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October 2018: Updates to Notification/ Prior Authorization Requirements for Specialty Medical Injectable Drugs for UnitedHealthcare Commercial, Community Plan and Medicare Advantage Members

We’re making some updates to our coverage review requirements for certain specialty medications for many of our UnitedHealthcare commercial, Community Plan and Medicare Advantage members. Implementing these requirements is important to us to provide our members access to care that’s medically appropriate as we work toward the Triple Aim of improving health care services, health outcomes, and overall cost of care. These requirements will apply whether members are new to therapy or have already been receiving these medications.

If you administer any of these medications without first completing the notification/prior authorization process, the claim may be denied. Members can’t be billed for services denied due to failure to complete the notification/prior authorization process.

Clinical Coverage Reviews

Clinical coverage reviews will be conducted as part of our prior authorization process. If the member’s benefit plan requires that services be medically necessary to be covered, the reviews will evaluate whether the drugs listed below are appropriate for the individual member, taking into account:

  • Terms of the member’s benefit plan 
  • Our drug coverage policy
  • Applicable Medicare guidance (for Medicare Advantage plans)
  • Applicable state Medicaid guidelines (for Community plans) 
  • The member’s treatment history 
  • Dosage recommendation from the FDA-approved labeling 
  • Medically necessary site of care (not applicable for Medicare Advantage plans) 

Additional criteria may be considered. We encourage you to submit any information you want reviewed as part of your prior authorization request. When a coverage determination is made, we’ll inform you and the member of the coverage determination. If an adverse determination is made, we’ll provide you with appeal information. As a reminder, self-administered medications should be submitted to the Pharmacy Benefit Manager to determine coverage under the pharmacy benefit plan. For commercial plans, self-administered medications are typically a medical benefit plan exclusion.

For UnitedHealthcare Community plans, coverage of these products is also dependent on state Medicaid program decisions. Certain state Medicaid programs may choose to cover a drug through the state’s fee-for-service program and not the managed care organizations such as UnitedHealthcare or they may provide other coverage guidelines and protocols. We encourage you to verify benefits for your patients before submitting the prior authorization request or administering the medication.

Submitting Notification/Prior Authorization Requests

To submit notification/prior authorization requests for these medications, please use one of the following methods:

  • Online: Use the Prior Authorization and Notification tool on Link. Go to UHCprovider.com/priorauth for more information..
  • Call: Use the Provider Services phone number on the member’s health care identification card.
  • Send your request by fax (option for Community and Commercial plans): Complete a prior authorization form and fax it to the number provided on the form. Some states require the notification/ prior authorization to be submitted on a designated request form. 

For UnitedHealthcare commercial plans, you can access forms at UHCprovider.com/priorauth. Go to UHCprovider.com/priorauth > Clinical Pharmacy and Specialty Drugs > Forms and Additional Resources.

For UnitedHealthcare Community plans, you can access forms at UHCprovider.com > Health Plans By State > Select your state.

When Making Referrals

If you’re referring a member to other care providers for this medication, please refer to in-network care providers. If you have any questions, please call the Provider Service number on the back of the member’s ID card.

Reminder: Please consider requesting pre-service coverage reviews for medications listed on UnitedHealthcare’s Review at Launch Commercial or Community Plan Medication Lists.

UnitedHealthcare adds certain new drugs to the Review at Launch Commercial or Community Medication Lists once they are approved by the U.S. Food and Drug Administration (FDA). Drugs will remain on the Review at Launch List until we communicate otherwise.

Under some benefit plans, a member may not be eligible for coverage for medications on the Review at Launch Commercial or Community Medication Lists for a period of time. For medications on the Lists, we encourage you to request pre-service coverage reviews so you can check whether a medication is covered before providing services. Clinical coverage reviews can also help avoid starting a patient on therapy that may later be denied due to lack of medical necessity. Your claims may be denied if a pre-service coverage review is not completed.

What’s Changing for UnitedHealthcare Commercial Plans

The following requirements will apply to UnitedHealthcare commercial plans, including affiliate plans such as UnitedHealthcare of the Mid-Atlantic, UnitedHealthcare of the River Valley, UnitedHealthcare Oxford and Neighborhood Health Partnership:

For dates of service on or after Jan. 1, 2019, we’ll require notification/prior authorization for the following medications:

  • Onpattro - The FDA recently approved Onpattro as a treatment for hereditary transthyretin amyloidosisassociated polyneuropathy.
  • Ilumya - The FDA recently approved Ilumya for the treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy. When Ilumya is self-administered it will be evaluated for coverage under the pharmacy benefit, consistent with our standard benefit plan design.
  • Hemlibra - The FDA approved Hemlibra to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients with hemophilia A (congenital factor VIII deficiency) with factor VIII inhibitors. When Hemlibra is self-administered it will be evaluated for coverage under the pharmacy benefit, consistent with our standard benefit plan design. 

For dates of service before Jan. 1, 2019, we encourage you to request pre-service coverage reviews so you can check whether a medication is covered before providing services. If you request a pre-service coverage review, you must wait for our determination before rendering the service.

Onpattro and Ilumya have been added to the Review at Launch List. Some members may not be eligible for coverage of these medications at this time. Please reference the Review at Launch for New to Market Medications drug policy for additional details.

What’s Changing for UnitedHealthcare Community Plan

We’ll be adding prior authorization requirements for the following drugs for UnitedHealthcare Community Plan members. Additionally, for some of the drugs, we’ll evaluate services requested in the outpatient hospital setting for medical necessity.

Effective Oct. 15, 2018

State:
Arizona
Maryland
Ohio

Drug:
Actemra
Entyvio
Infliximab (Inflectra, Remicade, Renflexis)
Orencia
Simponi Aria

Authorization:
Prior authorization plus Site of Care review for the outpatient hospital setting. All listed drugs apply to Arizona, Maryland and Ohio.

Effective Dec. 1, 2018

State:
Florida MMA

Drug:
Spinraza

Authorization:   
Prior authorization

Effective Jan. 1, 2019

For dates of service on or after Jan. 1, 2019, we’ll require prior authorization for the following drugs for UnitedHealthcare Community Plan members in many states:

  • Ilumya 
  • Onpattro

Additionally, if Ilumya is requested in the outpatient hospital setting, this site of care will be reviewed for medical necessity.

Onpattro and Ilumya have been added to the Review at Launch Drug List for UnitedHealthcare Community Plan which is located at UHCprovider.com/en/policiesprotocols/comm-planmedicaid-policies/medicaidcommunity-state-policies.html through the Review at Launch for New to Market Medications drug policy.

All codes that would be used to bill for Onpattro and Ilumya will require prior authorization, including any Q or C codes that CMS may assign to these medications. If Onpattro and Ilumya are currently not covered in a state, but then become covered, prior authorization will be required upon coverage.

Also beginning Jan. 1, 2019, some states will have additional prior authorization requirements. Actemra, Entyvio, Infliximab (Inflectra, Remicade, Renflexis), Orencia, and Simponi Aria will require prior authorization in the following states:

Prior Authorization:
California
Florida
Iowa
Louisiana
Michigan
Mississippi
New York
Rhode Island
Tennessee
Virginia
Washington

Prior Authorization plus Site of Care Review for the Outpatient Hospital Setting
Hawaii
Kansas
Nebraska
Texas 

For dates of service before Jan. 1, 2019, we encourage you to request pre-service coverage reviews so you can check whether a medication is covered before providing services. If you request a pre-service coverage review, you must wait for our determination before rendering the service.