DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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20<br />
<strong>DRUG</strong><br />
Xopenex HFA 2<br />
Vasopressors - Heart Regulation Drugs<br />
Midodrine HCl 1<br />
Proamatine 3<br />
Twinject 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
BLooD FoRMATIon AnD coAGULATIon -<br />
<strong>DRUG</strong>S To TREAT BLooD DISoRDERS<br />
Anticoagulants - Blood Thinners<br />
Arixtra 4 QL<br />
Heparin Sodium 1<br />
Heparin Sodium DCU 1<br />
Heparin Sodium/D5W 1<br />
Heparin Sodium/NaCl<br />
0.45%<br />
1<br />
Innohep 4 QL<br />
coumadin 2<br />
Fragmin 2 QL<br />
Jantoven 1<br />
Lovenox 4 QL<br />
Warfarin Sodium 1<br />
Antihemorrhagic Agents - Drugs to Prevent Bleeding<br />
cyklokapron 2<br />
Antiplatelet Agents - Blood Thinners<br />
Anagrelide HCl 1<br />
Agrylin 4<br />
Persantine 3<br />
Pletal 3<br />
Ticlid 3<br />
Ticlopidine HCl 1<br />
Aggrenox 2 QL<br />
Cilostazol 1<br />
Dipyridamole 1<br />
Plavix 2 QL<br />
<strong>DRUG</strong><br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Hematopoietic Agents - Blood Formation Drugs<br />
Aranesp 4 B/D, PA<br />
Aranesp Albumin Free 4 B/D, PA<br />
Aranesp Albumin Free<br />
Sureclick<br />
Epogen (2000 unit/ml,<br />
4 B/D, PA<br />
3000 unit/ml, 4000 unit/ml<br />
Injectable Solution)<br />
Epogen (10000 unit/ml,<br />
3 B/D, PA, QL<br />
20000 unit/ml, 40000 unit/ml<br />
Injectable Solution)<br />
3 B/D, PA<br />
Leukine 4<br />
neulasta 4<br />
neumega 4<br />
neupogen<br />
Procrit (2000 unit/ml,<br />
4<br />
3000 unit/ml, 4000 unit/ml<br />
Injectable Solution)<br />
Procrit (10000 unit/ml,<br />
3 B/D, PA, QL<br />
20000 unit/ml, 40000 unit/ml<br />
Injectable Solution)<br />
Hemorrheologic Agents -<br />
Blood Thinners<br />
3 B/D, PA<br />
Pentopak 1<br />
Pentoxifylline CR 1<br />
Pentoxifylline ER 1<br />
Pentoxil 1<br />
Trental 3<br />
cARDIoVAScULAR <strong>DRUG</strong>S - <strong>DRUG</strong>S To TREAT<br />
HEART oR cIRcULATIon conDITIonS<br />
Alpha-Adrenergic Blocking Agents -<br />
Blood Pressure Drugs<br />
cardura 3<br />
cardura XL 3<br />
Doxazosin Mesylate 1<br />
Hytrin 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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