United healthcare medicare advantage prior authorization 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.

Disenrollment from a Medicare Advantage (Part C) or Medicare prescription drug (Part D) plan may occur automatically if you:

• Move your permanent residence out of the plan's service area (including incarceration).
• Lose your entitlement to Medicare benefits under Part A and/or are no longer enrolled in Part B.
• Fail to pay the monthly premium (if your plan has one) after your plan has made reasonable efforts to collect the unpaid premium.
• Become deceased.
• Knowingly misrepresent that you expect to receive reimbursement for covered Medicare prescription drug plan drugs through other third-party coverage.
• Enroll in a different prescription drug plan. You will automatically be disenrolled from your previous plan (if it has prescription drug coverage).
• Fail to pay your Part D-IRMAA to the government and CMS notifies the plan to effectuate the disenrollment.

ou may also be disenrolled for "disruptive behavior." Disruptive behavior is defined as behavior that substantially impairs UnitedHealthcare's ability to arrange or provide care for you or other plan members. Other Medicare prescription drug plan sponsors may decline your enrollment if you have been disenrolled for disruptive behavior. 

In all cases of disenrollment, your plan is required to provide proper notice to you and give you the opportunity to appeal the decision prior to disenrollment.

You can request disenrollment from your Medicare Advantage (Part C) plan, your Medicare Special Needs plan (SNP) or Medicare prescription drug (Part D) plan and switch to Original Medicare (Parts A and B) online or by mail/fax:

• Disenrollment Form (Online) Medicare Advantage Plan Disenrollment - Fill out the form and submit the request online.
• Disenrollment Form (PDF) Medicare Advantage Plan Disenrollment - Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Updated January 24, 2022

A UnitedHealthcare prior authorization form is used by physicians in the instances they need to prescribe a medication that isn’t on the preferred drug list (PDL). Person’s covered under a UnitedHealthcare Community Plan (UHC) have access to a wide range of prescription medication. The purpose of this form is to demonstrate medical justification for prescribing the drug in question when other drugs on the PDL might serve the same purpose. The form should be submitted to UHC where they will review the physician’s medical reasoning and either approve or deny the prescription. If the request is denied, the patient may choose to pay for the drug out of pocket or ask the physician to prescribe a similar drug from the PDL.

Form can be faxed to: 1 (866) 940-7328

Phone number: 1 (800) 310-6826

Preferred Drug List

How to Write

Step 1 – Enter today’s date at the top of the page.

Step 2 – “Section A” must be completed with the patient’s information. Include the patient’s full name, member ID, address, phone number, DOB, allergies, primary insurance, policy number, and group number.

Step 3 – Select the “NEW” box if the medication has not been prescribed before or select the “CONTINUATION” box if this is a renewal request. If the second box was checked, enter the start date. If the patient is currently hospitalized, select “YES” otherwise select “NO”.

Step 4 – In the “Physician Information” section, enter the physician’s full name, address, phone number, fax number, NPI number, specialty, and office contact name.

Step 5 – Under “Medical Information”, enter the name of the requested drug, the strength, and the directions of use. Be sure to include the diagnosis and the appropriate ICD codes.

Step 6 – If the patient is pregnant, you must disclose this information and include their due date.

Step 7 – Next, a space is provided for the physician to include their medical reasoning as to why this particular drug must be prescribed over other medication options.

Step 8 – Under “Other Medications Tried”, enter the name, strength, directions, dates of therapy, and reason for discontinuation of all medications that were previously prescribed to the patient to treat their condition.

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