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UnitedHealthcare | UMR is a third-party administrator (TPA) for self-funded plans. It offers Medical Benefit Drug Policies that assist in administering health benefit plans. These policies are informational and do not constitute medical advice. The treating physicians and healthcare providers decide what care to provide to their patients. The Medical Benefit Drug Policies determine whether a health service, such as a test, drug, device, or procedure, is proven effective based on published clinical evidence and whether it is medically necessary. The policies are regularly reviewed and updated. While UnitedHealthcare | UMR does not specify whether it covers prescription drug insurance, UnitedHealthcare, of which UMR is a part, does offer prescription drug lists for fully insured commercial plans.
| Characteristics | Values |
|---|---|
| Owner | UnitedHealthcare |
| Type | Third-party administrator (TPA) for self-funded plans |
| Eligibility | Employees working 30+ hours/week during a school year or calendar year |
| Coverage | Medical expenses, prescription drugs, diabetic equipment, continuous glucose monitors, etc. |
| Cost | Depends on the medical plan, type of prescription, and whether the annual deductible/out-of-pocket maximum has been met |
| Pharmacy Benefits | Included on the medical card; no separate card |
| Generic Drugs | Recommended; usually less expensive than brand-name drugs |
| Mail Order | Available for maintenance medication through Birdi, MedImpact's mail order service |
| Health Savings Account | Available, but with restrictions (cannot be combined with certain other insurance coverages) |
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What You'll Learn
- UMR is a third-party administrator for self-funded plans
- Medical Benefit Drug Policies are regularly reviewed and updated
- The amount paid for prescription drugs depends on the medical plan
- Specialty drugs are generally high-cost prescription medications
- Continuous glucose monitors are covered under the pharmacy benefit
UMR is a third-party administrator for self-funded plans
UMR is a third-party administrator (TPA) for self-funded plans. It is a wholly owned subsidiary of UnitedHealthcare, which is part of the UnitedHealth Group. As a TPA, UMR helps administer health care benefits for group health plans. This includes processing claims for services from healthcare providers and coordinating care for members who are hospitalized or dealing with serious health conditions. UMR provides prompt, personalized service to its members, who can also take advantage of 24/7 assistance through the UMR app or website.
UMR is the nation's largest TPA, serving more than 3,800 benefits plans and their 6 million members. It offers customized solutions, cost-effective networks, and compassionate service for self-funded medical and dental plans. In addition to integrated health plan management and claims processing services, UMR provides various programs to help clients control costs, including care management, pharmacy benefits administration, reinsurance products, claim recovery, claim repricing, provider data management, and non-network claims cost containment.
As a TPA with over 70 years of experience, UMR helps match employers to effective benefits strategies while continuously innovating healthcare solutions for the future. By combining personalized service with intuitive technology, UMR simplifies the healthcare experience for its members, making it seamless and affordable.
UMR's role as a third-party administrator involves handling the tasks associated with managing group health plans. This includes processing claims, coordinating care, and providing customer service to plan members. UMR also assists in administering health benefit plans by developing Medical Policies and Medical Benefit Drug Policies. These policies are designed to determine the effectiveness and medical necessity of health services based on published clinical evidence.
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Medical Benefit Drug Policies are regularly reviewed and updated
UnitedHealthcare | UMR Medical & Drug Policies are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision-making. The information presented in these policies and guidelines is believed to be accurate and current as of the date of publication and is provided on an "as is" basis.
UnitedHealthcare publishes a new announcement on the first calendar day of every month regarding recently approved and/or revised Medical Policies and Medical Benefit Drug Policies. The appearance of a health service (e.g., test, drug, device, or procedure) in the Medical Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of any inconsistency or conflict between the information provided in the bulletin and the posted policy, the provisions of the posted policy will prevail.
UnitedHealthcare has developed Medical Policies and Medical Benefit Drug Policies to assist in administering health benefit plans. These policies are provided for informational purposes and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
The Medical Policies and Medical Benefit Drug Policies express UnitedHealthcare's determination of whether a health service (e.g., test, drug, device, or procedure) is proven to be effective based on published clinical evidence. They are also used to decide whether a given health service is medically necessary. Additionally, UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist in administering health benefits. The InterQual® criteria are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider and do not constitute medical advice.
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The amount paid for prescription drugs depends on the medical plan
The amount you pay for prescription drugs depends on the type of medical plan you have and the type of drug you require. For instance, if you have Medicare coverage due to End-Stage Renal Disease (ESRD), your coverage, including immunosuppressive drug coverage, ends 36 months after a successful kidney transplant. However, Medicare offers a benefit to help cover immunosuppressive drugs beyond 36 months if you don't have certain other health coverage.
If you have Original Medicare, you can join a Medicare drug plan (Part D) to get coverage for prescription drugs. The amount you pay will depend on the specific plan you choose. You will typically pay a monthly premium for coverage, and you may have to pay a higher premium depending on your income. You will also need to pay a deductible, which is an annual amount you pay for covered drugs before your plan starts to pay. The deductible amount also depends on the plan.
