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UnitedHealthcare Connected® for MyCare Ohio
H2531-001

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Prior Authorizations

Prior Authorization Request

Download the List of Services that Require Prior Authorization (PDF 185.79 KB)
Download the Prescription Prior Authorization List (Coming Soon)

 

Prior Authorization Process

Prior authorization is an okay for services that must be approved by UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan). Your doctor must call Utilization Management (UM) at 1-800-366-7304 before you obtain a service or procedure that is listed as requiring an okay on pages 19-22. Our UM team is available Monday through Friday, 8 a.m. to 5 p.m. On-call staff is available 24 hours a day, 7 days a week for emergency okays.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) also reviews some of your services and care as they are happening. This is called concurrent review. Examples are when you are:

  • A patient in the hospital
  • Receiving home care by nurses
  • Certain outpatient services such as speech therapy and physical therapy

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) reviews your progress with your doctor to be sure you still need those services or if other services would be better for you.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) has policies and procedures to follow when the UM team makes decisions regarding medical services. The UM doctors and nurses make their decision based on your coverage and what you need for your medical condition. The goal is to make sure that services are medically necessary, that they are provided in an appropriate setting, and that quality care is provided.

We want to help you stay well. If you are sick we want you to get better.

  • UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) does not pay employees extra for limiting your care.
  • Our network doctors do not receive extra money or rewards if they limit your care.

If you have questions about UM decisions or processes, call Member Services at 1-877-542-9236 (TTY 711).

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To file an Appeal or Grievance, please visit or FAQ section.

Find A Drug

Search for drugs covered by UnitedHealthcare Connected™ for MyCare Ohio

Click here (PDF 968.84 KB) to download the UnitedHealthcare Connected™ for MyCare Ohio Formulary. To view the UnitedHealthcare Connected™ for MyCare Ohio Formulary in Espanol, please click here (PDF 1,003.6 KB).

 

Prior Authorizations

Prior Authorization Request 
Download the List of Services that Require Prior Authorization (PDF 185.79 KB)
Download the Prescription Prior Authorization List (Coming Soon)

 

Pharmacy Direct Member Reimbursement Request

Download a MAPD Prescription Reimbursement Request Form (PDF 188.1 KB) from OptumRx. 

Prescription Drugs - Not Covered by Medicare Part D

While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan).  You can view our plan’s List of Covered Drugs on our website at www.myuhc.com/communityplan.  Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan). You do not have any co-pays for non-Part D drugs covered by our plan.

Please note that our list of medications that require prior authorization can change so it is important for you and/or your provider to check this information when you need to fill/refill a medication.

Submit a Pharmacy Prior Authorization Request to OptumRx

Submit a Pharmacy Prior Authorization Request

Prescription Drug Transition Process

What to do if your current prescription drugs are not on the formulary or are limited on the formulary.

New members
As a new member of an UnitedHealthcare ConnectedUnitedHealthcare Connected™ for MyCare Ohio, insured through UnitedHealthcare, you may currently be taking drugs that are not on the UnitedHealthcare® formulary (drug list), or they are on the formulary but your ability to get them is limited.

In instances like these, start by talking with your doctor about appropriate alternative medications available on the formulary. If no appropriate alternatives can be found, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug for a specified period of time. While you and your doctor are determining your course of action, you may be eligible to receive an initial 31-day transition supply (unless your prescription is written for fewer days) of the drug anytime during the first 90 days you are a plan member.

For each of your drugs that is not on the formulary or if your ability to get your drugs is limited, UnitedHealthcare will cover a 31-day supply (unless your prescription is for fewer days) when you go to a network pharmacy. If the prescription is written for less than 31 days, multiple fills are allowed to provide up to a total of 31 days of drugs. After your first 31-day transition supply, these drugs may not continue to be covered. Talk with your doctor about appropriate alternative medications. If there are none on the formulary, you or your doctor can request a formulary exception.

