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 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 and Wholesaler Acquisition Cost, 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. The MAC lists are reviewed on a monthly basis.
- Kansas Maximum Allowable Cost (MAC) Price Lookup
- Maximum Allowable Cost Appeal Submission Guide
- Maximum Allowable Cost List Administration
If you have questions related to your contract with us or other issues related to the UnitedHealthcare Community Plan of Kansas Pharmacy Network, please feel free to contact our network relations line at 1-800-613-3591.
For contracting Issues: 1-800-613-3591
Claims processing issues: 1-800-842-4195
For dates of service on and after Jan. 1, 2018, the Medicare Part D Copayment assistance amount will be $8.35 per 30-day supply with a maximum of up to $25.05 for a 90-day supply.
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.
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.
Resources from UnitedHealthcare and Optum
- Medicated Assisted Treatment: Locate a Provider (Last Modified 10.01.2017)
- Naloxone Coverage for UnitedHealthcare Members (Last Modified 01.12.2018)
- Naloxone: What You Need to Know (Last Modified 11.15.2017)
- Opioid Tapering Recommendations (Last Modified 02.02.2018)
- Opioid Use Disorder (Last Modified 03.05.2019)
- The Role of Dentists in Managing Opioids (Last Modified 02.01.2018)
- Treatment Alternatives for Common Pain Conditions (Last Modified 02.08.2018
- Agency for Healthcare Research and Quality (AHRQ): Interagency Guideline on Prescribing Opioids for Pain
- Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain
- Centers for Disease Control and Prevention (CDC): CDC Opioid Overdose Guideline Resources
- Substance Abuse and Mental Health Services Administration (SAMHSA): The Role of Prevention in Addressing Neonatal Abstinence Syndrome
KanCare offers a Universal Pharmacy/Medical Prior Authorization Form. The universal form is intended to simplify the prior authorization process by unifying health plan and Fee-For-Service forms. All forms for all drugs requiring prior approval for all KanCare members are located on the Kansas Department of Health and Environment website.
This form can be used for any drug prior authorization request. It’s important to review drug criteria and complete the form with all relevant information. If the information required in the specific drug criteria is not included in the prior authorization request, the request may be denied for lack of information.
The Universal Pharmacy/Medical Prior Authorization Form provides all contact information for all KanCare health plans and Fee-For-Service (FFS) Pharmacy and Medical Prior Authorization Departments.
Fax completed forms to the Pharmacy or Medical Prior Authorization department based on where the drugs are being billed and dispensed:
- Pharmacy Prior Authorization - Drug dispensed from a pharmacy
- Medical Prior Authorization - Drug dispensed from a provider office, hospital, or outpatient stock
Forms and Prior Authorization Medication List
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.
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.
Specialty pharmacy medications covered under the member’s medical benefit may be obtained through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.
Network 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 pharmacy:
- BriovaRx 855-427-4682
Additional Specialty Pharmacies
The following specialty pharmacies also provide certain types of specialty medications:
- Accredo (Nursing Services) 800-803-2523
- Enzyme Deficiency
- Gaucher's Disease
- Immune Globulin
- Pulmonary Hypertension
- Option Care (Nursing Services) 866-827-8203
- Enzyme Deficiency
- Gaucher's Disease
- Immune Globulin
- CVS Caremark Specialty Pharmacy 800-237-2767
- Pulmonary Hypertension
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.
UnitedHealthcare Community Plan - KanCare
UnitedHealthcare Community Plan uses the Kansas Department of Health and Environment’s Preferred Drug List (PDL) and related policies for KanCare members. We follow the state’s policies for generic substitution and therapeutic interchange, quantity limits and step therapy.
- Preferred Drug List Policies for KanCare - Quick Reference Guide
- UnitedHealthcare Community Plan - KanCare Preferred Drug List
- UnitedHealthcare Community Plan - KanCare Preferred Drug List Search
Preferred Drug List Updates
- Preferred Drug List Update 08.02.2019
- Pharmacy Prior Authorization and Preferred Drug List (PDL) Updates (Last Modified 07.09.2018)
UnitedHealthcare Dual Complete® (HMO-SNP) Program
The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete (HMO-SNP).
Additional Pharmacy Resources
- KanCare 90-Day Supply Maintenance Medication Policy (Last Modified 10.01.2017)
- Medication Quantity Limits (Last Modified 06.22.2018)
- Medication Therapy Management (MTM) Program Information
- OptumRx Commercial and Medicaid Payer Sheet - This document provides information on electronic claims processing, specific to NCPDP defined fields and requirements, for OptumRx Commercial and Medicaid business.
- OptumRx Pharmacy Manual - Review in conjunction with the Pharmacy Provider Manual.
- OptumRx UnitedHealthcare Community Plan of Kansas (Dual Eligible Only) Payer Sheet - This document outlines the processing instructions for OptumRx UHC Plan of Kansas (Dual Eligible Only) business.
- Synagis Enrollment Form
- Synagis Dosing and Prior Authorization Process