UPMC Health Plan Latest Updates


February 2024 Updates:


Winter 2024 Quarterly Advantage newsletter

This edition of the Quarterly Advantage newsletter is full of important and interesting information:

  • The scoop on our new plan for 2024: UPMC First Care™
  • How the University of Pittsburgh is advancing treatments for long COVID
  •  The opening of the new UPMC Health Plan Connect Center in Monroeville
  • Details on how the UPMC Children’s Hospital of Pittsburgh expanded inpatient pediatrics at UPMC Hamot
  • How to handle electronic invoicing and payments through Employer OnLine
  • The expansion of the UPMC Partner Network
  • Breaking down Section 201 of the Consolidated Appropriations Act
  • Specifics on hearing health care benefits among UPMC Health Plan’s ancillary offerings
  • How the UPMC Outpatient Emergency Department earned an Acute Stroke Ready Certification

The Quarterly Advantage | Winter 2024 


New! Fertility Health and Family-Forming Benefits through Carrot Fertility

  • UPMC Health Plan issued the following announcement to Mid-Market clients (51+ as defined by their previous calendar year’s Average Total Number Employees)
  • The new partnership with Carrot Fertility allows greater accessibility to fertility health and family-forming benefits.
  • Our NFP BNGA Team is gathering more detail from UPMC’s mid-market division and will share additional resources when available.

View UPMC Update                  Carrot Fertility Flyer 

January 2024 Updates:


Updates to Underwriting Guidelines 2024

The 1-50 ACA Compliance Rules have been modified based on feedback.

  • Added rule 11 to establish 30-day documentation timeframe to support timely submissions and to align with ineligible letter communications.
  • Updated rule 16 to allow all small groups to elect up to two extended network plans (previously 1-20 was allowed only one EXT plan).

1-50 Compliance Guidelines 2024 (for ACA) Revised 


Leap Year Reminder for February 2024 Termination Requests

As a reminder, 2024 is a leap year, and February will have 29 days rather than the typical 28. As such, please ensure that any termination requests for your accounts for the end of February reflect Feb. 29, 2024, as the termination date. Doing so will ensure that an individual’s coverage is not terminated prematurely, and it will help us avoid processing delays that could result from the need for outreach to confirm termination dates. Please contact your UPMC Health Plan account manager with questions.

View UPMC Update 


2024 UPMC Health Plan Formulary Updates

  • Updates to the medications on two of UPMC’s popular formularies, are communicated in the Producer Update below.
    • Your Choice Formulary: a formulary option that is available to non-ACA clients (small group and mid/large market)
    • Advantage Choice Formulary: the sole formulary affiliated to ACA small group clients
  • Search engine for RX formulary is available via UPMC Health Plan | Find a Medication and Formulary resources have been updated accordingly (link below)
  • UPMC has indicated below that impacted members(whose currently prescribed medications are affected by these changes) will be contacted. If you receive follow-up questions or concerns, theses could be directed to UPMC’s Pharmacy unit.

View UPMC Update 


December 2023 Updates:


2024 Compliance & Underwriting Guidelines


November 2023 Updates:


Consolidated Appropriations Act Section 201 (“Gag Clause”)

Commercial Accounts, for which UPMC has a contact email address on file, will receive the following communication from the carrier.

  • With the Consolidated Appropriations Act (CAA) Gag Clause Prohibition Attestation deadline approaching on 12/31/2023, it is important for Employer groups to know whether action is needed or whether their carrier will file the attestation on their behalf.
  • Per below, UPMC Health Plan will file on behalf of all clients that carried UPMC coverage during a portion of the current submission period.
  • Additional information is available in a link below for Frequently Asked Questions.

View UPMC Update 


Reminder: Electronic Invoicing and Payment

UPMC Health Plan takes further steps to move towards electronic billing for clients.

  • New clients are set up for paperless billing and cannot opt out of that option.
  • For existing clients prior (only those that carried coverage prior to that change), clients could take steps to opt for paper invoices as an exception.
  • At the 2024 Renewal cycle, clients that continue to receive paper invoices will see an additional $10 fee on each applicable paper invoice. Reminder: UPMC invoices each differing sub-group independently, so multiple fees may apply for a client.

