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Clinical Pharmacy Clinical Guidelines & Policies - UnitedHealthcare Community Plan of Arizona

UnitedHealthcare Community Plan’s 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.

These guidelines apply to the following plans:

Arizona AHCCCS Complete Care / Medicaid
Arizona Developmentally Disabled (DD) Program
Arizona Long Term Care

Azelastine Ophthalmic Solution - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Azelastine Ophthalmic Solution,
Actemra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Actemra (tocilizumab) subcutaneous
Acthar Gel - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Actimmune (interferon gamma-1b) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Actimmune (interferon gamma-1b)
ADHD Products - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

ADHD Products (Stimulants and Non-Stimulants). Adderall XR (amphetamine/dextroamphetamine salts extended release) capsule Adderall (amphetamine/dextroamphetamine salts) tablet Aptensio XR (methylphenidate) capsule 24hr Concerta (methylphenidate) ER tablet Daytrana (methylphenidate) patch Dyanavel XR (amphetamine) suspension Focalin XR (dexmethylphenidate extended release) capsule Methylin (methylphenidate) solution Quillichew ER (methylphenidate extended release) chewable tablet Quillivant XR (methylphenidate) suspension Ritalin LA 10mg (methylphenidate ER) capsule Vyvanse (lisdexamfetamine) capsule Vyvanse (lisdexamfetamine) chewable tablet Amphetamine-dextroamphetamine tablets Atomoxetine capsule Clonidine tablet Clonidine extended release tablet (generic Kapvay) Dexmethylphenidate tablet (generic Focalin) Dextroamphetamine tablet Guanfacine extended release tablet Guanfacine tablet Methylphenidate controlled release/ 24 hr tablet Methylphenidate extended release capsule (generic Metadate CD) Methylphenidate extended release tablet (generic Metadate ER) Methylphenidate tablet,
Afinitor (everolimus) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Afrezza - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Afrezza (insulin human)
Aldurazyme - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Alecensa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Alecensa (alectinib)
Alfa Interferons - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.01.2018
Alinia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Alinia (nitazoxanide)
Alunbrig (brigatinib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Alunbrig™ (brigatinib)
Alzheimer's Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Ampyra (dalfampridine) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Anthelmintics - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.01.2018
Anticonvulsants - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Aptiom (eslicarbazepine), Briviact (brivaracetam), Felbatol (felbamate), Fycompa (perampanel), Vimpat (lacosamide), Gabitril (tiagabine), Banzel (rufinamide), Onfi (clobazam), Epidiolex (cannabidiol), Sympazan (clobazam), Sabril, (vigabatrin), Diacomit (stiripentol)
Antidepressants - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Antiemetics - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.15.2019
Antiglaucoma Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.15.2019
Antipsoriatic Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Calcipotriene cream, calcipotriene ointment, calcitriol ointment
Antipsychotics - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Apokyn - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Apokyn (apomorphine HCl injection)
Aquadeks - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Aralast NP - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.18.2019
Arcalyst - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Arikayce - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Austedo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Azole Antifungals - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Sporanox (itraconazole) capsules, Sporanox (itraconazole) oral solution, Onmel (itraconazole) tablets, Vfend (voriconazole) tablets, Vfend (voriconazole) powder for oral suspension, Noxafil (posaconazole) tablets, Noxafil (posaconazole) oral suspension, Cresemba (isavuconazonium) capsules, Tolsura (itraconazole) capsule
Balversa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Balversa (erdafitinib)
Belbuca / Butrans - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Belbuca (buprenorphine hydrochloride film), Butrans (buprenorphine patch, extended-release)
Benlysta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Benlysta (belimumab) *This program applies to the subcutaneous formulation of belimumab
Benznidazole - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Berinert - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Berinert® (C1 esterase inhibitor, human)
Biltricide - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Biltricide (praziquantel),
Bonjesta and Diclegis - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Diclegis (doxylamine/pyridoxine), Bonjesta (doxylamine/pyridoxine extended-release)
Bosulif - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Braftovi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Braftovi (encorafenib)
Breast Cancer - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.18.2019
Brilinta / Effient - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Brilinta (ticagrelor), Effient (prasugrel)
Buphenyl - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Buphenyl (sodium phenylbutyrate) powder for oral solution, Buphenyl (sodium phenylbutyrate) tablets
Cablivi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Cabometyx - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Calquence - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Calquence (acalabrutinib),
Caprelsa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Caprelsa (vandetanib)
Carbaglu.docx, Carbaglu - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Carbaglu (carglumic acid)
Cayston - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Celebrex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Cesamet, Marinol, Syndros - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Cesamet (nabilone), Marinol (dronabinol), Syndros (dronabinol) oral solution
Cesamet, Marinol, Syndros - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2018
CGRP.docx, CGRP - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab)
Cholbam - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Cholbam (cholic acid)
Cialis for BPH - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Cimzia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Cimzia (certolizumab pegol)
Cinryze.docx, Cinryze - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Cinryze® (C1 esterase inhibitor, human)
Ciprodex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
CMV and Herpes Virus Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.18.2019
Colcrys - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.18.2019
Colony Stimulating Factors - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Combination Basal Insulin / GLP-1 Receptor Agonist - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Preferred: Soliqua (insulin glargine/lixisenatide). Non-Preferred: Xultophy (insulin degludec/liraglutide)
Combination DPP4-SGLT2 - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.18.2019
Cometriq (cabocantinib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Cometriq (cabozantinib)
Complement Inhibitors - Soliris - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.04.2020

