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