Information by UCare Plan
UCare Individual & Family Plans
Commercial products for individual and family (IFP) coverage available through MNsure, including UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview.
UCare Medicare Plans, UCare Medicare Plans with M Health Fairview and North Memorial, UCare Medicare Group Plans, UCare Advocate Plans and EssentiaCare.
Medicare + Medical Assistance
UCare Connect + Medicare and Minnesota Senior Health Options (MSHO)
State Medical Assistance Programs
UCare Connect (Special Needs BasicCare), Minnesota Senior Care Plus (MSC Plus), MinnesotaCare (MnCare), Prepaid Medical Assistance Program (PMAP)
Resources & Information
Electronic Prior Authorization (ePA):
ePA is the preferred method to submit Prior Authorization requests to Express Scripts for pharmacy benefit drugs. Providers may use ePA through ExpressPAth, Surescripts, CoverMyMeds or through the Electronic Health Record.
Prior authorization requests for medical drugs administered in a doctor's office will be reviewed by Care Continuum, a subsidiary of Express Scripts. See information in Medical Injectable Drug Prior Authorization Resources.
Care Continuum reviews Medical Drug Prior Authorization requests for all UCare plans.
To submit an authorization request, use one of the following ways:
- Online (ePA) via the ExpressPAth Portal at www.express-path.com/. Providers can submit requests, check on the status of submitted requests, and submit an authorization renewal on the ExpressPAth Portal. The site also provides 24/7 access, potential for real-time approvals, and email notifications once a decision is reached.
- Fax an authorization form to Care Continuum at 1-877-266-1871.
- Call Care Continuum at 1-800-818-6747.
To request an adjustment to an existing prior authorization:
- Providers should contact Care Continuum – for 2020 prior authorization changes.
- The authorization must be active.
- End date extensions can be completed due to scheduling issues or health reasons (ex: chemo delayed due to blood count) that may prevent the administration of the previously approved drug.
- Required information for these requests:
- Reason for extension.
- Revised end date.
- Adjustments are not approved for the reasons listed below. A new review/renewal is required.
- Additional drug is requested.
- The patient is due for a renewal.
Non-participating providers should send requests using this form:
- by fax to UCare Clinical Services at 612-884-2300.
- or by mail to UCare, Attn: Clinical Services at P.O. Box 52, Minneapolis, MN 55440-0052.
Providers that received a claim denial due to no authorization in place will continue to work through the provider claims appeal process using the Provider Claim Reconsideration Request Form.
See the 2020 Medical Injectable Drugs requiring prior authorization.
Our Medication Therapy Management (MTM) Program is a free service for eligible UCare members to optimize individual medication therapy, experience and outcomes. Members receive a one-on-one consultation with a pharmacist to review their entire medication regimen (including prescription, over-the-counter medications and herbal supplements) to help resolve any potential medication-related issues regarding indication, effectiveness, safety and convenience.
UCare partners with many pharmacists across the state of Minnesota and provides reimbursement for MTM services.
Following is a high-level overview of the MTM Program. Please refer to the MTM section of the provider manual for full program information including detailed topics such as eligibility, expectations, audits, billing and more.
- Most UCare plans with prescription drug coverage are eligible for MTM services and can receive these services with contracted local pharmacists.
- Internal UCare telephonic MTM services are only available to Medicare, Connect + Medicare and MSHO members.
UCare’s expectation is that MTM services will be billed using MTM CPT codes 99605, 99606 and 99607. Billing is based on complexity, not time, for all lines of business.
Important Time Sensitive Requirement Reminders
- Medicare members must be provided with CMS standardized format materials (including medication action plan and personalized medication list) within 14 days of the encounter.
- A Continuity of Care Document (CCD) must be submitted within 45 days of the original visit.
- Member opt-outs from the MTM program must be received within 30 days of member’s decision to opt-out.
Continuity of Care Document (CCD)
MTM providers are required to maintain and submit a CCD for all Medicare visits. It is acceptable to send information for non-Medicare members as well.
For any questions or inquiries regarding the MTM program at UCare, please contact us via email at firstname.lastname@example.org.
