UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) Dagiti Alikamen a Pagbirok

Prior Authorizations

Download the list of services that require prior authorizations. 

Prior Authorization Process

Prior authorization is an okay for services that must be approved by UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan).

Your doctor must call Utilization Management (UM) at 1-800-366-7304 before you obtain a service or procedure that is listed as requiring an okay on pages 19-22. Our UM team is available Monday through Friday, 8 AM to 5 PM On-call staff is available 24 hours a day, 7 days a week for emergency okays.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) also reviews some of your services and care as they are happening. This is called concurrent review. Examples are when you are:

• A patient in the hospital
• Receiving home care by nurses
• Certain outpatient services such as speech therapy and physical therapy

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) reviews your progress with your doctor to be sure you still need those services or if other services would be better for you.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) has policies and procedures to follow when the UM team makes decisions regarding medical services. The UM doctors and nurses make their decision based on your coverage and what you need for your medical condition. The goal is to make sure that services are medically necessary, that they are provided in an appropriate setting, and that quality care is provided.

We want to help you stay well. If you are sick we want you to get better.

• UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) does not pay employees extra for limiting your care.
• Our network doctors do not receive extra money or rewards if they limit your care.

If you have questions about UM decisions or processes, call Member Services at 1-877-542-9236 (TTY 711).

Appeal or Grievance

To file an Appeal or Grievance, please visit or FAQ section.

Prior Authorizations

Pharmacy Prior Authorization Request to OptumRx

Submit a Pharmacy Prior Authorization Request to OptumRx.

Naireseta nga Agas - Saan a Sakup ti Medicare Part D

While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan).  You can view our plan’s List of Covered Drugs on our website at https://member.uhc.com/communityplan. 

Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan). You do not have any co-pays for non-Part D drugs covered by our plan.

Please note that our list of medications that require prior authorization can change so it is important for you and/or your provider to check this information when you need to fill/refill a medication.

Agsapul iti Tagaipaay iti Ngipen

Agbiruk iti dentista dita lugarmo. Pislem ti "Search for a Dentist" iti baba tapno irugim ti agbiruk.

Agbiruk iti Dentista
 

Prior Authorization Process

Prior authorization is an okay for services that must be approved by UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan).

Your doctor must call Utilization Management (UM) at 1-800-366-7304 before you obtain a service or procedure that is listed as requiring an okay. Our UM team is available Monday through Friday, 8 AM to 5 PM On-call staff is available 24 hours a day, 7 days a week for emergency okays.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) also reviews some of your services and care as they are happening. This is called concurrent review. Examples are when you are:

• A patient in the hospital
• Receiving home care by nurses
• Certain outpatient services such as speech therapy and physical therapy

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) reviews your progress with your doctor to be sure you still need those services or if other services would be better for you.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) has policies and procedures to follow when the UM team makes decisions regarding medical services. The UM doctors and nurses make their decision based on your coverage and what you need for your medical condition. The goal is to make sure that services are medically necessary, that they are provided in an appropriate setting, and that quality care is provided.

We want to help you stay well. If you are sick we want you to get better.

• UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) does not pay employees extra for limiting your care.
• Our network doctors do not receive extra money or rewards if they limit your care.

If you have questions about UM decisions or processes, call Member Services at 1-877-542-9236 (TTY 711).

Appeal or Grievance

To file an Appeal or Grievance, please visit or FAQ section.

Agsapul iti Parmasia

Birukem ditoy baba ti UnitedHealthcare network pharmacy.

Parmasia

This part of the directory provides a list of pharmacies in UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) network. These network pharmacies are pharmacies that have agreed to provide prescription drugs to you as a member of the plan.

• UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) Members must use network pharmacies to get prescription drugs.
  • You must use network pharmacies except in emergency or urgent care situations. If you go to an out-of-network pharmacy for prescriptions when it is not an emergency or urgent care situation, including when you are out of the service area, call UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) toll-free Member Services or 24-hour nurse advice line for assistance in getting your prescription filled.
  • If you go to an out-of-network pharmacy for prescriptions when it is not an emergency, you will have to pay out of pocket for the service. Read the UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) Member Handbook for more information.
• Some network pharmacies may not be listed in this Directory.
  • Some network pharmacies may have been added or removed from our plan after this Directory was published.

For up to date information about UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) network pharmacies in your area, please visit our web site at www.UHCCommunityPlan.com or call Member Services at 1-877-542-9236, TTY users should call 711, 8 AM - 8 PM, local time, Monday - Friday. Ti tawag ket libre.

