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Prescription Drug Transition Process

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

New Nembers
As a new member of UnitedHealthcare Connected™, 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
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 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
• Diabetes
• Chronic Obstructive Pulmonary Disease (COPD)
• Osteoporosis

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. 

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).

These programs may have limited eligibility criteria and are not considered a benefit. 

Prior Authorizations

Prior Authorization Request 

Download the Prescription Prior Authorization List (Coming Soon)
 

Pharmacy Prior Authorization Request to OptumRx

Submit a Pharmacy Prior Authorization Request to OptumRx.

Pharmacy Delivery

Click here for a list of pharmacies that deliver.

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

• UnitedHealthcare Connected 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 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 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 network pharmacies in your area, please visit our web site at www.UHCCommunityPlan.com or call Member Services at 1-800-256-6533, TTY users should call 711, 8 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 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 1-800-256-6533, TTY 711, 8a.m. - 8 p.m., local time, Monday - Friday.

Home Infusion Pharmacies
You can get home infusion therapy if UnitedHealthcare Connected 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 1-800-256-6533, TTY 711, 8 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 through the facility’s pharmacy or another network pharmacy.

For more information, you can call Member Services at 1-800-256-6533, TTY 711, 8 a.m. - 8 p.m., local time, Monday - Friday.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.