Medicare Advantage Plan Information and Forms | UnitedHealthcare®

Medicare Advantage Plans

Plan Information and Forms

Smart decisions begin with finding the right information. The resources on this page are designed to help you make good health care choices.

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Premium payment forms and information

How to pay your premium 
Electronic Funds Transfer (EFT) Form (PDF) (636.9 KB)
Social Security Premium Withholding Form (PDF) (39.9 KB)


Forms and information for plans with Part D prescription drug coverage

OptumRx Mail Service Pharmacy 
Prescription Mail Order Form - Preferred Mail Service Pharmacy through OptumRx (PDF) (749.8 KB)
Prescription grievances, coverage determinations and appeals 
How to appoint a representative 
Appointment of Representative Form (PDF)
Authorization to Share Personal Information Form (PDF) (158.9 KB) - Complete this form to give others access to your account. Choose someone you trust such as a spouse, family member, caregiver or friend to access or help you manage your health plan.
MAPD Prescription Drug Plan - Direct Member Reimbursement Form (PDF) (276.0 KB)
MAPD Prescription Drug Plan - Medication Prior Authorization Request Form (PDF) (41.1 KB)
Specialty Pharmacy Prior Authorization Request Forms
Medicare Part D Coverage Determination Request Form (PDF) (54.6 KB) - (for use by members and providers) 
Redetermination Request Form (PDF) (52.2 KB)
Medication Therapy Management (MTM) Program 
Prescription drug transition process 
Find out how to get financial help with prescription drugs


Enrollment forms

To get a MedicareComplete or MedicareDirect plan enrollment form (PDF), go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You'll find the form you need in the Helpful Resources section.


Other resources and plan information

Summary of Benefits and Evidence of Coverage - Go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the information you need in the Helpful Resources section. 
UnitedHealthcare Medicare Advantage Coverage Summaries

Disenrollment Form (PDF) (75.9 KB)
Commitment to quality (PDF) (218.0 KB)
Member rights and responsibilities 
Appeals and grievances 
Potential for Contract Termination (PDF) (67.6 KB)
Medicare Supplement plan (Medigap) Termination Letter (PDF)(928.7 KB) - Complete this letter when a member is terminating their Medicare supplement plan (Medigap) and replacing it with a UnitedHealthcare Medicare Advantage plan.

Recursos en Español (Resources in Spanish)

 

To request disenrollment from your plan and switch to Original Medicare only, you have two options. You can either complete the Online Disenrollment Form electronically or download the Disenrollment Form (PDF), then follow the directions on that form to complete it and return it by mail or fax.

Medicare Advantage Plan Disenrollment

Medicare Advantage Plan – PFFS Disenrollment

Medicare Advantage Prescription Drug Plan Disenrollment

Find Medicare Advantage Plans in Your Area

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