Individual Exchange plans, also referred to as UnitedHealthcare Individual & Family ACA Marketplace plans Prior Authorization and Exceptions

Learn about Prior Authorization and Exceptions for UnitedHealthcare Individual & Family plans in the following states: AL, AZ, CO, FL, GA, IL, KS, LA, MD, MI, MO, MS, NC, NJ, NM, OH, OK, SC, TN, TX, VA, WA, WI.

Some medications require prior authorization or may need an exception. This includes medications that:

• Require a prior authorization, including compounded prescription medications
• Require step therapy
• Exceed quantity limits
• Exceed opioid safety edits
  • 7-day supply limit for members who have not filled an opioid prescription recently or
  • Opioid use that exceeds the established morphine milligram equivalent (MME) level
• Are not listed in the PDL (also called non-formulary drugs)
• May be covered at no cost when specific requirements are met such as preventive medications

Submitting prior authorization or exception requests
OptumRx, our Pharmacy Benefit Manager, processes prior authorization and exception requests on behalf of UnitedHealthcare Individual Exchange Plans. Healthcare providers can submit a request:

• Online
• By calling 800-711-4555
• By faxing a request form to 844-403-1027
  • State-specific request forms are at Individual Exchange Plan Information for Providers

The request should include the diagnosis, medication history, clinical justification, medical records/lab tests as needed, and other supporting information. If information is missing, we will contact you and request additional information. We may deny the request if the information isn’t supplied or if there’s no response.

Members can also start a request by calling the member services number on their ID card or at myuhc.com/exchange. If the member submits a request, we’ll contact the prescribing provider for more information to help process the request.

Clinical Policies and Criteria
UnitedHealthcare uses FDA-approved product labeling, peer-reviewed medical literature, including randomized clinical trials, drug comparison studies, pharmacoeconomic studies, outcomes research data, published clinical practice guidelines, comparisons of efficacy, side effects, potential for off-label use and claims data analysis to create our clinical policies.

Clinical criteria can be found at Individual Exchange Plan Information for Providers.

For a summary of upcoming changes to the clinical criteria:

• Notice of Changes to Prior Authorization Requirements and Coverage Criteria - Effective March 1, 2024
• Notice of Changes to Prior Authorization Requirements and Coverage Criteria - Effective April 1, 2024
• Notice of Changes to Prior Authorization Requirements and Coverage Criteria - Effective May 1, 2024
• Notice of Changes to Prior Authorization Requirements and Coverage Criteria - Effective June 1, 2024

Notification of the decision
We’ll issue a decision within the timeframes required by state¹ and federal laws.

We’ll send written notification of the decision to both providers and members. If a healthcare provider does not agree with the decision, this notification will provide instructions on requesting a peer-to-peer review or requesting an appeal.

Non-formulary drugs

For requests to cover non-formulary drugs (medications not listed on the PDL), see Drug Exception Timeframes and Enrollee Responsibilities at Transparency in Coverage.

Related Links: Prior Authorization Utilization Review Statistics

¹Colorado: For exception requests, decisions are issued within 72 hours for standard requests and 24 hours for expedited requests. For standard prior authorization requests, decisions are issued within 2 business days for requests received through an electronic pre-authorization system and 3 business days for requests received by facsimile, mail or verbally. For expedited prior authorization requests, decisions are issued within 1 business day.  For step therapy requests, decisions are issued within 3 business days for standard requests and 24 hours for expedited requests. 3 CCR 702-4 Series 4-2-49-5

¹Florida: Decisions for step therapy exception requests are issued within 15 days for standard requests and 72 hours for expedited requests. Adverse determinations may be appealed within 180 days by following the directions on the denial letter.