Medicare Advantage Plan Information and Forms | UnitedHealthcare®
close hamburger search alert

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.

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.

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® Home Delivery
Prescription Mail Order Form - OptumRx Home Delivery (PDF)(207.9 KB)
Prescription grievances, coverage determinations and appeals 
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.
MA/MAPD - Medical Reimbursement Form (PDF)(58.2 KB)
MA/Medical Reimbursement Form - For Outside of United States and U.S. Territories (PDF)(85.7 KB)

MAPD Prescription Drug Plan - Drug Reimbursement Form (PDF) (276.0 KB)
MAPD Prescription Drug Plan - Medication Prior Authorization Request Form (PDF)(276.4 KB)
Specialty Pharmacy Prior Authorization Request Forms
Medicare Part D Coverage Determination Request Form (PDF) (122.8 KB) - (for use by members and providers) 
Redetermination Request Form (PDF) (66.5 KB)
Medication Therapy Management (MTM) Program 
Prescription drug transition process 
Find out how to get financial help with prescription drugs

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)

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

Commitment to quality (PDF) (218.1 KB)
Member rights and responsibilities 
Appeals and grievances 
Potential for Contract Termination (PDF) (189.7 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)



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

Page last updated: 12.15.2016 at 12:01 AM CT | Y0066_161028_162930 Accepted

Find Medicare Advantage Plans in Your Area

Go Example: 55105
look upZIP code

Questions ?

Call UnitedHealthcare toll-free at:
(TTY 711)

Hours: 8 a.m. – 8 p.m. local time, 7 days a week

Need help?

Chat live with a sales agent.