Find pharmacy information related to prescription drugs including prescription drug lists, step therapy, quantity limits and prior authorization requirements for Community Plan care providers.
UnitedHealthcare Community Plan Pharmacy benefit is effective April 1, 2021. Below is information and resources for our UHC Community Plan Pharmacy benefit, including prescription drug lists, step therapy, quantity limits and prior authorization requirements for Community Plan care providers.
Maximum Allowable Cost List Administration
UnitedHealthcare Community Plan works with OptumRx to manage the Pharmacy network. Multiple sources are used by OptumRx in order to assure the Maximum Allowable Cost (MAC) list accurately reflects market pricing and availability of generic drugs. Sources include de-identified market pricing, benchmark data including Average Wholesale Price (AWP) and Wholesaler Acquisition Cost (WAC), wholesaler information on market availability, and individual pharmacy feedback.
The synthesis of this information helps create a market based MAC price for generic items included on the MAC list. These sources are monitored, and updates are used to help manage the market fluctuations of pricing on the MAC list.
MAC lists are reviewed twice weekly with additional updates implemented on an as-needed basis based on market forces and other additional information.
For Indiana Medicaid MAC inquiries, please contact OptumRx through email at firstname.lastname@example.org.
If you have questions related to your contract with us or other issues related to the UnitedHealthcare Community Plan of Indiana Pharmacy Network, please feel free to contact our network relations line at 1-800-613-3591.
Mental Health Medications
In accordance with Indiana law, all antianxiety, antidepressant, antipsychotic, and "cross indicated" drugs are considered as being preferred. Drugs that are (1) classified in a central nervous system drug category or classification (according to Drug Facts and Comparisons) created after March 12, 2002, and (2) prescribed for the treatment of a mental illness (as defined by the most recent publication of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders) are also considered as preferred. Please note that since these drugs/classes are preferred, they are not shown on the PDL document. Lack of inclusion on the PDL does not mean these drugs are non-covered by the IHCP. Click the following link for a list of utilization edits on mental health medications: https://prdgov-rxadmin.optum.com/rxadmin/INM/20210401_AAAX_List.pdf.
Right Choices Program (RCP)
The RCP will identify members who use covered services more extensively than their peers and/or exhibit drug-seeking behaviors. The program is designed to monitor members who would benefit from increased care coordination. The RCP follows the CMS design of a Patient Review and Restrict (PRR) program that is focused on behaviors of Doctor Shopping and excessive utilization of Controlled Substances, especially Opioids. UHCCP will provide appropriate disease management, care management or complex case management services to the RCP members. Click on the following link for more detailed information: https://www.in.gov/medicaid/files/right%20choices%20program.pdf
In response to the U.S. opioid epidemic, UnitedHealthcare has developed programs to help our members receive the care and treatment they need safely and effectively.
We’ve also established measures based on the Centers for Disease Control and Prevention’s (CDC) opioid treatment guidelines to help prevent overuse of short-acting and long-acting opioid medications.
The PreCheck MyScript Solution on Link helps make it easy to run a pharmacy trial claim and get real-time prescription coverage detail for your patients who are UnitedHealthcare benefit plan members.
CoverMyMeds streamlines the medication prior authorization process, electronically connecting providers, pharmacists and plan/PBMs to improve time to therapy and decrease prescription abandonment with electronic prior authorization.
Specialty pharmacy medications covered under the member’s medical benefit may be provided through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.
If you don’t want to buy and bill a specialty pharmacy medication covered under the member’s medical benefit, you may order it through the following network specialty pharmacies:
Coverage of a requested medication depends on the member’s benefit, and availability of a specific drug from a network specialty pharmacy may vary.
Upon request, a specialty pharmacy can deliver the medication to your office or another site such as a member’s home.
Medications obtained through a specialty pharmacy will be directly billed to the patient’s health plan.
340B claims are only accepted from CE (covered entity) pharmacies and Contract pharmacies may not submit 340B claims. The 340B CE Pharmacy shall submit Claims for 340B acquired drugs at the Pharmacy’s 340B AAC with values of “08” in the Basis of Cost Determination field 423-DN OR in the Compound Ingredient Basis of Cost Determination field 490-UE AND insert “20” in the Submission Clarification Code field 420-DK.