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Pharmacy Program

 

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Looking for Paper Pharmacy Prior Authorization Fax Forms? They are now available at UHCprovider.com 

 

Opioid Program and Resources

In response to the U.S. opioid epidemic, UnitedHealthcare has developed programs to help our members receive the care and treatment they need safely and effectively.

We’ve also established measures based on the Centers for Disease Control and Prevention’s (CDC) opioid treatment guidelines to help prevent overuse of short-acting and long-acting opioid medications.

Resources from UnitedHealthcare and Optum

Naloxone Coverage for UnitedHealthcare Members (PDF 323.61 KB)
Naloxone: What You Need to Know
(PDF 62.67 KB)
Opioid Tapering Recommendations
(PDF 102.65 KB)
The Role of Dentists in Managing Opioids
(PDF 448.16 KB)
Treatment Alternatives for Common Pain Conditions 
(PDF 96.61 KB)


Other Resources

Agency for Healthcare Research and Quality (AHRQ)
Interagency Guideline on Prescribing Opioids for Pain

Centers for Disease Control and Prevention (CDC)
CDC Guideline for Prescribing Opioids for Chronic Pain (2016)
CDC Opioid Overdose Guideline Resources

Substance Abuse and Mental Health Services Administration (SAMHSA)
The Role of Prevention in Addressing Neonatal Abstinence Syndrome

 

AHCCCS Complete Care


AHCCCS/Medicaid

Pharmacy Program 

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by AHCCCS/Medicaid.

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

Preferred Drug List (PDL) Search
AHCCCS/Medicaid Preferred Drug List  (PDF 1.06 MB)

4/1/2018 PDL Update (PDF 216.22 KB)
1/1/2018 PDL Update (PDF 157.01 KB)
10/1/2017 PDL Update (PDF 58.09 KB)
7/1/2017 PDL Update (PDF 132.61 KB)


Step Therapy Information 

Step Therapy (PDF 21.02 KB)

 

Pharmacy Bulletins

UnitedHealthcare Community Plan Specialty Pharmacy Program Changes (PDF 246.6 KB)
Synagis Enrollment Form  (PDF 225.02 KB)
Synagis Program
(PDF 58.92 KB)
Synagis Program 5 Doses  (PDF 51.26 KB)

 

Clinical Guidelines

Our Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

 

 

