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.
Already a plan member? You can sign in to your account to see your plan documents. Premium payment forms and information
Electronic Funds Transfer (EFT) Form (PDF) (530.21 KB)
Social Security/Railroad Retirement Board Deduction Form (PDF) (373.4 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) (89 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 doctors/providers. Complete this form to request a formulary exception, tiering exception, prior authorization or reimbursement.
Other resources and plan information
Terms and Conditions of Payment – Private Fee-For-Service (PFFS) Plans (PDF)
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) (974.67 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)
Partes de los Conceptos Básicos de Medicare – Parte A
Partes de los Conceptos Básicos de Medicare – Parte B
Partes de los Conceptos Básicos de Medicare – Parte C (Medicare Advantage)
Partes de los Conceptos Básicos de Medicare – Cobertura de Medicamentos con Receta de la Parte D
6 Consejos Oportunos de Medicare para Quienes Cumplen 65 Años
Las Diferencias entre Medicare y Medicaid
4 Programas de Asistencia que Podrían Ayudar a Pagar Sus Costos de Medicare
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 CMS hasn't provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration. |