Medicare Part B Reimbursement Request Form

Participant Information

Please read the instructions before submitting your Medicare Part B Reimbursement Request form:

1. Please complete the following form. All fields are required.
2. If you are submitting for your spouse or disabled dependent, please complete another submission of this form.

Participant First Name^* Please enter a valid First Name.

Participant Last Name^* Please enter a valid Last Name.

UPMC Plan Member ID^* Please enter a valid Member ID.

*These fields are required to complete the above form.

Medicare Part B Reimbursement

1. In the Coverage Period section, enter the first of the month in which you are eligible for Medicare Part B this year and enter the last day of the year. For example, if you are eligible for Medicare Part B on January 1, 2019, you will fill in 1/1/2019 to 12/31/2019.
2. Submit a copy of your Social Security cost-of-living adjustment (COLA) statement as proof of your payment (usually mailed starting in November the year before the adjustment becomes effective) or any other documentation showing your annual Medicare Part B premiums.
3. If Medicare Part B premiums are not deducted from your Social Security check, submit a copy (front and back) of the cleared check or a bank/credit card statement that indicates your Medicare Part B premium payment.

I am requesting reimbursement of the following paid Medicare Part B premiums:

Coverage Period

Start^* Date format: MM/DD/YYYY   End^*

One-time annual request for Medicare Part B premium^* The maximum annual reimbursement is $600 for 2020 and before, $800 for 2021 and after. Total cannot exceed this amount.

Upload Documents

Please attach documents showing your monthly Medicare Part B premium(s) paid. The documents must include the period for which you have paid, proof of the premium payment, the name of the insurance company, the type of expense (Medicare Part B premiums), and the covered participant’s name. If you are attaching a copy of a cleared check, please submit an attachment of the front of the check.

*These fields are required to complete the above form.

Reimbursement Distribution

Please select the method in which you would like to receive your Medicare Part B reimbursement.

I am electing to have my Medicare part B reimbursement made:

Participant Signature/Authorization

The information furnished by me in support of this application for reimbursement is true and correct to the best of my knowledge. I understand that Medicare Part B premiums submitted for reimbursement must qualify under the provisions of the plan.

I hereby authorize any individual or organization to release any information requested by UPMC Benefit Management Services with respect to this specific request.

I elect to have my Medicare Part B reimbursement made by direct deposit into the account indicated above (this process will remain in effect until I cancel it in writing). If I change accounts, I will inform UPMC Benefit Management Services by submitting a revised authorization form.

Participant Full Name/Signature^* Please enter a valid Signature.

Phone Number^* Phone format: xxx-xxx-xxxx Please enter a valid Phone Number

Date^* Date format: mm/dd/yyyy

*These fields are required to complete the above form.

Thank you for your submission. If you have selected to receive your reimbursement by mail, you should expect to receive your reimbursement check in the next 5-7 business days. If you chose to receive your reimbursement by direct deposit into your bank account, you should expect your reimbursement deposit to be made in the next 3-5 business days.

If you have any questions or concerns, please call us at 1-877-648-9641.