DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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10<br />
<strong>DRUG</strong><br />
Myambutol 3<br />
Mycobutin 2<br />
nydrazid 3<br />
Paser 3<br />
Priftin 3<br />
Pyrazinamide 1<br />
Rifadin 3<br />
Rifamate 3<br />
Rifampin 1<br />
Rifater 3<br />
Seromycin 3<br />
Trecator 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Azoles - Antifungals<br />
Diflucan (50 mg Tablet,<br />
100 mg Tablet, 200 mg<br />
Tablet, Suspension <strong>for</strong><br />
Reconstitution)<br />
3<br />
Diflucan (150 mg Tablet) 3 QL<br />
Diflucan in Iso-osmotic<br />
Dextrose<br />
3<br />
Diflucan in nacl<br />
Fluconazole<br />
3<br />
(50 mg Tablet, 100 mg Tablet,<br />
200 mg Tablet, Suspension<br />
<strong>for</strong> Reconstitution)<br />
1<br />
Fluconazole<br />
(150 mg Tablet)<br />
1 QL<br />
Fluconazole in Dextrose 1<br />
Fluconazole in NaCl 1<br />
Itraconazole 1<br />
Ketoconazole 1<br />
nizoral 3<br />
noxafil 4<br />
Sporanox (capsule) 3<br />
Sporanox (Kit) 4<br />
Sporanox (Solution) 3 PA<br />
<strong>DRUG</strong><br />
Sporanox Pulsepak 3<br />
Vfend 4<br />
Vfend IV 4<br />
cephalosporins - Antibiotics<br />
cedax 3<br />
Cefaclor 1<br />
Cefaclor ER 1<br />
Cefadroxil 1<br />
Cefazolin 1<br />
Cefdinir<br />
(Generic <strong>for</strong> Omnicef)<br />
1<br />
cefizox in Dextrose 5% 3<br />
Cefotaxime Sodium 1<br />
cefotetan 3<br />
Cefpodoxime Proxetil 1<br />
Cefprozil 1<br />
ceftin 3<br />
Ceftriaxone in Iso-Osmotic<br />
Dextrose<br />
1<br />
Ceftriaxone Sodium 1<br />
Ceftriaxone/Dextrose 1<br />
Cefuroxime Axetil 1<br />
Cefuroxime Sodium 1<br />
Cefuroxime/Dextrose 1<br />
cefzil 3<br />
Cephalexin 1<br />
cla<strong>for</strong>an 3<br />
cla<strong>for</strong>an Infusion Bottles 3<br />
cla<strong>for</strong>an/D5W Galaxy 3<br />
Duricef<br />
Fortaz (1 gm Solution<br />
<strong>for</strong> Reconstitution, 2 gm<br />
3<br />
Solution <strong>for</strong> Reconstitution,<br />
6 gm Solution <strong>for</strong><br />
Reconstitution)<br />
3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
*For Lower-cost Drug Options see Page 73<br />
PA = Prior Authorization QL = Quantity Limits ST = Step Therapy B/D = Medicare Part B
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