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

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 non-formulary drugs or are not covered on the prescription drug list (PDL)
• Could be covered at $0 due to health care reform when used for prevention and specific requirements are met
  • This includes birth control (contraceptives) and HIV pre-exposure prophylaxis (PrEP)

Submitting prior authorization or exception requests

OptumRx, our Pharmacy Benefit Manager, processes prior authorization and exception requests on behalf of UnitedHealthcare Individual Exchange Plans. Health care professionals 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.

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 health care professional 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. 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.