2019 Humana Drug List - HealthPlanStore

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2019Humana Drug ListThis is a list of covered drugsPlease read: This documentcontains information about thedrugs we cover in this plan.2019 Rx4 EHB Drug ListBuscando oespañol?Haga clic aqui.Humana.com2019Rx4EHBCPDL0010

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.Prescription medicines are grouped into one of four levels – Level 1, Level 2, Level 3, or Level 4. Generic medicineshave the same active ingredients as brand medicines and are prescribed for the same reasons. The FDA requiresgenerics to be safe and work the same as brand name medicines. Generic medicines often cost much less. Level 1 – Includes low-cost generic and brand-name medicines. Level 2 – Includes higher-cost generic and brand-name medicines. Level 3 – Includes high-cost, mostly brand-name medicines. These medicines may have generic or brand-namealternatives in Levels 1 or 2. Level 4 – Includes highest-costs medicines. *Specialty Medicines: High-cost/high-technology medicines that can often only be obtained at specialtypharmacies. Please visit Humana.com and log into MyHumana to view specific prescription drug benefits,including copayments or cost-share, limitations and exclusions; OR refer to your Certificate of Coverage/Insuranceor Summary Plan Description/Policy of Insurance.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.2 - DRUG LIST Updated 10/2018

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. 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?The amount you pay often depends on which level your medicine is covered on this Drug List and whether you fill yourprescription at a network pharmacy. Please refer to your Certificate of Coverage/ Summary Plan Description/Policy ofInsurance or call the number on the back of your Humana ID card to reach customer care to find out more about yourpharmacy coverage. Click here to find a list of preventive medications that are covered for free when prescriptions arefilled by pharmacies in your plan's pharmacy network. Many contraceptive drugs may be available to you at no cost.Other contraceptive drugs not on the drug list may be available to you at no cost if medically necessary. To ask for amedical necessity review for a contraceptive drug, your health care provider can contact HCPR (Humana ClinicalPharmacy 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 Rx4 EHB 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.ACA – Affordable Care Act 0 Preventive Medication Coverage. These medicines are available to you at no cost. Youmust have a prescription from your health care provider and fill the medication at an in-network pharmacy for us toprocess a claim for preventive medicines or products under your pharmacy plan. This list may not apply to allhealthcare plans and may change over time. Some restrictions may apply.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 lists the drug level. See page 2 for more details on the drug levels in your plan.The third column shows the utilization management requirements for the medicine. Utilization management meansthat Humana may have requirements for covering that medicine. These can include prior authorization, quantitylimits, 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 MM8-MOP 10 MG CAPSULEabacavir 20 mg/ml solution MMabacavir 300 mg tablet MMabacavir-lamivudine 600-300 mg MMabacavir-lamivudine-zidov tab MMABELCET 5 MG/ML INTRAVENOUS SUSPENSIONABSTRAL 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 MMacarbose 100 mg tablet MMacarbose 25 mg tablet MMacarbose 50 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 KITACCU-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 LANCETSDRUG 1311UTILIZATIONMANAGEMENTREQUIREMENTSQL(960 per 30 days)QL(60 per 30 days)QL(30 per 30 days)QL(60 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)QL(150 per 30 days)QL(153 per 30 days)QL(150 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 SOFTCLIX LANCING DEVICE LANCETS KITACCUTREND GLUCOSE CONTROL SOLUTION MMACCUTREND GLUCOSE STRIPS MMACE AEROSOL CLOUD ENHANCER SPACERacebutolol 200 mg capsule MMacebutolol 400 mg capsule MMacetamin-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 solutionacetylcysteine 10% vialacetylcysteine 20% vialacetylcysteine 6 gram/30 ml vlACIPHEX 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,LDACTEMRA 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION MM,SP,LDACTEMRA 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION MM,SP,LDACTEMRA 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION MM,SP,LDACTHAR H.P. 80 UNIT/ML INJECTION GEL SP,LDACTHIB (PF) 10 MCG/0.5 ML INTRAMUSCULAR SOLUTION ACAACTI-LANCE LANCETS 17 GAUGEACTI-LANCE LANCETS 23 GAUGEACTI-LANCE LANCETS 28 GAUGEACTIMMUNE 100 MCG (2 MILLION UNIT)/0.5 ML SUBCUTANEOUS SOLUTION SP,LDACTIVE FE 75 MG IRON-1,250 MCG TABLETACUVAIL (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 MMADACEL (TDAP ADOLESN/ADULT)(PF)2 LF-(2.5-5-3-5)-5 LF/0.5 ML IM SYRINGE ACAADACEL (TDAP ADOLESN/ADULT)(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP ACAadapalene 0.1% creamadapalene 0.1% geladapalene-bnzyl perox 0.1-2.5%ADASUVE 10 MG BREATH ACTIVATED SPADCIRCA 20 MG TABLET MM,SPADDERALL 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 MMST - Step Therapy QL - Quantity Limit PA - Prior Authorization6 - DRUG LIST Updated 10/2018DRUG 4**3333UTILIZATIONMANAGEMENTREQUIREMENTSQL(150 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)PAPAPAPA,QL(3.6 per 28 days)PAPAPAPA,QL(30 per 30 days)PA,QL(24 per 30 days)STPAPA,QL(30 per 30 days)PA,QL(60 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(60 per 30 days)QL(60 per 30 days)

