Get the free UPMC Health Plan Prescription Drug Claim Form

This document is a claim form for patients to submit their prescription drug expenses to UPMC Health Plan for reimbursement. It requires various patient and prescription details along with signatures.

How to fill out upmc health plan prescription

How to fill out UPMC Health Plan Prescription Drug Claim Form

1. Obtain the UPMC Health Plan Prescription Drug Claim Form from the UPMC website or your local pharmacy.
2. Fill in your personal information including your name, address, and member ID number.
3. Provide details of the prescription, including the name of the medication, dosage, and the date it was filled.
4. Attach the original pharmacy receipt showing the prescription filled, including the date and total amount paid.
5. Sign and date the form, confirming that all information provided is accurate.
6. Submit the completed form and receipts to the address specified on the claim form.

Who needs UPMC Health Plan Prescription Drug Claim Form?

1. Members of the UPMC Health Plan who have out-of-pocket prescription expenses.
2. Individuals who need reimbursement for prescription medications purchased outside of their plan coverage network.
3. Patients whose prescriptions were not processed at the pharmacy due to issues with their health plan.
4. Anyone who needs to file a claim for medications covered under the UPMC Health Plan.

People Also Ask about

How do I submit a claim to the UPMC?

Submitting a Claim Access the UPMC Consumer Advantage Portal via Health Plan Access (navigate to Health Savings and Spending Accounts from the Your Insurance section, then select Visit UPMC Consumer Advantage Portal) Select "File A Claim" under the "I Want To” Select the account type and complete electronic form.

How to submit a claim to UPMC?

Submitting a Claim Access the UPMC Consumer Advantage Portal via Health Plan Access (navigate to Health Savings and Spending Accounts from the Your Insurance section, then select Visit UPMC Consumer Advantage Portal) Select "File A Claim" under the "I Want To” Select the account type and complete electronic form.

What is a prescription drug claim?

Prescription Drug Claim means a Member Submitted Claim or claim for payment submitted by a Participating Pharmacy as a result of dispensing a Covered Drug to a Member.

What is the timely filing limit for UPMC claims?

UPMC Health Plan accepts claims up to 180 days after the date of service for UPMC Community HealthChoices (Medical Assistance), UPMC for Kids (CHIP), and UPMC for You (Medical Assistance) Members. UPMC for You EPSDT claims must be submitted within 90 days after the date of service.

Who is the parent company of UPMC Health Plan?

It is owned by the University of Pittsburgh Medical Center (UPMC), a world-renowned health care provider.

What is the certificate of coverage for UPMC?

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.

How do I submit a claim for post hospitalization?

To claim post-hospitalisation expenses, you must submit a claim along with the necessary documents such as medical bills, prescription documents, and receipts. Additionally, you will need to provide a discharge summary that details the medical condition and treatment provided during the hospitalisation.

For pdfFiller’s FAQs

What is UPMC Health Plan Prescription Drug Claim Form?

The UPMC Health Plan Prescription Drug Claim Form is a document used by members to request reimbursement for prescription medications purchased outside of the network or to file a claim for medications covered under their health plan.

Who is required to file UPMC Health Plan Prescription Drug Claim Form?

Members of UPMC Health Plan who incur prescription drug expenses outside the network or those who need to claim reimbursement for covered medications must file the form.

How to fill out UPMC Health Plan Prescription Drug Claim Form?

To fill out the form, provide personal information including your member ID, details of the prescription medications, purchase information, and any supporting documents like receipts. Follow the instructions on the form carefully.

What is the purpose of UPMC Health Plan Prescription Drug Claim Form?

The purpose of the form is to facilitate the reimbursement process for members who incur costs for prescription drugs that are covered by their UPMC health plan but were purchased outside the preferred pharmacy network.

What information must be reported on UPMC Health Plan Prescription Drug Claim Form?

Members must report personal information such as their member ID, the prescription details including the drug name, quantity, date of purchase, the pharmacy where the drug was purchased, and attach any receipts or invoices related to the claim.