DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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26<br />
<strong>DRUG</strong><br />
Effexor 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Effexor XR 2 QL<br />
Emsam 3 QL<br />
Fluoxetine HCl 1<br />
Fluvoxamine Maleate 1<br />
Imipramine HCl 1<br />
Imipramine Pamoate 1<br />
Lexapro 2<br />
Limbitrol 3<br />
Limbitrol DS 3<br />
Maprotiline HCl 1<br />
Marplan 2<br />
Mirtazapine 1<br />
nardil 2<br />
Nefazodone HCl 1<br />
norpramin 3<br />
Nortriptyline HCl 1<br />
Pamelor 3<br />
Parnate 3<br />
Paroxetine HCl 1<br />
Paxil 3<br />
Paxil cR 3 QL<br />
Perphenazine/Amitriptyline 1<br />
Pexeva 3<br />
Prozac 3<br />
Prozac Weekly 3 QL<br />
Rapiflux 3<br />
Remeron 3<br />
Remeron Soltab 3<br />
Sarafem 3 QL<br />
Sertraline HCl 1<br />
Surmontil 2<br />
Symbyax 3<br />
Tofranil 3<br />
Tofranil-PM 3<br />
<strong>DRUG</strong><br />
Tranylcypromine Sulfate 1<br />
Trazodone HCl 1<br />
Trimipramine Maleate 1<br />
Venlafaxine HCl 1<br />
Vivactil 2<br />
Wellbutrin 3<br />
Wellbutrin SR 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Wellbutrin XL<br />
(150 mg 24-Hour Tablet)<br />
2 QL<br />
Wellbutrin XL (300 mg<br />
24-Hour Tablet)<br />
3 QL<br />
Zoloft 3<br />
Antimanic Agents - Mood Stabilizers<br />
Lithium Carbonate 1<br />
Lithium Carbonate ER 1<br />
Lithium Citrate (Syrup) 1<br />
Lithobid<br />
Antipsychotic Agents<br />
2<br />
Abilify 3<br />
Abilify Discmelt 3<br />
Chlorpromazine HCl 1<br />
Clozapine 1<br />
clozaril 3<br />
Equetro 2<br />
Fazaclo 2<br />
Fluphenazine Decanoate 1<br />
Fluphenazine HCl 1<br />
Geodon 3<br />
Haldol 3<br />
Haldol Decanoate-50 3<br />
Haldol Decanoate-100 3<br />
Haloperidol 1<br />
Invega 3<br />
Loxapine Succinate 1<br />
Loxitane 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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