View UPMC Update 


UPMC Health Plan New Business Producer Incentive Program

UPMC Health Plan announces their Producer Incentive for Mid & Large Market new business sales with January-April 2024 effective dates. NFPBNGA will pass through this incentive in its entirety to our Producer Partners.

View UPMC Update 


Fall 2023 Quarterly Advantage Newsletter

This edition includes timely topics surrounding Open Enrollment as well as key resources to maximize the advantages of offering UPMC Health Plan coverage.

The Quarterly Advantage | Fall 2023


October 2023 Updates:


2024 Benefit Plan Summaries Released

2024 Benefit Plan Summaries 2-50
2024 Benefit Plan Summaries 51+


Join Us for a Pittsburgh Business Times Event
October 10 from 8:00-10:00am at Fairmont Pittsburgh

UPMC Health Plan extends an invitation to the Pittsburgh Business Times event on Oct. 10 at Fairmont Pittsburgh. UPMC subject matter experts of varying specialties will serve on the discussion panel. If you are interested in this event, you can register (with free admission) via the link and instruction below.

*Register with the code upmcguest to obtain free admission.

Register Here 


September 2023 Updates:

Member Letters Sent in Error

In September, UPMC Health Plan sent coverage termination letters to some members in error.

  • The letters advised that UPMC received notice to terminate their employer-sponsored coverage, and information on alternative coverage options was provided.
  • If you represent employer groups with employees who received this letter in error, UPMC will distribute correction letters to them.

View UPMC Update 


CAA Gag Clause Attestation

UPMC provided information regarding CAA Gag Clause Prohibition Attestation.

View UPMC’s CAA Section 201 (Gag Clause) FAQ  


UPMC has confirmed that no clients were eligible for MLR rebates the 2022 year.



July 2023 Updates:

UPMC notified clients of August Dental & Vision premium & administration fee billing delays.

  • Impacted groups will receive updated invoices that should be paid in full by the stated deadline.
  • For groups using Autopay, the combined amount of all outstanding invoices will be pulled on the scheduled Autopay date.
  • UPMC is continuing to monitor any outstanding Dental and Vision billing that may become past due as a result of this error.



June 2023 Updates:

UPMC announced upcoming changes to SaveOnSP Program:

  • Medications included in the SaveOnSP program to change effective July 1.
  • Click here for a list of medication changes.
  • Impacted members mailed letters as outlined below:
    • 60 days before the effective date of change for drugs that are being added to the program.
    • 30 days before the effective date of the change for drugs that are being removed from the program.
  • Please note the following clarifications as confirmed by UPMC:
    • All fully insured non-HSA plans include SaveOnSP regardless of deductible.
    • The excluded groups from SaveOnSP are ASO groups (they have to opt-in on their own), SelfAssure level funded groups, Grandmothered 2-50 groups, and any HSA plan.

CAA RxDC Update from UPMC:

  • Confirmation that UPMC submitted the required 2022 RxDC reports to the department by the deadline of June 1.
    • Please note that UPMC did not & will not be able to submit this information on behalf of clients who did not complete the UPMC CAA RxDC survey.
  • UPMC will work to refine the data collection process for the calendar year 2023 data, due on June 1, 2024.



May 2023 Updates:

UPMC to offer a new Zero-Dollar Select Generic Medications Tier Prescription Drug Initiative:

  • Available for both fully insured and ASO groups, effective 1/1/24:
    • ASO groups are strongly encouraged to participate in this initiative, and must notify UPMC by June 2 if they want to opt-out.
    • If you have an ASO group with questions, please reach out to your NFP BNGA team ASAP.
  • Certain medications will move to a new tier with no member cost share (deductible may still apply) called the Select Generic Medications Tier.
    • To include generic blood pressure, high cholesterol, depression, diabetes, and other medications.
  • Click here to view a full list of generic drugs that will move to the Select Generic Medications Tier.
  • If you have any questions, please reach out to your NFP BNGA team.



April 2023 Updates:

Effective April 1, 2023 UPMC has officially transitioned receipt and review of bills to online only via Employer OnLine:

  • Online payment is not required but is encouraged, fast and secure
  • Groups will need to make sure they have access to EOL – please reach out to your NFP BNGA team if you need help with this.

