MA pharmacy - Chapter 8, 2022 UnitedHealthcare Administrative Guide
A member may fill prescriptions from any network pharmacy in the pharmacy directory or online at optumrx.com. Reimbursement for prescriptions from a non-network pharmacy is available to some members in limited circumstances.
MA prescription drug formulary
We use the United States Pharmacopoeia’s drug classification system for development of the Formulary for MA.
The Pharmacy & Therapeutics Committee conducts formulary development and oversight. The committee is also responsible for identifying safe, cost-effective and medically appropriate drug therapies that reflect community and national standards of practice.
MA formulary tier structure
The MA Prescription Drug Formulary is a list of drugs covered as a pharmacy plan benefit for MA members.
For non-group plans, we categorize medications into 5 tiers:
Tier 1: Preferred generic drugs
Tier 2: Generic drugs
Tier 3: Preferred brand-name drugs
Tier 4: Non-preferred drugs
Tier 5: Specialty drugs
Note: Tiers 2-4 may include higher-cost generic drugs as well.
For group plans, several formularies are available. Medications are often categorized into 4 tiers:
Tier 1: Preferred generic drugs
Tier 2: Preferred brand-name drugs
Tier 3: Non-preferred drugs
Tier 4: Specialty drugs
Note: Tiers 2 and 3 may include higher-cost generic drugs as well.
For MA Prescription Drug Formulary information, see AARPMedicarePlans.com, UHC.com/medicare, or uhcprovider.com. If a drug is not on our formulary, you might be able to switch the member to a different drug that we do cover, or you can request a formulary exception. While we are evaluating the exception, we may provide members with a temporary supply.
MA prescription drug benefit
UnitedHealthcare offers several prescription drug coverage plans based on the member’s county of residence and the member’s prescription drug needs. The benefit structure follows the CMS model:
Prescription drug deductible — Some benefit plans have a deductible the member must meet before getting access to the prescription drug benefit. In some plans, this deductible will only apply to specific drug tiers (e.g., Tier 3, Tier 4 and Tier 5 only).
Initial coverage limit — During this period, the member is responsible for a specific copayment or coinsurance for prescription drugs.
Coverage gap — While in the coverage gap, the member will pay 25% of the total cost of brand name and generic drugs in 2022. Coverage plans vary, and the member may pay a different amount.
Catastrophic coverage level — Members who reach this level may have a significantly lower copayment/coinsurance for prescription drugs until the end of the year. Coverage plans vary, and the member may pay a different amount
Prescriptions for a non-formulary or non-covered drug are not covered unless the member or the member’s health care provider requests and receives an approved formulary exception through the prior authorization process.
The member pays 100% of our contracted rate with the pharmacy if this amount is less than the member’s applicable copayment/coinsurance for the prescription. This process does not apply to excluded medications.
Refer to the exceptions process included in the following section for the coverage criteria of a non-formulary or non-covered drug.
MA Part D members
Prior authorization requests
OptumRx® follows the coverage determination timelines as established by CMS. We must complete standard coverage determinations within 72 hours of receipt of request or prescriber’s supporting statement for exceptions. OptumRx must complete expedited coverage determinations within 24 hours of receipt of request or prescriber’s supporting statement for exceptions.
OptumRx may ask for more information from the prescriber or their designee. We may also ask the member if needed and send notification of the resulting case decision.
Different types of requests include:
Prior authorization (PA).
Medicare Part B vs Medicare Part D.
Non-formulary exception (NF).
Step therapy (ST).
Quantity limit (QL).
Opioid safety edits.
Tier cost-sharing exception (TCSE).
TCSE rules vary by specific benefit plan and available alternatives. Criteria for copayment reduction TCSE are:
The requested drug is FDA-approved for the condition being treated.
One of the following:
Diagnosis is supported as a use in American Hospital Formulary Service (AHFS), under the Therapeutic Uses section.
Diagnosis is supported in the Therapeutic Uses section in DRUGDEX Evaluation with a Strength of Recommendation rating of IIb or better.