  • Actemra (PDF 56.53 KB)
  • Actimmune (PDF 88.98 KB)
  • ADHD Medications (PDF 60.12 KB)
  • Afinitor (PDF 230.97 KB)
  • Afrezza (PDF 100.39 KB)
  • Aldurazyme (PDF 40.32 KB)
  • Alecensa (PDF 44.85 KB)
  • Alfa Interferons (PDF 107.46 KB)
  • Alinia (PDF 46.99 KB)
  • Ampyra (PDF 89.12 KB)
  • Anthelmintics (PDF 104.39 KB)
  • Anticonvulsants (PDF 55.34 KB)
  • Antipsychotics (PDF 143.47 KB)
  • Antipsoriatic Agents (PDF 56.5 KB)
  • Apokyn (PDF 44.7 KB)
  • Arcalyst (PDF 56.5 KB)
  • Aricept 23mg (PDF 41.77 KB)
  • Austedo (PDF 50.85 KB)
  • Azole Antifungals (PDF 223.95 KB)
  • Benlysta (PDF 47.08 KB)
  • Benznidazole (PDF 41.88 KB)
  • Berinert (PDF 96.91 KB)
  • Biltricide (PDF 44.25 KB)
  • Bosulif (PDF 54.09 KB)
  • Brilinta / Effient (PDF 71.85 KB)
  • Buphenyl (PDF 41.21 KB)
  • Cabometyx (PDF 48.95 KB)
  • Calquence (PDF 42.01 KB)
  • Caprelsa (PDF 100.36 KB)
  • Carbaglu (PDF 102.91 KB)
  • Cayston (PDF 49.03 KB)
  • Celebrex (PDF 48.49 KB)
  • Cesamet / Marinol (PDF 114.74 KB)
  • CGRP (PDF 51.69 KB)
  • Cholbam (PDF 44.64 KB)
  • Cialis for BPH (PDF 45.93 KB)
  • Cimzia (PDF 69.19 KB)
  • Cinryze (PDF 128.47 KB)
  • Ciprodex (PDF 44.65 KB)
  • Colony Stimulating Factors (PDF 164.86 KB)
  • Combination Basal Insulin, GLP-1 Receptor Agonist (PDF 46.99 KB)
  • Cometriq (PDF 90.7 KB)
  • Complera (PDF 96.46 KB)
  • Compounds and Bulk Powders (PDF 82.81 KB)
  • Concentrated Insulins (PDF 43.34 KB)
  • Copper Chelating Agents (PDF 57.65 KB)
  • Corlanor (PDF 47.85 KB)
  • Cosentyx (PDF 50.86 KB)
  • Cotellic (PDF 44.64 KB)
  • Crestor (PDF 112.01 KB)
  • Cystaran (PDF 42.24 KB)
  • Daliresp (PDF 50.17 KB)
  • Daraprim (PDF 68.79 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 52.04 KB)
  • DPP-4 Inhibitors (PDF 52.2 KB)
  • Dry Eye Disease (PDF 52.37 KB)
  • Duopa (PDF 44.89 KB)
  • Dupixent (PDF 59.37 KB)
  • Egrifta (PDF 45.24 KB)
  • Elaprase (PDF 39.2 KB)
  • Elidel / Protopic (PDF 63.24 KB)
  • Elmiron (PDF 44.69 KB)
  • Emflaza (PDF 92.17 KB)
  • Endari (PDF 42.59 KB)
  • Entocort (PDF 45.04 KB)
  • Entresto (PDF 50.89 KB)
  • Epaned (PDF 47.58 KB)
  • Erivedge (PDF 45.27 KB)
  • Eucrisa (PDF 44.36 KB)
  • Evzio (PDF 48.22 KB)
  • Exondys 51 - Drug Policy (PDF 103.09 KB)
  • Fabrazyme (PDF 39.65 KB)
  • Farydak (PDF 48.43 KB)
  • Fenofibrate (PDF 48.37 KB)
  • Fentanyl IR (PDF 58.32 KB)
  • Firazyr (PDF 107.04 KB)
  • Forteo
  • Gattex (PDF 44.12 KB)
  • Gaucher's Disease Agents (PDF 48.84 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 96.12 KB)
  • GLP-1 Agonists (PDF 50.26 KB)
  • Growth Hormone / Growth Stimulating Agents (PDF 191.77 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 92.68 KB)
  • Gout (PDF 46.97 KB)
  • Haegarda (PDF 39.9 KB)
  • HCG (PDF 43.9 KB)
  • Hepatitis C Criteria
  • Hemlibra (PDF 42.77 KB)
  • Hemangeol (PDF 45.4 KB)
  • Hemophilia (PDF 46.74 KB)
  • Hetlioz (PDF 107.21 KB)
  • HIV Medications (PDF 48.58 KB)
  • HP Acthar Repository Corticotropin Injection (PDF 154.66 KB)
  • Humira (PDF 129.67 KB)
  • Hycamtin (PDF 45.7 KB)
  • Ibrance (PDF 102.25 KB)
  • IBS - Diarrhea (PDF 53.49 KB)
  • Iclusig (PDF 51.83 KB)
  • ICS.LABA Combo (PDF 64.72 KB)
  • Idhifa (PDF 43.73 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 50.78 KB)
  • Ilaris (PDF 62.15 KB)
  • Imbruvica (PDF 59.65 KB)
  • Impavido (PDF 66.86 KB)
  • Inderal LA (PDF 41.3 KB)
  • Ingrezza (PDF 47.15 KB)
  • Inhaled Corticosteroids (PDF 52.86 KB)
  • Inlyta (PDF 99.47 KB)
  • Iressa (PDF 52.77 KB)
  • Iron Chelators (PDF 72.6 KB)
  • Irritable Bowl Syndrome-Constipation (PDF 75.48 KB)
  • Isotretinoin (PDF 116.21 KB)
  • Jakafi (PDF 52.28 KB)
  • Juxtapid (PDF 60.57 KB)
  • Kalydeco (PDF 54.92 KB)
  • Keveyis (PDF 43.14 KB)
  • Kevzara (PDF 48.04 KB)
  • Kineret (PDF 62.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 46.19 KB)
  • Kuvan (PDF 43.8 KB)
  • Kynamro (PDF 63.31 KB)
  • Lenvima (PDF 126.69 KB)
  • Lidocaine Patch (PDF 55.41 KB)
  • Lidoderm (PDF 125.01 KB)
  • Long-Acting Opioid Products (PDF 119.06 KB)
