New specialty pharmacy requirements
New drug added and updated requirements for UnitedHealthcare Oxford and UnitedHealthcare Freedom Plans
Effective for dates of service on or after Dec. 1, 2022, we will require participating outpatient hospitals to obtain the oncology supportive care drugs listed on the Specialty Pharmacy Requirements Drug List for UnitedHealthcare Oxford and UnitedHealthcare Freedom Plan members from indicated specialty pharmacies, unless otherwise authorized by UnitedHealthcare.
Oncology drug billing
If the oncology supportive care drug is obtained through an indicated specialty pharmacy, it will bill UnitedHealthcare Oxford or UnitedHealthcare Freedom Plans directly for the drugs under the member’s medical benefit. Outpatient hospitals may not seek any reimbursement from the member for the medication.
We anticipate the contracted specialty pharmacies will be able to supply the requested specialty medications to be administered in an outpatient hospital.
In addition, effective for dates of service beginning on or after Dec. 1, 2022, 1 more specialty drug will be subject to the UnitedHealthcare requirement to use a specialty pharmacy for certain medications for outpatient hospital providers that participate in UnitedHealthcare commercial plans.
| Medication name | Therapeutic class | Code | Specialty pharmacy |
|---|---|---|---|
| Skyrizi™ | Inflammatory conditions | C9399 J3490 J3590 |
To be announced* |
*We will announce the specialty pharmacies for this drug prior to Dec. 1, 2022.
Specialty pharmacy requirement
Outpatient hospitals are required to obtain the medications linked above from the indicated specialty pharmacies for administration of these medications, unless otherwise authorized by us. In the event the specialty medication is obtained through the specialty pharmacy, it will bill us directly for these medications under the member’s medical benefit.
Questions?
Please contact your Network Management or Provider Relations teams.
