A coverage determination (coverage decision) is a decision UnitedHealthcare makes about your benefits and coverage, or about the amount UnitedHealthcare pays for your prescription drugs under the Part D benefit in your plan.
In some cases, UnitedHealthcare may decide a drug isn’t covered or is no longer covered by Medicare for you. If you (or your doctor) don’t agree with our coverage decision, you (or your doctor) can file an appeal.
How to request a coverage determination (coverage decision)
Your doctor can request a coverage determination (coverage decision) for you, or you can request a coverage determination yourself.
If you're a new user to www.optumrx.com, you'll need to register first.
After you register, look for the Prior Authorization tool under Benefits and Claims > Prior Authorization.
When you submit your request, OptumRx will attempt to contact your doctor to get a supporting statement and/or additional clinical information needed to make a decision.
To have your doctor make a request
Your 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.
In 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 2020, 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 the back of your member ID card.
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 decision
You have a limited amount of time to appeal a coverage decision. You'll need to submit your appeal:
within 60 days of the date the unfavorable determination was issued or
within 60 days from the date of the denial of reimbursement request.
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.
Appeal 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).
When 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.
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:
Issues with the service you receive from Customer Service.
If you feel that you are being encouraged to leave (disenroll from) the plan.
If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
We don't give you a decision within the required time frame.
We don't give you required notices.
You believe our notices and other written materials are hard to understand.
Waiting too long for prescriptions to be filled.
Rude behavior by network pharmacists or other staff.
We don't forward your case to the Independent Review Entity if we do not give you a decision on time.
How to file a grievance
If 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 the back of 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 the back of your member ID card to file an expedited grievance.
Timing of the response depends on the type of request.
Type of Request
Timing of Coverage Decision
Over the phone, your complaint will be resolved immediately, if possible
Most complaints are answered in 30 calendar days
If more information is needed or if you ask for more time, it can take up to 14 more calendar days to answer
Expedited (fast) complaint
You'll receive an answer within 24 hours
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 Determinations
OptumRx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Medicare Part D Appeals and Grievance Department
P.O. Box 6106, M/S CA 124-0197
Cypress, CA 90630
If your prescribing doctor calls on your behalf, no representative form is required.
Every 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:
The name of the affected covered Medicare Part D drug.
Information on whether the covered Medicare Part D drug is being removed from the formulary, or changing its preferred or tiered cost-sharing status.
The reason the covered Medicare Part D drug is being removed from the formulary, or changing its preferred or tiered cost-sharing status.
Alternative drugs in the same therapeutic category, class or cost-sharing tier, and the expected cost sharing for that drug.
How members may get an updated coverage determination or an exception to a coverage determination.
For certain prescription drugs, there are special rules for how and when the plan covers them. A team of doctors and pharmacists developed these rules.
Helps members use drugs in the most effective ways.
Helps control overall drug costs, to keep drug coverage more affordable.
Helps ensure safe, effective and affordable drug use.
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.
You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred drug copay will apply. You can't ask for an exception to the copayment or coinsurance amount you're required to pay for the drug.
If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
Drugs in some of our cost-sharing tiers aren't eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's drug list, we can't lower the cost-sharing amount for that drug. In addition:
Tier exceptions aren't available for drugs in the Specialty Tier.
Tier exceptions aren't available for drugs in the Preferred Generic Tier.
Tier exceptions aren't available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that doesn't contain branded drugs used for your condition.
Tier exceptions aren't available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs used for your condition.
Tier exceptions may be granted only if there are alternatives of the same type (branded, generic, biological drugs) in the lower tiers used to treat the same condition as your drug.
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.
The 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:
reducing adverse drug events and drug interactions
optimizing medication utilization and
providing incentives to reduce costs when medically appropriate.
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.
As part of the UM/QA program, all prescriptions are screened by drug utilization review systems to detect and address the following clinical issues:
Morphine Milligram Equivalent (MME) limits
Opioid day supply limits (7-day supply)
Therapeutic dose limits
Clinically significant drug-drug and drug-disease interactions
Inappropriate dosage or duration of therapy
Patient-specific drug contraindications (e.g., based on gender or age)
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.