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
- Iowa
- Illinois
- Indiana
- Kansas
- Louisiana
- Maryland
- Michigan
- Missouri
- Mississippi
- Nebraska
- North Carolina
- New Jersey
- New Mexico
- Ohio
- Oklahoma
- South Carolina
- Tennessee
- Texas
- Virginia
- Washington
- Wisconsin
- Wyoming
- 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 medication 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.
Tiers are the different cost levels you pay for a medication. A medication is assigned to a tier based on factors such as a medication’s effectiveness, safety, cost, and the availability of alternative medications to treat the same or similar medical condition. Each tier is assigned a cost, and you can find cost-sharing information in your plan documents. This determines how much you will pay when you fill a prescription at a network pharmacy.
Using lower-tier medications can help you pay the lowest out-of-pocket cost. If you are prescribed a medication on a higher tier, you can ask your healthcare provider if a lower-tier medication can work for your condition.
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:
Plan year 2024
Plan year 2025
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 for 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 human immunodeficiency virus (HIV) prevention or breast cancer prevention.
- Check the manufacturer’s website for savings programs or coupons.
Yes, your plan covers certain preventive vaccines at no cost to you. You can get vaccines from a healthcare provider, including a pharmacist. View your PDL to find vaccines your plan covers and find a network pharmacy that offer vaccines.
Sometimes unexpected situations happen, and you may need to use a pharmacy that’s not in the network. If that happens, submit a reimbursement online or by mail 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
You may see the name Optum Rx on your prescription benefits. This is the UnitedHealthcare pharmacy service provider. Optum Rx offers coverage through a large network of retail chain pharmacies and independent pharmacies. It also offers coverage through its mail order pharmacy, Optum Home Delivery Pharmacy.
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.