DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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22<br />
<strong>DRUG</strong><br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
norpace cR<br />
(100 mg 12-Hour capsule)<br />
2<br />
norpace cR<br />
(150 mg 12-Hour capsule)<br />
3<br />
Pacerone (100 mg Tablet,<br />
300 mg Tablet)<br />
2<br />
Pacerone (200 mg Tablet) 1<br />
Pacerone (400 mg Tablet) 3<br />
Procainamide HCl 1<br />
Procainamide HCl ER 1<br />
Procainamide HCl SR 1<br />
Procanbid 2<br />
Pronestyl 3<br />
Pronestyl SR 3<br />
Propafenone HCl 1<br />
Quinidine Gluconate 3<br />
Quinidine Gluconate CR 1<br />
Quinidine Gluconate ER 1<br />
Quinidine Gluconate SA 1<br />
Quinidine Sulfate 1<br />
Quinidine Sulfate ER 1<br />
Rythmol 3<br />
Rythmol SR 2<br />
Tambocor 3<br />
Tikosyn 2<br />
Beta-Adrenergic Blocking Agents -<br />
Blood Pressure and Heart Regulation Drugs<br />
Acebutolol HCl 1<br />
Atenolol 1<br />
Atenolol/Chlorthalidone 1<br />
Betapace 3<br />
Betapace AF 3<br />
Betaxolol HCl 1<br />
Bisoprolol Fumarate 1<br />
Bisoprolol Fumarate/<br />
Hydrochlorothiazide<br />
1<br />
<strong>DRUG</strong><br />
cartrol 3<br />
Carvedilol 1<br />
coreg 2<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
coreg cR* 3 QL<br />
corgard 3<br />
corzide 3<br />
Inderal 3<br />
Inderal LA 3<br />
Inderide 40/25 3<br />
Innopran XL 3<br />
Kerlone 3<br />
Labetalol HCl 1<br />
Levatol 3<br />
Lopressor 3<br />
Lopressor HcT 3<br />
Metoprolol Succinate ER 1<br />
Metoprolol Tartrate 1<br />
Metoprolol/<br />
Hydrochlorothiazide<br />
1<br />
Nadolol 1<br />
Pindolol 1<br />
Propranolol HCl 1<br />
Propranolol HCl ER 1<br />
Propranolol/<br />
Hydrochlorothiazide<br />
1<br />
Sectral 3<br />
Sorine 1<br />
Sotalol HCl 1<br />
Sotalol HCl (AF) 1<br />
Tenoretic 50 3<br />
Tenoretic 100 3<br />
Tenormin 3<br />
Timolide 10/25 3<br />
Timolol Maleate 1<br />
Toprol XL 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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