UnitedHealthcare Community Plan
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Pharmacy Program

 

AHCCCS/Medicaid

Pharmacy Program 

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by AHCCCS/Medicaid.

Click on the link below to view the Preferred Drug List.

Preferred Drug List (PDL) Search
AHCCCS/Medicaid Preferred Drug List  (PDF 1.01 MB)

7/1/2017 PDL Update (PDF 132.61 KB)
4/1/2017 PDL Update (PDF 186.03 KB)
1/1/2017 PDL Update  (PDF 126.35 KB)
10/1/2016 PDL Update (PDF 77.24 KB)
8/1/2016 PDL Update (PDF 77.19 KB)


Step Therapy Information 

Step Therapy (PDF 21.02 KB)

 

Pharmacy Bulletins

UnitedHealthcare Community Plan Specialty Pharmacy Program Changes (PDF 246.6 KB)
Synagis Enrollment Form  (PDF 511.58 KB)
Synagis Program
(PDF 58.92 KB)
Synagis Program 5 Doses (PDF 51.26 KB)

 

Prior Authorization 

Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.

Pharmacy Prior Authorization Forms

Click on the arrow above to view the pharmacy prior authorization forms.

 

Clinical Guidelines

Our Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

Clinical Guidelines and Policies

Click on the arrow above to view clinical pharmacy

 

 

 

