Please select the state where you practice.

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)

1/1/2018 PDL Update (PDF 157.01 KB)
10/1/2017 PDL Update (PDF 58.09 KB)
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)


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 225.02 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.

 

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.

 

 

  • Actemra (PDF 56.53 KB)
  • Actimmune (PDF 88.98 KB)
  • Afinitor (PDF 230.97 KB)
  • Afrezza (PDF 100.39 KB)
  • Aldurazyme (PDF 40.32 KB)
  • Alecensa (PDF 44.85 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 57.41 KB)
  • Antipsoriatic Agents (PDF 56.5 KB)
  • Apokyn (PDF 44.7 KB)
  • Arcalyst (PDF 56.5 KB)
  • Aricept 23mg (PDF 41.77 KB)
  • Austedo (PDF 50.46 KB)
  • Azole Antifungals (PDF 223.95 KB)
  • Benlysta (PDF 47.08 KB)
  • Berinert (PDF 96.91 KB)
  • Biltricide (PDF 44.25 KB)
  • Bosulif (PDF 101.53 KB)
  • Brilinta / Effient (PDF 71.85 KB)
  • Buphenyl (PDF 41.21 KB)
  • Cabometyx (PDF 85.22 KB)
  • Caprelsa (PDF 100.36 KB)
  • Carbaglu (PDF 102.91 KB)
  • Cayston (PDF 49.25 KB)
  • Celebrex (PDF 42.75 KB)
  • Cerdelga / Cerezyme / Zavesca (PDF 47.58 KB)
  • Cesamet / Marinol (PDF 114.74 KB)
  • Cholbam (PDF 44.64 KB)
  • Cialis for BPH (PDF 155.64 KB)
  • Cimzia (PDF 69.19 KB)
  • Cinryze (PDF 128.47 KB)
  • Ciprodex (PDF 91.21 KB)
  • Colony Stimulating Factors (PDF 175.51 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 82.81 KB)
  • Concentrated Insulins (PDF 43.34 KB)
  • Copper Chelating Agents (PDF 57.65 KB)
  • Corlanor (PDF 101.08 KB)
  • Cosentyx (PDF 97.33 KB)
  • Cotellic (PDF 94.36 KB)
  • Crestor (PDF 112.01 KB)
  • Cystaran (PDF 42.24 KB)
  • Daliresp (PDF 50.17 KB)
  • Daraprim (PDF 100.73 KB)
  • Deferasirox Products (PDF 63.73 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 119.02 KB)
  • DPP-4 Inhibitors (PDF 53.75 KB)
  • Dry Eye Disease (PDF 52.37 KB)
  • Duopa (PDF 44.89 KB)
  • Dupixent (PDF 59.37 KB)
  • Egrifta (PDF 45.54 KB)
  • Elaprase (PDF 39.2 KB)
  • Elidel / Protopic (PDF 62.37 KB)
  • Elmiron (PDF 44.69 KB)
  • Emflaza (PDF 92.17 KB)
  • Entocort (PDF 45.04 KB)
  • Entresto (PDF 51.86 KB)
  • Epaned (PDF 47.58 KB)
  • Erivedge (PDF 45.27 KB)
  • Eucrisa (PDF 44.36 KB)
  • Exondys 51 - Drug Policy (PDF 103.09 KB)
  • Fabrazyme (PDF 39.65 KB)
  • Farydak (PDF 98.5 KB)
  • Fenofibrate (PDF 103.21 KB)
  • Fentanyl IR (PDF 58.32 KB)
  • Ferriprox (PDF 100.82 KB)
  • Firazyr (PDF 107.04 KB)
  • Forteo (PDF 101.72 KB)
  • Gattex (PDF 44.12 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 113.54 KB)
  • GLP-1 Agonists (PDF 49.83 KB)
  • Growth Hormone / Growth Stimulating Agents (PDF 196.08 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 92.68 KB)
  • Haegarda (PDF 40.41 KB)
  • HCG (PDF 44.76 KB)
  • Hepatitis C Criteria (PDF 110.97 KB)
  • Hemangeol (PDF 45.4 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 54.3 KB)
  • Iclusig (PDF 96.1 KB)
  • ICS Single Agent (PDF 51.12 KB)
  • ICS.LABA Combo (PDF 61.02 KB)
  • Idhifa (PDF 43.73 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 50.78 KB)
  • Ilaris (PDF 125.03 KB)
  • Imbruvica (PDF 59.65 KB)
  • Impavido (PDF 67.44 KB)
  • Inderal LA (PDF 41.42 KB)
  • Ingrezza (PDF 47.15 KB)
  • Inlyta (PDF 99.47 KB)
  • Insulins (PDF 100.4 KB)
  • Iressa (PDF 51.18 KB)
  • Isotretinoin (PDF 65.95 KB)
  • Jakafi (PDF 47.1 KB)
  • Juxtapid (PDF 60.57 KB)
  • Kalydeco (PDF 54.92 KB)
  • Keveyis (PDF 97.2 KB)
  • Kevzara (PDF 48.04 KB)
  • Kineret (PDF 62.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 97.74 KB)
  • Kuvan (PDF 43.8 KB)
