Core Benefits & Cost Sharing

We want to help keep you healthy. We strive to do that by providing the health care benefits you need, when you need them. Core health care benefits that are covered for all our UPHP members include;

  • Preventive & Medical Care
  • Dental, Hearing & Vision
  • Mental Health Care
  • Pharmacy

For specific information regarding your benefits and cost-sharing as a member of the Upper Peninsula Health Plan (UPHP), refer to the UPHP Evidence of Coverage.  The Evidence of Coverage contains detailed information regarding premiums, copayments, coinsurance, limitations, and more.

Stay active and make new friends with Upper Peninsula Health Plan’s (UPHP) Live Fit benefit!

At UPHP, we know that staying active both physically and socially are important at all stages of our lives.  But, as we age it becomes more challenging.  Find out more about the benefit and how to use it below.

What is Live Fit?

UPHP has partnered with fitness centers across the Upper Peninsula to provide members the Live Fit benefit.  It is a monthly membership to participating fitness centers where you can go to get and stay active.  There you can find the encouragement, support and tools you need to stay fit, as well as make new friends.

Who is eligible for Live Fit?

All active members of UPHP’s Medicare Advantage plans are eligible.  These plans include UPHP Advantage (HMO-POS) and UPHP Choice (HMO).

What is included in the benefit?

Your benefit includes a no-cost, basic membership to participating fitness centers.  Services covered may include orientations, classes, and more, but may vary from one location to another.  Additional services such as personal training, additional classes, towel or locker services, etc. may be available at an additional cost to you.  Contact your preferred gym to find out what is included and what additional services are available.

 How do I use Live Fit?

You can easily get started by following these simple steps:

  1. Find a participating fitness center near you.
  2. Call UPHP at 1-877-349-9324 to choose your Home Fitness Center or complete the
    Home Fitness Center Election/Change Form
    and mail or fax it to the address on the bottom of the form.
  3. Visit your Home Gym and show them your UPHP ID card.
  4. Complete your Home Gym’s registration process.
  5. Begin using your fitness center and have fun!

What if my preferred fitness center does not participate with Live Fit?

We’d love to have your gym join our network.  Simply complete the Nominate My Fitness Center form below.

Fitness Center Nomination Form

    Every fall, the Upper Peninsula Health Plan (UPHP) provides our Medicare members with an Annual Notice of Changes booklet. It tells you about the changes to your benefits and costs that will go into effect in January of the upcoming plan year.

    To decide what is best for you, review the Annual Notice of Changes below for the plan in which you are currently enrolled and compare it with the benefits and costs of other Medicare health plans in your area, as well as the benefits and costs of Original Medicare.

    2021 UPHP Advantage Annual Notice of Changes
    2021 UPHP Choice Annual Notice of Changes

    2022 UPHP Advantage Annual Notice of Changes
    2022 UPHP Choice Annual Notice of Changes

    Below is a list of your out-of-pocket costs:

    CostUPHP Advantage (HMO-POS)UPHP Choice (HMO)
    Plan Premium

    $114 (2021)

    $120 (2022)

    $0
    Yearly Deductible Amount$0

    Part B: $0

    Part D: $285
    (Applies to Tiers 2, 3, 4 and 5)

    Maximum Out-of-Pocket Limit for Medicare-covered Services

    $7,550 (2021)

    $6,700 (2022)

    $11,300 (POS)

    $7,550 (2021)

    $6,700 (2022)

    Copayments and CoinsuranceSee the benefits chart in Chapter 4 of the UPHP Evidence of Coverage to learn about copayments and coinsurance.See the benefits chart in Chapter 4 of the UPHP Evidence of Coverage to learn about copayments and coinsurance.

    Premiums, copayments, coinsurance, and deductibles may vary based on the level of extra help you receive.  Please contact the plan for further details.

    If you currently pay a Medicare Part B premium, you must continue to pay it in addition to the costs above.

    Benefits, formulary, pharmacy network, premium, and/or copayments and coinsurance may change Jan. 1 of each year.  Limitations, copayments, and restrictions may apply.  The benefit information provided here is a brief summary, not a complete description of benefits.  Contact UPHP for more information.

