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

Actemra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
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 09.29.2019

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)
Alecensa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Alinia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Alunbrig (brigatinib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Alunbrig™ (brigatinib)
Ampyra (dalfampridine) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Anticonvulsants - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Antidepressants - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Antipsychotics - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Antipsychotics. Haldol® (haloperidol) concentrate/tablets* Haldol decanoate® (haloperidol decanoate solution)* Loxitane® (loxapine) capsules* Trilafon (perphenazine) tablets* Mellaril® (thioridazine) tablets* Navane® (thiothixene) capsules* Orap® (pimozide) tablets* Prolixin® (fluphenazine hydrochloride) concentrate/elixir/tablets* Prolixin® (fluphenazine decanoate) solution Stelazine® (trifluoperazine) tablets* Thorazine® (chlorpromazine) tablets /solution* Lithium carbonate capsules/tablets Lithium carbonate CR tablet (Lithobid)* Lithium solution Abilify® (aripiprazole) tablets* Clozaril® (clozapine) tablets/orally dispersible tablet * Geodon® (ziprasidone) capsules* Fazaclo (clozapine orally disintergrating tablet) Latuda (lurasidone) tablets Risperdal® (risperidone) oral solution/tablets* Risperdal M-Tab® (risperidone) orally disintegrating tablet* Seroquel® (quetiapine) tablets* Zyprexa® (olanzapine) tablets* Zyprexa Zydis® (olanzapine) orally dispersible tablet* Abilify Maintena ® (aripiprazole) IM injection Aristada (aripiprazole lauroxil) IM injection
Apokyn - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.18.2019
Aquadeks - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
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
Azole Antifungals - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
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 07.17.2019
Benlysta - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
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)
Bonjesta and Diclegis - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 10.01.2018
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 03.31.2019
Buphenyl - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
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 03.31.2019
Caprelsa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.28.2018
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
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 11.30.2018
Cialis for BPH - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Cimzia- ARIZONA.docx, Cimzia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

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
Colony Stimulating Factors - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Combination Basal Insulin / GLP-1 Receptor Agonist - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 06.29.2018
Cometriq (cabocantinib) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Cometriq (cabozantinib)
Complement Inhibitors (Soliris® & Ultomiris™) -Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Copiktra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
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 03.31.2019
Cosentyx - ARIZONA.docx, Cosentyx - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Cosentyx (secukinumab)
Cotellic - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Crestor - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Cystaran (cysteamine) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Cystaran (cysteamine) ophthalmic solution
Daraprim - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.12.2019
Daurismo.docx, Daurismo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Dificid - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Doptelet - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
DPP-4 Inhibitors - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
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 11.30.2018
Dupixent - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
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 11.01.2018
Emflaza - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Enbrel - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Endari - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Entresto - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Epaned - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Erivedge - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Erleada (apalutmide) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
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
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
Fenofibrate - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
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 04.24.2019
Forteo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Gattex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
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)
GLP-1 Agonists - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Preferred Products: Victoza (liraglutide), Byetta (exenatide), Bydureon (exenatide extended-release) Non-Preferred Products: Bydureon BCise (exenatide extended-release),Trulicity (dulaglutide), Adlyxin (lixisenatide), Ozempic (semaglutide)
Glumetza-Fortamet-Glucophage XR - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Glumetza-Fortamet-Glucophage XR - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Growth Hormone / Growth Stimulating Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 06.25.2018
HCG - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Hemlibra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Hemophilia Products - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.25.2019
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)
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 05.24.2019
Hycamtin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
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 01.30.2019
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 12.28.2018
Idiopathic Pulmonary Fibrosis - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Ilaris - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Ilumya- ARIZONA.docx, Ilumya - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Ilumya (tildrakizumab-asmn)
Imbruvica - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Immune Globulin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
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 12.28.2018
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 09.28.2018
Insulin Pen Needles and Syringes - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 02.19.2019
Iressa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Iron Chelators - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Irritable Bowel Syndrome (IBS) Constipation - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Amitiza (lubiprostone), Linzess (linaclotide), Movantik (naloxegol), Trulance (plecanatide), Symproic (naldemedine), Motegrity (prucalopride)
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 07.17.2019
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 11.30.2018
Jynarque.docx, Jynarque - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Jynarque (tolvaptan)
Kalydeco - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.01.2018
Keveyis - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Kevzara- ARIZONA.docx, Kevzara - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Kevzara (sarilumab)
Kineret- ARIZONA.docx, Kineret - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Kineret (anakinra)
Kisqali - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
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
Kynamro - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Lenvima - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Lidocaine - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Long-Acting Opioid Products - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.15.2019

