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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.

 

Preferred Drug List and Updates

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Child Health Plus.

Click on the link below to view the Preferred Drug List.

Preferred Drug List (PDL) Search
Preferred Drug List
(PDF 1.48 MB)

1/1/2018 PDL Update (PDF 165.33 KB)
10/1/2017 PDL Update (PDF 60.17 KB)
7/1/2017 PDL Update (PDF 122.33 KB)
4/1/2017 PDL Update (PDF 63.1 KB)
1/1/2017 PDL Update (PDF 137.39 KB)

 

Step Therapy Program

Step Therapy (PDF 21.03 KB)

 

Pharmacy Bulletins

Synagis Enrollment Form (PDF 225.02 KB)
Synagis Program (PDF 58.92 KB)
Synagis Program Immunoprophylaxis Duration (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)

Preferred Drug List and Updates

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Essential Plan. Click on a link below to view the Preferred Drug List. 

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 1.41 MB)


1/1/2018 PDL Update (PDF 165.33 KB)
10/1/2017 PDL Update (PDF 60.17 KB)
7/1/2017 PDL Update (PDF 122.33 KB)
4/1/2017 PDL Update (PDF 63.1 KB)
1/1/2017 PDL Update (PDF 137.39 KB)


Drug Quantity Limits 

Quantity Limits (PDF 20.11 KB)


Step Therapy Program 

Step Therapy (PDF 21.03 KB)


Pharmacy Prior Authorization Forms

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

Standard Prior Authorization Request Form (PDF 119.1 KB)

Preferred Drug List and Updates

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by NY Community Plan MLTSS.

Click on the link below to view the Preferred Drug List.

Preferred Drug List (PDL) Search

Preferred Drug List (PDL) (PDF 1.42 MB)
PDL Updates (PDF 61.89 KB)


1/1/2018 PDL Update (PDF 165.33 KB)
10/1/2017 PDL Update (PDF 60.17 KB)
7/1/2017 PDL Update (PDF 122.33 KB)
4/1/2017 PDL Update (PDF 63.1 KB)
1/1/2017 PDL Update (PDF 137.39 KB)

 

Drug Quantity Limits 

Quantity Limits (PDF 20.11 KB)


Step Therapy Program 

Step Therapy (PDF 21.03 KB)


Pharmacy Bulletins

Synagis Enrollment Form (PDF 225.02 KB)  
Synagis Program 
(PDF 245.92 KB)
Synagis Program 5 Doses (PDF 51.26 KB)


Pharmacy Prior Authorization Forms

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

Preferred Drug List and Updates

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Community Plan.

Click on the links below to view the Preferred Drug List.

Preferred Drug List (PDL) Search

Preferred Drug List (PDL) (PDF 1.39 MB)
PDL Updates (PDF 61.89 KB)


1/1/2018 PDL Update (PDF 165.33 KB)
10/1/2017 PDL Update (PDF 60.17 KB)
7/1/2017 PDL Update (PDF 122.33 KB)
4/1/2017 PDL Update (PDF 63.1 KB)
1/1/2017 PDL Update (PDF 137.39 KB)

 

Drug Quantity Limits 

Quantity Limits (PDF 20.11 KB)


Step Therapy Program 

Step Therapy (PDF 21.03 KB)


Pharmacy Bulletins


May 2017 Medicaid Update for Hemo Pharmacy Providers (PDF 193.98 KB) - 7.13.2017
Synagis Enrollment Form (PDF 225.02 KB)  
Synagis Program (PDF 58.92 KB)
Synagis Program 5 Doses (PDF 51.26 KB)


Pharmacy Prior Authorization Forms

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

Standard Prior Authorization Request Form (PDF 119.1 KB) 

Preferred Drug List

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Advantage.

Click on the link below to view the Preferred Drug List.

Preferred Drug List (PDL) Search

Preferred Drug List 

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete (HMO SNP). 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)

 

Pharmacy Prior Authorization Forms 

Submit a Pharmacy Prior Authorization Request to Prescription Solutions.

Medicare Prescription Drug Determination Request Form

Pharmacy Benefits 

New York Health and Recovery Plan (HARP) Pharmacy Benefits (PDF 51.85 KB):
New York City - Effective Oct. 1, 2015
Rest of New York State - Effective July 1, 2016
 

Preferred Drug List

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Wellness4Me.

Click on the link below to view the Preferred Drug List.

Wellness4ME Preferred Drug List Search
Preferred Drug List (PDF 1.39 MB)

 

Drug Quantity Limits 

Quantity Limits (PDF 20.11 KB)


Step Therapy Program 

Step Therapy (PDF 21.03 KB)


Pharmacy Bulletins

Synagis Enrollment Form (PDF 225.02 KB)  
Synagis Program  (PDF 58.92 KB)
Synagis Program 5 Doses (PDF 51.26 KB)


Pharmacy Prior Authorization Forms

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

Standard Prior Authorization Request Form (PDF 119.1 KB)
Re-Review Reconsideration Request Form
(PDF 158.04 KB)