  • Kynamro (PDF 63.31 KB)
  • Lenvima (PDF 126.69 KB)
  • Lidocaine Patch (PDF 56.81 KB)
  • Lidoderm (PDF 125.01 KB)
  • Lonsurf (PDF 46.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 98.96 KB)
  • Lyrica (PDF 121.26 KB)
  • Lysteda (PDF 45.84 KB)
  • Mekinist (PDF 94.23 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 120.16 KB)
  • Mozobil (PDF 99.11 KB)
  • MS Agents (PDF 62.48 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Myozyme / Lumizyme (PDF 43.17 KB)
  • Mytesi (PDF 42.53 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 48.64 KB)
  • Nerlynx (PDF 42.19 KB)
  • Nexavar (PDF 224 KB)
  • Ninlaro (PDF 96.41 KB)
  • Nityr (PDF 41.22 KB)
  • Non-Preferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 44.75 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 49.18 KB)
  • Nuplazid (PDF 89.32 KB)
  • Overactive Bladder (OAB) Agents (PDF 51.22 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 44.6 KB)
  • Omega (PDF 114.61 KB)
  • Opioid Products (PDF 183.55 KB)
  • Optivar (PDF 89 KB)
  • Orencia (PDF 52.01 KB)
  • Orfadin (PDF 42.24 KB)
  • Orkambi (PDF 92.11 KB)
  • Otezla (PDF 49.62 KB)
  • PAH Agents (PDF 70.28 KB)
  • Panretin (PDF 94.25 KB)
  • Pomalyst (PDF 47.77 KB)
  • Progesterone Oral (PDF 39.4 KB)
  • Proton Pump Inhibitors (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 65.67 KB)
  • Pulmozyme (PDF 67.3 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 91.71 KB)
  • Ravicti (PDF 68.11 KB)
  • Rectiv (PDF 42.28 KB)
  • Regranex (PDF 27.13 KB)
  • Relistor (PDF 97.21 KB)
  • Renvela (PDF 106.83 KB)
  • Repatha (PDF 120.32 KB)
  • Revlimid (PDF 138.81 KB)
  • Rhofade (PDF 42.17 KB)
  • Rozerem (PDF 90.26 KB)
  • Rubraca (PDF 48.04 KB)
  • Ruconest (PDF 97.14 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 47.2 KB)
  • Sandostatin (PDF 89.53 KB)
  • Selzentry (PDF 41.73 KB)
  • Sensipar (PDF 48.55 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 133.84 KB)
  • Simponi (PDF 70.31 KB)
  • Sivextro (PDF 58.12 KB)
  • Soliris - Drug Policy (PDF 89.68 KB)
  • Somavert (PDF 100.05 KB)
  • Soriatane (PDF 73.6 KB)
  • Spinraza - Drug Policy (PDF 122.07 KB)
  • Sprycel (PDF 92.24 KB)
  • Stelara (PDF 63.04 KB)
  • Stivarga (PDF 52.51 KB)
  • Strensiq (PDF 102.66 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (SLIT) (PDF 51.29 KB)
  • Suboxone / Subutex (PDF 138.83 KB)
  • Sutent (PDF 192.84 KB)
  • Symlin (PDF 50.06 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 65.38 KB)
  • Test Strips (PDF 68.47 KB)
  • Thalomid (PDF 182.93 KB)
  • Therapeutic Duplication (PDF 84.33 KB)
  • Tobramycin Inhalation (PDF 55.79 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 122.45 KB)
  • Topical Retinoid Products (PDF 58.41 KB)
  • Tremfya (PDF 56.98 KB)
  • Triptans (PDF 131.79 KB)
  • Tykerb (PDF 54.08 KB)
  • Tymlos (PDF 167.12 KB)
  • Uloric (PDF 89.18 KB)
  • Valchlor (PDF 46.49 KB)
  • Vancocin (PDF 50.35 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Votrient (PDF 213.49 KB)
  • Xalkori (PDF 93.63 KB)
  • Xeljanz / Xeljanz XR (PDF 47.25 KB)
  • Xenazine (PDF 58.96 KB)
  • Xifaxan (PDF 93.58 KB)
  • Xopenex Respules (PDF 70.31 KB)
  • Xtandi (PDF 47.1 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 197.74 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 95.46 KB)
  • Zetia (PDF 33.07 KB)
  • Zinbryta (PDF 60 KB)
  • Zolinza (PDF 91.2 KB)
  • Zontivity (PDF 44.19 KB)
  • Zurampic (PDF 43.17 KB)
  • Zydelig (PDF 55.81 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 43.97 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 225.02 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.

