UnitedHealthcare Community Plan
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UnitedHealthcare Community Plan - IA Health Link


UnitedHealthcare Community Plan hawk-i

Preferred Drug List (PDL) Search

Preferred Drug List

 


Pharmacy Prior Authorization Forms

 

  • Alpha1-Proteinase Inhibitor Enzymes (PDF 37.29 KB)
  • Alpha 2 Agonist, Extended Release (PDF 74.41 KB)
  • Dalfampridine (Ampyra) (PDF 27.64 KB)
  • Amylino Mimetic (PDF 56.81 KB)
  • Anti-Acne (PDF 59.05 KB)
  • Antidepressant (PDF 29.33 KB)
  • Anti-Diabetic, Non-Insulin Agents (PDF 32.42 KB)
  • Antiemetic-5HT3 receptor Antogonists/Substance P Neurokinin Agents (PDF 49.73 KB)
  • Anti-Fungal (PDF 55.1 KB)
  • Antihistamines (PDF 45.04 KB)
  • Apixaban (Eliquis) (PDF 49.4 KB)
  • Apremilast (Otezla) (PDF 39.59 KB)
  • Angiotension Receptor Blocker Before ACE Inhibitor (PDF 44.92 KB)
  • Binge Eating Disorder Agents (PDF 35.87 KB)
  • Benzodiazepines (PDF 59.53 KB)
  • Biologicals for Ankylosing Spondylitis (PDF 62.81 KB)
  • Biologicals for Arthritis (PDF 40.93 KB)
  • Biologicals for Inflammatory Bowel Disease (PDF 63.02 KB)
  • Biologicals for Plaque Psoriasis (PDF 61.3 KB)
  • Buprenophine/Naloxone (PDF 36.42 KB)
  • Buprenorphine (Butrans) Transdermal System (PDF 25.96 KB)
  • Nebivolol (Bystolic) (PDF 48.08 KB)
  • Cholic Acid (Cholbam) (PDF 69.93 KB)
  • Chronic Pain Syndromes (PDF 64.27 KB)
  • CNS Stimulants (PDF 73.72 KB)
  • Colchicine (Colcrys) (PDF 55.27 KB)
  • Concurrent IM/PO Antipsychotic (PDF 43.94 KB)
  • Dabigatran (Pradaxa) (PDF 59.3 KB)
  • Deferasirox (Exjade) (PDF 36.5 KB)
  • Edoxaban (Savaysa) (PDF 51.85 KB)
  • Erythropoesis Stimulating Agents (PDF 30.53 KB)
  • Extended Release Formulation (PDF 26.55 KB)
  • Febuxostat (Uloric) (PDF 34.38 KB)
  • Fentanyl, Short Acting Oral Products (PDF 57.82 KB)
  • Fifteen Day Initial Prescription Supply Override (PDF 25.62 KB)
  • Granulocyte Colony Stimulating Factor PA (PDF 26.74 KB)
  • Growth Hormone (PDF 36.11 KB)
  • Hepatitis C Treatments (PDF 142.18 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 53.14 KB)
  • Insulin, Pre-Filled Pens (PDF 55.69 KB)
  • Isotretinoin (Oral) (PDF 57.64 KB)
  • Janus Kinase Inhibitors (PDF 34.91 KB)
  • Kalydeco (ivacaftor) (PDF 31.91 KB)
  • Ketorolac (PDF 35.45 KB)
  • Lidocaine Patch (Lidoderm) (PDF 27.49 KB)
  • Long-Acting Narcotics (PDF 27.2 KB)
  • Methotrexate Injection (PDF 60.44 KB)
  • Korlym (mifepristone) (PDF 26.12 KB)
  • Miscellaneous (PDF 44.25 KB)
  • Modified Formulations (PDF 27.65 KB)
  • Muscle Relaxants (PDF 33.2 KB)
  • Narcotic Agonist Antagonist Nasal Spray (PDF 57.32 KB)
  • Nicotine Replacement Therapy (PDF 32.18 KB)
  • Non-Parenteral Vasopressin Derivatives (PDF 57.92 KB)
  • Non-Preferred Drug (PDF 25.33 KB)
  • Non-Steroidal Anti-Inflammatory Drugs (PDF 58.65 KB)
  • Dextromethorphan and Quinidine (Nuedexta™) (PDF 67.53 KB)
  • Oral Constipating Agents (PDF 67.03 KB)
  • Oral Immunotherapy (PDF 79.81 KB)
  • Multiple Sclerosis Agents - Oral (PDF 50.14 KB)
  • Lumacaftor/Ivacaftor (Orkambi) (PDF 40.82 KB)
  • Pavilizumab (Synagis®) (PDF 34.23 KB)
  • Proton Pump Inhibitors (PDF 36.33 KB)
  • Pulmonary Arterial Hypertension (PDF 49.93 KB)
  • Quantity Limit Override (PDF 48.08 KB)
  • Becaplermin (Regranex) (PDF 55.48 KB)
  • Repository Corticotropin Injection (PDF 25.1 KB)
  • Roflumilast (Daliresp™) (PDF 42.17 KB)
  • Sedative/Hypnotic-Non-benzodiazepine (PDF 61.47 KB)
  • Selected Brand Name Drug (PDF 62.26 KB)
  • Select Oncology Agents (PDF 29.58 KB)
  • Serotonin 5-HT1-receptor Agonists (PDF 49.4 KB)
  • Short Acting Narcotics (PDF 31.04 KB)
  • Smoking Cessation Therapy - Oral (PDF 31.04 KB)
  • Tasimelteon (Hetlioz) (PDF 30.85 KB)
  • Testosterone Products (PDF 70.42 KB)
  • Thrombopoietin Receptor Agonists (PDF 76.41 KB)
  • Topical Antifungals for Onychomycosis (PDF 25.67 KB)
  • Topical Corticosteroids (PDF 24.45 KB)
  • Immunomodulators - Topical (PDF 29.34 KB)
  • Topical Retinoids (PDF 34.52 KB)
  • Vitamins Minerals and Multiple Vitamins (PDF 22.28 KB)
  • Vorapaxar (Zontivity) (PDF 26.41 KB)
  • Vusion Ointment (PDF 51.96 KB)
  • Rivaroxaban (Xarelto) (PDF 93.58 KB)
  • Omalizumab (Xolair) (PDF 35.73 KB)
  • Sodium Oxybate (Xyrem) (PDF 58.95 KB)
  • Linezolid (Zyvox) (PDF 57.79 KB)
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