    If you have paid a bill that you think Upper Peninsula Health Plan (UPHP) should pay some or all of, you can ask UPHP to pay you back. This is called reimbursement.

    Below are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received.

    You can receive emergency services from any provider, whether or not the provider is a part of our network. When you receive emergency or urgently needed care from a provider who is not part of our network, you are only responsible for paying your share of the cost, not for the entire cost. You should ask the provider to bill the plan for our share of the cost.

    • If you pay the entire amount yourself at the time you receive the care, you need to ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you have made.
    • To make sure you are giving us all the information we need to make a decision, you can fill out our UPHP Claim Reimbursement Form to make your request for payment.
    • At times you may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along with documentation of any payments you have already made.
      • If the provider is owed anything, we will pay the provider directly.
      • If you have already paid more than your share of the cost of the service, we will determine how much you owed and pay you back for our share of the cost.

    Network providers should always bill the plan directly, and ask you only for your share of the cost. But sometimes they make mistakes, and ask you to pay more than your share.

    • Whenever you get a bill from a network provider that you think is more than you should pay, send us the bill. We will contact the provider directly and resolve the billing problem.
    • If you have already paid a bill to a network provider, but you feel that you paid too much, send us the bill along with documentation of any payment you have made. You should ask us to pay you back the difference between the amount you paid and the amount you owed under the plan.
    • To make sure you are giving us all the information we need to make a decision, you can fill out our UPHP Claim Reimbursement Form to make your request for payment.

    Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first day of enrollment has already passed. The enrollment date may even have occurred last year.)

    If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered services or drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork for us to handle the reimbursement.

    • Please contact UPHP Customer Service for additional information about how to ask us to pay you back and deadlines for making your request.

    If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. We cover prescriptions filled at out-of-network pharmacies only in a few special situations. Please refer to the UPHP Evidence of Coverage to learn more.

    Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.

    If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or to look up your plan enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself.

    Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.

    You may pay the full cost of the prescription because you find that the drug is not covered for some reason.

    • For example, the drug may not be on the plan’s UPHP Advantage and UPHP Choice List of Covered Drugs (Formulary); or it could have a requirement or restriction that you did not know about or do not think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it.
    • Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost of the drug.

    Copies of bills and/or receipts may be mailed to:

    For Medical Requests:
    Upper Peninsula Health Plan
    853 West Washington Street
    Marquette, MI 49855

    To make sure you are giving us all the information we need to make a decision, you can fill out our UPHP Claim Reimbursement Form to make your request for payment.

    For Pharmacy Requests:
    Magellan Rx Management
    Direct Member Reimbursement
    PO Box 2187
    Maryland Heights, MO 63043

    To make sure you are giving Magellan Rx Management all the information they need to make a decision, you can fill out the Magellan Rx Management Direct Member Reimbursement Form to make your request for payment.

    If you have questions, call UPHP Customer Service at 1-877-349-9324 (TTY: 711), Monday through Friday from 8 a.m. to 9 p.m. Eastern time, with weekend hours from Oct. 1 through March 31. The call is free.

     
     

    If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

    This table shows you what your monthly plan premium will be if you get extra help.

    Your Level of Extra Help2021 Monthly Premium for UPHP Advantage*2022 Monthly Premium for UPHP Advantage*Monthly Premium for UPHP Choice*
    100%$83.90$88.50$0
    75%$91.40$96.40$0
    50%$99.00$104.30$0
    25%$106.50$112.10$0

    *This does not include any Medicare Part B Premium that you may have to pay.

    UPHP Advantage and UPHP Choice premiums include coverage for both medical services and prescription drug coverage.

    If you are not getting extra help, you can see if you qualify by calling:

    1-800-MEDICARE (TTY/TTD users call 1-877-486-2048) 24 hours a day, seven days a week, your state Medicaid office, or the Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

    If you have questions, please call UPHP Customer Service at 1-877-349-9324 (TTY: 711) Monday through Friday from 8 a.m. to 9 p.m. Eastern time, with weekend hours from Oct. 1 through March 31. The call is free.

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    Page Last Updated: 10/1/2021