CurrentUnitedHealthcarePolicy N/A

Medication sourcing protocol — specialty pharmacy sourcing and billing for certain outpatient-administered drugs

Defines requirements for participating outpatient providers to obtain certain drugs from specified specialty pharmacies for UnitedHealthcare commercial plans and describes billing expectations; affects outpatient hospitals, physician offices, home and ambulatory infusion providers (subject to state law exclusions).

Policy Summary

PayerUnitedHealthcare

PolicyMedication sourcing protocol — specialty pharmacy sourcing and billing for certain outpatient-administered drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionParticipating outpatient providers must source listed drugs from the indicated specialty pharmacies and may only bill for administration while the specialty pharmacy bills UnitedHealthcare directly for the drug.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+listed medications and specialty pharmacy mappings in this partial document

Multipleplaces of service covered

16listed pharmacy/infusion providers in this section

Includedcontact info present

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

protocol not applicable in some states

Sourcing and Coverage Criteria

Sourcing and billing criteria (high-level)

For medications listed in the tables, outpatient providers must obtain certain drugs through the designated specialty pharmacies; specialty pharmacies bill UnitedHealthcare directly for the drug and outpatient providers bill only for administration.

Participating outpatient providers are required to obtain certain drugs from the indicated specialty pharmacies unless otherwise authorized by service or state-specific exclusions.

When the medication is obtained through the indicated specialty pharmacy, the specialty pharmacy will bill UnitedHealthcare directly for the drug under the member's medical benefit; outpatient providers may only seek reimbursement for administering the medication and may not bill the member for the medication.

Protocol places of service: outpatient hospital, physician office, home, ambulatory infusion; protocol may not apply in certain states or to specified UnitedHealthcare product lines.

Inclusion of a drug in the list does not guarantee coverage; drugs may be subject to other requirements or exclusions (e.g., Review at Launch, therapeutic equivalents, plan-specific exclusions).

Medication-specific sourcing table (partial)

Examples of medication entries with therapeutic class, billing code(s), specialty pharmacy(ies), and national ancillary network infusion provider(s).

Example medication entry

Drug: Entyvio; Therapeutic class: Inflammatory conditions; Code(s): J3380; Specialty pharmacies: Accredo Health Group; AllianceRx Walgreens Pharmacy; Amber Specialty Pharmacy; Caremark (CVS Specialty); Option Care Health; Optum Specialty Pharmacy; National ancillary network infusion providers: Metro Infusion Center; CarePoint Infusion Center.
Drug: Aldurazyme; Therapeutic class: Enzyme replacement therapy; Code(s): J1931; Specialty pharmacies: Accredo Health Group; AllianceRx Walgreens Pharmacy; Amber Specialty Pharmacy; Caremark (CVS Specialty); Option Care Health; Optum Specialty Pharmacy; Orsini Pharmaceutical Services; National ancillary network infusion providers: Metro Infusion Center; AleraCare; Amerita.
Drug: Adakveo; Therapeutic class: Sickle cell disease; Code(s): J0791; Specialty pharmacies: Amber Specialty Pharmacy; Caremark (CVS Specialty); Option Care Health; Optum Specialty Pharmacy; National ancillary network infusion providers: AleraCare; FloMed Infusion Services; Metro Infusion Center.

Sourcing mappings (example node)

Medication entries map drug name, therapeutic class, billing code(s), specialty pharmacy(ies), and national ancillary infusion provider(s).

Example mapping: Drug = Nucalaf; Therapeutic class = Asthma; Code(s) = J2182; Specialty pharmacies = Accredo Health Group; Amber Specialty Pharmacy; Optum Specialty Pharmacy; National ancillary network infusion providers = Vivo Infusion; AleraCare; FloMed Infusion Services.

Example mapping: Drug = Ocrevuso; Therapeutic class = Multiple sclerosis; Code(s) = J2350; Specialty pharmacies = Accredo Health Group; Amber Specialty Pharmacy; Caremark (CVS Specialty); Option Care Health; Optum Specialty Pharmacy; National ancillary network infusion providers = AleraCare; Amerita; FloMed Infusion Services.

Example mapping: Drug = Privigen; Therapeutic class = Immune globulin; Code(s) = J1459; Specialty pharmacies = Accredo Health Group; AllianceRx Walgreens Pharmacy; Amber Specialty Pharmacy; Caremark (CVS Specialty); Optum Infusion; National ancillary network infusion providers = Palmetto Infusion Services; IVX Health; Option Care Health.

