Pharmacy

Electronic Prior Authorization (ePA):

ePA is the preferred method to submit Prior Authorization requests to Express Scripts for pharmacy benefit drugs. Providers may use ePA through ExpressPAth, Surescripts, CoverMyMeds or through the Electronic Health Record.

Prior authorization requests for medical drugs administered in a doctor's office will be reviewed by Care Continuum, a subsidiary of Express Scripts. See information in Medical Injectable Drug Prior Authorization Resources.

Care Continuum reviews Medical Drug Prior Authorization requests for all UCare plans.

• See the Medical Injectable Drugs requiring prior authorization.
• Review Medical Drug Policies.

To submit an authorization request, use one of the following ways:

• Online (ePA) via the ExpressPAth Portal at www.express-path.com/. Providers can submit requests, check on the status of submitted requests, and submit an authorization renewal on the ExpressPAth Portal. The site also provides 24/7 access, potential for real-time approvals, and email notifications once a decision is reached.
• Fax an authorization form to Care Continuum at 1-877-266-1871.
• Call Care Continuum at 1-800-818-6747.
  

To request an adjustment to an existing prior authorization:

• Providers should contact Care Continuum for prior authorization changes.
• The authorization must be active.
• End date extensions can be completed due to scheduling issues or health reasons (ex: chemo delayed due to blood count) that may prevent the administration of the previously approved drug.
• Required information for these requests:
  • Reason for extension.
  • Revised end date.
• Adjustments are not approved for the reasons listed below. A new review/renewal is required.
  • Additional drug is requested.
  • The patient is due for a renewal.

Non-participating providers should send requests using this form:

• by fax to UCare Clinical Services at 612-884-2300.
• or by mail to UCare, Attn: Clinical Services at P.O. Box 52, Minneapolis, MN 55440-0052.

Providers that received a claim denial due to no authorization in place will continue to work through the provider claims appeal process using the Provider Claim Reconsideration Request Form. 

Our Medication Therapy Management (MTM) Program is a free service for eligible UCare members to optimize individual medication therapy, experience and outcomes. Members receive a one-on-one consultation with a pharmacist to review their entire medication regimen (including prescription, over-the-counter medications and herbal supplements) to help resolve any potential medication-related issues regarding indication, effectiveness, safety and convenience.

UCare partners with many pharmacists across the state of Minnesota and provides reimbursement for MTM services.

Following is a high-level overview of the MTM Program. Please refer to the MTM section of the provider manual for full program information including detailed topics such as eligibility, expectations, audits, billing and more.

Eligibility

• Most UCare plans with prescription drug coverage are eligible for MTM services and can receive these services with contracted local pharmacists.
• Internal UCare telephonic MTM services are only available to Medicare, Connect + Medicare, MSHO, and select Medicaid members.
  

Billing

UCare’s expectation is that MTM services will be billed using MTM CPT codes 99605, 99606 and 99607. Billing is based on complexity, not time, for all lines of business.

Program Information

Important Time Sensitive Requirement Reminders

• Medicare members must be provided with CMS standardized format materials (including medication action plan and personalized medication list) within 14 days of the encounter.
• A Continuity of Care Document (CCD) must be submitted within 45 days of the original visit.
• Member opt-outs from the MTM program must be received within 30 days of member’s decision to opt-out.

Continuity of Care Document (CCD)

MTM providers are required to maintain and submit a CCD for all Medicare visits. It is acceptable to send information for non-Medicare members as well.

• UCare Continuity of Care Document
  

Questions

For any questions or inquiries regarding the MTM program at UCare, please contact us via email at pharmacyliaison@ucare.org.

Additional Helpful Resources

• Medication Therapy Management | Centers for Medicare & Medicaid Services
• MHCP Provider Manual - Medication Therapy Management Services (MTMS)

November 15, 2022 - Pharmacy Formulary and Benefit Changes for 2023
November 15, 2022 - Medical Benefit Drug Prior Authorization for 2023
November 12, 2021 - Changes to 2022 Part D Vaccine Billing for MSHO and Connect + Medicare
November 18, 2020 - UCare Medicare Part D Vaccine Information

The Pharmacy and Therapeutics Committee, a group of practicing physicians and pharmacists, meets up to six times per year to recommend medication inclusion or exclusion to our formularies. The Pharmacy and Therapeutics Committee evaluates drugs based on clinical evidence and efficacy (drug monographs, peer reviewed literature, compendia resources), therapeutic guidelines, medication safety and comparable data to other therapeutic alternatives. This committee reviews all new drugs approved by the FDA, new generics, new dosage forms, new indications as well as regular therapeutic class reviews and annual review of all utilization management criteria. 

Pharmacy Benefit Prior Authorization
Express Scripts - State Medical Assistance Programs and UCare Individual & Family Plans
Phone: 1-877-558-7523
Fax: 1-877-251-5896

Express Scripts - Medicare, Medicare + Medical Assistance (dual eligibles)
Phone: 1-877-558-7521
Fax: 1-877-251-5896

Medical Injectable Drug Prior Authorization
Care Continuum, a subsidiary of Express Scripts
Online (ePA): ExpressPAth Portal at www.express-path.com/.
Phone: 1-800-818-6747
Fax: 1-877-266-1871

UCare Clinical Services Intake
Fax: 612-884-2300

Specialty Pharmacy Contact Information
Fairview Specialty Pharmacy
Phone: 612-672-5260 or 1-800-595-7140 toll free
Fax: 1-866-347-4939
https://www.fairview.org/services/specialty-pharmacy
*exclusive network provider of specialty drugs for UCare Individual & Family Plans and State Medical Assistance Programs

Accredo
www.accredo.com

Mail Order Contact Information
Express Scripts Mail Order Pharmacy
Phone: 1-866-544-7950
Fax: 1-800-837-0959
ePrescribing: Express Scripts Home Delivery Pharmacy