  • Lonsurf (PDF 46.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 58.64 KB)
  • Lyrica (PDF 121.26 KB)
  • Lysteda (PDF 45.84 KB)
  • Mekinist (PDF 50.55 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 56.82 KB)
  • Mirvaso (PDF 43.15 KB)
  • Mozobil (PDF 50.89 KB)
  • Multiple Sclerosis (MS) Agents (PDF 63.72 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Myozyme / Lumizyme (PDF 43.17 KB)
  • Mytesi (PDF 42.38 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 48.64 KB)
  • Nerlynx (PDF 42.19 KB)
  • Nexavar (PDF 224 KB)
  • Ninlaro (PDF 46.68 KB)
  • Nityr (PDF 41.22 KB)
  • Non-Preferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 57.52 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 49.18 KB)
  • Nuplazid (PDF 89.32 KB)
  • Overactive Bladder (OAB) Agents (PDF 51.22 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 44.6 KB)
  • Omega (PDF 114.61 KB)
  • Optivar (PDF 44.26 KB)
  • Orencia (PDF 52.01 KB)
  • Orfadin (PDF 42.24 KB)
  • Orkambi (PDF 66.92 KB)
  • Otezla (PDF 49.62 KB)
  • Pulmonary Arterial Hypertension (PAH) Agents (PDF 70.47 KB)
  • Panretin (PDF 47.69 KB)
  • Pomalyst (PDF 47.77 KB)
  • Pradaxa (PDF 68.27 KB)
  • Praluent (PDF 102.63 KB)
  • Procysbi (PDF 101.67 KB)
  • Progesterone (PDF 41.72 KB)
  • Progesterone - Oral (PDF 39.38 KB)
  • Proton Pump Inhibitors (PPI) (PDF 381.09 KB)
  • Promacta (PDF 51.05 KB)
  • Provigil / Nuvigil (PDF 66.39 KB)
  • Pulmozyme (PDF 66.94 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 45.83 KB)
  • Ravicti (PDF 68.11 KB)
  • Rectiv (PDF 42.28 KB)
  • Regranex (PDF 27.13 KB)
  • Relistor (PDF 61.24 KB)
  • Renvela (PDF 45.32 KB)
  • Repatha (PDF 110.22 KB)
  • Revlimid (PDF 138.81 KB)
  • Rhofade (PDF 42.17 KB)
  • Rozerem (PDF 42.42 KB)
  • Rubraca (PDF 46.15 KB)
  • Ruconest (PDF 97.14 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 47.2 KB)
  • Sandostatin (PDF 89.53 KB)
  • Selzentry (PDF 41.73 KB)
  • Sensipar (PDF 48.55 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Short-Acting Opioid Products (PDF 91.64 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 55.17 KB)
  • Simponi (PDF 70.31 KB)
  • Sivextro (PDF 58.21 KB)
  • Soliris - Drug Policy (PDF 89.68 KB)
  • Somavert (PDF 100.05 KB)
  • Soriatane (PDF 73.6 KB)
  • Spinraza - Drug Policy (PDF 122.07 KB)
  • Sprycel (PDF 50.46 KB)
  • Stelara (PDF 63.04 KB)
  • Stivarga (PDF 52.51 KB)
  • Strensiq (PDF 51.19 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (SLIT) (PDF 65.96 KB)
  • Suboxone / Subutex (PDF 54.46 KB)
  • Sutent (PDF 106.77 KB)
  • Symdeko (PDF 69.32 KB)
  • Symlin (PDF 50.06 KB)
  • Synribo (PDF 43.78 KB)
  • Tafinlar (PDF 53.56 KB)
  • Tagrisso (PDF 50.44 KB)
  • Taltz (PDF 64.28 KB)
  • Tarceva (PDF 60.32 KB)
  • Targretin (PDF 46.02 KB)
  • Tasigna (PDF 51.26 KB)
  • Temodar (PDF 65.38 KB)
  • Test Strips (PDF 67.28 KB)
  • Thalomid (PDF 182.93 KB)
  • Tobramycin Inhalation (PDF 55.79 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 53.09 KB)
  • Topical Retinoid Products (PDF 58.68 KB)
  • Tremfya (PDF 56.98 KB)
  • Triptans (PDF 131.79 KB)
  • Tykerb (PDF 54.08 KB)
  • Tymlos (PDF 71.83 KB)
  • Uloric (PDF 89.18 KB)
  • Valchlor (PDF 46.49 KB)
  • Vancocin (PDF 50.35 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Verzenio (PDF 45.84 KB)
  • Votrient (PDF 82.3 KB)
  • Xalkori (PDF 50.15 KB)
  • Xeljanz / Xeljanz XR (PDF 55.79 KB)
  • Xenazine (PDF 58.96 KB)
  • Xifaxan (PDF 93.58 KB)
  • Xopenex Respules (PDF 42.58 KB)
  • Xtandi (PDF 47.1 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 197.74 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 68.44 KB)
  • Zetia (PDF 33.07 KB)
  • Zolinza (PDF 43.77 KB)
  • Zontivity (PDF 44.19 KB)
  • Zydelig (PDF 55.81 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 43.97 KB)
  • Zyvox (PDF 110.09 KB)
  •  


    Children's Rehabilitative Services (CRS) Program

    Pharmacy Program 

     

    The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by Children's Rehabilitative Services (CRS) Program. Click on the link below to view the Preferred Drug List.

