DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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14<br />
<strong>DRUG</strong><br />
Amoxil<br />
(250 mg/5ml Suspension <strong>for</strong><br />
Reconstitution, Capsule)<br />
1<br />
Ampicillin 1<br />
Ampicillin-Sulbactam 1<br />
Augmentin 3<br />
Augmentin ES-600 3<br />
Augmentin XR 3<br />
Bactocill in Dextrose 3<br />
Bicillin c-R 2<br />
Bicillin L-A 2<br />
Dicloxacillin Sodium 1<br />
Dispermox 3<br />
Geocillin<br />
Nafcillin Sodium<br />
(1 gm Solution <strong>for</strong><br />
3<br />
Reconstitution, 2 gm<br />
Solution <strong>for</strong> Reconstitution,<br />
10 gm Solution <strong>for</strong><br />
Reconstitution)<br />
1<br />
nallpen Iso-osmotic<br />
in Dextrose<br />
4<br />
nallpen/Dextrose 4<br />
oxacillin Sodium 3<br />
Penicillin G Potassium 1<br />
Penicillin G Potassium in<br />
Iso-Osmotic Dextrose<br />
1<br />
Penicillin G Procaine 3<br />
Penicillin G Sodium 1<br />
Penicillin V Potassium 1<br />
Pfizerpen-G 3<br />
Piperacillin Sodium 3<br />
Timentin 2<br />
Trimox 1<br />
Unasyn 3<br />
Unasyn Add-Vantage 3<br />
Unasyn Bulk Pack 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
<strong>DRUG</strong><br />
Unasyn Piggyback Unit 3<br />
Veetids 1<br />
Zosyn 2<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Polyenes - Antifungals<br />
Abelcet 4<br />
Ambisome 4 B/D<br />
Amphocin 1<br />
Amphotec 3<br />
Amphotericin B 1<br />
Bio-Statin 3<br />
Nystatin<br />
Pyrimidines - Antifungals<br />
1<br />
Ancobon<br />
Quinolones - Antibiotics<br />
4<br />
Avelox (Solution) 2<br />
Avelox (Tablet) 2 QL<br />
Avelox ABc Pack 2 QL<br />
cipro 3<br />
cipro I.V. 3<br />
cipro I.V.-in D5W 3<br />
cipro XR 3<br />
Ciprofloxacin (Injection) 1<br />
Ciprofloxacin ER 1<br />
Ciprofloxacin HCl 1<br />
Factive 3 QL<br />
Levaquin (Solution) 2<br />
Levaquin (Tablet) 2 QL<br />
Levaquin Leva-Pak 2 QL<br />
Levaquin Premix 2<br />
noroxin 3 QL<br />
Ofloxacin 1<br />
Proquin XR 3 QL<br />
Sulfonamides (Systemic) - Antibiotics<br />
Azulfidine 3<br />
Azulfidine En-Tabs 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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