The Specialty Pharmacy Program supports the health care provider/patient relationship to help better manage rare and complex chronic conditions. Here are answers to common questions that may help you assist patients/members in maximizing their specialty pharmacy benefits.
You and your patients can search for specialty pharmacies on the UnitedHealthcare General Plan Directory or by calling the 800 number on the back of their Member ID card.
How to Search for a Specialty Pharmacy:
- Go to UnitedHealthcare General Plan Directory
- Pick the Plan > by Name
- Enter your ZIP Code > and pick a Place
- Select from Convenience Clinic or Urgent Care to find a list of local pharmacies.
*Subject to state specific requirements
Frequently Asked Questions about Prescription Drug Benefits
The Specialty Pharmacy Program gives members and health care professionals the tools they need to manage members’ covered medications.
The Specialty Pharmacy Program offers UnitedHealthcare members access to nationally contracted specialty pharmacies. You and your patients can find specialty pharmacies on the UnitedHealthcare General Plan Directory or by calling the 800 number on the back of their Member ID card.
After speaking with a specialty pharmacist, members may receive a welcome kit which includes educational resources and information. Members are then contacted each month to set up their refills. Members may also be eligible for clinical management and/or adherence programs depending on the medications they're taking.
The Specialty Pharmacy Program is designed to support your treatment plan for specialty conditions and facilitate the physician/patient relationship. This program can help your patient receive cost-effective care by finding out if his or her medication has specific protocols or an optimal place of service. This program also helps your patients use the right medications for their condition.
For information about specialty medications for patients who are UnitedHealthcare members please refer to the UnitedHealthcare Care Provider Administrative Guide.
For information about the specific drug policy for specific medications, refer to Commercial Medical & Drug Policies and Coverage Determination Guidelines.
For information about prior authorization and notification requirements, refer to Clinical Pharmacy and Specialty Drug Prior Authorization and Notification.
Yes. Patients using specialty medications may have conditions that require support and coordination. Certain specialty medications may be subject to:
- Drug Policies − UnitedHealthcare's evidence-based criteria for clinical use
- Administrative Guide Protocols − Mandatory sourcing through participating specialty pharmacies
- Supply Limits − Maximum days’ supply or quantity of medications that can be dispensed or billed at one time
- Notifications − Providers must submit clinical information about the member in order for a covered prescription to be dispensed
Some specialty medications have procurement protocols as described in the UnitedHealthcare Physician, Health Care Professional, Facility, and Ancillary Provider Administrative Guide.
Your patient can contact the specialty pharmacy directly to enroll in a clinical management and medication adherence program.
A specially trained pharmacist routinely assesses your patient's specialty medication regimen to make sure it is achieving the desired results. The pharmacist may ask you to clarify a diagnosis or dosage. They may also notify you of an adverse drug effect, drug interaction, adherence issue, or depression screening outcome.
Specialty medications given by a health care professional are most commonly stocked in your office, clinic, or are provided to members by a nurse from a home infusion provider, depending on the benefit plan.
UnitedHealthcare supports an Average Sales Price (ASP)-based physician fee schedule as a cost-efficient means to reimburse covered medications and leave the sourcing through "buy and bill". This can improve convenience both for the care provider and member and help to prevent drug waste.
If "buy and bill" is not an option for certain medications, you may use one of UnitedHealthcare's contracted specialty pharmacies or direct your patient to use an infusion provider. The medications can be delivered to your office or clinic or to your patient at an infusion center or through a home health care service.
United Healthcare contracts with select specialty pharmacies to provide availability of medications for our members. The national specialty pharmacy network includes:
- Optum Infusion Services FKA BriovaRx Infusion Services
- Optum Pharmacy FKA BriovaRx Specialty Pharmacy
- Option Care Health
Optum Infusion Services / Optum Pharmacy FKA BriovaRx
- General Enrollment Form
- Botulin Toxins Enrollment Form
- Synagis / Season Respiratory Syncytial Virus (RSV) Enrollment Form
Medication Sourcing Expansion Specialty Pharmacy Forms:
- Accredo Health Group
- Option Care Health
- Optum Infusion Pharmacy
- Optum Pharmacy (Specialty)
- Orsini Pharmaceutical Services: