UnitedHealthcare health plans are offered by United Healthcare Insurance Company. We (and other private insurance companies) work with federal and state agencies to provide government-sponsored health insurance. We are not part of Medicare. We work with the Centers for Medicare & Medicaid Services (CMS) and many state governments to provide health coverage for Medicare and Medicaid recipients. Show
Disenrollment from a Medicare Advantage (Part C) or Medicare prescription drug (Part D) plan may occur automatically if you:
ou may also be disenrolled for "disruptive behavior." Disruptive behavior is defined as behavior that substantially impairs UnitedHealthcare's ability to arrange or provide care for you or other plan members. Other Medicare prescription drug plan sponsors may decline your enrollment if you have been disenrolled for disruptive behavior. In all cases of disenrollment, your plan is required to provide proper notice to you and give you the opportunity to appeal the decision prior to disenrollment. You can request disenrollment from your Medicare Advantage (Part C) plan, your Medicare Special Needs plan (SNP) or Medicare prescription drug (Part D) plan and switch to Original Medicare (Parts A and B) online or by mail/fax:
Prescription Drug Coverage Determinations, Appeals and GrievancesTo make your own requestCallContact UnitedHealthcare or call the number on your member ID card. Have this information ready:
Mail / FaxDownload the form below and mail or fax it to UnitedHealthcare: Mail: OptumRx Prior Authorization Department
Medicare Part D Coverage Determination Request Form (PDF) (387.51 KB) (for use by members and doctors/providers)
OnlineLog on to www.optumrx.com to submit a request.
To have your doctor make a requestYour doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request. The plan’s decision on your request will be provided to you by telephone and/or mail. In addition, the initiator of the request (your doctor or provider) will be notified by telephone and/or fax. Your doctor can also request a coverage decision by going to OptumRx Prior Authorization. When to expect a decision from UnitedHealthcareTiming of the coverage decision depends on the type of request. Type of RequestTiming of Coverage DecisionStandard Request for Part D Benefits Within 72 hours after receipt of your request or your doctor's supporting statement (if required) Expedited Request for Part D Benefits – if you or your doctor believe your health will be harmed by waiting 72 hours Within 24 hours after receipt of your request or your doctor's supporting statement (if required) Current drugs not on your drug list in the upcoming 2023 plan year If the request is made after October 15, 2022 and the exception is approved before January 1, 2023, you'll be able to get the drug at the start of the new plan year Within 14 calendar days after receipt of your request What to do while waiting for a coverage decisionIn some situations, UnitedHealthcare will cover a one-time, temporary supply of a needed prescription. While you're getting a temporary supply of a drug, talk with your doctor to decide what to do when your temporary supply runs out. You could switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. If you're a member and you already completed the coverage determination process for your medications in 2022, you may not have to do it again. Look for the approved through date on your approval letter. This will tell you when your approval expires. After the expiration date on your approval letter, you'll need to get a new approval to continue covering the drug—if the drug still requires review and you and your doctor feel it's needed. To ask about the status of any coverage decision, call the number on your member ID card. What happens if UnitedHealthcare denies your request?If UnitedHealthcare denies your request, you'll get a written reply explaining why. If an initial decision doesn't give you everything that you requested, you have the right to appeal the decision. See
How to appeal a coverage decision. When to appeal a coverage decision How to appeal a coverage decision How to file an appeal When will UnitedHealthcare decide on your appeal? If UnitedHealthcare makes a coverage decision that you're not satisfied with, you can "appeal" the decision. When you make an appeal, the Medicare Part D Appeals and Grievance Department reviews the coverage decision to check to see if all of the rules were properly followed. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When to appeal a coverage decisionYou have a limited amount of time to appeal a coverage decision. You'll need to submit your appeal:
Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe. How to appeal a coverage decisionAppeal Level 1 – You can ask UnitedHealthcare to review an unfavorable coverage decision—even if only part of the decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination." Information on how to file an Appeal Level 1 is included in the unfavorable coverage decision letter. If UnitedHealthcare doesn't make a decision within 7 calendar days, your appeal will automatically move to Appeal Level 2. Appeal Level 2 – If UnitedHealthcare reviewed your appeal at Appeal Level 1 and didn't decide in your favor, you have the right to appeal to the Independent Review Entity (IRE). How to file an appealWhen you file an appeal, include any paperwork that may help UnitedHealthcare research your case. Also, make sure to provide your name, your member identification number, your date of birth, and the drug you need. Mail or FaxWrite a letter describing your appeal or use the Redetermination Request Form (PDF) (67.62 KB). Mail or fax the letter or completed form to UnitedHealthcare. Mail: Medicare
Part D Appeals and Grievances Department Fax: 1-866-308-6296 OnlineCall (Expedited)When will UnitedHealthcare decide on your appeal?Timing of the appeal answer depends on the type of request. Type of RequestTiming of Appeal AnswerReimbursement for a Part D drug you have paid for and received
Appeal review requests for drugs you have not yet received
Expedited (fast) request for Part D drug that you have not yet received
