Drug Lists and Pharmacy

The Prescription Drug List (PDL) is a list of prescription medications commonly chosen by doctors and pharmacies. Prescription drug coverage varies by member benefit plan.

• Commercial Prescription Drug List - Effective January 1, 2025open_in_new
• Commercial Prescription Drug List - Effective September 1, 2024open_in_new
• Commercial Prescription Drug List - Effective May 1, 2024open_in_new
• Commercial Prescription Drug List - Effective January 1, 2024open_in_new
  
  
• Community Plan / Medicaid: Visit Health Plans by State > Select State > select "Pharmacy Resources and Physician Administered Drugs" from left navigation
  
  
• Medicare: Medicare Advantage Drug Formulary - UHC.com/medicare (enter zip code, select plan)open_in_new

Prescription Drug List Updates

• Community Plan: Q2 2025 Preferred Drug List Updatesopen_in_new
• Community Plan: Q1 2025 Preferred Drug List Updatesopen_in_new
• Community Plan: Q4 2024 Preferred Drug List Updatesopen_in_new
• Community Plan: Q3 2024 Preferred Drug List Updatesopen_in_new

• Commercial Plan Pharmacy Benefit Coverage Update - Effective January 1, 2025open_in_new
• Commercial Plan Pharmacy Benefit Coverage Update - Effective September 1, 2024open_in_new

• Individual and Family Plans Pharmacy Benefit Coverage Updates
  

• Vital Medication Program - Commercialopen_in_new

• Advantage 3-Tier PDL update summary - Effective May 1, 2025open_in_new
• Advantage 3-Tier PDL update summary - Effective January 1, 2025open_in_new

Temporary Coverage for Drug Shortages

To help address current shortages of drugs that are covered by our plans, we’ve updated our Prescription Drug Lists (PDLs) for all plans to temporarily cover some therapeutic equivalent and alternative medications to ensure member access while the covered drugs are in short supply.

• Temporary Coverage for Drug Shortagesopen_in_new

UnitedHealthcare now offers the option to enroll in emailing clinical information for prior authorization and appeal requests for Medicare pharmacy claims. This process will allow you to send and receive clinical documents in a secure, HIPAA-compliant, electronic environment, allowing you more time with your patients and less time on paperwork.

Video: Learn how to save time by sending and receiving documents electronically

View video transcriptopen_in_new

Review these documents for more information about prior authorization requirements and medical necessity coverage criteria for Part B medications that have utilization management programs in place.

• Medicare Part B Step Therapy Programsopen_in_new
• Medicare Prior Authorization Requirements

Learn more about Medicare Prior Authorization and Notification

These UnitedHealthcare reference documents provide prior authorization, notification and medical necessity coverage criteria for medications with utilization management programs in place.

• Learn more about Commercial Prior Authorization and Medication Notification

UnitedHealthcare’s Step Therapy program helps encourage use of less expensive, but similarly effective medications. Members must try a lower-cost medication (known as step 1) before progressing to a higher-cost alternative (known as step 2).

Find Commercial Pharmacy Specific Step Therapy Programs.

Supply limits are based on several factors including Food and Drug Administration (FDA) approved dosing, medical literature and other supportive and analytic data.

Quantity Duration (QD) limits define the maximum quantity of medications that may be covered in a specified time period. For example, 30 units or 1,000 mg per month.

• Quantity Duration (QD) Supply Limits per Duration Medication Listopen_in_new

Quantity Level Limits (QLLs) define the maximum quantity of medications that may be covered per prescription or copayment. For example, 30 units per prescription.

• Quantity Level Limits (QLL) Supply Limits per Copay Medication Listopen_in_new

Specialty pharmacies focus primarily on specialty medications that need special handling and storage. They can also provide extra services such as clinical support and education for members.

Learn more about the Specialty Pharmacy Program.

Members who have questions about their specialty drug coverage should call the Customer Service number listed on the back of their Medical ID Card.

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

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

• Opioid overutilization prevention and use disorder treatment programs - Quick Reference Guideopen_in_new
• Short-Acting Opioid Review Criteria for Opioid Naive Membersopen_in_new

Resources from UnitedHealthcare and Optum

• Opioid Supply Limits - Greater than 34 Day Supply for Opioids at Retailopen_in_new

Other Resources

• Agency for Healthcare Research and Quality (AHRQ) Interagency Guideline on Prescribing Opioids for Painopen_in_new
• Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain
• Centers for Disease Control (CDC) Fact Sheetopen_in_new
• Centers for Disease Control (CDC) Opioid Overdose Guideline Resourcesopen_in_new

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

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

Other Resources

• Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Painopen_in_new
  
• Centers for Disease Control and Prevention (CDC): CDC Opioid Overdose Guideline Resourcesopen_in_new 

UnitedHealthcare is confronting the opioid epidemic from all angles. We’re joining with care providers and communities to prevent opioid misuse and addiction. Through touch points, we help support safe and appropriate opioid use right from the start.