DRUG NAMEADDERALL 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 DEVICEADVAIR 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 LANCING DEVICE KITADVANCED TRAVEL LANCETS 28 GAUGEADVANCED TRAVEL LANCETS 30 GAUGEADVOCATE CONTROL SOLUTION HIGH 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 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" MMAEROBIKA OSCILLATING PEP SYSTEM DEVICEAEROCHAMBER 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 KITAEROTRACH PLUS SPACERDRUG 2111211UTILIZATIONMANAGEMENTREQUIREMENTSQL(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)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)ST - Step Therapy QL - Quantity Limit PA - Prior AuthorizationDRUG LIST Updated 10/2018 - 7

DRUG NAMEAEROVENT 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 SYRINGEDRUG L(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)ACAAFLURIA 2018-2019 45 MCG (15 MCG X 3)/0.5 ML INTRAMUSCULAR SUSPENSION3ACAAFLURIA QUAD 2018-2019 (PF) 60 MCG/0.5 ML INTRAMUSCULAR SYRINGE ACAAFLURIA QUAD 2018-2019 60 MCG/0.5 ML INTRAMUSCULAR SUSPENSION ACAAGAMATRIX CONTROL HIGH SOLUTION MMAGAMATRIX CONTROL NORM-HI SOLUTION MMak-poly-bac 500 unit-10,000 unit/gram eye ointmentAKYNZEO (NETUPITANT) 300 MG-0.5 MG CAPSULEala-cort 2.5 % topical creamalbendazole 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 MMalclometasone dipr 0.05% ointalclometasone dipro 0.05% crmALCOHOL 70% SWABSALCOHOL PADSALCOHOL PREP PADSALCOHOL PREP SWABSALCOHOL WIPESALECENSA 150 MG CAPSULE MM,SP,LDalendronate sod 70 mg/75 ml MMalendronate sodium 10 mg tab MMalendronate sodium 35 mg tab MMalendronate sodium 40 mg tab MMalendronate sodium 5 mg tablet MMalendronate sodium 70 mg tab MMALFENTANIL 500 MCG/ML AMPULEALFERON N 5 MILLION UNIT/ML INJECTION SOLUTION SPalfuzosin hcl er 10 mg tablet MMALINIA 100 MG/5 ML ORAL SUSPENSION SPALINIA 500 MG TABLET SPST - Step Therapy QL - Quantity Limit PA - Prior Authorization8 - DRUG LIST Updated (4 per 28 days)PA,QL(240 per 30 days)QL(300 per 30 days)QL(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(450 per 30 days)PA,QL(4 per 30 days)QL(30 per 30 days)QL(150 per 30 days)QL(40 per 30 days)