Complement Inhibitors (Soliris),
Compounds Bulk Powders - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Compounds and Bulk Powders
Concentrated Insulins - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 06.25.2018
Constipation Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Copiktra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Copiktra® (duvelisib)
Copper Chelating Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Copper Chelating Agents [Syprine (trientine), Cuprimine (penicillamine), Depen Titratable (penicillamine)]
Corlanor - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Corlanor® (ivabradine) tablets and oral solution
Cosentyx - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Cosentyx (secukinumab)
Cotellic - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Cotellic® (cobimetinib)
Crestor - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Crestor (rosuvastatin)
Cystaran (cysteamine) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Cystaran (cysteamine) ophthalmic solution
Daliresp - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Daliresp (roflumilast)
Daraprim - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.12.2019
Daurismo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
DDAVP - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.18.2019
Declomycin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.18.2019
Dificid - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Dofetilide - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Doptelet - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Doptelet (avatrombopag)
DPP-4 Inhibitors - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Preferred Products: Tradjenta (linagliptin), Januvia (sitagliptin), Onglyza (saxagliptin), Kombiglyze XR (saxagliptin/metformin extended release), Janumet (sitagliptin/metformin), Janumet XR (sitagliptin/metformin extended-release), Jentadueto (linagliptin/metformin). Non-Preferred Products: alogliptin, alogliptin/metformin, alogliptin/pioglitazone, Jentadueto XR (linagliptin/metformin extended-release).,
Dry Eye Disease - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Duexis and Vimovo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.16.2019
Duopa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Duopa (carbidopa and levodopa) enteral suspension
Dupixent - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Dupixent (dupilumab)
Egrifta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Elidel / Protopic - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Elidel (pimecrolimus) and Protopic (tacrolimus)
Elmiron - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Elmiron (pentosan polysuflate sodium)
Emflaza - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Emflaza (deflazacort)
Emsam - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Enbrel - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Enbrel (etanercept)
Endari - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