If you live in a long-term care facility, UnitedHealthcare will cover a temporary 31-day transition supply (unless your prescription is for fewer days). UnitedHealthcare will cover more than one refill of these drugs for the first 90 days for plan members, up to a 93-day supply. If you need a drug that is not on the formulary or your ability to get your drugs is limited, but you are past the first 90 days of plan membership, the transition program will cover a 31-day emergency supply of that drug (unless your prescription is for fewer days) while you pursue a formulary exception.

You may face unplanned transitions after the first 90 days of plan enrollment, such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge), If you are prescribed a drug that is not on the formulary or your ability to get your drugs is limited, you are required to use the plan's exception process. You can request a one-time emergency supply of up to 31 days to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

Continuing members
As a continuing member in the plan, you receive an Annual Notice of Changes (ANOC). You may notice that a formulary medication you are currently taking is either not on the upcoming year's formulary or its cost sharing or coverage is limited in the upcoming year.

For coverage requests received each year by December 15, and approved, the plan will cover the drug as of January 1. For coverage requests initiated on or after December 16, normal time frames for resolution apply: you will receive an answer within 24 hours for urgent requests and within 72 hours for all other requests. If your request is still in process on January 1, you may receive a temporary supply of the drug for your current plan cost-sharing until your request is answered.

If you have any questions about this transition policy or need help asking for a formulary exception, a UnitedHealthcare representative can help.

Related Information
Medicare Part D Coverage Determination Request Form - (for use by members and providers)
The Coverage Determination Request Form may be found under Appeal a Coverage Decision section on this page.

Medication Therapy Management Program

UnitedHealthcare's Medication Therapy Management program was developed by a team of pharmacists and doctors to help eligible members make better use of their coverage and to improve their understanding and use of medications.  It also helps protect members from the possible risks of drug side effects and from potentially harmful drug combinations.

This program is available at no additional cost to you.  You will be automatically enrolled in the Medication Therapy Management Program if you:

  • take eight (8) or more chronic Part D medications, and
  • have three (3) or more long-term health conditions, and
  • might spend more than $3,967 a year on covered Part D medications

Below is a list of health conditions that may make you eligible for the Medication Therapy Management program. You need to have three or more of these conditions to qualify for this program.

  • Diabetes
  • Hypertension (High Blood Pressure)
  • Heart Failure
  • High Cholesterol
  • Rheumatoid Arthritis

UnitedHealthcare’s Medication Therapy Management program offers a Comprehensive Medication Review (CMR) for all eligible members over the phone. A pharmacist will review the member’s medication history, including prescription and over-the-counter medications, and identify any issues.  Upon completion of the medication review, the member is mailed a Medication Action Plan that summarizes any clinical concerns identified and a Personal Medication List of their medication history.  In addition, the member’s doctor is contacted and this information is provided to them. 

To help you track your medications, you can also download a blank Personal Medication List (PDF 123.02 KB) for your personal use.

Members may also receive helpful information in the mail. This can include additional information about their medications and suggestions from our pharmacists about how to make the most of your medications and benefits. This information can be helpful when meeting with your doctor or pharmacist.

For more information on UnitedHealthcare’s Medication Therapy Management program, please talk to a UnitedHealthcare representative (the phone number is on the back of your plan member ID card).

Please note that these programs may have limited eligibility criteria and are not considered a benefit.

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To file an Appeal or Grievance, please visit or FAQ section.

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Prior Authorization Request
Download the List of Services that Require Prior Authorization (PDF 185.79 KB)
Download the Prescription Prior Authorization List (Coming Soon)

 

Prior Authorization Process

Prior authorization is an okay for services that must be approved by UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan). Your doctor must call Utilization Management (UM) at 1-800-366-7304 before you obtain a service or procedure that is listed as requiring an okay on pages 19-22. Our UM team is available Monday through Friday, 8 a.m. to 5 p.m. On-call staff is available 24 hours a day, 7 days a week for emergency okays.

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) also reviews some of your services and care as they are happening. This is called concurrent review. Examples are when you are:

  • A patient in the hospital
  • Receiving home care by nurses
  • Certain outpatient services such as speech therapy and physical therapy

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) reviews your progress with your doctor to be sure you still need those services or if other services would be better for you.

