Specialty Pharmacy – Medical Benefit Management (Provider Administered Drugs)

Medical Benefit Specialty Injectable Drug Programs and Prior Authorization Tools

Specialty Guidance Program (SGP)

You can submit prior authorization requests online using the Specialty Pharmacy Transactions tool on Link. Access Link by clicking the blue SGP Tool button below or by clicking on the “sign in to Link” icon in the upper right corner.

  • Select the Prior Authorization and Notification tile on the Link dashboard. Then select Specialty Pharmacy Transactions to be redirected to the SGP website.

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.

Email: specialtyguidanceprogram@optum.com
Phone: 888–397–8129
Monday – Friday (7am – 7pm Central Time)

Search for Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, Utilization Review Guidelines, and corresponding update bulletins for UnitedHealthcare Commercial plans here.

  • Enterprise Prior Authorization List
    • Expand the ‘Commercial Advanced Notification / Prior Authorization Requirements’ section to find the current prior authorization requirements.

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.

Preferred product strategies can be found in their corresponding medical drug policies by searching on the individual drug policies within the Medical & Drug Policies and Coverage Determination Guidelines list.

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: