Optum – an affiliate company of UnitedHealthcare – manages prior authorization requests for certain medical benefit injectable medications for UnitedHealthcare commercial plan members. This includes the affiliate plans UnitedHealthcare of Mid-Atlantic, Inc., Neighborhood Health Partnership and UnitedHealthcare of the River Valley.
The process is designed to ease the administrative burden of obtaining a prior authorization, while also reducing the turnaround time for a determination. The system will document clinical requirements during the intake process and prompt providers to provide responses to the clinical criteria questions.
For certain specialty medications, UnitedHealthcare requires providers to use a lower-cost specialty medication before coverage for a clinically similar, higher-cost medication. The initial lower-cost specialty medication is known as the “preferred product.” As part of our preferred product strategies, we may also require providers to prescribe clinically appropriate, lower-cost, self-administered medications available through the pharmacy benefit before we’ll cover infused or provider-administered medications administered through the medical benefit.
UnitedHealth Group aims to improve cost efficiencies for the overall health care system. One way we do that is by conducting site of care medical necessity reviews. The utilization review guideline we use to help facilitate our site of care medical necessity determinations for services is available at UHCprovider.com/policies, or choose from one of these links:
Medication sourcing is a phrase used when an infusion provider (physician or facility) receives a specialty medication from an outside specialty pharmacy (sourced) and the patient visits the physician’s office or infusion facility for administration.
If the medication does not have a sourcing requirement, providers can buy-and-bill. Buy-and-bill is when a physician purchases a medication directly from a specialty distributor or pharmaceutical wholesaler, administers the medication to a patient and submits a claim for reimbursement for the drug and any other medical services.
To learn more about which medications have a sourcing requirement, consult the following resources:
Administrative Guide > Administrative Guide for Commercial, Medicare Advantage and DSNP > Specialty pharmacy and Medicare Advantage pharmacy
We’re committed to providing our members with access to high-quality medications at the lowest possible cost. In some cases, we ask you to consider prescribing lower-cost options when there are multiple medications that are used to treat the same condition for your patients. Effective July 1, 2022, we’ll implement the Medical Benefit Therapeutic Equivalent Medications - Excluded Drugs policy for fully insured (FI) UnitedHealthcare commercial plan members. This policy is a long-term exclusion capability for certain targeted medical benefit medications administered by a health care professional. A medication will be subject to medical drug exclusion when it’s listed on the Medical Benefit Therapeutic Equivalent Medications - Excluded Drug List with Preferred Alternatives and as allowed by the member’s benefit documents and by law. All excluded medications will have a therapeutically equivalent alternative option available for coverage