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- Reimbursement Policy
Opioid Program and Resources
In response to the U.S. opioid epidemic, UnitedHealthcare has 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
Medicated Assisted Treatment: Locate a Provider (PDF 84.58 KB)
Naloxone Coverage for UnitedHealthcare Members (PDF 323.61 KB)
Naloxone: What You Need to Know (PDF 62.67 KB)
Opioid Tapering Recommendations (PDF 102.65 KB)
The Role of Dentists in Managing Opioids (PDF 448.16 KB)
Treatment Alternatives for Common Pain Conditions (PDF 96.61 KB)
Agency for Healthcare Research and Quality (AHRQ)
Interagency Guideline on Prescribing Opioids for Pain
Centers for Disease Control and Prevention (CDC)
CDC Guideline for Prescribing Opioids for Chronic Pain (2016)
CDC Opioid Overdose Guideline Resources
Substance Abuse and Mental Health Services Administration (SAMHSA)
The Role of Prevention in Addressing Neonatal Abstinence Syndrome
Assistance with Locating a Pharmacy
Providers who would like to assist their UnitedHealthcare Community Plan patients with finding nearby open pharmacies in areas impacted by disaster, please refer to the following organizations.
Healthcare Ready at HealthcareReady.org
Louisiana Independent Pharmacies Association at lipanow.org
For additional pharmacy information, contact customer service at 866-675-1607.
Preferred Drug List and Updates
The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Community Plan of Louisiana.
Click on the link below to view the Preferred Drug List.
Paper Pharmacy Prior Authorization Fax Forms are now available at UHCprovider.com. Additionally, UnitedHealthcare accepts a standard single page prior authorization form for outpatient pharmacy services as a complement to our existing prior authorization processes. Use the single page Provider Authorization Form.
Step Therapy Program
Step Therapy Policy (PDF 21.02 KB)
Drug Quantity Limit Initiatives
Quantity Limit Policy (PDF 20.11 KB)
ADHD and Medication: What You Should Know to Get the Best Results (PDF 141.39 KB)
Louisiana Practitioner Bulletin Q4 2015 Update (PDF 61.62 KB)
Synagis Enrollment Form (PDF 225.02 KB)
Synagis Program (PDF 53.22 KB)
Synagis Program 5 Doses (PDF 42.79 KB)
Maximum Allowable Cost List Administration
UnitedHealthcare Community Plan works with OptumRx to manage the Pharmacy network. Multiple sources are used by OptumRx in order to assure the Maximum Allowable Cost (MAC) list accurately reflects market pricing and availability of generic drugs.
Sources include de-identified market pricing, benchmark data including Average Wholesale Price (AWP) and Wholesaler Acquisition Cost (WAC), wholesaler information on market availability, and individual pharmacy feedback.
The synthesis of this information helps create a market based MAC price for generic items included on the MAC list. These sources are monitored and updates are used to help manage the market fluctuations of pricing on the MAC list. The MAC lists are reviewed on a monthly basis.
For Louisiana Medicaid MAC inquiries, please contact OptumRx through email at RxReimbursement@Optum.com.
MAC Price Lookup
A contracted pharmacy may access MAC prices here.
For general contract information, please contact OptumRx at 1-800-797-9798.
Pharmacies with specific claim related questions should contact OptumRx at 1-866-328-3108.
Specialty pharmacy medications covered on the Medical Benefit may be provided through a variety of channels – home infusion provider, outpatient facility, physician, or specialty pharmacy.
Click the arrow above to view the medical injectable information.
Specialty pharmacy medications covered under the member’s medical benefit may be obtained through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.
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 the following network specialty pharmacy:
Network Specialty Pharmacy
The following specialty pharmacies also provide certain types of specialty medications:
Network Specialty Pharmacy
Accredo (nursing services)
Option Care (nursing services)
CVS Caremark 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.
Pharmacy and Therapeutics Committee
If you are interested in speaking at a committee meeting, please refer to the following document Pharmacy and Therapeutics Committee Speaker Request Form (PDF 77.92 KB).
2018 Pharmacy & Therapeutics Committee Meetings
Monday, June 25th, 2018
5:00-6:30 p.m. Central Time