Pharmacy Resources and Physician Administered Drugs

Effective January 1, 2021, the Kentucky Department for Medicaid Services (DMS) requires UnitedHealthcare Community Plan to follow the Kentucky Fee-For-Service PDL and Clinical Criteria. Additional pharmacy benefit and medication information can be found below in this section to assist our providers.

Kentucky PDL information can be found in the Preferred Drug Guide.

For submission of a prior authorization for a UnitedHealthcare Community Plan of Kentucky Member:

Prior Authorization Requests - Prescribers may submit prior authorizations for Community Plan Members:

• By calling 1-800-310-6826 or by fax at 866-940-7328
• Online at  uhcprovider.com> Link Sign In (top right) > sign in with your Optum ID > Prior Authorization & Notification application

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
• Non-Opioid Alternatives
• Opioid Tapering Recommendations
  
• Opioid Use Disorder
• Opioid Prescriber Reference Guide

Other Resources

• 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

For submission of a prior authorization for a UnitedHealthcare Community Plan of Kentucky Member:

Prior Authorization Requests - Prescribers may submit prior authorizations for Community Plan Members: 

• By calling 1-800-310-6826 or by fax at 866-940-7328
• Online at  uhcprovider.com> Link Sign In (top right) > sign in with your Optum ID > Prior Authorization & Notification application

• UnitedHealthcare Community Plan of Kentucky Preferred Drug List (PDL)
  
• Kentucky Single Preferred Drug List (PDL) - Effective January 1, 2021
• Kentucky Preferred Drug List Search

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.

Network Specialty Pharmacies 

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:

• Optum Specialty Pharmacy: 855-427-4682 
• Accredo: 800-803-2523
• Biologics: 800-850-4306
• Caremark Specialty Pharmacy: 800-237-2767
• Eversana: 800-305-7881
• Option Care Health: 866-827-8203
• Orsini Pharmaceutical Services: 800-410-8575
• PantheRx: 855-726-8479
• US Bioservices: 888-518-7246

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 of Kentucky maintains a generic drug MAC program to promote generic utilization and cost containment. Maximum Allowable Cost (MAC) means the upper limits for payment for generic drugs and for brand name drugs that have a generic version available. This program is compliant with all maximum allowable cost laws and administrative regulations.

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.

Pharmacies with MAC questions: Call OptumRx Pharmacy Network Relations at (877) 633-4701, option 7 or email rxreimbursement@optum.com