    Search for Drugs Covered by CRS 
    Search for Drugs Covered by CRS - Partially Integrated Acute 
    Search for Drugs Covered by CRS - Fully Integrated Acute 
    Search for Drugs Covered by CRS - Partially Integrated Behavioral Health

    Children's Rehabilitative Services Preferred Drug List (PDF 1.07 MB)
    Preferred Drug List Updates (PDF 36.79 KB)

     

    Step Therapy Information 

    Step Therapy (PDF 21.02 KB)


    Pharmacy Bulletins

    UnitedHealthcare Community Plan Specialty Pharmacy Program Changes (PDF 246.6 KB) 
    Synagis Enrollment Form (PDF 225.02 KB) 
    Synagis Program (PDF 58.92 KB)
    Synagis Benefit Coverage (PDF 42.77 KB)
    Synagis Program 5 Doses (PDF 51.26 KB)

     

     

    Clinical Guidelines

    Our Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

     

     

  • Actemra (PDF 56.53 KB)
  • Actimmune (PDF 88.98 KB)
  • ADHD Medications (PDF 60.12 KB)
  • Afinitor (PDF 230.97 KB)
  • Afrezza (PDF 100.39 KB)
  • Aldurazyme (PDF 40.32 KB)
  • Alecensa (PDF 44.85 KB)
  • Alfa Interferons (PDF 107.46 KB)
  • Alinia (PDF 46.99 KB)
  • Ampyra (PDF 89.12 KB)
  • Anthelmintics (PDF 104.39 KB)
  • Anticonvulsants (PDF 55.34 KB)
  • Antipsychotics (PDF 143.47 KB)
  • Antipsoriatic Agents (PDF 56.5 KB)
  • Apokyn (PDF 44.7 KB)
  • Arcalyst (PDF 56.5 KB)
  • Aricept 23mg (PDF 41.77 KB)
  • Austedo (PDF 50.85 KB)
  • Azole Antifungals (PDF 223.95 KB)
  • Benlysta (PDF 47.08 KB)
  • Benznidazole (PDF 41.88 KB)
  • Berinert (PDF 96.91 KB)
  • Biltricide (PDF 44.25 KB)
  • Bosulif (PDF 54.09 KB)
  • Brilinta / Effient (PDF 71.85 KB)
  • Buphenyl (PDF 41.21 KB)
  • Cabometyx (PDF 48.95 KB)
  • Calquence (PDF 42.01 KB)
  • Caprelsa (PDF 100.36 KB)
  • Carbaglu (PDF 102.91 KB)
  • Cayston (PDF 49.03 KB)
  • Celebrex (PDF 48.49 KB)
  • Cesamet / Marinol (PDF 114.74 KB)
  • CGRP (PDF 51.69 KB)
  • Cholbam (PDF 44.64 KB)
  • Cialis for BPH (PDF 45.93 KB)
  • Cimzia (PDF 69.19 KB)
  • Cinryze (PDF 128.47 KB)
  • Ciprodex (PDF 44.65 KB)
  • Colony Stimulating Factors (PDF 164.86 KB)
  • Combination Basal Insulin, GLP-1 Receptor Agonist (PDF 46.99 KB)
  • Cometriq (PDF 90.7 KB)
  • Complera (PDF 96.46 KB)
  • Compounds and Bulk Powders (PDF 82.81 KB)
  • Concentrated Insulins (PDF 43.34 KB)
  • Copper Chelating Agents (PDF 57.65 KB)
  • Corlanor (PDF 47.85 KB)
  • Cosentyx (PDF 50.86 KB)
  • Cotellic (PDF 44.64 KB)
  • Crestor (PDF 112.01 KB)
  • Cystaran (PDF 42.24 KB)
  • Daliresp (PDF 50.17 KB)
  • Daraprim (PDF 68.79 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 52.04 KB)
  • DPP-4 Inhibitors (PDF 52.2 KB)
  • Dry Eye Disease (PDF 52.37 KB)
  • Duopa (PDF 44.89 KB)
  • Dupixent (PDF 59.37 KB)
  • Egrifta (PDF 45.24 KB)
  • Elaprase (PDF 39.2 KB)
  • Elidel / Protopic (PDF 63.24 KB)
  • Elmiron (PDF 44.69 KB)
  • Emflaza (PDF 92.17 KB)
  • Endari (PDF 42.59 KB)
  • Entocort (PDF 45.04 KB)
  • Entresto (PDF 50.89 KB)
  • Epaned (PDF 47.58 KB)
  • Erivedge (PDF 45.27 KB)
  • Eucrisa (PDF 44.36 KB)
  • Evzio (PDF 48.22 KB)
  • Exondys 51 - Drug Policy (PDF 103.09 KB)
  • Fabrazyme (PDF 39.65 KB)
  • Farydak (PDF 48.43 KB)
  • Fenofibrate (PDF 48.37 KB)
  • Fentanyl IR (PDF 58.32 KB)
  • Firazyr (PDF 107.04 KB)
  • Forteo
  • Gattex (PDF 44.12 KB)
  • Gaucher's Disease Agents (PDF 48.84 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 96.12 KB)
  • GLP-1 Agonists (PDF 50.26 KB)
  • Growth Hormone / Growth Stimulating Agents (PDF 191.77 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 92.68 KB)
  • Gout (PDF 46.97 KB)
  • Haegarda (PDF 39.9 KB)
  • HCG (PDF 43.9 KB)
  • Hepatitis C Criteria
  • Hemlibra (PDF 42.77 KB)
  • Hemangeol (PDF 45.4 KB)
  • Hemophilia (PDF 46.74 KB)
  • Hetlioz (PDF 107.21 KB)
  • HIV Medications (PDF 48.58 KB)
  • HP Acthar Repository Corticotropin Injection (PDF 154.66 KB)
  • Humira (PDF 129.67 KB)
  • Hycamtin (PDF 45.7 KB)
  • Ibrance (PDF 102.25 KB)
  • IBS - Diarrhea (PDF 53.49 KB)
  • Iclusig (PDF 51.83 KB)
  • ICS.LABA Combo (PDF 64.72 KB)
  • Idhifa (PDF 43.73 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 50.78 KB)
  • Ilaris (PDF 62.15 KB)
  • Imbruvica (PDF 59.65 KB)
  • Impavido (PDF 66.86 KB)
  • Inderal LA (PDF 41.3 KB)
  • Ingrezza (PDF 47.15 KB)
  • Inhaled Corticosteroids (PDF 52.86 KB)
  • Inlyta (PDF 99.47 KB)
  • Iressa (PDF 52.77 KB)
  • Iron Chelators (PDF 72.6 KB)
  • Irritable Bowl Syndrome-Constipation (PDF 75.48 KB)
  • Isotretinoin (PDF 116.21 KB)
  • Jakafi (PDF 52.28 KB)
  • Juxtapid (PDF 60.57 KB)
  • Kalydeco (PDF 54.92 KB)
  • Keveyis (PDF 43.14 KB)
  • Kevzara (PDF 48.04 KB)
