Pharmacy benefits for members with UnitedHealthcare Individual & Family ACA Marketplace plans
As you’re getting started with using your pharmacy benefits, it may help to get guidance on how it all works. Explore the tips below to learn how to use your pharmacy benefit if you’re a member with a UnitedHealthcare Individual & Family Affordable Care Act (ACA) Marketplace plan in one of these following states:
- Arizona
- Alabama
- Colorado
- Florida
- Georgia
- Illinois
- Kansas
- Louisiana
- Maryland
- Michigan
- Missouri
- Mississippi
- North Carolina
- New Jersey
- New Mexico
- Ohio
- Oklahoma
- South Carolina
- Tennessee
- Texas
- Virginia
- Washington
- Wisconsin
- Arizona
- Alabama
- Colorado
- Florida
- Georgia
- Illinois
- Kansas
- Louisiana
- Maryland
- Michigan
- Missouri
- Mississippi
- North Carolina
- New Jersey
- New Mexico
- Ohio
- Oklahoma
- South Carolina
- Tennessee
- Texas
- Virginia
- Washington
- Wisconsin
Frequently asked questions (FAQs) about pharmacy benefits for Individual and Family ACA Marketplace plans
Welcome to your new plan. Here are some steps you can take as you get started using your pharmacy benefits.
- Review your plan benefit documents to learn about your pharmacy coverage. This includes information about deductibles, co-payment, co-insurance and out-of-pocket maximums.
- Check if your medications are covered. Call the number on your member ID card if:
- You need help understanding your medication coverage
- You run out of mediation before you can talk to your healthcare provider about a drug that’s not covered
- Find a network pharmacy. If your pharmacy is part of our network, let them know you have new insurance. If your pharmacy is not part of our network, ask your new pharmacy to transfer your prescription.
Your plan covers certain medications at no cost to you when filled at a network pharmacy. This includes some preventive medications. View these lists to learn more:
Here are some tips that may help you save on your prescription medications.
- Choose a medication in Tier 1 or Tier 2 for your lowest cost options. If your medication is in a higher tier, you may pay more. Ask your health care provider if a lower cost medication can work to treat your condition.
- Check the price of a drug to find your lowest cost options. For maintenance medications, ordering a 3-month supply may save you money.
- Some medications are available at a lower cost if you meet certain requirements. Find more details about how to search for medications and see PDLs by state. This will help you see which medications are eligible. Examples include medications used for HIV (human immunodeficiency virus) prevention or breast cancer prevention.
- Check the manufacturer’s website for savings programs or coupons.
There are 2 ways to manage prescription payments.
- You can save money by using a network pharmacy. Simply ask your pharmacy to submit the prescription electronically.
- You can submit a reimbursement form.
Sometimes unexpected situations happen, and you may need to use a pharmacy that’s not in the network. If that happens, use the mail-in forms to let us know the situation and ask for coverage for your prescription.
- Check if another network pharmacy can fill your medication
- Ask your health care provider about other medications that can treat your condition
- If your generic medication is unavailable but your pharmacy can fill the brand name medication, ask your pharmacy to contact Optum Rx at the number listed on your health plan ID card
Common pharmacy terms
When you’re using your pharmacy benefits, you may hear terms that are unfamiliar, like prior authorization, step therapy or quantity limits. You can find some quick definitions to help you know what these may mean for your benefits and payments.
Looking for more resources?
Sign in to your health plan account to find more plan-specific information about your pharmacy benefits.