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UPMC for Life Plan Documents

To view this page accurately, please make sure you are using the most current version of one of the following web browsers: Chrome, Firefox, or Microsoft Edge. If you have trouble viewing the forms, please set your browser to allow pop-ups from this webpage. View UPMC for Life’s non-discrimination policy and translation services.

To access your Annual Notice of Changes, Evidence of Coverage, Summary of Benefits, provider directory, or prescription drug formulary, visit our UPMC for Life shop page or UPMC for Life Complete Care shop page and enter your ZIP code. You can also log in to MyHealth OnLine (your secure member website) or download the UPMC Health Plan mobile app.


Medical Coverage Decision (Organization Determination)

You can ask our plan to provide a medical coverage decision if you are in any of the following situations.
  • If you are not getting certain medical care you want, and you believe that 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 that this care is covered by the plan.
  • You are being told that coverage for certain medical care you have been getting that was previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.
  • To learn more about medical coverage decisions for UPMC for Life, view your plan's Evidence of Coverage.
Requests can be made via:
Fax: 412-454-2057
Mail: UPMC for Life
Clinical Operations, 11th Floor
600 Grant Street
Pittsburgh, PA 15219


UPMC for Life HMO/PPO members can call our Member Services Department at 1-877-539-3080 (TTY: 711) seven days a week from 8 a.m. to 8 p.m. UPMC for Life Complete Care (HMO SNP) members can call 1-800-606-8648 (TTY:711) 24 hours a day, 7 days a week.

Designate a Personal Representative

If you would like another person to act on your behalf when discussing your health care coverage and benefit information, you will need to fill out the form below and fax or mail it back to 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 personal representative.

Personal Representative Designation Form

Fax to: 412-454-7829
Mail to:
UPMC Health Plan
PO Box 2965
Pittsburgh, Pennsylvania 15230-2965

Medical Claim Reimbursement Form


If you are a UPMC for Life member and have paid out-of-pocket for covered medical services, you can submit the form below to apply for reimbursement. Please follow these steps to submit a medical care claim reimbursement form to us.
  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
If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

Vision Claim Reimbursement Form

If you are a UPMC for Life member who has paid out-of-pocket for seeing a non-network vision provider, you can fill out the Vision Claim Form and fax or mail it to the address below for reimbursement. You will be reimbursed for your out-of-pocket costs up to the vision allowance amount for your plan. Please refer to your Summary of Benefits or Evidence of Coverage for your routine vision allowance.

Vision Claim Form

Fax: 1-844-201-4655
Mail: UPMC Vision Care
P.O. Box 106039
Pittsburgh, PA 15230-6039

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

Dental Claim Reimbursement Form

If you are a UPMC for Life member who has paid out-of-pocket for seeing a non-network dental provider, you can fill out the Dental Claim Form and fax or mail it to the address below for reimbursement. You will be reimbursed for your out-of-pocket costs according to your plan benefits up to the dental allowance amount for your plan. Please refer to your Summary of Benefits or Evidence of Coverage for your comprehensive dental allowance.

Dental Claim Form

Fax: 412-454-8519
Mail: UPMC Dental Advantage
Claims Department
PO Box 1600
Pittsburgh, PA 15230-1600

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

University of Pittsburgh Retirees Vision Claim Reimbursement 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:

Envolve Vision
Attn: Claims
PO Box 7548
Rocky Mount, NC 27804

Vision Claim Form

UPMC for Life Prescription Drug Transition Policy

During the first 90 days that you are a member of UPMC for Life, we may cover a limited amount of your current non-formulary drug therapy in certain cases while you talk to your doctor to determine the right course of action for you. Click on the links below for more information.
  • 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

Please follow these steps to submit prescription drug determination forms to us.

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:
  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.

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

Medication Therapy Management (MTM) program

UPMC Health Plan has developed a unique medication therapy management program for members who take many medications and meet certain criteria.

Use the links below to learn more.

Pharmacy Claim Reimbursement

If you are a UPMC for Life member, complete the form below to apply for reimbursement for Part D prescription drugs. Please follow these steps to submit a prescription drug claim reimbursement form to us.

  1. Open this form: 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 Health Plan Pharmacy Services Department
    U.S. Steel Tower, 12th Floor
    600 Grant Street
    Pittsburgh, PA 15219

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

Service Area Map

Privacy Information

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

Fraud, Waste, and Abuse

The Centers for Medicare & Medicaid Services has information about how to protect yourself against various types of fraud and identity theft.

Disaster and Catastrophic Events

In the event of a presidential emergency declaration, a presidential (major) disaster declaration, a declaration of emergency or disaster by a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, UPMC for Life benefits will temporarily change to allow members access to out-of-network Medicare-certified facilities with reduced cost sharing. To learn more, click on the link below.

Disaster and Catastrophic Event Policy

Monthly Premium Payment Form

You can fill out this form if you would like to pay your monthly premium by credit card or Electronic Funds Transfer (EFT). Complete and sign this form below and mail it to the following address:

UPMC Health Plan Accounts Receivable Department
U.S. Steel Tower, 36th Floor
600 Grant Street
Pittsburgh, PA 15219

Payment Election Form

If you need help understanding your UPMC for Life premium invoice, you can view an invoice tutorial at the link below.

UPMC for Life premium invoice tutorial

Helpful Websites About Medicare

Other Important Information

UPMC for Life members have rights and responsibilities when disenrolling from a UPMC for Life plan. Use the links below to learn more.


