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Medical Specialty

Specialty Coverage Under the Medical Benefit.

Specialty drugs are managed not only under the pharmacy benefit, but under the medical benefit as well. Specialty medications represent 50% of all drug costs for the pharmacy and medical benefits combined. By utilizing both benefits, we ensure the right drug is administered in the most cost effective, timely and convenient manner for our members, physicians and customers. The results? Reduced costs for our clients, less disruption and more convenience for members.

How do we decide which benefit is best for managing specialty drugs?

We choose whether we cover a medication under the pharmacy or the medical benefit based on a combined network, clinical and benefit model that is ideal for the medication. The critical questions to be answered first:

How is the drug administered? Which benefit supports better care?

By managing certain medications under the medical benefit we can reduce waste, delays in treatment, and improve the clinical support necessary for some acute specialty conditions. By evaluating each drug and condition, members receive the best care for their specific condition.

UnitedHealthcare also manages more than 7 million fully insured lives. Why is that important? We share your goals to lower cost where possible and provide an affordable, quality benefit. This motivates us to manage specialty drugs under the most appropriate benefit.

Features of our specialty medical benefit management

Lowest physician network costs – Our contracted physician drug reimbursement rates are 12% below the industry norm*.

Better clinical management – Providing physicians with timely access means members get proper clinical oversight. We promote appropriate use and limit waste – something typically only managed with the pharmacy benefit.

Driving physician prescribing of lower cost drugs – We influence lower-cost options through our physician protocols and increased reimbursement for generics and lower cost alternatives.

Integrated reporting – With medical and pharmacy reporting, our customers have insight in to cost management across both benefits.

* Industry Average as reported by the 2010 EMD Serono Specialty Digest – 6th Edition/2009 physician drug reimbursement rates

Watch This!

The UnitedHealthcare Specialty Pharmacy Program

Specialty Pharmacy Member Experience

Specialty Pharmacy Patient Story