DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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42<br />
<strong>DRUG</strong><br />
Levlite-28 3<br />
Levora 0.15/30-28 1<br />
Lo/ovral-28 3<br />
Loestrin 1.5/30-21 3<br />
Loestrin 1/20-21 3<br />
Loestrin 24 Fe 3<br />
Loestrin Fe 1.5/30 3<br />
Loestrin Fe 1/20 3<br />
Low-Ogestrel 1<br />
Lutera 1<br />
Microgestin 1.5/30 1<br />
Microgestin 1/20 1<br />
Microgestin Fe 1<br />
Microgestin Fe 1.5/30 1<br />
Modicon-28 3<br />
MonoNessa 1<br />
Necon 0.5/35-28 1<br />
Necon 1/35-28v 1<br />
Necon 1/50-28 1<br />
Necon 10/11-28 1<br />
Necon 7/7/7 1<br />
Nora-BE 1<br />
nordette-28 3<br />
norinyl 1+35 3<br />
nor-QD 3<br />
Nortrel 0.5/35 (28) 1<br />
Nortrel 1/35 (21) 1<br />
Nortrel 1/35 (28) 1<br />
Nortrel 7/7/7 1<br />
Ogestrel 1<br />
ortho Evra 2<br />
ortho Micronor 3<br />
ortho Tri-cyclen 3<br />
ortho Tri-cyclen Lo 3<br />
ortho-cept-28 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
<strong>DRUG</strong><br />
ortho-cyclen-28 3<br />
ortho-novum 1/35-28 3<br />
ortho-novum 1/50-28 3<br />
ortho-novum 7/7/7-28 3<br />
ovcon-35 3<br />
ovcon-50 28 3<br />
Plan B 3<br />
Portia-28 1<br />
Previfem 1<br />
Quasense 1<br />
Reclipsen 1<br />
Seasonale 3<br />
Seasonique 3<br />
Solia 1<br />
Sprintec 28 1<br />
Sronyx 1<br />
Tri-Legest FE 1<br />
Tri-Levlen 3<br />
Tri-Levlen contract Pack 3<br />
TriNessa 1<br />
Tri-norinyl 28 3<br />
Triphasil 28 3<br />
Tri-Previfem 1<br />
Tri-Sprintec 1<br />
Trivora-28 1<br />
Velivet 1<br />
Yasmin 28 2<br />
Yaz 2<br />
Zovia 1/35E 1<br />
Zovia 1/50E 1<br />
nuvaRing 2<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Estrogen Agonist-Antagonists<br />
Evista<br />
Estrogens<br />
2 QL<br />
Activella 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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