UnitedHealthcare Community Plan Preferred Drug List (PDL) - Outpatient Pharmacy Coverage Criteria
Defines the outpatient pharmacy preferred drug list (PDL), selection criteria, exclusions, prior authorization and dispensing rules for UnitedHealthcare Community Plan members covered under the pharmacy benefit.
Policy Summary
PayerUnitedHealthcare
PolicyPreferred Drug List (PDL) — outpatient pharmacy coverage criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization for non‑PDL, SP-designated, PA-flagged, or QL-exceeding medications using the plan's PA form (fax 866-940-7328) and include supporting documentation.
No material clinical or coverage changes in this revision.
one-monthstandard days' supply per prescription
5-dayone-time non-PDL override dispensing supply
4max controlled substance fills in 30 days without PA
quarterlyP&T Committee meetings
800-310-6826PA phone
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866-940-7328Specialty PA fax
Coverage Criteria and General Rules
General coverage criteria — Covered outpatient prescription drugs and usage rules
Covered outpatient prescription drugs and usage rules
ALL of the following
Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines.
Eligibility for outpatient prescription drug benefits is based on the individual member's benefit plan; some items are covered only with prior authorization.
Days supply dispensing limitations: Members may receive up to a one-month supply per prescription order or refill unless an extended days' supply is specifically allowed for certain chronic medications; refill thresholds may vary by plan and by controlled vs non-controlled substances.
Mandatory generic substitution: Generic substitution is required when an FDA-equivalent generic is available; brand-name drugs may be covered only with prior authorization documenting medical necessity.
Quantity limits (QL): Prescriptions for monthly quantities greater than the indicated limit require prior authorization. Quantity limits are established based on FDA dosing and the Efficient Medication Dosing Program to consolidate dosing into the most efficient daily quantity; overrides available via medical exception (PA).
Specialty pharmaceutical management: Injectable specialty medications designated to the Specialty Program require plan authorization and are not available through the retail pharmacy network; providers must submit the Prior Authorization form to the Pharmacy Department (fax 866-940-7328).
Outpatient Prescription Coverage
Outpatient prescription coverage — medically necessary when prescribed by authorized prescriber; PA/formulary rules may apply
ALL of the following
Medications included on the UnitedHealthcare Community Plan PDL are selected for clinical appropriateness and affordability; prescribers should select PDL alternatives when clinically appropriate.
Medications not included on the PDL may be considered medically necessary on a case-by-case basis through the Prior Authorization (PA) process; requests must include supporting clinical documentation and be submitted by the prescribing provider (fax 866-940-7328).
Temporary 5-day supply substitution: For urgent needs, the claims system may allow a one-time 5-day supply of a non-PDL medication; pharmacy must submit the claim as a 5-day supply with PA type '8' and authorization number '00000000120' and contact the prescriber to pursue a PDL alternative or PA as appropriate.
PDL exceptions and PA decisions will be reviewed and responded to in accordance with state requirements; contact Pharmacy Prior Notification Service at 800-310-6826 for assistance.
PDL coverage and exception criteria
PDL coverage and exceptions — covered when plan rules and authorization requirements are met
ALL of the following
The PDL requires mandatory generic substitution for the majority of products; brand products are not included on the standard PA list when an equivalent generic is covered.
Non-preferred (Tier 2) agents and certain products on the PDL may be subject to utilization management controls including Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Specialty (SP) routing, Diagnosis requirement (DXZRX), and age limits (AL).
When a PDL alternative is available, pharmacists should contact the prescriber to request a change; if a PDL alternative is not appropriate, the prescriber may submit a PA request with documentation supporting medical necessity.
PDL-listed specialty drugs are designated with 'SP' and require specialty program routing and prior authorization; preferred and non-preferred agents lists (Tier assignments) and accompanying flags (PA, QL, ST, etc.) dictate coverage pathways.
Controlled Substances Limits
Controlled Substances Limits — fills and limits
ALL of the following
Controlled substances fills and limits: Members may fill up to four medications from specified controlled substance classes within any 30-day period without prior authorization. The specified classes include sedative-hypnotic agents, barbiturates, and select muscle relaxants.
Additional fills beyond the four-medication/30-day limit require prior authorization. Medications in these classes may also be subject to individual quantity limits in the claims processing system.
Pharmacies and prescribers should check member-specific plan rules for controlled-substance refill thresholds and any plan-level restrictions; contact Pharmacy Prior Notification Service at 800-310-6826 with questions.
Prior authorization (PA) is required for certain branded or non-PDL medications, specialty injectables, and for prescriptions exceeding quantity limits; PA requests should be submitted using the plan PA form (fax 866-940-7328).