UPMC is waiving the $28 enrollment fee for standard gyms only April thru June:

  • Code included in flyer – view here.
  • Great resource to share with UPMC clients!

UPMC announces approach to end of Public Health Emergency:

  • End of COVID-19 PHE is May 11, 2023.
  • Members’ cost sharing will change for the below outlined benefits and services:
    • COVID-19 diagnostic and antibody testing
    • At-home, over-the-counter COVID-19 testing
    • Prescription antiviral treatment
    • Evaluation services used to diagnose COVID-19; including telemedicine, office, urgent care, and emergency room visits
  • Covid vaccines will continue to be covered at $0 at in network pharmacies/facilities.



March 2023 Updates:

UPMC announces change in refill of prescription eye drops:

  • Pennsylvania State Bill No. 1201 (Act 162 of 2022) permits the early refill of prescription eye drops in certain circumstances
  • UPMC allows for early refills of all medications once members have used 75% of their medication
  • This new bill allows early refills of prescription eye drops once members have used 70% of their medication
  • Change is effective for fully insured groups July 1, 2023

Final reminder: UPMC is shifting all clients to paperless billing effective April 1, 2023:

  • Groups will need to access Payments & Billing via Employer OnLine
  • Groups will be required to appoint an Online Account Administrator & this individual with register for access to EOL
  • Please direct any questions to your NFP BNGA team



February 2023 Updates:

UPMC called renewed attention to the SaveON SP Copay Program:

  • This program is for all fully insured groups regardless of group size as of 1/1/23 or at the time of their 2023 renewal
  • UPMC has communicated that a small subset of membership is impacted depending on use of specialty medication – please contact your NFP BNGA team for more information

UPMC clients are shifting to paperless billing:

  • Change is effective 4/1 – groups will need to access Payments & Billing via Employer OnLine
  • Groups will be required to appoint an Online Account Administrator & this individual with register for access to EOL
  • Please direct any questions to your NFP BNGA team

UPMC announces compensation increases in the 51+ Market:

  • Effective 4/1
  • More information to follow regarding how this change effects your General Agency compensation schedules



January 2023 Updates:



December 2022 Updates:



November 2022 Updates:
  • UPMC released their 2023 ACA Benefit Plan Summary brochures:



October 2022 Updates:
  • UPMC VirtualCare updates:
    • Innovative, lower-cost group health plan for employers with 2-50 employees in Allegheny & Erie counties – to be offered with the UPMC Partner Network in 2023.
    • Access to convenient, affordable care from virtually enabled in-network providers.
    • $0 copay for virtual visits
    • Virtual specialist visits for half the copay of in-person
    • Video linked here
    • Flyer linked here
  • UPMC Essential Pharmacy Network:
    • Offered to Individuals on and off the Exchange, as well as to small market (2-50) employer groups (excluding MUW) – available upon group’s 2023 renewal date.
    • Provides most members access to at least 2 participating pharmacies within 5 miles of their home.
    • Network includes more than 19,000 participating pharmacies nationwide & over 1,200 pharmacies in PA.
    • Producer training webinar available here
  • UPMC encouraging clients to go paperless:



September 2022 Updates:
  • UPMC hosted a VirtualCare & Essential Pharmacy Network Webinar on 9/27:
  • Employer groups are able to schedule On-Site Flue Vaccination Clinics through UPMC:
  • Telehealth Awareness Week (9/18 – 9/24) highlighted approved access to quality care on telehealth platforms, such as UPMC AnywhereCare.
    • Additional digital health UPMC services available to covered members:
      • Exclusive digital health tools and resources, such as MyHealth OnLine and the UPMC Health Plan app.
      • RxWell, a cutting-edge app for depression, stress, anxiety, and other health and well-being concerns.
      • MyUPMC, which allows members to have a virtual visit with a UPMC physician, view test results, schedule appointments, renew their medications, and pay bills they’ve received from UPMC providers.



August 2022 Updates:
  • Vision Advantage plan changes:
    • All Vision Advantage plans are phasing into Vision Care products at upcoming client renewals – please keep in mind as you review renewals with your UPMC clients. They must indicate new Vision plan selection or coverage will terminate effective the last day of month prior to renewal.



