DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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12<br />
<strong>DRUG</strong><br />
E.E.S. 200 1<br />
E.E.S. 400 1<br />
E.E.S. Granules 3<br />
Eryc 3<br />
Eryped 2<br />
Eryped 200 3<br />
Eryped 400 2<br />
Ery-Tab 2<br />
Erythrocin 2<br />
Erythrocin Lactobionate 2<br />
Erythrocin Stearate 1<br />
Erythromycin 1<br />
Erythromycin Base 1<br />
Erythromycin Ethylsuccinate 1<br />
Erythromycin Lactobionate 2<br />
Erythromycin/Sulfisoxazole 1<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Ketek 3 PA, QL<br />
Ketek Pak 3 PA, QL<br />
PcE 3<br />
Pediazole 3<br />
Zithromax (Pack, Solution<br />
<strong>for</strong> Reconstitution,<br />
Suspension <strong>for</strong><br />
Reconstitution)<br />
3<br />
Zithromax (Tablet) 3 QL<br />
Zithromax Tri-Pak 3 QL<br />
Zithromax Z-Pak 3 QL<br />
Zmax<br />
Miscellaneous Antibacterials<br />
3 QL<br />
Baciim 1<br />
Bacitracin (Solution <strong>for</strong><br />
Reconstitution)<br />
3<br />
cleocin (75 mg capsule,<br />
Suppository)<br />
2<br />
cleocin (150 mg capsule,<br />
300 mg capsule, cream)<br />
3<br />
<strong>DRUG</strong><br />
cleocin Galaxy 2<br />
cleocin Pediatric Granules 2<br />
cleocin Phosphate 3<br />
Clindamycin HCl 1<br />
Clindamycin Phosphate 1<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Clindamycin Phosphate<br />
Add-Vantage<br />
1<br />
Colistimethate Sodium 1<br />
coly-Mycin-M 3<br />
cubicin 4<br />
Grifulvin V (Suspension) 3<br />
Grifulvin V (Tablet) 2<br />
Lincocin 3<br />
Polymyxin B Sulfate 3<br />
Synercid 4<br />
Vancocin Hcl (capsule) 4<br />
Vancocin Hcl (Solution) 3<br />
Vancocin Hcl Iso-osmotic<br />
Dextrose<br />
3<br />
Vancomycin HCl 1<br />
Xifaxan 3 QL<br />
Zyvox<br />
Miscellaneous Antifungals<br />
4<br />
Griseofulvin Microsize 1<br />
Gris-Peg<br />
Miscellaneous Anti-Infectives<br />
2<br />
Helidac 3 QL<br />
Pylera 3<br />
Miscellaneous Antimycobacterials -<br />
Drugs to Treat Miscellaneous Infections<br />
Dapsone<br />
Miscellaneous Antiprotozoals<br />
2<br />
Alinia 3 QL<br />
Flagyl 3<br />
Flagyl ER 3<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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