Pharmacy Resources and Physician Administered Drugs
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 benefit, 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.
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:
Expedited delivery to the member’s home or physician’s office
Proper handling and packaging according to the product’s storage requirements, with instructions provided for the member if any refrigeration or special storage conditions exist.
Patient-friendly educational material that includes drug information which speaks to medication administration and compliance.
Medication administration training/assistance
Pharmacy Benefit Manager Changes
On July 1, 2021, we will work with a new Pharmacy Benefits Manager, MedImpact.
All prior authorizations will be managed by MedImpact.
Pharmacy Prior Authorization:
Prescribers can submit requests:
• Online: Care providers can submit prior authorization requests online through Cover My Meds, Surescripts, or CenterX ePA portals.
• Fax: They can fax completed prior authorization forms to 858-357-2612 beginning July 1, 2021.
• Phone: Call 844-336-2676 from 8 a.m. to 7 p.m., Monday through Friday, Eastern Time.
For all medically billed drug (J Code) PA requests, please continue to send those directly to the United Healthcare for review.
Clinical Pharmacy Guidelines and Policies
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.