Diagnosis is listed in the Therapeutic Uses section in DRUGDEX Evaluation and carries a Strength of Recommendation of III or Class Indeterminate; and Efficacy is rated as “Effective” or “Evidence Favors Efficacy.”
History of failure, contraindication or intolerance to all applicable formulary alternatives in the lower qualifying tiers.
For some drugs, we may require authorization before the drug can be prescribed (prior authorization), limit the quantity that can be prescribed per prescription (quantity limits) or require that you prescribe drugs in a sequence (step therapy), trying one drug before another drug.
We provide an exception process to allow for the chance the formulary may not accommodate the unique medical needs of a member. To make an exception to these restrictions or limits, or to initiate a prior authorization, submit a coverage determination request:
More information about requirements is available at professionals.optumrx.com > Resources > Formulary Listsor by calling the OptumRx Prior Authorization department at the number above.
Part B covered drugs
Drugs covered under Part B are typically administered and obtained at the health care provider’s office (e.g., certain cancer drugs, administered by a physician in their office). Some drugs covered under Part B are dispensed by outpatient pharmacies (e.g., certain oral cancer drugs, insulin when administered by a pump, immunosuppressants for Medicare-covered transplants, and diabetic test supplies).
MA diabetes monitoring supplies
Some plans have a Preferred Diabetic Supply program for members who have diabetes (insulin and non-insulin users). Covered services include supplies to monitor blood glucose (blood glucose monitor, blood glucose test strips, lancet devices and lancets) and glucose control solutions for checking the accuracy of test strips and monitors.
UnitedHealthcare only covers the following brands of blood glucose monitors and test strips:
Blood glucose monitors: OneTouch Verio Flex®, OneTouch Verio Reflect®, OneTouch® Verio, OneTouch®Ultra 2, Accu-Chek® Guide Me and Accu-Chek® Guide. Test strips: OneTouch Verio®, OneTouch Ultra®, Accu-Chek® Guide, Accu-Chek® Aviva Plus and Accu-Chek® SmartView.
Other brands are not covered.
The Preferred Diabetic Supply program is a Part B covered benefit. It is also available through OptumRx as well as through some of our DME providers.
Drugs covered under Part B or Part D
Some drugs can fall under either Part B or Part D. We base our coverage determination on if the drug is Part B or Part D on several factors, such as diagnosis, route of administration and method of administration. For a list of medications in each category, refer to the CMS website at cms.gov > Medicare > Prescription Drug Coverage - General Information> Downloads and select the appropriate document. You may also call 1-800-711-4555.
Long-term care facility (includes mental health facilities) pharmacies
We provide convenient access to network long-term care (LTC) pharmacies for all members residing in LTC and mental health facilities. For a list of network pharmacies covering long-term care facilities, refer to the provider directory on uhcprovider.com/findprovider.
Our plan will cover home infusion therapy drugs for home infusion services provided by a home infusion therapy network pharmacy. However, Medicare Part D does not cover the supplies and equipment needed for administration. For information on home infusion therapy, call our Pharmacy department at 1-877-306-4036.
Part D covers most vaccines and the associated administration fees. Our plan provides coverage of a number of vaccines. Some vaccines are medical benefits (Part B medications) and others are Part D drugs.
Part D covers most preventive vaccines; Part B covers flu, pneumococcal, hepatitis B (for intermediate or high-risk individuals), and some other vaccines (e.g., rabies) for intermediate or high-risk individuals when directly related to the treatment of an injury or direct exposure to a disease or condition.
The rules for coverage of vaccinations are complex and dependent on a number of factors. If you are unsure of the member’s benefit coverage for vaccines, call 1-877-842-3210.
For a current list of vaccines and how they are covered, visit professionals.optumrx.com > Resources > Formulary.
We may require prior authorization for injectable medications administered in your office or self-administered medications from a specialty pharmacy supplier. Refer to the Drug Utilization Review Program section for more information.
Request these authorizations 1-2 weeks in advance of the service date to allow for eligibility, coverage review and shipping.
Call 1-800-711-4555 for details on the rules governing injectable medications or to submit a prior authorization request for injectable medications obtained by the pharmacy. For medications provided and administered in the office (i.e., buy and bill), call 1-877-842-3210.