Specialty pharmacy requirements for certain medical benefit specialty medications (commercial plans – not applicable to UnitedHealthcare West) - Ch.8, 2022 Administrative Guide
The Optum specialty medication guidance program manages prior authorization process for certain outpatient medical benefit specialty medications
Optum manages prior authorization requests for certain medical benefit injectable medications for these commercial plan members. This includes the affiliate plans UnitedHealthcare of Mid-Atlantic, Inc., Neighborhood Health Partnership and UnitedHealthcare of the River Valley. You will be notified when other commercial plans and lines of business migrate to this new process.
How the process works
Click on the Specialty Pharmacy Transactions tool on the UnitedHealthcare Provider Portal. The system will document clinical requirements during the intake process and prompt you to provide responses to the clinical criteria questions. Attach medical records, if requested. For additional questions, call 1-888-397-8129.
Coverage of self-infused/injectable medications under the pharmacy benefit
This protocol applies to the provision and billing of self-infused/injectable medications, such as Hemophilia Factor products, under the pharmacy benefit.
Under most UnitedHealthcare products, self-infused/injectable medications are generally excluded from coverage under the medical benefit. A pharmacy rider can provide coverage for a self-infused/injectable medication. This exclusion from the medical benefit does not apply to self-infused/injectable medications due to their characteristics, as determined by UnitedHealthcare, that are typically administered or directly supervised by a qualified physician or licensed/certified health care professional in an outpatient setting.
If medications are subject to this exclusion, participating physicians, health care professionals, home infusion providers, hemophilia treatment centers or pharmacies fulfilling, distributing, and billing for the provision of self- infused/injectable medications to members are required to submit claims for reimbursement under the member’s pharmacy benefit.
Prohibition of provision of non-contracted services
This protocol applies to the provision and billing of specific specialty pharmacy medications covered under a member’s medical benefit.
Specialty pharmacy or home infusion health care providers may not provide non-contracted services for a therapeutic category, even if the specialty pharmacy or home infusion health care provider is contracted for other medical benefit medications and services, and billing us as a non-participating or non-contracted specialty pharmacy or home infusion health care provider.
This protocol does not apply when a physician or other health care professional, who procures and bills us directly for specific specialty mediations, administers specialty medications in an office setting.
Requirement of specialty pharmacy and home infusion providers to be a network provider
We have contracted with a network of specialty pharmacy and home infusion health care providers by therapeutic category to distribute specialty medications covered under a member’s medical benefit. We selected the contracted specialty pharmacy and home infusion health care providers by therapeutic category for network inclusion based on their distribution, contracting, clinical capabilities, and member services. This national network provides fulfillment and distribution of the specialty medications on a timely basis to meet the needs of our members and our network. Full program participation requirements are identified in the contracted specialty pharmacy or home infusion health care provider’s Agreement.
Requirement to use a participating specialty pharmacy health care provider for certain medications
This requirement applies to the specialty medications listed on uhcprovider.com/pharmacy > Specialty Pharmacy Program - Commercial > Specialty Pharmacy - Medical Benefit Management (Provider Administered Drugs) > Administrative Guide Medication Sourcing. The drug list identifies those drugs for which sourcing requirements apply to all outpatient health care providers and those for which the requirements only apply to outpatient facilities.
The medications subject to our sourcing requirement are subject to change. The requirement does not apply when Medicare or another health benefit plan is the primary payer and we are the secondary payer.
We have contracted health care providers for the distribution of these specialty medications. Our participating specialty pharmacy health care providers give fulfillment and distribution services to meet the needs of our members and our health care providers. Our participating specialty pharmacy health care providers provide reviews consistent with our drug policies for these drugs. They work directly with the clinical coverage review unit to determine whether treatment is covered. Our National Pharmacy & Therapeutics Committee (NPTC) periodically reviews and updates our drug policies for these drugs. The committee helps ensure the policies are consistent with published clinical evidence and professional specialty society guidance. Our participating specialty pharmacy health care providers report clinical data and related information and are audited on an ongoing basis to support our clinical and quality improvement activities. You must acquire these specialty medications from a participating specialty pharmacy health care provider in our specialty pharmacy network, except as otherwise authorized by us.
Overview of submission, administration and billing processes
To fill a prescription through a contracted specialty pharmacy health care provider, submit a prescription request and enrollment form found at uhcprovider.com/pharmacy > Specialty Pharmacy Program > Enrollment Formsdirectly to the specialty pharmacy. The specialty pharmacy will advise the member of any medication cost-share responsibility and arrange for collection of any amount due before dispensing the medication to the service location. The specialty pharmacy will dispense these medications to you in compliance with the UnitedHealthcare Drug Policy and the member’s benefit plan and eligibility. It will bill UnitedHealthcare for the medication. You may bill for administration of the medication. You cannot bill us or the member for the medication itself.
For a list of the medications and participating specialty pharmacy provider(s), refer to the sourcing drug list.
For more information about the sourcing requirement and participating specialty pharmacies, go to uhcprovider.com/pharmacy > Specialty Pharmacy Program.
Administrative actions for acquisition of certain specialty medications from non-participating pharmacies
We anticipate that all health care providers will be able to procure certain medications from a participating specialty pharmacy health care provider.
We may deny, in whole or in part, any claim from the use of non-participating specialty pharmacy health care providers, wholesalers or direct purchase from the manufacturers by you or any other health care professional without prior approval from us. You may also be subject to other administrative actions as provided in your Agreement.
Contact your local UnitedHealthcare network management representative if you have any questions.