MA Pharmacy - Chapter 7, 2018 UnitedHealthcare Administrative Guide

Pharmacy Network

A member may fill prescriptions from any network pharmacy in the Pharmacy directory or online at optumrx.com.

Reimbursement for prescriptions from a non network pharmacy may be available to some members without of network coverage.

MA Prescription Drug Formulary

We utilize the United States Pharmacopoeia’s drug classification system for development of the Formulary for MA.

The Pharmacy & Therapeutics Committee conducts formulary development and oversight. The committee is also responsible for identifying safe, cost-effective and medically appropriate drug therapies that reflect community and national standards of practice

MA Formulary Tier Structure

The MA Prescription Drug Formulary is a list of drugs that are covered as a pharmacy plan benefit for MA members. 

For non-group plans, we categorize medications into five tiers:

  • Tier 1: Preferred generic drugs
  • Tier 2: Non-preferred generic drugs
  • Tier 3: Preferred brand-name drugs
  • Tier 4: Non-preferred drugs
  • Tier 5: Specialty drugs

For group plans, several formularies are available. Medications are often categorized into four tiers:

  • Tier 1: Preferred generic drugs
  • Tier 2: Preferred brand-name drugs
  • Tier 3: Non-preferred drugs
  • Tier 4: Specialty drugs

For MA Prescription Drug Formulary information, see AARPMedicarePlans.com, UHCMedicareSolutions.com, or UHCprovider.com. If a drug is not on our formulary, you might be able to switch the member to a different drug that we do cover, or you can request a formulary exception. While we are evaluating the exception, we may provide members with a temporary supply.

MA Prescription Drug Benefit

UnitedHealthcare offers several prescription drug coverage plans based on the member’s county of residence and the member’s prescription drug needs. The benefit structure follows the CMS model:

  • Prescription Drug Deductible — some benefit plans have a deductible the member must meet before getting access to the prescription drug benefit. In some plans, this deductible will only apply to specific drug tiers, (e.g., Tier 3, Tier 4 and Tier 5 only). 
  • Initial coverage limit — During this period the member is responsible for a specific copayment or coinsurance for prescription drugs. 
  • Coverage gap — While in the coverage gap, the member will pay 35% of the total cost of brand-name drugs and 44% of the total cost of generic drugs in 2018. Coverage plans vary and the member may pay less if their plan offers additional coverage in the coverage gap.
  • Catastrophic coverage level — Members who reach this level will have a significantly lower copayment/coinsurance for prescription drugs, until the end of the year.

Prescriptions for a non-formulary or non-covered drug are not covered unless the member or the member’s care provider requests and receives an approved formulary exception through the prior authorization process.

The member pays 100% of our contracted rate with the pharmacy. This process does not apply to excluded medications.

Refer to the exceptions process described below for the criteria for coverage of a non-formulary or non-covered drug.

MA Part D Members

OptumRx follows the coverage determination timelines as established by CMS. We must complete standard coverage determinations within 72 hours. OptumRx must complete expedited coverage determinations within 24 hours. Turnaround time varies by case type, and may be extended beyond the initial 24 or 72 hours if there are incomplete service level agreements (SLAs) as agreed upon by the specific benefit plan and CMS.

OptumRx will ask for more information from the physician, or their designee, and the member if needed, and sends notification of the resulting case decision.

Different types of requests include:

  • Prior Authorization (PA)
  • Medicare Part B vs Medicare Part D
  • Non-Formulary Exception (NF)
  • Step Therapy (ST)
  • Quantity Limit (QL)
  • Tier Cost Sharing Exception (TCSE)*

Tier Cost Sharing Exception rules vary by specific benefit plan and available alternatives. Criteria for copayment reduction TCSE are:

  • The requested drug is FDA-approved for the condition being treated; or 
  • One of the following:
    • Diagnosis is supported as a use in AHFS under the Therapeutic Uses section; or
    • Diagnosis is supported in the Therapeutic Uses section in DRUGDEX Evaluation with a Strength of Recommendation rating of IIb or better; or
    • Diagnosis is listed in the Therapeutic Uses section in DRUGDEX Evaluation and carries a Strength of Recommendation of III or Class Indeterminate; and Efficacy is rated as “Effective” or “Evidence Favors Efficacy”; and
    • History of failure, contraindication, or intolerance to all formulary alternatives in the lower qualifying tiers.