To get a complete description of your prescription coverage, including how to fill your prescriptions, please read the Member Handbook and UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) List of Covered Drugs. You received the List of Covered Drugs in the mail when you became a member of this plan. You may also visit our web site at www.UHCCommunityPlan.com for the drug list.

Identifying Pharmacies in Our Network
Along with retail pharmacies, your plan’s network of pharmacies includes:

• Mail-Order Pharmacies
• Home infusion pharmacies
• Long-term care (LTC) pharmacies

You are not required to continue going to the same pharmacy to fill your prescriptions. You can go to any of the pharmacies in our network.

Mail Order Pharmacy(ies)
You can get prescription drugs shipped to your home through our network mail order delivery program which is called OptumRx® home delivery pharmacy. Prescription orders sent directly from your doctor must have your approval before we can send your medications. This includes new prescriptions and prescriptions refills. We will contact you, by phone, to get your approval. If we are unable to reach you for approval, your prescription will not be sent to you.

You also have the choice to sign up for automated mail order delivery through our OptumRx® home delivery pharmacy. Typically, you should expect to get your prescription drugs from 4 to 6 days from the time that the mail order pharmacy gets the order.

If you do not get your prescription drug(s) within this time, if you would like to cancel an automatic order, or if you need to ask for a refund for prescriptions you got that you did not want or need, please contact us at 1-877-542-9236, TTY 711, 8 AM - 8 PM, local time, Monday - Friday.

Home Infusion Pharmacies
You can get home infusion therapy if UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) has approved your prescription for home infusion therapy and if you get your prescription from an authorized prescriber.

For more information, please see your Member Handbook, or call Member Services at 1-877-542-9236, TTY 711, 8 AM - 8 PM, local time, Monday - Friday.

Long-Term Care Pharmacies
Residents of a long-term care facility, such as a nursing home, may access their prescription drugs covered under UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) through the facility’s pharmacy or another network pharmacy.

For more information, you can call Member Services at 1-877-542-9236, TTY 711, 8 AM - 8 PM, local time, Monday - Friday.

Prior Authorizations

Prior authorization is an okay for services that must be approved by UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan). Your doctor must call Utilization Management (UM) at 1-800-366-7304 before you obtain a service or procedure that is listed as requiring an okay. Our UM team is available Monday through Friday, 8 AM to 5 PM On-call staff is available 24 hours a day, 7 days a week for emergency okays.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) also reviews some of your services and care as they are happening. This is called concurrent review. Examples are when you are:

• A patient in the hospital
• Receiving home care by nurses
• Certain outpatient services such as speech therapy and physical therapy

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) reviews your progress with your doctor to be sure you still need those services or if other services would be better for you.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) has policies and procedures to follow when the UM team makes decisions regarding medical services. The UM doctors and nurses make their decision based on your coverage and what you need for your medical condition. The goal is to make sure that services are medically necessary, that they are provided in an appropriate setting, and that quality care is provided.

We want to help you stay well. If you are sick we want you to get better.

• UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) does not pay employees extra for limiting your care.
• Our network doctors do not receive extra money or rewards if they limit your care.

If you have questions about UM decisions or processes, call Member Services at 1-877-542-9236 (TTY 711).

Proseso ti Panagsukat iti Maireseta nga Agas

Ania iti aramidem no iti agdama nga naireseta nga agas mo ket awan iti ayan ti pormulary wenno limitado iti ayan ti pormulary.

Dagiti baro nga kameng
As a new member of UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan), insured through UnitedHealthcare, you may currently be taking drugs that are not on the UnitedHealthcare® formulary (drug list), or they are on the formulary but your ability to get them is limited.

Iti kayarigan a kas kadagitoy, ruggian a makitungtong iti doktor mo panggep iti umno nga alternatibo nga agas nga adda iti ayan ti pormulary. No awan iti masarakan nga umno nga alternatibo, sika wenno iti doktor mo ket mabalin nga agkiddaw iti pannakailaksid iti pormulary. No iti pannakailaksid ket maaprobaran, kabaelamto nga manggun-od iti agas para iti maipadung nga battalay. Bayat nga am-amirisem ken ti doktormo iti turong ti pagtignayam, nalabit nga adda kababalin a mangawat iti inisyal nga 31-aldaw a panagbaliw iti suplay (malaksid no iti resetam ket naisurat para iti ababbaba nga aldaw) ti agas iti aniaman nga oras bayat iti umuna a 90 nga aldaw a pannakikameng mo ti plano.

