DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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40<br />
<strong>DRUG</strong><br />
GoLD coMPoUnDS<br />
Gold compounds - Arthritis Drugs<br />
Ridaura 2<br />
HEAVY METAL AnTAGonISTS<br />
Heavy Metal Antagonists<br />
chemet 3<br />
cuprimine 2<br />
Depen Titratabs 2<br />
Exjade 4<br />
Syprine 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
HoRMonES AnD SYnTHETIc SUBSTITUTES<br />
Adrenals - corticosteroids - Anti-Inflammatory Drugs<br />
Aerobid 3<br />
Aerobid-M 3<br />
A-Methapred 1<br />
Aristospan Intra-Articular 3<br />
Aristospan Intralesional 3<br />
Asmanex<br />
14 Metered Doses<br />
2 QL<br />
Asmanex<br />
30 Metered Doses<br />
2 QL<br />
Asmanex<br />
60 Metered Doses<br />
2 QL<br />
Asmanex<br />
120 Metered Doses<br />
2 QL<br />
Azmacort 3<br />
celestone 3<br />
cortef 3<br />
Cortisone Acetate 1<br />
Depo-Medrol<br />
(20 mg/ml Suspension)<br />
2<br />
<strong>DRUG</strong><br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Depo-Medrol<br />
(40 mg/ml Suspension,<br />
80 mg/ml Suspension)<br />
3<br />
Dexamethasone 1<br />
Dexamethasone Intensol 1<br />
Dexamethasone Sodium<br />
Phosphate<br />
1<br />
Dexpak 13 Day 3<br />
Entocort Ec 3<br />
Florinef 3<br />
Flovent HFA 2<br />
Fludrocortisone Acetate 1<br />
Hydrocortisone<br />
(Enema, Tablet)<br />
1<br />
Kenalog-10 2<br />
Kenalog-40 2<br />
Medrol 3<br />
Medrol Dosepak 3<br />
Methylprednisolone 1<br />
Methylprednisolone<br />
Acetate<br />
1<br />
Methylprednisolone<br />
Sodium Succinate<br />
1<br />
orapred 3<br />
orapred oDT 3<br />
Pediapred 3<br />
Prednisone 1<br />
Prednisone Intensol 1<br />
Prelone 3<br />
Pulmicort Respules 3 B/D, PA<br />
Pulmicort Flexhaler 3<br />
QVAR 2<br />
Solu-cortef 2<br />
Solu-Medrol (2 gm Solution<br />
<strong>for</strong> Reconstitution)<br />
2<br />
Solu-Medrol Act-o-Vial 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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