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January 01, 2023

Medication Sourcing drug list updates

Updated specialty pharmacy requirement includes 3 new specialty drugs and 1 new complex and rare disease drug.

Effective for dates of service on or after April 1, 2023, we’re adding the following specialty medications to the specialty pharmacy requirements drug list for UnitedHealthcare commercial plans. This applies to outpatient hospitals only for specialty and oncology supportive care drugs and to all outpatient places of service for certain complex and rare disease drugs.

Medication name Therapeutic class Code Specialty pharmacy
Xenpozyme™* Enzyme replacement therapy J3490
J3590
C9399
Kroger Specialty Pharmacy
Option Care Health
Spevigo®* Inflammatory conditions J3490
J3590
C9399
To be determined 
Tzield™* Immune modulator J3490
J3590
C9399
To be determined 
Hemgenix** Cellular therapy J3490
J3590
C9399
To be determined 
*Specialty or oncology supportive care drug (outpatient hospital only)
**Complex & rare disease drug (all outpatient places of service)

We’ll announce the specialty pharmacies that will supply these drugs prior to April 1, 2023.

Specialty pharmacy requirement

Providers are required to obtain the medications linked above from the indicated specialty pharmacies, unless otherwise authorized by us. When the specialty medication is obtained through the specialty pharmacy, the specialty pharmacy will bill us directly for these medications under the member’s medical benefit. The facility administering the specialty drug is not to bill us for the medication obtained through the specialty pharmacy.

Questions?

Please contact your Network Management or Provider Relations teams.

PCA-1-22-04117-PH-NEWS_12132022
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