Step Therapy (ST): Specific PDL drugs require documented trials of designated first-line agents for specified durations before coverage of the step agent will be approved (examples include 30-day or 90-day trials as listed on the PDL).
See PDL for drug-specific ST requirements (e.g., Advair HFA 30-day ICS trial or 30-day LABA or inhaled anticholinergic trial; Aricept 23 mg requires 90-day trial of 10 mg).
Quantity Limits (QL) and Efficient Medication Dosing: QLs are enforced in the claims system to consolidate dosing; prescriptions exceeding monthly QLs require PA. The Efficient Medication Dosing Program sets limits based on FDA-approved dosing and tablet/capsule consolidation.
Formulary Codes, Tiers, and Refill Metrics
Formulary agents and plan flagsmixed
INVEGA HAFYERA
Tier 2; PA; QL; AL
INVEGA SUSTENNA
Tier 2; DXZRX; ST; QL; AL
INVEGA TRINZA
Tier 2; PA; QL; AL
RISPERDAL ORAL TABLET 0.5 MG, 7 MG, 2 MG, 3 MG
Tier 2; PA; QL; AL
lurasidone hcl (generic for LATUDA)
Tier 1; QL; AL
olanzapine oral (generic for ZYPREXA)
Tier 1; QL; AL
PERSERIS
Tier 2; ST; QL; AL
SAPHRIS (asenapine maleate)
Tier 1: Generic; Tier 2: Brand; Available without PA for participating Behavioral Health Prescribers; AL
RISPERDAL CONSTA suspension (multiple strengths)
Tier 2 or Tier 1 depending on form; DXZRX; PA; ST; QL; AL
risperidone oral solution
Tier 1; Members >= 8 years of age will require PA; QL; AL
1–10 of 11
1/2
Formulary control codesmixed
DXZRX
Diagnosis Required
PA
Prior Auth Required
QL
Quantity Limit
SP
Specialty Medication
ST
Therapy Step
AL
Age Limitation
Formulary entries (no explicit CPT/HCPCS/ICD-10 codes in this excerpt)mixed
No codes listed
Preferred CPT-like drug listings (antibacterials)NDCCovered
Listed products (no procedure or billing codes present in excerpt)mixed
No codes listed
Refill utilization thresholds
Refill utilization threshold (controlled substances)Refills allowed when 90% of original supply has been utilized
Refill utilization threshold (non-controlled)Refills allowed when 85% of original supply has been utilized
Days supply limit per prescriptionStandard dispensing up to a one-month supply per prescription
Refill timing thresholds
Controlled substances — early refill timingClaim will reject if submitted before 90% of the controlled substance supply has been used
Prior Authorization, Documentation, Step Therapy, and Billing Actions
Prior Authorization
Prior Authorization, Documentation, Step Therapy, and Billing Actions
Prior authorization (PA) may be required for many outpatient prescription drugs depending on the member's benefit plan. Drugs designated as PA on the PDL, non‑PDL (non‑preferred) drugs, Tier 2/brand agents, specialty (SP) agents, and agents flagged with age (AL), diagnosis required (DXZRX), quantity limits (QL), or step therapy (ST) indicators will be denied at point of sale or by claims adjudication if PA or other conditions are not met.
PA is required for medications marked "PA" on the formulary and for many Tier 2 (brand) and SP (specialty) agents.
Non‑PDL (non‑preferred) medications: prescribers must submit a PA request with supporting documentation. A one‑time 5‑day (or 3‑day/5‑day depending on booklet version) temporary supply override is allowed at the point of sale using PA Type 8 and Prior Authorization number "00000000120" when immediate therapy is needed; pharmacies should then obtain a PA for ongoing therapy.
Specialty injectable medications (SP) require plan authorization and are not available via retail pharmacies; providers must fax the specialty PA form to the Pharmacy Department (fax below).
Controlled substances: dispensing more than four medications from listed controlled substance classes (e.g., sedative‑hypnotics, barbiturates, select muscle relaxants) within a 30‑day period requires prior authorization; these agents may also be subject to individual quantity limits.
Quantity limits (QL): monthly quantities exceeding published QL require PA (medical exception) and may be denied without approval.
