Pharmacy Resources and Physician Administered Drugs
UnitedHealthcare Community Plan Quantity Limit Policy
UnitedHealthcare Community Plans may have monthly quantity limitations on certain medications. Prescriptions for quantities greater than the indicated monthly limits will require prior authorization. Quantity limits exist to promote efficient medication dosing and safe dosing administration.
Additions to the Quantity Limit (QL) program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the prior authorization (PA) process.
In response to the U.S. opioid epidemic, UnitedHealthcare 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 from UnitedHealthcare and Optum
Other Resources
- Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain
- Centers for Disease Control and Prevention (CDC): CDC Opioid Overdose Guideline Resources
Get real-time prescription costs and coverage detail
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.
Streamline your prior authorization process with CoverMyMeds
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.
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 by a health care professional and monitored by a health care professional. The medication is administered in a physician 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, click here: Provider Vendor Assistance List - Specialty Pharmacy.
- Inclusion of a drug in the Provider Vendor Assistance List does not infer coverage. Check your patients' coverage and plan details with the Eligibility and Benefits feature on the UnitedHealthcare Provider Portal.
- Network Vendors in the Provider Vendor Assistance List are in no particular order; no preference should be interpreted based on the order of the listing, when multiple options are available.
Specialty Program Description
UnitedHealthcare Community Plan administers a Specialty Pharmacy Management Program that provides high-quality, cost-effective care for our members. This program optimizes the patient experience and clinical outcomes by using a network of specialty pharmacies that offer clinical programs which include, but are not limited to, educating and supporting our members concerning their chronic condition(s), promoting medication adherence and reducing the risk of side effects, and promoting multi-disciplinary practice and collaboration to achieve continuity of care.
Our network specialty pharmacies are selected based on their clinical expertise, the quality of clinical management and adherence programs provided, and overall cost of therapy. Specialty pharmacy providers are specifically trained on specialty medications and the conditions they treat, and can provide comprehensive clinical services. The contracting/credentialing process ensures consistency with the requirements, the highest level of quality provided to members, and access to all specialty pharmacy medications.
The specialty pharmacies provide patient education and training, not only for the medication, but also the chronic condition being treated. The specialty teams proactively reach out to patients each month prior to refilling their prescription. During this outreach, patients are asked if they have questions about their condition or drugs, and if they would like to speak directly to a clinician. Medication adherence is also checked, with any potential issues identified and addressed. Additionally, their Member Support Services provides patients with access to a clinician trained in their condition and drug therapy 24 hours a day, 7 days week.
Some of the services our network specialty pharmacies offer include:
- Expedited delivery to the member’s home or physician’s office
- Proper handling and packaging according to the product’s storage requirements, with instructions provided for the member if any refrigeration or special storage conditions exist
- Patient-friendly educational material that includes drug information which speaks to medication administration and compliance
- Adherence programs
- Medication administration training/assistance
If you don’t want to buy and bill a specialty pharmacy medication covered under the member’s medical benefit, you may order it through a network 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.
UnitedHealthcare Community Plan of New Mexico is a product of UnitedHealthcare Insurance Company.