CurrentUnitedHealthcarePolicy PCA-1-25-01932-M&R-QRG_09252025

Pharmacy authorizations and exceptions — UnitedHealthcare Individual Exchange plans

Governance of prior authorization, step therapy, quantity limits, opioid safety edits, and exception requests for medications under UnitedHealthcare Individual Exchange (Individual & Family ACA Marketplace) plans, excluding Nevada. Affects prescribers, pharmacies, and members covered by these plans.

Policy Summary

PayerUnitedHealthcare

PolicyPharmacy authorizations and exceptions — Individual Exchange plans

Policy CodePolicy PCA-1-25-01932-M&R-QRG_09252025

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization or exception requests to Optum Rx with required supporting documentation (diagnosis, medication history, clinical justification, medical records/lab tests) via the online portal, phone, or fax.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Optum Rxpharmacy benefit manager processing requests

800-711-4555prescriber prior authorization phone line

844-403-1027fax number for PA requests

Excludes NVstate applicability exception

Varies

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Coverage and Eligibility Rules

Covered with prior authorization and policy compliance

Medications are covered subject to plan-specific prior authorization, step therapy, quantity limits, opioid safety edits, and formulary status when ALL of the following plan processes are satisfied:

Plan administrative requirements: Provider submits required prior authorization or exception request to Optum Rx with supporting documentation (diagnosis, medication history, clinical justification, medical records/lab tests).

See submission methods and potential denial for missing information (Optum Rx processing).

Formulary and limits: Drug is on the plan formulary or an approved non-formulary exception is granted; does not exceed quantity limits or opioid safety edits unless an exception is approved.

Includes compounded medications, 7-day supply limit for members without recent opioid fills, and MME-based opioid limits.

Step therapy and prior authorization: If the drug is subject to step therapy, required prior steps must be completed per plan rules; certain medications require prior authorization as listed by the plan.

Some medications require prior authorization including compounded medications, drugs exceeding quantity or opioid safety edits, and non-formulary drugs.

Clinical policy compliance: Coverage decisions follow UnitedHealthcare clinical policies approved by the Pharmacy and Therapeutics Committee; when clinical policy requirements are not met, a pharmacist or medical director will make the final determination.

Access state-specific clinical criteria and policies on the Individual Exchange plans page.

Plan-level utilization controls: Coverage is also subject to plan-level prior authorization, step therapy, quantity limits, and opioid safety edits implemented by the plan and administered by Optum Rx.

Includes opioid 7-day supply limit and MME thresholds per plan/state rules.

This guide applies to UnitedHealthcare Individual Exchange plans but does not apply to plans in Nevada. Providers and pharmacies should confirm state applicability before submitting prior authorization or exception requests for members in the Individual Exchange product line.

Coding and Safety Thresholds

Opioid safety edits / MME

MME thresholdsOpioid use that exceeds the established morphine milligram equivalent (MME) level is subject to opioid safety edits; exact MME values are established per plan and state rules (values not specified in this document).

Relation to state rulesMME thresholds are determined in accordance with plan-specific and state-specific rules; providers should consult the member's plan and applicable state requirements for exact limits.

Impact on coveragePrescriptions exceeding established MME thresholds may require prior authorization or an exception for coverage to be approved.

7-day supply opioid limit

7-day supply limitA 7-day supply limit applies for members who have not filled an opioid prescription recently; such fills are subject to prior authorization or exception if limits are exceeded.

Applicability

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Certain medications require prior authorization or an exception before they will be covered. This includes compounded prescriptions, drugs that require step therapy, medications that exceed quantity limits or opioid safety edits, non‑formulary drugs, and medications that may be covered only when specific preventive requirements are met.

Compounded prescription medications
Medications subject to step therapy
Drugs that exceed quantity limits
Medications exceeding opioid safety edits or MME thresholds
7‑day opioid supply limit for members without recent opioid fills
Non‑formulary drugs (not listed on the PDL)
Preventive medications that are covered only when specific criteria are met

Step Therapy

Step Therapy May Be Required

Policy Background

This document is administrative guidance describing how prior authorization and exception requests are processed for UnitedHealthcare Individual Exchange pharmacy benefits. It explains that certain medications require prior authorization or an exception and that Optum Rx is the pharmacy benefit manager that processes those requests; it also summarizes submission methods and supporting documentation expectations.

Providers must submit required prior authorization or exception requests to Optum Rx with supporting documentation such as diagnosis, medication history, clinical justification, and relevant medical records or lab tests. Optum Rx may request additional information and can deny requests if required information is not provided.

Some medications are subject to step therapy, quantity limits, and opioid safety edits (including 7-day supply limits and morphine milligram equivalent thresholds). Coverage depends on meeting plan-specific formulary and clinical policy requirements; when clinical policy is not met, a pharmacist or medical director may make the final determination.

Requests may be submitted via the Optum prior authorization prescriber portal, by calling the Optum Rx prescriber prior authorization line, or by fax. Providers should follow plan-specific submission instructions and be aware that state decision timeframes may vary.

Step Therapy Requirements

Requirement	When it applies	Provider action	Coverage status
Prior authorization
Medications listed by the plan that require prior authorization, including compounded prescriptions
Submit prior authorization or exception request to Optum Rx with supporting documentation (diagnosis, medication history, clinical justification, medical records/lab tests)
Coverage available when prior authorization or approved exception is granted
Step therapy
Drugs identified by the plan as subject to step therapy
Complete required step-therapy trials per plan rules or request an exception
Coverage for later-line agents requires completion of or exemption from step therapy
Quantity limits / opioid safety edits
Medications exceeding quantity limits, 7-day opioid supply for members without recent fills, or exceeding established MME thresholds
Request an exception or prior authorization if prescribing beyond limits; provide clinical justification
Coverage only if an approved exception or prior authorization is granted
Non‑formulary drugs
Drugs not listed on the plan prescription drug list (PDL)
Request non‑formulary exception through Optum Rx; include required documentation
Coverage possible with approved non‑formulary exception

Quantity Limits and Opioid Policies

Opioids (general)

7-day supply ruleOpioids (general): a 7-day supply limit applies for members who have not filled an opioid prescription recently.

MME-based limitsAdditional limits apply for opioid use that exceeds the established morphine milligram equivalent (MME) level; exact MME values are set by plan and state rules.

Prior authorization/exceptionPrescriptions exceeding the 7-day supply or established MME thresholds may require prior authorization or an exception for coverage.

Formulary considerationOpioids not listed on the prescription drug list (PDL) may also require an exception in addition to meeting quantity or MME limits.