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) has policies and procedures to follow when the UM team makes decisions regarding medical services. The UM doctors and nurses make their decision based on your coverage and what you need for your medical condition. The goal is to make sure that services are medically necessary, that they are provided in an appropriate setting, and that quality care is provided.

We want to help you stay well. If you are sick we want you to get better.

  • UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) does not pay employees extra for limiting your care.
  • Our network doctors do not receive extra money or rewards if they limit your care.

If you have questions about UM decisions or processes, call Member Services at 1-877-542-9236 (TTY 711).

OH_MME_UHC_Logo

To file an Appeal or Grievance, please visit or FAQ section.

Find A Pharmacy

Search for a UnitedHealthcare network pharmacy below.

Provider/Pharmacy Directories
Pharmacies

This part of the Directory provides a list of pharmacies in UnitedHealthcare Connected for MyCare Ohio’s network. These network pharmacies are pharmacies that have agreed to provide prescription drugs to you as a member of the plan.

  • UnitedHealthcare Connected for MyCare Ohio Members must use network pharmacies to get prescription drugs.
    • You must use network pharmacies except in emergency or urgent care situations. If you go to an out-of-network pharmacy for prescriptions when it is not an emergency or urgent care situation, including when you are out of the service area, call UnitedHealthcare Connected for MyCare Ohio toll-free Member Services or 24-hour nurse advice line for assistance in getting your prescription filled.
    • If you go to an out-of-network pharmacy for prescriptions when it is not an emergency, you will have to pay out of pocket for the service. Read the UnitedHealthcare Connected for MyCare Ohio Member Handbook for more information.
  • Some network pharmacies may not be listed in this Directory.
    • Some network pharmacies may have been added or removed from our plan after this Directory was published.

For up to date information about UnitedHealthcare Connected for MyCare Ohio network pharmacies in your area, please visit our web site at www.UHCCommunityPlan.com or call Member Services at 1-877-542-9236, TTY users should call 711, 7 a.m. - 8 p.m., local time, Monday - Friday. The call is free.

To get a complete description of your prescription coverage, including how to fill your prescriptions, please read the Member Handbook and UnitedHealthcare Connected for MyCare Ohio’s List of Covered Drugs. You received the List of Covered Drugs in the mail when you became a member of this plan. You may also visit our web site at www.UHCCommunityPlan.com for the drug list.

Identifying pharmacies in our network
Along with retail pharmacies, your plan’s network of pharmacies includes:

  • Mail-Order Pharmacies
  • Home infusion pharmacies
  • Long-term care (LTC) pharmacies

You are not required to continue going to the same pharmacy to fill your prescriptions. You can go to any of the pharmacies in our network.

Mail Order Pharmacy(ies)
You can get prescription drugs shipped to your home through our network mail order delivery program which is called OptumRx® home delivery pharmacy. Prescription orders sent directly from your doctor must have your approval before we can send your medications. This includes new prescriptions and prescriptions refills. We will contact you, by phone, to get your approval. If we are unable to reach you for approval, your prescription will not be sent to you.

You also have the choice to sign up for automated mail order delivery through our OptumRx® home delivery pharmacy. Typically, you should expect to get your prescription drugs from 4 to 6 days from the time that the mail order pharmacy gets the order. If you do not get your prescription drug(s) within this time, if you would like to cancel an automatic order, or if you need to ask for a refund for prescriptions you got that you did not want or need, please contact us at 1-877-542-9236, TTY 711, 7 a.m. - 8 p.m., local time, Monday - Friday.

Home Infusion Pharmacies
You can get home infusion therapy if UnitedHealthcare Connected for MyCare Ohio has approved your prescription for home infusion therapy and if you get your prescription from an authorized prescriber. For more information, please see your Member Handbook, or call Member Services at 1-877-542-9236, TTY 711, 7 a.m. - 8 p.m., local time, Monday - Friday.

