UnitedHealthcare Community Plan
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Pharmacy Program

 

AHCCCS/Medicaid

Pharmacy Program 

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

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 (PDF 21.02 KB)

 

Pharmacy Bulletins

UnitedHealthcare Community Plan AZ 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)


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 77.62 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 511.71 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

Pharmacy Program 

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
 
(PDF 21.02 KB)

Pharmacy Bulletins

UnitedHealthcare Community Plan AZ 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)


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)
Celebrex (PDF 63.28 KB)
Compound Medications - 24 Hour Urgent (PDF 76.86 KB)
Growth Hormone (PDF 167.93 KB)
ICS-LABA Combination Productions (PDF 56.84 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)
Lovenox (PDF 85.29 KB)
Lupron (PDF 121.95 KB)
Onglyza, Kombiglyze XR, Tradjenta, Jentadueto (PDF 51.47 KB)
Prior Authorization Request Form (PDF 85.31 KB)
Proton Pump Inhibitors (PDF 61.58 KB)
Specialty Medication Prior Authorization Cover Sheet (PDF 21.44 KB)
Testosterone (PDF 97.34 KB)
Topical NSAIDs (PDF 55.45 KB)
VFend (PDF 53.31 KB)


Developmentally Disabled Program

Pharmacy Program 

Preferred Drug List (PDL) Search
Developmentally Disabled Preferred Drug List (PDF 1.01 MB)
Step Therapy (PDF 21.02 KB) 

Pharmacy Bulletins

UnitedHealthcare Community Plan AZ 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)

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 511.71 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

Pharmacy Program

Preferred Drug List (PDL) Search
Preferred Drug List (PDF 1.09 MB)

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)
5/1/2016 PDL Update (PDF 81.2 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 511.71 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

Pharmacy Program 

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