Physician Administered Drugs / Medical Injectables / Specialty Pharmacy
Specialty medications can be covered under the pharmacy benefit, the medical benefit or both benefits, depending on the benefit structure for the member’s coverage.
Pharmacy benefit medications are typically self-administered by the patient or a caregiver, after filling the prescription through a pharmacy. These medications are labeled for self-administration by the Food and Drug Administration but may require some instruction to the patient or caregiver.
Typically, medications administered orally, topically or through subcutaneous injection by the patient or a caregiver after receiving instruction are covered under the pharmacy benefit.
Medical benefit medications are typically administered and monitored by a health care professional. The medication is administered in a physician’s office, at home, in an ambulatory infusion suite or in an outpatient facility. These medications can be administered by infusion, injection or intramuscularly with the help of an infusion nurse.
Specialty Pharmacy medications can be shipped from a specialty pharmacy directly to a health care setting (i.e., sourced) or a provider may purchase them directly using their standard distribution process (i.e., buy and bill). If the drugs are administered at home, they may be shipped from a specialty pharmacy directly to the member’s home.
Coverage of a requested medication depends on the member’s Medicaid coverage as determined by the State Medicaid agency, and the availability of a specific drug from a network specialty pharmacy may vary.
Medications obtained through a specialty pharmacy will be directly billed to the member’s health plan.
To locate a contracted specialty pharmacy, download the list: Provider Vendor Assistance - Specialty Pharmacy.
In response to the U.S. opioid epidemic, UnitedHealthcare has developed programs to help our members receive the care and treatment they need safely and effectively.
We’ve also established measures based on the Centers for Disease Control and Prevention’s (CDC) opioid treatment guidelines to help prevent overuse of short-acting and long-acting opioid medications.
Resources
Providers can contact the following organizations on behalf of UnitedHealthcare Community Plan patients that need help finding nearby open pharmacies in areas impacted by the disaster.
As of January 1, 2019, the State of Louisiana requires all health care providers to use their state-specific form for prescription drug prior authorization requests.
Health care providers should entirely fill out and submit the completed form to the fax number listed on the form. Please include any additional documentation such as clinical notes, lab values, etc. that support your prior authorization request.
NOTE: Any prior authorization requests that are not submitted using the Louisiana Uniform Prescription Drug Prior Authorization Form will be cancelled and the health care provider will be asked to re-submit their request using the correct form.
CoverMyMeds streamlines the medication prior authorization process, electronically connecting providers, pharmacists and plan/PBMs to improve time to therapy and decrease prescription abandonment with electronic prior authorization.
The PreCheck MyScript Solution helps make it easy to run a pharmacy trial claim and get real-time prescription coverage detail for your patients who are UnitedHealthcare benefit plan members.
Specialty pharmacy medications covered under the member’s medical benefit may be obtained through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.
Coverage of a requested medication depends on the member’s benefit, and availability of a specific drug from a network specialty pharmacy may vary.
Upon request, a specialty pharmacy can deliver the medication to your office or another site such as a member’s home.
Medications obtained through a specialty pharmacy will be directly billed to the patient’s health plan.
To see the latest PDL updates, visit Drug Lists and Pharmacy > UnitedHealthcare Prescription Drug Lists (PDL) / Drug Formulary > Prescription Drug List Updates.