Pharmacy information and requirements for commercial and MA plans are in Chapter 8: Specialty pharmacy and Medicare Advantage pharmacy.
We may delegate decisions to authorize specific pharmacy services based on your Agreement.
A member or care provider may request authorization from you for medication carved out of your Agreement terms. Notify the member you are not responsible for the authorization of these services. Recommend the member refer to any Part D coverage they may have.
The care provider medical group (medical group/IPA) must request prior authorization for select drugs. Get prior authorization forms on UHCprovider.com/priorauth or by contacting your provider advocate or clinical contacts at UnitedHealthcare. Our staff will not process the request until we receive all necessary information. Once we make a determination, we notify you within the correct time frame.
We make authorizations following benefit design, provided the member does not exceed benefit restrictions (applied to the requested agents/therapeutic class, and the prior authorization process).
We fax the case resolution to you. For denials, we send a letter to the member and care provider stating why we denied the requested medication. The letter outlines the process for filing standard and expedited appeals.
If UnitedHealthcare has financial responsibility for medications currently covered under the commercial member’s medical benefit, this policy applies to those medications listed in your Agreement.
UnitedHealthcare uses a prior authorization process to review 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. Non-compliant services are not eligible for coverage or payment reimbursement by UnitedHealthcare. If the medical group/IPA does not get this review and receive prior authorization from us before administering these drugs, we deny reimbursement. This policy does not apply to bevacizumab (Avastin) used for non-oncological indications.
Members may initiate an appeal for coverage of a prescription drug if the initial determination is adverse to them. They may start an appeal in the following circumstances: