Find pharmacy information related to prescription drugs including prescription drug lists, step therapy, quantity limits and prior authorization requirements for Community Plan care providers.
Clinical and non-clinical policies (ex. Denied Drug Codes – Pharmacy Benefit Drugs) for Physician Administered Drugs/Medical Injectables are available at Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines.
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 (AWP) and Wholesaler Acquisition Cost (WAC), 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.
MAC lists are reviewed twice weekly with additional updates implemented on an as-needed basis based on market forces and other additional information.
For Washington Medicaid MAC inquiries, please contact OptumRx through email at firstname.lastname@example.org.
If you believe a specific claim was paid incorrectly, please see the MAC appeals submissions guide for instructions. The MAC Appeals form can be downloaded from the submissions guide website.
MAC appeals contact information
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.
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.
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.
Specialty pharmacy medications covered under the member’s medical benefit may be provided 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 pharmacies:
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 UnitedHealthcare Community Plan Apple Health.