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UnitedHealthcare uses specialty pharmacy networks to provide certain medications in connection with many of our benefit plans. The specialty pharmacy network includes specialty pharmacies, each selected based on their clinical expertise for the targeted therapeutic classes, quality of clinical and customer services and cost. Their pharmacists are trained to help educate members and create personalized care plans, if needed, for these specialty medications, which may help improve treatment adherence.
Our fully insured benefit plans use the Specialty Pharmacy Program and it is optional for our large self-funded customers. In 2006, we initiated programs for Rhematoid Arthritis, Multiple Sclerosis, Hepatitis C, Anemia/Neutropenia, Infertility, and Growth Hormone. This year we are adding Transplantation, HIV/AIDS, Oral Oncology, and Pulmonary Arterial Hypertension effective August 1, 2007. Members using and physicians prescribing drugs in the Oral Oncology therapeutic classes recently received letters explaining the Specialty Pharmacy Network and how to transfer their prescriptions using the Specialty Pharmacy Referral Line. Members participating in the Specialty Pharmacy Network will be allowed grace periods for two 30 day prescriptions or one 90 day mail order prescription while they transition to the Specialty Pharmacy Network.
The Oncology Specialty Pharmacy Network includes two specialty pharmacies: Care Advantage, a subsidiary of U.S. Oncology and IVPCare, a subsidiary of OTN (Oncology Therapeutic Networks). The medications affected by this program are covered under the pharmacy benefit:
- Gleevec
- Nexavar
- Revlimid
- Sprycel
- Sutent
- Tarceva
- Temodar
- Thalomid
- Tykerb
- Vesanoid
- Xeloda
- Zolinza
Specialty Pharmacy Process
Physicians write a prescription for one of the above listed oral chemotherapy agents and the member takes the prescription to the pharmacy of their choice. For members who are covered under a plan participating in the Specialty Pharmacy Network, the member may receive up to two 30 day supplies at retail or one 90 day supply at mail order during the transition to the specialty pharmacy. The member will be directed by their local or mail order pharmacy to access the Specialty Pharmacy Network Program. This messaging will include the Specialty Pharmacy Referral Line for the member to call and get warm transferred to one of the two oncology specialty pharmacies. The call center will assign a specialty pharmacy to the member and assist the member with the transition.
Oral Prescriptions
This program only applies to 12 oral chemotherapy drugs listed above. All other chemotherapy and supportive agents administered in the physician office are covered under the medical benefits and are NOT impacted by this program. Oral prescription medications for outpatient use are covered under the pharmacy benefit. If a physician distributes oral prescription medications for outpatient use, and bills UnitedHealthcare, the services are NOT eligible for coverage. For most benefit plans, this is a specific exclusion of the member's MEDICAL certificate of coverage. The member will be responsible for 100% of the expenses.
For additional questions about the Specialty Pharmacy Network, please call the Specialty Pharmacy Referral Line at 1-866-429-8177.
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