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

 

Optum Home Delivery Order Form (PDF) (743.42 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.


Prior Authorization for Prescribers   - For use by doctors/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.

Disenrollment and contract termination 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 Information about Disenrollment and Contract Termination 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.