Pharmacy Direct Member Reimbursement Request
Download a MAPD Prescription Reimbursement Request Form from OptumRx.
Prescription Drug Transition Process
What to do if your current prescription drugs are not on the formulary or are limited on the formulary.
As a new member of an UnitedHealthcare Dual Complete® (HMO D-SNP), 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., changing a long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Medicare Part D coverage or when taken off of hospice care). 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.
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.
If you have any questions about this transition policy or need help asking for a formulary exception, a UnitedHealthcare representative can help.
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 not a plan benefit and 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 chronic conditions, and
- might spend more than $4,376 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.
- Hyperlipidemia – High Cholesterol
- Chronic Heart Failure – Heart Failure
- Chronic Obstructive Pulmonary Disease
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 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.