Pharmacy

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

For info on Medical Injectable Drug Prior Authorization requests, see "Medical Injectable Drug Prior Authorization Resources" on the Pharmacy page.

See the Medical Injectable Drugs requiring prior authorization.

Review Medical Drug Policies.

Participating providers can submit prior authorization, authorization adjustment and pre-determination requests to Care Continuum one of the following ways:

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

Non-participating and MultiPlan providers can submit prior authorization, authorization adjustment and pre-determination requests to UCare one of the following ways:

• Fax an authorization request form to UCare Clinical Pharmacy Intake at 612-617-3948.
• By mail to UCare, Attn: Pharmacy at P.O. Box 52, Minneapolis, MN 55440-0052.

Providers that receive a claim denial 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 their 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 problems regarding indication, effectiveness, safety and convenience.

UCare partners with many pharmacists across the state of Minnesota and provides reimbursement for MTM services for in-network pharmacist practitioners.

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

• All Medicare members must be provided with CMS standardized format materials (including medication action plan and personalized medication list). These should be provided within 14 days of the encounter.
• UCare's Continuity of Care Document (CCD) must be submitted within 45 days of the original visit for Medicare members.
• 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 12, 2024 - Pharmacy formulary and benefit changes for 2025
November 10, 2023 - UCare Selects Navitus Health Solutions As New Pharmacy Benefit Manager for 2024
November 10, 2023 - Pharmacy Formulary and Benefit Changes for 2024
November 10, 2023 - Medical Drug Prior Authorization for 2024 and Preferred Product Step Therapy Information
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. 

View the following Pharmacy and Therapeutics Committee Decisions:
December 2024
September 2024
June 2024
April 2024
March 2024
January 2024
November 2023
September 2023
June 2023
April 2023
March 2023
January 2023

Pharmacy Benefit Prior Authorization - Navitus Health Solutions

State Medical Assistance Programs

• Phone: 1-833-837-4300
• Fax: 1-855-668-8553

UCare Individual & Family Plans

• Phone: 1-833-837-4300
• Fax: 1-833-210-5963

Medicare and Medicare + Medical Assistance (dual eligibles)

• Phone: 1-833-837-4300
• Fax: 1-855-668-8552

Medical Injectable Drug Prior Authorization
Participating Providers Contact
Care Continuum, a subsidiary of Express Scripts:

• Online (ePA): OnePA Portal at www.EviCore.com
• Phone: 1-800-818-6747
• Fax: 1-877-266-1871

Non-Participating Providers Contact
UCare Clinical Pharmacy Intake:

• Phone: 612-676-6504
• Fax: 612-617-3948

Fairview Specialty Pharmacy (exclusive network provider of specialty drugs for UCare Individual & Family Plans and State Medical Assistance Programs)

• Phone: 612-672-5260 or 1-800-595-7140 toll free
• Fax: 1-866-347-4939
• Website: https://specialtypharmacy.fairview.org/

Lumicera Specialty Pharmacy

• Phone: 1-855-847-3554
• Fax: 1-855-847-3558
• Website: www.lumicera.com

Costco Mail Order Pharmacy

• Phone: 1-800-607-6861
• Fax: 1-877-258-9584
• ePrescribing: Costco Mail Order Pharmacy #1348