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UnitedHealthcare Dual Complete® - SH (HMO-POS D-SNP) Lookup Tools
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Cameron, Hidalgo, Willacy Counties
We're dedicated to improving your health and well-being. Members have access to specialized behavioral health services, which includes mental health and may include substance use treatment. Coverage services may vary based on eligibility.
Find A Drug
Pharmacy Prior Authorization Request
Appeal a Coverage Decision
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
Click here to send an email with your appeal request.
Download the Evidence of Coverage for this plan and review the grievance and appeals section.
Or you may download our Drug Coverage Determination Request Form, fill it out and mail it to us.
Pharmacy Direct Member Reimbursement Form
Download a MAPD Prescription Reimbursement Request Form from OptumRx.
Prescription Drug Transition Process
What to do if your current prescription drugs are not on the Drug List (formulary) or are restricted in some way
Drugs aren’t on list section
What to do if your drugs aren’t on the Drug List (formulary) or are restricted in some way.
Sometimes, you may take a prescription drug that isn’t on your plan’s Drug List or it’s restricted in some way. Whether you’re a new member or a continuing member, there’s a way to get help.
Start by talking to your doctor. Your doctor can help decide if there’s another drug on the Drug List you can switch to. If there isn’t a good alternative drug, you, your representative or your doctor can ask for a formulary exception. If the exception is approved, you can keep getting your current drug for a certain period of time.
Review your Evidence of Coverage (EOC) to find out exactly what your plan covers. If you’re a continuing member, you’ll get an Annual Notice of Changes (ANOC). Review the ANOC carefully to find out if your current drugs will be covered the same way in the upcoming year.
Whether you’re switching drugs or waiting for an exception approval, you may be eligible for a transition supply of your current drug.
- You must get your 1-month supply, as described in EOC, during the first 90 days of membership with the plan as a new member OR within the first 90 days of the calendar year if you are a continuing member and your drug has encountered a negative formulary change.
- You may also be eligible for a one-time, temporary 1-month supply if you qualify for an emergency fill while residing in a long-term care (LTC) facility after the first 90 days as a new member or you have encountered a level of care change.
- If your doctor writes your prescription for fewer days and the prescription has refills, you may refill the drug until you’ve received at least a 1-month supply, as described in your EOC.
As a new plan member, you may currently be taking drugs that are not on the plan’s formulary (drug list), or they are on the formulary but are restricted in some way.
In instances like these, start by talking with your doctor about appropriate alternative medications available on the formulary. If no appropriate alternatives can be found, you or your doctor can request a formulary exception. If the exception is approved, you may be able to obtain the drug for a specified period of time.
During the first 90 days of your membership in the plan if you are a new member, you can request at least a 1-month supply, as described in your plan’s Evidence of Coverage.
During the first 90 days of the calendar year if you were in the plan last year and your drug encountered a negative formulary change, you can request at least a 1-month supply, as described in your plan’s Evidence of Coverage.
Members who have unplanned transitions such as hospital discharges (including psychiatric hospitals) or level of care changes (i.e., changing long-term care facilities, exiting and entering a long-term care facility, ending Part A coverage within a skilled nursing facility, or ending hospice coverage and reverting to Medicare coverage) at any time during the plan year. You can request at least a 1-month supply, as described in your plan’s Evidence of Coverage.
As a continuing member in the plan, you receive an Annual Notice of Changes (ANOC). You may notice that a drug you are currently taking is either not on the upcoming year’s formulary or is on the formulary but restricted in some way in the upcoming year.
Starting October 15, 2022, you may request a 2023 coverage review. If your request is approved, the plan will cover the drug as of January 1, 2023.
If your drug is subject to new formulary restrictions on January 1, 2023 and you have not discussed switching to an alternative formulary medication or pursued a formulary exception with your doctor, you may receive a temporary supply within the first 90 days of the new calendar year when you go to a network pharmacy. This would be at least a 1-month supply, as described in your plan’s Evidence of Coverage, to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.
If you live in a long-term care facility, you can obtain multiple refills until you’ve reached at least a 31-day supply, including when prescriptions are dispensed for less than the written amount due to drug utilization edits that are based on approved product labeling.
There may be unplanned transitions such as hospital discharges or level of care changes (i.e., changing long-term care facility or in the week before or after a long-term care discharge, end of skilled nursing facility stay and reverting to Part D coverage or when taken off hospice care) that can occur anytime. If you are prescribed a drug that is not on our formulary or your ability to get your drugs is restricted in some way, you are required to use the plan's exception process. For most drugs, you may request a one-time temporary supply of at least one month, as described in your plan’s Evidence of Coverage, to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.
For members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away, we will cover at least a 31-day temporary supply, as described in your plan’s Evidence of Coverage.
If you have any questions about this transition policy or need help asking for a formulary exception, contact a member services representative.
For prescription drug transition process information in Spanish, go to Forms and Resources and view section 5.2 of your Evidence of Coverage (Spanish) for more information.
If you’re out of medication after receiving a temporary transition supply and you’re working with your prescriber to switch to an alternative drug or request an exception, call the number on your member ID card or contact UnitedHealthcare Customer Service.
The Coverage Determination Request Form may be found under Appeal a Coverage Decision section on this page.
Medication Therapy Management Program
UnitedHealthcare’s Medication Therapy Management (MTM) program was developed by a team of pharmacists and doctors. The MTM program provides members with a comprehensive medication review (CMR) with a pharmacist or other qualified health care provider. The program helps members understand their drug coverage and how to use their medications, and also educates members of potentially harmful drug interactions and/or risks of side effects.
- take eight (8) or more chronic Part D medications, and
- have three (3) or more long-term health conditions from the following list:
- Chronic obstructive pulmonary disease (COPD)
- Heart Failure
- High Cholesterol
- and are likely to spend more than $4,935 a year on covered Part D medications
- are in a Drug Management Program to help better manage and safely use medications such as those for pain.
What You Need to Do
Within 60 days of becoming eligible for the MTM program, you’ll receive an offer by mail to complete a Comprehensive Medication Review (CMR). You may also receive this offer by phone.
You can complete the CMR by phone or in person with a qualified health care provider. It takes about 30 minutes. A pharmacist, or qualified CMR provider, will review your medication history, including prescription and over-the-counter medications, and look for any issues.
Within 14 days of the CMR, you’ll receive a packet containing a summary of the review including action items discussed and a list of the medications you are taking and why you take them. This can be helpful when meeting with your doctor or pharmacist. The results may be sent to your doctor. In addition, members in the MTM program will receive information on the safe disposal of prescription medications including controlled substances.
You can also download a blank Medication List (PDF) for your own personal use.
In addition to the CMR, Targeted Medication Reviews are done at least quarterly. This is done to find any drug-drug interactions or other medication concerns. Those reviews will be sent to your doctor.
The Medication Therapy Management program isn’t a plan benefit. For more information on UnitedHealthcare’s Medication Therapy Management program, please call the number on the back of your plan member ID card or you may call the OptumRx MTM clinical call center team at 1-866-216-0198, TTY 711, Monday – Friday 9AM – 9PM EST.
Learn more about dual special needs plans
UnitedHealthcare Dual Complete® (HMO-POS D-SNP)
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