Optum – an affiliate company of UnitedHealthcare – manages prior authorization requests for certain medical benefit injectable medications for UnitedHealthcare commercial plan members. This includes the affiliate plans UnitedHealthcare of Mid-Atlantic, Inc., Neighborhood Health Partnership and UnitedHealthcare of the River Valley.
The process is designed to ease the administrative burden of obtaining a prior authorization, while also reducing the turnaround time for a determination. The system will document clinical requirements during the intake process and prompt providers to provide responses to the clinical criteria questions.
For certain specialty medications, UnitedHealthcare requires providers to use a lower-cost specialty medication before coverage for a clinically similar, higher-cost medication. The initial lower-cost specialty medication is known as the “preferred product.” As part of our preferred product strategies, we may also require providers to prescribe clinically appropriate, lower-cost, self-administered medications available through the pharmacy benefit before we’ll cover infused or provider-administered medications administered through the medical benefit.
UnitedHealth Group aims to improve cost efficiencies for the overall health care system. One way we do that is by conducting site of care medical necessity reviews. The utilization review guideline we use to help facilitate our site of care medical necessity determinations for services is available at UHCprovider.com/policies, or choose from one of these links:
Medication sourcing is a phrase used when an infusion provider (physician or facility) receives a specialty medication from an outside specialty pharmacy (sourced) and the patient visits the physician’s office or infusion facility for administration.
If the medication does not have a sourcing requirement, providers can “buy and bill.” “Buy and Bill” is when a physician purchases a medication directly from a specialty distributor or pharmaceutical wholesaler, administers the medication to a patient and submits a claim for reimbursement for the drug and any other medical services.
To learn more about which medications have a sourcing requirement, consult the following resources:
Our new specialty pharmacy requirements, known as the Medication Sourcing Expansion protocol, apply when a medication is provided in the outpatient hospital setting. This protocol requires the facility to obtain certain specialty medications from participating specialty pharmacies.
If the medication does not have a sourcing requirement, providers can “buy and bill” the medication. To learn more about which medications are included in the MSE protocol, consult the following resources: