Total Health Care Approach
UnitedHealthcare makes pharmacy coverage decisions based on an understanding of how our coverage affects total health care. We do this by integrating pharmacy coverage with medical management, accessing information in a database including pharmacy, medical and laboratory data.
Pharmacy is one of the most highly used benefits. Our goal is to provide members with wide-ranging, cost-effective medication choices. Therefore, we review clinical and pharmacoeconomic evidence when developing our prescription drug list (PDL) and clinical programs. This evidence helps us determine a medication's overall value relative to other medications in its class so we can effectively manage overall cost and care.
Our personalized member engagement strategies aim to make health care work better for members. When provided with the right resources, a member can be empowered to discuss their options with their care providers and help make more educated decisions.
Check current prescription coverage and price, including out-of-pocket prescription costs for UnitedHealthcare members at their selected pharmacy with the PreCheck MyScript App on Link.
- 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 UnitedHealthcare reference documents provide prior authorization, notification and medical necessity coverage criteria for medications with utilization management programs in place.
The Prescription Drug List (PDL) is a list of prescription medications commonly chosen by doctors and pharmacies. Prescription drug coverage varies by member benefit plan.
- Prescription Drug List - Jan. 1, 2018
- Prescription Drug List ‒ July 1, 2017
- Summary of Prescription Drug Lists for UnitedHealthcare and OptumRx Pharmacy Benefit Plans
We combine clinical and pharmacoeconomic data to define a medication's overall value in its class so we can effectively manage overall cost and care.
UnitedHealthcare’s Step Therapy program helps encourage use of less expensive, but similarly effective medications. Members must try a lower-cost medication (known as step 1) before progressing to a higher-cost alternative (known as step 2).
Supply limits are 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).
Specialty pharmacies focus primarily on specialty medications that need special handling and storage. They can also provide extra services such as clinical support and education for members.
Members who have questions about their specialty drug coverage can call the Customer Service number listed on the back of the Medical ID Card.
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.
- Opioid Overutilization Cumulative Drug Utilization Review Criteria
- Short-Acting Opioid Review Criteria for opioid naive members
- Quick Reference Guide: Opioid Overutilization Prevention and Opioid Use Disorder Treatment Programs
Additional resources from UHC and Optum
- Dentists Managing Opioids
- Locate a Medication-Assisted Treatment Provider
- Naloxone Coverage for UnitedHealthcare Members
- Naloxone: What You Need to Know
- Non-Opioid Alternatives for Treating Pain
- Office-Based Opioid Treatment (OBOT) Behavioral Clinical Policy (Optum Behavioral)
- Opioid Tapering Guide
- Opioid Treatment Program (Maintenance Therapy) Behavioral Clinical Policy (Optum Behavioral)
- OptumRx quantity limit changes effective July 1, 2017
- Member Brochure: Learn to Safely Use Opioid Medications
- Agency for Healthcare Research and Quality (AHRQ) Interagency Guideline on Prescribing Opioids for Pain
- Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain (2016)
- CDC Fact Sheet (2016)
- CDC Opioid Overdose Guideline Resources
- National Initiative on Pain Control (NIPC) Pain Assessment Scales
- Opioid External Resources Flyer for Providers
UnitedHealthcare Oxford offers these pharmacy resources to help care providers manage prescription drug coverage and ensure appropriate use of medications for members.
- Cardiovascular Disease - Oxford
- Diabetes Medications – DPP4 Inhibitors – Oxford
- Diabetes Medications – SGLT2 Inhibitors – Oxford
- Erectile Dysfunction Agents – Oxford
- Insulin – Oxford
- Select Brand Medications – Oxford
- Test Strips – Oxford
- Triptans Supply Limits - Oxford
For additional information visit, UnitedHealthcare Oxford Health.
- Drugs with Clinical Programs
- Opioid Overutilization Prevention and Opioid Use Disorder Treatment Programs
- Pharmacy Update: Notice of Changes to Prior Authorization Requirements and Coverage Criteria for UnitedHealthcare Commercial and UnitedHealthcare Oxford Plans - Effective May 1, 2018.
Learn more from these online partners and affiliates:
- BriovaRx Patient Care
- UnitedHealthcare Community Plan for Medicaid
- UnitedHealthcare Medicare
- UnitedHealthcare Neighborhood Health Partnership
- UnitedHealthcare Oxford Health
- UnitedHealthcare of the River Valley
Pharmacies & Pricing
NOTE: The information on this website is intended to provide general pharmacy information for care providers. The information on this site is NOT specific to a member’s benefit plan.