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Specialty pharmacy requirementsfor UnitedHealthcare commercialplan membersMedication sourcing requirement – all outpatient providersPlaces of service: Outpatient facility, physician office, home, ambulatory infusionTo support the care provider/patient relationship in managing rare and complex chronic conditions, we requirecare providers who participate in UnitedHealthcare commercial plans to follow specialty pharmacy requirementswhen obtaining certain specialty medications covered under the member’s medical benefit. To meet therequirements, you must order certain medications from the specialty pharmacies listed in the table below.Please note: The requirements do not apply to UnitedHealthcare West members.Therapeutic classBotulinum Toxin A and BBrand nameBotox , Dysport ,Myobloc , Xeomin Enzyme Replacement TherapyBrineura Gene TherapyLuxturna Immune ModulatorGamifant RSV PreventionSynagis Spinal Muscular AtrophySpinraza Peyronie’s Disease,Dupuytren’s contractureXiaflex *Spinal Muscular AtrophyZolgensma Specialty pharmacyOptum Pharmacy (Specialty)Phone: 855-242-2241Fax: 877-342-4596Orsini Pharmaceutical ServicesPhone: 800-240-9572Fax: 847-427-7976Accredo Health GroupPhone: 877-222-7336Fax: 866-579-4655Biologics, Inc.Phone: 800-850-4306Fax: 800-823-4506Optum Pharmacy (Specialty)Phone: 855-242-2241Fax: 877-342-4596Accredo Health GroupPhone: 877-222-7336Fax: 866-579-4655US BioservicesPhone: 888-518-7246Fax: 888-418-7246Accredo Health GroupCustomer Service phone: 877-787-8704Clinician phone: 800-987-5254Fax: 877-327-8413Orsini Pharmaceutical Services, LLCPhone: 800-697-5048Fax: 877-471-5704*Effective for dates of service on or after April 1, 2021PCA-1-21-01106-PH-WEB 03232021
Medication sourcing expansion requirement – outpatient hospital providers onlyUnitedHealthcare is expanding medication sourcing requirements to apply to additional drugs that are administeredin an outpatient hospital setting. To meet the requirements, outpatient hospital providers must order the medicationslisted in the chart from the indicated specialty pharmacies, unless otherwise authorized by UnitedHealthcare. Effective for dates of service starting June 7, 2021, to include 12 oncology supportive care drugsEffective for dates of service starting July 1, 2021, to include 2 more specialty drugsAt this time, these requirements apply to UnitedHealthcare commercial plans, but do not apply toUnitedHealthcare West, UMR, Student Resources, UnitedHealthOne Golden Rule and Sierra plans.UnitedHealthcare Oxford commercial plans are subject to a separate specialty pharmacy requirement, which canbe viewed at UHCprovider.com Policies and Protocols Commercial Policies UnitedHealthcare OxfordClinical, Administrative and Reimbursement Policies Specialty Pharmacy for Certain Specialty MedicationsAdministered in an Outpatient Hospital Setting – Oxford Clinical Policy.The following states/territories are excluded from the expanded requirements. All other states are included. Alaska, Hawaii, Kentucky, Maryland, Puerto Rico, Rhode Island, Utah and U.S. Virgin IslandsSpecialty drug and pharmacy listMedication nameTherapeutic classCodeActemra Inflammatory ConditionsJ3262Adakveo Sickle Cell DiseaseJ0791Aldurazyme Enzyme Replacement TherapyJ1931Amondys-45*CNS AgentsJ3490J3590C9399Specialty pharmacyCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Optum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesTo be announcedAccredo Health GroupAllianceRx Walgreens PrimeAralast NP Alpha1-Proteinase InhibitorsJ0256Caremark (CVS Specialty)Option Care HealthJ1599Asceniv Immune GlobulinAccredo Health GroupJ1554Option Care HealthAvsola Inflammatory ConditionsQ5121Orsini Pharmaceutical ServicesPCA-1-21-01106-PH-WEB 03232021