     

    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.

     

     

  • Actemra (PDF 56.53 KB)
  • Actimmune (PDF 88.98 KB)
  • Afinitor (PDF 230.97 KB)
  • Afrezza (PDF 100.39 KB)
  • Aldurazyme (PDF 40.32 KB)
  • Alecensa (PDF 44.85 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 57.41 KB)
  • Antipsoriatic Agents (PDF 56.5 KB)
  • Apokyn (PDF 44.7 KB)
  • Arcalyst (PDF 56.5 KB)
  • Aricept 23mg (PDF 41.77 KB)
  • Austedo (PDF 50.46 KB)
  • Azole Antifungals (PDF 223.95 KB)
  • Benlysta (PDF 47.08 KB)
  • Berinert (PDF 96.91 KB)
  • Biltricide (PDF 44.25 KB)
  • Bosulif (PDF 101.53 KB)
  • Brilinta / Effient (PDF 71.85 KB)
  • Buphenyl (PDF 41.21 KB)
  • Cabometyx (PDF 85.22 KB)
  • Caprelsa (PDF 100.36 KB)
  • Carbaglu (PDF 102.91 KB)
  • Cayston (PDF 49.25 KB)
  • Celebrex (PDF 42.75 KB)
  • Cerdelga / Cerezyme / Zavesca (PDF 47.58 KB)
  • Cesamet / Marinol (PDF 114.74 KB)
  • Cholbam (PDF 44.64 KB)
  • Cialis for BPH (PDF 155.64 KB)
  • Cimzia (PDF 69.19 KB)
  • Cinryze (PDF 128.47 KB)
  • Ciprodex (PDF 91.21 KB)
  • Colony Stimulating Factors (PDF 175.51 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 82.81 KB)
  • Concentrated Insulins (PDF 43.34 KB)
  • Copper Chelating Agents (PDF 57.65 KB)
  • Corlanor (PDF 101.08 KB)
  • Cosentyx (PDF 97.33 KB)
  • Cotellic (PDF 94.36 KB)
  • Crestor (PDF 112.01 KB)
  • Cystaran (PDF 42.24 KB)
  • Daliresp (PDF 50.17 KB)
  • Daraprim (PDF 100.73 KB)
  • Deferasirox Products (PDF 63.73 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 119.02 KB)
  • DPP-4 Inhibitors (PDF 53.75 KB)
  • Dry Eye Disease (PDF 52.37 KB)
  • Duopa (PDF 44.89 KB)
  • Dupixent (PDF 59.37 KB)
  • Egrifta (PDF 45.54 KB)
  • Elaprase (PDF 39.2 KB)
  • Elidel / Protopic (PDF 62.37 KB)
  • Elmiron (PDF 44.69 KB)
  • Emflaza (PDF 92.17 KB)
  • Entocort (PDF 45.04 KB)
  • Entresto (PDF 51.86 KB)
  • Epaned (PDF 47.58 KB)
  • Erivedge (PDF 45.27 KB)
  • Eucrisa (PDF 44.36 KB)
  • Exondys 51 - Drug Policy (PDF 103.09 KB)
  • Fabrazyme (PDF 39.65 KB)
  • Farydak (PDF 98.5 KB)
  • Fenofibrate (PDF 103.21 KB)
  • Fentanyl IR (PDF 58.32 KB)
  • Ferriprox (PDF 100.82 KB)
  • Firazyr (PDF 107.04 KB)
  • Forteo (PDF 101.72 KB)
  • Gattex (PDF 44.12 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 113.54 KB)
  • GLP-1 Agonists (PDF 49.83 KB)
  • Growth Hormone / Growth Stimulating Agents (PDF 196.08 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 92.68 KB)
  • Haegarda (PDF 40.41 KB)
  • HCG (PDF 44.76 KB)
  • Hepatitis C Criteria (PDF 110.97 KB)
  • Hemangeol (PDF 45.4 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 54.3 KB)
  • Iclusig (PDF 96.1 KB)
  • ICS Single Agent (PDF 51.12 KB)
  • ICS.LABA Combo (PDF 61.02 KB)
  • Idhifa (PDF 43.73 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 50.78 KB)
  • Ilaris (PDF 125.03 KB)
  • Imbruvica (PDF 59.65 KB)
  • Impavido (PDF 67.44 KB)
  • Inderal (PDF 41.42 KB)
  • Ingrezza (PDF 47.15 KB)
  • Inlyta (PDF 99.47 KB)
  • Insulins (PDF 100.4 KB)
  • Iressa (PDF 51.18 KB)
  • Isotretinoin (PDF 65.95 KB)
  • Jakafi (PDF 47.1 KB)
  • Juxtapid (PDF 60.57 KB)
  • Kalydeco (PDF 54.92 KB)
  • Keveyis (PDF 97.2 KB)
  • Kevzara (PDF 48.04 KB)
  • Kineret (PDF 62.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 97.74 KB)
  • Kuvan (PDF 43.8 KB)
  • Kynamro (PDF 63.31 KB)
  • Lenvima (PDF 126.69 KB)
  • Lidocaine Patch (PDF 56.81 KB)
  • Lidoderm (PDF 125.01 KB)
  • Lonsurf (PDF 46.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 98.96 KB)
