UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) 찾아보기 도구

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 오전 to 5 오후 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.

처방약 - 메디케어 파트 D에서 보장하지 않는 처방약

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.

치과 제공자 검색

가까운 치과를 찾습니다. 검색을 시작하려면 아래에서 "치과 검색"을 클릭하십시오.

치과 검색

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 오전 to 5 오후 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.

약국 찾기

아래에서 유나이티드 헬스케어 네트워크 약국을 검색하십시오.

약국

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, 오전 8:00 - 오후 8:00, local time, Monday - Friday. 이 전화 통화는 무료입니다.

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, 오전 8:00 - 오후 8:00, 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, 오전 8:00 - 오후 8:00, 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, 오전 8:00 - 오후 8:00, 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 오전 to 5 오후 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).

처방약 전환 프로세스

현재 처방약이 보험적용 의약품 목록에 없거나 보험적용 의약품 목록에서 이용이 제한된 경우 어떻게 해야 할까요?

신규 회원
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.

이와 같은 경우에 보험적용 의약품 목록의 적절한 대체 의약품에 대해 의사와 상의하십시오. 적절한 대체 의약품을 찾을 수 없는 경우 회원님이나 담당 의사가 보험적용 의약품 목록 예외를 요청할 수 있습니다. 예외가 승인되면 지정된 기간 동안 해당 의약품을 받을 수 있습니다. 회원님과 담당 의사가 치료 과정을 결정하는 동안 회원님은 플랜 회원이 된지 첫 90일 동안 언제든 초기 31일의 의약품 전환 제공 혜택을 받을 수 있습니다(해당 의약품이 보다 짧은 기간으로 처방되지 않는 한).

보험적용 의약품 목록에 없는 각 의약품에 대해 또는 해당 의약품을 받을 수 있는 자격이 제한된 경우 UnitedHealthcare는, 회원님이 네트워크 약국을 이용할 경우 31일의 약품 제공 기간을 보장합니다(해당 의약품이 보다 짧은 기간으로 처방되지 않는 한). 처방 기간이 31일보다 짧은 경우 여러 번의 조제를 허용하여 총 31일 동안 의약품을 제공할 수 있습니다. 첫 31일 전환 제공 기간이 지난 후에는 이러한 의약품을 계속 보장하지 못할 수 있습니다. 이런 경우 담당 의사와 적절한 대체 의약품을 논의하시기 바랍니다. 대체 의약품이 보험적용 의약품 목록에 없는 경우 회원님 또는 담당 의사가 보험적용 의약품 목록 예외를 요청할 수 있습니다.

장기 치료 시설에서 거주하는 경우 UnitedHealthcare에서 초기 31일 임시 전환을 보장합니다(해당 의약품이 보다 짧은 기간으로 처방되지 않는 한). UnitedHealthcare에서는 플랜 회원에 대해 첫 90일 동안 이러한 의약품의 리필을 두 번 이상 보장하여, 최대 93일간 의약품 제공을 보장합니다. 보험적용 의약품 목록에 없는 의약품이 필요하거나 복용하던 의약품을 받을 수 있는 자격이 제한되었지만 플랜 회원이 된지 첫 90일이 경과된 경우, 전환 프로그램은 회원님이 보험적용 의약품 목록 예외를 신청하는 동안 첫 31일의 해당 의약품 응급 제공을 보장합니다(해당 의약품이 보다 짧은 기간으로 처방되지 않는 한).

플랜에 등록한지 첫 90일 후 예상치 않은 전환이 일어날 수 있습니다(예: 병원 퇴원 또는 치료 수준 변화 - 장기 치료 시설에서 퇴원하기 전 주). 보험적용 의약품 목록에 없는 의약품을 처방받았거나 복용 중인 의약품을 받을 수 있는 자격이 제한된 경우 플랜의 예외 프로세스를 이용해야 합니다. 최대 31일간 1회 응급 제공을 요청하므로 시간을 두고 담당 의사와 대체 치료 방법을 논의하거나 보험적용 의약품 목록 예외를 신청할 수 있습니다.

기존 회원
플랜의 기존 회원은 ANOC(연간 변경 알림)를 받습니다. 현재 복용 중인 보험적용 의약품이 내년 보험적용 의약품 목록에서 빠지거나 내년에는 비용 분담이나 보장 범위가 제한되는 경우 알림을 보내 드립니다.

매년 12월 15일까지 접수되어 승인된 보장 요청에 대해 플랜은 1월 1일 기준으로 의약품을 보장합니다. 12월 16일에 또는 그 이후에 시작된 보장 요청에 대해서는 다음과 같은 일반적인 해결 시한이 적용됩니다. 긴급 요청에 대해서는 24시간 내에 그리고 기타 모든 요청에 대해서는 72시간 내에 답변을 드립니다. 1월 1일에도 요청이 여전히 처리 중인 경우 요청에 대한 답변을 드릴 때까지 현재 플랜 비용 분담을 위해 임시로 의약품을 제공할 수 있습니다.

이와 같은 전환 정책에 대해 질문이 있거나 보험적용 의약품 목록 예외 요청과 관련하여 도움이 필요한 경우 UnitedHealthcare 담당자에게 문의하십시오.

관련 정보
The Coverage Determination Request Form may be found under Appeal a Coverage Decision section on this page.