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Drug Lists and Pharmacy

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UnitedHealthcare now offers the option to enroll in emailing clinical information for prior authorization and appeal requests for Medicare pharmacy claims. This process will allow you to send and receive clinical documents in a secure, HIPAA-compliant, electronic environment, allowing you more time with your patients and less time on paperwork.

Video: Learn how to save time by sending and receiving documents electronically

Review these documents for more information about prior authorization requirements and medical necessity coverage criteria for Part B medications that have utilization management programs in place.

Learn more about Medicare Prior Authorization and Notification

These UnitedHealthcare reference documents provide prior authorization, notification and medical necessity coverage criteria for medications with utilization management programs in place.

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).

Find Commercial Pharmacy Specific Step Therapy Programs.

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.

Learn more about the Specialty Pharmacy Program.

Members who have questions about their specialty drug coverage should call the Customer Service number listed on the back of their 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.

Resources from UnitedHealthcare and Optum

Other Resources

UnitedHealthcare is confronting the opioid epidemic from all angles. We’re joining with care providers and communities to prevent opioid misuse and addiction. Through touch points, we help support safe and appropriate opioid use right from the start.

To help with this effort, we developed the following UnitedHealthcare pharmacy-based programs to align with The Centers for Medicare and Medicaid Services (CMS) Medicare Part D Opioid Overutilization Policy.

These programs are specific to UnitedHealthcare Medicare Advantage and Prescription Drug Plans.

Resources from UnitedHealthcare

The following formularies are unique to individuals covered under The New York State Empire Plan.

UnitedHealthcare Oxford offers these pharmacy resources to help care providers manage prescription drug coverage and ensure appropriate use of medications for members.

In addition to other applicable clinical programs as noted in the Prior Authorization, Step Therapy, and Specialty Pharmacy sections, the programs below are uniquely for Oxford lines of business.

Pharmacy Partners and Affiliates

Learn more from these UnitedHealthcare partners and affiliates.

Pharmacies and Pricing

At Optum® Infusion Pharmacy, our pharmacists, nurses, patient care coordinators and benefits experts deliver full-service acute and chronic specialty infusion care, so you and your patients can focus on treatment, not obstacles.

Licensed in 50 states, Optum Infusion Pharmacy serves infusion patients nationwide:

  • >50 pharmacy locations
  • 50 sterile compounding facilities
  • 40 ambulatory infusion suites
  • >1,100 Optum-employed nurses

Areas of excellence

  • Anti-infectives
  • Biologics
  • Chemotherapy/oncology
  • Inotropics/cardiac therapy
  • Parenteral and enteral nutrition
  • Hemophilia and Bleeding Disorders
  • Immunoglobulin (IVIG and SCIG) therapy across multiple specialties, including:
    • Allergy/Immunology
    • Dermatology
    • Hematology/Oncology
    • Infectious disease
    • Neurology
    • Rheumatology

For IG support, locate an IG care specialist near you.

Top five reasons to refer to Optum Infusion Pharmacy

1. Patient access, safety, convenience and care

We offer home infusion and are adding infusion pharmacy locations, services and nationwide. Choose the most convenient setting for each patient’s medication and dose regimen, whether it’s home infusion or an infusion suite with a reclining chair, television and free Wi-Fi.

Patient safety

Our nurses and infusion staff are specially trained in infusion care.

<0.5% of patients have an adverse event or an unplanned hospitalization due to an infection, adverse drug reaction, vein trauma or other treatment complication.1

2. Proactive service

We help resolve insurance denials, geographical challenges, cost concerns and more, so that treatment can continue uninterrupted. We’re in-network for most major insurance carriers, and our site-specific teams are experts in regional insurance requirements.

Our experienced appeals team, made up mostly of nurses, overturns 8 out of 10 insurance denials.2

3. Clinical expertise, personalized care

Our pharmacists ensure safe, seamless care whether treatment is administered by a nurse or patients themselves. Disease-specific nurses empower patients and caregivers by educating them on the condition, treatment, self-administration if applicable, and more.

4. Patient comfort and resources

For patients who use home infusion, we ship and, if needed, hand-deliver medication, supplies and instructions to their home. Patients have access to disease-specific education, video libraries of others’ treatment experiences, and 24/7 face-to-face video consultations with a disease-expert clinician.

5. Frequent sales team communication

We stay in direct contact with you while we monitor labs, tolerance, adherence and clinical status throughout treatment.

To learn more about infusion services, visit infusion.optum.com or call 1-877-342-9352.

For hemophilia, call 1-855-855-8754.

For IG, locate a care specialist near you. 

Or, to start referring patients, locate our referral forms

References
1. Optum internal data. 2021.
2. Optum Specialty Pharmacy. Internal analysis. 2020

 

 

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.

Evidence-Based Care

Pharmacy is one of the most highly used benefits. Our goal is to provide members with wide-ranging, cost-effective medication choices. 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.

Member Engagement

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.

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.