MA Coverage Limitations

For some drugs we may require authorization before the drug can be prescribed (prior authorization), we may limit the quantity that can be prescribed per prescription (quantity limits), or we may require that you prescribe drugs in a sequence (step therapy), trying one drug before another drug.

We provide an exception process to allow for the chance the formulary may not accommodate the unique medical needs of a member. To make an exception to these restrictions or limits, fill out and submit a prior authorization form available on professionals.optumrx.com > Prior Authorizations > Fax Forms

More information about requirements is available at professionals.optumrx.com > Resources > Formulary Lists or by calling our Pharmacy department.

Part B Covered Drugs

Drugs covered under Part B are typically administered and obtained at the care provider’s office. For example, certain cancer drugs, administered by a physician in their office; insulin when administered via pump and diabetes test strips.

Diabetes Monitoring Supplies

The Preferred Diabetic Supply program is for members who have diabetes (insulin and non-insulin users). Covered services include supplies to monitor blood glucose (blood glucose monitor, blood glucose test strips, lancet devices and lancets) and glucose control solutions for checking the accuracy of test strips and monitors.

UnitedHealthcare only covers the following brands of blood glucose monitors and test strips: 

OneTouch® Ultra® 2, OneTouch® Verio™, OneTouch® Verio Flex™, OneTouch® UltraMini™, OneTouch® Verio® IQ, ACCU-CHEK® Aviva Plus, ACCU-CHEK® Guide, ACCUCHEK ® Nano SmartView, and ACCU-CHEK Aviva Connect. 

Other brands are not covered. There is a $0 copayment for Medicare-covered diabetes monitoring supplies. 

The Preferred Diabetic Supply program is a Part B covered benefit. It is also available through OptumRx as well as through some of our DME providers.

Drugs Covered Under Part B or Part D

Some drugs can fall under either Part B or Part D. We base our determination of coverage as to whether the drug is Part B or Part D on several factors such as diagnosis, route of administration and method of administration. For a list of medications in each category, refer to the CMS website at cms.gov > Medicare > Prescription Drug Coverage-General Information > Downloads, and select the appropriate document. You may also call 800-711-4555.

Long Term Care Facility (Includes Mental Health Facilities) Pharmacies

We provide convenient access to network long-term care (LTC) pharmacies for all members residing in LTC and mental health facilities. For a list of network pharmacies covering long-term care facilities, refer to the provider directory on UHCprovider.com/findprovider.

Home Infusion

Our plan will cover drugs for home infusion therapy for home infusion services provided by a home infusion therapy network pharmacy. However, Medicare Part D does not cover the supplies and equipment needed for administration. For information on home infusion therapy, contact our Pharmacy department.

Vaccines

Part D covers most vaccines and the associated administration fees. Our plan provides coverage of a number of vaccines. Some vaccines are medical benefits (Part B medications) and others are Part D drugs.

Part D covers most preventative vaccines; Part B covers flu, pneumococcal, hepatitis B, and some other vaccines (e.g., rabies) for intermediate or high-risk individuals when directly related to the treatment of an injury or direct exposure to a disease or condition. 

The rules for coverage of vaccinations are complex and dependent on a number of factors. If you are unsure of the member’s benefit coverage for vaccines, call 800-711-4555. 

For a current list of vaccines and how they are covered, visit professionals.optumrx.com > Resources > Formulary

Injectable Medications

We may require prior authorization for injectable medications administered in a provider’s office or selfadministered medications from a specialty pharmacy supplier. Refer to the Drug Utilization Review Program section for more information. Request these authorizations one to two weeks in advance of the service date to allow for eligibility and coverage review and for shipping. To order injectable medications, complete and submit a prior authorization form. The forms are available at professionals.optumrx.com > Prior Authorizations > Fax Forms

Call 800-711-4555 for details on the rules governing injectable medications.