DRUG - UnitedHealthcare MedicareRx for Groups

38
DRUG
Mesalamine 1
Pentasa 3
Rowasa 3
UnitedHealth Rx
for Groups
TIER LIMITS
cathartics and Laxatives - Bowel Treatment Drugs
Amitiza 3 PA,QL
colyte 3
colyte-Flavor Packs 3
Glycolax
Golytely (227.1 gm;
1
2.82 gm; 6.36 gm; 5.53
gm; 21.5 gm Solution for
Reconstitution)
Golytely (236 gm; 2.97 gm;
3
6.74 gm; 5.86 gm; 22.74 gm
Solution for Reconstitution)
2
Halflytely Bowel Prep Kit 2
Moviprep 2
nulytely 2
osmoprep 2
Polyethylene Glycol 3350 1
Polyethylene Glycol 3350/
Electrolytes
1
Trilyte 2
Visicol 2
cholelitholytic Agents - Drugs to Treat Gall Stones
Actigall 3
Urso 250 2
Urso Forte 2
Ursodiol
Digestants - Digestive Enzymes
1
creon 5 2
creon 10 2
creon 20 2
Dygase 3
Enzycap 3
Enzymax 3
DRUG
Kutrase 3
Ku-Zyme 3
Ku-Zyme HP 3
Lapase 3
Lipram 4500 3
Lipram-Pn10 3
Lipram-Pn16 3
Lipram-Pn20 3
Lipram-UL12 3
Lipram-UL18 3
Lipram-UL20 3
Palcaps 10 3
Palcaps 20 3
Palipase 3
Palipase MT 16 3
Palipase MT 20 3
Palpeon DR 10 3
Palpeon DR 20 3
Palpeon MT 20 3
Paltrase V8 3
Pancrease MT 4 3
Pancrease MT 10 3
Pancrease MT 16 3
Pancrease MT 20 3
Pancrecarb MS-4 3
Pancrecarb MS-8 3
Pancrecarb MS-16 3
Pancrelipase 3
Pancrelipase MST-16 3
Pancron 10 3
Pancron 20 3
Pangestyme cn 10 3
Pangestyme cn 20 3
Pangestyme Ec 3
Pangestyme MT 16 3
UnitedHealth Rx
for Groups
TIER LIMITS
*For Lower-cost Drug Options see Page 73
PA = Prior Authorization QL = Quantity Limits ST = Step Therapy B/D = Medicare Part B