Specialty medications can be covered under the pharmacy benefit, the medical benefit or both benefits, depending on the benefit structure for the member’s coverage.
Pharmacy benefit medications are typically self-administered by the patient or a caregiver, after filling the prescription through a pharmacy. These medications are labeled for self-administration by the Food and Drug Administration but may require some instruction to the patient or caregiver.
Typically, medications administered orally, topically or through subcutaneous injection by the patient or a caregiver after receiving instruction are covered under the pharmacy benefit.
Medical benefit medications are typically administered by a health care professional and monitored by a health care professional. The medication is administered in a physician’s office, at home, in an ambulatory infusion suite or in an outpatient facility. These medications can be administered by infusion, injection or intramuscularly with the help of an infusion nurse.
Specialty Pharmacy medications can be shipped from a specialty pharmacy directly to a health care setting (i.e., sourced) or a provider may purchase them directly using their standard distribution process (i.e., buy and bill). If the drugs are administered at home, they may be shipped from a specialty pharmacy directly to the member’s home.
Coverage of a requested medication depends on the member’s Medicaid coverage as determined by the State Medicaid agency, and the availability of a specific drug from a network specialty pharmacy may vary.
Medications obtained through a specialty pharmacy will be directly billed to the member’s health plan.
Inclusion of a drug in the Provider Vendor Assistance List does not infer coverage. Check your patients' coverage and plan details with the Eligibility and Benefits feature on the UnitedHealthcare Provider Portal.
Network Vendors in the Provider Vendor Assistance List are in no particular order; no preference should be interpreted based on the order of the listing, when multiple options are available
Specialty Program Description UnitedHealthcare Community Plan administers a Specialty Pharmacy Management Program that provides high-quality, cost-effective care for our members. This program optimizes the patient experience and clinical outcomes by utilizing a network of specialty pharmacies that offer clinical programs which include, but are not limited to, educating and supporting our members concerning their chronic condition(s), promoting medication adherence and reducing the risk of side effects, and promoting multi-disciplinary practice and collaboration to achieve continuity of care.
Our network specialty pharmacies are selected based on their clinical expertise, the quality of clinical management and adherence programs provided, and overall cost of therapy. Specialty pharmacy providers are specifically trained on specialty medications, the conditions they treat, and can provide comprehensive clinical services. The contracting/credentialing process ensures consistency with the requirements, the highest level of quality provided to members, and access to all specialty pharmacy medications.
The specialty pharmacies provide patient education and training, not only for the medication, but also the chronic condition being treated. The specialty teams proactively reach out to patients each month prior to refilling their prescription. During this outreach, patients are asked if they have questions about their condition or drugs, and if they would like to speak directly to a clinician. Medication adherence is also checked, with any potential issues identified and addressed. Additionally, their Member Support Services provides patients with access to a clinician trained in their condition and drug therapy 24 hours a day, 7 days a week.
Some of the services our network specialty pharmacies offer include:
Expedited delivery to the member’s home or physician’s office
Proper handling and packaging according to the product’s storage requirements, with instructions provided for the member if any refrigeration or special storage conditions exist
Patient-friendly educational material that includes drug information which speaks to medication administration and compliance
UnitedHealthcare Community Plan’s Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.
UnitedHealthcare Community Plan Quantity Limit Policy
UnitedHealthcare Community Plans may have monthly quantity limitations on certain medications. Prescriptions for quantities greater than the indicated monthly limits will require prior authorization. Quantity limits exist to promote efficient medication dosing and safe dosing administration.
Quantity limits also apply to certain classes of medications. Patients have access to any FOUR medications from the following classes in a 30-day period: opiate analgesics, benzodiazepines, sedative hypnotic agents, barbiturates, and select muscle relaxants. Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits.
Additions to the Quantity Limit (QL) program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the prior authorization (PA) process.
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