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.docx, Lorbrena - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Lucemyra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
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 12.28.2018
Makena- ARIZONA.docx, Makena - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

17-ALPHA-HYDROXYPROGESTERONE CAPROATE (MAKENA AND 17P)
Mavenclad - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Mayzent - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
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 03.31.2019
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 11.01.2018
Mozobil - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
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 01.30.2019
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 11.30.2018
Nerlynx - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Nexavar - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.28.2018
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
Non-Preferred Drugs - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Non-Preferred Drugs
Non-Solid Dosage Forms - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 05.24.2019
Nuplazid - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.02.2018
Nuzyra - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.31.1969

Nuzyra (omadacycline) oral tablets
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 11.30.2018
Olumiant - ARIZONA.docx, Olumiant - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Olumiant (baricitinib)
Optivar - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Orencia- ARIZONA.docx, Orencia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Orencia (abatacept) Subcutaneous
Orfadin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Orilissa.docx, Orilissa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Orkambi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Osphena - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Otezla- ARIZONA.docx, Otezla- Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Otezla (apremilast)
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 07.19.2019
Palynziq.docx, Palynziq - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Palynziq (pegvaliase-pqpz)
Panretin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
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 01.30.2019
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 03.31.2019
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.docx, Provigil / Nuvigil - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Pulmonary Arterial Hypertension (PAH) Agents - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 06.26.2018
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 11.01.2018
Ranexa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.01.2018
Ravicti - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Regranex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2018
Relistor.docx, Relistor - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Relistor (methylnaltrexone bromide)
Renvela - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.28.2018
Repatha.docx, Repatha - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
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 09.29.2019

Rhofade (oxymetazoline) and Mirvaso (brimonidine)
Rubraca - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan
Last Published 11.30.2018
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 12.31.1969

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 11.30.2018
Sandostatin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Sensipar - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
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 11.30.2018
Siliq - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Siliq (brodalumab)
Simponi- Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

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

Sivextro (tedizolid)
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 11.30.2018
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 07.19.2019
Sprycel - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Stelara - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

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 / Subutex - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
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 05.24.2019
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
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 01.30.2019
Takhzyro - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Takhzyro™ (lanadelumab-flyo)
Taltz - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Taltz (ixekizumab)
Talzenna - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Tarceva - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Targretin - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Tavalisse - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Tegsedi.docx, Tegsedi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Temodar - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
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 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 09.29.2019

Tremfya (guselkumab)
Triptans - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.19.2019
Tykerb - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2018
Tymlos - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Uloric - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Uloric (febuxostat)
UnitedHealth Pharmaceutical Solutions, Tasigna - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Valchlor - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
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)
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.docx, Vitrakvi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Vizimpro - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Votrient.docx, Votrient - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
Vyndaqel and Vyndamax - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis)
Xalkori - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Xeljanz and Xeljanz XR - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Xeljanz and Xeljanz XR (tofacitinib)
Xermelo - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 08.30.2019

Xermelo (telotristat ethyl)
Xolair - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Xolair (omalizumab)
Xospata - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 04.24.2019
Xtandi - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2018
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 09.28.2018
Yonsa.docx, Yonsa - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 03.31.2019
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
Zolinza - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 01.30.2019
Zontivity - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 12.28.2018
Zydelig - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 11.30.2018
Zykadia - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Zykadia™ (ceritinib)
Zytiga (abriaterone acetate) - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 07.17.2019
Zyvox - Clinical Pharmacy Program Guidelines - UnitedHealthcare Community Plan of Arizona
Last Published 09.29.2019

Zyvox (linezolid)

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

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