Pharmacy

Information by UCare Plan

 

UCare Individual & Family Plans

 

Commercial products for individual and family coverage available through MNsure, including UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview.

Medicare Programs

 

UCare Medicare Plans, UCare Medicare Plans with M Health Fairview and North Memorial, UCare Medicare Group 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.

Starting Jan 1, 2020, 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. 

2020

Beginning Jan.1, 2020, Care Continuum, a subsidiary of Express Scripts, will review Medical Drug Prior Authorization requests for all UCare plans. See the 2020 Medical Drug PA bulletin.

See more information by selecting a UCare Plan at the top of this page and reviewing Medical Injectable Drug Prior Authorization Resources.  

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.

January 2019 Decisions


 

Pharmacy Benefit Prior Authorization

Express Scripts - State Medical Assistance Programs, 2018 UCare Choices, and 2019 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
* exclusive network provider of specialty drugs for 2018 UCare Choices, 2019 UCare Individual & Family Plans and State Medical Assistance Programs
 
Accredo
 

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   
If you have other questions, contact the Provider Assistance Center:

612-676-3300 or 1-888-531-1493
Hours:  8 a.m. to 5 p.m.,  Monday through Friday

Newsletters & Alerts

 

See Full Provider News Library

February 2020 Health Lines

Read about 2020 Medical Drug Prior Authorizations with Care Continuum, the Ineligible Provider List January Update, Using the Correct Payor ID for UCare Medicare Plans, Documentation Improvement for Thrombocytosis; Behavioral Health Department reminders and Health promotion programs including Quit for Life, Strong & Stable and ROSEBUD for high risk pregnancy. 

See the February 2020 Health Lines.

 

 

Inhaler Preferred Drug List Status Changes 

Coverage for Advair Diskus and Ventolin HFA inhaler products on the UCare Minnesota State Health Care Programs formulary will change on Oct. 1, 2019. Proactive review of preferred alternative products, if appropriate, can be made prior to the effective date.  
 
Read the Sept. 6 bulletin for the inhalers and health plans impacted.
 
 
 

2020 Changes to Medical Benefit  Drug Prior Authorizations

Beginning Jan. 1, 2020, Care Continuum, a subsidiary of Express Scripts, will be performing Medical Benefit Drug Prior Authorization reviews for all of UCare’s lines of business. Learn about how to initiate prior authorization requests with Care Continuum, which medical drugs requiring prior authorization and additional changes for 2020 and Biosimilar step therapy for medical drugs in 2020.

Read the 2020 Drug PA Bulletin. 

 

 

Pharmacy Formulary and Benefit Changes for 2020

The 2020 UCare pharmacy formulary changes are now available on the ucare.org/providers website. From the Pharmacy page, you can find the 2019 and 2020 formularies for each health plan. Also covered is a $25 copay cap for each covered insulin prescription filled for UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview with a list of covered formulary insulin and a summary of formulary changes for Medicare and Individual & Family Plans.

Read the 2020 Formulary Changes bulletin .

 

 

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Service Category

 Essentia Health Provider Requirements Other EssentiaCare Network Providers

Codes Requiring Authorization - CPT/HCPC Codes

 

Outpatient Therapy (PT, OT & ST)

Includes therapy in the home and outpatient therapy provided in a nursing facility.

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Physical Therapy - Authorization required beyond threshold of 20 visits per calendar year.

Occupational Therapy - Authorization required beyond threshold of 20 visits per calendar year.

Speech Therapy - Authorization required beyond threshold of 30 visits per calendar year.

Magellan Healthcare: 
PH 952-225-5700, 
1-888-660-4705 (toll free)

Physical Therapy - Authorization required beyond threshold of 20 visits per calendar year.

Occupational Therapy - Authorization required beyond threshold of 20 visits per calendar year.

Speech Therapy - Authorization required beyond threshold of 30 visits per calendar year.

Magellan Healthcare: 
PH 952-225-5700, 
1-888-660-4705 (toll free)

 20560, 20561, 92507, 92508, 92526,
92606, 92630, 92633, 97012, 97014,
97016, 97018, 97022, 97024, 97026,
97028, 97032, 97033, 97034, 97035,
97036, 97039, 97110, 97112, 97113,
97116, 97124, 97139, 97140, 97150,
97164, 97168, 97530, 97533, 97535,
97537, 97542, 97750, 97755, 97760,
97761, 97799, G0151, G0152, G0153
       

 

 

Updated February 2020

Region

UCare Product

Eligibility

Service Area
(Minnesota Counties)

Narrow network?
North

UCare Medicare Plans (HMO-POS)

