Useful Forms
Appointing a Representative Form
If you wish to appoint someone to act on your behalf when requesting a coverage determination, use the Appointing a Representative Form. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already by authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date this form.
Direct Claim Form - Updated 8/07
Use this form to submit claims for medications dispensed at a nonparticipating pharmacy due to an emergency. You must submit claims within 3 months of date of purchase.
Mail Order Form
Use this form if you wish to receive your drug prescriptions through the mail.
Request for Medicare Prescription Drug Coverage Determination
Use this form if you wish to request a formulary exception, a tiering exception, a prior authorization for a drug, or file an appeal.
Mail completed form to:
United American Insurance Company
Attn: Group Part D Information
P.O. Box 8080
McKinney, TX 75070
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