To help with this effort, we developed the following UnitedHealthcare pharmacy-based programs to align with The Centers for Medicare and Medicaid Services (CMS) Medicare Part D Opioid Overutilization Policy.

These programs are specific to UnitedHealthcare Medicare Advantage and Prescription Drug Plans.

Resources from the Centers for Medicare & Medicaid Services

• Medicare Part D Opioid Policies: Information for Pharmacistsopen_in_new
• Medicare Part D Opioid Policies: Information for Prescribersopen_in_new

The following formularies are unique to individuals covered under The New York State Empire Plan.

• Empire Plan Advanced Flexible Formularyopen_in_new
• Empire Plan Flexible Formularyopen_in_new

Visit the state-specific pharmacy section on the Individual Exchange Plan Information for Providers page for the most current information.

UnitedHealthcare Oxford offers these pharmacy resources to help care providers manage prescription drug coverage and ensure appropriate use of medications for members.

In addition to other applicable clinical programs as noted in the Prior Authorization, Step Therapy, and Specialty Pharmacy sections, the programs below are uniquely for Oxford lines of business.

• Diabetes Medications, DPP4 Inhibitors – Oxfordopen_in_new
• Diabetes Medications, SGLT2 Inhibitors – Oxfordopen_in_new
• Diagnostic Agents PA/Medical Necessity – Oxfordopen_in_new
• Livalo PA/Medical Necessisity - Oxfordopen_in_new
• Triptans Supply Limits - Oxfordopen_in_new
  

Pharmacy Partners and Affiliates

Learn more from these UnitedHealthcare partners and affiliates.

• Optum® Infusion Pharmacy
• UnitedHealthcare Community Plan for Medicaid
  
• UnitedHealthcare Medicareopen_in_new
• UnitedHealthcare Neighborhood Health Partnership
• UnitedHealthcare of the River Valley

Pharmacies and Pricing

• OptumRx Pharmaciesopen_in_new

At Optum® Infusion Pharmacy, our pharmacists, nurses, patient care coordinators and benefits experts deliver full-service acute and chronic specialty infusion care, so you and your patients can focus on treatment, not obstacles.

Licensed in 50 states,open_in_new Optum Infusion Pharmacy serves infusion patients nationwide:

• >50 pharmacy locations
• 50 sterile compounding facilities
• 40 ambulatory infusion suites
• >1,100 Optum-employed nurses

Areas of excellence

• Anti-infectives
• Biologics
• Chemotherapy/oncology
• Inotropics/cardiac therapy
• Parenteral and enteral nutrition
• Hemophilia and Bleeding Disorders
• Immunoglobulin (IVIG and SCIG) therapy across multiple specialties, including:
  • Allergy/Immunology
  • Dermatology
  • Hematology/Oncology
  • Infectious disease
  • Neurology
  • Rheumatology

For IG support, locate an IG care specialistopen_in_new near you.

Top five reasons to refer to Optum Infusion Pharmacy

1. Patient access, safety, convenience and care

We offer home infusion and are adding infusion pharmacy locations, services and nationwide. Choose the most convenient setting for each patient’s medication and dose regimen, whether it’s home infusion or an infusion suite with a reclining chair, television and free Wi-Fi.

Patient safety

Our nurses and infusion staff are specially trained in infusion care.

<0.5% of patients have an adverse event or an unplanned hospitalization due to an infection, adverse drug reaction, vein trauma or other treatment complication.¹

2. Proactive service

We help resolve insurance denials, geographical challenges, cost concerns and more, so that treatment can continue uninterrupted. We’re in-network for most major insurance carriers, and our site-specific teams are experts in regional insurance requirements.

Our experienced appeals team, made up mostly of nurses, overturns 8 out of 10 insurance denials.²

3. Clinical expertise, personalized care

Our pharmacists ensure safe, seamless care whether treatment is administered by a nurse or patients themselves. Disease-specific nurses empower patients and caregivers by educating them on the condition, treatment, self-administration if applicable, and more.

4. Patient comfort and resources

For patients who use home infusion, we ship and, if needed, hand-deliver medication, supplies and instructions to their home. Patients have access to disease-specific education, video libraries of others’ treatment experiences, and 24/7 face-to-face video consultations with a disease-expert clinician.

5. Frequent sales team communication

We stay in direct contact with you while we monitor labs, tolerance, adherence and clinical status throughout treatment.

To learn more about infusion services, visit infusion.optum.comopen_in_new or call 1-877-342-9352.

For hemophilia, call 1-855-855-8754.

For IG, locate a care specialistopen_in_new near you. 

Or, to start referring patients, locate our referral forms. 

References

^1. Optum internal data. 2021.
^2. Optum Specialty Pharmacy. Internal analysis. 2020