Initial Trial and Product-Specific Requirements
General outpatient pharmacy coverage
Covered when ALL of the following are met
PDL coverage prerequisites: (1) Drug is prescribed by a provider licensed to prescribe legend drugs; (2) Drug is listed on the member's pharmacy benefit or has an approved prior authorization if not listed; (3) For specialty/injectable drugs, plan authorization and coordination for delivery are completed where required
Eligibility and PA requirements per member's benefit
Product-specific prior trial requirements
Covered when ALL of the following prior trials or conditions are met as specified for each product:
Inhaled combination products: Require documented 30‑day trials of specified first‑line agents (inhaled corticosteroid OR long‑acting beta2‑agonist OR inhaled anticholinergic) prior to coverage of listed combination inhalers30 days
Step Therapy Requirements and Tables
PDL placement influence
How placement affects coverage
PA / Step implications
P&T Committee review of new-to-market drugs
Drugs reviewed relative to similar agents on the PDL to promote clinically useful, cost‑effective options
Placement on PDL may require use of preferred agents first; exceptions via prior authorization
Therapeutic class comparisons during selection
Committee may delete or retain agents based on comparative safety, efficacy, and pharmacoeconomics
Non‑PDL or non‑preferred placement often triggers PA for brand requests and may invoke step therapy (ST) edits
Preference for generics (Tier 1) when available
Generics are preferred first‑line; branded equivalents often placed Tier 2
Brand coverage requires PA documenting medical necessity unless prescriber is participating behavioral health provider for select agents
Product / Example
Documented first-line trial required
Minimum duration / notes
Advair HFA
Trial of a listed first-line agent (inhaled corticosteroid OR long-acting beta2-agonist OR inhaled anticholinergic)
30-day trial of one listed first-line agent
Symbicort / Dulera
Trial of a listed first-line agent (inhaled corticosteroid OR long-acting beta2-agonist OR inhaled anticholinergic)
30-day trial of one listed first-line agent
Aricept 23 mg
Trial of donepezil 10 mg daily
90-day trial required prior to coverage
Uloric
Trial of allopurinol up to specified dose
8‑week trial of up to 600 mg allopurinol required first
Document topical corticosteroid trial; age limits apply for some agents
Vancomycin oral (VANC0CIN)
ST noted on some vancomycin entries
Requires prior metronidazole fill or trial per entry
ST flag entry
Typical meaning
Provider action
Antipsychotic long‑acting injectables annotated with ST (e.g., ABILIFY MAINTENA, ARISTADA, PERSERIS)
Indicates step therapy requirement for coverage of these branded long‑acting products
Document trial/failure of first‑line oral/injectable alternatives per formulary; submit PA if meeting exceptions
Device/specialty listings with ST (e.g., glucose monitoring readers/sensors)
ST may indicate required prior trials or adherence to preferred supplies/formats
Follow per‑line ST and PA instructions for device coverage
ST flag
Applies to
Coverage consequence
ST notation in formulary legend
Applied across multiple therapeutic classes where listed (antipsychotics, inhaled/respiratory combinations, dermatologics, cardiovascular agents)
Where ST is present, coverage requires documented trial/failure of first‑line agents before approving later‑step therapy
Tiering preference (Tier 1 vs Tier 2)
Generics (Tier 1) preferred; branded Tier 2 agents may be subject to ST and PA
Providers should attempt preferred Tier 1 agents first or submit PA documenting necessity
Tiering example
Tier 1 (preferred) vs Tier 2 (brand)
Step/PA implication
Contraceptive examples
Many oral and generic contraceptives listed Tier 1; NUVARING brand is Tier 2
Implied preference: trial of Tier 1 generics before coverage of Tier 2 brand (may require PA)
Antibacterials/Topicals
Topical antibiotics and other antibacterials primarily Tier 1 with some Tier 2 brands
Brand agents placed Tier 2 may require PA or be subject to ST/QL as annotated
Device / supply listings
Preferred device supplies listed Tier 1/2 with ST or QL flags on some entries
Coverage contingent on meeting ST or PA requirements where annotated
Quantity Limits and Refill Policies
Quantity limit enforcement (per QL program)
Monthly quantities > QL limit require PAPrescriptions for monthly quantities greater than the indicated limit require prior authorization per the QL program
Efficient Medication Dosing consolidationQL program consolidates dosing to the most efficient daily quantity per FDA dosing; pharmacist may request a new prescription if limit reached
Override pathwayOverrides available via the medical exception (prior authorization) process; contact Pharmacy Prior Notification Service for questions
Efficient dosing / consolidation (PDL drugs)
QL program scope for listed PDL drugsQuantity limits consolidate dosing to the most efficient daily quantity based on FDA dosing and available strengths
Pharmacy prompt on QL reach
Specialty Medication Channels and Distribution
Note
Note
Note
Note
Note
Key Terms and Abbreviations
PDL — definition
PDL definitionPreferred Drug List (PDL): An organized list of drugs by generic name used to guide prescribing under the outpatient pharmacy benefit
Brand names as referenceBrand names are included for product recognition; generics are preferred as first-line when available
PDL organizationThe PDL is organized by therapeutic groups or disease state and indicates applicable formulations/strengths
DESI — definition and coverage note
DESI drugs definitionDESI: Drugs first marketed 1938–1962 that were initially approved for safety only and reviewed under the FDA DESI program for efficacy determinations
Coverage stance for DESIUnitedHealthcare Community Plan does not cover DESI products classified as 'less than fully effective'
PDL Background and Scope
The Preferred Drug List is intended to provide clinically appropriate and cost‑effective outpatient medication options. An independent Pharmacy & Therapeutics (P&T) Committee meets regularly to evaluate drugs for inclusion based on safety, efficacy, indications, administration, outcomes and pharmacoeconomics, and the PDL guides prescribing and utilization under the outpatient pharmacy benefit.
