Pharmacy Resources and Physician Administered Drugs
Find pharmacy information related to prescription drugs including prescription drug lists, step therapy, quantity limits and prior authorization requirements for Community Plan care providers.
Generic Drug Pricing and Appeals
UnitedHealthcare Community Plan works with OptumRx to manage the Pharmacy network. Effective January 1st, 2023, pricing methodology of generic drugs has transitioned to National Average Drug Acquisition Cost (NADAC). Maximum Allowable Cost (MAC) pricing is no longer used for generic drug pricing.
NADAC is a publicly available database published by Centers for Medicare & Medicaid Services (CMS) which is utilized by our pharmacy claims adjudication systems for generic drugs. NADAC pricing updates are captured at least weekly.
Pharmacies may use the OptumRx MAC appeal form to submit generic claim appeals. OptumRx follows state-specific requirements for processing and reviewing generic claim appeals.
Step therapy drug programs are applied to therapeutic classes that have multiple medication options. While clinical effectiveness may be similar among medication options in a therapeutic class, pricing and factors promoting optimal drug utilization can vary. Step therapy drugs require a trial of clinically appropriate alternative(s) before allowing coverage for the non-preferred medications.
Physician Administered Drugs / Medical Injectables / Specialty Pharmacy
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.
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.
Medication administration training/assistance
Prescription Drug and Vendor List, Drug Search, Updates
UnitedHealthcare Community Plan of Nebraska
Preferred Drug List
The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by the Nebraska Department of Medicaid. The Preferred Drug List is produced by the state of Nebraska.