July 2022 Updates:

Active&Fit Direct is offering a “Summer Special” through the end of August:

  • Waived $25 enrollment fee
  • Provides UPMC Health Plan members over the age of 18, & spouses, the opportunity to join A&FD for $25 / month
  • Members can use any of their 11,600+ Standard Fitness Centers & over 7,600 digital on demand workouts
  • Get started here (UPMC log in required).



June 2022 Updates

Click the links below to access UPMC commonly used forms:

Click the links below to access UPMC User Guides for Employer OnLine:

UPMC to comply with Transparency in Coverage Final Rule – Machine Readable Files (MRFs) will be available online effective July 1, 2022



May 2022 Updates:

UPMC Health Plan, Express Scripts Inc., and SaveOnSP are pleased to provide the SaveOnSP specialty cost-share assistance service for Health Plan members:

  • Begins on July 1, 2022
  • Targets specific high-cost specialty medications & leverage funds from manufacturer patient assistance programs to lower cost sharing for members who enroll
  • Members will be able to work with UPMC Health Plan’s preferred specialty pharmacies (Chartwell and Accredo) to apply manufacturer assistance to eligible pharmacy claims.
  • Visit here to check the SaveOnSP drug list.

Please contact your UPMC account manager with any questions.

UPMC Enrollment Form Step-by-Step



April 2022 Updates:

UPMC Update: Enrollment Contact Form – Moving to Producer OnLine

Important: Vision plan transition for ACA renewals



Recently Archived Updates

Review Adjusted Best Practices surrounding UPMC’s MSP Attestation Submission

UPMC Health Plan Virtual Concierge on Amazon Alexa & Google Home

UPMC Health Plan Extends Members’ Out-Of-Pocket Cost Waivers for In-Network Telehealth Visits, Inpatient COVID-19 Treatment and Monoclonal Treatment (extension in effect through July 20, 2021

UPMC Partner Network Now Available for Groups with 51+ Employees (Beginning with 7/1/2021 Effective Dates)

UPMC Client Communication – UPMC COBRA Subsidies under America Rescue Plan

All Pennsylvanians age 16 and older are now eligible to receive the COVID-19 vaccine. UPMC encourages you to schedule your vaccine today at a UPMC COVID-19 Vaccine Clinic in your region and provides online opportunities for those 18+ to schedule a COVID-19 Vaccine at UPMC. To schedule for a 16 or 17 year old, contact (844)-UPMCVAC (844-876-2822).

UPMC Health Plan has not mailed hard copy 1095B Forms to members covered under fully insured small group plans for the 2020 tax year.  Members have access to their 1095B via their MyHealth Online Member Portal (in the Forms and Guides section) to download for their records.

UPMC Initiates Authentication Process for Producer OnlineRead Two Step Authentication FAQs

UPMC introduces RxWell as a partner for their UPMC Prescription for Wellness portfolio

The American Rescue Plan Act of 2021 Signed Into Law

COVID-19 Vaccines at UPMC – Vaccine Information & Updates

UPMC Client Communications – Introducing the UPMC Small Group Help Line

The UPMC Account Management Department has been restructured for groups 1-99.

  • New segments have been developed based on group size (1-5, 6-50, 51-99) with a dedicated UPMC Account Manager in each segment.
  • Client letters are being mailed by the carrier to introduce the changes.
  • For details on how your UPMC Clients’ Account Managers may have changed, contact your NFP-BNGA team.

UPMC COVID-19 Vaccine Information – issued directly to UPMC Employer Group Clients

UPMC has resurfaced their initiative to change how claims are adjudicated for clients that fall under 20 employees (with Medicare deemed Primary).  The following resources have been shared by UPMC.

UPMC Clients with 20 or fewer participants on their UPMC coverage are being contacted by UPMC via email or mail to notify them of their current Medicare Primary status and how it can impact Medicare eligible members.  In the communication, clients are provided guidance to attest (via online link) the Medicare Primary status if they have 20+ employees.  The attestation is the way to appeal for adjustment to Medicare Secondary Payer status in the system.  Be on the lookout for more on this topic from our NFP-BNGA Group & Medicare Team.

UPMC COVID-19 Employer FAQs including Vaccine Details