Pharmacy Resources and Physician Administered Drugs

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

MDHHS listed of coverable COVID-19 tests: MIRx_covered_ndcs_covidtests.pdf (magellanrx.com)

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 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

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 (michigan.gov)

MDHHS COVID-19 Response fee: COVID-19-012021.pdf (michigan.gov)

• Drug-specific Paper Prior Authorization Forms
• Michigan Prior Authorization Request Form for Prescription 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 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.

• Inclusion of a drug in the Provider Vendor Assistance List does not infer coverage. Check your patients' coverage and plan details with the Eligibility and benefits feature on the UnitedHealthcare Provider Portal.
• Network Vendors in the Provider Vendor Assistance List are in no particular order; no preference should be interpreted based on the order of the listing, when multiple options are available.

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.
• Adherence programs
• Medication administration training/assistance

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.

• UnitedHealthcare Community Plan Preferred Drug List (PDL) Search 
• UnitedHealthcare Community Plan Single Preferred Drug List (SPDL)
• Machine Readable PDL
• Michigan Department of Health & Human Services Managed Care Common Formulary (Medicaid Health Plan Pharmacy Benefit)
• Provider Vendor Assistance List - Specialty Pharmacy

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 medicaid.gov.

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 Medicaid.gov 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.

• Medicaid Drug Rebate Program Labeler List PDF
• Medicaid Drug Manufacturer Contacts
• Medicaid New/Reinstated & Terminated Labeler Information