Prescription drug formulary and other plan documents
Prescription drug mail order forms
Premium payment forms and information
Reimbursement and claims forms
Authorization forms and information
Medication authorization forms
Other resources and plan information
Recursos en Español (Resources in Spanish)
Declaration of Disaster or Emergency
To find UnitedHealthcare Medicare Advantage or Medicare Special Needs plan information and documents:
- Go to View plans and pricing and enter your ZIP code.
- Click the "View Plans" link under "Medicare Advantage (Part C) Plans" or "Medicare Special Needs Plans."
- Look at one of the available plans in your area and click the "View Plan Details" button.
- Scroll down to the "Plan Documents" section to find the plan's prescription drug list (formulary), Evidence of Coverage (EOC), enrollment form and other plan information.
If you've created a profile with us, you can 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.
- How to pay your premium
- Electronic Funds Transfer (EFT) Form (PDF) (530.4 KB)
- Social Security / Railroad Retirement Board Deduction Form (PDF) (373.4 KB)
- Medical Reimbursement Request Form (PDF) (783.0 KB)
- Medicare Part D Claim Form (PDF) (569.8 KB) - Complete this form to request reimbursement for covered medications purchased at retail cost.
- How to appoint a representative
- Appointment of Representative Form (PDF) - Learn more about how to appoint a representative here.
- Authorization to Share Personal Information Form (PDF) (99.2 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.
Some medications require information from the prescriber (for example, your primary care physician) before filling the prescription. Give the prior authorization form to your prescriber to complete and return to OptumRx for processing.
- Drug-Specific Prior Authorization Request Forms - Find the form for your medication and provide to your prescriber to complete for faster decision.
- Medication Prior Authorization Request Form (PDF) (209.7 KB) - Provide this form to your prescriber if drug-specific form is unavailable or if requesting coverage in advance of upcoming year between October 15 and December 31 of the current year (e.g., between 10/15/2019 and 12/31/2019 for 2020 plan year)—please check "Proactive Benefit Review" box
- Medicare Part D Coverage Determination Request Form (PDF) (387.6 KB) - For use by members and providers
- Redetermination Request Form (PDF) (67.6 KB) - For use to appeal a denial
- MAPD and SNP prescription grievances, coverage determinations and appeals
- Medicare Advantage (no prescription drug coverage) appeals and grievances
- Medicare Plan Appeal & Grievance Form (PDF) - (for use by members) (761.0 KB)
- Medication Therapy Management (MTM) Program
- Prescription drug transition process
- Find out how to get financial help with prescription drugs
- Commitment to quality (PDF)(467.0 KB)
- Member rights and responsibilities
- Potential for Contract Termination (PDF) (102.4 KB)
- Medicare Supplement plan (Medigap) Termination Letter (PDF)(905.6 KB) - Complete this letter when a member is terminating their Medicare supplement plan (Medigap) and replacing it with a UnitedHealthcare Medicare Advantage plan.
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.
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.