We have a program that can help ensure members safely use their prescription opioid medications, and other medications that are frequently abused. If members use opioid medications from several doctors or pharmacies, we may talk to you to make sure the use of opioid medications is appropriate and medically necessary. Working with you, if we decide the use of prescription opioid medications is not safe, we may limit how the member can get those medications. The limitations may include:
The DMP may not apply to members who have certain medical conditions, such as cancer, are receiving hospice, palliative, or end-of-life care, or live in a long-term care facility.
If you have questions about the program, contact Optum Case Management at 1-855-218-3456.
To help address the misuse and abuse of opioids and other controlled substances, OptumRx home delivery pharmacy requires electronic prescribing for controlled substances. Several resources are available at professionals.optumrx.com/epcs to help you get started.
This only affects OptumRx home delivery services. If e-prescribing is not an option, members still have access to the retail pharmacy network.
We delegate prior authorization services to OptumRx. OptumRx staff adhere to CMS requirements, National Pharmacy and Therapeutics Committee (NPTC) practice guidelines, and other professionally recognized standards.
We offer a formulary exception process to allow for cases where the formulary or its restrictions may not accommodate the unique medical needs of members. To request an exception, submit a prior authorization request as described below. If you request an exception, you must also submit a supporting statement explaining why the exception is being requested.
Generally, we will only approve your request for an exception if alternative drugs included on our formulary list, a lower-tiered drug, or additional utilization restrictions would not be as effective in treating the member’s condition or would cause the member to have adverse medical effects.
New members taking drugs that are not on our formulary list, or for which there are restrictions, should talk with you to decide if they should switch to another appropriate drug that we do cover, or if you should request an exception.
You can request an authorization or exception by:
This online service enables physicians and health care professionals to submit a real-time prior authorization request 24 hours a day, 7 days a week. After logging on at optumrx.com with their unique NPI number and password, a physician or health care professional can submit patient details securely online, enter a diagnosis and medical justification for the requested medication, and, in many cases, receive authorization instantly.
Our network pharmacies may recommend or give members the generic version of a drug unless you tell us otherwise. Brand name drugs may require our approval if the generic equivalent is covered.
The pharmacy may contact you by phone, letter, or fax to request that a member be switched to a preferred alternative drug.