  • Kineret (PDF 62.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 46.19 KB)
  • Kuvan (PDF 43.8 KB)
  • Kynamro (PDF 63.31 KB)
  • Lenvima (PDF 126.69 KB)
  • Lidocaine Patch (PDF 55.41 KB)
  • Lidoderm (PDF 125.01 KB)
  • Long-Acting Opioid Products (PDF 119.06 KB)
  • Lonsurf (PDF 46.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 58.64 KB)
  • Lyrica (PDF 121.26 KB)
  • Lysteda (PDF 45.84 KB)
  • Mekinist (PDF 50.55 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 56.82 KB)
  • Mirvaso (PDF 43.15 KB)
  • Mozobil (PDF 50.89 KB)
  • Multiple Sclerosis (MS) Agents (PDF 63.72 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Myozyme / Lumizyme (PDF 43.17 KB)
  • Mytesi (PDF 42.38 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 48.64 KB)
  • Nerlynx (PDF 42.19 KB)
  • Nexavar (PDF 224 KB)
  • Ninlaro (PDF 46.68 KB)
  • Nityr (PDF 41.22 KB)
  • Non-Preferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 57.52 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 49.18 KB)
  • Nuplazid (PDF 89.32 KB)
  • Overactive Bladder (OAB) Agents (PDF 51.22 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 44.6 KB)
  • Omega (PDF 114.61 KB)
  • Optivar (PDF 44.26 KB)
  • Orencia (PDF 52.01 KB)
  • Orfadin (PDF 42.24 KB)
  • Orkambi (PDF 66.92 KB)
  • Otezla (PDF 49.62 KB)
  • Pulmonary Arterial Hypertension (PAH) Agents (PDF 70.47 KB)
  • Panretin (PDF 47.69 KB)
  • Pomalyst (PDF 47.77 KB)
  • Pradaxa (PDF 68.27 KB)
  • Praluent (PDF 102.63 KB)
  • Procysbi (PDF 101.67 KB)
  • Progesterone (PDF 41.72 KB)
  • Progesterone - Oral (PDF 39.38 KB)
  • Proton Pump Inhibitors (PPI) (PDF 381.09 KB)
  • Promacta (PDF 51.05 KB)
  • Provigil / Nuvigil (PDF 66.39 KB)
  • Pulmozyme (PDF 66.94 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 45.83 KB)
  • Ravicti (PDF 68.11 KB)
  • Rectiv (PDF 42.28 KB)
  • Regranex (PDF 27.13 KB)
  • Relistor (PDF 61.24 KB)
  • Renvela (PDF 45.32 KB)
  • Repatha (PDF 110.22 KB)
  • Revlimid (PDF 138.81 KB)
  • Rhofade (PDF 42.17 KB)
  • Rozerem (PDF 42.42 KB)
  • Rubraca (PDF 46.15 KB)
  • Ruconest (PDF 97.14 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 47.2 KB)
  • Sandostatin (PDF 89.53 KB)
  • Selzentry (PDF 41.73 KB)
  • Sensipar (PDF 48.55 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Short-Acting Opioid Products (PDF 91.64 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 55.17 KB)
  • Simponi (PDF 70.31 KB)
  • Sivextro (PDF 58.21 KB)
  • Soliris - Drug Policy (PDF 89.68 KB)
  • Somavert (PDF 100.05 KB)
  • Soriatane (PDF 73.6 KB)
  • Spinraza - Drug Policy (PDF 122.07 KB)
  • Sprycel (PDF 50.46 KB)
  • Stelara (PDF 63.04 KB)
  • Stivarga (PDF 52.51 KB)
  • Strensiq (PDF 51.19 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (SLIT) (PDF 65.96 KB)
  • Suboxone / Subutex (PDF 54.46 KB)
  • Sutent (PDF 106.77 KB)
  • Symdeko (PDF 69.32 KB)
  • Symlin (PDF 50.06 KB)
  • Synribo (PDF 43.78 KB)
  • Tafinlar (PDF 53.56 KB)
  • Tagrisso (PDF 50.44 KB)
  • Taltz (PDF 64.28 KB)
  • Tarceva (PDF 60.32 KB)
  • Targretin (PDF 46.02 KB)
  • Tasigna (PDF 51.26 KB)
  • Temodar (PDF 65.38 KB)
  • Test Strips (PDF 67.28 KB)
  • Thalomid (PDF 182.93 KB)
  • Tobramycin Inhalation (PDF 55.79 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 53.09 KB)
  • Topical Retinoid Products (PDF 58.68 KB)
  • Tremfya (PDF 56.98 KB)
  • Triptans (PDF 131.79 KB)
  • Tykerb (PDF 54.08 KB)
  • Tymlos (PDF 71.83 KB)
  • Uloric (PDF 89.18 KB)
  • Valchlor (PDF 46.49 KB)
  • Vancocin (PDF 50.35 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Verzenio (PDF 45.84 KB)
  • Votrient (PDF 82.3 KB)
  • Xalkori (PDF 50.15 KB)
  • Xeljanz / Xeljanz XR (PDF 55.79 KB)
  • Xenazine (PDF 58.96 KB)
  • Xifaxan (PDF 93.58 KB)
  • Xopenex Respules (PDF 42.58 KB)
  • Xtandi (PDF 47.1 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 197.74 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 68.44 KB)
  • Zetia (PDF 33.07 KB)
  • Zolinza (PDF 43.77 KB)
  • Zontivity (PDF 44.19 KB)
  • Zydelig (PDF 55.81 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 43.97 KB)
  • Zyvox (PDF 110.09 KB)
  •  


    Developmentally Disabled Program

    Pharmacy Program 

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

    Preferred Drug List (PDL) Search
    Developmentally Disabled Preferred Drug List (PDF 1.06 MB)

     

    Step Therapy Information 

    Step Therapy (PDF 21.02 KB)


    Pharmacy Bulletins

    UnitedHealthcare Community Plan Specialty Pharmacy Program Changes (PDF 246.6 KB) Synagis Enrollment Form (PDF 225.02 KB) 
    Synagis Program (PDF 58.92 KB)
    Synagis Program 5 Doses (PDF 51.26 KB)