  • Lyrica (PDF 121.26 KB)
  • Lysteda (PDF 45.84 KB)
  • Mekinist (PDF 94.23 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 120.16 KB)
  • Mozobil (PDF 99.11 KB)
  • MS Agents (PDF 62.48 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Myozyme / Lumizyme (PDF 43.17 KB)
  • Mytesi (PDF 42.53 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 48.64 KB)
  • Nerlynx (PDF 42.19 KB)
  • Nexavar (PDF 224 KB)
  • Ninlaro (PDF 96.41 KB)
  • Nityr (PDF 41.22 KB)
  • Non-Preferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 44.75 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 49.18 KB)
  • Nuplazid (PDF 89.32 KB)
  • Overactive Bladder (OAB) Agents (PDF 51.22 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 44.6 KB)
  • Omega (PDF 114.61 KB)
  • Opioid Products (PDF 183.55 KB)
  • Optivar (PDF 89 KB)
  • Orencia (PDF 52.01 KB)
  • Orfadin (PDF 42.24 KB)
  • Orkambi (PDF 92.11 KB)
  • Otezla (PDF 49.62 KB)
  • PAH Agents (PDF 70.28 KB)
  • Panretin (PDF 94.25 KB)
  • Pomalyst (PDF 47.77 KB)
  • Proton Pump Inhibitors (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)
  • Progesterone Oral (PDF 39.4 KB)
  • Promacta (PDF 90.69 KB)
  • Provigil / Nuvigil (PDF 65.67 KB)
  • Pulmozyme (PDF 67.3 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 91.71 KB)
  • Ravicti (PDF 68.11 KB)
  • Rectiv (PDF 42.28 KB)
  • Regranex (PDF 27.13 KB)
  • Relistor (PDF 97.21 KB)
  • Renvela (PDF 106.83 KB)
  • Repatha (PDF 120.32 KB)
  • Revlimid (PDF 138.81 KB)
  • Rhofade (PDF 42.17 KB)
  • Rozerem (PDF 90.26 KB)
  • Rubraca (PDF 48.04 KB)
  • Ruconest (PDF 97.14 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 47.2 KB)
  • Sandostatin (PDF 89.53 KB)
  • Selzentry (PDF 41.73 KB)
  • Sensipar (PDF 48.55 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 133.84 KB)
  • Simponi (PDF 70.31 KB)
  • Sivextro (PDF 58.12 KB)
  • Soliris - Drug Policy (PDF 89.68 KB)
  • Somavert (PDF 100.05 KB)
  • Soriatane (PDF 73.6 KB)
  • Spinraza - Drug Policy (PDF 122.07 KB)
  • Sprycel (PDF 92.24 KB)
  • Stelara (PDF 63.04 KB)
  • Stivarga (PDF 52.51 KB)
  • Strensiq (PDF 102.66 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (SLIT) (PDF 51.29 KB)
  • Suboxone / Subutex (PDF 138.83 KB)
  • Sutent (PDF 192.84 KB)
  • Symlin (PDF 50.06 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 65.38 KB)
  • Test Strips (PDF 68.47 KB)
  • Thalomid (PDF 182.93 KB)
  • Therapeutic Duplication (PDF 84.33 KB)
  • Tobramycin Inhalation (PDF 55.79 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 122.45 KB)
  • Topical Retinoid Products (PDF 58.41 KB)
  • Tremfya (PDF 56.98 KB)
  • Triptans (PDF 131.79 KB)
  • Tykerb (PDF 54.08 KB)
  • Tymlos (PDF 167.12 KB)
  • Uloric (PDF 89.18 KB)
  • Valchlor (PDF 46.49 KB)
  • Vancocin (PDF 50.35 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Votrient (PDF 213.49 KB)
  • Xalkori (PDF 93.63 KB)
  • Xeljanz / Xeljanz XR (PDF 47.25 KB)
  • Xenazine (PDF 58.96 KB)
  • Xifaxan (PDF 93.58 KB)
  • Xopenex Respules (PDF 70.31 KB)
  • Xtandi (PDF 47.1 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 197.74 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 95.46 KB)
  • Zetia (PDF 33.07 KB)
  • Zinbryta (PDF 60 KB)
  • Zolinza (PDF 91.2 KB)
  • Zontivity (PDF 44.19 KB)
  • Zurampic (PDF 43.17 KB)
  • Zydelig (PDF 55.81 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 43.97 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 225.02 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.

