2019 Humana Drug List
2019Humana Drug ListThis is a list of covered drugsPlease read: This documentcontains information about thedrugs we cover in this plan.2019 HDHP TraditionalDrug ListBuscando oespañol?Haga clic aqui.Humana.com2019HDHPTCPDL0010
Welcome to HumanaThe Humana Drug List (also known as a formulary) is effective on January 1st unless otherwise specified. This is anall-inclusive list and may change throughout the year.What is the Drug List?The Drug List is a list of covered medicines selected by Humana. The medicines in the Drug List are covered byHumana as long as the medicine is medically necessary, the prescription is filled at a Humana network pharmacy andother plan rules are followed.If you have insurance through your employer and live in Texas, Louisiana, Illinois, or Puerto Rico: You will continue touse the 2018 version of this Drug List until your plan's renewal date in 2019. Otherwise, this Drug List is effective as ofJanuary 1, 2019. You can find that Drug List at Humana.com/DrugList.How do I use the Drug List?Medicines are listed in the Drug List alphabetically.What if my medicine is not on the Drug List?You can use the drug search tool by signing into MyHumana at Humana.com to view alternatives for your medicine.You can access the drug search tool "Drug Pricing Tool" under "Tools & Resources" at the bottom of the page.Your health care provider can also ask Humana to make an exception. Generally, Humana will only approve a requestif a covered medicine wouldn't work as well OR would have a negative effect on your health. To ask for an approval,your health care provider can contact HCPR (Humana Clinical Pharmacy Review) at 1-800-555-2546 between 8 a.m. –8 p.m. EST, Monday – Friday.Some covered medicines may have additional requirements or limits on coverage. These requirements and limitsmay include: Prior authorization (PA): Some medicines need to be approved in advance to be covered under your pharmacyplan. For these medicines to be covered, your health care provider must get approval from Humana. Your planbenefits won't cover this medicine without prior authorization. You may pay the entire cost of the medicine if youbuy it without first getting a prior authorization. Quantity limits (QL): You may have a limit on how much you can get of some medicines at one time. The quantitylimit for each medicine is based on safety or health care concerns and whether your health care providerprescribes a supply for 30, 60, or 90 days. These limits help prevent misuse of medicines. If your prescription isover the limit there are two choices:–You can get the amount of medicine that's covered by your plan, and then pay out-of-pocket for any medicinethat's over the limit.Or–If your health care provider thinks you need more than the amount allowed, he or she can ask for priorauthorization from Humana for the amount of the medicine that goes over the limit.Step therapy (ST): Sometimes there's more than one medicine that works to treat a health condition. Somemedicines may cost less but still work for you. Before a prescription is filled for a medicine that costs more, youmay be asked to try at least one other medicine first.Talk to your health care provider if your medicine has an additional requirement. Ask your health care provider tocontact Humana Clinical Pharmacy Review (HCPR) to ask for approval for a medicine that requires prior authorization,quantity limit, or step therapy. Your health care provider can contact HCPR at 1-800-555-2546 between 8 a.m. – 8 p.m.EST, Monday – Friday to request an approval. Please allow 24-48 hours for Humana to review and provide a responseback to your health care provider.You can find out if your medicine has any additional requirements or limits by looking in the drug list that begins onpage 5.Please note:If your medicine isn't included in this printed list of covered medicines, you should visit Humana.com following theinstructions below to see if your medicine is covered.2 - DRUG LIST Updated 10/2018
