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Pharmacy, Capitation and/or Delegation Supplement - 2019 UnitedHealthcare Administrative Guide

Pharmacy information and requirements for commercial
and MA plans are in Chapter 7: Pharmacy.

Medications Not Covered Under Capitation (Medicare Advantage)

We may delegate decisions to authorize specific pharmacy services to you in the terms of your agreement.

A member or care provider may request authorization from you for medication carved out of the terms of your agreement. You should notify the member that you are not responsible for the authorization of these services. You may want to recommend the member refer to any Part D coverage they may have.

Prior Authorization is Necessary for Payment to be Processed

The request prior authorization for select drugs must be made by the care provider medical group (medical group/IPA). You can get prior authorization forms on, or by contacting your provider advocate or clinical contacts at UnitedHealthcare. Our staff will not process the request until all necessary information has been received. Once we receive all the information requested and make a determination we will communicate the decision to you within the correct timeframe. We will not make a decision on a request that is incomplete or requires additional information. We make authorizations following benefit design, provided the member’s benefit restrictions (applied to the requested agent(s)/therapeutic class, and the prior authorization process), are not exceeded.

We will fax a written communication of case resolution to you. For denials, we send a letter to the member and care provider stating why the requested medication is denied. The letter outlines the process for filing standard and expedited appeals.

Prior Authorization Process for Medications Carved Out of Capitation

If UnitedHealthcare has financial responsibility for medications currently covered under the Commercial member’s medical benefit, then this policy will apply to those medications listed in your agreement.

UnitedHealthcare has a “prior authorization” process in place to provide for review of any medication carved out of capitation. This authorization process affects medical groups/IPA providing care to UnitedHealthcare members when UnitedHealthcare has retained financial responsibility for these medications.

We review the administration of these medications for compliance with the National Comprehensive Cancer Network’s Drugs & Biologics Compendium (NCCN Compendium®) recommended uses for the drug, as it pertains to treatment regimen and/or line of therapy. Noncompliant services are not eligible for coverage or payment reimbursement by UnitedHealthcare to the medical group/IPA. If the medical group/IPA does not get this review and receive prior authorization from us prior to administration of these drugs we will deny reimbursement for the drug. This policy does not apply to bevacizumab (Avastin) used for non-oncological indications.

Prescription Drug Appeals Process

Care providers should be aware that members may initiate an appeal for coverage of a prescription drug if the initial determination is adverse to the member. An appeal may be initiated in the following circumstances:

  • The requested drug is not on the formulary
  • The drug is not considered medically necessary
  • The drug is furnished by an out-of-network care provider pharmacy
  • The drug is not a drug for which Medicare will pay under Part D
  • A coverage determination is not provided in a timely manner
  • The delay would adversely affect the health of the member
  • A request for an exception is denied, or
  • The member is dissatisfied with a decision regarding the copayment required for a prescription drug.