DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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32<br />
<strong>DRUG</strong><br />
Vicoprofen 3<br />
Vopac 2<br />
Xodol 3<br />
Zerlor 1<br />
Zydone 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
opiate Antagonists - narcotic Pain Relievers<br />
Depade 1<br />
Naloxone HCl 1<br />
Naltrexone HCl 1<br />
narcan 3<br />
Revex 3<br />
Revia 3<br />
Vivitrol 4<br />
opiate Partial Agonists - narcotic Pain Relievers<br />
Buprenorphine HCl 1<br />
Butorphanol Tartrate 1<br />
Pentazocine/<br />
Acetaminophen<br />
1<br />
Pentazocine/Naloxone HCl<br />
Selective Serotonin Agonists -<br />
Migraine and Headache Drugs<br />
1<br />
Amerge 3 QL<br />
Axert 3 QL<br />
Frova 3 QL<br />
Imitrex 2 QL<br />
Imitrex Statdose Pen 2 QL<br />
Imitrex Statdose Refill 2 QL<br />
Maxalt 2 QL<br />
Maxalt-MLT 2 QL<br />
Relpax 3 QL<br />
Zomig 3 QL<br />
Zomig ZMT 3 QL<br />
Succinimides - Seizure control Drugs<br />
celontin 2<br />
Ethosuximide 1<br />
<strong>DRUG</strong><br />
Zarontin 3<br />
DEVIcES<br />
Devices<br />
Alcohol Swabs 1<br />
BD Insulin needles, Pens,<br />
1<br />
Syringes, Safety Syringes<br />
Insulin needles, Pens,<br />
Syringes, Safety Syringes 2<br />
(non-BD Brand Products)<br />
Gauze Pads 1<br />
ELEcTRoLYTIc, cALoRIc, AnD<br />
WATER BALAncE<br />
Acidifying Agents<br />
Ammonium chloride<br />
Alkalinizing Agents<br />
3<br />
Potassium Citrate<br />
Extended-Release<br />
1<br />
Urocit-K 5 3<br />
Urocit-K 10<br />
Ammonia Detoxicants<br />
3<br />
Buphenyl (Powder) 4<br />
Buphenyl (Tablet) 3<br />
Constulose 1<br />
Enulose 1<br />
Generlac 1<br />
Kristalose 2<br />
Lactulose 1<br />
Lithostat 3<br />
Diuretics - Drugs <strong>for</strong> Water Balance<br />
Amiloride HCl 1<br />
Amiloride/<br />
Hydrochlorothiazide<br />
1<br />
Bumetanide 1<br />
Bumex 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<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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