UnitedHealthcare Updates Requirements for Specialty Medical Injectable Drugs

July 2019 ~

UnitedHealthcare (UHC) has made changes to their requirements for requesting notification/prior authorization for a specialty medication listed under the injectable medications section on the Enterprise Prior Authorization List.

These requirements apply to UHC members new to therapy as well as members already receiving these medications. The requirements stated below apply to all applicable billing codes assigned to these drugs, including any Q or C codes assigned by CMS.

UHC Commercial Plan Outpatient Medical Benefit Injectable Medication Prior Authorization Process Change for Certain Specialty Drugs

Effective October 1, 2019, Optum, an affiliate company of UHC, will start managing prior authorization requests for certain medical benefit injectable medications for UHC commercial plan members. This includes the affiliate plans UHC of Mid-Atlantic, Inc., Neighborhood Health Partnership and UHC of the River Valley.

Providers should continue to request notification/prior authorization for UHC Oxford, UMR, UHC Community Plan and UHC Medicare Advantage members through the existing processes until future notice.

The insurer notes that providers will need to use a new process to request a prior authorization once the existing authorization expires or if the therapy is changed. Changes in therapy include place of therapy, dose or frequency of administration. Active prior authorizations that were obtained through the current process will remain in place.

The new process is designed to reduce the turnaround time for a determination. The system will document clinical requirements during the intake process and prompt users to provide responses to the clinical criteria questions. Please attach medical records, if requested.

Providers must 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 Briova RX® specialty pharmacy according to the 2019 UHC Administrative Guide.

Alpha1-Proteinase Inhibitors

Some Drug Examples (Not an All-Inclusive List): Aralast NP, Glassia®, Prolastin-C® or Zemaira®

Asthma

Some Drug Examples (Not an All-Inclusive List): Cinqair®, Fasenra, Nucala® or Xolair®

Blood Modifiers

Some Drug Examples (Not an All-Inclusive List): Soliris® or Ultomiris

Botulinum Toxins A and B

Some Drug Examples (Not an All-Inclusive List): Botox®, Dysport®, Myobloc® or Xeomin®

Central Nervous System Agents

Some Drug Examples (Not an All-Inclusive List): Spinraza, Exondys-51®, Onpattro or Radicava®

Endocrine

Some Drug Examples (Not an All-Inclusive List): Crysvita® or H.P. Acthar gel®

Enzyme Deficiency

Some Drug Examples (Not an All-Inclusive List): Brineura, Fabrazyme®, Lumizyme® and Revcovi

Enzyme Replacement Therapy for Gaucher’s Disease

Some Drug Examples (Not an All-Inclusive List): Vpriv®, Cerezyme® or Elelyso®

Gonadotropin Releasing Hormone Analogs

Some Drug Examples (Not an All-Inclusive List): Lupron Depot®, Triptodur® and Zoladex®

Gene Therapy

Some Drug Examples (Not an All-Inclusive List): Luxturna

HIV Agents

Some Drug Examples (Not an All-Inclusive List): Trogarzo

Immune Globulin

Some Drug Examples (Not an All-Inclusive List): Bivigam®, Gamunex®-C, Gammagard®, HyQvia® and Privigen®

Immunomodulatory Agents

Some Drug Examples (Not an All-Inclusive List): Ilaris®, Benlysta® or Gamifant®

Inflammatory Agents

Some Drug Examples (Not an All-Inclusive List): Remicade®, Entyvio®, Orencia® IV and Ilumya

Multiple Sclerosis Agents

Some Drug Examples (Not an All-Inclusive List): Ocrevus® or Lemtrada®

Neutropenia

Some Drug Examples (Not an All-Inclusive List): Neulasta®, Fulphila® or Udenyca®

Opioid Addiction

Some Drug Examples (Not an All-Inclusive List): Sublocade or Probuphine®

Osteoarthritis

Some Drug Examples (Not an All-Inclusive List): Sodium Hyaluronate such as Durolane®, Euflexxa® and Gelsyn-3

Osteoporosis

Some Drug Examples (Not an All-Inclusive List): Evenity®

RSV Prevention

Some Drug Examples (Not an All-Inclusive List): Synagis®

 

Scope of Changes for UHC Commercial Plans

The following changes and requirements that apply to UHC commercial plans, will include affiliate plans such as UHC of the Mid-Atlantic, Inc., UHC of the River Valley, UHC Oxford, UMR and Neighborhood Health Partnership.

 

Specialty Medical Injectable Drugs Added to Review at Launch Program

For the UHC Commercial Plan Review at Launch Medication List, go to UHCprovider.com > Policies and Protocols > Commercial Policies > Medical & Drug Policies and Coverage Determination Guidelines for UHC Commercial Plans > Review at Launch for New to Market Medications > Review at Launch Medication List.

For the UHC Community Plan Review at Launch Medication List, go to UHCprovider.com > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan > Review at Launch for New to Market Medications > Review at Launch Medication List.

For Medicare Advantage, Review at Launch drugs are added as a Review at Launch Part B Medication in the Medications/Drugs (Outpatient/Part B) Coverage Summary. Go to UHCprovider.com > Policies and Protocols > Medicare Advantage Policies > Coverage Summaries for Medicare Advantage Plans > Medications/Drugs (Outpatient/Part B)Medicare Advantage Coverage Summary > Attachment A: Guideline 5 – Other Examples of Specific Drugs/Medications.

Providers administering any of these medications without first completing the notification/prior authorization process, the claim may be denied. Members can’t be billed for services denied due to failure to complete the notification/prior authorization process.

For UHC Community Plan members, coverage is also dependent on state Medicaid program decisions. Certain state Medicaid programs may choose to cover a drug through the state’s fee-for-service program and not the managed care organizations, such as UHC, or they may provide other coverage guidelines and protocols.

UHC encourages providers to verify patient benefits before submitting the prior authorization request or administering the medication.

 

New Procedure Codes for Injectable Medications – Effective July 1, 2019

Based on updates from CMS, new procedure codes will become effective July 1, 2019, for certain injectable medications. 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:

  • Gamifant® – C9050
  • Ultomiris – C9052

For more information and complete details on these changes, see page 11-19 in the July 2019 UnitedHealthcare Network Bulletin.

Source(s): UnitedHealthcare Network Bulletin July 2019;

 

 

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