Pharmacy Resources and Physician Administered Drugs

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 and Wholesaler Acquisition Cost, 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.

• Kansas Maximum Allowable Cost (MAC) Price Lookupopen_in_new
• Maximum Allowable Cost Appeal Submission Guideopen_in_new
  
• Maximum Allowable Cost List Administrationopen_in_new

If you have questions related to your contract with us or other issues related to the UnitedHealthcare Community Plan of Kansas Pharmacy Network, please feel free to contact our network relations line at 1-800-613-3591.

Email: pharmacycontracts@optum.com
For contracting Issues: 1-800-613-3591
Claims processing issues: 1-800-842-4195
Fax: 1-866-811-4224

For dates of service on and after January 1, 2025, the Medicare Part D Copayment assistance amount will be $12.15 per 30-day supply with a maximum of up to $36.45 for a 90-day supply.

For dates of service on and after January 1, 2024, the Medicare Part D Copayment assistance amount will be $11.20 per 30-day supply with a maximum of up to $33.60 for a 90-day supply.

UnitedHealthcare Community Plan Quantity Limit Policy

UnitedHealthcare Community Plans may have monthly quantity limitations on certain medications. Prescriptions for quantities greater than the indicated monthly limits will require prior authorization. Quantity limits exist to promote efficient medication dosing and safe dosing administration.

Additions to the Quantity Limit (QL) program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the prior authorization (PA) process.

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

• Opioid Prescriber Reference Guideopen_in_new
  

Other Resources

• Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Painopen_in_new
  
• Centers for Disease Control and Prevention (CDC): CDC Opioid Overdose Guideline Resourcesopen_in_new

To submit a request for prior authorization, please use the PA forms available on the Kansas Medicaid (KanCare and KMAP) Pharmaceutical Programopen_in_new website.

These forms can be used for drug prior authorization request. It’s important to review drug criteria and complete the form with all relevant information. If the information required in the specific drug criteria is not included in the prior authorization request, the request may be denied.

Fax completed forms to the Pharmacy or Medical Prior Authorization department based on where the drugs are being billed and dispensed:

• Pharmacy Prior Authorization - Drug dispensed from a pharmacy
• Medical Prior Authorization - Drug dispensed from a provider office, hospital, or outpatient stock

Kansas PA Criteria and Kansas PA Forms

• Prior Authorization - Clinical Criteriaopen_in_new
• Prior Authorization - Non-Preferred PDL PAopen_in_new

KanCare Medication Request Forms

• Drug-Specific PA Forms (PDF)open_in_new – This is a table to identify if a specific medication requires Clinical PA and which Clinical PA criteria and PA form should be used to request a prior authorization.
• Non-Preferred PDL PA Formopen_in_new – This is a form that can be used for drugs that are Non-Preferred and does not require a Clinical PA. Refer to the Kansas Preferred Drug List (PDL)open_in_new.

Specialty Pharmacy

Specialty pharmacy providers are specifically trained on specialty medications, the conditions they treat, and can provide comprehensive clinical services. The contracting / credentialing process ensures consistency with the requirements, the highest level of quality provided to members, and access to all specialty pharmacy medications.

The specialty pharmacies provide patient education and training, not only for the medication, but also the chronic condition being treated. The specialty teams proactively reach out to patients each month prior to refilling their prescription. During this outreach, patients are asked if they have questions about their condition or drugs, and if they would like to speak directly to a clinician. Medication adherence is also checked, with any potential issues identified and addressed. Additionally, Specialty Pharmacies can have Member Support Services which may provide patients with access to a clinician trained in their condition and drug therapy 24 hours a day, 7 days week.

Some of the services specialty pharmacies offer may include:                                     

• Expedited delivery to the member’s home or physician’s office
• Proper handling and packaging according to the product’s storage requirements, with instructions provided for the member if any refrigeration or special storage conditions exist.
• Patient-friendly educational material that includes drug information which speaks to medication administration and compliance.
• Adherence programs
• Medication administration training/assistance

The pharmacy directory is available to locate a specialty pharmacy near you. 

Network Pharmacy Provider Locator – Inclusive of specialty pharmaciesopen_in_new

UnitedHealthcare Community Plan - KanCare

UnitedHealthcare Community Plan uses the Kansas Department of Health and Environment’s Preferred Drug List (PDL) and related policies for KanCare members. We follow the state’s policies for generic substitution and therapeutic interchange, quantity limits and step therapy. 

• UnitedHealthcare Community Plan - KanCare Preferred Drug Listopen_in_new
• UnitedHealthcare Community Plan - KanCare Preferred Drug List Searchopen_in_new
• HCPCS Code Search (kmap-state-ks.us)open_in_new
• NDC Search (kmap-state-ks.us)open_in_new
• Machine Readable PDLopen_in_new
• Provider Vendor Assistance List - Specialty Pharmacy

UnitedHealthcare Dual Complete® (HMO-SNP) Program

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete (HMO-SNP)

• View the UnitedHealthcare Dual Complete (HMO-SNP) Preferred Drug List

To see the latest PDL updates, visit Drug Lists and Pharmacy > UnitedHealthcare Prescription Drug Lists (PDL) / Drug Formulary > Prescription Drug List Updates.