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
Prescription Drug Benefit Information
OptumRx Mail Service Pharmacy
Prescription Mail Order Form – Preferred Mail Service Pharmacy through OptumRx (PDF)(302.0 KB)
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)
Medication Prior Authorization Request Form (PDF) (41.1 KB)
Specialty Pharmacy Prior Authorization Request Forms
Medicare Part D Coverage Determination Request Form (PDF) (75.3 KB) – for use by members and providers
Redetermination Request Form (PDF) (52.2 KB)
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) (217.2 KB)
Appeals and grievances
To request disenrollment from your Medicare Special Needs 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.