The Patient Protection and Affordable Care Act (ACA) introduced a new option for consumers to access health insurance using a Health Insurance Marketplace, also known as an Exchange. These online Marketplaces let consumers research, compare and enroll for health insurance plans. 

UnitedHealthcare Exchange plan participation

In 2022, we'll offer Individual Exchange plans in 7 new states. Select your state to view the welcome kit.

• Alabama
• Florida
• Georgia
• Illinois
• Louisiana
• Michigan
• Texas

We'll continue to offer Individual Exchange plans in these states:

• Arizona
• Maryland
• North Carolina
• Oklahoma
• Tennessee
• Virginia
• Washington

In 2020, UnitedHealthcare participated in the Health Insurance Marketplace (Exchanges) in 4 states:  Colorado, Nevada, Massachusetts and New York. 

• The Colorado Exchange Plans are administered by Rocky Mountain Health Plans.  For more information on these plans visit: https://www.rmhp.org/family-individual-health-insurance/healthcare-plans/front-range-plans-from-rmhp
• The Nevada Exchange Plans are administered by Sierra.  For more information on these plans, visit: Nevadahealthlink.com
• The Massachusetts Exchange Plans are administered by UnitedHealthcare.  For more information on these plans visit: uhcprovider.com > Massachusetts > Commercial > UnitedHealthcareNavigate.  (See State specific section for MA Insurance Exchange)
• The New York Exchange Plans are administered by UnitedHealthcare. For more information on these plans visit: uhcprovider.com > NewYork > Commercial > UnitedHealthcare Compass 

Learn more about Individual Exchange plans in 2022

• Exchange Plans Quick Reference Guide

Individual Exchange Plan Policies

• UnitedHealthcare Individual Exchange Medical and Drug Policies and Coverage Determination Guidelines
• Reimbursement Policies for UnitedHealthcare Individual Exchange Plans

Select the guidelines for your state:

• Alabama Plan Clinical Criteria (Effective 10/1/2022)
• Arizona Plan Clinical Criteria (Effective 10/1/2022)
• Colorado Plan Clinical Criteria (Effective 10/1/2022)
• Florida Plan Clinical Criteria (Effective 10/1/2022)
• Georgia Plan Clinical Criteria (Effective 10/1/2022)
• Illinois Plan Clinical Criteria (Effective 10/1/2022)
• Louisiana Plan Clinical Criteria (Effective 10/1/2022)
• Maryland Plan Clinical Criteria (Effective 10/1/2022)
• Michigan Plan Clinical Criteria (Effective 10/1/2022)
• North Carolina Plan Clinical Criteria (Effective 10/1/2022)
• Oklahoma Plan Clinical Criteria (Effective 10/1/2022)
• Tennessee Plan Clinical Criteria (Effective 10/1/2022)
• Texas Plan Clinical Criteria (Effective 10/1/2022)
• Virginia Plan Clinical Criteria (Effective 10/1/2022)
• Washington Plan Clinical Criteria (Effective 10/1/2022)

Prior Authorization

• Individual Exchange Plans - Advanced Notification/Prior Authorization Requirements
• Cardiology
• Radiology

Pharmacy and Formularies

• Find a network pharmacy
• Pharmacy
• Prior Authorization: If a drug requires prior authorization, step therapy, utilization management, or an exception, providers can contact OptumRx. Please provide information on diagnosis, medication history, medical records or lab tests as needed, clinical justification, and other supporting information.
  • Pharmacy prior authorization form 
    
  • Colorado prior authorization form
  • Illinois Prior Authorization Form
  • Texas Prior Authorization Form
  • Louisiana Prior Authorization Form
  • For Florida, decisions for step therapy exception requests are issued within 72 hours for urgent requests and 15 days for all other requests.  Adverse determinations may be appealed within 180 days by following the directions on the denial letter.
• State PDLs:
  • 2022 Alabama PDL
  • 2022 Arizona PDL
  • 2022 Colorado PDL
  • 2022 Florida PDL
  • 2022 Georgia PDL
  • 2022 Illinois PDL
  • 2022 Louisiana PDL
  • 2022 Maryland PDL 
  • 2022 Michigan PDL
  • 2022 North Carolina PDL
  • 2022 Oklahoma PDL 
  • 2022 Tennessee PDL
  • 2022 Texas PDL
  • 2022 Virginia PDL
  • 2022 Washington PDL
• State PDL Booklets
  • 2022 Alabama PDL Booklet
  • 2022 Arizona PDL Booklet
  • 2022 Colorado PDL Booklet
  • 2022 Florida PDL Booklet
  • 2022 Georgia PDL Booklet
  • 2022 Illinois PDL Booklet
  • 2022 Louisiana PDL Booklet
  • 2022 Maryland PDL Booklet 
  • 2022 Michigan PDL Booklet
  • 2022 North Carolina PDL Booklet
  • 2022 Oklahoma PDL Booklet 
  • 2022 Tennessee PDL Booklet
  • 2022 Texas PDL Booklet
  • 2022 Virginia PDL Booklet
  • 2022 Washington PDL Booklet
• PreCheck MyScript:  Check current prescription coverage and price, including out-of-pocket prescription costs for UnitedHealthcare members at their selected pharmacy. Get information on lower-cost prescription alternatives, if available, to help save members money.
• Opioid management, overutilization prevention and treatment programs

Training

• UnitedHealthcare Individual Exchange Plans in 2022

Referrals:

• UnitedHealthcare Individual Exchange Referral Fax Form
• UnitedHealthcare Individual and Family Plan Referral Fax form