  • Actimmune (PDF 88.98 KB)
  • Afinitor (PDF 128.68 KB)
  • Afrezza (PDF 100.39 KB)
  • Alecensa (PDF 95.6 KB)
  • Alinia (PDF 88.98 KB)
  • Amitiza Linzess Movantik (PDF 93.75 KB)
  • Ampyra (PDF 89.12 KB)
  • Anthelmintics (PDF 104.39 KB)
  • Anticonvulsants (PDF 99.9 KB)
  • Antipsoriatic Agents (PDF 102.19 KB)
  • Apokyn (PDF 91.77 KB)
  • Arcalyst (PDF 98.38 KB)
  • Aricept 23mg (PDF 88 KB)
  • Azole Antifungals (PDF 138.26 KB)
  • Berinert (PDF 94.73 KB)
  • Biltricide (PDF 96.24 KB)
  • Bosulif (PDF 101.53 KB)
  • Brilinta and Effient (PDF 100.04 KB)
  • Buphenyl (PDF 99.08 KB)
  • Cabometyx (PDF 85.22 KB)
  • Caprelsa (PDF 96.81 KB)
  • Cayston (PDF 109.29 KB)
  • Celebrex (PDF 126.52 KB)
  • Cerdelga Zavesca (PDF 94.34 KB)
  • Cesamet Marinol (PDF 114.74 KB)
  • Cholbam (PDF 93.05 KB)
  • Cialis for BPH (PDF 100.2 KB)
  • Cinryze (PDF 101.8 KB)
  • Ciprodex (PDF 91.21 KB)
  • Combination Basal Insulin, GLP-1 Receptor Agonist (PDF 98.73 KB)
  • Cometriq (PDF 90.7 KB)
  • Complera (PDF 96.46 KB)
  • Compounds and Bulk Powders (PDF 163.76 KB)
  • Copper Chelating Agents (PDF 97.08 KB)
  • Corlanor (PDF 101.08 KB)
  • Cosentyx (PDF 97.33 KB)
  • Cotellic (PDF 94.36 KB)
  • Crestor (PDF 100.56 KB)
  • Cystaran (PDF 85.2 KB)
  • Daliresp (PDF 98.51 KB)
  • Daraprim (PDF 100.73 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 119.02 KB)
  • Dry Eye Disease (PDF 50.76 KB)
  • Duopa (PDF 90.59 KB)
  • Dupixent (PDF 47.03 KB)
  • Egrifta (PDF 104.28 KB)
  • Elidel Protopic (PDF 115.32 KB)
  • Elmiron (PDF 97.87 KB)
  • Emflaza (PDF 92.17 KB)
  • Entocort (PDF 104.35 KB)
  • Entresto (PDF 62.41 KB)
  • Epaned (PDF 96.43 KB)
  • Eucrisa (PDF 41.94 KB)
  • Farydak (PDF 98.5 KB)
  • Fenofibrate (PDF 103.21 KB)
  • Fentanyl IR (PDF 95.65 KB)
  • Ferriprox (PDF 100.82 KB)
  • Firazyr (PDF 94.47 KB)
  • Forteo (PDF 185.93 KB)
  • Gattex (PDF 94 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 113.54 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 90.85 KB)
  • HCG (PDF 43.51 KB)
  • Hemangeol (PDF 91.02 KB)
  • Hetlioz (PDF 107.21 KB)
  • HP Acthar Repository Corticotropin Injection (PDF 154.66 KB)
  • Humira (PDF 129.67 KB)
  • Hycamtin (PDF 93.94 KB)
  • Ibrance (PDF 102.25 KB)
  • IBS-Diarrhea (PDF 94.29 KB)
  • Iclusig (PDF 96.1 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 126.27 KB)
  • Ilaris (PDF 125.03 KB)
  • Imbruvica (PDF 55.32 KB)
  • Impavido (PDF 99.86 KB)
  • Inlyta (PDF 97.84 KB)
  • Insulins (PDF 100.4 KB)
  • Iressa (PDF 94.56 KB)
  • Isotretinoin (PDF 104.41 KB)
  • Jakafi (PDF 47.1 KB)
  • Juxtapid (PDF 117.8 KB)
  • Kalydeco (PDF 105.58 KB)
  • Keveyis (PDF 97.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 97.74 KB)
  • Kuvan (PDF 96.13 KB)
  • Kynamro (PDF 116.36 KB)
  • Lenvima (PDF 96.23 KB)
  • Lidocaine Patch (PDF 49.98 KB)
  • Lidoderm (PDF 125.01 KB)
  • Lonsurf (PDF 102.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 98.96 KB)
  • Lyrica (PDF 97.88 KB)
  • Lysteda (PDF 22.2 KB)
  • Mekinist (PDF 94.23 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 120.16 KB)
  • Mozobil (PDF 99.11 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Mytesi (PDF 105.65 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 100.25 KB)
  • Nexavar (PDF 121.77 KB)
  • Ninlaro (PDF 96.41 KB)
  • Nonpreferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 89.27 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 102.35 KB)
  • Nuplazid (PDF 88.73 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 99.73 KB)
  • Omega (PDF 69.93 KB)
  • Optivar (PDF 89 KB)
  • Orfadin (PDF 92.85 KB)
  • Orkambi (PDF 92.11 KB)
  • Panretin (PDF 94.25 KB)
  • Pomalyst (PDF 47.77 KB)
  • PPI (PDF 381.09 KB)
  • Pradaxa (PDF 68.27 KB)
  • Praluent (PDF 114.09 KB)
  • Procysbi (PDF 101.67 KB)
  • Progesterone (PDF 86.66 KB)
  • Promacta (PDF 90.69 KB)
  • Provigil Nuvigil (PDF 173.6 KB)
  • Pulmozyme (PDF 98.87 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 91.71 KB)
  • Ravicti (PDF 107.84 KB)
  • Rectiv (PDF 82.78 KB)
  • Regranex (PDF 85.49 KB)
  • Relistor (PDF 97.21 KB)
  • Renvela (PDF 106.83 KB)
  • Repatha (PDF 120.32 KB)
  • Revlimid (PDF 138.81 KB)
  • Rozerem (PDF 90.26 KB)
  • Rubraca (PDF 48.04 KB)
  • Ruconest (PDF 94.47 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 98.07 KB)
  • Sandostatin (PDF 123.76 KB)
  • Selzentry (PDF 96.06 KB)
  • Sensipar (PDF 92.19 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 133.84 KB)
  • Sivextro (PDF 109.77 KB)
  • SLIT (PDF 51.29 KB)
  • Somavert (PDF 90.94 KB)
  • Soriatane (PDF 108.38 KB)
  • Sprycel (PDF 92.24 KB)
  • Stivarga (PDF 101.07 KB)
  • Strensiq (PDF 102.66 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (PDF 109.38 KB)
  • Suboxone_Subutex (PDF 138.83 KB)
  • Sutent (PDF 105.93 KB)
  • Symlin (PDF 97.69 KB)
  • Tafinlar (PDF 103.59 KB)
  • Tagrisso (PDF 95.49 KB)
  • Taltz (PDF 147.75 KB)
  • Tarceva (PDF 105.16 KB)
  • Targretin (PDF 89.72 KB)
  • Tasigna (PDF 93.72 KB)
  • Temodar (PDF 111.83 KB)
  • Test Strips (PDF 109.94 KB)
  • Thalomid (PDF 182.93 KB)
  • Therapeutic Duplication (PDF 84.33 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 122.45 KB)
  • Topical Retinoid Products (PDF 120.17 KB)
  • Triptans (PDF 131.79 KB)
  • Uloric (PDF 81.93 KB)
  • Valchlor (PDF 95.83 KB)
  • Vancocin (PDF 94.9 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Votrient (PDF 107.68 KB)
  • Xalkori (PDF 93.63 KB)
  • Xenazine (PDF 103.44 KB)
  • Xifaxan (PDF 109.83 KB)
  • Xopenex Respules (PDF 70.31 KB)
  • Xtandi (PDF 95.52 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 129.23 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 95.46 KB)
  • Zetia (PDF 95.38 KB)
  • Zinbryta (PDF 95.46 KB)
  • Zolinza (PDF 91.2 KB)
  • Zontivity (PDF 92.88 KB)
  • Zurampic (PDF 43.17 KB)
  • Zydelig (PDF 98.5 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 91.58 KB)
  • Zyvox (PDF 161.28 KB)
  •  

     

     

     

     

     

     


    Children's Rehabilitative Services (CRS) Program

    Pharmacy Program 

     

    The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Children's Rehabilitative Services (CRS) Program. Click on the link below to view the Preferred Drug List.

