UHC Updates Requirements for Specialty Medical Injectable Drugs

September 2019 ~

Effective October 1, 2019, Optum (an affiliate of UnitedHealthcare (UHC)) will make changes to and start managing prior authorization requests and processes for certain medical benefit injectable medications for UHC commercial plan members.

According to the insurer, the new process is designed to ease 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 ask for responses to the clinical criteria questions.

Under the new process, providers will submit prior authorization requests online using the Specialty Pharmacy Transactions tool on Link. The new requirements apply to members new to therapy and members already receiving these medications and apply to all applicable billing codes assigned to these drugs, including any Q or C codes that CMS may assign.

Updates to Requirements for Specialty Medical Injectable Drugs

UHC asks that providers use the new process when requesting notification/prior authorization for a specialty medication listed under the injectable medications section on the Enterprise Prior Authorization List, or a medication that is required to be provided by BriovaRX® specialty pharmacy according to the UnitedHealthcare Administrative Guide. Examples of the medications that will be managed under the new process include:

Changes to Notification/Prior Authorization Requirements

Upon prior authorization renewal, the updated policy will apply. UHC states the insurer will honor all approved prior authorizations on file until the end date on the authorization or the date the member’s eligibility changes. Providers are not required to submit a new notification/prior authorization request for members who already have an authorization for these medications on October 1, 2019.

New and Updated Procedure Codes for Injectable Medications

Effective October 1, the following new procedure codes will become active due to updates from CMS. Correct coding rules dictate that assigned and permanent codes should be used when available.

The following injectable medications that may be subject to prior authorization and/or Administrative Guide Protocols will have new codes:

  • Onpattro – J0222
  • Ultomiris – J1303
  • Evenity – J3111
  • Synojoynt – J7331
  • Triluron – J7332
  • Gamifant – J921

For more information on these changes, refer to UHC’s pharmacy bulletin which outlines the upcoming, new, and revised clinical programs and implementation dates.

Source(s): UnitedHealthcare Network Bulletin;