UnitedHealthcare Community Plan
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AHCCCS/Medicaid


Preferred Drug List (PDL) Search
AHCCCS/Medicaid Preferred Drug List  (PDF 1,016.06 KB)

10/1/2016 PDL update (PDF 77.24 KB)
8/1/2016 PDL update (PDF 77.19 KB)
5/1/2016 PDL update (PDF 81.2 KB)
1/1/2016 PDL update (PDF 51.64 KB)

 Step Therapy (PDF 21.02 KB)

 

Pharmacy Bulletins


UnitedHealthcare Community Plan AZ Specialty Pharmacy Program Changes 
Synagis Enrollment Form
(PDF 246.6 KB) 
Synagis Program
(PDF 52.46 KB)
Synagis Program 5 Doses (PDF 51.26 KB)


Pharmacy Prior Authorization Forms

Re-Review Reconsideration Request Form (PDF 158.04 KB)

Acthar Gel (PDF 56.9 KB)
Advair/Dulera/Symbicort (PDF 61.24 KB)
Ampyra (PDF 57.82 KB)
Aranesp Epogen Procrit (PDF 164.88 KB)
Celebrex (PDF 63.28 KB)
Effient (PDF 46.2 KB)
Elidel Protopic (PDF 54.09 KB)
Fenofibrate (PDF 55.7 KB)
Forteo (PDF 106.46 KB)
Growth Hormone (PDF 167.93 KB)
Hepatitis C (PDF 158.5 KB)
ICS-LABA Combination Productions (PDF 56.84 KB)
Increlex (PDF 69.23 KB)
Inhaled Corticosteroids (PDF 57.28 KB)
Itraconazole (PDF 82.75 KB)
Januvia, Janumet, and Janumet XR (PDF 99.29 KB)
Kuvan (PDF 56.37 KB)
Long-Acting Opiates (PDF 63.04 KB)
Lovaza (PDF 56.24 KB)
Lovenox (PDF 85.29 KB)
Lupron (PDF 121.95 KB)
Multaq (PDF 75.78 KB)
Onglyza, Kombiglyze XR, Tradjenta, Jentadueto (PDF 51.47 KB)
Oral Chemo (PDF 72.85 KB)
Prior Authorization Request Form (PDF 85.31 KB)
Promacta (PDF 65.36 KB)
Proton Pump Inhibitors (PDF 61.58 KB)
Renvela (PDF 53.33 KB)
Sensipar (PDF 45.17 KB)
Singulair (PDF 61.87 KB)
Soriatane (PDF 64.33 KB)
Specialty Medication Prior Authorization Cover Sheet (PDF 21.44 KB)
Suboxone (PDF 68.56 KB)
Symlin (PDF 54.29 KB)
Synagis (PDF 245.92 KB)
Testosterone (PDF 97.34 KB)
Topical NSAIDs (PDF 55.45 KB)
TZDs and DPP-4 (PDF 62.6 KB)
Uloric (PDF 55.33 KB)
VFend (PDF 53.31 KB)
Xenazine (PDF 67.28 KB)
Xifaxin (PDF 51.05 KB)
Xolair (PDF 57.61 KB)
Zetia (PDF 57.92 KB)
Zyvox (PDF 47.87 KB)


Children's Rehabilitative Services (CRS) Program


Developmentally Disabled Program

Preferred Drug List (PDL) Search
Developmentally Disabled Preferred Drug List (PDF 1,016.06 KB)
Step Therapy (PDF 21.02 KB)

Pharmacy Bulletins

UnitedHealthcare Community Plan AZ Specialty Pharmacy Program Changes (PDF 246.6 KB) Synagis Enrollment Form (PDF 245.92 KB) 
Synagis Program (PDF 52.46 KB)
Synagis Program 5 Doses (PDF 51.26 KB)

Pharmacy Prior Authorization Guidelines
Olysio (PDF 94.56 KB)
Sovaldi (PDF 149.44 KB)


Pharmacy Prior Authorization Forms

Re-Review Reconsideration Request Form (PDF 158.04 KB)

