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.
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 email@example.com.
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.
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
Get real-time prescription costs and coverage detail
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.
Streamline your prior authorization process with CoverMyMeds
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.
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.
For physician-administered claims (CMS-1500 or UB-04), modifiers:
JG- Drug or biological acquired with 340B drug pricing program discount
TB- Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes
Pharmacies seeking additional questions regarding 340B policy, please contact the pharmacy helpdesk at 1-866-215-5046 or see the OptumRx Pharmacy Provider manual for additional detail on 340B requirements.