CurrentUnitedHealthcarePolicy N/A

Exemption requests for zero-cost preventive care medications

Procedures and forms for UnitedHealthcare commercial plan providers to request cost-share exemptions (zero-cost coverage) for preventive medications, including contraceptives and certain non-contraceptive preventive drugs, with instructions for standard and expedited requests and required supporting information.

Policy Summary

PayerUnitedHealthcare

PolicyExemption requests for zero-cost preventive care medications

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete the health care reform copay waiver request form and submit via the specified fax numbers or mail addresses (use expedited fax if urgent) to request a cost-share exemption.

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Form required (health care reform copay waiver request form)

3Submission pathways (contraceptive, non-contraceptive, expedited)

Policy overview

UnitedHealthcare provides processes for providers on its commercial plans to request cost-share exemptions for certain preventive medications that are not listed as zero-cost on its Prescription Drug Lists under the Affordable Care Act. Requests may be for contraceptive or non-contraceptive medications and require completion of the health care reform copay waiver request form with all fields completed. Submission pathways include contacting Optum Rx Prior Authorization by phone or fax for contraceptives, fax or mail for non-contraceptives, and a specific expedited fax number when expedited review is needed.

Exemption request criteria

Standard exemption request requirements

Exemption requests should include evidence from the prescribing health care professional that the medication is medically necessary and include ALL of the following:

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Expedited exemption request criteria

An expedited medication exemption request may be submitted when standard processing time could significantly increase risk to the member's health or ability to regain maximum function; submit same form via expedited fax number.

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Actions required by providers

Prior Authorization

Submit cost-share exemption request for contraceptives

Contact Optum Rx Prior Authorization by calling 800-711-4555 or complete the health care reform copay waiver request form and fax to 844-403-1027 to request a cost-share exemption for contraceptive medications.

Phone: 800-711-4555
Fax: 844-403-1027

Prior Authorization

Submit cost-share exemption request for non-contraceptives

Complete the health care reform copay waiver request form and send it by fax to 801-994-1345 or by mail to UnitedHealthcare PO Box 30573 Salt Lake City, UT 84130-0573 to request a cost-share exemption for non-contraceptive preventive medications.

Fax: 801-994-1345
Mail: UnitedHealthcare PO Box 30573 Salt Lake City, UT 84130-0573

Prior Authorization

Submit expedited cost-share exemption for non-contraceptives

If expedited processing is required because delay could significantly increase risk to the member's health or ability to regain maximum function, complete the health care reform copay waiver request form and fax it to 801-994-1058 to request expedited review.

Expedited fax: 801-994-1058

Documentation Required

Complete required form fields

Ensure all fields on the health care reform copay waiver request form are completed (all fields are required) and include member ID, provider NPI, medication details, indication, prior medication trials, contraindications/intolerances, and any supporting labs or test results.

Member ID
Provider NPI
Medication name, strength, dosage form, directions
Indication/use
Prior medication trials (meds, strengths, length of trial, reason for discontinuation)
Contraindications or intolerances (specify medication and issue)
Supporting labs or test results

Billing Rule

Where to send requests

Send requests via the specified fax numbers or mailing address; follow the specific fax number for contraceptives, standard non-contraceptives, or expedited non-contraceptives as provided.

Contraceptives fax: 844-403-1027 (or call Optum Rx Prior Authorization 800-711-4555)
Standard non-contraceptives fax: 801-994-1345 or mail to UnitedHealthcare PO Box 30573 Salt Lake City, UT 84130-0573
Expedited non-contraceptives fax: 801-994-1058

NPI	National Provider Identifier number (requested on form)
ICD-10	Diagnosis code(s) requested for non-contraceptive medication requests

OpenPayer

Exemption requests for zero-cost preventive care medications

Policy overview

Exemption request criteria

Identifiers and administrative codes

Actions required by providers

Definitions

Document changes