Medicare Advantage Plan Information and Forms | UnitedHealthcare®
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Medicare Advantage and Special Needs 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.

Note: PDF (Portable Document Format) files can be viewed with Adobe® Reader®. If you don't already have this viewer on your computer, download it free from the Adobe website.

 

Prescription drug mail order forms

Prescription Mail Order Form - OptumRx Home Delivery (PDF)(207.9 KB)

 

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) (48.3 KB)

 

Reimbursement forms

Medical Reimbursement Form (PDF)(782.2 KB)

Prescription Drug Reimbursement Form (PDF) (276.0 KB)

 

Authorization forms and information

How to appoint a representative 
Appointment of Representative Form (PDF)
Authorization to Share Personal Information Form (PDF)(81.3 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.

 

Medication authorization forms

Some medications require information from the prescriber (for example, your primary care physician) before filling the prescription. The prior authorization form can be given to your prescriber to complete and return to OptumRx for processing.

Drug-Specific Prior Authorization Request Forms

Medication Prior Authorization Request Form (PDF)(169.9 KB)

Medicare Part D Coverage Determination Request Form (PDF)(153.2 KB) – (for use by members and providers)

Redetermination Request Form (PDF)(66.5 KB)

 

Other resources and plan information

MAPD and SNP prescription grievances, coverage determinations and appeals

Medicare Advantage (no prescription drug coverage) appeals and grievances

Medicare Plan Appeals & Grievances Form (PDF) – (for use by members)(132.1 KB)

Medication Therapy Management (MTM) Program

Prescription drug transition process

Find out how to get financial help with prescription drugs

Learn more about OptumRx® Home Delivery


Pharmacy Directory – Medicare Advantage plans with prescription drug coverage (MAPDs)

Use the online directory to find a pharmacy and map its location.

Find a pharmacy near you

For more information about network pharmacies, please take a look at the Pharmacy Directory Information (PDF) below.

Pharmacy Directory Information (PDF)(34.3 KB)

Información del Directorio de Farmacias (en PDF)(39.4 KB)

Pharmacy Directory – Medicare Special Needs Plans
Use the online directory to find a pharmacy and map its location.
Find a pharmacy near you

For more information about network pharmacies, please take a look at the Pharmacy Directory Information (PDF) below.
Pharmacy Directory Information (PDF) – Dual Special Needs Plan (DSNP)
(33.3 KB)
Información del Directorio de Farmacias (en PDF) – Plan Dual para Personas con Necesidades Especiales (DSNP)
(38.1 KB)
Pharmacy Directory Information (PDF) – All Other Special Needs Plans
(34.3 KB)
Información del Directorio de Farmacias (en PDF) – Todos los demás Planes para Personas con Necesidades Especiales
(39.4 KB)


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 Plan Documents table.

Commitment to quality (PDF) (71.6 KB)
Member rights and responsibilities

Potential for Contract Termination (PDF) (189.8 KB)

Medicare Supplement plan (Medigap) Termination Letter (PDF)(978.9 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)

 

Enrollment information

To get a UnitedHealthcare Medicare Advantage 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 Plan Documents table.

For more information about Medicare Special Needs plan enrollment, go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and click the "Learn More" button for a specific plan.

 

Disenrollment information

To request disenrollment from your plan and switch to Original Medicare only, you have two options to choose from:

Medicare Advantage Plan Disenrollment

Medicare Advantage Plan – PFFS Disenrollment

Medicare Advantage Prescription Drug Plan Disenrollment

Medicare Special Needs Plan Disenrollment

To request disenrollment from your Medicare Special Needs plan and switch to Original Medicare only, you have two options to choose from:

Page last updated: 07.17.2017 at 12:01 AM CT | Y0066_170710_100724 Accepted

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