Policy Summary
PayerUnitedHealthcare
PolicyPreferred Drug List (PDL) — outpatient pharmacy coverage criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization for non‑PDL, SP-designated, PA-flagged, or QL-exceeding medications using the plan's PA form (fax 866-940-7328) and include supporting documentation.
Specialty Program (SP): Medications designated 'SP' are managed through the Specialty Pharmaceutical Management Program — injectable specialty medications require plan authorization and are not available via retail pharmacy; if authorized, UnitedHealthcare will coordinate delivery to member or provider.
Denial risk and alternatives: Brand medications with available generics may be denied without a PA documenting medical necessity. DESI ('less than fully effective') products and specified exclusion categories (e.g., anti-obesity agents, cosmetic drugs, vaccines when excluded by the plan, nutritional supplements, blood products, fertility agents) are not covered under the outpatient pharmacy benefit or the PDL.
Non-controlled substances — early refill timingClaim will reject if submitted before 85% of the non-controlled supply has been used
Rejection messageClaims submitted earlier will receive a 'refill too soon' rejection
Refill thresholds (alternate)
Controlled substances — refill thresholdRefills permitted when 90% of original supply used; earlier claims reject as 'too soon'
Non-controlled substances — refill thresholdRefills permitted when 85% of original supply used; earlier claims reject as 'too soon'
Standard days' supplyUp to a one-month supply per prescription
Age thresholds and PA waivers
Age threshold requiring PA for many agentsMembers >= 8 years of age will require prior authorization for specified agents
Behavioral health prescriber waiverPrior authorization not required for ages >= 6 when prescribed by a psychiatric clinician, behavioral health pediatrician, or participating behavioral health provider for listed behavioral health agents
Age flags on formulary linesAL indicator denotes age limits; providers must document member age when AL is present
Dose-specific QL / tiering examples
PIQRAY dose-specific listingPIQRAY listed by daily dose (200 mg / 250 mg / 300 mg) with Tier 2 designation and PA; QL and SP apply
LUMAKRAS dose-specific listingLUMAKRAS oral tablet 120 mg and 320 mg listed separately with Tier 2; PA; SP; QL
Dose/formulation-dependent QL/tieringQuantity limits and tier/PA/SP flags vary by formulation and dose as annotated per product line
Step therapy (ST): medications annotated with ST require documented trial and failure of specified first‑line agents (see Step Therapy rules) before approval; some antipsychotic long‑acting injectables and other select agents carry ST flags.
Generic substitution: generics are required when available; brand products may be denied unless PA documents medical necessity.
Age and diagnosis flags (AL, DXZRX): when AL or DXZRX appear, age or diagnosis must be documented on the PA or claim; some antipsychotics and other agents require PA for members above/below certain ages.
Documentation: PA requests for non‑PDL, brand, or unlisted drugs must include clinical justification and supporting medical records demonstrating medical necessity and prior trials when applicable.
Providers may submit suggestions for PDL additions with supporting clinical literature to the Director of Pharmacy Services (contact below).
Documentation Required
PA Submission and Temporary Override Procedures
How to submit prior authorization requests and temporary override procedures:
Use the UnitedHealthcare Community Plan prior authorization request form (available in the provider manual) and submit with supporting clinical documentation.
Fax PA requests to UnitedHealthcare Community Plan Pharmacy Services Department: 1-866-940-7328.
Phone Pharmacy Services for PA assistance: 1-800-310-6826.
Non‑PDL immediate need: pharmacy may process a one‑time temporary 5‑day supply override (PA Type 8; Prior Authorization number "00000000120"); follow up with physician‑submitted PA for continuation.
Specialty injectable drugs: submit the specialty PA form by fax to 1-866-940-7328; if authorized, UnitedHealthcare will coordinate delivery to the member or provider.
Documentation Required
Required Documentation and Clinical Evidence
Documentation and evidence requirements for PA and non‑PDL requests:
Provide clinical records, prior treatment history, rationale why PDL alternatives are inappropriate, and any relevant diagnostic information to support medical necessity.
When DXZRX (Diagnosis Required) or AL (Age Limit) flags apply, include the member's diagnosis and age on the PA request and claims.