Additional Helpful Resources
November 18, 2020 - Pharmacy Formulary and Benefit Changes for 2021
November 18, 2020 - UCare Medicare Part D Vaccine Information
November 18, 2020 - Medical Benefit Drug Prior Authorization for 2021 and Biosimilar Step Therapy Information
June 11, 2020 - FDA Recall of Certain Manufacturers of Metformin Extended-Release Tablets
January 15, 2021 - New Prior Authorization Requirement for Victoza and Nubeqa
October 14, 2021 - FDA Announces Chantix Recall
November 12, 2021 - Pharmacy Formulary and Benefit Changes for 2022
November 12, 2021 - Medical Benefit Drug Prior Authorization for 2022
November 12, 2021 - Changes to 2022 Part D Vaccine Billing for MSHO and Connect + Medicare
The Pharmacy and Therapeutics Committee, a group of practicing physicians and pharmacists, meets up to six times per year to recommend medication inclusion or exclusion to our formularies. The Pharmacy and Therapeutics Committee evaluates drugs based on clinical evidence and efficacy (drug monographs, peer reviewed literature, compendia resources), therapeutic guidelines, medication safety and comparable data to other therapeutic alternatives. This committee reviews all new drugs approved by the FDA, new generics, new dosage forms, new indications as well as regular therapeutic class reviews and annual review of all utilization management criteria.
View the January 2021 Pharmacy and Therapeutics Committee Decisions Here.
View the March 2021 Pharmacy and Therapeutics Committee Decisions Here.
View the April 2021 Pharmacy and Therapeutics Committee Decisions Here.
View the June 2021 Pharmacy and Therapeutics Committee Decisions Here.
View the September 2021 Pharmacy and Therapeutics Committee Decisions Here.
Pharmacy Benefit Prior Authorization
Express Scripts - State Medical Assistance Programs and UCare Individual & Family Plans
Express Scripts - Medicare, Medicare + Medical Assistance (dual eligibles)
Medical Injectable Drug Prior Authorization
Care Continuum, a subsidiary of Express Scripts
Online (ePA): ExpressPAth Portal at www.express-path.com/.
UCare Clinical Services Intake
Specialty Pharmacy Contact Information
Fairview Specialty Pharmacy
Phone: 612-672-5260 or 1-800-595-7140 toll free
*exclusive network provider of specialty drugs for UCare Individual & Family Plans and State Medical Assistance Programs
Mail Order Contact Information
Express Scripts Mail Order Pharmacy
ePrescribing: Express Scripts Home Delivery Pharmacy
News & Alerts
Provider News Library
Updates and Reminders to Avoid Claim and Claim Line DenialsIn preparation for the final stage of our new claims system implementation, UCare analyzed claim submission patterns against published billing standards and guidance, as well as UCare-specific requirements published in the Provider Manual. The new claims system automates a greater portion of billing-related edits than UCare’s legacy system. As a result, providers may see much more consistency in their claim and claim line denials beginning in 2022.
See the January 18 Provider Bulletin for more details.
Updated Prior Authorization Criteria for Drugs on the IFP Formulary
Starting March 1, 2022, UCare is updating prior authorization criteria for 22 drugs that are on the UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview formulary.
January 2022 Health Lines
Learn about the New Claims System Implementation, No Surprises Act Began Jan. 1, 2022, New Coverage Policies and Annual Review Added, Medical Necessity Guidelines, Flu Vaccine Reminder, New Health Promotion Programs for 2022, Documentation Improvement: Annual Evaluation, Ineligible Provider List Updated Jan. 4, 2022, Accurate Member Information is Key to Smooth Claim Submissions, Upcoming Holidays and more.
UCare Claims Rejection Analysis, Reminders and Requests
UCare began transitioning to a new claims system in January 2019. Throughout the implementation cycle of each product into the new claims system, UCare analyzed common reasons for claims rejections, claims denials and claims appeals. As UCare begins processing claims for the largest segment of our business – Prepaid Medical Assistance Plans, MinnesotaCare, UCare Connect, Minnesota Senior Care Plus, UCare’s Minnesota Senior Health Options and UCare Connect + Medicare, there is a greater likelihood provider groups will see an increase in claims rejections.
See the January 6 Provider Bulletin for a summary of common errors and tips for how to avoid them.
Specialty Provider Referrals for Restricted Recipients
Beginning Jan. 1, 2022, UCare’s Restricted Recipient Program (RRP) will only accept specialty provider referrals that were submitted within 90 days of the service being rendered.
See the Dec. 20, 2021 Provider Bulletin for more information.
