Network Bulletin - An important message to health care professionals and facilities
In this Issue Volume 53, January 2013

Pharmacy Updates

Articles:


Prior Authorization Required for H.P. Acthar Gel and Immune Globulin Medications for UnitedHealthcare Commercial Members

Effective April 1, 2013, UnitedHealthcare will implement an important change in the advanced notification review process for the administration of certain specialty medications covered under the medical benefit.

All participating network physicians will be required to submit for prior authorization review and approval prior to administration of H.P. Acthar® (repository corticotropin injection) and immune globulins for members (intravenous or subcutaneous immunoglobulin pooled from human plasma) with UnitedHealthcare commercial coverage plans, including those members currently on therapy. This will impact any dates of service beginning April 1, 2013. These requests may be subject to medical necessity review to determine coverage.

Currently it is optional for network physicians prescribing H.P. Acthar (or immune globulin medications to submit for advanced notification prior to the administration of these medications. Drug policy criteria and/or manufacturer package labeling are used to review these requests and are the basis for coverage determination.

Medical necessity review addresses the clinical evidence supporting a health service; the medical appropriateness of the service for a specific patient; and the cost-effectiveness of the service.

Impacted medications*

J-Code Drug Name
J0800 H.P. Acthar
J1459 Privigen
J1557 Gammaplex
J1559 Hizentra
J1561 Gamunex
Gamunex-C
Gammaked
J1566 Carimune
Gammagard S/D
J1568 Octagam
J1569 Gammagard Liquid
J1572 Flebogamma
J1599 Intravenous Immune Globulin Not Otherwise Specified
CPT-Code Drug Name
90283 Intravenous Immune Globulin
90284 Subcutaneous Immune Globulin

*This list is subject to change as new immune globulin medications, CPT-Code and/or J-Codes are released.

Advanced notification process

Obtaining prior authorization is mandatory for dates of service beginning April 1, 2013. To obtain prior authorization:

  1. Review UnitedHealthcare’s drug policies at UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources > Policies, Protocols and Guides.

  2. Using the criteria outlined in the applicable drug policy, submit the appropriate medical records and prescription enrollment form to support documentation for the specified drug and indication for all UnitedHealthcare commercial members. The enrollment form can be found at UnitedHealthcareOnline.com>Tools and Resources>Pharmacy Resources.

    1. The enrollment is not required for services that take place in an emergency room, observation unit and urgent care facility or during an inpatient stay

  3. Fax the completed form and supporting documentation to 866-756-9733. If you need assistance, please call the UnitedHealthcare call center at 877-842-3210 and follow the call prompts.

  4. A clinician will review the prior authorization request.

    1. If coverage is approved, the physician will receive confirmation via phone and fax.

    2. If coverage is denied, the physician will receive confirmation via phone and fax, including information on appeal rights.

Note:
In accordance with the physician’s contract, if physician fails to obtain prior authorization, or if a required coverage review was still in process on the date of administration (and the service is deemed not covered), the claim will be denied and the member may not be billed for the service. UnitedHealthcare’s standard appeal process will apply to any denied claims.

Complete information about prior authorization for specialty medications is available in the 2013 Administrative Guide under Specialty Drug Prior Authorization Process (Commercial).

To view the current guide, visit UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources > Policies, Protocols and Guides.

If you have questions about the prior authorization review process, please contact your local network manager or call the Administrative Services number on the back of the member’s UnitedHealthcare ID card.

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If you do not contract directly with UnitedHealthcare, and participate in our network through an arrangement in which we "Lease" a network from some other entity, some of the information provided in this communication may not be applicable to you and/or impact you differently. If you have questions regarding any of the information or need to better understand its impact on you, please contact your local Network Account Representative, Physician Advocate or Hospital & Facility Advocate. If you are not sure who your contact is, please visit UnitedHealthcareOnline.com > Contact Us > Network Contacts.

Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. or its affiliates.

Questions or Comments? Write to us at: UnitedHealthcare, MN012-S117, P.O. Box 1459, Minneapolis, MN 55440-1459. For more information, visit our Web site unitedhealthcareonline.com or call our telephone self-service system at: 877-842-3210.

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