For step therapy (ST) requirements, document the trial duration and outcome of first‑line agents (e.g., 30‑day inhaled corticosteroid trial for certain inhaled products; 90 days where specified).
Quantity limit (QL) overrides require clinical justification and must be requested via the medical exception (PA) process.
Denial Risk
Denial Risks and Utilization Management Triggers
Provider actions and utilization management triggers that may cause claim denial or delay:
Claims may be denied if a PA is required but not obtained for PA‑flagged, Tier 2, SP, AL, DXZRX, QL, or ST items.
Brand products may be denied if a therapeutically equivalent generic exists and PA does not document medical necessity.
Early refill edits: controlled substances reject if refill submitted before 90% of original supply used; non‑controlled medicines reject before 85% used.
Quantity limit exceedances will reject unless an approved PA/medical exception is on file.
Tier 2 / Non‑Preferred status frequently triggers PA or step requirements; review formulary flags before prescribing or dispensing.
Prior Authorization
Behavioral Health and Specialty Drug Requirements
Special considerations for antipsychotics, behavioral health, and specialty drugs:
Many antipsychotic brand formulations are flagged for PA, DXZRX, QL, AL, and/or ST; members >= 8 years of age often require PA for certain antipsychotics unless prescribed by participating behavioral health prescribers—confirm flags on the PDL.
Long‑acting injectable antipsychotics may carry ST or PA flags and require documentation of prior trials or behavioral health prescriber status for expedited access.
Specialty agents (SP), including many oncology, biologic, and orphan drugs, generally require PA and may require coordination through the Specialty Pharmaceutical Management Program.
Note
Contacts and PDL Suggestion Process
Provider resources, PDL suggestions, and contact points:
To suggest additions or changes to the PDL, providers should send clinical literature and rationale to the Director of Pharmacy Services (address and fax in provider manual).
For PA forms, status, or specialty program questions call Pharmacy Services at 1-800-310-6826 or fax requests to 1-866-940-7328.
Pharmacies should contact Pharmacy Services at 1-800-310-6826 for assistance with temporary overrides or provider outreach.
Examples: Advair HFA, Symbicort, Dulera
Aricept 23 mg prerequisite: Requires a 90‑day trial of Aricept (donepezil) 10 mg daily prior to coverage of Aricept 23 mg90 days
Per PDL step therapy entries
Topical calcineurin and vitamin D analogs: Certain topical agents (e.g., calcipotriene, calcitriol, Elidel, tacrolimus) require trials of topical corticosteroids (and age minimums where specified) prior to coveragevaries (age limits as noted)
Elidel minimum age 2 years; tacrolimus strength‑specific age limits
Fenofibrate: Require either a recent statin fill or 90 days of gemfibrozil within the prior 180 days before coverage of fenofibrate90 days within 180 days
Per PDL step therapy entries
Formulary coverage and restrictions
Covered status and restrictions are indicated per listed agent with tier and plan flags
Formulary placement and flags: Agents are assigned Tier 1 (generic) or Tier 2 (brand) and may carry utilization flags: PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy), SP (Specialty), AL (Age Limit), DXZRX (Diagnosis Required)
See formulary line items for per‑agent flags
Age‑based PA rules: Some agents require prior authorization for specified member ages (for example, members >= 8 years for selected behavioral health agents); PA may be waived for ages >=6 when prescribed by participating behavioral health prescribersage thresholds as noted
See individual agent entries
Brand coverage vs generic: When a therapeutically equivalent generic is available, generic must be used; brand products will require prior authorization documenting medical necessity to be covered
Pharmacy should contact prescriber to switch to PDL alternative
Formulary tier and utilization control rules
Formulary coverage and utilization controls apply as follows:
Tiering and utilization controls: Drugs are assigned to Tier 1 (preferred generics) or Tier 2 (non‑preferred brands) and may include flags that impose utilization controls: PA, QL, ST, SP, AL, DXZRX; coverage requires meeting the indicated controls for each agent
Examples and flags are listed per formulary line
Claims processing system will prompt pharmacist to request a new prescription order when QL is reached
PA for exceptionsOverrides to QL are available through prior authorization (medical exception)
Controlled substance class limits
Controlled substance fills without PAA member may fill up to four medications from specified controlled substance classes in a 30-day period without prior authorization
Classes includedClasses include sedative hypnotic agents, barbiturates, and select muscle relaxants
Additional fills require PAAdditional fills beyond four in 30 days require prior authorization and may be subject to individual QLs
PDL medications with monthly QL
Monthly QL indicated on PDL linesMany PDL-listed medications have monthly quantity limits; quantities exceeding these limits require prior authorization
Provider notification of QL additionsAdditions to the QL program drug list will be made periodically and providers will be notified