Medication nameTherapeutic classCodeBenlysta Monoclonal Antibody MiscellaneousJ0490Bivigam Immune GlobulinJ1556Cerezyme Enzyme Deficiency (Gaucher Disease)J1786Cimzia Inflammatory ConditionsJ0717Cinqair AsthmaJ2786Crysvita EndocrineJ0584Cutaquig Immune GlobulinJ3590Cuvitru Immune GlobulinJ1555Elaprase Enzyme Replacement TherapyJ1743Elelyso Enzyme Deficiency (Gaucher Disease)J3060Entyvio Inflammatory ConditionsJ3380Specialty pharmacyAccredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Optum InfusionOptum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesAccredo Health GroupOptum Pharmacy (Specialty)Optum Pharmacy (Specialty)Accredo Health GroupCaremark (CVS Specialty)OrsiniOrsini PharmaceuticalPharmaceutical ServicesServicesPantheRxPANTHERx Rare PharmacyOption Care HealthOptum InfusionAccredo Health GroupOption Care HealthOptum InfusionOptum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesAccredo Health GroupCaremark (CVS Specialty)Orsini Pharmaceutical ServicesAccredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Option Care HealthExondys 51 CNS AgentsJ1428Orsini Pharmaceutical ServicesPCA-1-21-01106-PH-WEB 03232021
Medication nameTherapeutic classCodeFabrazyme Enzyme Replacement TherapyJ0180Fasenra AsthmaJ0517Gammagard Liquid Immune GlobulinJ1569Gammaked Immune GlobulinJ1561Gammaplex Immune GlobulinJ1557Gamunex-C Immune GlobulinJ1561Givlaari Blood-Modifying AgentsJ0223Glassia Alpha1-Proteinase InhibitorsJ0257Specialty pharmacyAccredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesAccredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Optum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum InfusionOptum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeOption Care HealthOptum InfusionOptum Pharmacy (Specialty)AllianceRx Walgreens PrimeOption Care HealthOptum InfusionOptum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum InfusionOptum Pharmacy (Specialty)Accredo Health GroupPANTHERx Rare PharmacyAccredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthAccredo Health GroupAllianceRx Walgreens PrimeHizentra Immune GlobulinJ1559Option Care HealthOptum InfusionOptum Pharmacy (Specialty)PCA-1-21-01106-PH-WEB 03232021
Medication nameTherapeutic classCodeHyQvia Immune GlobulinJ1575Ilaris Immune ModulatorJ0638Ilumya Inflammatory ConditionsJ3245Inflectra Inflammatory ConditionsQ5103Kanuma Enzyme Replacement TherapyJ2840Krystexxa Anti-Gout AgentsJ2507Lemtrada Multiple SclerosisJ0202Lumizyme Enzyme Replacement TherapyJ0221Mepsevii Enzyme Replacement TherapyJ3397Naglazyme Enzyme Replacement TherapyJ1458Nucala AsthmaJ2182Ocrevus Multiple SclerosisJ2350PCA-1-21-01106-PH-WEB 03232021Specialty pharmacyAccredo Health GroupAllianceRx Walgreens PrimeOption Care HealthOptum InfusionOptum Pharmacy (Specialty)Accredo Health GroupCaremark (CVS Specialty)Accredo Health GroupCaremark (CVS Specialty)Optum Pharmacy (Specialty)Accredo Health GroupOption Care HealthOptum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesOptum Pharmacy (Specialty)Accredo Health GroupCaremark (CVS Specialty)Accredo Health GroupCaremark (CVS Specialty)Optum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesAccredo Health GroupAccredo Health GroupCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesAccredo Health GroupOptum Pharmacy (Specialty)Accredo Health GroupCaremark (CVS Specialty)Option Care HealthOptum InfusionOptum Pharmacy (Specialty)
Medication nameTherapeutic classCodeOctagam Immune GlobulinJ1568Onpattro CNS AgentsJ0222Specialty pharmacyAccredo Health GroupAllianceRx Walgreens PrimeOption Care HealthOptum InfusionOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesUS BioservicesAccredo Health GroupOrencia IV Inflammatory ConditionsOxlumo *EndocrineJ0129AllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)J3490J3590C9074Panzyga Immune GlobulinJ1599Privigen Immune GlobulinJ1459Prolastin-C Alpha1-Proteinase InhibitorsJ0256Radicava CNS AgentsJ1301ReblozylRemicade AnemiaInflammatory ConditionsJ0896J1745Renflexis Inflammatory ConditionsQ5104Revcovi Enzyme Replacement TherapyJ3590C9399C9399Simponi Aria Inflammatory ConditionsJ1602Soliris Blood-Modifying AgentsJ1300PCA-1-21-01106-PH-WEB 03232021To be announcedAccredo Health GroupOption Care HealthOptum InfusionOptum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum InfusionOptum Pharmacy (Specialty)EversanaAllianceRx Walgreens PrimeOption Care HealthOptum Pharmacy (Specialty)Option Care HealthCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)AllianceRx Walgreens PrimeAccredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)Accredo Health GroupAllianceRx Walgreens PrimeCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)