L-glutamine powder for solution (Endari),
Entocort - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Entocort EC (budesonide),
Entresto - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Entresto (valsartan-sacubitril)
Epaned - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Epaned (enalapril oral solution)
Eplerenone - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Erivedge - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Erivedge (vismodegib)
Erleada (apalutmide) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Erleada (apalutamide)
Erythropoietic Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Erythropoietic Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Esbriet, Ofev - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Esbriet (pirfenidone), Ofev (nintedanib)
Estrogens - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Etoposide - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Eucrisa.docx, Eucrisa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Eucrisa (crisaborole)
Exondys 51 - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Farydak - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Fasenra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Fasenra Pen™ (benralizumab),
Fenofibrate - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Fentanyl IR - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Abstral (fentanyl sublingual tablets), Actiq (fentanyl transmucosal lozenge), Fentora (fentanyl buccal tablet), Lazanda (fentanyl nasal spray), Subsys (fentanyl sublingual spray), and fentanyl citrate
Firazyr.docx, Firazyr - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Firazyr (icatibant)
Firdapse - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Firdapse (amifampridine)
Flexeril - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Flucytosine - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Forteo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Forteo™ (teriparatide)
Galafold - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Galafold (migalastat)
Gattex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Gattex (teduglutide), for injection, for subcutaneous use
Gaucher’s Disease Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Gilotrif (afatinib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Gilotrif (afatinib)
Gleevec - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Gleevec (imatinib mesylate)
GLP-1 Agonists - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Preferred Products: Victoza (liraglutide), Byetta (exenatide), Bydureon (exenatide extended-release). Non-Preferred Products: Bydureon BCise (exenatide extended-release),Trulicity (dulaglutide), Adlyxin (lixisenatide), Ozempic (semaglutide) , Rybelsus (semaglutide)
Glumetza-Fortamet-Glucophage XR - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Fortamet (metformin extended-release, brand and generic), Glucophage XR (metformin extended-release, brand only) and Glumetza (metformin extended-release, brand and generic)
Glumetza-Fortamet-Glucophage XR - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Gonadotropin-Releasing Hormone Agonists - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Gralise, Horizant - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Haegarda - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.28.2018
HCG - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Hemangeol - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Hemangeol (propranolol hydrochloride oral solution)
Hemlibra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Hemlibra® (emicizumab-kxwh)
Hemophilia Products - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.25.2019
Hepatitis B - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Hepatitis C Criteria - ARIZONA.docx, Hepatitis C Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Hepatitis C Agents Preferred Agents: Mavyret™ (glecaprevir/pibrentasvir) Non-Preferred Agents: Daklinza® (daclatasvir), Epclusa (sofosbuvir/velpatasvir), sofosbuvir/velpatasvir (authorized generic of Epclusa), Harvoni™ (ledipasvir/sofosbuvir), ledipasvir/sofosbuvir (authorized generic of Harvoni), Olysio® (simeprevir), Sovaldi® (sofosbuvir), Technivie™ (ombitasvir, paritaprevir, and ritonavir tablets), Viekira Pak™ (ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir tablets), Viekira XR™ (dasabuvir, ombitasvir, paritaprevir, and ritonavir extended-release tablets), Vosevi™ (sofosbuvir/velpatasvir/voxilaprevir), Zepatier™ (elbasvir/grazoprevir)
Hepatitis-C-Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Preferred Agents: Mavyret™(glecaprevir/pibrentasvir) Sofosbuvir/Velpatasvir (Authorized generic of Epclusa). Non-Preferred Agents: Daklinza® (daclatasvir), Epclusa (sofosbuvir/velpatasvir), Harvoni™ (ledipasvir/sofosbuvir), ledipasvir/sofosbuvir (authorized generic of Harvoni), Olysio® (simeprevir), Sovaldi® (sofosbuvir), Technivie™ (ombitasvir, paritaprevir, and ritonavir tablets), Viekira Pak™ (ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir tablets), Viekira XR™ (dasabuvir, ombitasvir, paritaprevir, and ritonavir extended-release tablets), Vosevi™ (sofosbuvir/velpatasvir/voxilaprevir), Zepatier™ (elbasvir/grazoprevir)
Hetlioz - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Humira - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Humira (adalimumab)
Hycamtin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Hycamtin® (topotecan hydrochloride)
Ibrance - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Iclusig - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Iclusig® (ponatinib)
ICS.LABA Combo- ARIZONA.docx, ICS.LABA Combination Products - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Advair HFA (fluticasone/salmeterol) Dulera (mometasone/formoterol) Symbicort (budesonide/formoterol) Advair Diskus (fluticasone/salmeterol) AirDuo (fluticasone/salmeterol) Breo Ellipta (fluticasone/vilanterol) fluticasone/salmeterol (authorized generic of AirDuo) fluticasone propionate/salmeterol diskus (generic for Advair Diskus) Wixela Inhub (generic for Advair Diskus)
Idhifa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Idhifa (enasidenib)
Idiopathic Pulmonary Fibrosis - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Esbriet (pirfenidone), Ofev (nintedanib)
Ilaris - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Ilaris (canakinumab)
Ilumya - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Ilumya (tildrakizumab-asmn)
Imbruvica - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Imbruvica (ibrutinib)
Immune Globulin (IVIG and SCIG) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Immune Globulin (IVIG and SCIG)
Impavido - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 06.25.2018
Inbrija.docx, Inbrija - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Inbrija (levodopa inhalation powder)
Ingrezza - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Ingrezza (valbenazine)
Inhaled Corticosteroids- ARIZONA.docx, Inhaled Corticosteroids - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