Contact for QL questionsContact Pharmacy Prior Notification Service at 800-310-6826 for QL questions or PA assistance
Standard supply per prescriptionMembers may receive up to a one-month supply of a medication per prescription order or refill
Reorder/refill timingRefill allowed when 90% (controlled) or 85% (non-controlled) of prior supply has been used
Call for helpCall Pharmacy Department at 800-310-6826 for questions or dosage change authorization
Monthly QL enforcement (applies to listed QL drugs)
Monthly quantities > indicated limit require PAFor listed QL drugs, monthly quantities greater than the indicated limit require prior authorization
Pharmacy claims enforcementClaims processing system enforces monthly QL limits and will prompt pharmacist when limits are reached
Override via PAMedical exception (PA) available for patient‑specific variables
Exceeds monthly quantity limit — PA required
Exceeding monthly QL requires PAIf a prescription exceeds the monthly quantity limit indicated for a PDL item, prior authorization is required
Efficient dosing rationaleQLs set per FDA dosing and availability of total daily dose in fewest tablets/capsules
Contact for assistancePharmacy Prior Notification Service at 1-800-310-6826 for QL or PA assistance
Exceeding monthly QL (PDL items)
Exceeds monthly quantity limit — PA requiredProducts flagged with QL on formulary lines require prior authorization if monthly quantity limits are exceeded
QL flag meaningQL indicates quantity limits apply to that product line
Overrides via PAOverrides available through prior authorization (medical exception)
Multiple antipsychotics — QL per product
Antipsychotics — per-product QL indicatedMultiple antipsychotic products include QL annotations; quantity limits apply as shown per product line
ST and AL flags for antipsychoticsSome long‑acting injectables and branded antipsychotics carry ST (step therapy) and AL (age limit) flags requiring compliance
PA requirements by ageMembers >= 8 years may require PA for many antipsychotic agents; participating behavioral health prescribers may have waivers for ages >=6
Multiple listed agents — QL indicated
Multiple agents with QL flagNumerous listed agents across therapeutic classes are flagged QL indicating quantity limits apply
Per-line QL enforcementQuantity limits are applied at the product line level and enforced by claims processing
PA for exceptionsOverrides to QL are available through prior authorization (medical exception)
Per-line numeric QL codesVarious numeric QL codes are applied in the listing for topical products
PA/override pathwayIf monthly quantity exceeds the QL, prior authorization is required
Multiple listed agents — QL flags
Formulary entries flagged QLMultiple agents across sections include QL annotations indicating quantity limits apply
Consult product-specific QLRefer to the product line in the PDL for the specific quantity limit assigned
PA for quantities over QLPrior authorization required for monthly quantities greater than the indicated limit
Multiple agents — QL indicated
Multiple agents — QL indicatedA range of non-preferred and specialty agents are annotated with QL in the formulary listing; quantity limits apply per product
PDL enforces per-dose listingsDose-specific listings (e.g., oncology agents) may have distinct QL per dose/formulation
PA required for QL exceedanceExceeding the per-line QL will require prior authorization
Various listed agents — per-line QL
Per-line QL indicatedVarious listed agents include per-line QL annotations; quantity limits apply as noted for each drug
Coverage depends on meeting controlsCoverage requires adherence to indicated controls (PA, QL, ST, AL, DXZRX) on the product line
PA for exceedanceIf monthly quantity exceeds the QL, prior authorization is required
Multiple listed agents — QL on device/supply lines
Multiple listed agents — QL indicatedProduct listings (including devices and supplies) carry QL flags where shown; quantity limits apply per entry
Device/supply QL enforcementSome devices (e.g., glucose sensors/readers) require PA and have QL or ST flags
Refer to line-item for specificsSee specific PDL line for the numeric QL or PA requirements
Vitamin D / multivitamins — QL
Vitamin D and multivitamin products — QL where annotatedMultiple vitamin D and multivitamin formulations are listed with QL annotations where noted in the PDL
Per-line QL guidanceRefer to each product line for specific quantity limits assigned to vitamin products
Overrides via PAPrior authorization may be requested if patient-specific needs exceed QL
ZOLGENSMA — QL and SP annotations
ZOLGENSMA — QL annotatedZOLGENSMA weight-based presentations are listed with PA; SP; and QL annotations per weight band
Per-presentation limitsEach weight-based presentation has its own listing and associated utilization controls
PA and specialty routingZOLGENSMA requires prior authorization and specialty pharmacy handling (SP)
Product-specific QL designations
Product-specific QL designationsVarious listed products include QL flags; consult the PDL line for product-specific quantity limits
QL enforcement by claims systemClaims processing enforces QL and will prompt pharmacist when limits are reached
PA available for exceptionsMedical exceptions through prior authorization are available for patient-specific needs
