How to Obtain Prescription Drug Benefits
Network Pharmacies
If you use a UnitedHealthcare network retail pharmacy for your covered prescriptions, you pay the appropriate copay (if you are enrolled in the UnitedHealthcare Choice or Value PPO plan), or the coinsurance (if you are enrolled in the UnitedHealthcare Basic or Premium HSA plan and you have met your deductible). When you present your UnitedHealthcare ID card at a network pharmacy, there are no claims to file.
Home Delivery Service
The home delivery service allows you to order up to a 90-day supply of maintenance medication through the mail. Maintenance medications are prescription drugs taken on a regular or long-term basis. Examples include oral contraceptives and blood pressure medication. Covered prescriptions are delivered directly to your home in unmarked, tamper-resistant packages by First Class mail or a national delivery service. For added convenience, you may order refills by phone or via the Internet.
You pay the appropriate copay (if you are enrolled in the UnitedHealthcare Choice or Value PPO plan), or the coinsurance (if you are enrolled in a UnitedHealthcare HSA plan and you have met your deductible).
Non-Network Pharmacies
If you use a pharmacy outside the network, you pay the full cost of the prescription at the time of purchase. You then must submit a claim form and itemized receipt to UnitedHealthcare. Your reimbursement will be the amount you paid less the applicable copay, coinsurance or deductible within 45 days of the purchase. If the reimbursement claim is submitted 46 days or later, your reimbursement will be equal to UnitedHealthcare's discounted drug costs, minus the appropriate copay, coinsurance or deductible.
Prior Authorization
Certain medications must be reviewed and approved by UnitedHealthcare for medical necessity before your prescription is filled. Your doctor or your pharmacist can obtain prior authorization by calling 800 387 7508. The UnitedHealthcare prior authorization team will obtain information about your diagnosis and your doctor's drug therapy treatment plan, and determine whether the prescription is approved. Generally, prior authorizations are valid for one year.
Examples of drug and therapeutic classes that currently require prior authorization include but are not limited to:
  • Avita-Penderm
  • Avodart
  • Compound medications- any compound over $50 requires prior authorization.
  • Differin-Galderma
  • Growth hormones
  • Narcotic analgesics
  • Regranex
  • Retin-A
  • Seizure medications (brand)
  • Tracleer
This list may change from time to time, as determined by UnitedHealthcare.
Non-Network Pharmacy Prior Authorization
If you do not obtain prior authorization from UnitedHealthcare before you fill a prescription at a non-network pharmacy, you can ask the Plan to consider reimbursement. You will be required to pay for the prescription drug at the pharmacy. You may seek reimbursement from the Plan by submitting a claim form. In such a case, you may be responsible for the full cost of the prescription.
If you submit a claim for a prescription filled at a non-network pharmacy with a prior authorization from UHC, the amount you are reimbursed* will be the amount you paid less the applicable copay, coinsurance or deductible within 45 days of the purchase. If the reimbursement claim is submitted 46 days or later, your reimbursement* will be equal to UnitedHealthcare's discounted drug cost, minus the appropriate copay, coinsurance or deductible.
* UnitedHealthcare's Discounted Drug Cost – the amount the Plan will pay to reimburse you for a prescription drug product that is dispensed at a non-network pharmacy. UnitedHealthcare's discounted drug cost for a particular prescription drug product dispensed at a non-network pharmacy includes a dispensing fee and any applicable sales tax.
Clinical Programs
Specialty Pharmacy
Some medications are covered as medical benefits rather than as prescription benefits. Please see "Specialty Pharmacy" in the Medical Benefits section for further details.
Step Therapy
Certain prescription drug products or pharmaceutical products for which benefits are described in this Benefits Summary are subject to step therapy requirements. This means that in order to receive benefits for such prescription drug products or pharmaceutical products, you are required to use a different prescription drug product or pharmaceutical product first.
You may determine whether a particular prescription drug product or pharmaceutical product is subject to step therapy requirements at UnitedHealthcare's web site at www.myuhc.com or by calling Customer Care at 800 387 7508.
Quantity Level Limits / Quantity Per Duration
Certain prescription drug products or pharmaceutical products for which benefits are described in this Benefits Summary are limited to a certain amount of medication covered per copay or coinsurance or in a specific time period.
Vacation/Travel Overrides
If you are going to be away from home for an extended period of time, you may want to refill your prescription before you leave—even if you have not used up your current supply of medication. In these situations, contact UnitedHealthcare at 800 387 7508 to request special authorization for the prescriptions you need to take with you on your trip. If you prefer, you can ask your pharmacy to call UnitedHealthcare to make the request on your behalf.
Rebates
UnitedHealthcare receives rebates for certain brand-name medications included on the preferred drug list. A portion of these rebate payments are shared with Stryker and are used to offset the cost of Stryker's health plan. Neither UnitedHealthcare nor Stryker are required to pass on to you, and do not pass on to you, amounts payable under rebate or other discount programs.
Smart Fill Program for Specialty Drugs
Certain specialty prescription drug products are included in the Smart Fill Program. Find a complete list of these drugs through the internet at www.myuhc.com or by calling the telephone number on your ID card.
Split Fill
Through the Smart Fill Program, certain oral oncology specialty prescription drug products may be dispensed by UHC's specialty pharmacy in 15-day supplies at a pro-rated copayment or coinsurance. You will receive a 15-day supply of your oral oncology specialty drug prescription to determine if you will tolerate the drug prior to purchasing a full supply. The UHC specialty pharmacy will contact you each time prior to dispensing the 15-day supply to confirm if you are tolerating the drug.
Specialty Pharmacy Coupon Adjustment Benefit Plan Protection
When you fill a prescription through UHC's specialty pharmacy, if a manufacturer drug coupon or manufacturer copay card is used, the amount of the coupon or copay card will not apply to your deductible and/ or out-of-pocket maximum amounts. Only your actual payment amount (after the manufacturer coupon is applied) will apply to the deductible and out-of-pocket maximum amounts.
Notice of Creditable Coverage
If you are approaching age 65, you will receive information before your 65th birthday about Medicare Part D, the government's prescription drug program, and how it will work with Stryker coverage.
How to Reach UnitedHealthcare
UnitedHealthcare
Stryker Group #: 703997
P.O. Box 740800
Atlanta, GA 30374-0800
800 387 7508