UCare Welcomes Former Blue Plus Members From Ramsey and Scott CountiesOn Jan. 1, 2022, UCare will welcome former Blue Plus members from Ramsey and Scott counties to its Prepaid Medical Assistance Plan (PMAP) and MinnesotaCare plans. Blue Plus will no longer be an option for these plans in Ramsey and Scott counties in 2022, and former Blue Plus members may elect or be defaulted to UCare’s plan.
See the Dec. 17, 2021 Provider Bulletin for more information.
Important Reminders About UCare’s Taxonomy Requirements
UCare relies on provider-submitted taxonomy for accurate and timely claims processing. As UCare moves to our new claims system, it is important to remind providers of several of the key taxonomy requirements to support claims processing.
See the Dec. 16, 2021 Provider Bulletin for more information.
No Surprises Act
Federal legislation titled the No Surprises Act (NSA) takes effect beginning Jan. 1, 2022.
See the Dec. 15, 2021 Provider Bulletin for more information.
2022 Code and Editing UpdatesNew codes have been identified for 2022 and will be accepted into the UCare system. New codes will have published effective dates but are subject to the editing update and implementation dates.
See the Dec. 10 Provider Bulletin for more information.
UCare's 2022 Authorization & Notification Grids
The UCare 2022 authorization and notification requirements are now available.
View the 2022 auth grids in the Resources and Information section of the Authorizations page.
Pharmacy Formulary and Benefit Changes for 2022
Information about the 2022 formularies and changes to benefits is now available.
Medical Benefit Drug Prior Authorization for 2022
2022 Medical Benefit Drug Prior Authorization (PA) information is available.
Changes to 2022 Part D Vaccine Billing for UCare’s MSHO and UCare Connect + Medicare
Vaccine and administration will need to be billed through the member’s Part D benefit.
FDA Announces Chantix Recall
On Sept. 16, 2021, Pfizer announced a voluntary recall of all lots of Chantix 0.5 mg and 1 mg tablets to the patient (consumer/user) level. Patients should continue taking Chantix until they consult with their health care professional who can prescribe a replacement.
UCare’s pharmacy department will send letters to impacted members.
See the Oct. 14 Provider Bulletin for details.
Medical and Pharmacy Benefit Duplicate Payments and Recoupment Process
Effective Oct. 1, 2021, UCare began performing duplicate payment audits of medical benefit and pharmacy benefit claims.
See the Oct. 15 Provider Bulletin for more information.
UCare 2022 Medicare Plans Earn 5-Star Rating from CMS
UCare is pleased to announce its 5-Star Rating from CMS for its 2022 Medicare plans.
Quantity Limits (QL) Updated for Continuous Glucose Monitors on All UCare Formularies
Effective Sept. 1, 2021, quantity limits for continuous glucose monitor products will be updated.
Monoclonal Antibody Treatments for COVID-19
The Food and Drug Administration has authorized Emergency Use Authorization and approved multiple monoclonal antibody therapies for treatment of mild-to-moderate COVID-19 in adults and pediatric patients who are at high risk for progressing to severe COVID-19 and/or hospitalization.
Reminder: UCare Medicare Part D Vaccine InformationStarting Jan. 1, 2021, UCare began denying claims for providers administering Part D vaccines in their clinics. Provider will need to bill both the vaccine and administration through the member’s Part D benefit.
See the Feb. 4 bulletin for details.
New Prior Authorization Requirement for Victoza and NubeqaStarting March 1, 2021, UCare is adding a prior authorization requirement for Victoza and Nubeqa for members on UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview.
See the Jan 15, 2021 Provider Bulletin for details.
Changes to the Payment and Remittance Selection ProcessEffective immediately, UCare is changing the process to request updates to the provider’s payment and remittance selections.
Read the Dec. 18 bulletin for additional details on the changes.
Medication Therapy Management (MTM) Program UpdateOn Jan. 1, 2021, UCare will introduce new changes to its Medicare Medication Therapy Management (MTM) Program. No changes have been made to the MTM program for Medicaid or Individual and Family Plans (IFP). The MTM Program is a free service for eligible UCare members to optimize their medication therapy and experience.
See the Nov. 4 bulletin.
FDA Alert on Voluntary Recall of Albuterol Inhalers Manufactured by PerrigoOn Sept. 21, 2020, the FDA announced a voluntary recall of all unexpired albuterol inhalers manufactured by Perrigo. This recall is to the retail pharmacy level. The FDA urges patients to continue using the inhaler they have on hand. UCare’s pharmacy department is contacting impacted members and their providers.
Read the October 6 Bulletin for more information.