UnitedHealthcare Community Plan
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Pharmacy Program

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

 

Child Health Plus

Click on the arrow above to view the pharmacy information for Child Health Plus. 

Preferred Drug List (PDL) Search
Preferred Drug List
(PDF 1.11 MB)

4/1/2017 PDL Update (PDF 63.1 KB)
1/1/2017 PDL Update (PDF 137.39 KB)
10/1/2016 PDL Update (PDF 53.13 KB)
8/1/2016 PDL Update (PDF 62.53 KB)

Step Therapy (PDF 21.03 KB)


Pharmacy Bulletins

Synagis Enrollment Form (PDF 511.58 KB)  
Synagis Program  (PDF 58.92 KB)
(PDF 42.79 KB)Synagis Program 5 Doses (PDF 51.26 KB)


Pharmacy Prior Authorization Forms

Standard Prior Authorization Request Form (PDF 119.1 KB)

Re-Review Reconsideration Request Form (PDF 158.04 KB)

Essential Plan

Click on the arrow above to view the pharmacy information for Essential Plan. 

United Healthcare Community Plan Essential Plan 1 Preferred Drug List (PDL) Search
United Healthcare Community Plan Essential Plan 2 Preferred Drug List (PDL) Search
United Healthcare Community Plan Essential Plan 3 Preferred Drug List (PDL) Search
United Healthcare Community Plan Essential Plan 4 Preferred Drug List (PDL) Search

NY Essential Plan Preferred Drug List (PDF 1.18 MB)

Quantity Limits  (PDF 20.11 KB)
Step Therapy (PDF 21.03 KB)


Pharmacy Bulletins

 


Pharmacy Prior Authorization Forms

Standard Prior Authorization Request Form (PDF 119.1 KB)

Re-Review Reconsideration Request Form (PDF 158.04 KB)

NY Community Plan MLTSS

Click on the arrow above to view the pharmacy information for NY Community Plan MLTSS.

Preferred Drug List (PDL) Search

Preferred Drug List  (PDF 1.07 MB)
PDL Updates  (PDF 61.89 KB)
Quantity Limits  (PDF 20.11 KB)
Step Therapy (PDF 21.03 KB)


Pharmacy Bulletins

Synagis Enrollment Form (PDF 245.92 KB)  
Synagis Program 
(PDF 245.92 KB)
Synagis Program 5 Doses (PDF 51.26 KB)


Pharmacy Prior Authorization Forms

UnitedHealthcare Community Plan

Click on the arrow above to view pharmacy information for UnitedHealthcare Community Plan. 

Preferred Drug List (PDL) Search

 

Preferred Drug List (PDF 1.12 MB)
PDL Updates (PDF 61.89 KB)
Quantity Limits (PDF 20.11 KB)
Step Therapy (PDF 21.03 KB)


Pharmacy Bulletins

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

Standard Prior Authorization Request Form (PDF 119.1 KB)

Re-Review Reconsideration Request Form (PDF 158.04 KB)

UnitedHealthcare Dual Advantage

Click on the arrow above to view the pharmacy information for UnitedHealthcare Dual Advantage.

UnitedHealthcare Dual Complete® (HMO SNP)

Click on the arrow above to view the pharmacy information for UnitedHealthcare Dual Complete (HMO SNP).

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 Wellness4Me

Click on the arrow above to view the pharmacy information for UnitedHealthcare Wellness4Me.

Pharmacy benefit summary BH /HARP implementation (PDF 267.71 KB)

Wellness4ME Preferred Drug List Search
Preferred Drug List (PDF 1.12 MB)

Quantity Limits  (PDF 20.11 KB)
Step Therapy (PDF 21.03 KB)


Pharmacy Bulletins

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

Standard Prior Authorization Request Form (PDF 119.1 KB)

Re-Review Reconsideration Request Form (PDF 158.04 KB)