DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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50<br />
<strong>DRUG</strong><br />
capex 3<br />
carmol-Hc 3<br />
Cetacort 1<br />
Clobetasol Propionate 1<br />
Clobetasol Propionate E 1<br />
Clobetasol Propionate<br />
Emollient<br />
1<br />
Clobevate 1<br />
clobex 3<br />
cloderm 3<br />
Colocort 1<br />
cordran 3<br />
cordran SP 3<br />
cordran Tape 3<br />
Cormax 1<br />
cortifoam 2<br />
cortisporin<br />
(cream, ointment)<br />
2<br />
cutivate 3<br />
Del-Beta 1<br />
Derma-Smoothe/<br />
FS Body oil<br />
3<br />
Derma-Smoothe/<br />
FS Scalp oil<br />
3<br />
Dermatop 3<br />
Desonate 3<br />
Desonide 1<br />
Desowen 3<br />
Desoximetasone 1<br />
Diflorasone Diacetate 1<br />
Diprolene 3<br />
Diprolene AF 3<br />
Elocon 3<br />
Fluocinolone Acetonide 1<br />
Fluocinonide 1<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
<strong>DRUG</strong><br />
Fluocinonide<br />
Emollient Base<br />
1<br />
Fluocinonide-E 1<br />
Fluticasone Propionate 1<br />
Halobetasol Propionate 1<br />
Halog 3<br />
Hydrocortisone<br />
(Cream, Lotion, Ointment)<br />
1<br />
Hydrocortisone<br />
(Enema, Tablet)<br />
1<br />
Hydrocortisone Butyrate 1<br />
Hydrocortisone in<br />
Absorbase<br />
1<br />
Hydrocortisone Valerate 1<br />
Hytone 3<br />
Isovate 1<br />
Kenalog<br />
(Aerosol Solution)<br />
2<br />
Kenalog<br />
(cream, Lotion, ointment)<br />
3<br />
Lacticare-HC 1<br />
Lidex 3<br />
Lidex-E 3<br />
Locoid 3<br />
Locoid Lipocream 2<br />
Lokara 1<br />
Luxiq 3<br />
Mometasone Furoate 1<br />
Nystatin/Triamcinolone 1<br />
olux 3<br />
olux-E 3<br />
Pandel 3<br />
Prednicarbate 1<br />
Proctocort 3<br />
Proctocream-HC 1<br />
Procto-Kit 1<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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