DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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44<br />
<strong>DRUG</strong><br />
novolin 70/30 2<br />
novolin 70/30 Innolet 2<br />
novolin 70/30 Penfill 2<br />
novolin n 2<br />
novolin n Innolet 2<br />
novolin n U-100 Penfill 2<br />
novolin R 2<br />
novolin R Innolet 2<br />
novolin R U-100 2<br />
novolin R U-100 Penfill 2<br />
novolog 2<br />
novolog FlexPen 2<br />
novolog Mix 70/30 2<br />
novolog Mix 70/30 Penfill 2<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
novolog Mix 70/30 Prefilled<br />
FlexPen<br />
2<br />
novolog Penfill 2<br />
Relion 70/30 3<br />
Relion 70/30 Innolet 3<br />
Relion n 3<br />
Relion n Innolet 3<br />
Relion R<br />
Meglitinides - Diabetes Drugs<br />
3<br />
Prandin 3 QL<br />
Starlix<br />
Miscellaneous Diabetes Drugs<br />
2 QL<br />
Byetta 2 ST<br />
Januvia 3<br />
Janumet 3<br />
Symlin 2 PA<br />
Miscellaneous Antihypoglycemic Agents<br />
Proglycem<br />
Parathyroid<br />
3<br />
Forteo 4 B/D, PA<br />
Fortical 2 QL<br />
<strong>DRUG</strong><br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Miacalcin* (200 unit/ml<br />
Injectable Solution)<br />
3 B/D, PA<br />
Miacalcin* (200 unit/act<br />
nasal Solution)<br />
Pituitary<br />
3 QL<br />
DDAVP 3<br />
Desmopressin Acetate 1<br />
Minirin 1<br />
Stimate<br />
Progestins<br />
4<br />
Aygestin 3<br />
crinone 2<br />
Depo-Provera 2<br />
Depo-Provera contraceptive 3<br />
Depo-Subq Provera 104 3<br />
Endometrin 3<br />
Medroxyprogesterone<br />
Acetate<br />
1<br />
Megace ES 3<br />
Norethindrone Acetate 1<br />
Prochieve 2<br />
Prometrium 2<br />
Provera 3<br />
Somatotropin Agonists - Growth Deficiency Drugs<br />
Genotropin 4 PA<br />
Genotropin Miniquick 4 PA<br />
Humatrope 4 PA<br />
Humatrope combo Pack 4 PA<br />
Increlex 4 PA<br />
Iplex 4 PA<br />
norditropin cartridge 4 PA<br />
norditropin nordiflex 4 PA<br />
norditropin nordiflex Pen 4 PA<br />
nutropin 4 PA<br />
nutropin AQ 4 PA<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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