For some medicines not listed below, medical coverage may apply.If Humana doesn't cover your medicine, your health care provider can ask Humana for approval. Generally,Humana will only approve a request if a covered medicine wouldn't work as well OR would have a negative effecton your health.Some covered medicines may have additional requirements or limits on coverage, such as requiring your healthcare provider to get advance approval from Humana in order to be covered under your pharmacy plan (alsoknown as prior authorization). Please follow the instructions on page 3 to get information on specific medicinecoverage. Can the Drug List change?Yes. Humana reviews and updates the Drug List as needed. New medicines may be added and medicines that aredeemed unsafe by the Food and Drug Administration (FDA) or a drug's manufacturer are immediately removed.We will communicate changes to the Drug List to members, by mail, based on the Drug List notification requirementsestablished by each state. Members can view the most up-to-date Drug List on Humana.com.How much will I pay for covered medicines?If you have a High Deductible Health Plan (HDHP), you pay the full price for your prescriptions until your plandeductible is reached. You pay a copayment or a coinsurance amount after you have met your plan deductible. Somecontraceptive drugs covered on the drug list may be available to you at no cost if medically necessary. To ask for amedical necessity review to receive your contraceptive drug at no cost, your health care provider can contact HCPR(Humana Clinical Pharmacy Review) at 1-800-555-2546 between 8 a.m. – 8 p.m. EST, Monday – Friday.For specific coverage and cost information for existing members: Visit Humana.com and log into MyHumana. Access the drug search tool through "Drug Pricing Tool" under "Tools & Resources" at the bottom of the page. Search for your medicine by name. Please note: MyHumana only shows benefits as of the date of log in. Depending on your plan, you should waituntil after your plan's 2019 renewal date to see your new benefit information.-For More InformationNot all the medicines listed on this drug list are covered by all prescription drug benefit plans. For more detailedinformation about your Humana prescription drug coverage, please review your Certificate of Insurance/SummaryPlan Description/Policy of Insurance and other plan materials.If you're thinking about enrolling in a Humana plan, please call the Customer Care number listed in your enrollmentmaterials.If you're already enrolled in a Humana plan, please call the number on the back of your Humana member ID card orlog into MyHumana.-DRUG LIST Updated 10/2018 - 3
2019 HDHP Traditional Drug ListThe Drug List that begins on the next page provides coverage information about some of the medicines coveredby Humana.How to read your Drug ListThe first column of the chart lists medicine names in alphabetical order. Brand-name medicines are listed in UPPERCASE and generic medicines are listed in lower case. Next to the medicine name you may see the following indicatorsto tell you about additional coverage information for that medicine:MM – Maintenance medicines are taken long-term such as medicines you take for high cholesterol, mental health, orhigh blood pressure. Coverage may be different by plan and you may be required to fill your prescriptions using yourplan's mail-delivery pharmacy.SP – Specialty medicines are typically high-cost/high-technology medicines that can often only be obtained atspecialty pharmacies. Specialty medicine coverage may be different by plan.LD – This medicine is limited distribution and may not be available at all in-network pharmacies, please call HumanaCustomer Service at 1-800-833-6917 for additional information. This list may not be all inclusive and is subject tochange.The second column shows the utilization management requirements for the medicine. Utilization managementmeans that Humana may have requirements for covering that medicine. These can include prior authorization,quantity limits, or step therapy. See page 2 for more details on these requirements for your plan.4 - DRUG LIST Updated 10/2018