     

    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.

     

  • Actemra (PDF 56.53 KB)
  • Actimmune (PDF 88.98 KB)
  • Afinitor (PDF 230.97 KB)
  • Afrezza (PDF 100.39 KB)
  • Aldurazyme (PDF 40.32 KB)
  • Alecensa (PDF 44.85 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 57.41 KB)
  • Antipsoriatic Agents (PDF 56.5 KB)
  • Apokyn (PDF 44.7 KB)
  • Arcalyst (PDF 56.5 KB)
  • Aricept 23mg (PDF 41.77 KB)
  • Austedo (PDF 50.46 KB)
  • Azole Antifungals (PDF 223.95 KB)
  • Benlysta (PDF 47.08 KB)
  • Berinert (PDF 96.91 KB)
  • Biltricide (PDF 44.25 KB)
  • Bosulif (PDF 101.53 KB)
  • Brilinta / Effient (PDF 71.85 KB)
  • Buphenyl (PDF 41.21 KB)
  • Cabometyx (PDF 85.22 KB)
  • Caprelsa (PDF 100.36 KB)
  • Carbaglu (PDF 102.91 KB)
  • Cayston (PDF 49.25 KB)
  • Celebrex (PDF 42.75 KB)
  • Cerdelga / Cerezyme / Zavesca (PDF 47.58 KB)
  • Cesamet / Marinol (PDF 114.74 KB)
  • Cholbam (PDF 44.64 KB)
  • Cialis for BPH (PDF 155.64 KB)
  • Cimzia (PDF 69.19 KB)
  • Cinryze (PDF 128.47 KB)
  • Ciprodex (PDF 91.21 KB)
  • Colony Stimulating Factors (PDF 175.51 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 82.81 KB)
  • Concentrated Insulins (PDF 43.34 KB)
  • Copper Chelating Agents (PDF 57.65 KB)
  • Corlanor (PDF 101.08 KB)
  • Cosentyx (PDF 97.33 KB)
  • Cotellic (PDF 94.36 KB)
  • Crestor (PDF 112.01 KB)
  • Cystaran (PDF 42.24 KB)
  • Daliresp (PDF 50.17 KB)
  • Daraprim (PDF 100.73 KB)
  • Deferasirox Products (PDF 63.73 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 119.02 KB)
  • DPP-4 Inhibitors (PDF 53.75 KB)
  • Dry Eye Disease (PDF 52.37 KB)
  • Duopa (PDF 44.89 KB)
  • Dupixent (PDF 59.37 KB)
  • Egrifta (PDF 45.54 KB)
  • Elaprase (PDF 39.2 KB)
  • Elidel / Protopic (PDF 62.37 KB)
  • Elmiron (PDF 44.69 KB)
  • Emflaza (PDF 92.17 KB)
  • Entocort (PDF 45.04 KB)
  • Entresto (PDF 51.86 KB)
  • Epaned (PDF 47.58 KB)
  • Erivedge (PDF 45.27 KB)
  • Eucrisa (PDF 44.36 KB)
  • Exondys 51 - Drug Policy (PDF 103.09 KB)
  • Fabrazyme (PDF 39.65 KB)
  • Farydak (PDF 98.5 KB)
  • Fenofibrate (PDF 103.21 KB)
  • Fentanyl IR (PDF 58.32 KB)
  • Ferriprox (PDF 100.82 KB)
  • Firazyr (PDF 107.04 KB)
  • Forteo (PDF 101.72 KB)
  • Gattex (PDF 44.12 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 113.54 KB)
  • GLP-1 Agonists (PDF 49.83 KB)
  • Growth Hormone / Growth Stimulating Agents (PDF 196.08 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 92.68 KB)
  • Haegarda (PDF 40.41 KB)
  • HCG (PDF 44.76 KB)
  • Hepatitis C Criteria (PDF 110.97 KB)
  • Hemangeol (PDF 45.4 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 54.3 KB)
  • Iclusig (PDF 96.1 KB)
  • ICS Single Agent (PDF 51.12 KB)
  • ICS.LABA Combo (PDF 61.02 KB)
  • Idhifa (PDF 43.73 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 50.78 KB)
  • Ilaris (PDF 125.03 KB)
  • Imbruvica (PDF 59.65 KB)
  • Impavido (PDF 67.44 KB)
  • Inderal LA (PDF 41.42 KB)
  • Ingrezza (PDF 47.15 KB)
  • Inlyta (PDF 99.47 KB)
  • Insulins (PDF 100.4 KB)
  • Iressa (PDF 51.18 KB)
  • Isotretinoin (PDF 65.95 KB)
  • Jakafi (PDF 47.1 KB)
  • Juxtapid (PDF 60.57 KB)
  • Kalydeco (PDF 54.92 KB)
  • Keveyis (PDF 97.2 KB)
  • Kevzara (PDF 48.04 KB)
  • Kineret (PDF 62.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 97.74 KB)
  • Kuvan (PDF 43.8 KB)
  • Kynamro (PDF 63.31 KB)
  • Lenvima (PDF 126.69 KB)
  • Lidocaine Patch (PDF 56.81 KB)
  • Lidoderm (PDF 125.01 KB)
  • Lonsurf (PDF 46.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 98.96 KB)
  • Lyrica (PDF 121.26 KB)