Medication nameTherapeutic classCodeSpecialty pharmacyOption Care HealthOptum Pharmacy (Specialty)Accredo Health GroupOption Care HealthAccredo Health GroupCaremark (CVS Specialty)Option Care HealthAllianceRx Walgreens PrimeOption Care HealthOptum Pharmacy (Specialty)Accredo Health GroupCaremark (CVS Specialty)Option Care HealthOptum Pharmacy (Specialty)US BioservicesStelara Inflammatory ConditionsJ3358Tepezza EndocrineJ3241Trogarzo HIVJ1746Tysabri Multiple SclerosisJ2323Ultomiris Blood-Modifying AgentsJ1303Uplizna Immune ModulatorJ1823PANTHERx Rare PharmacyViltepso CNS AgentsJ3490J3590J3590Orsini Pharmaceutical ServicesJ1427Vimizim Enzyme Replacement TherapyJ1322VPRIV Enzyme Deficiency(Gaucher’s Disease)J3385Vyepti CNS AgentsJ3032Vyondys-53 CNS AgentsJ1429Xembify Immune GlobulinJ1558Xolair AsthmaJ2357ZemairaxAlpha1-Proteinase InhibitorsJ0256*Effective for dates of service on or after July 1, 2021PCA-1-21-01106-PH-WEB 03232021Accredo Health GroupCaremark (CVS Specialty)Orsini Pharmaceutical ServicesAccredo Health GroupAllianceRx Walgreens PrimeOption Care HealthOptum Pharmacy (Specialty)Orsini Pharmaceutical ServicesAllianceRx Walgreens PrimeOption Care HealthOrsiniOrsini PharmaceuticalPharmaceutical ServicesServicesOption Care HealthOrsini Pharmaceutical ServicesAccredo Health GroupOptum InfusionAccredo Health GroupAllianceRx Walgreens PrimeOptum Pharmacy (Specialty)Accredo Health GroupCaremark (CVS Specialty)Option Care Health
Oncology supportive care medication and pharmacy list – outpatient hospital providers,when used for treatment of an oncology indication onlyEffective for dates of service on or after June 7, 2021Medication nameTherapeutic classCodeSpecialty pharmacyFulphilaColony-Stimulating FactorsQ5108Accredo Health Group)Optum Pharmacy (Specialty)GranixColony-Stimulating FactorsJ1447Accredo Health GroupOptum Pharmacy (Specialty)LeukineColony-Stimulating FactorsJ2820Accredo Health GroupOptum Pharmacy (Specialty)NeulastaColony-Stimulating FactorsJ2505Accredo Health GroupOptum Pharmacy (Specialty)NeupogenColony-Stimulating FactorsJ1442Accredo Health GroupOptum Pharmacy (Specialty)NivestymColony-Stimulating FactorsQ5110Accredo Health GroupOptum Pharmacy (Specialty)NyvepriaColony-Stimulating FactorsQ5122Accredo Health GroupProliaBone-Modifying AgentJ0897UdenycaColony-Stimulating FactorsQ5111XgevaBone-Modifying AgentJ0897ZarxioColony-Stimulating FactorsQ5101ZiextenzoColony-Stimulating FactorsQ5120Specialty pharmacy contactsAccredo Health Group – specialty drugsPhone: 877-222-7336Fax: 866-579-4655Accredo Health Group – oncology supportive care drugsPhone: 877-783-2262Fax: 888-302-1028AllianceRx/Walgreens PrimePhone: 888-282-5166Fax: 888-570-4700PCA-1-21-01106-PH-WEB 03232021Accredo Health Group)Optum Pharmacy (Specialty)Accredo Health GroupOptum Pharmacy (Specialty)Accredo Health GroupOptum Pharmacy (Specialty)Accredo Health GroupOptum Pharmacy (Specialty)Accredo Health GroupOptum Pharmacy (Specialty)
CVS/CaremarkPhone: 800-237-2767Fax: 800-323-2445EversanaPhone: 866-849-4481Fax: 877-473-3172Option Care HealthPhone: 833-730-HOPD (4673)Fax: 888-979-8904Optum Infusion PharmacyPhone: 877-342-9352Fax: 877-542-9352Optum Pharmacy (Specialty)Phone: 855-427-4685Fax: 877-342-4596Orsini Pharmaceutical ServicesPhone: 800-697-5048Fax: 877-471-5704PANTHERx Rare PharmacyPhone: 855-726-8479 X 1115Fax: 888-550-7441US BioservicesPhone: 888-518-7246Fax: 888-418-7246*Optum Pharmacy (Specialty)/Optum Infusion Services are affiliates of UnitedHealthcare.Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona,Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare ofthe Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, UnitedHealthcare of New York, Inc., UnitedHealthcare Insurance Company of New York,UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Pennsylvania, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcareBenefits of Texas, Inc., UnitedHealthcare of Utah, Inc., UnitedHealthcare of Washington, Inc., Optimum Choice, Inc., Oxford Health Insurance, Inc., Oxford HealthPlans (NJ), Inc., Oxford Health Plans (CT), Inc., All Savers Insurance Company, or other affilia
care providers who participate in UnitedHealthcare commercial plans to follow specialty pharmacy requirements when obtaining certain specialty medications covered under the member’s medical benefit. To meet the requirements, you must order certain medications from