Once you have Medicare drug coverage, you will receive an Explanation of Benefits (EOB) each month, detailing the prescriptions you filled, what your plan paid, your coverage stage, and what counts toward your out-of-pocket costs. If you have Part B deductible coverage, you typically pay up to 20% of the Medicare-approved amount for covered Part B prescription drugs. Your coinsurance amount can change depending on the price of your prescription drug.
It's important to note that Part B does not cover "self-administered drugs" in a hospital outpatient setting. If you get non-covered prescription drugs in such a setting, you will pay the full cost unless you have other drug coverage.
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Specialty drugs are generally high-cost prescription medications
Specialty drugs are prescription medications that treat complex, chronic, or rare conditions such as cancer, rheumatoid arthritis, or multiple sclerosis. They are generally high-cost prescription medications for several reasons. Firstly, they are often complex to develop and manufacture, which drives up their price. Secondly, they tend to offer larger benefits to health and well-being, which justifies their higher cost. For example, they can reduce the need for services provided by physicians and hospitals, improve quality of life, and extend life. Thirdly, they often serve relatively small markets, which means that the development and manufacturing costs need to be recouped from a smaller number of consumers.
The high cost of specialty drugs has implications for both individuals and healthcare systems. For individuals, high prices can reduce access to necessary medications, particularly for those without insurance coverage or with high out-of-pocket costs. For healthcare systems, the strain on budgets can be significant, impacting funding for other areas. In the United States, for example, the inability of Medicare to directly negotiate with drug manufacturers has resulted in higher spending. Between 2012 and 2017, the US spent $6.8 billion solely due to price increases on brand-name cancer drugs, while the rest of the world spent $1.7 billion less due to decreases in similar drug prices.
The cost of specialty drugs has been rising, with spending per person in the US increasing by $255 since 2009. In 2015, specialty drugs accounted for 88% of spending on new drugs in Medicare Part D and 39% of prescriptions for new drugs. By 2018, they represented the largest share of new drugs over the 2014-2018 period, with far higher costs per patient than non-specialty drugs. This trend is expected to continue, with projections indicating that specialty drugs will make up more than half of all US drug spending in recent years.
Managing the rising costs of specialty drugs requires novel approaches. While traditional tools like formulary placement, prior authorization, and step therapy are necessary, they are insufficient for the diverse, targeted, and expensive nature of specialty medications. Value-based health models that consider total cost and care outcomes, as well as coordinated patient care approaches, are important considerations. Additionally, addressing the monopoly held by drug companies and their ability to set high prices without competition could help alleviate the financial burden of specialty drugs.
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Continuous glucose monitors are covered under the pharmacy benefit
Continuous glucose monitors (CGM) are covered by Medicare, but only under certain conditions. The American Diabetes Association (ADA) recommends the use of CGMs for people with type 1 or type 2 diabetes who take insulin. Medicare's coverage criteria for CGMs are aligned with the ADA's standards of care.
For Medicare to cover a CGM, a doctor or healthcare provider must prescribe it, and the patient must take insulin or have a history of problems with low blood sugar (hypoglycemia). Additionally, the patient or their caregiver must be trained to use the CGM as prescribed. Medicare requires the use of a CGM system with a stand-alone receiver or an insulin infusion pump classified as durable medical equipment (DME) to display glucose data. Patients can use a compatible smartphone, watch, or similar personal device in conjunction with a dedicated CGM receiver, but the receiver must be used at least some of the time for Medicare coverage to apply.
Medtronic offers an automated insulin delivery system that integrates CGM with an insulin pump, which is a CGM option for Medicare beneficiaries who would benefit from this type of insulin delivery system. It is important to note that Medtronic's stand-alone CGM system solely displays data on a non-DME device, so it is not currently approved for Medicare coverage.
If a pharmacy states that CGM is not covered, patients can try resending the prescription to a DME supplier. It is recommended to familiarize oneself with the eligibility requirements, approved CGM systems, and the approval process to ensure a smooth transition to using CGM.
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Frequently asked questions
UMR is a third-party administrator (TPA) for self-funded plans. It is a wholly owned subsidiary of UnitedHealthcare, a part of UnitedHealth Group. UMR provides Medical Benefit Drug Policies to assist in administering health benefit plans.
The coverage provided by UMR Commercial Prescription Drug Insurance depends on the specific plan chosen. Generally, prescription drug coverage includes a network of pharmacies where you can fill your prescriptions, and the amount you pay depends on the type of prescription and your chosen plan's annual deductible or out-of-pocket maximum.
To find out what drugs are covered, you can refer to the Prescription Drug Lists (PDLs) provided by UnitedHealthcare for their fully insured commercial plans. These lists offer general pharmacy benefits information, and you can access specific details by signing into your member account or calling the number on your health plan ID card.