    Search for Drugs Covered by CRS 
    Search for Drugs Covered by CRS Partially Integrated Acute 
    Search for Drugs Covered by CRS Fully Integrated Acute 
    Search for Drugs Covered by CRS Partially Integrated Behavioral Health

    Children's Rehabilitative Services Preferred Drug List (PDF 1.03 MB)
    Preferred Drug List Updates (PDF 36.79 KB)

     

    Step Therapy Information 

    Step Therapy (PDF 21.02 KB)


    Pharmacy Bulletins

    UnitedHealthcare Community Plan Specialty Pharmacy Program Changes (PDF 246.6 KB) 
    Synagis Enrollment Form (PDF 511.58 KB) 
    Synagis Program (PDF 58.92 KB)
    Synagis Benefit Coverage (PDF 42.77 KB)
    Synagis Program 5 Doses (PDF 51.26 KB)

     

    Prior Authorization

    Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.

    Pharmacy Prior Authorization Forms

    Click on the arrow above to view the pharmacy prior authorization forms.

     

    Clinical Guidelines

    Our Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

    Clinical Guidelines and Policies

    Click on the arrow above to view clinical pharmacy

     

     

     

  • Actimmune (PDF 88.98 KB)
  • Afinitor (PDF 128.68 KB)
  • Afrezza (PDF 100.39 KB)
  • Alecensa (PDF 95.6 KB)
  • Alinia (PDF 88.98 KB)
  • Amitiza Linzess Movantik (PDF 93.75 KB)
  • Ampyra (PDF 89.12 KB)
  • Anthelmintics (PDF 104.39 KB)
  • Anticonvulsants (PDF 99.9 KB)
  • Antipsoriatic Agents (PDF 102.19 KB)
  • Apokyn (PDF 91.77 KB)
  • Arcalyst (PDF 98.38 KB)
  • Aricept 23mg (PDF 88 KB)
  • Azole Antifungals (PDF 138.26 KB)
  • Berinert (PDF 94.73 KB)
  • Biltricide (PDF 96.24 KB)
  • Bosulif (PDF 101.53 KB)
  • Brilinta and Effient (PDF 100.04 KB)
  • Buphenyl (PDF 99.08 KB)
  • Cabometyx (PDF 85.22 KB)
  • Caprelsa (PDF 96.81 KB)
  • Cayston (PDF 109.29 KB)
  • Celebrex (PDF 126.52 KB)
  • Cerdelga Zavesca (PDF 94.34 KB)
  • Cesamet Marinol (PDF 114.74 KB)
  • Cholbam (PDF 93.05 KB)
  • Cialis for BPH (PDF 100.2 KB)
  • Cinryze (PDF 101.8 KB)
  • Ciprodex (PDF 91.21 KB)
  • Combination Basal Insulin, GLP-1 Receptor Agonist (PDF 98.73 KB)
  • Cometriq (PDF 90.7 KB)
  • Complera (PDF 96.46 KB)
  • Compounds and Bulk Powders (PDF 163.76 KB)
  • Copper Chelating Agents (PDF 97.08 KB)
  • Corlanor (PDF 101.08 KB)
  • Cosentyx (PDF 97.33 KB)
  • Cotellic (PDF 94.36 KB)
  • Crestor (PDF 100.56 KB)
  • Cystaran (PDF 85.2 KB)
  • Daliresp (PDF 98.51 KB)
  • Daraprim (PDF 100.73 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 119.02 KB)
  • Dry Eye Disease (PDF 50.76 KB)
  • Duopa (PDF 90.59 KB)
  • Dupixent (PDF 47.03 KB)
  • Egrifta (PDF 104.28 KB)
  • Elidel Protopic (PDF 115.32 KB)
  • Elmiron (PDF 97.87 KB)
  • Emflaza (PDF 92.17 KB)
  • Entocort (PDF 104.35 KB)
  • Entresto (PDF 62.41 KB)
  • Epaned (PDF 96.43 KB)
  • Eucrisa (PDF 41.94 KB)
  • Farydak (PDF 98.5 KB)
  • Fenofibrate (PDF 103.21 KB)
  • Fentanyl IR (PDF 95.65 KB)
  • Ferriprox (PDF 100.82 KB)
  • Firazyr (PDF 94.47 KB)
  • Forteo (PDF 185.93 KB)
  • Gattex (PDF 94 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 113.54 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 90.85 KB)
  • HCG (PDF 43.51 KB)
  • Hemangeol (PDF 91.02 KB)
  • Hetlioz (PDF 107.21 KB)
  • HP Acthar Repository Corticotropin Injection (PDF 154.66 KB)
  • Humira (PDF 129.67 KB)
  • Hycamtin (PDF 93.94 KB)
  • Ibrance (PDF 102.25 KB)
  • IBS-Diarrhea (PDF 94.29 KB)
  • Iclusig (PDF 96.1 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 126.27 KB)
  • Ilaris (PDF 125.03 KB)
  • Imbruvica (PDF 55.32 KB)
  • Impavido (PDF 99.86 KB)
  • Inlyta (PDF 97.84 KB)
  • Insulins (PDF 100.4 KB)
  • Iressa (PDF 94.56 KB)
