Update to Prior Authorization Process for Medical Specialty Drug Review
There are changes to the prior authorization process for UniCare’s Medical Specialty Drug Review. Effective July 1, 2021, CarelonRx will begin to review most non-oncology specialty drugs. UniCare will continue to review oncology specialty drugs. Certain other non-oncology drugs will continue to be reviewed by Express Scripts.
Express Scripts, the administrator for the prescription drug plan or UniCare's non-Medicare members, covers and dispenses self- or office-administered specialty drugs (non-oncology). In addition, some specialty drugs require review and dispensing by Express Scripts, for non-Medicare members only. The list of these specialty drugs is updated periodically and posted. Review the Express Scripts Specialty Drug List.
Express Scripts Specialty Drug List.
View UniCare’s Medical Specialty Drug Review list effective July 1, 2022 (non-oncology).
View UniCare’s Medical Specialty Drug Review list effective July 1, 2022 (oncology).
View UniCare’s Preapprovals list for Genetic Testing effective July 1, 2022.
Our Provider Reference Sheet identifies which services are reviewed by UniCare, which are reviewed by Carelon Medical Benefits Management or CarelonRx, and how much notice is required. The reference sheet also includes information about member copays, notification requirements for preapprovals, and selected procedures for pre-review.
Effective January 1, 2021, the Provider Reference Sheet was updated to remove preapproval requirements for ECT (Electroconvulsive Therapy) as well as psychological and neuropsychological testing. Review the list of Procedure Codes for ECT and Psychological and Neuropsychological Testing
For preapprovals you also need to submit:
- Standardized Prior Authorization Form
- Precertification worksheets (Upon navigating to the PDF Library, please filter by the “Precertification” category)
For more information, refer to our member handbooks for plan benefits, conditions, limitations and exclusions.
How to Request Preapproval
Here is who to notify to request preapproval:
- UniCare reviews: UniCare Provider Services at 800-442-9300
- Carelon Medical Benefits Management reviews: Contact Carelon Medical Benefits Management directly through the Carelon Medical Benefits Management web application or call 866-766-0247
- CarelonRx reviews: 833-293-0659; covermymeds.com/main/prior-authorization-forms
- Express Scripts: For review of certain non-oncology specialty drugs for non-Medicare members only, call 855-283-7679
UniCare's partnership with Carelon Medical Benefits Management lets our providers use Carelon Medical Benefits Management's web-based application for services reviewed by Carelon Medical Benefits Management. Providers can log into the Carelon Medical Benefits Management application and complete the intake. In many cases, the entire review and approval process can be done online. Providers who already use Carelon Medical Benefits Management's web application will not have to re-register for UniCare.
Express Scripts, the administrator for the prescription drug plan or UniCare's non-Medicare members, covers and dispenses self- or office-administered specialty drugs (non-oncology). In addition, some specialty drugs require review and dispensing by Express Scripts, for non-Medicare members only. The list of these specialty drugs is updated periodically and posted. Review the Express Scripts Specialty Drug List.
Expanded review is required for certain infused specialty drugs. If a non-Medicare member will be getting infusions of certain non-oncology specialty drugs in a hospital outpatient setting, an expanded review will be conducted to review both the drug for clinical appropriateness and the level of care/site of service. The lists of specialty drugs that require level of care review is included in the Provider Reference Sheet.