  • Lysteda (PDF 45.84 KB)
  • Mekinist (PDF 94.23 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 120.16 KB)
  • Mozobil (PDF 99.11 KB)
  • MS Agents (PDF 62.48 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Myozyme / Lumizyme (PDF 43.17 KB)
  • Mytesi (PDF 42.53 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 48.64 KB)
  • Nerlynx (PDF 42.19 KB)
  • Nexavar (PDF 224 KB)
  • Ninlaro (PDF 96.41 KB)
  • Nityr (PDF 41.22 KB)
  • Non-Preferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 44.75 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 49.18 KB)
  • Nuplazid (PDF 89.32 KB)
  • Overactive Bladder (OAB) Agents (PDF 51.22 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 44.6 KB)
  • Omega (PDF 114.61 KB)
  • Opioid Products (PDF 183.55 KB)
  • Optivar (PDF 89 KB)
  • Orencia (PDF 52.01 KB)
  • Orfadin (PDF 42.24 KB)
  • Orkambi (PDF 92.11 KB)
  • Otezla (PDF 49.62 KB)
  • PAH Agents (PDF 70.28 KB)
  • Panretin (PDF 94.25 KB)
  • Pomalyst (PDF 47.77 KB)
  • Progesterone Oral (PDF 39.4 KB)
  • Proton Pump Inhibitors (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 65.67 KB)
  • Pulmozyme (PDF 67.3 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 91.71 KB)
  • Ravicti (PDF 68.11 KB)
  • Rectiv (PDF 42.28 KB)
  • Regranex (PDF 27.13 KB)
  • Relistor (PDF 97.21 KB)
  • Renvela (PDF 106.83 KB)
  • Repatha (PDF 120.32 KB)
  • Revlimid (PDF 138.81 KB)
  • Rhofade (PDF 42.17 KB)
  • Rozerem (PDF 90.26 KB)
  • Rubraca (PDF 48.04 KB)
  • Ruconest (PDF 97.14 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 47.2 KB)
  • Sandostatin (PDF 89.53 KB)
  • Selzentry (PDF 41.73 KB)
  • Sensipar (PDF 48.55 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 133.84 KB)
  • Simponi (PDF 70.31 KB)
  • Sivextro (PDF 58.12 KB)
  • Soliris - Drug Policy (PDF 89.68 KB)
  • Somavert (PDF 100.05 KB)
  • Soriatane (PDF 73.6 KB)
  • Spinraza - Drug Policy (PDF 122.07 KB)
  • Sprycel (PDF 92.24 KB)
  • Stelara (PDF 63.04 KB)
  • Stivarga (PDF 52.51 KB)
  • Strensiq (PDF 102.66 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (SLIT) (PDF 51.29 KB)
  • Suboxone / Subutex (PDF 138.83 KB)
  • Sutent (PDF 192.84 KB)
  • Symlin (PDF 50.06 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 65.38 KB)
  • Test Strips (PDF 68.47 KB)
  • Thalomid (PDF 182.93 KB)
  • Therapeutic Duplication (PDF 84.33 KB)
  • Tobramycin Inhalation (PDF 55.79 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 122.45 KB)
  • Topical Retinoid Products (PDF 58.41 KB)
  • Tremfya (PDF 56.98 KB)
  • Triptans (PDF 131.79 KB)
  • Tykerb (PDF 54.08 KB)
  • Tymlos (PDF 167.12 KB)
  • Uloric (PDF 89.18 KB)
  • Valchlor (PDF 46.49 KB)
  • Vancocin (PDF 50.35 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Votrient (PDF 213.49 KB)
  • Xalkori (PDF 93.63 KB)
  • Xeljanz / Xeljanz XR (PDF 47.25 KB)
  • Xenazine (PDF 58.96 KB)
  • Xifaxan (PDF 93.58 KB)
  • Xopenex Respules (PDF 70.31 KB)
  • Xtandi (PDF 47.1 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 197.74 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 95.46 KB)
  • Zetia (PDF 33.07 KB)
  • Zinbryta (PDF 60 KB)
  • Zolinza (PDF 91.2 KB)
  • Zontivity (PDF 44.19 KB)
  • Zurampic (PDF 43.17 KB)
  • Zydelig (PDF 55.81 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 43.97 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)

    1/1/2018 PDL Update (PDF 157.01 KB)
    10/1/2017 PDL Update (PDF 58.09 KB)
    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)

    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.