Para iti tunggal agas nga awan iti ayan ti pormulary wenno iti kabaelam nga manggun-od kadagiti agas mo ket limitado, sungbatan ti UnitedHealthcare iti 31-aldaw nga suplay (malaksid no iti resetam ket para iti ababbaba nga aldaw) no mapan ka iti network nga parmasya. No iti reseta ket naisurat para iti nababbaba ngem 31 nga aldaw, maruay a panagpusek ket mapalubosan tapno mangipaay iti dagup agingga 31 nga aldaw nga agas. Kalpasan iti umuna nga 31-aldaw a panagsukat ti suplay, dagitoy nga agas ket nalabit a saan nga maituloy a masungbatan. Kasarita iti doktor mo panggep iti umno nga alternatibo nga agas. No awan iti ayan ti pormulary, sika wenno iti doktor mo ket mabalin nga agkiddaw iti pannakailaksid ti pormulary.

No agnaedka iti sayud a pagtaripatoan iti akaba a termino, sungbatan ti UnitedHealthcare iti apagbiit nga 31-aldaw a panagsukat ti suplay (malaksid no ti resetam ket para iti nababbaba nga aldaw). Sungbatan ti UnitedHealthcare iti surok maysa a panagpusek manen kadagitoy nga agas para iti umuna a 90 nga aldaw para kadagiti kameng ti plano, agingga 93-aldaw nga suplay. No kasapulam iti agas nga awan iti ayan ti pormulary wenno iti kabaelam nga manggun-od kadagitoy nga agas ket limitado, ngem leppaskan iti umuna a 90 nga aldaw iti pannakikameng mo ti plano, sungbatan iti programa ti panagsukat iti 31-aldaw a darikmat nga suplay iti dayta nga agas (malaksid no iti resetam ket para iti ababbaba nga aldaw) bayat iti panagpursigem ti ilalaksid mo iti pormulary.

Mabalin nga sangoemto iti saan a naplano nga panagsukat kalpasan iti umuna a 90 nga aldaw ti panagpalistam iti plano, kas iti panagpawayawaya ti ospital wenno panagsukat iti lebel ti taripato (i.e., iti uneg ti lawas sakbay ti panagpawayawaya iti akaba nga termino ti panagtaripato), No naresetaanka iti agas nga awan iti ayan ti pormulary wenno iti kabaelam nga manggun-od kadagitoy nga agas ket limitado, masapol nga usarem iti proseso ti pannakailaksid ti plano. Mabalinmo nga agkiddaw iti maninsan a darikmat nga suplay nga agpatingga 31 nga aldaw tapno maikkanka iti oras tapno pagsaritaanyo ti doktormo panggep ti alternatibo nga panagpaagas wenno ti panagpursigem iti ilalaksidmo ti pormulary.

Dagiti agpatpatuloy nga kameng
Kas agpatpatuloy nga kameng iti plano, makaawat ka iti Tinawen nga Pakaammo ti Panagsukat wenno Annual Notice of Changes (ANOC). Madlawmo nga iti promulary nga agas nga tumtumarem iti agdama ket nalabit nga awan iti ayan ti sumangbay a pormulary ti tawen wenno iti panangibinglay ti gatad wenno masakupan ket limitado iti sumangbay a tawen.

Para kadagiti masakupan a kiddaw nga nagun-od tunggal tawen sigod ti Disyembre 15, ken naaprobaran, ti plano sungbatanna iti agas agsipod Enero 1. Para kadagiti masakupan a kiddaw a nairugi iti wenno kalpasan ti Disyembre 16, iti kadawyan nga oras a gagan-ayan para iti resolusyon ket maipakat: makaawatka iti sungbat iti uneg ti 24 nga oras para iti magaganat nga kiddaw ken iti uneg ti 72 nga oras para iti amin a sabalipay nga kiddaw. No iti kiddaw mo ket addapay iti proseso agsipod Enero 1, mabalin nga makaawatka iti apagbiit nga suplay ti agas para iti agdama nga planom ti panangibinglay ti gatad aginnga nga iti kiddaw mo ket masungbatan.

No addaanka iti aniaman nga saludsod panggep iti daytoy nga pagalagaden ti panagsukat wenno kasapulam iti tulong tapno agkiddaw iti pannakailaksid ti pormulary, makatulong iti pannakabagi ti UnitedHealthcare.

Maisilpo nga Impormasyon
The Coverage Determination Request Form may be found under Appeal a Coverage Decision section on this page.