Regulatory contextDESI program reviewed pre-1962 drugs for effectiveness; a few remain classified as less than fully effective pending administrative disposition
PA — abbreviation and usage
PA abbreviationPA = Prior Authorization required
PA legend usagePA is used in the formulary legend to indicate products that require prior authorization
PA forms/contactPA requests and forms are referenced for submitting prior authorization (see specialty PA fax 1-866-940-7328 and Pharmacy contact 1-800-310-6826)
QL — abbreviation and usage
QL abbreviationQL = Quantity Limit
QL legend usageQL indicates quantity limits apply to the product line in the PDL
QL enforcementMonthly quantities greater than the indicated QL require prior authorization
SP — abbreviation and implication
SP abbreviationSP = Specialty Pharmaceuticals (requires program authorization and coordination)
SP designation implicationSP-designated injectable/specialty products require plan authorization and are not available through retail pharmacies
SP submissionPA for SP products must be submitted via the Specialty PA process (fax 1-866-940-7328)
ST — abbreviation and usage
ST abbreviationST = Step Therapy
ST usageST indicates therapy step requirements; items flagged ST require documented trials of specified first-line agents per PDL rules
ST referencesSee Step Therapy section/pages for drug‑specific trial durations and requirements
Therapeutic equivalence / FDA A/B ratings
Therapeutic equivalence noteFDA A/B ratings denote bioequivalence; generics with FDA A ratings are considered therapeutically equivalent to the brand
Generic substitution policyGeneric substitution is required when a therapeutically equivalent generic is available; brand may be covered via prior authorization
Clinical implicationNo additional clinical testing is required when substituting FDA‑equivalent generics
DESI drugs — descriptor and regulatory context
DESI descriptorDESI drugs are those marketed 1938–1962 reviewed under the FDA program for efficacy; some remain 'less than fully effective', and are excluded from coverage
PDL non-coverageUnitedHealthcare Community Plan's PDL does not cover DESI 'less than fully effective' drug products
Regulatory historyThe DESI program reviewed pre-1962 drugs to determine effectiveness for labeled indications
PDL organization and purpose
PDL organizationPDL is organized by therapeutic group or disease state and lists products by generic name; generics are preferred as first-line when available
Formulary flagsFormulary lines include tier and utilization flags (PA, QL, ST, SP, AL, DXZRX) to indicate controls
PDL purposeIntended to provide clinically appropriate and cost-effective medication options under the outpatient pharmacy benefit
DESI — non-coverage note
DESI non-coverage noteUnitedHealthcare Community Plan does not cover DESI products classified as 'less than fully effective'
DESI classificationSome products remain classified as less than fully effective pending final administrative disposition
Provider actionProviders should not expect coverage for DESI 'less than fully effective' products under the PDL
Where shownThese abbreviations appear in the PDL legend and on formulary lines to indicate utilization controls
Reference pagesSee the PDL legend pages for full abbreviation explanations and application
PDL usage and provider guidance
PDL usage by UnitedHealthcare Community PlanPDL lists covered outpatient medications by generic name and indicates included formulations, tiers, and utilization controls
Provider guidancePrescribers should consider generics first-line; non‑PDL or brand alternatives may require prior authorization
PDL review processPDL is reviewed by an independent P&T Committee (meets quarterly) to evaluate inclusion based on clinical and economic criteria
SP designation in PDL — meaning and implication
SP designation meaningSP indicates a medication is part of the Specialty Products program and requires plan authorization and special dispensing coordination
Implication for accessSP-designated injectables are not available through retail pharmacies; plan will coordinate delivery if authorized
Submission pathwayProviders must submit PA forms for SP products to the Pharmacy Department (fax 1-866-940-7328)
PA / Prior Authorization — meaning
PA meaningPA = Prior Authorization required (coverage requires prior authorization)
PA triggersPA is indicated per drug line when coverage is conditional on prior authorization
How to submitPA requests should use the plan's PA form and be submitted per instructions (fax/phone provided)
QL / Quantity Limit — meaning
QL meaningQL = Quantity Limit (limits on the amount dispensed in a time period)
QL enforcementPrescriptions for monthly quantities greater than the indicated QL require prior authorization
QL noted on formulary linesQL appears on product lines to signal the presence of quantity limits
ST / Step Therapy — meaning
ST meaningST = Step Therapy (therapy step requirement) — items flagged 'ST' require documented trials of specified first-line agents
ST enforcementCoverage requires adherence to the specified step trial durations and documented failure/intolerance where applicable
See PDL for detailsDrug-specific ST requirements and trial durations are listed in the Step Therapy section of the PDL
AL / Age Limit — meaning