Acthar Gel (PDF 56.9 KB)
Advair/Dulera/Symbicort (PDF 61.24 KB)
Ampyra (PDF 57.82 KB)
Aranesp Epogen Procrit (PDF 164.88 KB)
Celebrex (PDF 63.28 KB)
Effient (PDF 46.2 KB)
Elidel Protopic (PDF 54.09 KB)
Fenofibrate (PDF 55.7 KB)
Forteo (PDF 106.46 KB)
Growth Hormone (PDF 167.93 KB)
Hepatitis C (PDF 144.54 KB)
ICS-LABA Combination Productions (PDF 56.84 KB)
Increlex  (PDF 69.23 KB)
Inhaled Corticosteroids (PDF 57.28 KB)
Itraconazole (PDF 82.75 KB)
Kuvan (PDF 56.37 KB)
Long-Acting Opiates (PDF 63.04 KB)
Lovaza (PDF 56.24 KB)
Lovenox (PDF 85.29 KB)
Lupron (PDF 121.95 KB)
Multaq (PDF 75.78 KB)
Oral Chemo (PDF 72.85 KB)
Prior Authorization Request Form (PDF 85.31 KB)
Promacta (PDF 65.36 KB)
Proton Pump Inhibitors (PDF 61.58 KB)
Renvela (PDF 53.33 KB)
Sensipar (PDF 45.17 KB)
Singulair (PDF 61.87 KB)
Soriatane (PDF 64.33 KB)
Specialty Medication Prior Authorization Cover Sheet (PDF 21.44 KB)
Suboxone (PDF 68.56 KB)
Symlin (PDF 54.29 KB)
Synagis (PDF 245.92 KB)
Testosterone (PDF 97.34 KB)
Topical NSAIDs (PDF 55.45 KB)
TZDs and DPP-4 (PDF 62.6 KB)
Uloric (PDF 55.33 KB)
VFend (PDF 53.31 KB)
Xenazine (PDF 67.28 KB)
Xifaxin (PDF 51.05 KB)
Xolair (PDF 57.61 KB)
Zetia (PDF 57.92 KB)
Zyvox (PDF 47.87 KB)
Olysio (PDF 94.56 KB)
Sovaldi (PDF 149.44 KB)


KidsCare


Long Term Care


Preferred Drug List (PDL) Search
Preferred Drug List (PDF 1.07 MB)
1/1/2016 PDL update (PDF 53.35 KB)
11/1/2015 PDL update (PDF 70.83 KB)
Dual Eligible Drug Coverage (Wrap List) (PDF 3.42 MB)

 

Important Step Therapy Information
Step Therapy Policy (PDF 21.02 KB)

Quantity Limit Initiatives
Quantity Limit Policy (PDF 20.11 KB)

Pharmacy Bulletins

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

Pharmacy Prior Authorization Guidelines
Olysio (PDF 94.56 KB)
Sovaldi (PDF 149.44 KB)

Pharmacy Prior Authorization Forms

Re-Review Reconsideration Request Form (PDF 158.04 KB)

Acthar Gel (PDF 56.9 KB)
Advair/Dulera/Symbicort (PDF 61.24 KB)
Ampyra (PDF 57.82 KB)
Aranesp Epogen Procrit (PDF 164.88 KB)
Celebrex (PDF 63.28 KB)
Compound Medications - 24 Hour Urgent (PDF 76.86 KB)
Effient (PDF 46.2 KB)
Elidel Protopic (PDF 54.09 KB)
Fenofibrate (PDF 55.7 KB)
Forteo (PDF 106.46 KB)
Growth Hormone (PDF 167.93 KB)
Hepatitis C (PDF 144.54 KB)
ICS-LABA Combination Productions (PDF 56.84 KB)
Increlex  (PDF 69.23 KB)
Inhaled Corticosteroids (PDF 57.28 KB)
Itraconazole (PDF 82.75 KB)
Januvia, Janumet, and Janumet XR (PDF 99.29 KB)
Kuvan (PDF 56.37 KB)
Long-Acting Opiates (PDF 63.04 KB)
Lovaza (PDF 56.24 KB)
Lovenox (PDF 85.29 KB)
Lupron (PDF 121.95 KB)
Multaq (PDF 75.78 KB)
Onglyza, Kombiglyze XR, Tradjenta, Jentadueto (PDF 51.47 KB)
Oral Chemo (PDF 72.85 KB)
Prior Authorization Request Form (PDF 85.31 KB)
Promacta (PDF 65.36 KB)
Proton Pump Inhibitors (PDF 61.58 KB)
Renvela (PDF 53.33 KB)
Sensipar (PDF 45.17 KB)
Singulair (PDF 61.87 KB)
Soriatane (PDF 64.33 KB)
Specialty Medication Prior Authorization Cover Sheet (PDF 21.44 KB)
Suboxone (PDF 68.56 KB)
Symlin (PDF 54.29 KB)
Testosterone (PDF 97.34 KB)
Topical NSAIDs (PDF 55.45 KB)
TZDs and DPP-4 (PDF 62.6 KB)
Uloric (PDF 55.33 KB)
VFend (PDF 53.31 KB)
Xenazine (PDF 67.28 KB)
Xifaxin (PDF 51.05 KB)
Xolair (PDF 57.61 KB)
Zetia (PDF 57.92 KB)
Zyvox (PDF 47.87 KB)


UnitedHealthcare Dual Complete (HMO SNP)
H0321-002

Preferred Drug List (PDL) Search

Download (PDF 1.04 MB) 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)