     

     

    Clinical Guidelines

    Our Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

     

     

  • Actemra (PDF 56.53 KB)
  • Actimmune (PDF 88.98 KB)
  • ADHD Medications (PDF 60.12 KB)
  • Afinitor (PDF 230.97 KB)
  • Afrezza (PDF 100.39 KB)
  • Aldurazyme (PDF 40.32 KB)
  • Alecensa (PDF 44.85 KB)
  • Alfa Interferons (PDF 107.46 KB)
  • Alinia (PDF 46.99 KB)
  • Ampyra (PDF 89.12 KB)
  • Anthelmintics (PDF 104.39 KB)
  • Anticonvulsants (PDF 55.34 KB)
  • Antipsychotics (PDF 143.47 KB)
  • Antipsoriatic Agents (PDF 56.5 KB)
  • Apokyn (PDF 44.7 KB)
  • Arcalyst (PDF 56.5 KB)
  • Aricept 23mg (PDF 41.77 KB)
  • Austedo (PDF 50.85 KB)
  • Azole Antifungals (PDF 223.95 KB)
  • Benlysta (PDF 47.08 KB)
  • Benznidazole (PDF 41.88 KB)
  • Berinert (PDF 96.91 KB)
  • Biltricide (PDF 44.25 KB)
  • Bosulif (PDF 54.09 KB)
  • Brilinta / Effient (PDF 71.85 KB)
  • Buphenyl (PDF 41.21 KB)
  • Cabometyx (PDF 48.95 KB)
  • Calquence (PDF 42.01 KB)
  • Caprelsa (PDF 100.36 KB)
  • Carbaglu (PDF 102.91 KB)
  • Cayston (PDF 49.03 KB)
  • Celebrex (PDF 48.49 KB)
  • Cesamet / Marinol (PDF 114.74 KB)
  • CGRP (PDF 51.69 KB)
  • Cholbam (PDF 44.64 KB)
  • Cialis for BPH (PDF 45.93 KB)
  • Cimzia (PDF 69.19 KB)
  • Cinryze (PDF 128.47 KB)
  • Ciprodex (PDF 44.65 KB)
  • Colony Stimulating Factors (PDF 164.86 KB)
  • Combination Basal Insulin, GLP-1 Receptor Agonist (PDF 46.99 KB)
  • Cometriq (PDF 90.7 KB)
  • Complera (PDF 96.46 KB)
  • Compounds and Bulk Powders (PDF 82.81 KB)
  • Concentrated Insulins (PDF 43.34 KB)
  • Copper Chelating Agents (PDF 57.65 KB)
  • Corlanor (PDF 47.85 KB)
  • Cosentyx (PDF 50.86 KB)
  • Cotellic (PDF 44.64 KB)
  • Crestor (PDF 112.01 KB)
  • Cystaran (PDF 42.24 KB)
  • Daliresp (PDF 50.17 KB)
  • Daraprim (PDF 68.79 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 52.04 KB)
  • DPP-4 Inhibitors (PDF 52.2 KB)
  • Dry Eye Disease (PDF 52.37 KB)
  • Duopa (PDF 44.89 KB)
  • Dupixent (PDF 59.37 KB)
  • Egrifta (PDF 45.24 KB)
  • Elaprase (PDF 39.2 KB)
  • Elidel / Protopic (PDF 63.24 KB)
  • Elmiron (PDF 44.69 KB)
  • Emflaza (PDF 92.17 KB)
  • Endari (PDF 42.59 KB)
  • Entocort (PDF 45.04 KB)
  • Entresto (PDF 50.89 KB)
  • Epaned (PDF 47.58 KB)
  • Erivedge (PDF 45.27 KB)
  • Eucrisa (PDF 44.36 KB)
  • Evzio (PDF 48.22 KB)
  • Exondys 51 - Drug Policy (PDF 103.09 KB)
  • Fabrazyme (PDF 39.65 KB)
  • Farydak (PDF 48.43 KB)
  • Fenofibrate (PDF 48.37 KB)
  • Fentanyl IR (PDF 58.32 KB)
  • Firazyr (PDF 107.04 KB)
  • Forteo
  • Gattex (PDF 44.12 KB)
  • Gaucher's Disease Agents (PDF 48.84 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 96.12 KB)
  • GLP-1 Agonists (PDF 50.26 KB)
  • Growth Hormone / Growth Stimulating Agents (PDF 191.77 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 92.68 KB)
  • Gout (PDF 46.97 KB)
  • Haegarda (PDF 39.9 KB)
  • HCG (PDF 43.9 KB)
  • Hepatitis C Criteria
  • Hemlibra (PDF 42.77 KB)
  • Hemangeol (PDF 45.4 KB)
  • Hemophilia (PDF 46.74 KB)
  • Hetlioz (PDF 107.21 KB)
  • HIV Medications (PDF 48.58 KB)
  • HP Acthar Repository Corticotropin Injection (PDF 154.66 KB)
  • Humira (PDF 129.67 KB)
  • Hycamtin (PDF 45.7 KB)
  • Ibrance (PDF 102.25 KB)
  • IBS - Diarrhea (PDF 53.49 KB)
  • Iclusig (PDF 51.83 KB)
  • ICS.LABA Combo (PDF 64.72 KB)
  • Idhifa (PDF 43.73 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 50.78 KB)
  • Ilaris (PDF 62.15 KB)
  • Imbruvica (PDF 59.65 KB)
  • Impavido (PDF 66.86 KB)
  • Inderal LA (PDF 41.3 KB)
  • Ingrezza (PDF 47.15 KB)
  • Inhaled Corticosteroids (PDF 52.86 KB)
  • Inlyta (PDF 99.47 KB)
  • Iressa (PDF 52.77 KB)
  • Iron Chelators (PDF 72.6 KB)
  • Irritable Bowl Syndrome-Constipation (PDF 75.48 KB)
  • Isotretinoin (PDF 116.21 KB)
  • Jakafi (PDF 52.28 KB)
  • Juxtapid (PDF 60.57 KB)
  • Kalydeco (PDF 54.92 KB)
  • Keveyis (PDF 43.14 KB)
  • Kevzara (PDF 48.04 KB)
  • Kineret (PDF 62.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 46.19 KB)
  • Kuvan (PDF 43.8 KB)
  • Kynamro (PDF 63.31 KB)
  • Lenvima (PDF 126.69 KB)
  • Lidocaine Patch (PDF 55.41 KB)
  • Lidoderm (PDF 125.01 KB)
  • Long-Acting Opioid Products (PDF 119.06 KB)
  • Lonsurf (PDF 46.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 58.64 KB)
  • Lyrica (PDF 121.26 KB)
  • Lysteda (PDF 45.84 KB)
  • Mekinist (PDF 50.55 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 56.82 KB)
  • Mirvaso (PDF 43.15 KB)
  • Mozobil (PDF 50.89 KB)
  • Multiple Sclerosis (MS) Agents (PDF 63.72 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Myozyme / Lumizyme (PDF 43.17 KB)
  • Mytesi (PDF 42.38 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 48.64 KB)
  • Nerlynx (PDF 42.19 KB)
  • Nexavar (PDF 224 KB)
  • Ninlaro (PDF 46.68 KB)
  • Nityr (PDF 41.22 KB)
  • Non-Preferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 57.52 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 49.18 KB)
  • Nuplazid (PDF 89.32 KB)
  • Overactive Bladder (OAB) Agents (PDF 51.22 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 44.6 KB)
  • Omega (PDF 114.61 KB)
  • Optivar (PDF 44.26 KB)
  • Orencia (PDF 52.01 KB)
  • Orfadin (PDF 42.24 KB)
  • Orkambi (PDF 66.92 KB)
  • Otezla (PDF 49.62 KB)
  • Pulmonary Arterial Hypertension (PAH) Agents (PDF 70.47 KB)
  • Panretin (PDF 47.69 KB)
  • Pomalyst (PDF 47.77 KB)
  • Pradaxa (PDF 68.27 KB)
  • Praluent (PDF 102.63 KB)
  • Procysbi (PDF 101.67 KB)
  • Progesterone (PDF 41.72 KB)
  • Progesterone - Oral (PDF 39.38 KB)
  • Proton Pump Inhibitors (PPI) (PDF 381.09 KB)
  • Promacta (PDF 51.05 KB)
  • Provigil / Nuvigil (PDF 66.39 KB)
  • Pulmozyme (PDF 66.94 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 45.83 KB)
  • Ravicti (PDF 68.11 KB)
  • Rectiv (PDF 42.28 KB)
  • Regranex (PDF 27.13 KB)
  • Relistor (PDF 61.24 KB)
  • Renvela (PDF 45.32 KB)
  • Repatha (PDF 110.22 KB)
  • Revlimid (PDF 138.81 KB)
  • Rhofade (PDF 42.17 KB)
  • Rozerem (PDF 42.42 KB)
  • Rubraca (PDF 46.15 KB)
  • Ruconest (PDF 97.14 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 47.2 KB)
  • Sandostatin (PDF 89.53 KB)
  • Selzentry (PDF 41.73 KB)
  • Sensipar (PDF 48.55 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Short-Acting Opioid Products (PDF 91.64 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 55.17 KB)
  • Simponi (PDF 70.31 KB)
  • Sivextro (PDF 58.21 KB)
  • Soliris - Drug Policy (PDF 89.68 KB)
  • Somavert (PDF 100.05 KB)
  • Soriatane (PDF 73.6 KB)
  • Spinraza - Drug Policy (PDF 122.07 KB)
  • Sprycel (PDF 50.46 KB)
  • Stelara (PDF 63.04 KB)
  • Stivarga (PDF 52.51 KB)
  • Strensiq (PDF 51.19 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (SLIT) (PDF 65.96 KB)
  • Suboxone / Subutex (PDF 54.46 KB)
  • Sutent (PDF 106.77 KB)
  • Symdeko (PDF 69.32 KB)
  • Symlin (PDF 50.06 KB)
  • Synribo (PDF 43.78 KB)
  • Tafinlar (PDF 53.56 KB)
  • Tagrisso (PDF 50.44 KB)
  • Taltz (PDF 64.28 KB)
  • Tarceva (PDF 60.32 KB)
  • Targretin (PDF 46.02 KB)
  • Tasigna (PDF 51.26 KB)
  • Temodar (PDF 65.38 KB)
  • Test Strips (PDF 67.28 KB)
  • Thalomid (PDF 182.93 KB)
  • Tobramycin Inhalation (PDF 55.79 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 53.09 KB)
  • Topical Retinoid Products (PDF 58.68 KB)
  • Tremfya (PDF 56.98 KB)
  • Triptans (PDF 131.79 KB)
  • Tykerb (PDF 54.08 KB)
  • Tymlos (PDF 71.83 KB)
  • Uloric (PDF 89.18 KB)
  • Valchlor (PDF 46.49 KB)
  • Vancocin (PDF 50.35 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Verzenio (PDF 45.84 KB)
  • Votrient (PDF 82.3 KB)
  • Xalkori (PDF 50.15 KB)
  • Xeljanz / Xeljanz XR (PDF 55.79 KB)
  • Xenazine (PDF 58.96 KB)
  • Xifaxan (PDF 93.58 KB)
  • Xopenex Respules (PDF 42.58 KB)
  • Xtandi (PDF 47.1 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 197.74 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 68.44 KB)
  • Zetia (PDF 33.07 KB)
  • Zolinza (PDF 43.77 KB)
  • Zontivity (PDF 44.19 KB)
  • Zydelig (PDF 55.81 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 43.97 KB)
  • Zyvox (PDF 110.09 KB)
  •  


