Medicare Special Needs Plan Forms & Information | UnitedHealthcare®
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Special Needs Plans

Special Needs 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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Prescription drug information and forms

OptumRx® Home Delivery

Prescription Mail Order Form – OptumRx Home Delivery (PDF)(151.7 KB)
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.
Medical Reimbursement Form (PDF)(58.2 KB)
Medical Reimbursement Form – For Outside of United States and U.S. Territories (PDF) (85.6 KB)

MAPD Prescription Drug Plan – Drug Reimbursement Form (PDF)(276.4 KB)
Medication Prior Authorization Request Form (PDF) (42.1 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) (52.2 KB)

Medication Therapy Management (MTM) program
Find out how to get financial help with prescription drugs


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

Tips for improving your health care experience (PDF) (194.6 KB)

Commitment to quality (PDF) (218.1 KB)
Appeals and grievances


Declaration of disaster or emergency – 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 in-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.


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

Find Medicare Special Needs Plans in Your Area

Example: 55105
look up ZIP code


Call UnitedHealthcare toll-free at:
(TTY 711)

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