UnitedHealthcare Community Plan
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UnitedHealthcare Community Plan

Preferred Drug List (PDL) Search

 

Preferred Drug List (PDF 1.83 MB)
PDL Updates (PDF 41.79 KB)
Prior Authorization List (PDF 311.14 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)


Pharmacy Prior Authorization Guidelines
Olysio (PDF 94.56 KB)
Sovaldi (PDF 149.44 KB)

Prior Authorization and Medical Exception Forms
Abilify (Atypical Antipsychotic - 24 Hour - Urgent) (PDF 55.62 KB)
Acthar Gel (PDF 56.9 KB)
Advair/Dulera/Symbicort (PDF 61.8 KB)
Ampyra (PDF 57.82 KB)
Aranesp Epogen Procrit (PDF 164.88 KB)
Aranesp Epogen Procrit - Urgent (PDF 154.72 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)
Growth Hormone - Urgent (PDF 166.94 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 178.62 KB)
Multaq (PDF 75.78 KB)
Oral Chemo (PDF 72.85 KB)
Prior Authorization Request Form (PDF 85.31 KB)
Prior Authorization Request Form - Urgent (PDF 85.46 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)


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