Appointment of Representative

You can ask our plan to provide a medical coverage decision if you are in any of the following situations:

• You are not getting certain medical care you want, and you believe this care is covered by our plan.
• Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe this care is covered by the plan.
• You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.

Please refer to your Evidence of Coverage for complete details. You can access your Evidence of Coverage in the UPMC Health Plan member site, your secure member website, or through the UPMC Health Plan mobile app:

Log in to the UPMC Health Plan member site
Download the UPMC Health Plan mobile app

If you would like to appoint a person to act in your behalf, print the form and complete the required fields. Fax or mail the completed form to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative.

Fax: 412-454-2070
Mail: UPMC for Life
Clinical Operations, 37th Floor
600 Grant Street
Pittsburgh, PA 15219

Appointment of Representative Form
Nombramiento de Representante
Language Assistance

You can request a medical claim reimbursement if you are a UPMC for Life member and have paid out-of-pocket for covered medical services. If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).

Fax: 412-454-8519
Mail: UPMC Health Plan/UPMC Health Benefits
Claims Department
PO Box 2999
Pittsburgh, PA 15230

Appointment of Representative Form
Nombramiento de Representante
Language Assistance

If you have paid out-of-pocket for seeing a non-network vision or dental provider, you can request to be reimbursed up to the vision or dental allowance amount of your plan. See your Summary of Benefits or Evidence of Coverage to confirm your routine vision or dental allowance amount. You can access these documents in the UPMC Health Plan member site, your secure member website, or through the UPMC Health Plan mobile app:

Log in to the UPMC Health Plan member site
Download the UPMC Health Plan mobile app

If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).

Fax: 412-454-8519
Mail: UPMC Health Plan/UPMC Health Benefits
Claims Department
PO Box 2999
Pittsburgh, PA 15230

Appointment of Representative Form
Nombramiento de Representante
Language Assistance

UPMC for Life members can request a coverage determination/exception for a Part D prescription drug. View the types of coverage determination requests.

If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).

Fax: 412-454-7722
Mail: UPMC Health Plan Pharmacy Department
U.S. Steel Tower, 12th Floor
600 Grant Street
Pittsburgh, PA 15219

Appointment of Representative Form
Nombramiento de Representante
Language Assistance

If UPMC for Life denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision.

If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).

Fax: 412-454-7920
Mail: UPMC Health Plan
ATTN: Appeals and Grievances
PO BOX 2939
Pittsburgh, PA 15230-2939

Appointment of Representative Form
Nombramiento de Representante
Language Assistance

A UPMC for Life member who has been disenrolled for nonpayment of plan premiums can request to be reinstated by calling our Member Services Department at 1-877-539-3080 (TTY: 711).

If you would like to request reinstatement on behalf of the member, you and the member must complete the Appointment of Representative form below. Print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. Once received, this form will be valid for one year from the date you and your representative sign it. A new form will not be needed for each request until after a year unless you wish to designate another representative. If you have any questions, please call our Member Services Department at 1-877-539-3080 (TTY: 711).

Fax: 412-454-7520
Mail: UPMC for Life
PO BOX 2987
Pittsburgh, PA 15230-2987

Appointment of Representative Form
Nombramiento de Representante
Language Assistance