ICS Single Agents. Asmanex Twisthaler (mometasone) Flovent HFA (fluticasone) Pulmicort Flexhaler (budesonide) Budesonide 1mg Respule (generic)
Inlyta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Inlyta (axitinib)
Inrebic - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Insulin Pen Needles and Syringes - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Insulin Pen Needles and Syringes
Iressa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Iressa (gefitinib)
Iron Chelators - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Exjade (deferasirox), Jadenu (deferasirox) tablet, Jadenu (deferasirox) sprinkle, Ferriprox (deferiprone) tablet and oral solution
Irritable Bowel Syndrome - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Isotretinoin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Myorisan (isotretinoin), Claravis (isotretinoin), Amnesteem (isotretinoin), Zenatane (isotretinoin),
Jakafi (ruxolitinib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Juxtapid - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Juxtapid (lomitapide)
Jynarque - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Jynarque (tolvaptan)
Kalydeco - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Kalydeco (ivacaftor)
Keveyis - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Kevzara - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Kevzara (sarilumab)
Kineret - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Kineret (anakinra)
Kisqali - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Kisqali (ribociclib)
Kisqali Femara Co-Pack - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Kisqali Femara Co-Pack (ribociclib/letrozole)
Kisqali Femera Co-Pack - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.21.2018
Korlym - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Kuvan.docx, Kuvan - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Kuvan® (sapropterin dihydrochloride) tablet and powder
LAMA / LABA - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Lenvima - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Lenvima™ (lenvatinib)
Leucovorin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Lidocaine - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Lidocaine Patch - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 06.25.2018
Lokelma, Veltassa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Lokelma-Veltassa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.10.2019
Long-Acting Opioid Products - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Morphine sulfate controlled-release tablets, fentanyl transdermal*, Embeda (morphine sulfate and naltrexone), Xtampza ER (oxycodone extended-release), tramadol extended release tablets (non-biphasic release tablets) Avinza (morphine sulfate extended-release capsules), Exalgo (hydromorphone extended-release), Kadian (morphine sulfate sustained-release capsules), MS Contin [brand name], Opana ERcrush resistant (oxymorphone extended-release), fentanyl transdermal 37.5mcg/hr, 62.5mcg/hr, and 87.5mcg/hr, Zohydro ER (hydrocodone extended-release), oxymorphone ER (generic non-crush resistant), methadone, Arymo (morphine sulfate extended-release tablet) ER, Morphabond ER (morphine sulfate extended-release), Troxyca ER (oxycodone and naltrexone extended-release), Vantrela ER (hydrocodone bitartrate extendedrelease), Hysingla ER (hydrocodone extended release), OxyContin (oxycodone controlled release), Nucynta ER (tapentadol extended release), tramadol extended release capsules, tramadol extended release biphasic release tablets
Lonhala and Yupelri - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.25.2019
Lonsurf - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Lorbrena - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Lorbrena (lorlatinib),
Lucemyra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Lucemyra (lofexidine)
Lynparza (olaparib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Lyrica - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Lyrica capsules, Lyrica Solution, Lyrica CR tablets (pregabalin)
Lysteda - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Lysteda (tranexamic acid)
Makena - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

