Additional Documents & Forms

To see the documents and forms, please select the plan year and area below.

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1. Choose the plan year:   


2. Choose the plan document type:   


3. Choose where you currently live:   
3. Choose your state:   


4. Choose your county:   
This information is not a complete description of benefits. Call 1-866-405-8762 (TTY: 711) for more information. Out-of-network/non-contracted 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). We are available October 1 through March 31, seven days a week from 8 a.m. to 8 p.m. From April 1 through September 30, we are available Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m.

UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plan has 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 for You Inc.

Tivity Health, SilverSneakers, SilverSneakers FLEX and SilverSneakers BOOM are registered trademarks or trademarks of Tivity Health, Inc. and/or its subsidiaries and/or affiliates in the USA and/or other countries. © 2018. All rights reserved

*Our hours of operation change twice a year.

You can call us:

October 1 through March 31:
seven days a week from 8 a.m. to 8 p.m.

April 1 through September 30:
Monday through Friday: 8 a.m. to 8 p.m.
Saturday: 8 a.m. to 3 p.m.

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Last Updated: 10/01/2018
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