The Patient Protection and Affordable Care Act allows health care professionals to request exemptions from cost sharing plan requirements for certain preventive care medications. Requesting a cost share exemption for contraceptive medications To request a cost share exemption, please contact the Optum Rx® Prior Authorization department by calling 800-711-4555, or complete the health care reform copay waiver request form on page 2 of this document and fax it to 844-403-1027.
Requesting a cost share exemption for non-contraceptive medications Resources
To request an exemption, please complete the health care reform copay waiver The Prescription Drug Lists request form on page 2 of this document and send it to us using one of the (PDLs) page at myuhc.com® following options: includes lists of zero-cost • Fax: 801-994-1345 preventive care medications. • Mail: UnitedHealthcare P.O. Box 30573 Salt Lake City, UT 84130-0573
Requesting an expedited cost share exemption for non-contraceptive medications
You may request an expedited medication exemption request if the time needed to complete a standard exemption request could significantly increase the risk to the member’s health or ability to regain maximum function. To request an expedited exemption, please complete the form on page 2 and fax it to us at 801-994-1058.
Information required to request an exemption
If a medication isn’t on one of our zero-cost preventive care medications lists, you may submit an exemption request for us to cover it without cost sharing. These exemption requests should have evidence from the prescribing health care professional that the medication is medically necessary and include the following information: • What the patient will use the medication for • Attestation that the medication is medically necessary for the patient – For some non-contraceptive preventive medications, please include whether the patient has attempted other alternatives. Addition information can be found on our Clinical Pharmacy Prior Authorization, Notification and Medical Necessity Requirements – Commercial page.
PCA-1-23-03353-Clinical-FM_10042023 Health care reform copay waiver request form All fields are required. Please do not save this form for future use, as we update it often.
Member information Provider information
Name: Name: Member ID number: National provider identifier (NPI) number: Specialty:
Date of birth: Office phone:
Street address: Office fax:
City: State: ZIP code: Office street address:
Phone: City: State:
Medication information Medication name: Strength: Dosage form:
Check if requesting a brand medication Directions for use:
Check if requesting continuation of therapy Clinical information For contraceptives: Do you attest that the medication you’re requesting is medically necessary for contraceptive purposes? Yes No For non-contraceptives: What’s the patient’s diagnosis for the medication you’re requesting? ICD-10 code(s):
If applicable, what medication(s) has the patient tried and had an inadequate response to? Please specify all medication(s)/strengths tried, length of trial and reason for discontinuation of each medication.
If applicable, what medication(s) does the patient have a contraindication or intolerance to? Please specify all medication(s) with the associated contraindication to or specific issues resulting in intolerance to each medication.
If applicable, please indicate if there are supporting labs or test results:
If you have additional comments or information, including diagnoses, symptoms or medications attempted or failed, please provide them here:
This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of UnitedHealthcare. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, UnitedHealthcare of New York, Inc., UnitedHealthcare Insurance Company of New York, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Pennsylvania, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc., UnitedHealthcare of Washington, Inc., Optimum Choice, Inc., Oxford Health Insurance, Inc., Oxford Health Plans (NJ), Oxford Health Plans (CT), Inc., All Savers Insurance Company, Tufts Health Freedom Insurance Company or other affiliates. Administrative services provided by OptumHealth Care Solutions, LLC, OptumRx, Oxford Health Plans LLC, United HealthCare Services, Inc., Tufts Health Freedom Insurance Company or other affiliates. Behavioral health products provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH), or its affiliates.