Long-Term Care Pharmacies
Residents of a long-term care facility, such as a nursing home, may access their prescription drugs covered under UnitedHealthcare Connected for MyCare Ohio through the facility’s pharmacy or another network pharmacy. For more information, you can call Member Services at 1-877-542-9236, TTY 711, 7 a.m. - 8 p.m., local time, Monday - Friday.

Prior Authorizations

Prior Authorization Request
Download the List of Services that Require Prior Authorization (PDF 185.79 KB)

 

Prior Authorization Process

Prior authorization is an okay for services that must be approved by UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan). Your doctor must call Utilization Management (UM) at 1-800-366-7304 before you obtain a service or procedure that is listed as requiring an okay on pages 19-22. Our UM team is available Monday through Friday, 8 a.m. to 5 p.m. On-call staff is available 24 hours a day, 7 days a week for emergency okays.

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) also reviews some of your services and care as they are happening. This is called concurrent review. Examples are when you are:

  • A patient in the hospital
  • Receiving home care by nurses
  • Certain outpatient services such as speech therapy and physical therapy

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) reviews your progress with your doctor to be sure you still need those services or if other services would be better for you.

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) has policies and procedures to follow when the UM team makes decisions regarding medical services. The UM doctors and nurses make their decision based on your coverage and what you need for your medical condition. The goal is to make sure that services are medically necessary, that they are provided in an appropriate setting, and that quality care is provided.

We want to help you stay well. If you are sick we want you to get better.

  • UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) does not pay employees extra for limiting your care.
  • Our network doctors do not receive extra money or rewards if they limit your care.

If you have questions about UM decisions or processes, call Member Services at 1-877-542-9236 (TTY 711).

Questions?

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1-877-542-9236
TTY: 711

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Member Information

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UnitedHealthcare Connected®; for MyCare Ohio

Disclaimer Information

Looking for the federal government’s Medicaid website? Look here at Medicaid.gov.

UnitedHealthcare Dual Complete Plans

By submitting information, you agree that a UnitedHealthcare sales representative may contact you about Medicare Advantage or Part D plans. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan's contract renewal with Medicare.

Nurseline Disclaimer

This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your doctor's care. Your health information is kept confidential in accordance with the law. The service is not an insurance program and may be discontinued at any time.

UnitedHealthcare Connected™ for MyCare Ohio (Medicare-Medicaid Plan)

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. If you have any problem reading or understanding this or any other UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) information, please contact our Member Services at 1-877-542-9236 (TTY 711) from 7 a.m. to 8 p.m. Monday through Friday (voice mail available 24 hours a day/7 days a week) for help at no cost to you.

Si tiene problemas para leer o comprender esta o cualquier otra documentación de UnitedHealthcare® Connected™ de MyCare Ohio (plan Medicare-Medicaid), comuníquese con nuestro Departamento de Servicio al Cliente para obtener información adicional sin costo para usted al 1-877-542-9236 (TTY 711) de lunes a viernes de 7 a.m. a 8 p.m. (correo de voz disponible las 24 horas del día, los 7 días de la semana).

UnitedHealthcare Connected™ (Medicare-Medicaid Plan)

UnitedHealthcare Connected (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

UnitedHealthcare Connected Benefit Disclaimer

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. Benefits and/or copayments may change on January 1 of each year.

UnitedHealthcare Senior Care Options (HMO SNP) Plan

UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.

Availability of Non-English Disclaimer

This information is available for free in other languages. Please call our customer service number at 1-800-905-8671, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.

Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al número 1-800-905-8671, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana.

Star Ratings Disclaimer

Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

Formularies

The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary.

NCQA

UnitedHealthcare Connected has a Model of Care approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) through 2016 based on a review of UnitedHealthcare Connected’s Model of Care.

UnitedHealthcare Connected™ for MyCare Ohio (Medicare-Medicaid Plan)

UnitedHealthcare Connected for MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook.

Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook.

Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

You can get this information for free in other languages. Call 1-877-542-9236 (TTY: 711) The call is free.

Usted puede obtener esta información de forma gratuita en otros idiomas. Llame 1-877-542-9236 (TTY: 711). La llamada es gratuita.

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