UPMC for Life renews our contract with the Medicare program each year. If we plan to leave a service area, we must notify members accordingly.

Contract Termination Information

If a member must seek care or pharmacy access outside the UPMC for Life network or service area, the member must take steps to ensure the care provided will be covered by our plan. Use the link below to learn more.

Out-of-Network Coverage

Filing an Appeal or Grievance

UPMC for Life works hard to improve the quality of care and service that you get as a member. Let us know right away if you have questions or problems with covered services or the care you receive. You can also call us to check on the status of an appeal, grievance, or exception.

UPMC for Life HMO/PPO members can call our Member Services Department at 1-877-539-3080 (TTY: 711) seven days a week from 8 a.m. to 8 p.m. If you are a provider, please call Provider Services at 1-866-918-1595.

UPMC for Life Complete Care members can call 1-800-606-8648 (TTY: 711), 24 hours a day, 7 days a week. If you are a provider, please call Provider Services at 1-866-918-1595.

How to File an Appeal or Grievance

Submit an online complaint to Medicare

If you would like to file an appeal or grievance on behalf of a member, please visit our Appointment of Representative page for more information.

How to obtain the total number of grievances, appeals, and exceptions filed with UPMC for Life

We can give you the total number of grievances, appeals, and exceptions filed with UPMC for Life. If you would like this information, UPMC for Life HMO/PPO members can call our Member Services Department at 1-877-539-3080 (TTY: 711) seven days a week from 8 a.m. to 8 p.m. UPMC for Life Complete Care (HMO SNP) members can call 1-800-606-8648 (TTY: 711), 24 hours a day, 7 days a week.

Prescription Drug Determination/Exception or Redetermination

UPMC for Life members may ask for a coverage determination or redetermination (appeal) for a Part D prescription drug. Use the links below to learn more.

Determination/Exception Request

Members can request a coverage determination/exception by completing and signing the form below. It can be mailed or faxed to UPMC Health Plan. You may also call our Member Services Department to file an appeal, get information about this process, check on the status of a request, or obtain an aggregate number of appeals, grievances, and exceptions for our plan. Please contact us by:
  • Phone: UPMC for Life HMO/PPO members can call our Member Services Department at 1-877-539-3080 (TTY: 711) seven days a week from 8 a.m. to 8 p.m. UPMC for Life Complete Care (HMO SNP) members can call 1-800-606-8648 (TTY: 711) 24 hours a day, 7 days a week.
  • Fax: 412-454-7722
  • Mail: UPMC Health Plan Pharmacy Department
    U.S. Steel Tower, 12th Floor
    600 Grant Street
    Pittsburgh, PA 15219
UPMC for Life Prescription Drug Coverage Determination/Exception Request Form

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

Redetermination (Appeal) Request

Members can request a redetermination (appeal) by completing and signing one of the forms below. It can be mailed or faxed to UPMC Health Plan. You may also call our Member Services Department to file an appeal, get information about this process, check on the status of a request, or obtain an aggregate number of appeals, grievances, and exceptions for our plan. Please contact us by:
  • Phone: UPMC for Life HMO/PPO members can call our Member Services Department at 1-877-539-3080 (TTY: 711) seven days a week from 8 a.m. to 8 p.m. UPMC for Life Complete Care (HMO SNP) members can call 1-800-606-8648 24 hours a day, 7 days a week.
  • Fax: 412-454-7920
  • Mail: UPMC Health Plan
    ATTN: Appeals and Grievances
    PO BOX 2939
    Pittsburgh, PA 15230-2939
UPMC for Life Medicare Prescription Drug Coverage Redetermination Request Form

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.

Member Rights and Responsibilities

UPMC for Life members have rights and responsibilities when using our health management programs. Members also have rights and responsibilities when disenrolling from one of our plans. Use the links below to learn more.

Medicare Contract Information

UPMC for Life renews our contract with the Medicare program each year. If we plan to leave a service area, we must notify members accordingly.

Contract Termination Information

Nonpayment of Premium Information

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. UPMC for Life HMO/PPO members can call 1-877-539-3080 (TTY: 711) seven days a week from 8 a.m. to 8 p.m.

If you would like to appoint a person to act on behalf of the member, please visit our Appointment of Representative page for more information.
This information is not a complete description of benefits. Call 1-866-400-5077 (TTY: 711) for more information. Out-of-network/Noncontracted providers are under no obligation to treat UPMC for Life members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services. Other physicians/providers are available in the UPMC for Life network.

This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711).

UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., UPMC Health Benefits Inc., and UPMC Health Coverage Inc.

SilverSneakers is a registered trademark of Tivity Health Inc. SilverSneakers GO is a trademark of Tivity Health Inc. © 2021 Tivity Health Inc. All rights reserved.
UPMC for Life Members
Call us toll-free: 1-877-539-3080
TTY: 711

Oct. 1 – March 31:
Seven days a week from 8 a.m. to 8 p.m.

April 1 – Sept. 30:
Monday through Friday from 8 a.m. to 8 p.m., Saturday from 8 a.m. to 3 p.m.

UPMC for Life Prospective Members
Call us toll-free: 1-866-400-5077
TTY: 711

Jan. 1 – Sept. 30:
Seven days a week from 8 a.m. to 8 p.m.

Oct. 1 – Dec. 31:
Seven days a week from 7 a.m. to 9 p.m.

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Last Updated: 10/01/2022