for PDL007DRUG NAME1ST TIER UNIFINE PENTIPS 29 GAUGE X 1/2" NEEDLE MM1ST TIER UNIFINE PENTIPS 31 GAUGE X 1/4" NEEDLE MM1ST TIER UNIFINE PENTIPS 31 GAUGE X 3/16" NEEDLE MM1ST TIER UNIFINE PENTIPS 31 GAUGE X 5/16" NEEDLE MM1ST TIER UNIFINE PENTIPS 32 GAUGE X 5/32" NEEDLE MM1ST TIER UNIFINE PENTIPS PLUS 29 GAUGE X 1/2" NEEDLE MM1ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 1/4" NEEDLE MM1ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 3/16" NEEDLE MM1ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 5/16" NEEDLE MM1ST TIER UNIFINE PENTIPS PLUS 32 GAUGE X 5/32" NEEDLE MM1ST TIER UNILET COMFORTOUCH LANCET 28 GAUGE1ST TIER UNILET COMFORTOUCH LANCET 30 GAUGE2TEK CONTROL (HIGH-NORMAL) SOLUTION MM2TEK GLUCOSE/BLOOD PRESSURE KIT MM8-MOP 10 MG CAPSULEabacavir 20 mg/ml solution MMabacavir 300 mg tablet MMabacavir-lamivudine 600-300 mg MMabacavir-lamivudine-zidov tab MMABILIFY 10 MG TABLET MMABILIFY 15 MG TABLET MMABILIFY 2 MG TABLET MMABILIFY 20 MG TABLET MMABILIFY 30 MG TABLET MMABILIFY 5 MG TABLET MMABSORICA 10 MG CAPSULEABSORICA 20 MG CAPSULEABSORICA 25 MG CAPSULE SPABSORICA 30 MG CAPSULEABSORICA 35 MG CAPSULE SPABSORICA 40 MG CAPSULEABSTRAL 100 MCG SUBLINGUAL TABLET SPABSTRAL 200 MCG SUBLINGUAL TABLET SPABSTRAL 300 MCG SUBLINGUAL TABLET SPABSTRAL 400 MCG SUBLINGUAL TABLET SPABSTRAL 600 MCG SUBLINGUAL TABLET SPABSTRAL 800 MCG SUBLINGUAL TABLET SPacamprosate calc dr 333 mg tab MMACANYA 1.2 %-2.5 % TOPICAL GEL WITH PUMPacarbose 100 mg tablet MMacarbose 25 mg tablet MMacarbose 50 mg tablet MMACCOLATE 10 MG TABLET MMACCOLATE 20 MG TABLET MMACCU-CHEK AVIVA CONNECT METERACCU-CHEK AVIVA CONTROL SOLN SOLUTION MMACCU-CHEK AVIVA PLUS METERACCU-CHEK AVIVA PLUS TEST STRIPS MMACCU-CHEK COMPACT PLUS CARE KITUTILIZATIONMANAGEMENTREQUIREMENTSSTQL(960 per 30 days)QL(60 per 30 days)QL(30 per 30 days)QL(60 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)ST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,QL(120 per 30 days)PA,QL(128 per 30 days)PA,QL(128 per 30 days)PA,QL(128 per 30 days)PA,QL(128 per 30 days)PA,QL(128 per 30 days)PA,QL(128 per 30 days)QL(180 per 30 days)STQL(60 per 30 days)QL(60 per 30 days)QL(150 per 30 days)ST - Step Therapy QL - Quantity Limit PA - Prior AuthorizationDRUG LIST Updated 10/2018 - 5
DRUG NAMEACCU-CHEK COMPACT PLUS CONTROL SOLUTION MMACCU-CHEK COMPACT PLUS TEST STRIPS MMACCU-CHEK FASTCLIX LANCET DRUMACCU-CHEK FASTCLIX LANCING DEVICE KITACCU-CHEK GUIDE GLUCOSE METERACCU-CHEK GUIDE L1-L2 CONTROL SOLUTION MMACCU-CHEK GUIDE STRIPS MMACCU-CHEK MULTICLIX LANCETACCU-CHEK MULTICLIX LANCET KITACCU-CHEK NANOACCU-CHEK SAFE-T-PRO 23 GAUGEACCU-CHEK SAFE-T-PRO PLUS 23 GAUGEACCU-CHEK SMARTVIEW CONTROL SOLUTION MMACCU-CHEK SMARTVIEW TEST STRIPS MMACCU-CHEK SOFTCLIX LANCETSACCU-CHEK SOFTCLIX LANCING DEVICE LANCETS KITACCUPRIL 10 MG TABLET MMACCUPRIL 20 MG TABLET MMACCUPRIL 40 MG TABLET MMACCUPRIL 5 MG TABLET MMACCURETIC 10 MG-12.5 MG TABLET MMACCURETIC 20 MG-12.5 MG TABLET MMACCURETIC 20 MG-25 MG TABLET MMACCUTREND GLUCOSE CONTROL SOLUTION MMACCUTREND GLUCOSE STRIPS MMACE AEROSOL CLOUD ENHANCER SPACERacebutolol 200 mg capsule MMacebutolol 400 mg capsule MMACEON 4 MG TABLET MMACEON 8 MG TABLET MMacetamin-caff-dihydrocod 320.5acetamin-caff-dihydrocod 325acetamin-codein 300-30 mg/12.5acetaminop-codeine 120-12 mg/5acetaminop-codeine 120-12 mg/5acetaminophen-cod #2 tabletacetaminophen-cod #3 tabletacetaminophen-cod #4 tabletacetazolamide 125 mg tablet