    KidsCare


    Long Term Care

    Pharmacy Program

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

    Preferred Drug List (PDL) Search
    Preferred Drug List (PDF 1.25 MB)

    Preferred Drug List for Complete Care (PDF 1.26 MB) 

    4/1/2018 PDL Update (PDF 216.22 KB)
    1/1/2018 PDL Update (PDF 157.01 KB)
    10/1/2017 PDL Update (PDF 58.09 KB)
    7/1/2017 PDL Update (PDF 132.61 KB)

    Dual Eligible Drug Coverage (Wrap List) (PDF 3.42 MB)


    Step Therapy Program Information

    Step Therapy Policy (PDF 21.02 KB)


    Quantity Limit Initiatives

    Quantity Limit Policy (PDF 20.11 KB)

     

    Pharmacy Bulletins

    UnitedHealthcare Community Plan Specialty Pharmacy Program Changes (PDF 246.6 KB)

     

     

    Clinical Guidelines

    Our Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

     

     

  • Actemra (PDF 56.53 KB)
  • Actimmune (PDF 88.98 KB)
  • ADHD Medications (PDF 60.12 KB)
  • Afinitor (PDF 230.97 KB)
  • Afrezza (PDF 100.39 KB)
  • Aldurazyme (PDF 40.32 KB)
  • Alecensa (PDF 44.85 KB)
  • Alfa Interferons (PDF 107.46 KB)
  • Alinia (PDF 46.99 KB)
  • Ampyra (PDF 89.12 KB)
  • Anthelmintics (PDF 104.39 KB)
  • Anticonvulsants (PDF 55.34 KB)
  • Antipsychotics (PDF 143.47 KB)
  • Antipsoriatic Agents (PDF 56.5 KB)
  • Apokyn (PDF 44.7 KB)
  • Arcalyst (PDF 56.5 KB)
  • Aricept 23mg (PDF 41.77 KB)
  • Austedo (PDF 50.85 KB)
  • Azole Antifungals (PDF 223.95 KB)
  • Benlysta (PDF 47.08 KB)
  • Benznidazole (PDF 41.88 KB)
  • Berinert (PDF 96.91 KB)
  • Biltricide (PDF 44.25 KB)
  • Bosulif (PDF 54.09 KB)
  • Brilinta / Effient (PDF 71.85 KB)
  • Buphenyl (PDF 41.21 KB)
  • Cabometyx (PDF 48.95 KB)
  • Calquence (PDF 42.01 KB)
  • Caprelsa (PDF 100.36 KB)
  • Carbaglu (PDF 102.91 KB)
  • Cayston (PDF 49.03 KB)
  • Celebrex (PDF 48.49 KB)
  • Cesamet / Marinol (PDF 114.74 KB)
  • CGRP (PDF 51.69 KB)
  • Cholbam (PDF 44.64 KB)
  • Cialis for BPH (PDF 45.93 KB)
  • Cimzia (PDF 69.19 KB)
  • Cinryze (PDF 128.47 KB)
  • Ciprodex (PDF 44.65 KB)
  • Colony Stimulating Factors (PDF 164.86 KB)
  • Combination Basal Insulin, GLP-1 Receptor Agonist (PDF 46.99 KB)
  • Cometriq (PDF 90.7 KB)
  • Complera (PDF 96.46 KB)
  • Compounds and Bulk Powders (PDF 82.81 KB)
  • Concentrated Insulins (PDF 43.34 KB)
  • Copper Chelating Agents (PDF 57.65 KB)
  • Corlanor (PDF 47.85 KB)
  • Cosentyx (PDF 50.86 KB)
  • Cotellic (PDF 44.64 KB)
  • Crestor (PDF 112.01 KB)
  • Cystaran (PDF 42.24 KB)
  • Daliresp (PDF 50.17 KB)
  • Daraprim (PDF 68.79 KB)
  • Diclegis (PDF 26.25 KB)
  • Dificid (PDF 52.04 KB)
  • DPP-4 Inhibitors (PDF 52.2 KB)
  • Dry Eye Disease (PDF 52.37 KB)
  • Duopa (PDF 44.89 KB)
  • Dupixent (PDF 59.37 KB)
  • Egrifta (PDF 45.24 KB)
  • Elaprase (PDF 39.2 KB)
  • Elidel / Protopic (PDF 63.24 KB)
  • Elmiron (PDF 44.69 KB)
  • Emflaza (PDF 92.17 KB)
  • Endari (PDF 42.59 KB)
  • Entocort (PDF 45.04 KB)
  • Entresto (PDF 50.89 KB)
  • Epaned (PDF 47.58 KB)
  • Erivedge (PDF 45.27 KB)
  • Eucrisa (PDF 44.36 KB)
  • Evzio (PDF 48.22 KB)
  • Exondys 51 - Drug Policy (PDF 103.09 KB)
  • Fabrazyme (PDF 39.65 KB)
  • Farydak (PDF 48.43 KB)
  • Fenofibrate (PDF 48.37 KB)
  • Fentanyl IR (PDF 58.32 KB)
  • Firazyr (PDF 107.04 KB)
  • Forteo
  • Gattex (PDF 44.12 KB)
  • Gaucher's Disease Agents (PDF 48.84 KB)
  • Genvoya (PDF 100.94 KB)
  • Gilotrif (PDF 97.26 KB)
  • Gleevec (PDF 96.12 KB)
  • GLP-1 Agonists (PDF 50.26 KB)
  • Growth Hormone / Growth Stimulating Agents (PDF 191.77 KB)
  • Gonadotropin Releasing Hormone Agonists (PDF 92.68 KB)
  • Gout (PDF 46.97 KB)
  • Haegarda (PDF 39.9 KB)
  • HCG (PDF 43.9 KB)
  • Hepatitis C Criteria
  • Hemlibra (PDF 42.77 KB)
  • Hemangeol (PDF 45.4 KB)
  • Hemophilia (PDF 46.74 KB)
  • Hetlioz (PDF 107.21 KB)
  • HIV Medications (PDF 48.58 KB)
  • HP Acthar Repository Corticotropin Injection (PDF 154.66 KB)
  • Humira (PDF 129.67 KB)
  • Hycamtin (PDF 45.7 KB)
  • Ibrance (PDF 102.25 KB)
  • IBS - Diarrhea (PDF 53.49 KB)
  • Iclusig (PDF 51.83 KB)
  • ICS.LABA Combo (PDF 64.72 KB)
  • Idhifa (PDF 43.73 KB)
  • Idiopathic Pulmonary Fibrosis (PDF 50.78 KB)
  • Ilaris (PDF 62.15 KB)
  • Imbruvica (PDF 59.65 KB)
  • Impavido (PDF 66.86 KB)
  • Inderal LA (PDF 41.3 KB)
  • Ingrezza (PDF 47.15 KB)
  • Inhaled Corticosteroids (PDF 52.86 KB)
  • Inlyta (PDF 99.47 KB)
  • Iressa (PDF 52.77 KB)
  • Iron Chelators (PDF 72.6 KB)
  • Irritable Bowl Syndrome-Constipation (PDF 75.48 KB)
  • Isotretinoin (PDF 116.21 KB)
  • Jakafi (PDF 52.28 KB)
  • Juxtapid (PDF 60.57 KB)
  • Kalydeco (PDF 54.92 KB)
  • Keveyis (PDF 43.14 KB)
  • Kevzara (PDF 48.04 KB)
  • Kineret (PDF 62.2 KB)
  • Kisqali (PDF 104.06 KB)
  • Korlym (PDF 46.19 KB)
  • Kuvan (PDF 43.8 KB)
  • Kynamro (PDF 63.31 KB)
