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UnitedHealthcare Community Plan
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Pharmacy Program

UnitedHealthcare Community Plan

Preferred Drug List (PDL) Search


Preferred Drug List (PDF 1.14 MB)
PDL Updates (PDF 316.6 KB)
Prior Authorization List (PDF 160.25 KB)
Step Therapy Policy (PDF 16.75 KB)
Quantity Limit Policy (PDF 24.38 KB)


Pharmacy Bulletins

Synagis Enrollment Form (PDF 187.35 KB)  
Synagis Program 
(PDF 50.65 KB)
Synagis Program 5 Doses (PDF 42.79 KB)

Prior Authorization and Medical Exception Forms
Acthar Gel (PDF 56.9 KB)
Ampyra (PDF 57.82 KB)
Aranesp Epogen Procrit (PDF 105.19 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 105.38 KB)
Hepatitis C (PDF 162.86 KB)
Increlex (PDF 69.23 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 111.2 KB)
Multaq (PDF 75.78 KB)
Oral Chemo (PDF 72.85 KB)
Prior Authorization Request Form (PDF 56.68 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 68.42 KB)
Symlin (PDF 54.29 KB)
Synagis (PDF 139.67 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 99.06 KB)
Sovaldi (PDF 133.82 KB)

UnitedHealthcare Connected™ for MyCare Ohio

UnitedHealthcare Dual Complete™ (HMO SNP)

Preferred Drug List (PDL) Search

Download (PDF 3.56 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