MMacetazolamide 250 mg tablet MMacetazolamide er 500 mg cap MMacetic acid 2% ear solutionacetic acid-aluminum dropsacetylcysteine 10% vialacetylcysteine 20% vialACIPHEX 20 MG TABLET,DELAYED RELEASE MMACIPHEX SPRINKLE 10 MG CAPSULE,DELAYED RELEASE SPRINKLE MMACIPHEX SPRINKLE 5 MG CAPSULE,DELAYED RELEASE SPRINKLE MMacitretin 10 mg capsuleacitretin 17.5 mg capsuleacitretin 25 mg capsuleACTEMRA 162 MG/0.9 ML SUBCUTANEOUS SYRINGE MM,SP,LDST - Step Therapy QL - Quantity Limit PA - Prior Authorization6 - DRUG LIST Updated 10/2018UTILIZATIONMANAGEMENTREQUIREMENTSQL(153 per 30 days)QL(150 per 30 days)QL(150 per 30 days)QL(150 per 30 days)QL(300 per 30 days)QL(300 per 30 days)QL(5010 per 30 days)QL(5010 per 30 days)QL(5010 per 30 days)QL(390 per 30 days)QL(390 per 30 days)QL(390 per 30 days)QL(120 per 30 days)QL(120 per 30 days)QL(60 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)PAPAPAPA,QL(3.6 per 28 days)
DRUG NAMEACTHAR H.P. 80 UNIT/ML INJECTION GEL SP,LDACTI-LANCE LANCETS 17 GAUGEACTI-LANCE LANCETS 23 GAUGEACTI-LANCE LANCETS 28 GAUGEACTICLATE 150 MG TABLET SPACTICLATE 75 MG TABLET SPACTIGALL 300 MG CAPSULE MMACTIMMUNE 100 MCG (2 MILLION UNIT)/0.5 ML SUBCUTANEOUS SOLUTION SP,LDACTIQ 1,200 MCG LOZENGE ON A HANDLEACTIQ 1,600 MCG LOZENGE ON A HANDLEACTIQ 200 MCG LOZENGE ON A HANDLEACTIQ 400 MCG LOZENGE ON A HANDLEACTIQ 600 MCG LOZENGE ON A HANDLEACTIQ 800 MCG LOZENGE ON A HANDLEACTIVE FE 75 MG IRON-1,250 MCG TABLETACTIVE OB SOFTGEL MMACTIVELLA 0.5 MG-0.1 MG TABLET MMACTIVELLA 1 MG-0.5 MG TABLET MMACTONEL 150 MG TABLET MMACTONEL 30 MG TABLETACTONEL 35 MG TABLET MMACTONEL 5 MG TABLET MMACTOPLUS MET 15 MG-500 MG TABLET MMACTOPLUS MET 15 MG-850 MG TABLET MMACTOPLUS MET XR 15 MG-1,000 MG TABLET,EXTENDED RELEASE MMACTOPLUS MET XR 30 MG-1,000 MG TABLET,EXTENDED RELEASE MMACTOS 15 MG TABLET MMACTOS 30 MG TABLET MMACTOS 45 MG TABLET MMACULAR 0.5 % EYE DROPSACULAR LS 0.4 % EYE DROPSACUVAIL (PF) 0.45 % EYE DROPS IN A DROPPERETTEacyclovir 200 mg capsule MMacyclovir 200 mg/5 ml susp MMacyclovir 400 mg tablet MMacyclovir 5% ointmentacyclovir 800 mg tablet MMACZONE 5 % TOPICAL GELACZONE 7.5 % TOPICAL GEL WITH PUMPADALAT CC 30 MG TABLET,EXTENDED RELEASE MMADALAT CC 60 MG TABLET,EXTENDED RELEASE MMADALAT CC 90 MG TABLET,EXTENDED RELEASE MMadapalene 0.1% creamadapalene 0.1% geladapalene 0.1% lotionadapalene 0.1% solution SPadapalene 0.3% geladapalene 0.3% gel pumpadapalene-bnzyl perox 0.1-2.5%ADASUVE 10 MG BREATH ACTIVATED SPADCIRCA 20 MG TABLET MM,SPADDERALL 10 MG TABLET MMUTILIZATIONMANAGEMENTREQUIREMENTSPA,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(60 per 30 days)PA,QL(24 per 30 days)PA,QL(120 per 30 days)PA,QL(120 per 30 days)PA,QL(120 per 30 days)PA,QL(120 per 30 days)PA,QL(120 per 30 days)PA,QL(120 per 30 days)QL(1 per 30 days)QL(30 per 30 days)QL(4 per 28 days)QL(30 per 30 days)ST,QL(90 per 30 days)ST,QL(90 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)STSTSTPASTSTQL(60 per 30 days)QL(60 per 30 days)QL(60 per 30 days)STSTSTSTPA,QL(30 per 30 days)PA,QL(60 per 30 days)QL(90 per 30 days)ST - Step Therapy QL - Quantity Limit PA - Prior AuthorizationDRUG LIST Updated 10/2018 - 7
DRUG NAMEADDERALL 12.5 MG TABLET MMADDERALL 15 MG TABLET MMADDERALL 20 MG TABLET MMADDERALL 30 MG TABLET MMADDERALL 5 MG TABLET MMADDERALL 7.5 MG TABLET MMADDERALL XR 10 MG CAPSULE,EXTENDED RELEASE MMADDERALL XR 15 MG CAPSULE,EXTENDED RELEASE MMADDERALL XR 20 MG CAPSULE,EXTENDED RELEASE MMADDERALL XR 25 MG CAPSULE,EXTENDED RELEASE MMADDERALL XR 30 MG CAPSULE,EXTENDED RELEASE MMADDERALL XR 5 MG CAPSULE,EXTENDED RELEASE MMadefovir dipivoxil 10 mg tab SPADEMPAS 0.5 MG TABLET MM,SP,LDADEMPAS 1 MG TABLET MM,SP,LDADEMPAS 1.5 MG TABLET MM,SP,LDADEMPAS 2 MG TABLET MM,SP,LDADEMPAS 2.5 MG TABLET MM,SP,LDADJUSTABLE LANCING DEVICEADLYXIN 10 MCG/0.2 ML-20 MCG/0.2 ML SUBCUTANEOUS PEN INJECTORADLYXIN 20 MCG/0.2 ML SUBCUTANEOUS PEN INJECTOR MMADMELOG SOLOSTAR U-100 INSULIN LISPRO 100 UNIT/ML SUBCUTANEOUS PEN MMADMELOG U-100 INSULIN LISPRO 100 UNIT/ML SUBCUTANEOUS SOLUTION MMADVAIR DISKUS 100 MCG-50 MCG/DOSE POWDER FOR INHALATION MMADVAIR DISKUS 250 MCG-50 MCG/DOSE POWDER FOR INHALATION MMADVAIR DISKUS 500 MCG-50 MCG/DOSE POWDER FOR INHALATION MMADVAIR HFA 115 MCG-21 MCG/ACTUATION AEROSOL INHALER MMADVAIR HFA 230 MCG-21 MCG/ACTUATION AEROSOL INHALER MMADVAIR HFA 45 MCG-21 MCG/ACTUATION AEROSOL INHALER MMADVANCED GLUCOSE METERADVANCED GLUCOSE METER TEST STRIPS MMADVANCED LANCING DEVICE KITADVANCED TRAVEL LANCETS 28 GAUGEADVANCED TRAVEL LANCETS 30 GAUGEADVOCATE BLOOD GLUCOSE MONITORADVOCATE CONTROL SOLUTION HIGH MMADVOCATE DUO DEVICEADVOCATE DUO METER KIT MMADVOCATE LANCET 26 GAUGEADVOCATE LANCET 30 GAUGEADVOCATE LANCING DEVICEADVOCATE LOW CONTROL SOLUTION MMADVOCATE PEN NEEDLE 29 GAUGE X 1/2" MMADVOCATE PEN NEEDLE 31 GAUGE X 3/16" MMADVOCATE PEN NEEDLE 31 GAUGE X 5/16" MMADVOCATE PEN NEEDLE 33 GAUGE X 5/32" MMADVOCATE RAPID-SAFE LANCING DEVICEADVOCATE REDI-CODE DUO METERADVOCATE REDI-CODE GLUCOSE MONITORADVOCATE REDI-CODE GLUCOSE MONITOR KITADVOCATE REDI-CODE PLUSADVOCATE REDI-CODE PLUS STRIPS MMST - Step Therapy QL - Quantity Limit PA - Prior Authorization8 - DRUG LIST Updated 10/2018UTILIZATIONMANAGEMENTREQUIREMENTSQL(90 per 30 days)QL(90 per 30 days)QL(90 per 30 days)QL(60 per 30 days)QL(90 per 30 days)QL(90 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(30 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)ST,QL(6 per 28 days)ST,QL(6 per 28 days)STST,QL(240 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(12 per 30 days)QL(12 per 30 days)QL(12 per 30 days)STST,QL(150 per 30 days)STSTSTSTSTSTSTST,QL(150 per 30 days)
DRUG NAMEADVOCATE REDI-CODE STRIPS MMADVOCATE REDI-CODE CTRL HIGH SOLUTION MMADVOCATE REDI-CODE CTRL LOW SOLUTION MMADVOCATE SYRINGES 0.3 ML 29 GAUGE X 1/2" MMADVOCATE SYRINGES 0.3 ML 30 GAUGE X 5/16" MMADVOCATE SYRINGES 0.3 ML 31 GAUGE X 5/16" MMADVOCATE SYRINGES 0.5 ML 29 GAUGE X 1/2" MMADVOCATE SYRINGES 0.5 ML 31 GAUGE X 5/16" MMADVOCATE SYRINGES 1 ML 29 GAUGE X 1/2" MMADVOCATE SYRINGES 1 ML 30 GAUGE X 5/16" MMADVOCATE SYRINGES 1 ML 31 GAUGE X 5/16" MMADVOCATE SYRINGES 1/2 ML 30 GAUGE X 5/16" MMADVOCATE TEST STRIPS MMADZENYS ER 1.25 MG/ML SUSPENSION, EXTENDED RELEASE 24HR MMADZENYS XR-ODT 12.5 MG EXTENDED RELEASE DISINTEGRATING TABLET MMADZENYS XR-ODT 15.7 MG EXTENDED RELEASE DISINTEGRATING TABLET MMADZENYS XR-ODT 18.8 MG EXTENDED RELEASE DISINTEGRATING TABLET MMADZENYS XR-ODT 3.1 MG EXTENDED RELEASE DISINTEGRATING TABLET MMADZENYS XR-ODT 6.3 MG EXTENDED RELEASE DISINTEGRATING TABLET MMADZENYS XR-ODT 9.4 MG EXTENDED RELEASE DISINTEGRATING TABLET MMAEROCHAMBER MINIAEROCHAMBER MV SPACERAEROCHAMBER PLUS FLOW-VUAEROCHAMBER PLUS FLOW-VU,LARGE MASKAEROCHAMBER PLUS FLOW-VU,MEDIUM MASKAEROCHAMBER PLUS FLOW-VU,SMALL MASKAEROCHAMBER PLUS Z STAT LARGE MASKAEROCHAMBER PLUS Z STAT MEDIUM MASKAEROCHAMBER PLUS Z STAT SMALL MASKAEROCHAMBER PLUS Z STAT SPACERAEROCHAMBER WITH FLOWSIGNALAEROCHAMBER Z-STAT PLUS-FLOW SIGNALAEROGEAR ACTION ASTHMA KITAEROSPAN 80 MCG/ACTUATION HFA AEROSOL INHALER MMAEROTRACH PLUS SPACERAEROVENT PLUS SPACERafeditab cr 30 mg tablet,extended release MMafeditab cr 60 mg tablet,extended release MMAFINITOR 10 MG TABLET MM,SPAFINITOR 2.5 MG TABLET MM,SPAFINITOR 5 MG TABLET MM,SPAFINITOR 7.5 MG TABLET MM,SPAFINITOR DISPERZ 2 MG TABLET FOR ORAL SUSPENSION MM,SPAFINITOR DISPERZ 3 MG TABLET FOR ORAL SUSPENSION MM,SPAFINITOR DISPERZ 5 MG TABLET FOR ORAL SUSPENSION MM,SPAFLURIA 2018-2019 (PF) 45 MCG(15 MCG X 3)/0.5 ML INTRAMUSCULAR SYRINGEAFLURIA 2018-2019 45 MCG (15 MCG X 3)/0.5 ML INTRAMUSCULAR SUSPENSIONAFLURIA QUAD 2018-2019 (PF) 60 MCG/0.5 ML INTRAMUSCULAR SYRINGEAFLURIA QUAD 2018-2019 60 MCG/0.5 ML INTRAMUSCULAR SUSPENSIONAFREZZA 12 UNIT CARTRIDGE WITH INHALER MMAFREZZA 30-4 UNIT / 60-8 UNIT MMAFREZZA 4 UNIT (60)/8 UNIT (30) CARTRIDGE WITH INHALER MMUTILIZATIONMANAGEMENTREQUIREMENTSST,QL(150 per 30 days)ST,QL(150 per 30 days)ST,QL(450 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(17.8 per 30 days)QL(60 per 30 days)QL(60 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)ST - Step Therapy QL - Quantity Limit PA - Prior AuthorizationDRUG LIST Updated 10/2018 - 9
DRUG NAMEAFREZZA 4 UNIT (60)/8 UNIT (60)/12 UNIT (60) CARTRIDGE WITH INHALER MMAFREZZA 4 UNIT (90)/8 UNIT (90) CARTRIDGE WITH INHALER MMAFREZZA 4 UNIT CARTRIDGE WITH INHALER MMAFREZZA 60-8 UNIT / 30-12 UNIT MMAFREZZA 8 UNIT CARTRIDGE WITH INHALER MMAGAMATRIX AMP GLUCOSE MONITORING SYSTEMAGAMATRIX AMP TEST STRIPS MMAGAMATRIX CONTROL HIGH SOLUTION MMAGAMATRIX CONTROL NORM-HI SOLUTION MMAGGRENOX 25 MG-200 MG CAPSULE, EXTENDED RELEASE MMAGRYLIN 0.5 MG CAPSULE MMAIMOVIG AUTOINJECTOR 140 MG/2 PACK (70 MG/ML) SUBCUTANEOUS MMAIMOVIG AUTOINJECTOR 70 MG/ML SUBCUTANEOUS AUTO-INJECTOR MMAIRDUO RESPICLICK 113 MCG-14 MCG/ACTUATION BREATH ACTIVATED MMAIRDUO RESPICLICK 232 MCG-14 MCG/ACTUATION BREATH ACTIVATED MMAIRDUO RESPICLICK 55 MCG-14 MCG/ACTUATION BREATH ACTIVATED MMAJOVY 225 MG/1.5 ML SUBCUTANEOUS SYRINGEak-poly-bac 500 unit-10,000 unit/gram eye ointmentAKTEN (PF) 3.5 % EYE GELAKTIPAK 3 %-5 % TOPICAL GELAKYNZEO (NETUPITANT) 300 MG-0.5 MG CAPSULEALA-CORT 1 % TOPICAL CREAMala-cort 2.5 % topical creamALA-SCALP 2 % LOTIONalbendazole 200 mg tablet SPALBENZA 200 MG TABLET SPalbuterol 2.5 mg/0.5 ml sol MMalbuterol 5 mg/ml solution MMalbuterol sul 0.63 mg/3 ml sol MMalbuterol sul 1.25 mg/3 ml sol MMalbuterol sul 2.5 mg/3 ml soln MMalbuterol sulf 2 mg/5 ml syrup MMalbuterol sulfate 2 mg tab MMalbuterol sulfate 4 mg tab MMalbuterol sulfate er 4 mg tab MMalbuterol sulfate er 8 mg tab MMALCAINE 0.5% EYE DROPSalclometasone dipr 0.05% ointalclometasone dipro 0.05% crmALCOHOL 70% SWABSALCOHOL PADSALCOHOL PREP PADSALCOHOL PREP SWABSALCOHOL WIPESALDACTAZIDE 25 MG-25 MG TABLET MMALDACTAZIDE 50 MG-50 MG TABLET MMALDACTONE 100 MG TABLET MMALDACTONE 25 MG TABLET MMALDACTONE 50 MG TABLET MMALDARA 5 % TOPICAL CREAM PACKETALECENSA 150 MG CAPSULE MM,SP,LDalendronate sod 70 mg/75 ml MMST - Step Therapy QL - Quantity Limit PA - Prior Authorization10 - DRUG LIST Updated 10/2018UTILIZATIONMANAGEMENTREQUIREMENTSPA,QL(180 per 30 days)PA,QL(180 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)STST,QL(150 per 30 days)STPA,QL(2 per 30 days)PA,QL(2 per 30 days)ST,QL(1 per 30 days)ST,QL(1 per 30 days)ST,QL(1 per 30 days)PA,QL(4.5 per 90 days)PA,QL(4 per 28 days)QL(12 per 30 days)PA,QL(240 per 30 days)QL(300 per 30 days)
DRUG NAMEalendronate sodium 10 mg tab MMalendronate sodium 35 mg tab MMalendronate sodium 40 mg tab MMalendronate sodium 5 mg tablet MMalendronate sodium 70 mg tab MMalfuzosin hcl er 10 mg tablet MMALINIA 100 MG/5 ML ORAL SUSPENSION SPALINIA 500 MG TABLET SPALKERAN 2 MG TABLET SPALLERGIST TRAY 1/2 ML 27 GAUGE X 3/8" SYRINGEALLERGIST TRAY INTRADERMAL BEVEL 1 ML 26 GAUGE X 1/2" SYRINGEALLERGIST TRAY INTRADERMAL BEVEL 1 ML 26 GAUGE X 3/8" SYRINGEALLERGIST TRAY INTRADERMAL BEVEL 1 ML 27 GAUGE X 3/8" SYRINGEALLERGIST TRAY REGULAR BEVEL 1 ML 27 GAUGE X 3/8" SYRINGEallopurinol 100 mg tablet MMallopurinol 300 mg tablet MMALLZITAL 25 MG-325 MG TABLETalmotriptan malate 12.5 mg tabalmotriptan malate 6.25 mg tabALOCRIL 2 % EYE DROPSalogliptin 12.5 mg tablet MMalogliptin 25 mg tablet MMalogliptin 6.25 mg tablet MMalogliptin-metformin 12.5-1000 MMalogliptin-metformin 12.5-500 MMalogliptin-pioglit 12.5-15 mg MMalogliptin-pioglit 12.5-30 mg MMalogliptin-pioglit 12.5-45 mg MMalogliptin-pioglit 25-15 mg tb MMalogliptin-pioglit 25-30 mg tb MMalogliptin-pioglit 25-45 mg tb MMALOMIDE 0.1 % EYE DROPSALORA 0.025 MG/24 HR TRANSDERMAL PATCH MMALORA 0.05 MG/24 HR TRANSDERMAL PATCH MMALORA 0.075 MG/24 HR TRANSDERMAL PATCH MMALORA 0.1 MG/24 HR TRANSDERMAL PATCH MMalosetron hcl 0.5 mg tablet SPalosetron hcl 1 mg tablet SPALPHAGAN P 0.1 % EYE DROPS MMALPHAGAN P 0.15 % EYE DROPS MMalprazolam 0.25 mg tabletalprazolam 0.5 mg tabletalprazolam 1 mg tabletalprazolam 2 mg tabletalprazolam er 0.5 mg tabletalprazolam er 1 mg tabletalprazolam er 2 mg tabletalprazolam er 3 mg tabletalprazolam intensol 1 mg/ml oral concentratealprazolam odt 0.25 mg tabalprazolam odt 0.5 mg tabalprazolam odt 1 mg tabUTILIZATIONMANAGEMENTREQUIREMENTSQL(30 per 30 days)QL(4 per 28 days)QL(30 per 30 days)QL(30 per 30 days)QL(4 per 28 days)QL(30 per 30 days)QL(150 per 30 days)QL(40 per 30 days)QL(80 per 30 days)QL(360 per 30 days)ST,QL(9 per 30 days)ST,QL(9 per 30 days)STST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)STQL(8 per 28 days)QL(8 per 28 days)QL(8 per 28 days)QL(8 per 28 days)PA,QL(60 per 30 days)PA,QL(60 per 30 days)STSTQL(120 per 30 days)QL(120 per 30 days)QL(120 per 30 days)QL(150 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(120 per 30 days)QL(120 per 30 days)QL(120 per 30 days)ST - Step Therapy QL - Quantity Limit PA - Prior AuthorizationDRUG LIST Updated 10/2018 - 11
DRUG NAMEalprazolam odt 2 mg tabALREX 0.2 % EYE DROPS,SUSPENSIONALTABAX 1 % TOPICAL OINTMENTALTACE 1.25 MG CAPSULE MMALTACE 10 MG CAPSULE MMALTACE 2.5 MG CAPSULE MMALTACE 5 MG CAPSULE MMaltavera (28) 0.15 mg-0.03 mg tablet MMALTERNATE SITE LANCET 26 GAUGEALTERNATE SITE LANCING DEVICEALTOPREV 20 MG TABLET,EXTENDED RELEASE MM,SPALTOPREV 40 MG TABLET,EXTENDED RELEASE MM,SPALTOPREV 60 MG TABLET,EXTENDED RELEASE MM,SPALTRENO 0.05 % LOTIONALUNBRIG 180 MG TABLET MM,SPALUNBRIG 30 MG TABLET MM,SPALUNBRIG 90 MG (7)-180 MG (23) TABLETS IN A DOSE PACK SPALUNBRIG 90 MG TABLET MM,SPALVESCO 160 MCG/ACTUATION AEROSOL INHALER MMALVESCO 80 MCG/ACTUATION AEROSOL INHALER MMalyacen 1/35 (28) 1 mg-35 mcg tablet MMalyacen 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MMamabelz 0.5 mg-0.1 mg tablet MMamabelz 1 mg-0.5 mg tablet MMamantadine 100 mg capsule MMamantadine 100 mg tablet MMamantadine 50 mg/5 ml solution MMAMARYL 1 MG TABLET MMAMARYL 2 MG TABLET MMAMARYL 4 MG TABLET MMAMBIEN 10 MG TABLETAMBIEN 5 MG TABLETAMBIEN CR 12.5 MG TABLET,EXTENDED RELEASEAMBIEN CR 6.25 MG TABLET,EXTENDED RELEASEamcinonide 0.1% cream SPamcinonide 0.1% lotionamcinonide 0.1% ointment SPAMERGE 1 MG TABLETAMERGE 2.5 MG TABLETamethia 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack MMamethia lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose pack MMamethyst 90 mcg-20 mcg tablet MMAMICAR 1,000 MG TABLETAMICAR 250 MG/ML (25 %) ORAL SOLUTION SPAMICAR 500 MG TABLETamiloride hcl 5 mg tablet MMamiloride hcl-hctz 5-50 mg tab MMAMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONAMINOSYN 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONAMINOSYN II 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONAMINOSYN M 3.5 % INTRAVENOUS SOLUTIONAMINOSYN-HBC 7% INTRAVENOUS SOLUTIONST - Step Therapy QL - Quantity Limit PA - Prior Authorization12 - DRUG LIST Updated 10/2018UTILIZATIONMANAGEMENTREQUIREMENTSQL(90 per 30 days)STST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)PAPA,QL(30 per 30 days)PA,QL(180 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)ST,QL(18.3 per 28 days)ST,QL(18.3 per 28 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(9 per 30 days)ST,QL(9 per 30 days)QL(91 per 90 days)QL(91 per 90 days)