  • Isotretinoin (PDF 104.41 KB)
  • Jakafi (PDF 47.1 KB)
  • Juxtapid (PDF 117.8 KB)
  • Kalydeco (PDF 105.58 KB)
  • Keveyis (PDF 97.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 97.74 KB)
  • Kuvan (PDF 96.13 KB)
  • Kynamro (PDF 116.36 KB)
  • Lenvima (PDF 96.23 KB)
  • Lidocaine Patch (PDF 49.98 KB)
  • Lidoderm (PDF 125.01 KB)
  • Lonsurf (PDF 102.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 98.96 KB)
  • Lyrica (PDF 97.88 KB)
  • Lysteda (PDF 22.2 KB)
  • Mekinist (PDF 94.23 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 120.16 KB)
  • Mozobil (PDF 99.11 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Mytesi (PDF 105.65 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 100.25 KB)
  • Nexavar (PDF 121.77 KB)
  • Ninlaro (PDF 96.41 KB)
  • Nonpreferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 89.27 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 102.35 KB)
  • Nuplazid (PDF 88.73 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 99.73 KB)
  • Omega (PDF 69.93 KB)
  • Optivar (PDF 89 KB)
  • Orfadin (PDF 92.85 KB)
  • Orkambi (PDF 92.11 KB)
  • Panretin (PDF 94.25 KB)
  • Pomalyst (PDF 47.77 KB)
  • PPI (PDF 381.09 KB)
  • Pradaxa (PDF 68.27 KB)
  • Praluent (PDF 114.09 KB)
  • Procysbi (PDF 101.67 KB)
  • Progesterone (PDF 86.66 KB)
  • Promacta (PDF 90.69 KB)
  • Provigil Nuvigil (PDF 173.6 KB)
  • Pulmozyme (PDF 98.87 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 91.71 KB)
  • Ravicti (PDF 107.84 KB)
  • Rectiv (PDF 82.78 KB)
  • Regranex (PDF 85.49 KB)
  • Relistor (PDF 97.21 KB)
  • Renvela (PDF 106.83 KB)
  • Repatha (PDF 120.32 KB)
  • Revlimid (PDF 138.81 KB)
  • Rozerem (PDF 90.26 KB)
  • Rubraca (PDF 48.04 KB)
  • Ruconest (PDF 94.47 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 98.07 KB)
  • Sandostatin (PDF 123.76 KB)
  • Selzentry (PDF 96.06 KB)
  • Sensipar (PDF 92.19 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 133.84 KB)
  • Sivextro (PDF 109.77 KB)
  • SLIT (PDF 51.29 KB)
  • Somavert (PDF 90.94 KB)
  • Soriatane (PDF 108.38 KB)
  • Sprycel (PDF 92.24 KB)
  • Stivarga (PDF 101.07 KB)
  • Strensiq (PDF 102.66 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (PDF 109.38 KB)
  • Suboxone_Subutex (PDF 138.83 KB)
  • Sutent (PDF 105.93 KB)
  • Symlin (PDF 97.69 KB)
  • Tafinlar (PDF 103.59 KB)
  • Tagrisso (PDF 95.49 KB)
  • Taltz (PDF 147.75 KB)
  • Tarceva (PDF 105.16 KB)
  • Targretin (PDF 89.72 KB)
  • Tasigna (PDF 93.72 KB)
  • Temodar (PDF 111.83 KB)
  • Test Strips (PDF 109.94 KB)
  • Thalomid (PDF 182.93 KB)
  • Therapeutic Duplication (PDF 84.33 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 122.45 KB)
  • Topical Retinoid Products (PDF 120.17 KB)
  • Triptans (PDF 131.79 KB)
  • Uloric (PDF 81.93 KB)
  • Valchlor (PDF 95.83 KB)
  • Vancocin (PDF 94.9 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Votrient (PDF 107.68 KB)
  • Xalkori (PDF 93.63 KB)
  • Xenazine (PDF 103.44 KB)
  • Xifaxan (PDF 109.83 KB)
  • Xopenex Respules (PDF 70.31 KB)
  • Xtandi (PDF 95.52 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 129.23 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 95.46 KB)
  • Zetia (PDF 95.38 KB)
  • Zinbryta (PDF 95.46 KB)
  • Zolinza (PDF 91.2 KB)
  • Zontivity (PDF 92.88 KB)
  • Zurampic (PDF 43.17 KB)
  • Zydelig (PDF 98.5 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 91.58 KB)
  • Zyvox (PDF 161.28 KB)
  •  

     

     

     

     

     


    Developmentally Disabled Program

    Pharmacy Program 

    The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Developmentally Disabled Program. Click on the link below to view the Preferred Drug List.

