Find helpful resources including forms, plan materials and more.
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
Premium payment forms and information
Authorization forms and information
Medication authorization forms
Other resources and plan information
Recursos en Español (Resources in Spanish)
Declaration of Disaster or Emergency
- Electronic Funds Transfer (EFT) Form (PDF) (639.8 KB)
- Premium Deduction from Social Security Payment Form (PDF) (426.7 KB) - Mail the completed form to UnitedHealthcare, PO Box 29675, Hot Springs, AR 71913.
- Prescription Drug Reimbursement Form (PDF) (240.6 KB)
- 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.
- Appointment of Representative Form
- See more about how to appoint a representative here.
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 - Find the form for your medication and provide to your prescriber to complete for faster decision
- Medication Prior Authorization Request Form (PDF) [Updated 10/18/2018](42.6 KB) - Provide this form to your prescriber if drug-specific form is unavailable or if requesting coverage in advance of upcoming year between October 15 and December 31 of the current year (e.g., between 10/15/2019 and 12/31/2019 for 2020 plan year)--please check "Proactive Benefit Review" box
- Medicare Part D Coverage Determination Request Form (PDF) [Updated 10/18/2018](120.9 KB) – For use by members and providers
- Redetermination Request Form (PDF) (56.2 KB) - For use to appeal a denial
- 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 plan details. You'll find the information you need in the Helpful Resources section.
- Coverage determinations and appeals, drug conditions and limitations and quality assurance policies
- Medicare Plan Appeals & Grievances Form (PDF) – (for use by members) - Opens in a new window (83.8 KB)
- Medication Therapy Management (MTM)
- 60-day formulary change notice
- UnitedHealthcare Prescription Drug Transition Process
- How to Get Help with Prescription Drug Costs
To get an enrollment form for a UnitedHealthcare Medicare Part D plan, 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 section.
To request disenrollment from your Medicare prescription drug plan and switch to Original Medicare only, you have two options to choose from:
- Disenrollment Form (Online) - Opens in a new window - Fill out the form and submit the request online.
- Disenrollment Form (PDF) - Opens in a new window (72.7 KB) - Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.
If you’re affected by a disaster or emergency declaration by the President or a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.
- Part A, Part B, and supplemental Part C plan benefits are to be provided at specified non-contracted facilities (note that Part A and Part B benefits must be obtained at Medicare certified facilities);
- Where applicable, requirements for gatekeeper referrals are waived in full;
- Plan-approved out-of-network cost-sharing to network cost-sharing amounts are temporarily reduced; and
- The 30-day notification requirement to members is waived, as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the member.
If CMS hasn’t provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration.