DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
DRUG - UnitedHealthcare MedicareRx for Groups
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8<br />
THE <strong>DRUG</strong> LIST<br />
<strong>DRUG</strong><br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
AnTIHISTAMInE <strong>DRUG</strong>S -<br />
<strong>DRUG</strong>S To TREAT ALLERGIES AnD ITcHInG<br />
Ethanolamine Derivatives - Allergy Drugs<br />
Benadryl 3<br />
Clemastine Fumarate 1<br />
Diphenhydramine HCl 3<br />
Palgic (Liquid) 1<br />
Palgic (Tablet) 2<br />
Miscellaneous Derivatives - Allergy Drugs<br />
Cyproheptadine HCl<br />
Phenothiazine Derivatives -<br />
nausea and Vomiting Drugs<br />
3<br />
Phenadoz 3<br />
Phenergan 3<br />
Promethazine HCl 3<br />
Promethazine HCl Plain 3<br />
Promethazine VC 3<br />
Promethegan 3<br />
Propylamine Derivatives - Allergy Drugs<br />
Dexchlorpheniramine<br />
Maleate<br />
3<br />
Second Generation Antihistamines - Allergy Drugs<br />
Allegra (Suspension) 3 QL<br />
Allegra (Tablet) 3<br />
Allegra-D 12 Hour 3 QL<br />
Allegra-D 24 Hour 3 QL<br />
clarinex* 3 QL<br />
clarinex Reditabs 3 QL<br />
clarinex-D 12 Hour 3 QL<br />
clarinex-D 24 Hour 3 QL<br />
<strong>DRUG</strong><br />
Fexofenadine HCl 1<br />
Semprex-D 3<br />
UnitedHealth Rx<br />
<strong>for</strong> <strong>Groups</strong><br />
TIER LIMITS<br />
Zyrtec 3 QL<br />
Zyrtec-D 3 QL<br />
AnTI-InFEcTIVE AGEnTS -<br />
<strong>DRUG</strong>S To TREAT InFEcTIonS<br />
Adamantanes - Flu Drugs<br />
Amantadine HCl 1<br />
Flumadine 3<br />
Rimantadine HCl 1<br />
Symmetrel 3<br />
Allylamines - Antifungals<br />
Lamisil 3<br />
Terbinafine (Tablet) 1<br />
Amebicides<br />
Humatin 3<br />
Paromomycin Sulfate 1<br />
Aminoglycosides - Antibiotics<br />
Amikacin Sulfate 1<br />
Amikin 3<br />
Gentamicin Sulfate/0.9%<br />
NaCl<br />
(0.6 mg/ml; 0.9% Solution,<br />
0.8 mg/ml; 0.9% Solution, 1<br />
1 mg/ml; 0.9% Solution,<br />
1.2 mg/ml; 0.9% Solution,<br />
1.6 mg/ml; 0.9% Solution)<br />
Gentamicin Sulfate/0.9%<br />
nacl (0.9 mg/ml; 0.9%<br />
3<br />
Solution, 1.4 mg/ml; 0.9%<br />
Solution)<br />
Gentamicin Sulfate/NaCl 1<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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