DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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30<br />
<strong>DRUG</strong><br />
Astramorph 1<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Avinza 2 QL<br />
Balacet 325 1<br />
Buprenex 3<br />
Butalbital/Acetaminophen/<br />
Caffeine/Codeine<br />
1<br />
Butalbital/Aspirin/Caffeine/<br />
Codeine<br />
1<br />
capital/codeine 2<br />
Co-Gesic 1<br />
combunox 3<br />
Darvocet A500 3<br />
Darvocet-n 50 3<br />
Darvocet-n 100 3<br />
Darvon 3<br />
Darvon-n 3<br />
Demerol 3<br />
Depodur 4<br />
Dilaudid 3<br />
Dilaudid-5 3<br />
Dilaudid-HP 4<br />
Dolacet 1<br />
Dolagesic 1<br />
Dolophine 3<br />
Dolorex Forte 1<br />
Duragesic 3 QL<br />
Duramorph 1<br />
Endocet 1<br />
Eth-Oxydose 1<br />
Fentanyl (Patch) 1 QL<br />
Fentanyl Citrate (Injectable) 1<br />
Fentanyl Citrate Oral<br />
Transmucosal<br />
4 PA, QL<br />
Fentora 4 PA, QL<br />
Fioricet/codeine 3<br />
<strong>DRUG</strong><br />
Fiorinal/codeine #3 3<br />
Hycet 3<br />
Hydrocet 1<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Hydrocodone Bitartrate/<br />
Acetaminophen<br />
1<br />
Hydrocodone/<br />
Acetaminophen<br />
1<br />
Hydrocodone/<br />
Acetaminophen-HS<br />
1<br />
Hydrocodone/Ibuprofen 1<br />
Hydromorphone HCl 1<br />
Infumorph 200 3<br />
Infumorph 500 3<br />
Kadian 2 QL<br />
Levo-Dromoran 3<br />
Levorphanol Tartrate 1<br />
Lorcet 10/650 3<br />
Lorcet Plus 3<br />
Lortab 3<br />
Lortab 2.5 3<br />
Lortab 5 3<br />
Lortab 7.5 3<br />
Lortab 10 3<br />
Lynox 3<br />
Margesic-H 1<br />
Maxidone 3<br />
Meperidine HCl 1<br />
Meperitab 1<br />
Methadone HCl 1<br />
Methadose 1<br />
Morphine/D5W 1<br />
Morphine Sulfate 1<br />
Morphine Sulfate<br />
Add-Vantage<br />
1<br />
Morphine Sulfate<br />
Dilute-A-Jet<br />
1<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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