Documents and Forms
Plan Information
- 2026 PSHB Plan Brochure
- 2026 PSHB Open Season Benefit Guide
- 2026 Pharmacy Formulary
- Prescription Drug Rider
Reimbursement Forms
Other Claim Forms
- PSHB Disputed Claims Process
- PSHB Disputed Claims FAQ Sheet
- PSHB Medicare Disputed Claims Process - PDP
- PSHB Appeals and Grievance - Medicare
- Out-of-Network Care Claim Form
- Prescription Drug Claim Form Medicare Part D (Form is for flu shot reimbursement)
- Health Reimbursement Arrangement (HRA) Claim Form (Form is for prescription reimbursements only)
- ESI Mail-Order forms
- Transition of Care Form
Health Incentive Account Submission Form
Provider Network Forms
Contraceptive Resources
- Contraceptive Resources (Birth Control options – choosing methods that are right for you)
- Preventive Services Reference Guide (preventive contraceptive guidelines and downloadable provider prior authorization form for contraceptive coverage exceptions)
- Provider Contraceptive Prior Authorization Instructions
- UPMC Health Beat (for contraceptive health information and articles)
Members can contact OPM at contraception@opm.gov for assistance with contraceptive coverage or questions.
HIPAA Privacy Forms
- Notice of Privacy Practices
- Personal Representative Designation Form
- Member Authorization to Use or Disclose Protected Health Information
Updates to preventive guidelines can occur throughout the benefit year. Please check the following websites for any changes and updates:
Telehealth Resources for Members
- About Telemedicine Services at UPMC
- How To: Video Visits
- Schedule a Virtual Visit with a UPMC Health Plan Provider
- Telehealth FAQs
- National Telehealth Policy Research Center
- Health and Human Services (HHS) Telehealth
- Health and Human Services (HHS) Guide to Telehealth Data Privacy
In some instances, a more protective law may require an individual’s permission to disclose health information where HIPAA would permit the information to be disclosed without the individual’s authorization. For more information please visit: HIPAA versus State Laws - ONC - Office of the National Coordinator for Health Information Technology
Other Helpful Information
- Family Member Eligibility Form
- Assist America Brochure
- Fast Facts: Health Care Coverage Forms for Federal Employees
- Fast Facts: Health Care Coverage Forms for Annuitants
- Infertility Treatment and Diagnosis MP
- Maternity Program
- Moms.gov
- Prescription Drug Price Tool
- Notice of Protection Provided by Pennsylvania Life and Health Insurance Guaranty Association
- Your Rights and Protections Against Surprise Medical Bills
- Consumer Protections (opm.gov)
- COVID-19 Reimbursement Letter