April 01, 2022

Specialty Pharmacy Requirement updates for certain medical benefit medications

Effective for dates of service on or after July 1, 2022, we will be revising our specialty pharmacy requirements for UnitedHealthcare and Oxford commercial plan members to simplify and streamline Medication Sourcing.

Place of Service
We will continue to require participating hospitals to obtain certain specialty medications for UnitedHealthcare members from indicated specialty pharmacies, when administered in the outpatient hospital setting, unless otherwise authorized by UnitedHealthcare. The Medication Sourcing requirement for Botox®, Dysport®, Myobloc®, Xeomin®, Synagis® and Xiaflex® will apply only to participating hospitals under this revision. For these 6 specialty medications, the medication sourcing requirement will no longer apply to care providers in the following places of service:

  • Physician Office,
  • Home
  • Ambulatory Infusion

There will be no changes to the requirement for care providers who participate in UnitedHealthcare commercial plans to use a specialty pharmacy when obtaining certain specialty medications used to treat rare conditions such as:

  • Brineura®
  • Luxturna®
  • Gamifant®
  • Spinraza®
  • Zolgensma®

If the specialty drug is obtained through the indicated specialty pharmacy, the specialty pharmacy will bill UnitedHealthcare directly for the drug under the member’s medical benefit. Care providers may not seek any reimbursement from the member for the drug.

Prior Authorization
We will be adding prior authorization to the following drugs: Botox, Dysport, Myobloc and Xeomin. You don’t need to submit a new notification/prior authorization request for members who already have an authorization for these medications on the effective date noted above.

The drugs subject to Medication Sourcing can be found on the Specialty Pharmacy Requirements Drug List.

Specialty pharmacy drug list update
Effective for dates of service on July 1, 2022,
we’re adding the following specialty medications to our Specialty Pharmacy Requirements Drug List for UnitedHealthcare and Oxford commercial plans.

HCPCS code Medication Therapeutic Class Specialty Pharmacy
J3490
J3590
C9399

Apretude™

HIV

To be announced

J3490
J3590
C9399

Leqvio®

Cardiology

To be announced

J3490
J3590
C9399

Vyvgart™

Central Nervous System Agents

To be announced

J1566

Intravenous Immune Globulin

Immune Globulin

Optum Infusion
Optum® Specialty Pharmacy
 

We will announce the specialty pharmacy information for each drug prior to July 1, 2022.

Questions? Please contact your Network Management or Provider Relations teams.

PCA-1-22-00763-PH-NEWS-03222022