Specialty Pharmacy Requirements for Certain Specialty Medications (Commercial Plans - Not Applicable to UnitedHealthcare West)
Coverage of Self-Infused / Injectable Medications under the Pharmacy Benefit
This protocol applies to the provision and billing of selfinfused/injectable medications, such as Hemophilia Factor products, under the pharmacy benefit.
Under most UnitedHealthcare products, self-infused/injectable medications are generally excluded from coverage under the medical benefit. A pharmacy rider can provide coverage for a self-infused/injectable medication. This exclusion from the medical benefit does not apply to self-infused/injectable medications necessary to treat diabetes or to medications that, due to their characteristics, as determined by UnitedHealthcare, are typically administered or directly supervised by a qualified physician or licensed/certified health care professional in an outpatient setting.
If medications are subject to this exclusion, participating physicians, health care professionals, home infusion providers, hemophilia treatment centers or pharmacies fulfilling, distributing, and billing for the provision of selfinfused/injectable medications to members are required to submit claims for reimbursement under the member’s pharmacy benefit.
Prohibition of Provision of Non-Contracted Services
- This protocol applies to the provision and billing of specific specialty pharmacy medications covered under a member’s medical benefit.
- Specialty pharmacy or home infusion providers are prohibited from providing non-contracted services for a therapeutic category, even if the specialty pharmacy or home infusion provider is contracted for other medical benefit medications and services, and billing us as a nonparticipating or non-contracted specialty pharmacy or home infusion provider.
- This protocol does not apply when a physician or other health care professional, who procures and bills us directly for specific specialty mediations, administers special medications in an office setting.
Requirement of Specialty Pharmacy and Home Infusion Provider(s) to be a Network Care Provider
We have contracted with a network of specialty pharmacy and home infusion care providers by therapeutic category to distribute specialty medications covered under a member’s medical benefit. We selected the contracted specialty pharmacy and home infusion providers by therapeutic category for network inclusion based upon their distribution, contracting, clinical capabilities, and member services.
This national network provides fulfillment and distribution of the specialty medications on a timely basis to meet the needs of our members and our network. Full program participation requirements are identified in the contracted specialty pharmacy or home infusion provider’s Agreement.
Specialty Pharmacy Program Requirements
This protocol applies to the specialty medications listed on Specialty Pharmacy Program > Additional Specialty Pharmacy Resources.
The medications addressed in our Specialty Pharmacy Program are subject to change. This protocol does not apply when Medicare or another health benefit plan is the primary payer and we are the secondary payer.
Requirement to Use a Participating Specialty Pharmacy Provider for Certain Medications
We have contracted providers for the distribution of these specialty medications. Our participating specialty pharmacy providers give fulfillment and distribution services to meet the needs of our members and our care providers. Our participating specialty pharmacy providers provide reviews consistent with our drug policies for these drugs. They work directly with the Clinical Coverage Review unit in our Clinical Services to determine whether treatment is covered.
Our National Pharmacy & Therapeutics Committee periodically reviews and updates our drug policies for these drug preparations. The committee helps ensure the policies are consistent with published clinical evidence and professional specialty society guidance. Our participating specialty pharmacy providers report clinical data and related information and are audited on an ongoing basis to support our clinical and quality improvement activities.
You must acquire these specialty medications from a participating specialty pharmacy provider in our specialty pharmacy network, except as otherwise authorized by us. Submit requests for prescriptions of these specialty medications with the applicable enrollment request forms available on Specialty Pharmacy Program > Enrollment Forms. The specialty pharmacy will dispense these drugs in compliance with the UnitedHealthcare Drug Policy and the member’s benefit plan and eligibility, and bill UnitedHealthcare for the medication.
You only need to bill for administration of the medication. Do not bill us for the medication itself. The specialty pharmacy will advise the member of any medication cost share responsibility and arrange for collection of any amount due prior to dispensing of the medication to the physician office.
For a list of the medications and participating specialty pharmacy provider(s), refer to the enrollment forms online.
Administrative Actions for Non-Network Acquisition for Certain Specialty Medications
We anticipate that all care providers will be able to procure certain medications from a participating specialty pharmacy provider.
We may deny, in whole or in part, any claim from the use of non-participating specialty pharmacy providers, wholesalers, or direct purchase from the manufacturers by you or any other health care professional without prior approval from us. You may also be subject to other administrative actions as provided in your Agreement.
Please contact your local UnitedHealthcare Network Manager if you have any questions.