Clinical Pharmacy and Specialty Drugs Prior Authorization Programs
Select medications may require notification and review to determine coverage under the member's pharmacy benefit. Members or their providers may be required to provide additional information to UnitedHealthcare to determine if the medication is covered under the member's pharmacy benefit.
The criteria used to determine benefit coverage for the Notification programis based on FDA approved uses of the medication and medication labeling, which look at drug and diagnosis.
Medical Necessity goes beyond drug and diagnosis and takes into consideration other factors. Medical Necessity evaluates the clinical appropriateness of a medication in terms of condition being treated, severity of condition, type of medication, frequency of use and duration of therapy.
Step Therapyhelps to encourage the use of less expensive, but similarly effective medications. Step therapy requires members to try a lower-cost medication (known as step 1) before progressing to a higher-cost alternative (known as step 2).
Supply Limitsare based on several factors including Food and Drug Administration (FDA) approved dosing, medical literature and other supportive and analytic data. Quantity Duration (QD) limits define the maximum quantity of medications that may be covered in a specified time period (for example: 30 units or 1,000 mg per month). Quantity Level Limits (QLLs) define the maximum quantity of medications that may be covered per prescription or copayment (for example: 30 units per prescription).
Several states have enacted legislation requiring that exception requests must be approved if the member meets certain conditions or situations. Please contact the OptumRx Prior Authorization department at 1-800-711-4555 or https://professionals.optumrx.com/prior-authorization.html to determine if you qualify for an exception.
Check current prescription coverage and price, including out-of-pocket prescription costs for UnitedHealthcare members at their selected pharmacy with the PreCheck MyScript Tool in the UnitedHealthcare Provider Portal.
Get information on lower-cost prescription alternatives, if available, to help save members money.
See which prescriptions currently require prior authorization, or are non-covered or non-preferred.
Request prior authorization and receive status and results.
These programs promote the application of current, clinical evidence for certain specialty drugs. Prior authorization is required for outpatient and office services for those specialty drugs specified by the member’s benefit plan.
Prior authorization is not required for specialty drugs that are appropriately billed and administered during an inpatient stay or in:
An emergency room
An observation unit
An urgent care facility
Program requirements apply to all participating physicians, health care professionals, facilities and ancillary providers that order or administer specialty drugs covered by the program. If the prior authorization requirements are not met, claims may be denied, and the member cannot be billed for those services.
If clinical criteria or drug policy criteria as specified in the member’s benefit plan is not met, coverage may be denied. If denied, we’ll send denial notices to both the member and the care provider, along with information on our appeal process.
There are some variations in the list of specialty drugs that require prior authorization depending on plan type.
Commercial Specialty Drug Prior Authorization Program
For in-scope services provided in an office or outpatient setting, a physician or other health care professional may request prior authorization on an urgent or expedited basis. This applies to cases where there is a medical need to provide the service sooner than the conventional prior authorization process would allow.
Community Plan Specialty Drug Prior Authorization Program
Physicians are required to request prior authorization before administering certain drugs covered under medical benefits for UnitedHealthcare Community Plan members, including members who are currently on therapy.
Prior authorization for these medications is NOT required for services that take place in an emergency room, observation unit, urgent care facility or during an inpatient stay.
Please use the forms below to request prior authorization for drugs covered under the medical benefit. For forms to request prior authorization for drugs covered under the retail pharmacy benefit, please visit the OptumRx Healthcare Professionals Portal.