DRUG NAMEamiodarone hcl 100 mg tablet MMamiodarone hcl 200 mg tablet MMamiodarone hcl 400 mg tablet MMAMITIZA 24 MCG CAPSULE MMAMITIZA 8 MCG CAPSULE MMamitriptyline hcl 10 mg tab MMamitriptyline hcl 100 mg tab MMamitriptyline hcl 150 mg tab MMamitriptyline hcl 25 mg tab MMamitriptyline hcl 50 mg tab MMamitriptyline hcl 75 mg tab MMamlod-valsa-hctz 10-160-12.5mg MMamlod-valsa-hctz 10-160-25 mg MMamlod-valsa-hctz 10-320-25 mg MMamlod-valsa-hctz 5-160-12.5 mg MMamlod-valsa-hctz 5-160-25 mg MMamlodipine besylate 10 mg tab MMamlodipine besylate 2.5 mg tab MMamlodipine besylate 5 mg tab MMamlodipine-atorvast 10-10 mg MMamlodipine-atorvast 10-20 mg MMamlodipine-atorvast 10-40 mg MMamlodipine-atorvast 10-80 mg MMamlodipine-atorvast 2.5-10 mg MMamlodipine-atorvast 2.5-20 mg MMamlodipine-atorvast 2.5-40 mg MMamlodipine-atorvast 5-10 mg MMamlodipine-atorvast 5-20 mg MMamlodipine-atorvast 5-40 mg MMamlodipine-atorvast 5-80 mg MMamlodipine-benazepril 10-20 mg MMamlodipine-benazepril 10-40 mg MMamlodipine-benazepril 2.5-10 MMamlodipine-benazepril 5-10 mg MMamlodipine-benazepril 5-20 mg MMamlodipine-benazepril 5-40 mg MMamlodipine-olmesartan 10-20 mg MMamlodipine-olmesartan 10-40 mg MMamlodipine-olmesartan 5-20 mg MMamlodipine-olmesartan 5-40 mg MMamlodipine-valsartan 10-160 mg MMamlodipine-valsartan 10-320 mg MMamlodipine-valsartan 5-160 mg MMamlodipine-valsartan 5-320 mg MMammonium lactate 12% creamammonium lactate 12% lotionamnesteem 10 mg capsuleamnesteem 20 mg capsuleamnesteem 40 mg capsuleamox-clav 200-28.5 mg tab chewamox-clav 200-28.5 mg/5 ml susamox-clav 250-125 mg tabletUTILIZATIONMANAGEMENTREQUIREMENTSPA,QL(60 per 30 days)PA,QL(60 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(60 per 30 days)QL(30 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(120 per 30 days)ST - Step Therapy QL - Quantity Limit PA - Prior AuthorizationDRUG LIST Updated 10/2018 - 13
DRUG NAMEamox-clav 250-62.5 mg/5 ml susamox-clav 400-57 mg tab chewamox-clav 400-57 mg/5 ml suspamox-clav 500-125 mg tableta
DRUG LIST Updated 10/2018 - 3 For some medicines not listed below, medical coverage may apply. If Humana doesn't cover your medicine, your health care provider can ask Humana for approval. Generally, Humana will only approve a request if a covered medicine
Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana
2 - DRUG LIST Updated 10/2018 Welcome to Humana-The Humana Drug List (also known as a formulary) is effective on January 1st unless otherwise specified. This is an all-inclusive list and may change throughout the year. What is the Drug List? The Drug List is a list of covered medicines s
MyHumana at Humana.com or by calling 1-800-233-4013. Humana group dental plans are offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of New York, Humana Health Benefit Plan of Louisiana, The Dental Concern, Inc., Humana Medical
With most Humana Medicare Advantage plans, prescription drug coverage is usually built in. All questions can be answered from a knowledgeable Humana sales representative with a call to one number. 6. PROVEN TRUSTWORTHY Humana is going beyond insurance to become your partner in health. Humana is a Fortune 100 company with 60 years in the
DRUG LIST Updated 09/2017 - 3 For some medicines not listed below, medical coverage may apply. If Humana doesn't cover your medicine, your health care provider can ask Humana for approval. Generally, Humana will only approve a request if a covered medic
To get updated information about the drugs that Humana covers, please visit Humana.com. Select "Medicare Drug List" from the Humana Medicare Plans tab at the top left of the website. The Medicare Drug List search tool lets you search for your drug by name or drug type. For help and information, call
The Humana Drug List (also known as a formulary) is effective on January 1st unless otherwise specified. This is an all-inclusive list and may change throughout the year. What is the Drug List? The Drug List is a list of covered medicines selected by Humana. The medicines in the
"Administrim Publik" I. OFRIMII PROGRAMEVE TË STUDIMIT Standardi I.1 Institucioni i arsimit të lartë ofron programe studimi të ciklit të dytë “Master profesional” në përputhje me misionin dhe qëllimin e tij e që synojnë ruajtjen e interesave dhe vlerave kombëtare. Kriteret Vlerësimi i ekspertëve Kriteri 1. Institucioni ofron programe studimi që nuk bien ndesh me interesat .