     

    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.

     

     

  • Actemra (PDF 56.53 KB)
  • Actimmune (PDF 88.98 KB)
  • Afinitor (PDF 230.97 KB)
  • Afrezza (PDF 100.39 KB)
  • Aldurazyme (PDF 40.32 KB)
  • Alecensa (PDF 44.85 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 57.41 KB)
  • Antipsoriatic Agents (PDF 56.5 KB)
  • Apokyn (PDF 44.7 KB)
  • Arcalyst (PDF 56.5 KB)
  • Aricept 23mg (PDF 41.77 KB)
  • Austedo (PDF 50.46 KB)
  • Azole Antifungals (PDF 223.95 KB)
  • Benlysta (PDF 47.08 KB)
  • Berinert (PDF 96.91 KB)
  • Biltricide (PDF 44.25 KB)
  • Bosulif (PDF 101.53 KB)
  • Brilinta / Effient (PDF 71.85 KB)
  • Buphenyl (PDF 41.21 KB)
  • Cabometyx (PDF 85.22 KB)
  • Caprelsa (PDF 100.36 KB)
  • Carbaglu (PDF 102.91 KB)
  • Cayston (PDF 49.25 KB)
  • Celebrex (PDF 42.75 KB)
  • Cerdelga / Cerezyme / Zavesca (PDF 47.58 KB)
  • Cesamet / Marinol (PDF 114.74 KB)
  • Cholbam (PDF 44.64 KB)
  • Cialis for BPH (PDF 155.64 KB)
  • Cimzia (PDF 69.19 KB)
  • Cinryze (PDF 128.47 KB)
  • Ciprodex (PDF 91.21 KB)
  • Colony Stimulating Factors (PDF 175.51 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 82.81 KB)
  • Concentrated Insulins (PDF 43.34 KB)
  • Copper Chelating Agents (PDF 57.65 KB)
  • Corlanor (PDF 101.08 KB)
  • Cosentyx (PDF 97.33 KB)
  • Cotellic (PDF 94.36 KB)
  • Crestor (PDF 112.01 KB)
  • Cystaran (PDF 42.24 KB)
  • Daliresp (PDF 50.17 KB)
  • Daraprim (PDF 100.73 KB)
  • Deferasirox Products (PDF 63.73 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 119.02 KB)
  • DPP-4 Inhibitors (PDF 53.75 KB)
  • Dry Eye Disease (PDF 52.37 KB)
  • Duopa (PDF 44.89 KB)
  • Dupixent (PDF 59.37 KB)
  • Egrifta (PDF 45.54 KB)
  • Elaprase (PDF 39.2 KB)
  • Elidel / Protopic (PDF 62.37 KB)
  • Elmiron (PDF 44.69 KB)
  • Emflaza (PDF 92.17 KB)
  • Entocort (PDF 45.04 KB)
  • Entresto (PDF 51.86 KB)
  • Epaned (PDF 47.58 KB)
  • Erivedge (PDF 45.27 KB)
  • Eucrisa (PDF 44.36 KB)
  • Exondys 51 - Drug Policy (PDF 103.09 KB)
  • Fabrazyme (PDF 39.65 KB)
  • Farydak (PDF 98.5 KB)
  • Fenofibrate (PDF 103.21 KB)
  • Fentanyl IR (PDF 58.32 KB)
  • Ferriprox (PDF 100.82 KB)
  • Firazyr (PDF 107.04 KB)
  • Forteo (PDF 101.72 KB)
  • Gattex (PDF 44.12 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 113.54 KB)
  • GLP-1 Agonists (PDF 49.83 KB)
  • Growth Hormone / Growth Stimulating Agents (PDF 196.08 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 92.68 KB)
  • Haegarda (PDF 40.41 KB)
  • HCG (PDF 44.76 KB)
  • Hepatitis C Criteria (PDF 110.97 KB)
  • Hemangeol (PDF 45.4 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 54.3 KB)
  • Iclusig (PDF 96.1 KB)
  • ICS Single Agent (PDF 51.12 KB)
  • ICS.LABA Combo (PDF 61.02 KB)
  • Idhifa (PDF 43.73 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 50.78 KB)
  • Ilaris (PDF 125.03 KB)
  • Imbruvica (PDF 59.65 KB)
  • Impavido (PDF 67.44 KB)
  • Inderal LA (PDF 41.42 KB)
  • Ingrezza (PDF 47.15 KB)
  • Inlyta (PDF 99.47 KB)
  • Insulins (PDF 100.4 KB)
  • Iressa (PDF 51.18 KB)
  • Isotretinoin (PDF 65.95 KB)
  • Jakafi (PDF 47.1 KB)
  • Juxtapid (PDF 60.57 KB)
  • Kalydeco (PDF 54.92 KB)
  • Keveyis (PDF 97.2 KB)
  • Kevzara (PDF 48.04 KB)
  • Kineret (PDF 62.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 97.74 KB)
  • Kuvan (PDF 43.8 KB)
  • Kynamro (PDF 63.31 KB)
  • Lenvima (PDF 126.69 KB)
  • Lidocaine Patch (PDF 56.81 KB)
  • Lidoderm (PDF 125.01 KB)
