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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 health care providers.

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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

Resources

For UnitedHealthcare Community Plan and Wellness4me please refer to the NYRx, the Medicaid pharmacy program found here.

For Child Health Plus, Essential Plan, Dual Advantage, and Dual Advantage Complete® please continue to submit pharmacy prior authorizations to UHC as indicated below.

Get real-time prescription costs and coverage detail

The PreCheck MyScript Solution 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.

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 medications can be covered under the pharmacy benefit, the medical benefit or both benefits, depending on the benefit structure for the member’s coverage.

Starting April 1, 2023, for Child Health Plus, Essential Plan, Dual Advantage, and Dual Advantage Complete® bill UnitedHealthcare for pharmacy benefit medications.  For UnitedHealthcare Community Plan and Wellness4me please bill pharmacy benefit medications to NYRx, the Medicaid pharmacy program found here.

Medical benefit medications may continue to be billed to UnitedHealthcare Community Plan, Wellness4me, Child Health Plus, and Essential Plan even after April 1, 2023.

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 patient’s 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.

Prescription Drug and Vendor List / Drug Search and Updates

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Preferred Drug List 

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Child Health Plus.

To see the latest PDL updates, visit Drug Lists and Pharmacy > UnitedHealthcare Prescription Drug Lists (PDL) / Drug Formulary > Prescription Drug List Updates.

Preferred Drug List

Effective April 1, 2023 for Preferred Drug list please refer to the NYRx, the Medicaid pharmacy program found here.

Preferred Drug List

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Advantage. 

To see the latest PDL updates, visit Drug Lists and Pharmacy > UnitedHealthcare Prescription Drug Lists (PDL) / Drug Formulary > Prescription Drug List Updates.

Preferred Drug List

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete (HMO SNP). 

To see the latest PDL updates, visit Drug Lists and Pharmacy > UnitedHealthcare Prescription Drug Lists (PDL) / Drug Formulary > Prescription Drug List Updates.

Preferred Drug List

Effective April 1, 2023 for Preferred Drug list please refer to the NYRx, the Medicaid pharmacy program found here.

Additional Pharmacy Resources for Child Health Plus, Essential Plan, Dual Advantage, and Dual Advantage Complete®