Relevant Billing Codes

Sample HCPCS/J-codes listedHCPCS

J1414	Beqvez (example mapping shown)
J1413	Elevidyse (example mapping shown)

Sample J-codes presentHCPCS

J2182	Example J-code listed for Nucalaf (as provided)
J1809	Example J-code listed for Nulibryo
J2350	Example J-code listed for Ocrevuso

Provider Sourcing & Billing Actions

Note

Vendor Contact / Enrollment

Participating specialty pharmacy vendor contact and enrollment information. Providers should contact the listed specialty pharmacies for enrollment, onboarding, and questions about dispensing and billing for UnitedHealthcare-covered specialty medications. Use the phone/fax/enrollment form contacts below to initiate vendor enrollment or to verify contract participation.

Contact these specialty pharmacies to enroll as a provider or to coordinate patient drug sourcing for UnitedHealthcare members.
Verify the specialty pharmacy is an indicated vendor for the specific medication prior to ordering or directing patients to the pharmacy.
Use the pharmacy enrollment forms and phone/fax contacts to establish billing and delivery arrangements; specialty pharmacies bill UnitedHealthcare directly for the drug under the member's medical benefit when required by the sourcing protocol.

Definitions and Places of Service

Requirement that participating outpatient providers obtain certain drugs from indicated specialty pharmacies and related billing rules

Policy requirementParticipating outpatient providers are required to obtain certain drugs from the indicated specialty pharmacies unless otherwise authorized by service; when obtained through the indicated specialty pharmacy, the specialty pharmacy will bill UnitedHealthcare directly for the drug under the member's medical benefit.

Provider billing ruleOutpatient providers may only seek reimbursement for administering the medication and may not bill the member for the medication.

Scope limitationProtocol is subject to applicable state laws and does not apply to UnitedHealthcare West, UMR, Student Resources, UnitedHealthOne and Sierra plan members.

Provider questionsOutpatient providers can contact their Network Contractor with questions regarding contracts/fee schedules for listed drugs.

Outpatient hospital, physician office, home, ambulatory infusion

Policy Summary

PayerUnitedHealthcare

PolicyMedication sourcing protocol — specialty pharmacy sourcing and billing for certain outpatient-administered drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Drug: Nucalaf; Therapeutic class: Asthma; Code(s): J2182; Specialty pharmacies: Accredo Health Group; Amber Specialty Pharmacy; Optum Specialty Pharmacy; National ancillary network infusion providers: Vivo Infusion; AleraCare; FloMed Infusion Services.

Drug: Octagam; Therapeutic class: Immune globulin; Code(s): J1568; Specialty pharmacies: Accredo Health Group; AllianceRx Walgreens Pharmacy; Amber Specialty Pharmacy; Optum Infusion; National ancillary network infusion providers: AleraCare; FloMed Infusion Services; Palmetto Infusion Services.

Places of service coveredOutpatient hospital, physician office, home, ambulatory infusion.

State exceptionsProtocol for the drugs listed does not apply to providers in Maryland; subject to other state law exclusions.

Coverage disclaimerInclusion in the list does not indicate a drug is covered by a particular plan; drugs may be subject to other requirements or exclusions.

Specialty pharmacy

DefinitionSpecialty pharmacy — designated pharmacies listed for sourcing specific medications (examples include Accredo Health Group, Amber Specialty Pharmacy, Optum Specialty Pharmacy).

Example vendor contactOptum Specialty Pharmacy: Phone 855-427-4682; Fax 877-342-4596; Enrollment form available.

Example specialty pharmacies in tableAccredo Health Group; Amber Specialty Pharmacy; Optum Specialty Pharmacy; Biologics, Inc.; Caremark (CVS Specialty); Option Care Health.

National ancillary network infusion provider

DefinitionNational ancillary network infusion provider — listed infusion vendors associated with outpatient hospital administration of specified medications (examples include Vivo Infusion, AleraCare, FloMed Infusion Services, Amerita, AleraCare).

PurposeThese providers are the recommended infusion partners for administration of listed medications in the outpatient hospital setting.

Example mappingsNucalaf lists Vivo Infusion, AleraCare, FloMed Infusion Services as national ancillary network infusion providers.

rare specialty pharmacy example

Example rare specialty pharmacyPANTHERx Rare Pharmacy — Phone: 855-726-8479, x1115; Fax: 888-550-7441; Enrollment form available.

Related vendorOrsini Pharmaceutical Services — Phone: 800-697-5048; Enrollment form available.

RoleRare specialty pharmacies are listed as designated sourcing partners for specific high‑acuity or rare therapies in the protocol.