronic illness, or need specialized treatment, having access to experts can result in better outcomes.
Mental health is as vital as physical health. Behavioral health services4 address emotional well-being, substance abuse, and psychiatric conditions.
Hospitals provide critical care during emergencies, surgeries, and complex treatments.
- Emergency room care: Life-threatening situations
- Inpatient services: Surgeries, recovery, and specialized treatments
Health crises don’t follow schedules. Knowing how to access care after hours or during emergencies is crucial. For non-life-threatening issues outside regular hours, you’ll want to visit one of our UPMC-GoHealth Urgent Care Centers. For immediate care for severe conditions, you’ll want to visit an emergency room.
If you experience a physical or mental health emergency, go to the nearest emergency room, call 911, contact your local ambulance service, or call the Suicide and Crisis Lifeline at 988.
When you encounter issues or are dissatisfied with your health care experience, it’s essential to voice your concerns. Two ways you can do so are through complaints and appeals. Your feedback can contribute to better services for all of our members.
Complaints drive improvements and ensure your voice is heard. UPMC Health Plan investigates and promptly addresses concerns.
Appeals allow you to challenge decisions that UPMC Health Plan makes regarding your coverage. They ensure fairness and transparency. As part of the process, an independent reviewer examines your case. A successful appeal can grant you access to necessary treatments.
- Send written appeals to UPMC Health Plan, Appeals, PO Box 2939, Pittsburgh, PA 15230-2939. For additional information, call a Health Care Concierge at 1-833-854-7383. TTY users should call 711.
- Visit the Quality Assurance page for details on the complaints, grievances, and appeals process. If you enrolled through the Health Insurance Marketplace, all eligibility disputes must be filed with the Federally Facilitated Marketplace by calling 1-800-318-2596.
If you are dissatisfied with UPMC Health Plan’s final decision on your appeal, you may have the right request an external review by an Independent Review Organization (IRO) that is not directly affiliated with UPMC Health Plan.
Please refer to your member guide for more information on the complaint and appeal processes.
Navigating health insurance can be hard, especially when language barriers come into play. Language assistance services can bridge the gap by providing interpretation and translation support. These services are available to you at no cost. View a list of UPMC Health Plan's translation services below.
Translation services: Espanol | 繁體中文 | नेपाली | Русский | العربية | Tiếng Việt | Українська | Portugues | Francais | 한국어 | Deitsch | Deutsch | Asụ̀sụ́ Igbo | हिंदी | Italiano
Knowing your rights empowers you, whether you are advocating for fair treatment or appealing a coverage decision. Rights protect you from unfair denials or delays. Responsibilities ensure timely payments, allowing providers to focus on delivering quality care.
View a copy of UPMC Health Plan’s Member Rights and Responsibilities document to learn more.
This health insurance policy may not cover all your health care expenses. Read your contract or member handbook carefully to determine which health care services are covered. Call 1-844-220-4785 (TTY: 711) for additional information.
1UPMC employees can sign in to the UPMC Health Plan member site through Infonet. University of Pittsburgh employees can sign in to the site through Pitt Passport.
2Members who are in Pennsylvania at the time of a virtual visit may select a UPMC-employed provider, subject to availability and discretion of the provider. Members located outside of Pennsylvania at the time of service or those who select Talk Therapy or Psychiatry services will receive care from a provider employed or contracted by Online Care Network II PC (OCN), also known as Amwell Medical Group. It is at the discretion of OCN providers to choose whether to treat patients ages 0 to 2. OCN is not an affiliate of UPMC. Limitations may apply for members of ASO plans that have opted out of coverage. Talk Therapy or Psychiatry services through UPMC Health Plan telehealth services are not covered services for UPMC Community HealthChoices participants, UPMC for You members, or UPMC for Kids members. 24/7 video visits for children ages 0 to 2 are not available from 9 p.m. to 8 a.m. or outside of Pennsylvania. If a member is under the age of 18, the member’s parent or legal guardian must be with the member during the video portion of the visit, and the child and parent or legal guardian must be in Pennsylvania during the visit. Providers are not available to treat members who are in Puerto Rico.
3Preventive care will be covered at 100 percent only when it is received from a participating provider and it is billed as preventive. A separate cost may apply if additional medical services are received during the same visit of if your preventive care becomes diagnostic in nature.
4Not all services are covered by all plans. Before seeking services, please check your plan documents or call Member Services to learn what is covered by your plan.