UPMC for Life Plan Documents

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 - Opens in new tab
Formulario de Designación de Representante Personal - Opens in new tab

Mail to:
UPMC Health Plan
PO Box 2965
Pittsburgh, Pennsylvania 15230-2965

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.

1. Open this form: Medical Claim Reimbursement Form.
   
   
2. Print the form. Follow the instructions on the form and fill out as completely as possible.
   
   
3. For your claim to be processed, you will need to get your medical receipts or patient history printout from your provider.
   
   
4. 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.

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.

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.

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

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.

• For members in the first 90 days of enrollment—transition process
• For members currently residing in a long-term care facility—transition process
• For members moving from home to a long-term care facility or from a long-term care facility to home—transition process

The forms linked below can be used to request prior authorization, coverage determination and redetermination, or an exception for prescription drugs.

1. Select and open the appropriate form:
   • Use this link to submit a request for a drug not currently covered under your plan:
     UPMC for Life Prescription Drug Coverage Determination/Exception Request Form - Opens in new tab (PDF), last updated 4/17/2025
   • UPMC for Life Solicitud de Determinacion de Cobertura de Medicamentos de Medicare (PDF), last updated 1/23/2026
   • Use this link to submit a request or redetermination of a drug coverage request denied within the past 65 days:
     UPMC for Life Medicare Prescription Drug Coverage Redetermination Request Form - Opens in new tab (PDF), last updated 4/25/2025
2. Fill out the form and save it to your computer's hard drive.
3. Submit your request form using our online submission tool - Opens in new tab.

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.

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.

• How does UPMC for Life help make sure I’m safe on my prescription medications?
• How does UPMC for Life help members who take many medications?
• Who is eligible for UPMC for Life's medication management program?

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.

1. Open this form:
   • UPMC for Life Prescription Drug Claim Reimbursement Form
   • UPMC for Life Complete Care (HMO D-SNP) Prescription Drug Claim Reimbursement Form
2. Print the form. Follow the instructions on the form and fill out as completely as possible.
3. For your claim to be processed, you will need to get your prescription receipts or patient history printout from your pharmacy.
4. 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.

We take your privacy seriously at UPMC for Life. The documents below show the steps we take to protect your personal information.

• Privacy Statement - Opens in new tab
• Notice of Privacy Practices - Opens in new tab
• Aviso de prácticas de privacidad

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

 Enroll in Autopay
Choose either option below to sign up for automatic payments for your monthly plan premium:

1. Download or log in to the UPMC Health Plan app, then select Account and Manage Premium Payments.
2. Log in to UPMC Health Plan member site.

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.

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 Member Rights and Responsibilities
• UPMC for Life Member Disenrollment Rights and Responsibilities

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 - Opens in new tab