Find pharmacy information related to prescription drugs including prescription drug lists, step therapy, quantity limits and prior authorization requirements for Community Plan care providers.
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.
Medically Frail Criteria
To be determined medically frail, the member must either:
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:
Attn: Heritage Health Adult Medically Frail Determinations
P.O. Box 95026
Lincoln, NE 68509
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.
Contact the OptumRx Help Desk at 877-231-0131. Support is available 24 hours a day, 7 days a week.
Contact our Pharmacy Prior Authorization line at 800-310-6826.
Contact our Provider Service Center at 866-331-2243.
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 : firstname.lastname@example.org
Toll Free: 800-284-0626
Specialty pharmacy medications covered under the member’s medical benefit may be obtained through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.
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 pharmacy:
The following specialty pharmacies also provide certain types of specialty medications:
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.
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.