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.

Note: If you’re in Massachusetts, New York or Nevada, sign in to your health plan account to find your plan-specific pharmacy benefits.

Sign in to see pharmacy benefits for your plan

Sign in to your member account

Try the UnitedHealthcare app for members

Use your mobile device to get instant access to see your prescription drug coverage and benefits.

Learn more about the app for members

Download the UnitedHealthcare app to get instant access to see your benefits, manage your health plan details, find network providers and more.

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Check if your medication is covered

For each plan, there’s a Prescription Drug List (PDL). This is a list of covered prescription medications and supplies. The PDL includes information you need, like:

If your medication is not covered or has a coverage rule or limit, talk to your health care provider. They may be able to ask about a prior authorization or exception to get your medication covered or may switch you to a covered medication that can work for your condition.

Sign in to your health plan account to find your plan specific PDL.

View PDL without signing in to your account.

Find a network pharmacy

There are a couple of ways to fill your prescription medications using your pharmacy benefit. You can choose the option that works best for your situation.

1. Choose a network retail pharmacy

With locations available across the country, it’s likely you can find a network retail pharmacy near where you live. If you’re traveling or live out of state for school, you can also find a network pharmacy near where you are. To switch pharmacies, call your new pharmacy and ask them to transfer your prescription.

Find a network pharmacy

2. Get prescriptions delivered by Optum Home Delivery Pharmacy

You can also choose Optum Home Delivery Pharmacy. With this option, your prescriptions can be delivered directly to you. Ask your health care provider to send a prescription to Optum Home Delivery Pharmacy. Then, you can sign in to check status and set up payment.

Check the price for a drug

When your plan becomes effective, you can check the price of a drug to see if it’s covered and estimate your costs. You can also look for lower cost alternatives if they’re available. Your health care provider can find drug prices and alternatives as well, by using PreCheck MyScript.

Sign in to your health plan account to find the price of a drug.

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.
Sign in to your member account to view your plan details

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 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.

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.

Browse common pharmacy terms

Looking for more resources?

Sign in to your health plan account to find more plan-specific information about your pharmacy benefits.

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