New 2026 UnitedHealthcare Individual Exchange plan information

On Jan. 1, 2026, we’ll be offering UnitedHealthcare Individual Exchange plans¹ in 30 states. We’ll also be expanding the service area in 11 states.*

Final plan designs, benefits, cost shares and service areas for plan year 2026 are pending regulatory approval and subject to change. Please refer to our UnitedHealthcare Individual Exchange plan resources for the latest available information.

Important changes for Texas UnitedHealthcare Individual Exchange plans

In Texas, we’re now offering new plans featuring a capitated primary care group called Sanitas Medical Group in the San Antonio area. We’ll continue to offer the Kelsey-Seybold capitated network plans in the Houston area. More information on these plans can be found in the Interactive Guide or the Texas Quick Reference Guide for Exchanges.

Important changes for Massachusetts and New York UnitedHealthcare Individual Exchange plans

We’re excited to share that the UnitedHealthcare Massachusetts Individual Exchange plans (Navigate) and New York Individual Exchange Plans (Compass) will be migrate to a new claim’s platform on Jan. 1, 2026. This means your remits may look a bit different going forward. In addition, the claims appeal addresses for these states and plans will change to: 

Massachusetts and New York medical, OBH, dental or vision appeals information

For Massachusetts and New York medical, OBH, dental or vision cases, submit appeals to:

UnitedHealthcare

P.O. Box 6111

Mail Stop CA-0197

Cypress, CA 90630

Standard fax: 888-404-0949

Expedited fax: 888-808-9123 

UnitedHealthcare Provider Portal

Massachusetts and New York pharmacy appeals information

For pharmacy cases, if the appeal or non-formulary exception is prior to Jan. 1, 2026, and the member doesn’t have coverage after Jan. 1, 2026, submit appeals to:

UnitedHealthcare

P.O. Box 6111

Mail Stop CA-0197

Cypress, CA 90630

Standard fax: 888-404-0949 

Expedited fax: 888-808-9123 

UnitedHealthcare Provider Portal

For pharmacy cases, if the appeal or non-formulary exception is prior to Jan. 1, 2026, and the member has coverage after Jan. 1, 2026, submit appeals to:

Optum Rx

c/o Appeals Coordinator

P.O. Box 2975

Mission, KS 66201

Pharmacy fax: 877-239-4565

Pharmacy portal (If the initial prior authorization was originally submitted on CoverMyMeds)

Additional prior authorization information

Visit the list of codes requiring prior authorization for all UnitedHealthcare Individual Exchange plans.

Prepare for 2026 plan members

To help ensure your practice is ready to see these members in 2026, visit our UnitedHealthcare Individual Exchange plans resources to access:

• The new 2026 Individual Exchange plans self-paced interactive guide
• State-specific plan information
• Coverage determination guidelines
• Medical and reimbursement policies
• Pharmacy information
• Prior authorization/notification and referral requirements

You can also prepare by completing the following steps:

• Share information with your staff about your participation and referral requirements 
  • In most states,² these plans don’t require a referral from an in-network primary care provider (PCP) for a member to see a specialist³
  • Members must select a PCP to help coordinate their care, or we’ll assign them a PCP after 30 days
• Modify your business processes to recognize referral-required plans, if applicable
• Confirm that your staff has access to submit referrals and check referral statuses, if applicable
• Review the prior authorization list at: Advance Notification and Clinical Submission Requirements
• Review our UnitedHealthcare Individual Exchange Medical & Drug Policies and noting that we’ll conduct site of service medical necessity reviews for all procedures/codes

Questions? We’re here to help.

If you have questions, visit our Individual Exchange plans resources, contact your provider advocate or connect with us through chat 24/7 in the UnitedHealthcare Provider Portal.