17-ALPHA-HYDROXYPROGESTERONE CAPROATE (MAKENA AND 17P)
Mavenclad - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Mavenclad (cladribine)
Mayzent - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Mayzent (siponimod)
Mekinist - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Mektovi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Mektovi (binimetinib)
Mepron - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Migranal - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Mirvaso - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Mirvaso (brimonidine topical gel 0.33%)
Mozobil - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Mozobil® (plerixafor) injection
Mulpleta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Mulpleta (lusutrombopag)
Multaq - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Multaq (dronedarone)
Multiple Sclerosis (MS) Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Multiple Sclerosis - Aubagio (teriflunomide), Copaxone (glatiramer acetate), Gilenya (fingolimod), glatiramer acetate, Glatopa (glatiramer acetate), Plegridy (peginterferon β-1a), Tecfidera (dimethyl fumarate), Avonex (interferon β-1a), Rebif (interferon β-1a), Betaseron/Extavia (interferon β-1b), Mayzent (siponimod)
Myalept - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Mytesi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Namzaric - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Namzaric (memantine extended-release/donepezil)
Natpara - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Natpara (parathyroid hormone analog)
Nerlynx - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Nerlynx (neratinib)
Nexavar - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Nexavar (sorafenib tosylate)
Ninlaro - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Nityr - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Noctiva and Nocdurna - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2018
Noctiva and Nocdurna- Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Noctiva (desmopressin acetate), Nocdurna (desmopressin acetate),
Non-Preferred Drugs - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Non-Preferred Drugs
Non-Solid Dosage Forms - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Northera - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Northera (droxidopa),
Nourianz - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Nourianz (istradefylline),
Nubeqa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Nubeqa (darolutamide)
Nucala - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Nucala (mepolizumab) auto-injector and pre-filled syringe
Nuedexta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Nuedexta (dextromethorphan HBr/quinidine)
Nuplazid - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Nuplazid (pimavanserin tartrate)
Nuzyra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Ocaliva (obeticholic acid) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Ocaliva (obeticholic acid)
Odomzo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Odomzo (sonidegib)
Olumiant - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Olumiant (baricitinib)
Omega - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Lovaza (omega-3-acid ethyl esters), Vascepa (icosapent ethyl)
Orencia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Orencia (abatacept) Subcutaneous
Orfadin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Orilissa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Orilissa (elagolix)
Orkambi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Orkambi (lumacaftor/ivacaftor)
Osphena - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Otezla- Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Otezla (apremilast)
Overactive Bladder (OAB) Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Preferred: oxybutynin syrup, oxybutynin tablet, oxybutynin extended-release tablet, Oxytrol for Women (oxybutynin OTC) patch. Preferred with Step Therapy: tolterodine tablet, trospium tablet, Detrol LA (tolterodine) extended-release capsule. Non-Preferred: Oxytrol (oxybutynin Rx) patch, flavoxate tablet, trospium extended-release capsule, Enablex (darifenacin) extended-release tablet, Toviaz (fesoterodine) extended release tablet, Vesicare (solifenacin) tablet, Myrbetriq (mirabegron) extended-release tablet, Gelnique (oxybutynin) topical gel, Ditropan XL (oxybutynin) extended-release tablet, Detrol (tolterodine) tablet,
Oxervate - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
PAH Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Palynziq - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

