CurrentUnitedHealthcarePolicy N/A

Exemption requests for zero-cost preventive care medications

Describes how UnitedHealthcare commercial plan providers can request exemptions from member cost sharing for preventive medications (contraceptive and select non-contraceptive) and the required documentation and submission channels. Applies to UnitedHealthcare commercial plans.

Policy Summary

PayerUnitedHealthcare

PolicyExemption requests for zero-cost preventive care medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the health care reform copay waiver request form and submit via the appropriate channel (fax, mail, or expedited fax when indicated).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2submission channels listed for non-contraceptive requests (fax, mail)

1phone number for contraceptive exemption requests to Optum Rx PA

1expedited fax number for non-contraceptive requests

1form page referenced (page 2) containing required fields

Coverage Criteria for Exemption

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Exemption coverage criteria

Covered without member cost sharing when ALL of the following are met:

Medical necessity and documentation: Prescribing clinician provides evidence attesting the medication is medically necessary for the patient and specifies intended use.

Form requires attestation (contraceptives) or medical necessity statement (non-contraceptives).

Prior therapies for some non-contraceptives: Where applicable, documentation that the patient has tried alternatives, including medications/strengths, trial duration, and reason for discontinuation.

Required for some non-contraceptive preventive medications.

Contraindications/intolerances and supporting data: If applicable, list medications with associated contraindications or intolerance details and indicate supporting labs or test results.

Include supporting labs or test results when applicable.

Medications that are already included on UnitedHealthcare’s zero-cost preventive care medication lists do not require a cost-share exemption request. Exemption requests are intended only for medications not listed on those zero-cost lists and must include clinical documentation that the prescribing clinician attests the medication is medically necessary.

Definitions and Covered Lists

Zero-cost preventive care medications

DefinitionMedications listed on UnitedHealthcare's Prescription Drug Lists (PDLs) that are covered without member cost sharing under applicable plans.

EligibilityOnly medications NOT already on the zero-cost preventive care medication lists are eligible for an exemption request.

Required supporting evidenceSubmit evidence from the prescribing health care professional attesting that the medication is medically necessary for the patient.

Required information on requestInclude medication details and clinical justification as described on the copay waiver request form.

Applicable plansApplies to UnitedHealthcare commercial plans subject to the Patient Protection and Affordable Care Act provisions.

How Providers Submit Exemption Requests

Prior Authorization

Contraceptive exemption request

To request a cost share exemption for contraceptive medications, contact the Optum Rx Prior Authorization department by calling 800-711-4555, or complete the health care reform copay waiver request form (page 2 of the referenced document) and fax it to 844-403-1027.

Phone: 800-711-4555
Fax: 844-403-1027
Form: Health care reform copay waiver request form (page 2)

Prior Authorization

Expedited request

To request an expedited cost share exemption for non-contraceptive medications when the time needed for a standard review could significantly increase risk to the member's health or ability to regain maximum function, complete the exemption form (page 2) and fax it to 801-994-1058.

Use expedited request only when standard processing could significantly increase health risk or impair recovery
Fax for expedited requests: 801-994-1058
Complete the exemption form on page 2

Denial Risk

Insufficient medical necessity evidence

If the exemption request does not include sufficient medical necessity evidence, it may be denied or returned for more information. For non-contraceptives, include diagnosis ICD-10 code(s), prior medication trials with strengths, trial lengths and reasons for discontinuation, any contraindications or intolerances (with details), and any supporting labs or test results. Provide any additional comments or relevant clinical information to support medical necessity.

Include patient diagnosis and ICD-10 code(s)
List all prior medications tried (include strengths), trial duration, and reason for discontinuation
List contraindications or intolerances to alternative medications with specifics
Include supporting lab or test results when applicable
Provide any additional clinical comments or information

Documentation Required

Required documentation

General information required to request an exemption: an attestation that the medication is medically necessary for the patient, the intended use of the medication by the patient, and for some non-contraceptive preventive medications whether the patient has attempted other alternatives. Refer to the Clinical Pharmacy Prior Authorization, Notification and Medical Necessity Requirements Commercial page for additional information.

Attestation that the medication is medically necessary
Purpose: What the patient will use the medication for
For some non-contraceptive preventive medications: indicate whether alternatives were attempted
See Clinical Pharmacy Prior Authorization, Notification and Medical Necessity Requirements Commercial page for more details

Initial Therapy Request Fields

Initial therapy

Initial medication request fields

Medication details: Provide medication name, strength, dosage form, directions for use, and indicate if requesting a brand medication.

Fields present on the form.

Contraceptive attestation: For contraceptives, attestation that the medication is medically necessary for contraceptive purposes is required.

Yes/No checkbox on the form.

Non-contraceptive diagnosis and prior therapy: Provide ICD-10 diagnosis code(s) and, if applicable, details of prior medications tried including strengths, length of trial, and reason for discontinuation.

Form requests these specifics.

Requirement
For some non-contraceptive preventive medications, indicate prior alternative therapies on the exemption form, including whether the patient has attempted other alternatives.
Specify medications tried, trial duration, and reason for discontinuation or intolerance when applicable on the form.