AL meaningAL = Age Limit; indicates product is limited to members of a certain age
Age-based PA examplesSome agents list AL with PA requirements (e.g., members >=8 years may require PA for certain agents)
Documentation requiredProviders must document member age when AL is present on a formulary line
DXZRX — Diagnosis required
DXZRX meaningDXZRX = Diagnosis Required for coverage (a diagnosis must be documented when DXZRX is indicated)
DXZRX usageDXZRX appears on formulary lines where a documented diagnosis is required for coverage
Claim documentationWhen DXZRX is present, diagnosis must be documented on the claim or prior authorization submission
PA — alternate description
PA (alternate chunk) — meaningPA indicates prior authorization is required for the product and may be submitted via fax to the Pharmacy Department
PA effect on coverageItems marked PA will be denied without an approved prior authorization
Contact informationPharmacy Services telephone and fax are provided in the document for PA submissions and assistance
QL — alternate description
QL (alternate chunk) — meaningQL indicates quantity limits apply; monthly quantities greater than the indicated limit require prior authorization
QL enforcement noteClaims processing enforces QL and may prompt pharmacist to request a new prescription when limits are reached
Overrides via PAMedical exceptions are handled through prior authorization
AL — alternate description
AL (alternate chunk) — meaningAL indicates an age limitation applied to the product line; providers must verify member age for coverage
Age-based controlsAL often accompanies PA or QL flags to define age-specific coverage conditions
Documentation requirementMember age must be documented when AL applies
SP — alternate description
SP (alternate chunk) — meaningSP = Specialty Medication; products so designated require plan authorization and special dispensing coordination
SP implicationsSP items are not available through retail pharmacies and require coordination if authorized
Submission pathwayPA forms for SP items should be faxed to the Specialty Pharmacy contact as noted
Usage on formulary linesThese abbreviations are used throughout the PDL to signal utilization management controls
Provider responsibilitiesProviders must follow submission/documentation requirements when these flags are present
PA — alternate chunk
PA (alternate chunk) — requirementPA indicates prior authorization is required and may be submitted via the plan's PA form or fax to Pharmacy Services
ConsequenceItems marked PA will be denied without an approved prior authorization
Contact infoPharmacy Services phone/fax provided for PA submissions and assistance
QL — alternate chunk
QL (alternate chunk) — enforcementQL limits are set based on FDA dosing/consolidation principles; claims processing enforces these limits
Pharmacy promptPharmacy claims system will prompt pharmacist to request a new prescription when QL is reached
Override pathwayOverrides available through medical exception (prior authorization)
ST — alternate chunk
ST (alternate chunk) — meaningST indicates step therapy requirements; products marked ST require compliance with specified first-line trials
Documentation requirementProviders must document trials/failures of required first-line agents per ST rules
See Step Therapy sectionDrug-specific step requirements and durations are listed in the Step Therapy section
SP — alternate chunk
SP (alternate chunk) — meaningSP denotes specialty medication requiring plan authorization and specialty handling
Access implicationSP products are managed via the Specialty Pharmaceutical Management Program and not through retail pharmacy network
PA submissionPA for SP items must follow specialty submission instructions (fax 1-866-940-7328)
AL — alternate chunk
AL (alternate chunk) — meaningAL indicates an age limitation on coverage; providers must ensure member age meets the restriction
Age-based PA examplesExamples include members >=8 years requiring PA for some agents; participating behavioral health prescribers may have waivers for ages >=6
DocumentationMember age must be documented when AL applies
DXZRX — alternate chunk
DXZRX (alternate chunk) — meaningDXZRX = Diagnosis Required; a diagnosis must be documented on the claim when DXZRX is indicated
Formulary usageDXZRX appears on formulary lines where coverage requires documentation of diagnosis
Provider actionInclude diagnosis documentation with PA or on the claim when DXZRX is present
Tier 1 / Tier 2 — generic vs brand
Tier 1 / Tier 2 — generic vs brandTier 1 denotes generic preferred agents; Tier 2 denotes brand (non-preferred) agents and may be subject to PA or QL
Implication for step/PABranded Tier 2 agents are more likely to carry PA, QL, or ST flags compared with Tier 1 generics
Provider guidanceConsider Tier 1 generics first; request PA if brand is medically necessary
PA / QL / DXZRX / SP / AL — utilization abbreviations
Utilization abbreviations summaryPA = prior authorization; QL = quantity limit; DXZRX = diagnosis required; SP = specialty medication; AL = age limit; ST = step therapy
Formulary annotation usageThese abbreviations are used across the PDL to indicate program restrictions and routing
Provider responsibilitiesProviders must meet the indicated controls (PA, QL, ST, AL, DXZRX, SP) to obtain coverage