Palynziq (pegvaliase-pqpz)
Panretin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Panretin® (alitretinoin)
Pediculicides - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Piqray - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Piqray (alpelisib)
Pomalyst (pomalidomide) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Praluent - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Praluent (alirocumab),
Preferred Drugs - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.01.2018
Prevymis (letermovir) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Prevymis (letermovir)
Procysbi (cysteamine bitartrate) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Procysbi (cysteamine bitartrate)
Progesterone - Non-Oral - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Progesterone, Oral - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Promacta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Promacta® (eltrombopag)
Proton Pump Inhibitors (PPI) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Omeprazole capsule [Prilosec], Pantoprazole sodium tablet, Lansoprazole capsule [Prevacid], Esomeprazole magnesium OTC capsule [Nexium] 24 HR ‐ OTC], Esomeprazole magnesium granule [Nexium Granule Suspension], Lansoprazole solutab [Prevacid Solutab]
Provigil, Nuvigil - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Pulmozyme - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Quantity Limits - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Quantity Limits
Ranexa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Ranexa (ranolazine)
Ravicti - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Rayos - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Rayos (prednisone delayed-release tablet)
Rectiv - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Rectiv (nitroglycerin) ointment 0.4%
Regranex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Regranex (becaplermin gel)
Relistor - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

Relistor (methylnaltrexone bromide)
Renvela - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Renvela (sevelamer carbonate) tablets
Repatha - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Repatha (evolocumab),
Revlimid - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Rhofade - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

Rhofade (oxymetazoline) and Mirvaso (brimonidine)
Rinvoq - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Rinvoq (upadacitinib) extended-release tablets
Rozlytrek - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Rozlytrek (entrectinib)
Rubraca - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Rubraca (rucaparib)
Ruconest - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Ruzurgi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

Ruzurgi (amifampridine)
Rydapt (midostaurin) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Rydapt (midostaurin)
Samsca - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Samsca (tolvaptan)
Sandostatin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Sandostatin (octreotide acetate)
Sedative Hypnotics - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Sedative Hypnotics: zolpidem tartrate, suvorexant, estazolam, eszopiclone, flurazepam, triazolam, tasimelteon, temazepam, ramelteon, doxepin 3mg and 6mg only (generic of Silenor), zaleplon,
Sensipar - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Sensipar (cinacalcet)
Serevent Diskus - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
SGLT-2 Inhibitors - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
SGLT-2 Inhibitors - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Invokana (canagliflozin), Farxiga (dapagliflozin), Jardiance (empagliflozin), Invokamet (canagliflozin/metformin), Xigduo XR (dapagliflozin/metformin extended release), Synjardy (empagliflozin/metformin), Invokamet XR (canagliflozin/metformin extended release), Synjardy XR (empagliflozin/metformin extended release), Steglatro (ertugliflozin), Segluromet (ertugliflozin/metformin)
Short-Acting Opioid Products - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.15.2019

Short-Acting Opioids: Includes both brand and generic versions of the listed products unless otherwise noted: All salt forms, single and combination ingredient products, and all brand and generic formulations of the following: Butorphanol nasal spray, codeine, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, pentazocine, tramadol, tapentadol, meperidine, levorphanol tartrate, dihydrocodeine, opium, benzhydrocodone Short-Acting Opioids – Cough and cold products: Includes both brand and generic versions of the listed products unless otherwise noted: Products containing codeine or hydrocodone in combinations with one or more of the following: homatropine, chlorpheniramine, guaifenesin, pyrilamine, brompheniramine, phenylephrine, triprolidine, dexchlorpheniramine, promethazine, pseudoephedrine.
Signifor - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Signifor (pasireotide diaspartate)
Siliq - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Siliq (brodalumab)
Simponi- Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Simponi (golimumab) Subcutaneous
Sivextro - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Sivextro (tedizolid)
Skyrizi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Skyrizi (risankizumab-rzaa) injection
Somavert - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Somavert® (pegvisomant)
Soritane - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Soriatane (acitretin)
Spinraza - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Spravato - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Spravato (esketamine)
Sprycel - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Sprycel (dasatinib)
Stelara - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Stelara (ustekinumab)
Stivarga - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Stivarga (regorafenib)
Strensiq - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Sublingual Immunotherapy (SLIT) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Suboxone - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Suboxone (buprenorphine/naloxone), Zubsolv (buprenorphine/naloxone), Bunavail, (buprenorphine/naloxone), buprenorphine/naloxone tablet
Suboxone / Subutex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Subutex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Subutex (buprenorphine sublingual tablet)
Sucraid (sacrosidase) oral solution - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Sunosi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.31.1969

