Request a Provider Directory or Plan Materials
Request a Provider Directory or Plan Materials
Use our online form below to request a hard copy provider directory or other plan material. You can also send us a plan document or ask to be contacted by a member of our Health Care Concierge team.
Medicare Member Services Form
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: 412-454-2070
Mail: UPMC
for Life
Clinical Operations, 37th 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
Formulario de Designación de Representante Personal
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.
- Open this form: Medical Claim Reimbursement Form.
- Print the form. Follow the instructions on the form and fill out as completely as possible.
- For your claim to be processed, you will need to get your medical receipts or patient history printout from your provider.
- 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.
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.
- Select and open the appropriate form:
- Fill out the form and save it to your computer's hard drive.
- 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.
- Open this form:
- Print the form. Follow the instructions on the form and fill out as completely as possible.
- For your claim to be processed, you will need to get your prescription receipts or patient history printout from your pharmacy.
- 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
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 Payments
Use the
UPMC for Life premium invoice tutorial for help understanding your UPMC
for Life premium invoice.
Enroll in Autopay
Choose either option below to sign up for automatic payments for your monthly plan premium:
- Download or log in to the UPMC Health Plan app, then select Account and Manage Premium Payments.
- Log in to MyHealth OnLine. Under the Your Insurance section on the homepage, click on Premium Payments.
For help setting up autopay, call your Health Care Concierge team at
1-877-539-3080 (TTY: 711).
Use our 24/7 secure automated payment system
Call
1-877-539-3080 (TTY: 711) and press 1 to make premium payments, check your current premium balance, or verify if your most recent payment has been received.
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
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
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
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.