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Plan Information and Forms

Dual Special Needs Plan (DSNP)

Try home delivery from OptumRx. 

Forms for transfers and deductions.

Electronic Funds Transfer Form

Premium Deduction Form

Forms to ask us to pay you back.

Drug Reimbursement Form

Medical Reimbursement Form

Authorization and Appointment Forms.

Authorization to Share Personal Info

Appointment of Representative

Nombramiento de un Representante

Appointment of Representative (Editable PDF)

Medication and Part D Coverage and Authorization Forms.

Medicare Part D Coverage Determination Request Form

Medication Prior Authorization Request Form

Prescription Redetermination Request Form

Additional resources for you to download. 

UHC Commitment to Quality

Medicare Appeals and Grievances Form

Medicare Supplement Termination Letter

Potential Contract Termination

Complete this letter when a member is terminating their Medicare supplement plan (Medigap) and replacing it with a UnitedHealthcare Medicare Advantage plan.

Recursos en Espanol.

Medicare y Usted

To get a UnitedHealthcare Dual Special Needs plan enrollment form (PDF), go to UHCCP.com and enter your ZIP code and click the "Find Plans" button. When you find the plan you may want to enroll in, click the "View Plan Details" button to access your enrollment form.

UnitedHealthcare health plans are offered by United Healthcare Insurance Company. We (and other private insurance companies) work with federal and state agencies to provide government-sponsored health insurance. We are not part of Medicare. We work with the Centers for Medicare & Medicaid Services (CMS) and many state governments to provide health coverage for Medicare and Medicaid recipients.

Medicare Special Needs Plan Disenrollment Form

Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Medicare Prescription Drug Plan Disenrollment

Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Looking for the federal government’s Medicaid website? Look here at Medicaid.gov.

UnitedHealthcare Dual Complete Plans

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Call 1-800-905-8671 TTY 711 for more information. Benefits, features and/or devices vary by plan/area. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.  

Nurseline Disclaimer

The NurseLine service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your doctor's care. Your health information is kept confidential in accordance with the law. Access to this service is subject to terms of use.

Availability of Non-English Disclaimer

ATTENTION: If you speak [insert language], language assistance services, free of charge, are available to you. Call 1-800-905-8671 TTY 711.

ATENCIÓN: Si habla [ingrese el idioma], hay servicios de asistencia lingüística disponibles para usted y que no tienen cargo. Llame al 1-800-905-8671 TTY 711.

Star Ratings Disclaimer

Every year, Medicare evaluates plans based on a 5-star rating system.

Formularies

The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary.

NCQA

UnitedHealthcare Connected has a Model of Care approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) through YEAR based on a review of UnitedHealthcare Connected’s Model of Care. UnitedHealthcare Connected has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until YEAR based on a review of UnitedHealthcare Connected’s Model of Care.

Important Provider Information

The Choice is Yours

We will provide you with information to help you make informed choices, such as physicians' and health care professionals' credentials. This information, however, is not an endorsement of a particular physician or health care professional's suitability for your needs.

For more detailed information on provider directory data, you may use the following link:

Important Provider Information URL: https://www.uhc.com/legal/provider

American Disabilities Act Notice

In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 ("ADA"), UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

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.

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Last Updated: 05.07.2020 at 10:28 AM CDT

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