A member may fill prescriptions from any network care provider pharmacy in the pharmacy directory or online at optumrx.com.
A member who obtains a prescription from a non-network pharmacy will not be eligible for reimbursement of any charges incurred unless the prescription received was not available from a participating pharmacy site (e.g., urgent or emergent prescriptions, after hours, out of the service area, or Part D-covered vaccines provided by the care provider).
Each UnitedHealthcare West member with a prescription drug benefit is eligible to use our prescription mail service.
When appropriate, you can write prescriptions for a three-month 90 calendar day supply and up to three additional refills. Only medications taken for chronic conditions should be ordered through the mail. The member may obtain acute prescription needs, such as antibiotics and pain medications, through a network pharmacy site to avoid delay in treatment.
You may also elect to discourage members from using the mail service for medications where large quantities dispensed at one time to the member may pose a problem (e.g., tranquilizer).
The UnitedHealthcare SignatureValue formulary includes most generic drugs/medications and a broad selection of brand name drugs/medications. Prescription drugs and medications listed on the formulary are considered a covered benefit. However, select formulary medications may require prior authorization to be covered.
Any prescription for a non-formulary drug is the member’s financial responsibility, unless the member meets the criteria for coverage of a non-formulary drug and the care provider requests and receives prior authorization for such drug. Additionally, certain drugs may be excluded from the benefit plan.
Many members have a three-tier pharmacy benefit plan with coverage of formulary generics, formulary brand name drugs, and non-formulary drugs. A prior authorization process may apply to certain non-formulary drugs.
We update the formulary twice a year, in January and July. Care provider requests for formulary review of medications or pre-authorization guidelines are welcome. You can find formulary changes on UHCprovider.com/pharmacy or UHCprovider.com/priorauth > Clinical Pharmacy and Specialty Drugs.
Non-formulary prescriptions/medications not provided as a plan benefit are the member’s financial responsibility, unless the prescribing care provider requests and receives prior authorization for the non-formulary medications and the member meets criteria for coverage.
Commercial plan members may also have coverage when their employer purchases an Open Formulary or Buy-up Plan. The member may be charged the usual and customary cost of the medication or the non-formulary copayment depending on the member’s benefit design.
Drug Utilization Review Program
UnitedHealthcare West is dedicated to working with our network care providers to supply information and education needed for effective management in growing cost of pharmaceutical care. Our clinical pharmacists can identify and analyze areas where care providers may be able to prescribe products considered effective as well as economical.
Additionally, our pharmacy staff can help identify when a more detailed review of therapy may improve member care, such as:
- Overuse of controlled substances
- Duplicate therapies
- Drug interactions
Through pharmacist review and information, care providers are given the data needed to better manage the quality of their members’ care while also managing pharmacy program costs.
Prior Authorization Process
We delegate prior authorization services to OptumRx®. OptumRx staff adhere to benefit plan-approved criteria, National Pharmacy and Therapeutics Committee (NPTC) practice guidelines, and other professionally recognized standards.
You can request an authorization by:
- Online: OptumRx.com > Healthcare Professionals > Prior Authorizations.
This online service enables physicians and health care professionals to submit a real- time prior authorization request 24 hours per day, seven days per week. After logging on at OptumRx.com with their unique National Provider Identifier (NPI) number and password, you can submit patient details securely online, enter a diagnosis and medical justification for the requested medication, and, in many cases, receive authorization instantly.
- Phone: 800-711-4555
- Written request: You can obtain a Commercial Prescription Prior Authorization Form – CA on OptumRx. com > Health Care Professionals Portal > Prior Authorizations.
- Fax: 800-527-0531 for oral medications, and
- Fax: 800-853-3844 for injectable/specialty medications.
California Commercial HMO and PPO products:
Prescribing providers in California must use the Prescription Drug Prior Authorization Request Form when submitting authorization requests to OptumRx.
- California Health and Safety Code 1367.241 and California Code of Regulations, Chapter 28, section 1300.67.241. Section 1300.67.241 to Title 28 of the California Code of Regulations (CCR).
- Article 1.2 Section 2218.30 to the California Code of Regulations (CCR) Title 10, Chapter 5, Subchapter 2.
Also, the California utilization management delegates may have contractual responsibilities for payment of certain prescription medications. When the delegate requires prior authorization for use of those drugs prescribed by their care providers, the delegate must also require the use of Optum’s Prescription Drug Prior Authorization Request Form. The delegate must have a policy and process in place and be able to demonstrate compliance.