Optimizing UnitedHealthcare CVS Caremark Integration Workflows

Navigating UnitedHealthcare Prior Authorization Channels

UnitedHealthcare (UHC) manages prior authorizations through distinct channels based on the benefit type. Medical benefit prior authorizations, covering commercial, Medicare Advantage, and Community Plan lines, are primarily submitted via the UHCprovider.com portal or through X12 278 transactions via clearinghouses. Pharmacy benefit prior authorizations for UHC plans are managed by OptumRx, UHC's owned PBM, utilizing their provider PA system and ePA partners like CoverMyMeds and Surescripts for prescriber-initiated workflows.

Key Considerations for UnitedHealthcare Pharmacy PAs

• **OptumRx Management:** Pharmacy benefit PAs for UHC plans are processed through OptumRx, requiring adherence to their specific submission guidelines.
• **ePA Partner Connectivity:** For retail pharmacy benefits, Klivira supports electronic prior authorization (ePA) submissions via established partners like CoverMyMeds and Surescripts.
• **Specialty Drug Protocols:** Specialty injectables and infusions may fall under either the medical or pharmacy benefit, often managed by OptumRx Specialty Pharmacy, with specific site-of-care policies.
• **Medical Policy Library:** UHC's Medical Policy Library provides access to medical necessity criteria and coverage rules, including those for pharmacy benefits, often referencing MCG or NCCN guidelines.

Managing CVS Caremark Pharmacy Prior Authorizations

While UnitedHealthcare utilizes OptumRx for its pharmacy benefit management, Klivira recognizes the necessity of managing prior authorizations for other major PBMs, including CVS Caremark. Klivira's platform provides the capability to automate and streamline workflows for CVS Caremark-managed pharmacy benefits, distinct from UHC's processes. This includes navigating their specific submission portals, documentation requirements, and policy criteria, ensuring comprehensive PA coverage across diverse PBM landscapes.

Klivira's Approach to PBM Prior Authorization

• **Automated Portal Submissions:** Klivira automates data entry and document uploads to various PBM portals, including those for OptumRx and CVS Caremark.
• **ePA Connectivity:** Direct integration with ePA platforms like CoverMyMeds and Surescripts for efficient retail pharmacy PA submissions.
• **Dynamic Rules Engine:** Applies specific payer and PBM medical necessity criteria, step therapy requirements, and formulary rules to guide PA submissions.
• **Clinical Documentation Management:** Centralized system for managing and attaching required clinical documentation, ensuring complete submissions for both medical and pharmacy benefits.

Enhancing Efficiency and Compliance for Both PBMs

Leveraging Klivira for UnitedHealthcare and CVS Caremark integration means a reduction in manual administrative burden and an improvement in prior authorization turnaround times. For UnitedHealthcare's Medicare Advantage, Medicaid managed care, and QHP-on-FFM lines, Klivira supports compliance with CMS-0057-F requirements for electronic prior authorization. Our platform helps ensure that all submissions, whether to OptumRx or CVS Caremark, adhere to the relevant state-mandated minimums and payer-published service-level targets.

Operationalizing Payer and PBM Policy Adherence

• **Policy Library Integration:** Facilitates access to UnitedHealthcare's Medical Policy Library and other PBM-specific criteria for informed decision-making.
• **Criteria Application:** Supports the application of clinical criteria from sources like MCG and NCCN, where referenced by UHC policies.
• **Denial Management:** Identifies common denial reasons, such as medical necessity or step therapy non-compliance, for both UHC and CVS Caremark PAs, enabling proactive adjustments.
• **Appeal Pathway Support:** Streamlines the initiation and tracking of appeals, acknowledging distinct pathways for UHC lines of business and supporting PBM-specific appeal processes.