This pharmacy bulletin outlines new or revised clinical programs and implementation dates. It’s available online for UnitedHealthcare commercial and UnitedHealthcare Oxford commercial plans.
Outpatient Procedure Grouper mapping update On July 1, 2021, the UnitedHealthcare Outpatient Procedure Grouper (OPG) Exhibit will be updated to reflect quarterly reimbursement for outpatient and other procedures for commercial members.
New codes added to the prior authorization list Starting July 1, 2021, we’re adding additional codes to the prior authorization list for UnitedHealthcare Medicare Advantage plans and some UnitedHealthcare Community Plans (Medicaid, Long-Term Care).
Genetic and Molecular Testing
Genetic and molecular lab testing updates
We’re making some changes to our Genetic and Molecular Lab Testing Program, including new requirements for prior authorization and lab test registration. These changes apply to UnitedHealthcare plans that currently require prior authorization for certain genetic and molecular tests performed in an outpatient setting through BeaconLBS.
Coverage for preimplantation genetic testing Starting July 1, 2021, preimplantation genetic testing (PGT) will be covered as a standard benefit for eligible UnitedHealthcare commercial plan members when they or their partners are carriers for a specific genetic disorder.
Maternity claim submission requirement coming StartingJuly 1, 2021, all participating health care professionals and inpatient acute care facilities must report gestational age on maternity claims using the appropriate diagnosis code. This requirement is for commercial plans.
Prior authorization for anti-emetics Effective July 1, 2021, prior authorization is required for 8 anti-emetics codes for members with a cancer diagnosis. (Prior authorization requirements for outpatient injectable chemotherapy are not affected by this addition.) This requirement is for UnitedHealthcare Community Plan, Exchange and commercial plan members who require prior authorization today for outpatient injectable chemotherapy.
Specialty Pharmacy Drug List update Effective July 1, 2021 we’re adding 2 specialty medications, OxlumoTM and Amondys-45, to our Specialty Pharmacy Requirements Drug List for UnitedHealthcare commercial plans.
State and regional updates
Change in post-acute care management
Arizona, Colorado, Iowa, Michigan, Minnesota, North Dakota, Nebraska, South Dakota Effective June 1, 2021,NaviHealth will start managing certain post-acute care administrative processes for Medicare Advantage members.
New prior authorization for CGM
Arizona, California, Florida, Hawaii, Kansas, Kentucky, Maryland, Massachusetts, Michigan, New York, Ohio, Pennsylvania, Rhode Island, Texas, Virginia, Washington, Wisconsin.
Prior authorization will be required for personal long–term continuous glucose monitors (CGM) used for the management of type-2 intensive insulin and gestational diabetes. The durable medical equipment (DME) vendor or other rendering provider that has received a physician order for a CGM is required to obtain prior authorization. This requirement is for Medicaid, Long-Term Care and Medicare-Medicaid (MMP) plan.
Alabama and Georgia: Home health review process changes Effective July 1, 2021, for UnitedHealthcare Medicare Advantage and Dual Special Needs Plans, we will be launching a pilot program for the implementation of an initial authorization and continuation of care reviews for Home Health Agencies (HHAs).
Maryland: Plan changes in Prince George’s and Charles Counties Effective April 1, 2021, Prince George’s and Charles counties will no longer be part of the capitated radiology program for our Gated health maintenance organization (HMO) (M.D. IPA and Optimum Choice) members. Effective on that date, members who previously had RAD=PG and RAD=CHRLS on their member ID cards will have access and may be referred to the full contracted radiology network