UPMC for Life Plan Documents

1. Open this form: Medical Claim Reimbursement Form.
   
   
2. Print the form. Follow the instructions on the form and fill out as completely as possible.
   
   
3. For your claim to be processed, you will need to get your medical receipts or patient history printout from your provider.
   
   
4. Fax or mail the form and your receipts to us. Please do not staple or attach your receipts to another piece of paper.
   
   Fax: 1-844-201-4655
   Mail: UPMC Health Plan/UPMC Health Benefits
   Claims Department
   PO Box 2999
   Pittsburgh, PA 15230

Vision Claim Form

If you are a University of Pittsburgh retiree who has received vision services from a provider outside of the Envolve provider network, you can fill out the Vision Claim Form below and mail it to the following address:

• For members in the first 90 days of enrollment—transition process
• For members currently residing in a long-term care facility—transition process
• For members moving from home to a long-term care facility or from a long-term care facility to home—transition process

The forms linked below can be used to request prior authorization, coverage determination and redetermination, or an exception for prescription drugs.

1. Select and open the appropriate form:
   • Use this link to submit a request for a drug not currently covered under your plan:
     UPMC for Life Prescription Drug Coverage Determination/Exception Request Form (PDF)
   • Use this link to submit a request or redetermination of a drug coverage request denied within the past 60 days:
     UPMC for Life Medicare Prescription Drug Coverage Redetermination Request Form (PDF)
2. Fill out the form and save it to your computer's hard drive.
3. Submit your request form using our online submission tool.

Please note:
If you upload this file to us, it will remain on your computer.
If you are using a public or shared computer and you do not want to save your personal health information on that computer, you should consider calling Member Services or print and mail the form.

• How does UPMC for Life help make sure I’m safe on my prescription medications?
• How does UPMC for Life help members who take many medications?
• Who is eligible for UPMC for Life's medication management program?

1. Open this form:
   • UPMC for Life Prescription Drug Claim Reimbursement Form
   • UPMC for Life Complete Care (HMO SNP) Prescription Drug Claim Reimbursement Form
2. Print the form. Follow the instructions on the form and fill out as completely as possible.
3. For your claim to be processed, you will need to get your prescription receipts or patient history printout from your pharmacy.
4. Mail the form and your receipts to us at the address below. Please do not staple or attach your receipts to another piece of paper.
   
   UPMC for Life/UPMC for Life Complete Care Pharmacy Services Department
   U.S. Steel Tower, 12th Floor
   600 Grant Street
   Pittsburgh, PA 15219

We take your privacy seriously at UPMC for Life. The documents below show the steps we take to protect your personal information.

• Privacy Statement
• Notice of Privacy Practices

1. Download or log in to the UPMC Health Plan app, then select Account and Manage Premium Payments.
2. Log in to UPMC Health Plan Member Site. Under the Your Insurance section on the homepage, click on Premium Payments.

• UPMC for Life Member Rights and Responsibilities
• UPMC for Life Member Disenrollment Rights and Responsibilities