Pharmacy Resources and Physician Administered Drugs

UnitedHealthcare Community Plan’s Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

Texas allows certain supplies (Limited Home Health Supplies or LHHS) that are covered benefits of Texas Medicaid to be provided by a pharmacy benefit.

Our network of pharmacies will be allowed to provide a limited set of basic home health supplies to clients enrolled in Medicaid (STAR and STAR+PLUS members).

More information regarding this program, including a list of supplies available through the Texas Medicaid Preferred Drug List (PDL).

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.

• Texas Maximum Allowable Cost (MAC) Price Lookup
• Maximum Allowable Cost Appeal Submission Guide
  
• Maximum Allowable Cost List Administration

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

• Medicated Assisted Treatment: Locate a Provider (Last Modified 10.01.2017)
• Naloxone Coverage for UnitedHealthcare Members (Last Modified 01.12.2018)
• Naloxone: What You Need to Know (Last Modified 11.15.2017)
• Opioid Tapering Recommendations (Last Modified 02.02.2018)
• Opioid Use Disorder (Last Modified 03.05.2019)
  
• The Role of Dentists in Managing Opioids (Last Modified 02.01.2018)
• Treatment Alternatives for Common Pain Conditions (Last Modified 02.08.2018

Other Resources

• Agency for Healthcare Research and Quality (AHRQ): Interagency Guideline on Prescribing Opioids for Pain
• Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain
• Centers for Disease Control and Prevention (CDC): CDC Opioid Overdose Guideline Resources 
• Substance Abuse and Mental Health Services Administration (SAMHSA): The Role of Prevention in Addressing Neonatal Abstinence Syndrome 

• Pharmacy Drug-Specific Paper Prior Authorization Forms
• Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

• OptumRx Pharmacy Manual: Review in conjunction with the Texas Pharmacy Provider Manual 
• UnitedHealthcare Community Plan of Texas Pharmacy Care Provider Manual
  

Other Helpful Resources

• Provider Training
• Additional Care Provider Manuals

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.

Network 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:

• BriovaRx 855-427-4682

Additional Specialty Pharmacies 

The following specialty pharmacies also provide certain types of specialty medications:

• Accredo (Nursing Services) 800-803-2523
  • Enzyme Deficiency
  • Gaucher's Disease
  • Immune Globulin
  • Pulmonary Hypertension
• Option Care (Nursing Services) 866-827-8203
  • Enzyme Deficiency
  • Gaucher's Disease
  • Hemophilia
  • Immune Globulin
  • Makena
• CVS Caremark Specialty Pharmacy 800-237-2767
  • Pulmonary Hypertension

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. 

• Preferred Diabetic Supply Changes Effective Oct. 1, 2018: Insulin Syringes and Pen Needles
• Preferred Test Strips & Meters Effective Jan. 1, 2016
  

Preferred Drug Lists and Formulary Look Up Tool

Formulary Look Up Tool

The Formulary Look Up Tool is a list of FDA-approved drugs and coverage. You can search by drug name, therapeutic class and status tier.

• Formulary Lookup for Texas CHIP
• Formulary Lookup for Texas STAR, STAR Kids and STAR+PLUS

UnitedHealthcare Formulary Look Up Tool

The Formulary Look Up Tool is a list of FDA-approved drugs and coverage. You can search by drug name, therapeutic class and status tier.

• UnitedHealthcare Community Plan Formulary Lookup for Texas CHIP
• UnitedHealthcare Community Plan Formulary Lookup for Texas STAR, STAR Kids and STAR+PLUS

Preferred Drug List (PDL) Search

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by the STAR, STAR Kids and STAR+PLUS Programs.

• UnitedHealthcare Community Plan STAR, STAR Kids, STAR+PLUS Preferred Drug List Search

Preferred Drug List Updates

• 10/1/2018 PDL Update

Additonal Pharmacy Program Information

• Medicaid / CHIP Vendor Drug Program