    Preferred Drug List (PDL) Search
    Developmentally Disabled Preferred Drug List (PDF 1.01 MB)

     

    Step Therapy Information 

    Step Therapy (PDF 21.02 KB)


    Pharmacy Bulletins

    UnitedHealthcare Community Plan Specialty Pharmacy Program Changes (PDF 246.6 KB) Synagis Enrollment Form (PDF 511.58 KB) 
    Synagis Program (PDF 58.92 KB)
    Synagis Program 5 Doses (PDF 51.26 KB)

     

     

    Prior Authorization

    Prior authorization is required for some services. A current list of prior authorization services and forms can be found below.

    Pharmacy Prior Authorization Forms

    Click on the arrow above to view the pharmacy prior authorization forms.

     

    Clinical Guidelines

    Our Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

    Clinical Guidelines and Policies

    Click on the arrow above to view clinical pharmacy program policies and guidelines. 

     

     

     

  • Actimmune (PDF 88.98 KB)
  • Afinitor (PDF 128.68 KB)
  • Afrezza (PDF 100.39 KB)
  • Alecensa (PDF 95.6 KB)
  • Alinia (PDF 88.98 KB)
  • Amitiza Linzess Movantik (PDF 93.75 KB)
  • Ampyra (PDF 89.12 KB)
  • Anthelmintics (PDF 104.39 KB)
  • Anticonvulsants (PDF 99.9 KB)
  • Antipsoriatic Agents (PDF 102.19 KB)
  • Apokyn (PDF 91.77 KB)
  • Arcalyst (PDF 98.38 KB)
  • Aricept 23mg (PDF 88 KB)
  • Azole Antifungals (PDF 138.26 KB)
  • Berinert (PDF 94.73 KB)
  • Biltricide (PDF 96.24 KB)
  • Bosulif (PDF 101.53 KB)
  • Brilinta and Effient (PDF 100.04 KB)
  • Buphenyl (PDF 99.08 KB)
  • Cabometyx (PDF 85.22 KB)
  • Caprelsa (PDF 96.81 KB)
  • Cayston (PDF 109.29 KB)
  • Celebrex (PDF 126.52 KB)
  • Cerdelga Zavesca (PDF 94.34 KB)
  • Cesamet Marinol (PDF 114.74 KB)
  • Cholbam (PDF 93.05 KB)
  • Cialis for BPH (PDF 100.2 KB)
  • Cinryze (PDF 101.8 KB)
  • Ciprodex (PDF 91.21 KB)
  • Combination Basal Insulin, GLP-1 Receptor Agonist (PDF 98.73 KB)
  • Cometriq (PDF 90.7 KB)
  • Complera (PDF 96.46 KB)
  • Compounds and Bulk Powders (PDF 163.76 KB)
  • Copper Chelating Agents (PDF 97.08 KB)
  • Corlanor (PDF 101.08 KB)
  • Cosentyx (PDF 97.33 KB)
  • Cotellic (PDF 94.36 KB)
  • Crestor (PDF 100.56 KB)
  • Cystaran (PDF 85.2 KB)
  • Daliresp (PDF 98.51 KB)
  • Daraprim (PDF 100.73 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 119.02 KB)
  • Dry Eye Disease (PDF 50.76 KB)
  • Duopa (PDF 90.59 KB)
  • Dupixent (PDF 47.03 KB)
  • Egrifta (PDF 104.28 KB)
  • Elidel Protopic (PDF 115.32 KB)
  • Elmiron (PDF 97.87 KB)
  • Emflaza (PDF 92.17 KB)
  • Entocort (PDF 104.35 KB)
  • Entresto (PDF 62.41 KB)
  • Epaned (PDF 96.43 KB)
  • Eucrisa (PDF 41.94 KB)
  • Farydak (PDF 98.5 KB)
  • Fenofibrate (PDF 103.21 KB)
  • Fentanyl IR (PDF 95.65 KB)
  • Ferriprox (PDF 100.82 KB)
  • Firazyr (PDF 94.47 KB)
  • Forteo (PDF 185.93 KB)
  • Gattex (PDF 94 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 113.54 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 90.85 KB)
  • HCG (PDF 43.51 KB)
  • Hemangeol (PDF 91.02 KB)
  • Hetlioz (PDF 107.21 KB)
  • HP Acthar Repository Corticotropin Injection (PDF 154.66 KB)
  • Humira (PDF 129.67 KB)
  • Hycamtin (PDF 93.94 KB)
  • Ibrance (PDF 102.25 KB)
  • IBS-Diarrhea (PDF 94.29 KB)
  • Iclusig (PDF 96.1 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 126.27 KB)
  • Ilaris (PDF 125.03 KB)
  • Imbruvica (PDF 55.32 KB)
  • Impavido (PDF 99.86 KB)
  • Inlyta (PDF 97.84 KB)
  • Insulins (PDF 100.4 KB)
  • Iressa (PDF 94.56 KB)
  • Isotretinoin (PDF 104.41 KB)
  • Jakafi (PDF 47.1 KB)
  • Juxtapid (PDF 117.8 KB)
