Surest medical injectable policies to align with UnitedHealthcare commercial plans policies
To help streamline and improve your experience with Surest™ benefit plans, effective Aug. 1, 2024, the following aspects of the UnitedHealthcare medical injectable program will apply to Surest benefit plans:
- Medical drug policies, including site of care
Surest will use UnitedHealthcare medical drug policies, including the Provider Administered Drugs – Site of Care policy. For more information, see our UnitedHealthcare Commercial Medical & Drug Policies and Coverage Determination Guidelines.
- Medication sourcing protocol
Surest will use UnitedHealthcare commercial medication sourcing protocol, which requires participating outpatient providers to obtain certain drugs from indicated specialty pharmacies unless otherwise authorized by UnitedHealthcare. For more information, see the Medication Sourcing section on our Specialty Pharmacy – Medical Benefit Management (Provider Administered Drugs) page.
- Medical Benefit Therapeutic Equivalent Medications – Excluded Drugs Policy
In some cases, there are multiple options available for coverage when multiple medications have essentially the same efficacy and adverse effect profile. For more information and to see a list of the medications which are part of this exclusion, see the Medical Benefit Therapeutic Equivalent Medications – Excluded Drugs section on our Specialty Pharmacy – Medical Benefit Management (Provider Administered Drugs) page.
Changes to the prior authorization process
As of Aug. 1, Optum® will begin managing prior authorization requests for certain injectable medications for Surest plans. When you request these prior authorizations in the UnitedHealthcare Provider Portal, you’ll be directed to complete your request using the Specialty Guidance Program (SGP) tool. The system will prompt you to provide responses to clinical criteria questions.
If you obtain authorization prior to Aug. 1, that authorization will remain active until the original expiration date. If an existing authorization expires or if you change the therapy (e.g., place of therapy, dose or frequency of administration), please request a new prior authorization.
How to submit claims for payment
As of Aug. 1, providers will need to validate the accuracy of the authorized services when billing for services. This will help us accurately process claims according to the prior authorization we issued for the billed service. Surest may deny or reduce payment if the billed services don't match the services approved in the prior authorization.
Questions?
If you have questions, contact your provider advocate or network contract manager, or chat with us 7 a.m.–7 p.m. CT, Monday–Friday from the UnitedHealthcare Provider Portal.
For SGP questions, email specialtyguidanceprogram@optum.com or call 888-397-8129, 7 a.m.–7 p.m. CT, Monday–Friday.
PCA-1-24-01118-UHN-NN_04172024