  • Lonsurf (PDF 46.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 98.96 KB)
  • Lyrica (PDF 121.26 KB)
  • Lysteda (PDF 45.84 KB)
  • Mekinist (PDF 94.23 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 120.16 KB)
  • Mozobil (PDF 99.11 KB)
  • MS Agents (PDF 62.48 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Myozyme / Lumizyme (PDF 43.17 KB)
  • Mytesi (PDF 42.53 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 48.64 KB)
  • Nerlynx (PDF 42.19 KB)
  • Nexavar (PDF 224 KB)
  • Ninlaro (PDF 96.41 KB)
  • Nityr (PDF 41.22 KB)
  • Non-Preferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 44.75 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 49.18 KB)
  • Nuplazid (PDF 89.32 KB)
  • Overactive Bladder (OAB) Agents (PDF 51.22 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 44.6 KB)
  • Omega (PDF 114.61 KB)
  • Opioid Products (PDF 183.55 KB)
  • Optivar (PDF 89 KB)
  • Orencia (PDF 52.01 KB)
  • Orfadin (PDF 42.24 KB)
  • Orkambi (PDF 92.11 KB)
  • Otezla (PDF 49.62 KB)
  • PAH Agents (PDF 70.28 KB)
  • Panretin (PDF 94.25 KB)
  • Pomalyst (PDF 47.77 KB)
  • Progesterone Oral (PDF 39.4 KB)
  • Proton Pump Inhibitors (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 65.67 KB)
  • Pulmozyme (PDF 67.3 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 91.71 KB)
  • Ravicti (PDF 68.11 KB)
  • Rectiv (PDF 42.28 KB)
  • Regranex (PDF 27.13 KB)
  • Relistor (PDF 97.21 KB)
  • Renvela (PDF 106.83 KB)
  • Repatha (PDF 120.32 KB)
  • Revlimid (PDF 138.81 KB)
  • Rhofade (PDF 42.17 KB)
  • Rozerem (PDF 90.26 KB)
  • Rubraca (PDF 48.04 KB)
  • Ruconest (PDF 97.14 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 47.2 KB)
  • Sandostatin (PDF 89.53 KB)
  • Selzentry (PDF 41.73 KB)
  • Sensipar (PDF 48.55 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 133.84 KB)
  • Simponi (PDF 70.31 KB)
  • Sivextro (PDF 58.12 KB)
  • Soliris - Drug Policy (PDF 89.68 KB)
  • Somavert (PDF 100.05 KB)
  • Soriatane (PDF 73.6 KB)
  • Spinraza - Drug Policy (PDF 122.07 KB)
  • Sprycel (PDF 92.24 KB)
  • Stelara (PDF 63.04 KB)
  • Stivarga (PDF 52.51 KB)
  • Strensiq (PDF 102.66 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (SLIT) (PDF 51.29 KB)
  • Suboxone / Subutex (PDF 138.83 KB)
  • Sutent (PDF 192.84 KB)
  • Symlin (PDF 50.06 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 65.38 KB)
  • Test Strips (PDF 68.47 KB)
  • Thalomid (PDF 182.93 KB)
  • Therapeutic Duplication (PDF 84.33 KB)
  • Tobramycin Inhalation (PDF 55.79 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 122.45 KB)
  • Topical Retinoid Products (PDF 58.41 KB)
  • Tremfya (PDF 56.98 KB)
  • Triptans (PDF 131.79 KB)
  • Tykerb (PDF 54.08 KB)
  • Tymlos (PDF 167.12 KB)
  • Uloric (PDF 89.18 KB)
  • Valchlor (PDF 46.49 KB)
  • Vancocin (PDF 50.35 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Votrient (PDF 213.49 KB)
  • Xalkori (PDF 93.63 KB)
  • Xeljanz / Xeljanz XR (PDF 47.25 KB)
  • Xenazine (PDF 58.96 KB)
  • Xifaxan (PDF 93.58 KB)
  • Xopenex Respules (PDF 70.31 KB)
  • Xtandi (PDF 47.1 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 197.74 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 95.46 KB)
  • Zetia (PDF 33.07 KB)
  • Zinbryta (PDF 60 KB)
  • Zolinza (PDF 91.2 KB)
  • Zontivity (PDF 44.19 KB)
  • Zurampic (PDF 43.17 KB)
  • Zydelig (PDF 55.81 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 43.97 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