Sunosi (solriamfetol)
Sutent - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.16.2019
Symdeko - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Symdeko (tezacaftor/ivacaftor)
Symjepi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.31.1969

Symjepi
Symlin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Synagis® (Palivizumab) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Synagis (Palivizumab) ,
Synribo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Synribo (omacetaxine) injection
Tafinlar - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Tagrisso - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Tagrisso™ (osimertinib)
Takhzyro - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

Takhzyro™ (lanadelumab-flyo)
Taltz - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Taltz (ixekizumab)
Talzenna - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Talzenna (talazoparib),
Tarceva - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Tarceva® (erlotinib)
Targretin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Targretin® (bexarotene)
Tasigna - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Tasigna® (nilotinib)
Tavalisse - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Tavalisse (fostamatinib)
Tegsedi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Tegsedi (inotersen)
Temodar - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Temodar (temozolomide)
Test Strips, Blood Glucose - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Thalomid (thalomide)- Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Tibsovo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Tibsovo (ivosidenib)
Tobramycin Inhalation - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 06.17.2019
Topical Androgens - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.01.2018
Topical NSAIDs - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan
Last Published 02.21.2020

Flector Patch (diclofenac epolamine topical patch 1.3%), diclofenac sodium topical gel 1%, Pennsaid (diclofenac sodium topical solution 1.5%, 2%),
Topical NSAIDs.docx, Topical NSAIDs - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Topical Retinoid Products - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.25.2019
Trelegy Ellipta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Trelegy Ellipta
Tremfya - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Tremfya (guselkumab)
Tretinoin Capsules - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.20.2019
Tretinoin Topical - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Tretinoin cream (Retin- A), tretinoin gel (Retin-A)
Triptans - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Triptans
Turalio - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Turalio (pexidartinib)
Tykerb - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Tykerb (lapatinib)
Tymlos (abaloparatide) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Uloric - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

Uloric (febuxostat)
Valchlor - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Valchlor gel for topical use (mechlorethamine)
Vancomycin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Vecamyl - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Vecamyl (mecamylamine)
Vemlidy - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Vemlidy (tenofovir alafenamide)
Venclexta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Verzenio - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Vitrakvi (larotrectinib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Vizimpro - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Vizimpro® (dacomitinib)
Votrient - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Votrient (pazopanib)
Vyndaqel and Vyndamax - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis)
Wakix - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Xalkori (crizotinib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Xeljanz / Xeljanz XR - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.01.2018
Xeljanz and Xeljanz XR - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Xeljanz and Xeljanz XR (tofacitinib)
Xenazine - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.27.2019

Xenazine (tetrabenazine)
Xermelo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Xermelo (telotristat ethyl)
Xifaxan - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Xifaxan (rifaximin),
Xolair - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

Xolair (omalizumab)
Xopenex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Xospata - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Xpovio - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Xpovio (selinexor)
Xtandi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Xuriden - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Xuriden (uridine triacetate)
Xyrem - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Yonsa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Zejula - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Zelboraf - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Zetia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.21.2020

Zetia (ezetimibe),
Zolgensma (Onasemnogene Abeparvovec-Xioi) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2019

Onasemnogene Abeparvovec-Xioi
Zolinza - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.24.2020

Zolinza® (vorinostat)
Zontivity - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Zontivity (vorapaxar)
Zortress - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.20.2019
Zydelig - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.28.2019

Zydelig (idelalisib)
Zykadia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.21.2020

Zykadia™ (ceritinib)
Zytiga - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020
Zyvox - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2020