Last update: May 22, 2023
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 email@example.com.
If you believe a specific claim was paid incorrectly, please download this appeals form, and review the MAC appeals submissions guide for instructions.
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 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 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.
To locate a contracted specialty pharmacy, download the list: Provider Vendor Assistance List - Specialty Pharmacy.
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 week.
Some of the services our network specialty pharmacies offer include:
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.