  • Kalydeco (PDF 105.58 KB)
  • Keveyis (PDF 97.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 97.74 KB)
  • Kuvan (PDF 96.13 KB)
  • Kynamro (PDF 116.36 KB)
  • Lenvima (PDF 96.23 KB)
  • Lidocaine Patch (PDF 49.98 KB)
  • Lidoderm (PDF 125.01 KB)
  • Lonsurf (PDF 102.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 98.96 KB)
  • Lyrica (PDF 97.88 KB)
  • Lysteda (PDF 22.2 KB)
  • Mekinist (PDF 94.23 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 120.16 KB)
  • Mozobil (PDF 99.11 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Mytesi (PDF 105.65 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 100.25 KB)
  • Nexavar (PDF 121.77 KB)
  • Ninlaro (PDF 96.41 KB)
  • Nonpreferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 89.27 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 102.35 KB)
  • Nuplazid (PDF 88.73 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 99.73 KB)
  • Omega (PDF 69.93 KB)
  • Optivar (PDF 89 KB)
  • Orfadin (PDF 92.85 KB)
  • Orkambi (PDF 92.11 KB)
  • Panretin (PDF 94.25 KB)
  • Pomalyst (PDF 47.77 KB)
  • PPI (PDF 381.09 KB)
  • Pradaxa (PDF 68.27 KB)
  • Praluent (PDF 114.09 KB)
  • Procysbi (PDF 101.67 KB)
  • Progesterone (PDF 86.66 KB)
  • Promacta (PDF 90.69 KB)
  • Provigil Nuvigil (PDF 173.6 KB)
  • Pulmozyme (PDF 98.87 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 91.71 KB)
  • Ravicti (PDF 107.84 KB)
  • Rectiv (PDF 82.78 KB)
  • Regranex (PDF 85.49 KB)
  • Relistor (PDF 97.21 KB)
  • Renvela (PDF 106.83 KB)
  • Repatha (PDF 120.32 KB)
  • Revlimid (PDF 138.81 KB)
  • Rozerem (PDF 90.26 KB)
  • Rubraca (PDF 48.04 KB)
  • Ruconest (PDF 94.47 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 98.07 KB)
  • Sandostatin (PDF 123.76 KB)
  • Selzentry (PDF 96.06 KB)
  • Sensipar (PDF 92.19 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 133.84 KB)
  • Sivextro (PDF 109.77 KB)
  • SLIT (PDF 51.29 KB)
  • Somavert (PDF 90.94 KB)
  • Soriatane (PDF 108.38 KB)
  • Sprycel (PDF 92.24 KB)
  • Stivarga (PDF 101.07 KB)
  • Strensiq (PDF 102.66 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (PDF 109.38 KB)
  • Suboxone_Subutex (PDF 138.83 KB)
  • Sutent (PDF 105.93 KB)
  • Symlin (PDF 97.69 KB)
  • Tafinlar (PDF 103.59 KB)
  • Tagrisso (PDF 95.49 KB)
  • Taltz (PDF 147.75 KB)
  • Tarceva (PDF 105.16 KB)
  • Targretin (PDF 89.72 KB)
  • Tasigna (PDF 93.72 KB)
  • Temodar (PDF 111.83 KB)
  • Test Strips (PDF 109.94 KB)
  • Thalomid (PDF 182.93 KB)
  • Therapeutic Duplication (PDF 84.33 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 122.45 KB)
  • Topical Retinoid Products (PDF 120.17 KB)
  • Triptans (PDF 131.79 KB)
  • Uloric (PDF 81.93 KB)
  • Valchlor (PDF 95.83 KB)
  • Vancocin (PDF 94.9 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Votrient (PDF 107.68 KB)
  • Xalkori (PDF 93.63 KB)
  • Xenazine (PDF 103.44 KB)
  • Xifaxan (PDF 109.83 KB)
  • Xopenex Respules (PDF 70.31 KB)
  • Xtandi (PDF 95.52 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 129.23 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 95.46 KB)
  • Zetia (PDF 95.38 KB)
  • Zinbryta (PDF 95.46 KB)
  • Zolinza (PDF 91.2 KB)
  • Zontivity (PDF 92.88 KB)
  • Zurampic (PDF 43.17 KB)
  • Zydelig (PDF 98.5 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 91.58 KB)
  • Zyvox (PDF 161.28 KB)
  •  

     

     

     

     

     

     


    KidsCare


    Long Term Care

    Pharmacy Program

    The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Long Term Care. Click on the link below to view the Preferred Drug List.

