Pharmacy Resources and Physician Administered Drugs

Single Preferred Drug List (PDL) Drug Coverage Changes

Effective October 1, 2020, the Michigan Department of Health and Human Services (MDHHS) will require Medicaid Health Plans (MHPs) to follow the Michigan Fee-For-Service PDL. Members will be lettered prior to this date if they will be impacted. Members will be instructed to work with their provider to select a preferred medication listed in the letter or submit a prior authorization for review, if continuing current treatment. Members should continue their current medication until September 30, 2020. 

Find pharmacy information related to prescription drugs including prescription drug lists, step therapy, quantity limits and prior authorization requirements for Community Plan care providers.

Prior Authorization Information for Your Patient’s Medicaid Pharmacy Benefit

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MDHHS Bulletin MSA 21-50 provides authority for pharmacy coverage of COVID tests: MSA_21-50.pdf (

MDHHS listed of coverable COVID-19 tests: MIRx_covered_ndcs_covidtests.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.

Resources from UnitedHealthcare and Optum

Other Resources

Name of processor:

Bank Identification Number (BIN):

Processor Control Number (PCN):

Submitted Group (Group):





MDHHS authorized coverage of specific IM/SC COVID-19 Monoclonal Antibodies as a pharmacy benefit based on MDHHS Bulletin HASA 22-02. Below provides details of billing based on MDHHS COVID-19 Response fee:

  • Regen-COV (claims after 11/21/2020) – FDA authorized for SQ injections (HICL=47122; HIC3=W5D):
    • Currently Available NDCs:
      • NDC 61755003502 - REGEN-COV 2-VL DOSE PK (EUA)
        • GSN=081973; GCN=49255
      • NDC 13326004458 - CASIRIVIMAB-IMDEVIMAB 2VL(EUA)
        • GSN=081973; GCN=49255
      • NDC 61755004202 - CASIRIVIMAB-IMDEVIMAB 2VL(EUA)
        • GSN=081973; GCN=49255
      • NDC 61755003608 - REGEN-COV 8-VL DOSE PK (EUA)
        • GSN=081975; GCN=49257
      • NDC 61755003705 - REGEN-COV 5VL(1 CAS,4IMD)(EUA)
        • GSN=081974; GCN=49252
      • NDC 61755003805 - REGEN-COV 5VL(4CAS,1 IMD)(EUA)
        • GSN=081972; GCN=49254
      • NDC 61755003901 - REGEN-COV 600-600 MG/10ML(EUA)
        • GSN=081976; GCN=49778
    • Admin Fees (NCPDP Field 438-E3)
      • Pharmacy Admin Fee (POS-1) =
        • For dates of service of 11/21/20 to 12/31/20: $285.74
        • For dates of service of 01/01/21 to 05/05/21 : $285.51
        • For dates of service of 05/06/21 to 12/31/21 : $413.02
        • For dates of service of 01/01/22 onward: $413.61
      • Home Admin Fee (POS-12) =
        • For dates of service of 05/06/21 to 12/31/21: $688.93
        • For dates of service of 01/01/22 onward: $688.92
    • Dispensing Fee – N/A
    • Professional Service Code (NCPDP Field 440-E5) = MA
    • Basis of Cost Determination (NCPDP Field 423-DN) = 15
    • Place of Service (NCPDP Field 307-C7) = 1 (pharmacy) or 12 (home)
  • Evusheld (claims after 12/08/2021) – FDA authorized for IM injections (HICL=47712; HIC3=W5D):
    • Currently Available NDC:
      • NDC 00310744202 - EVUSHELD 2-VIAL DOSE PACK(EUA)
        • GSN=082896; GCN=51673
    • Admin Fees (NCPDP Field 438-E3)
      • Pharmacy Admin Fee (POS-1) =
        • For dates of service of 12/08/21 onward: $138.30
      • Home Admin Fee (POS-12) =
        • For dates of service of 12/08/21 onward: $230.17
    • Dispensing Fee – N/A
    • Professional Service Code (NCPDP Field 440-E5) = MA
    • Basis of Cost Determination (NCPDP Field 423-DN) = 15
    • Place of Service (NCPDP Field 307-C7) = 1 (pharmacy) or 12 (home) 

MDHHS Bulletin HASA 22-02: HASA-22-02.pdf (

MDHHS COVID-19 Response fee: COVID-19-012021.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.

Learn more about the PreCheck MyScript app on Link, including how the app can be used and where you go to access.

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.


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.

Preferred Drug List

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Community Plan of Michigan.

Click on the link below to view the Preferred Drug List.

Medicaid Drug Rebate Program Labeler List

UnitedHealthcare Community Plan of Michigan participates in the Medicaid Health Plan Common Formulary. Under the Common Formulary, Medicaid Health Plan formulary coverage is limited to products with a National Drug Code from manufacturers who participate in the Medicaid Drug Rebate Program. The following Medicaid Drug Rebate Program reference is reproduced from the Drug Manufacturer Contacts reference located on

A manufacturer’s labeler code is represented in the first five digits of a product’s NDC. Formulary NDCs included under a manufacturer’s labeler code are covered according to formulary coding established under the Common Formulary. If a NDC for a non-MDRP participating labeler is adjudicated on a pharmacy claim, NCPDP error AC (Product Not Covered non-Participating Manufacturer) will be included in the reject messaging.

UnitedHealthcare Community Plan of Michigan may consider making medical necessity accommodations for members who need a non-MDRP participating NDC when all formulary NDCs are unavailable. Prescribers must submit a prior authorization request. For urgent needs, pharmacies can call OptumRx Pharmacy Help Desk for assistance at 1-877-305-8952.

Please note: This reference is up to date as of the date included in the footer below. Updates to the MDRP may occur multiple times each week. For a current list of additional updates, please visit the New/Reinstated & Terminated Labeler Information reference on the website. Medicaid Health Plans apply the optional effective date for new/reinstated labelers. Labelers listed for termination are removed from coverage according to the effective date presented on the Terminated Labelers table.

Click on the link below to view the Preferred Drug List.

Additional Pharmacy Resources