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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.  

Prior Authorization Information for Your Patient’s Medicaid Pharmacy Benefit

The Heritage Health Adult program expands Medicaid coverage to adults ages 19 to 64 whose income is at or below 138 percent of the federal poverty level. Heritage Health Adult members are enrolled in managed care plans through the existing Heritage Health Program.

Benefit Tier Requirements

Unlike existing Medicaid-eligible individuals participating in the Heritage Health program, Heritage Health Adult members have a tiered benefit system with all eligible members receiving either Basic or Prime benefits.

  • Basic benefits include comprehensive medical, behavioral health and prescription drug coverage.
  • Prime benefits include Basic benefits plus vision, dental and over-the-counter medications. Heritage Health Adult members will receive Prime benefits if they’re one or more of the following:
    • Medically frail
    • Ages 19 or 20
    • Pregnant

Medically Frail Criteria

To be determined medically frail, the member must either:

  • Have a documented condition attested to by a qualified health care provider
  • Be identified through analysis and evaluation of historical claims data performed by a Medicaid managed care organization or information supplied by the Nebraska Department of Human Health and Human Services (DHHS) that falls into one or more of the following categories:
    • A disabling mental disorder (including serious mental illness)
    • A chronic substance abuse disorder
    • A physical, intellectual or developmental disability with functional impairment preventing the member from performing one or more activities of daily living for each activity occurrence
    • A disability determination based on Social Security criteria
    • A serious and complex medical condition(s)
    • Chronically homeless defined by the Department of Housing and Urban Development

Care Provider Requirements

Nebraska DHHS uses an attestation form to determine if a Heritage Health Adult member is medically frail. If you’re a care provider with diagnosing capabilities within your scope of practice, and you have a patient you believe meets the medically frail criteria, you’re required to complete the Medically Frail Attestation Form and send it to DHHS using one of the following methods:

  • Online: Upload it to dhhs.ne.gov/pages/accessnebraska.aspx
  • Email: dhhs.medfrailreview@nebraska.gov
  • Mail:

Attn: Heritage Health Adult Medically Frail Determinations

P.O. Box 95026

Lincoln, NE 68509

Resources:

Nebraska DHHS also has information on the Medicaid expansion available at dhhs.ne.gov.

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. The MAC lists are reviewed on a monthly basis.

For general contract information, contact OptumRx at 1-800-797-9798.

Pharmacies with specific claim related questions should contact OptumRx at 1-866-328-3108.

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

Rx Claims Processing Technical Assistance

Contact the OptumRx Help Desk at 877-231-0131. Support is available 24 hours a day, 7 days a week.

Pharmacy Prior Authorization Assistance

Contact our Pharmacy Prior Authorization line at 800-310-6826.

Medical Durable Medical Equipment (DME) Questions

Contact our Provider Service Center at 866-331-2243.

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.

 If you would like to be contracted for DME services offered to UnitedHealthcare Community Plan - Heritage Health members, contact Sr. Network Account Manager Angela Hogan at: 

Email : angela_hogan@uhc.com
Phone: 952-406-4955
Toll Free:  800-284-0626
Fax:  888-868-5011

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.

Additional Pharmacy Resources