UPMC Health Plan, headquartered in Pittsburgh, Pennsylvania, is among the nation’s fastest-growing health plans. It is owned by the University of Pittsburgh Medical Center (UPMC), a world-renowned health care provider. As part of an integrated health care delivery system, UPMC Health Plan is committed to providing its members better health, more financial security, and the peace of mind they deserve. People always ask What Does UPMC For You Cover? Continue reading below to find out.
UPMC Health Plan partners with UPMC and community network providers to produce a combination of knowledge and expertise that provides the highest quality care at the most affordable price. The UPMC Insurance Services Division—which includes UPMC Health Plan, Workpartners, UPMC for Life, UPMC for You, UPMC for Kids, UPMC Community HealthChoices, and Community Care Behavioral Health—offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance, and workers’ compensation products and services to more than 3.9 million members. Their local provider network includes UPMC as well as community providers, totaling more than 140 hospitals and more than 29,000 physicians throughout Pennsylvania and parts of Ohio, West Virginia, and Maryland.
What Does UPMC For You Cover?
As part of your benefits, UPMC for You helps you find a primary care provider (PCP) who can get to know you and your health concerns. UPMC for You can help provide you with medical, maternity, vision, and dental care as well as no-cost or low-cost prescription drugs when you get sick. We handle all that—and much more—so you can live your life with less worry.
1: Medical Coverage
UPMC for You covers doctor visits, with no copayments. (Some members may have a small copayment for chiropractors and podiatrists.)
Members choose a primary care practitioner (PCP). A PCP is a personal doctor or Certified Registered Nurse Practitioner (CRNP). He or she provides or arranges all of our members’ health care needs.
If a member needs to see a specialist, our doctors help take care of the details. There is no paperwork to worry about.
Services that do not require a referral:
- Well-woman visit
- Pregnancy/birth services
- Family planning
- Vision exams
- Substance abuse treatment
- Dental care
- Behavioral health
PCP can be a family and general practice doctor, a pediatrician, an internal medicine doctor, or a CRNP. Family and general practice doctors treat all family members. Most pediatricians treat children, and most internal medicine doctors treat adults. A CRNP is a registered nurse with advanced training in a specialty area, certified by the boards in that specialty area. A CRNP may diagnose a condition or prescribe medicine under the direction of a doctor.
View the UPMC for You Member Handbook for more information about covered benefits.
2: Dental Coverage
A general dentist is a health professional who specializes in caring for teeth, gums, and other tissues in the mouth. A dental specialist treats children and people who need special care for their teeth or gums.
The UPMC for You network includes general dentists and specialists. They cover exams, cleanings, and fillings for all UPMC for You members.
Members can call Dental Member Services at 1-888-257-0474 to get a dentist’s name or to see what dental benefits they have. TTY users should call toll-free 1-800-201-7165.
For more information on dental benefits, view the UPMC for You Member Handbook
3: Pharmacy Coverage
The UPMC for You Pharmacy Formulary (Non-PDL) is a list of Food and Drug Administration (FDA) approved medications. This list was developed by UPMC for You doctors and pharmacists and includes the most commonly used drugs. Medications on the formulary (drug list) that are prescribed by a doctor are paid for by UPMC for You. The list does not include every medication a doctor might prescribe. The drugs on the formulary have been selected because they are safe, work well, and cost less than other drugs that have the same level of effectiveness. You can also search for covered drugs with our online searchable formulary.
4: Vision Coverage
Optometrists are medical professionals for the eye. They can:
- Examine, diagnose, treat and manage diseases, injuries, and disorders of the eye and associated structures.
- Identify related conditions affecting the eye.
- Prescribe medications.
- Provide low vision rehabilitation and vision therapy.
- Offer vision services such as eye exams.
- Prescribe eye glasses and contact lenses as needed.
Ophthalmologists are medical and surgical physicians who treat eye problems. They can:
- Provide complete eye care as listed above.
- Do surgical procedures for cataracts, glaucoma, eye trauma, and other conditions.
UPMC for You members can self-refer to participating ophthalmologists or optometrists for a routine eye exam. If a UPMC for You member needs to see an ophthalmologist for a problem, he or she must get a referral from their primary care practitioner (PCP).
UPMC for You vision benefits are administered through Envolve Vision. A list of participating vision providers is available on the Envolve Vision provider search page.
For members age 21 and older:
- Routine vision exams twice a year
- $100 allowance toward eyeglasses (one frame and two lenses) or toward one pair of contact lenses and fitting per year*
- Glasses or contact lenses to treat cataracts or aphakia (medical condition)
- Specialist eye exam with referral from PCP
For members under the age of 21:
- Routine vision exams twice a year, or more often if medically necessary
- $100 allowance toward eye glasses or toward one pair of contact lenses and fitting*
- Two frames and four lenses per year. (Note: The second pair of glasses are available if medically necessary, for example, your prescription changes.) Exception to limits can be made if medically necessary with written documentation
- Replacement of eye glasses or contact lenses if they are broken or lost, or if prescription changes, provided written documentation of the necessity of the service is submitted by the provider
- Eyeglasses and all other vision services deemed medically necessary, provided written documentation of the necessity of the service is submitted by the provider
*If you choose standard eyeglasses or contact lenses that are within the allowance, there is no cost to you. If you exceed the allowance, you will be responsible for any cost over the $100.
Members who need help finding an eye care provider, or have questions about their vision benefit, can call Envolve Member Services at 1-866-458-2138. TTY users should call toll-free 1-800-361-2629. Representatives are available Monday through Friday from 8 a.m. to 7 p.m.
For more information on vision services, view the UPMC for You Member Handbook.
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How Long of A Treatment Stay Will UPMC Cover?
UPMC covers the duration, length of stay, of your treatment depending on your personal treatment plan. This is done to ensure that you receive the care you need with little to no money out of pocket. So regardless to if you enter into a 60 day inpatient program or 20 day outpatient program you will be able to get the help you need with little concern for costs.