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.

Prescription drug formulary and other plan documents

 

The Plan Documents search tool can help make it easier to find documents for a specific plan, like a plan's provider directory, drug list (formulary) or Evidence of Coverage.


If you've created a profile with us, you can also view documents for plans you’ve saved by logging into your profile and clicking on the name of one of your saved plans. Scroll down to the "Plan Documents" section to find the plan information you need.

 

Already a plan member? You can sign in to your account to see your plan documents.

Prescription drug mail order form

 

OptumRx Home Delivery Order Form (PDF) (743.42 KB)

Premium payment forms and information

 

How to pay your premium

 

Electronic Funds Transfer (EFT) Form (PDF) (530.21 KB)

 

Social Security/Railroad Retirement Board Deduction Form (PDF) (373.4 KB) 

Reimbursement forms

 

Medical Reimbursement Form (PDF) (782.78 KB)

 

Prescription Drug Direct Member Reimbursement Form (PDF) (569.04 KB)

 

FAQ – Prescription Drug Reimbursement Form (PDF) (597.65 KB) 

Authorization forms and information

 

Learn more about how to appoint a representative

 

Appointment of Representative Form (PDF) (120 KB)

 

Authorization to Share Personal Information Form (PDF) (99.24 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.

Prescription medication forms

 

Some medications require additional information from the prescriber (for example, your primary care physician). The forms below cover requests for exceptions, prior authorizations and appeals.

 

Medicare Prescription Drug Coverage Determination Request Form (PDF) (387.04 KB) (Updated 12/17/19) – For use by members and providers. Complete this form to request a formulary exception, tiering exception, prior authorization or reimbursement.


Prior Authorization for Prescribers - For use by providers. Your doctor can go online and request a coverage decision for you. 


Redetermination of Medicare Prescription Drug Denial Request Form (PDF) (67.61 KB)
- Complete this form to appeal a denial for coverage of (or payment for) a prescription drug.

Other resources and plan information

 

Prescription drug coverage determinations and appeals, drug conditions and limitations and quality assurance policies

 

Medicare Advantage (no prescription drug coverage) appeals and grievances

 

Medicare Plan Appeals & Grievances Form (PDF) (760.53 KB) – (for use by members)

 

Medication Therapy Management (MTM) Program

 

60-day formulary change notice

 

UnitedHealthcare Prescription drug transition process

 

Find out how to get financial help with prescription drugs

 

Commitment to quality (PDF) (466.93 KB)

 

Member rights and responsibilities

 

Medicare Advantage and Prescription Drug Plan Explanation of Benefits

 

Potential for Contract Termination (PDF) (102.4 KB)

 

Medicare Supplement plan (Medigap) Termination Letter (PDF) (905.59 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)

 

Medicare y Usted 

 

La guia Medicare Explicado

Disenrollment information

 

To learn about what can cause automatic disenrollment from a Medicare Part C or Part D plan or to request disenrollment from your current plan to switch to Original Medicare only, please visit the Disenrollment Information page.

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 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.