Medication Review Opt-Out Request

Medication Review Opt-Out

Not interested in a Medication Review this year? No problem. Please just let us know by completing the form below. Remember, this comprehensive Medication Review is available at no out-of-pocket cost and is part of your plan benefits.

For additional assistance, please call Prime Therapeutics clinical services center at (800) 424-4216 (TTY 711) Monday through Friday, 9 a.m. to 7 p.m. ET.

First Name

Last Name

Street Address

Street Address 2

City

State

Zip Code

Email Address

Please select desired action:

I would like to opt out of the MTM Program this year. I acknowledge that I may decline individual services without having to opt out from the program; if I wish to re-enroll, or permanently opt out for all future program years I can call (800) 424-4216 (TTY 711).

Complete Request

Univera Healthcare Medicare is an HMO and a PPO plan with a Medicare contract. Enrollment in Univera Healthcare depends on contract renewal.

Prime Therapeutics is an independent company that provides medication review services to Univera Healthcare eligible Medication Therapy Management program enrolled members.

Submit feedback about your Medicare presciption drug plan at www.Medicare.gov or by contacting the Medicare Ombudsman.

This page last updated 8/21/2024

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