Pharmacy information and requirements for commercial and MA plans are in Chapter 7: Pharmacy.
Medications Not Covered Under Capitation (Medicare Advantage)
We may delegate decisions to authorize specific pharmacy services based on your Agreement.
A member or care provider may request authorization from you for medication carved out of your Agreement terms. Notify the member you are not responsible for the authorization of these services. Recommend the member refer to any Part D coverage they may have.
Prior Authorization is Necessary for Payment to be Processed
The care provider medical group (medical group/IPA) must request prior authorization for select drugs. Get prior authorization forms on UHCprovider.com/priorauth or by contacting your provider advocate or clinical contacts at UnitedHealthcare. Our staff will not process the request until we receive all necessary information. Once we make a determination, we notify you within the correct timeframe.
We make authorizations following benefit design, provided the member does not exceed benefit restrictions (applied to the requested agents/therapeutic class, and the prior authorization process).
We fax the case resolution to you. For denials, we send a letter to the member and care provider stating why we denied the requested medication. The letter outlines the process for filing standard and expedited appeals.
Prior Authorization Process for Medications Carved Out of Capitation
If UnitedHealthcare has financial responsibility for medications currently covered under the commercial member’s medical benefit, this policy applies to those medications listed in your Agreement.
UnitedHealthcare uses a prior authorization process to review any medication carved out of capitation. This authorization process affects medical groups/IPA providing care to UnitedHealthcare members when UnitedHealthcare has retained financial responsibility for these medications.
We review the administration of these medications for compliance with the National Comprehensive Cancer Network’s Drugs & Biologics Compendium (NCCN Compendium®) recommended uses for the drug, as it pertains to treatment regimen and/or line of therapy. Non- compliant services are not eligible for coverage or payment reimbursement by UnitedHealthcare. If the medical group/ IPA does not get this review and receive prior authorization from us before administering these drugs, we deny reimbursement. This policy does not apply to bevacizumab (Avastin) used for non-oncological indications.
Prescription Drug Appeals Process
Members may initiate an appeal for coverage of a prescription drug if the initial determination is adverse to them. They may start an appeal in the following circumstances:
- The requested drug is not on the formulary.
- The drug is not considered medically necessary.
- The drug is furnished by an out-of-network care provider pharmacy.
- The drug is not a drug for which Medicare will pay under Part D.
- A coverage determination is not provided in a timely manner.
- The delay would adversely affect the health of the member.
- A request for an exception is denied.
- The member is dissatisfied with a decision regarding the copayment required for a prescription drug.