    Preferred Drug List (PDL) Search
    Preferred Drug List (PDF 1.25 MB)

    7/1/2017 PDL Update (PDF 132.61 KB)
    1/1/2017 PDL Update  (PDF 126.35 KB)
    10/1/2016 PDL Update (PDF 77.24 KB)
    8/1/2016 PDL Update (PDF 77.19 KB)

    Dual Eligible Drug Coverage (Wrap List) (PDF 3.42 MB)


    Step Therapy Program Information

    Step Therapy Policy (PDF 21.02 KB)


    Quantity Limit Initiatives

    Quantity Limit Policy (PDF 20.11 KB)

     

    Pharmacy Bulletins

    UnitedHealthcare Community Plan Specialty Pharmacy Program Changes (PDF 246.6 KB)

     

     

    Prior Authorization

    Prior authorization is required for some services. A current list of prior authorization services and forms can be found below.

    Pharmacy Prior Authorization Forms

    Click on the arrow above to view the pharmacy prior authorization forms.

     

    Clinical Guidelines

    Our Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

    Clinical Guidelines and Policies

    Click on the arrow above to view clinical pharmacy

     

     

  • Actimmune (PDF 88.98 KB)
  • Afinitor (PDF 128.68 KB)
  • Afrezza (PDF 100.39 KB)
  • Alecensa (PDF 95.6 KB)
  • Alinia (PDF 88.98 KB)
  • Amitiza Linzess Movantik (PDF 93.75 KB)
  • Ampyra (PDF 89.12 KB)
  • Anthelmintics (PDF 104.39 KB)
  • Anticonvulsants (PDF 99.9 KB)
  • Antipsoriatic Agents (PDF 102.19 KB)
  • Apokyn (PDF 91.77 KB)
  • Arcalyst (PDF 98.38 KB)
  • Aricept 23mg (PDF 88 KB)
  • Azole Antifungals (PDF 138.26 KB)
  • Berinert (PDF 94.73 KB)
  • Biltricide (PDF 96.24 KB)
  • Bosulif (PDF 101.53 KB)
  • Brilinta and Effient (PDF 100.04 KB)
  • Buphenyl (PDF 99.08 KB)
  • Cabometyx (PDF 85.22 KB)
  • Caprelsa (PDF 96.81 KB)
  • Cayston (PDF 109.29 KB)
  • Celebrex (PDF 126.52 KB)
  • Cerdelga Zavesca (PDF 94.34 KB)
  • Cesamet Marinol (PDF 114.74 KB)
  • Cholbam (PDF 93.05 KB)
  • Cialis for BPH (PDF 100.2 KB)
  • Cinryze (PDF 101.8 KB)
  • Ciprodex (PDF 91.21 KB)
  • Combination Basal Insulin, GLP-1 Receptor Agonist (PDF 98.73 KB)
  • Cometriq (PDF 90.7 KB)
  • Complera (PDF 96.46 KB)
  • Compounds and Bulk Powders (PDF 163.76 KB)
  • Copper Chelating Agents (PDF 97.08 KB)
  • Corlanor (PDF 101.08 KB)
  • Cosentyx (PDF 97.33 KB)
  • Cotellic (PDF 94.36 KB)
  • Crestor (PDF 100.56 KB)
  • Cystaran (PDF 85.2 KB)
  • Daliresp (PDF 98.51 KB)
  • Daraprim (PDF 100.73 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 119.02 KB)
  • Dry Eye Disease (PDF 50.76 KB)
  • Duopa (PDF 90.59 KB)
  • Dupixent (PDF 47.03 KB)
  • Egrifta (PDF 104.28 KB)
  • Elidel Protopic (PDF 115.32 KB)
  • Elmiron (PDF 97.87 KB)
  • Emflaza (PDF 92.17 KB)
  • Entocort (PDF 104.35 KB)
  • Entresto (PDF 62.41 KB)
  • Epaned (PDF 96.43 KB)
  • Eucrisa (PDF 41.94 KB)
  • Farydak (PDF 98.5 KB)
  • Fenofibrate (PDF 103.21 KB)
  • Fentanyl IR (PDF 95.65 KB)
  • Ferriprox (PDF 100.82 KB)
  • Firazyr (PDF 94.47 KB)
  • Forteo (PDF 185.93 KB)
  • Gattex (PDF 94 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 113.54 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 90.85 KB)
  • HCG (PDF 43.51 KB)
  • Hemangeol (PDF 91.02 KB)
  • Hetlioz (PDF 107.21 KB)
  • HP Acthar Repository Corticotropin Injection (PDF 154.66 KB)
  • Humira (PDF 129.67 KB)
  • Hycamtin (PDF 93.94 KB)
  • Ibrance (PDF 102.25 KB)
  • IBS-Diarrhea (PDF 94.29 KB)
  • Iclusig (PDF 96.1 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 126.27 KB)
  • Ilaris (PDF 125.03 KB)
  • Imbruvica (PDF 55.32 KB)
  • Impavido (PDF 99.86 KB)
  • Inlyta (PDF 97.84 KB)
  • Insulins (PDF 100.4 KB)
  • Iressa (PDF 94.56 KB)
  • Isotretinoin (PDF 104.41 KB)
  • Jakafi (PDF 47.1 KB)
  • Juxtapid (PDF 117.8 KB)
  • Kalydeco (PDF 105.58 KB)
  • Keveyis (PDF 97.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 97.74 KB)
  • Kuvan (PDF 96.13 KB)
  • Kynamro (PDF 116.36 KB)
  • Lenvima (PDF 96.23 KB)
  • Lidocaine Patch (PDF 49.98 KB)
