Pharmacy Resources and Physician Administered Drugs
Community Plan Prior Authorization Guidelines for Prescribers
Requesting prior authorization electronically saves time and reduces potential prescription interpretation errors. Authorization determination can be immediate but generally takes no more than 24 hours. You can use the following resources for help with your request:
CoverMyMeds streamlines the pharmacy prior authorization process by electronically connecting providers and pharmacists to improve time to therapy and decrease prescription abandonment.
Integrated directly with your EMR, PreCheck MyScript® allows you to easily run a pharmacy trial claim and get real-time prescription coverage details for your patients who are UnitedHealthcare benefit plan members.
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.
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 patients' 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.
Specialty Program Description
UnitedHealthcare Community Plan administers a Specialty Pharmacy Management Program that provides high quality, cost effective care for our members. This program optimizes the patient experience and clinical outcomes by utilizing a network of specialty pharmacies that offer clinical programs which include, but are not limited to, educating and supporting our members concerning their chronic condition(s), promoting medication adherence and reducing the risk of side effects, and promoting multi-disciplinary practice and collaboration to achieve continuity of care.
Our network specialty pharmacies are selected based on their clinical expertise, the quality of clinical management and adherence programs provided, and overall cost of therapy. Specialty pharmacy providers are specifically trained on specialty medications, the conditions they treat, and can provide comprehensive clinical services. The contracting / credentialing process ensures consistency with the requirements, the highest level of quality provided to members, and access to all specialty pharmacy medications.
The specialty pharmacies provide patient education and training, not only for the medication, but also the chronic condition being treated. The specialty teams proactively reach out to patients each month prior to refilling their prescription. During this outreach, patients are asked if they have questions about their condition or drugs, and if they would like to speak directly to a clinician. Medication adherence is also checked, with any potential issues identified and addressed. Additionally, their Member Support Services provides patients with access to a clinician trained in their condition and drug therapy 24 hours a day, 7 days week.
Some of the services our network specialty pharmacies offer include:
Expedited delivery to the member’s home or physician’s office
Proper handling and packaging according to the product’s storage requirements, with instructions provided for the member if any refrigeration or special storage conditions exist.
Patient-friendly educational material that includes drug information which speaks to medication administration and compliance.
Offer education on the indication for each medication including supplements and over the counter (OTC) products
Discuss possible adverse drug reactions and drug interactions between medications and food and remind patients to communicate about any side effects of prescription medications, OTC products or supplements
Assess medications that are not prescribed for a current diagnosis or are no longer effective and update the medication list at each visit using the medication reconciliation form
Review duplicative medications and ways to simplify the medication regimen
Identify Social Determinants of Health (SDoH) and other barriers to medication adherence
Suggest medication schedules and the importance of compliance
Talk about the importance of reviewing medications during transitions of care (within 7 and 30 days of hospitalization) and at each visit
Consider offering 90-day prescriptions, pill boxes, pill packs, mail order and other resources, as clinically appropriate
For more information about how our programs can help support your patients, check out our online resources:
Go to UHCprovider.com/pcms for more information for PrecheckMyscript to get real time, accurate, patient specific prescription data, lower cost alternative prescription options per state PDL requirements, request prior authorization and get results
Patient Care Opportunity Report (PCOR) is a monthly report you can use to identify your patients’ adherence to preventive screenings and treatments. To access your PCOR, go to UHCprovider.com and click the Sign In button in the top right corner. Then click Documents & Reporting > Physician Performance & Reporting > Open My Reports.
PATH is our quality care program that provides specifications for many of the quality measures and tools used to address care opportunities, as well as how to report data, and what billing codes to use. Learn more about PATH, its features and additional tools at UHCprovider.com/path or contact your physician advocate.
Provider Express is our behavioral health site that connects health care professionals to clinical and administrative resources and educational information. To access these resources and more, go to providerexpress.com and log in. You’ll need to create a profile if you’re a first-time user
Questions? For more information or UnitedHealthcare online resources, reach out to your physician advocate directly or call Customer Service at 888-887-9003.
Medical Necessity Supporting Documentation
When supporting documentation is necessary to determine medical necessity in a prior authorization review, the forms below should be faxed to 866-940-7328.
Use a drug-specific form if available. Otherwise, you can use the Texas Department of Insurance form for any prescription prior authorization request.
The response time for authorization determination with complete documentation is within 24 hours. It may take up to three days to receive a determination for members in the Children’s Health Insurance Program (CHIP).
If a pharmacist is unable to confirm a prior authorization for a medication that requires an authorization and the drug needs to be given without delay for the health of the member, a 72-hour supply can be dispensed. An authorization will need to later be initiated and obtained by the prescribing provider.
To be reimbursed for a 72-hour emergency prescription supply, pharmacies should submit the following information:
“Prior Authorization type Code” (Field 461-EU) = “8”
“Prior Authorization Number Submitted” (Field 462-EV) = “801”
“Day Supply” in the claim segment of the billing transaction (Field 405-D5) = “3”
If a three-day supply cannot be dispensed — inhaler, eye drops, creams — enter the quantity dispensed, but note that it is a three-day supply. If you have any questions or require assistance, please contact the OptumRx Pharmacy Help Desk at 877-305-8952 (24 hours a day, 7 days a week).
Opioid Program and Resources
At UnitedHealthcare we've 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.
If you have questions, please call our Pharmacy Help Desk at 800-310-6826. You can get answers to prescription questions and an immediate determination for a prior authorization Monday - Friday, 7 a.m. to 7 p.m. Central Time, with voicemail intake after hours.