How to file a grievance When will UnitedHealthcare give you an answer? A grievance is a complaint. The complaint process is only used for certain types of problems. This includes problems related to quality of care, waiting times, and the service you receive. You need to file the grievance (complaint) within 60 calendar days of the item you want to complain about—whether by phone or writing to UnitedHealthcare. Filing a grievance isn't the same as a request for a coverage decision. Grievances don't involve problems related to approving or paying for Medicare Part D drugs. Some types of problems that can lead to filing a grievance include:
How to file a grievanceIf you have a complaint (grievance), contact UnitedHealthcare or call the number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on your member ID card. UnitedHealthcare will try to resolve your complaint over the phone. If you prefer to write UnitedHealthcare—or you called and weren't satisfied—you can send it to us. If you're filing a grievance because your request for a "fast coverage decision" or a "fast appeal" was denied, you’ll automatically get a "fast" complaint. Be sure to include the words "fast", "expedited" or "24-hour review" on your request. You can also call the number on your member ID card to file an expedited grievance. Submit a written request for a grievance by completing the Medicare Plan Appeals & Grievances Form (PDF) (760.99 KB) and mailing or faxing it. Medicare Part D Appeals and Grievance Department FaxIf you ask for a written response, file a written grievance, or if your complaint is related to quality of care, UnitedHealthcare will respond in writing. When will UnitedHealthcare give you an answer?Timing of the response depends on the type of request. Type of RequestTiming of Coverage Decision
Expedited (fast) complaint
If UnitedHealthcare doesn't agree with some or all of your complaint or doesn't take responsibility for the problem you've made a complaint about, we'll let you know. The response will include the reasons for the answer. UnitedHealthcare must respond whether or not we agree with the complaint. An authorized representative is someone you name that can help with your coverage determinations, appeals, and grievances. The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during a period of time. Download the representative form. Both you and the person you name as your authorized representative must sign the form. Send this form to UnitedHealthcare. For Coverage DeterminationsOptumRx Prior Authorization Department For AppealsMedicare Part D Appeals and Grievance Department If your prescribing doctor calls on your behalf, no representative form is required. Formulary (drug list) change notice Drug requirements and limitations Quality assurance policies and procedures Formulary (drug list) change noticeEvery Medicare Part D plan has a drug list, but the drug list may change during the plan year. An immediate substitution of a generic drug can occur at any time of the year. A retrospective Immediate Generic Substitution member letter is sent to notify the member of the change. For other changes a Notice of Formulary Changes is a formal notification that is provided to members. The Notice is posted at least 30 days prior to the removal of a drug or a change in the preferred or tiered cost-sharing status a drug. Both the Immediate Generic Substitution letter and the posting include:
Back to top Drug requirements and limitationsFor certain prescription drugs, there are special rules for how and when the plan covers them. A team of doctors and pharmacists developed these rules.
If your drug has a restriction, it usually means that you (or your doctor) will have to use the coverage decision process and ask UnitedHealthcare to make an exception. The restriction may or may not be waived. NOTE: If you don't get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug. Find out if your drug has any restrictions by looking for the abbreviations next to the drug names in the plan's drug list (also known as a formulary) To find the drug list for a specific plan, use the Plan Documents Search Tool. Drug restrictions apply to retail and mail service. These may include:Prior Authorization (PA)The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug. Quantity Limits (QL)The plan will cover only a certain amount of this drug, or a cumulative amount across a category of drugs (such as opioids), for one copay or over a certain number of days. These limits are in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity. Step Therapy (ST)There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug. Medicare Part B or Medicare Part D Coverage Determination (B/D)Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare. IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES. You (and your doctor) can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make. Formulary Exceptions
Cost-Sharing Exceptions
Generally, the plan will only approve your request for an exception if your doctor provides information that the alternative drugs included in the plan's formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. Quality assurance policies and proceduresThe Utilization Management/Quality Assurance (UM/QA) program helps ensure safe and appropriate use of prescription drugs covered under Medicare Part D. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers. This program focuses on:
Utilization management The UM/QA program has utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits, and step therapy. Quality assurance As part of the UM/QA program, all prescriptions are screened by drug utilization review systems to detect and address the following clinical issues:
The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution. In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use. If you would like to provide feedback regarding your Medicare plan, you can contact Customer Service toll-free at 1-877-699-5710 (TTY: 711), 8 a.m. – 8 p.m., 7 days a week or you can provide feedback directly to Medicare through their Complaint Form about your Medicare health plan or prescription drug plan. |