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Commonly Used Forms and Documents for Members

You’ll find all of the documents detailing your coverage and benefits when you log in to MyHealth OnLine. If you would like printed copies instead, please call a Health Care Concierge at 1-844-220-4785.

Documents on MyHealth OnLine may include*:

  • Forms: Complete the right form to submit claims, get reimbursement for covered services such as flu shots, designate a personal representative, and check protected health information. The forms are easy to download, print, and fill out.
  • 1095-B Tax Forms: The 1095-B form is a tax form that reports the type of health insurance coverage you had, if you had any covered dependents, and the period of coverage from the prior year. Previously, you were required to file this form as part of your federal tax return. As of January 2020, the Internal Revenue Service no longer requires you to file the 1095-B form as part of your federal tax return because the tax penalty for failing to meet the individual mandate was eliminated by Congress. UPMC Health Plan will no longer mail the form to you, but you can easily obtain an electronic copy to print at your own convenience by:

    • Visiting MyHealth OnLine for quick and convenient access; search under Forms and Guides and navigate to Plans and Coverage.

    You may also request a printed copy of your 2020 Form 1095-B by:

    • Submitting your request by mail to ATTN 1095B Enrollment, UPMC Health Plan 600 Grant Street Pittsburgh, PA 15219.
    • Emailing your request to 1095BInquiry@upmc.edu.
    • Contacting Member Services at the number on the back of your member ID card.

    Please supply your member ID number with your request.

  • Medical Schedule of Benefits: A broad list of the medical services covered under your plan. The Schedule of Benefits also tells you your deductible as well as the copayment or coinsurance amounts you pay.
  • Prescription Drug Rider: Lists benefit limits and cost-sharing amounts for prescription drugs. It also tells you if there’s a deductible and lists the copayment or coinsurance you may pay for each prescription.
  • Certificate of Coverage: The legal contract between you and UPMC Health Plan. The contract notes your rights as a member and also details UPMC Health Plan’s obligations as a health insurer. It provides detailed descriptions of covered services and lists services that are not covered. The document also explains the complaint resolution process.
  • Rider: Describes added features to the insurance policy.
  • Summary of Benefits and Coverage (SBC): Summarizes your plan so that it’s easy for you to compare it to other plans. However, the SBC doesn’t include all of the services a particular plan offers.
  • Policy: A legal contract between you and UPMC Health Plan that describes covered services, as well as services not covered. It also explains the complaint resolution process.
  • Service Area Document: This document explains your plan’s service area.
  • Pediatric Dental Certificate of Insurance: The legal contract between you and UPMC Health Plan that lists all covered dental services, as well as services not covered, for your dependents under age 19. The document also explains the complaint resolution process.
  • Pediatric Dental Schedule of Benefits: Describes dental services that are included in your health plan for your dependents under age 19.
  • Pediatric Vision Certificate of Insurance: The legal contract between you and UPMC Health Plan that lists all covered vision services, as well as services not covered, for your dependents under age 19. The document also explains the complaint resolution process.
  • Pediatric Vision Schedule of Benefits: Describes the vision services included in your health plan for your dependents under age 19.

*Depending on your plan, some of the documents listed may not be applicable to you. Please contact Member Services if you have questions or concerns regarding your plan documents.