Information by UCare Plan
UCare Individual & Family Plans
Commercial products for individual and family (IFP) coverage available through MNsure, including UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview.
UCare Medicare Plans, UCare Medicare Plans with M Health Fairview and North Memorial, UCare Medicare Group Plans, UCare Advocate Plans and EssentiaCare.
Medicare + Medical Assistance
UCare Connect + Medicare and Minnesota Senior Health Options (MSHO)
State Medical Assistance Programs
UCare Connect (Special Needs BasicCare), Minnesota Senior Care Plus (MSC Plus), MinnesotaCare (MnCare), Prepaid Medical Assistance Program (PMAP)
Resources & Information
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.
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.
- 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 and MSHO members.
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.
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.
For any questions or inquiries regarding the MTM program at UCare, please contact us via email at email@example.com.
Additional Helpful Resources
November 18, 2020 - UCare Medicare Part D Vaccine Information
November 12, 2021 - Pharmacy Formulary and Benefit Changes for 2022
November 12, 2021 - Medical Benefit Drug Prior Authorization for 2022
November 12, 2021 - Changes to 2022 Part D Vaccine Billing for MSHO and Connect + Medicare
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
Express Scripts - Medicare, Medicare + Medical Assistance (dual eligibles)
Medical Injectable Drug Prior Authorization
Care Continuum, a subsidiary of Express Scripts
Online (ePA): ExpressPAth Portal at www.express-path.com/.
UCare Clinical Services Intake
Specialty Pharmacy Contact Information
Fairview Specialty Pharmacy
Phone: 612-672-5260 or 1-800-595-7140 toll free
*exclusive network provider of specialty drugs for UCare Individual & Family Plans and State Medical Assistance Programs
Mail Order Contact Information
Express Scripts Mail Order Pharmacy
ePrescribing: Express Scripts Home Delivery Pharmacy
News & Alerts
Provider News Library
Updated Prior Authorization Criteria for Drugs on the IFP Formulary
Starting November 1, 2022, UCare is updating prior authorization criteria for 10 drugs that are on the UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview formulary.
September 2022 Health Lines
Learn about the following: Welcome of Dr. Tenbit Emiru, How to Access the UCare for Providers Webpage, UCare Provider Portal Will Be Unavailable, Ineligible Provider List Updated August 31, Update to Prior Authorization Process for Acupuncture Services, Waivered Services Transportation Billing Requirements and more.
FDA Announces Recall of Magnesium Citrate Saline Laxative Oral Solution
On July 25, 2022, the U.S. Food and Drug Administration announced Vi-Jon, LLC has voluntarily recalled all lots of Magnesium Citrate Saline Laxative Oral Solution, 10 fl. oz. (296 mL) due to the presence of Gluconacetobacter liquefaciens.
UPDATE on CARC and RARC For Rural Health Clinic (RHC) Carve-out Services
UCare is updating its system to report CARC of 24 and RARC of N193 in the 835-remittance advice and on the EOP for RHC claims that qualify for payment by DHS. We expect this change will improve posting of payments/adjustments from DHS for RHC carve-out services.
Medical and Pharmacy Benefit Duplicate Payments and Recoupment Process ReminderUCare performs quarterly duplicate payment audits of medical benefit and pharmacy benefit claims submitted. This quarterly audit has a lookback period of 12 months. Duplicate claims are recouped under the medical benefit or Medicare Part C and are identified on the Explanation of Payment (EOP) with CARC OA18 and RARC N522.
See the August 19 Provider Bulletin for details.
Important: New Requirement for Non-Emergency Transportation Providers Expecting Rural Urban Commuting Area (RUCA) Adjustments Add-ons
UCare applies RUCA rates when claims are billed with the member ZIP code or the pick-up location in the appropriate fields on the claims. Providers are reminded to submit this information to ensure they get the applicable RUCA enhancements.
Critical Business Reminders
UCare informs providers of critical business reminders for the Credentialing and Recredentialing Process, Pharmacy, Complex Case Management Process, Utilization Management Information, Member Rights and Responsibilities, Practitioner Support Shared Decision-Making Aids and Clinical Practice Guidelines.
FDA Approval of Ukoniq Withdrawn Due to Safety ConcernsDue to safety concerns, the U.S. Food and Drug Administration (FDA) announced on June 1, 2022, it has withdrawn approval for the cancer medicine Ukoniq (umbralisib).
See the June 22 Provider Bulletin for details.
UCare to Deny Claims When Comprehensive Procedure Code is Not Applied
As a reminder, providers are required to bill the most comprehensive code for procedures versus individual (component) codes. Effective for claims received on or after June 28, 2022, UCare will apply edits to deny claims when the most comprehensive code is not billed.
Information on UCare’s New Claims SystemSee all related Provider Bulletins outlining the changes you can expect with UCare’s new claims system. Visit the New Claims System page.
UCare's 2022 Authorization & Notification Grids
The UCare 2022 authorization and notification requirements are now available.
View the 2022 auth grids in the Resources and Information section of the Authorizations page.
Pharmacy Formulary and Benefit Changes for 2022
Information about the 2022 formularies and changes to benefits is now available.
Medical Benefit Drug Prior Authorization for 2022
2022 Medical Benefit Drug Prior Authorization (PA) information is available.
Changes to 2022 Part D Vaccine Billing for UCare’s MSHO and UCare Connect + Medicare
Vaccine and administration will need to be billed through the member’s Part D benefit.
UCare 2022 Medicare Plans Earn 5-Star Rating from CMS
UCare is pleased to announce its 5-Star Rating from CMS for its 2022 Medicare plans.
Quantity Limits (QL) Updated for Continuous Glucose Monitors on All UCare Formularies
Effective Sept. 1, 2021, quantity limits for continuous glucose monitor products will be updated.
Reminder: UCare Medicare Part D Vaccine InformationStarting Jan. 1, 2021, UCare began denying claims for providers administering Part D vaccines in their clinics. Provider will need to bill both the vaccine and administration through the member’s Part D benefit.
See the Feb. 4 bulletin for details.