  • Lenvima (PDF 126.69 KB)
  • Lidocaine Patch (PDF 55.41 KB)
  • Lidoderm (PDF 125.01 KB)
  • Long-Acting Opioid Products (PDF 119.06 KB)
  • Lonsurf (PDF 46.54 KB)
  • Lovenox (PDF 110.44 KB)
  • Lynparza (PDF 58.64 KB)
  • Lyrica (PDF 121.26 KB)
  • Lysteda (PDF 45.84 KB)
  • Mekinist (PDF 50.55 KB)
  • Mepron (PDF 129.08 KB)
  • Migranal (PDF 56.82 KB)
  • Mirvaso (PDF 43.15 KB)
  • Mozobil (PDF 50.89 KB)
  • Multiple Sclerosis (MS) Agents (PDF 63.72 KB)
  • Multaq (PDF 99.24 KB)
  • Myalept (PDF 102.93 KB)
  • Myozyme / Lumizyme (PDF 43.17 KB)
  • Mytesi (PDF 42.38 KB)
  • Namzaric (PDF 87.09 KB)
  • Natpara (PDF 48.64 KB)
  • Nerlynx (PDF 42.19 KB)
  • Nexavar (PDF 224 KB)
  • Ninlaro (PDF 46.68 KB)
  • Nityr (PDF 41.22 KB)
  • Non-Preferred Drugs (PDF 50.86 KB)
  • Non-Solid Dosage Forms (PDF 57.52 KB)
  • Northera (PDF 105.88 KB)
  • Nuedexta (PDF 49.18 KB)
  • Nuplazid (PDF 89.32 KB)
  • Overactive Bladder (OAB) Agents (PDF 51.22 KB)
  • Ocaliva (PDF 88.84 KB)
  • Odomzo (PDF 44.6 KB)
  • Omega (PDF 114.61 KB)
  • Optivar (PDF 44.26 KB)
  • Orencia (PDF 52.01 KB)
  • Orfadin (PDF 42.24 KB)
  • Orkambi (PDF 66.92 KB)
  • Otezla (PDF 49.62 KB)
  • Pulmonary Arterial Hypertension (PAH) Agents (PDF 70.47 KB)
  • Panretin (PDF 47.69 KB)
  • Pomalyst (PDF 47.77 KB)
  • Pradaxa (PDF 68.27 KB)
  • Praluent (PDF 102.63 KB)
  • Procysbi (PDF 101.67 KB)
  • Progesterone (PDF 41.72 KB)
  • Progesterone - Oral (PDF 39.38 KB)
  • Proton Pump Inhibitors (PPI) (PDF 381.09 KB)
  • Promacta (PDF 51.05 KB)
  • Provigil / Nuvigil (PDF 66.39 KB)
  • Pulmozyme (PDF 66.94 KB)
  • Quantity Limits (PDF 54.54 KB)
  • Ranexa (PDF 45.83 KB)
  • Ravicti (PDF 68.11 KB)
  • Rectiv (PDF 42.28 KB)
  • Regranex (PDF 27.13 KB)
  • Relistor (PDF 61.24 KB)
  • Renvela (PDF 45.32 KB)
  • Repatha (PDF 110.22 KB)
  • Revlimid (PDF 138.81 KB)
  • Rhofade (PDF 42.17 KB)
  • Rozerem (PDF 42.42 KB)
  • Rubraca (PDF 46.15 KB)
  • Ruconest (PDF 97.14 KB)
  • Sabril (PDF 48.43 KB)
  • Samsca (PDF 47.2 KB)
  • Sandostatin (PDF 89.53 KB)
  • Selzentry (PDF 41.73 KB)
  • Sensipar (PDF 48.55 KB)
  • SGLT-2 Inhibitors (PDF 166 KB)
  • Short-Acting Opioid Products (PDF 91.64 KB)
  • Signifor (PDF 96.99 KB)
  • Siliq (PDF 55.17 KB)
  • Simponi (PDF 70.31 KB)
  • Sivextro (PDF 58.21 KB)
  • Soliris - Drug Policy (PDF 89.68 KB)
  • Somavert (PDF 100.05 KB)
  • Soriatane (PDF 73.6 KB)
  • Spinraza - Drug Policy (PDF 122.07 KB)
  • Sprycel (PDF 50.46 KB)
  • Stelara (PDF 63.04 KB)
  • Stivarga (PDF 52.51 KB)
  • Strensiq (PDF 51.19 KB)
  • Stribild (PDF 53.53 KB)
  • Sublingual Immunotherapy (SLIT) (PDF 65.96 KB)
  • Suboxone / Subutex (PDF 54.46 KB)
  • Sutent (PDF 106.77 KB)
  • Symdeko (PDF 69.32 KB)
  • Symlin (PDF 50.06 KB)
  • Synribo (PDF 43.78 KB)
  • Tafinlar (PDF 53.56 KB)
  • Tagrisso (PDF 50.44 KB)
  • Taltz (PDF 64.28 KB)
  • Tarceva (PDF 60.32 KB)
  • Targretin (PDF 46.02 KB)
  • Tasigna (PDF 51.26 KB)
  • Temodar (PDF 65.38 KB)
  • Test Strips (PDF 67.28 KB)
  • Thalomid (PDF 182.93 KB)
  • Tobramycin Inhalation (PDF 55.79 KB)
  • Topical Androgens (PDF 145.87 KB)
  • Topical NSAIDs (PDF 53.09 KB)
  • Topical Retinoid Products (PDF 58.68 KB)
  • Tremfya (PDF 56.98 KB)
  • Triptans (PDF 131.79 KB)
  • Tykerb (PDF 54.08 KB)
  • Tymlos (PDF 71.83 KB)
  • Uloric (PDF 89.18 KB)
  • Valchlor (PDF 46.49 KB)
  • Vancocin (PDF 50.35 KB)
  • Vecamyl (PDF 87.26 KB)
  • Veltassa (PDF 89.17 KB)
  • Venclexta (PDF 110.78 KB)
  • Verzenio (PDF 45.84 KB)
  • Votrient (PDF 82.3 KB)
  • Xalkori (PDF 50.15 KB)
  • Xeljanz / Xeljanz XR (PDF 55.79 KB)
  • Xenazine (PDF 58.96 KB)
  • Xifaxan (PDF 93.58 KB)
  • Xopenex Respules (PDF 42.58 KB)
  • Xtandi (PDF 47.1 KB)
  • Xuriden (PDF 88.23 KB)
  • Xyrem (PDF 197.74 KB)
  • Zejula (PDF 92.16 KB)
  • Zelboraf (PDF 68.44 KB)
  • Zetia (PDF 33.07 KB)
  • Zolinza (PDF 43.77 KB)
  • Zontivity (PDF 44.19 KB)
  • Zydelig (PDF 55.81 KB)
  • Zykadia (PDF 98.98 KB)
  • Zytiga (PDF 43.97 KB)
  • Zyvox (PDF 110.09 KB)
  •  


    UnitedHealthcare Dual Complete® (HMO SNP)
    H0321-002

    Pharmacy Program 

    The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete (HMO SNP) H0321-002. 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)

    Submit a Pharmacy Prior Authorization Request to Prescription Solutions.

    Request for Medicare Prescription Drug Determination Request form


    UnitedHealthcare Dual Complete® (HMO SNP)
    H5008-012


    UnitedHealthcare Dual Complete® ONE (HMO SNP)
    H0321-004

    Pharmacy Program

    The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by UnitedHealthcare Dual Complete (HMO SNP) H0321-004. Click on the link below to view the Preferred Drug List.

    Preferred Drug List (PDL) Search