Pharmacy Resources and Physician Administered Drugs
COVID-19 NY State PPE Fee Guidance
The New York State Department of Financial Services (DFS) recently issued guidance stating that care providers should not charge members additional fees for items such as personal protective equipment (PPE). DFS expects New York care providers to refund any of these charges paid by the member that were more than the member’s financial responsibility on a claim. If you have questions, please contact your provider advocate or network management contact. Thank you.
Additional COVID-19 Information and Resources
Additional COVID-19 Information and Resources are available including vaccine, testing, treatment, coding and reimbursement levels, telehealth services, prior authorization and ongoing patient care in addition to practice administration and credentialing and contracting processes.
New York Pharmacy Program Changes Effective April 1, 2023
Beginning April 1, 2023, all Medicaid members enrolled in UnitedHealthcare Community Plan and UnitedHealthcare Wellness4me will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.
Information about the transition of the pharmacy benefit from UnitedHealthcare Community Plan and UnitedHealthcare Wellness4me to NYRx, the Medicaid Pharmacy Program can be found HERE.
General information about NYRx, the Medicaid Pharmacy Program, can be found HERE, along with information for MEMBERS and PROVIDERS.
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.
Opioid Program and Resources
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.
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.
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.
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.
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
Child Health Plus
Preferred Drug List
The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Child Health Plus.