  • Essentials Rx
  • Total
  • Value
  • UCare Medicare Group Plans*
    		•

    Must have Medicare Part A & Part B to enroll

    Do not have end-stage renal disease

    		 Aitkin, Becker, Beltrami, Carlton, Cass, Clay, Clearwater, Cook, Crow Wing, Douglas, Grant, Hubbard, Itasca, Kanabec, Kittson, Koochiching, Lake, Lake of the Woods, Mahnomen, Marshall, Morrison, Norman, Otter Tail, Pennington, Pine, Polk, Red Lake, Roseau, St. Louis, Todd, Wadena, Wilkin All UCare network providers
    North

    UCare Medicare Plans (HMO-POS)

  • Classic
    		•

    Must have Medicare Part A & Part B

    Do not have end-stage renal disease

    		 Aitkin, Becker, Carlton, Cass, Clay, Cook, Crow Wing, Hubbard, Kanabec, Lake, Morrison, Pine and St. Louis All UCare network providers
    Metro

    UCare Medicare Plans (HMO-POS)

  • Prime
  • Essentials Rx
  • Complete
  • Classic
  • Total
  • Value
  • UCare Medicare Group Plans*
    		•

    Must have Medicare Part A & Part B

    Do not have end-stage renal disease

    		 Anoka, Benton, Carver, Chisago, Dakota, Hennepin, Isanti, Mille Lacs, Ramsey, Scott, Sherburne, Stearns, Washington, Wright All UCare network providers
    South

    UCare Medicare Plans (HMO-POS)

  • Standard
  • Complete
  • Total
  • Value
  • UCare Medicare Group Plans*
    		•

    Have Medicare Part A & Part B

    Do not have end-stage renal disease

    		 Big Stone, Blue Earth, Brown, Chippewa, Cottonwood, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, Jackson, Kandiyohi, Lac qui Parle, Le Sueur, Lincoln, Lyon, Martin, McLeod, Meeker, Mower, Murray, Nicollet, Nobles, Olmsted, Pipestone, Pope, Redwood, Renville, Rice, Rock, Sibley, Steele, Stevens, Swift, Traverse, Wabasha, Waseca, Watonwan, Winona, Yellow Medicine All UCare network providers
    South

    UCare Medicare Plans (HMO-POS)

  • Classic
    		•

    Have Medicare Part A & Part B

    Do not have end-stage renal disease

    		 Blue Earth, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, Le Sueur, Mower, Nicollet, Olmsted, Rice, Steele, Wabasha, Waseca, Watonwan, Winona All UCare network providers

    In-Network Services
    Primary Care Office Visits $0 copay $25 copay $0 copay $20 copay $0 copay $0 copay $0 copay
    Specialist Office Visits $35 copay $50 copay $20 copay $45 copay $40 copay $10 copay $35 copay
    Inpatient Hospital Care $400 copay per stay (not per day), then 100% coverage, unlimited days per admission $300 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission $250 copay per stay (not per day), then 100% coverage, unlimited days per admission $300 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission $500 copay per day (days 1 - 3), then 100% coverage, unlimited days per admission $100 copay per stay (not per day), then 100% coverage, unlimited days per admission $150 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission
    Urgent Care $50 copay $45 copay $50 copay $50 copay $40 copay $0 copay $50 copay
    Worldwide Emergency Care $100 copay $90 copay $100 copay $100 copay $90 copay $100 copay $100 copay
    Medicare Part D Prescription Drug Coverage* No Prescription Drug Coverage $400 deductible | Copays based on drug tiers $200 deductible | Copays based on drug tiers $400 deductible | Copays based on drug tiers $400 deductible | Copays based on drug tiers Copays based on drug tiers $200 deductible | Copays based on drug tiers
    Preventive Dental Coverage Yes No Yes Yes Yes No No
    Vision Coverage-Routine Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: Not Covered Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay
    Vision Coverage-Diagnostic Diagnostic Eye Exam: $35 copay Diagnostic Eye Exam: $50 copay Diagnostic Eye Exam: $20 copay Diagnostic Eye Exam: $45 copay Diagnostic Eye Exam: $40 copay Diagnostic Eye Exam: $10 copay Diagnostic Eye Exam: $35 copay
    Hearing Services-Routine Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: Not Covered Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay; $500 allowed every 36 months for hearing aids Routine Hearing Exam: 1 per year, $0 Copay
    Hearing Services-Diagnostic Diagnostic Hearing Exam: $35 copay Diagnostic Hearing Exam: $50 copay Diagnostic Hearing Exam: $20 copay Diagnostic Hearing Exam: $45 copay Diagnostic Hearing Exam: $40 copay Diagnostic Hearing Exam: $10 copay Diagnostic Hearing Exam: $35 copay
    Out of Pocket Maximum $3,400 $5,000 $3,400 $3,400 $4,500 $3,000 $3,000

     

    * Part D deductible only applies to some drugs. See the Drug Formulary for details. 

    Pharmacy benefit information

    Browse 2020 Medical Authorizations

    Download the 2020 UCare Medicare Authorization and Notification Requirements