Oxford specialty pharmacy requirement May 1, 2022

Effective for dates of service on or after May 1, 2022, we’re aligning the UnitedHealthcare Oxford health plan to the existing UnitedHealthcare commercial specialty pharmacy requirement.

How this affects hospitals

We’ll continue to require participating hospitals to obtain certain specialty medications for UnitedHealthcare Oxford members from indicated specialty pharmacies, unless otherwise authorized by Oxford. If the specialty drug is obtained through the indicated specialty pharmacy, the specialty pharmacy will bill UnitedHealthcare Oxford directly for the drugs under the member’s medical benefit. Hospitals may not seek any reimbursement from the member for the medication. The drugs on the Specialty Pharmacy Requirements Drug List are subject to this requirement. At this time, the UnitedHealthcare Oxford plan will not include oncology supportive care drugs. 

We anticipate the contracted specialty pharmacies will be able to supply the requested specialty medications to be administered in an outpatient hospital.

Important points

• This protocol applies to drugs dispensed in an outpatient hospital setting of participating hospitals for UnitedHealthcare Oxford plan members
• Hospitals will only need to bill UnitedHealthcare Oxford the appropriate code for administration of the medication and not for the medication itself
• This protocol doesn’t apply when Medicare or another health benefit plan is the primary payer and Oxford Health Plans is the secondary payer
• We may deny payment to hospitals that fail to follow the protocol and the hospital won’t be able to bill members for the medications
• The list of specialty medications is subject to change upon a 90-day written notice

If you have questions about how this applies to your facility, please contact your network contract manager.

Questions?
Please contact your provider advocate or network contract manager.

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