  • Lidoderm (PDF 125.01 KB)
  • Lonsurf (PDF 102.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 98.96 KB)
  • Lyrica (PDF 97.88 KB)
  • Lysteda (PDF 22.2 KB)
  • Mekinist (PDF 94.23 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 120.16 KB)
  • Mozobil (PDF 99.11 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Mytesi (PDF 105.65 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 100.25 KB)
  • Nexavar (PDF 121.77 KB)
  • Ninlaro (PDF 96.41 KB)
  • Nonpreferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 89.27 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 102.35 KB)
  • Nuplazid (PDF 88.73 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 99.73 KB)
  • Omega (PDF 69.93 KB)
  • Optivar (PDF 89 KB)
  • Orfadin (PDF 92.85 KB)
  • Orkambi (PDF 92.11 KB)
  • Panretin (PDF 94.25 KB)
  • Pomalyst (PDF 47.77 KB)
  • PPI (PDF 381.09 KB)
  • Pradaxa (PDF 68.27 KB)
  • Praluent (PDF 114.09 KB)
  • Procysbi (PDF 101.67 KB)
  • Progesterone (PDF 86.66 KB)
  • Promacta (PDF 90.69 KB)
  • Provigil Nuvigil (PDF 173.6 KB)
  • Pulmozyme (PDF 98.87 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 91.71 KB)
  • Ravicti (PDF 107.84 KB)
  • Rectiv (PDF 82.78 KB)
  • Regranex (PDF 85.49 KB)
  • Relistor (PDF 97.21 KB)
  • Renvela (PDF 106.83 KB)
  • Repatha (PDF 120.32 KB)
  • Revlimid (PDF 138.81 KB)
  • Rozerem (PDF 90.26 KB)
  • Rubraca (PDF 48.04 KB)
  • Ruconest (PDF 94.47 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 98.07 KB)
  • Sandostatin (PDF 123.76 KB)
  • Selzentry (PDF 96.06 KB)
  • Sensipar (PDF 92.19 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 133.84 KB)
  • Sivextro (PDF 109.77 KB)
  • SLIT (PDF 51.29 KB)
  • Somavert (PDF 90.94 KB)
  • Soriatane (PDF 108.38 KB)
  • Sprycel (PDF 92.24 KB)
  • Stivarga (PDF 101.07 KB)
  • Strensiq (PDF 102.66 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (PDF 109.38 KB)
  • Suboxone_Subutex (PDF 138.83 KB)
  • Sutent (PDF 105.93 KB)
  • Symlin (PDF 97.69 KB)
  • Tafinlar (PDF 103.59 KB)
  • Tagrisso (PDF 95.49 KB)
  • Taltz (PDF 147.75 KB)
  • Tarceva (PDF 105.16 KB)
  • Targretin (PDF 89.72 KB)
  • Tasigna (PDF 93.72 KB)
  • Temodar (PDF 111.83 KB)
  • Test Strips (PDF 109.94 KB)
  • Thalomid (PDF 182.93 KB)
  • Therapeutic Duplication (PDF 84.33 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 122.45 KB)
  • Topical Retinoid Products (PDF 120.17 KB)
  • Triptans (PDF 131.79 KB)
  • Uloric (PDF 81.93 KB)
  • Valchlor (PDF 95.83 KB)
  • Vancocin (PDF 94.9 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Votrient (PDF 107.68 KB)
  • Xalkori (PDF 93.63 KB)
  • Xenazine (PDF 103.44 KB)
  • Xifaxan (PDF 109.83 KB)
  • Xopenex Respules (PDF 70.31 KB)
  • Xtandi (PDF 95.52 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 129.23 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 95.46 KB)
  • Zetia (PDF 95.38 KB)
  • Zinbryta (PDF 95.46 KB)
  • Zolinza (PDF 91.2 KB)
  • Zontivity (PDF 92.88 KB)
  • Zurampic (PDF 43.17 KB)
  • Zydelig (PDF 98.5 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 91.58 KB)
  • Zyvox (PDF 161.28 KB)
  •  

     

     

     

     

     

     


    UnitedHealthcare Dual Complete® (HMO SNP)
    H0321-002

    Pharmacy Program 

    The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete (HMO SNP) H0321-002. Click on the link below to view the Preferred Drug List.

    Preferred Drug List (PDL) Search

    Download the Acrobat version of the Preferred Drug List (PDL)

    Submit a Pharmacy Prior Authorization Request to Prescription Solutions.

    Request for Medicare Prescription Drug Determination Request form


    UnitedHealthcare Dual Complete™ ONE (HMO SNP)
    H0321-004

    Pharmacy Program

    The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete (HMO SNP) H0321-004. Click on the link below to view the Preferred Drug List.

    Preferred Drug List (PDL) Search