DRUG NAMEALLERGIST 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 MMalmotriptan malate 12.5 mg tabalmotriptan malate 6.25 mg tabALOCRIL 2 % EYE DROPSALOMIDE 0.1 % EYE DROPSalosetron hcl 0.5 mg tablet SPalosetron hcl 1 mg tablet SPalprazolam 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 tabletALREX 0.2 % EYE DROPS,SUSPENSIONALTABAX 1 % TOPICAL OINTMENTaltavera (28) 0.15 mg-0.03 mg tablet MM,ACAALTERNATE 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,SPALUNBRIG 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,SPalyacen 1/35 (28) 1 mg-35 mcg tablet MM,ACAalyacen 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM,ACAamabelz 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 MMamcinonide 0.1% cream SPAMELUZ 10 % TOPICAL GELamethia 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack MM,ACAamethia lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose pack MMamethyst 90 mcg-20 mcg tablet MM,ACAamikacin sulf 1 gram/4 ml vialamiloride hcl 5 mg tablet MMamiloride hcl-hctz 5-50 mg tab MMaminocaproic acid 5 g/20 ml vlAMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONAMINOSYN 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONAMINOSYN II 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONDRUG 4214333UTILIZATIONMANAGEMENTREQUIREMENTSST,QL(9 per 30 days)ST,QL(9 per 30 days)STSTPA,QL(60 per 30 days)PA,QL(60 per 30 days)QL(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)STST,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(180 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)QL(91 per 90 days)QL(91 per 90 days)ST - Step Therapy QL - Quantity Limit PA - Prior AuthorizationDRUG LIST Updated 10/2018 - 9

DRUG NAMEAMINOSYN M 3.5 % INTRAVENOUS SOLUTIONAMINOSYN-HBC 7% INTRAVENOUS SOLUTIONamiodarone hcl 100 mg tablet MMamiodarone hcl 200 mg tablet MMamiodarone hcl 400 mg tablet 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 MMamlodipine besylate 10 mg tab MMamlodipine besylate 2.5 mg tab MMamlodipine besylate 5 mg tab 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-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 tabletamox-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 tabletamox-clav 600-42.9 mg/5 ml susamox-clav 875-125 mg tabletamox-clav er 1,000-62.5 mg tabamoxapine 100 mg tablet MMamoxapine 150 mg tablet MMamoxapine 25 mg tablet MMamoxapine 50 mg tablet MMamoxicillin 125 mg tab chewamoxicillin 125 mg/5 ml suspamoxicillin 200 mg/5 ml suspamoxicillin 250 mg capsuleamoxicillin 250 mg tab chewamoxicillin 250 mg/5 ml suspamoxicillin 400 mg/5 ml suspamoxicillin 500 mg capsuleamoxicillin 500 mg tabletST - Step Therapy QL - Quantity Limit PA - Prior Authorization10 - DRUG LIST Updated 10/2018DRUG 2222222UTILIZATIONMANAGEMENTREQUIREMENTSQL(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)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)

DRUG NAMEamoxicillin 875 mg tabletamphotericin b 50 mg vialampicillin 125 mg/5 ml suspampicillin 250 mg capsuleampicillin 250 mg/5 ml suspampicillin 500 mg capsuleAMPYRA 10 MG TABLET,EXTENDED RELEASE MM,SP,LDANADROL-50 50 MG TABLET SPanagrelide hcl 0.5 mg capsule MManagrelide hcl 1 mg capsule MManastrozole 1 mg tablet MMANDROGEL 1.62 % (20.25 MG/1.25 GRAM) TRANSDERMAL GEL PACKET MMANDROGEL 1.62 % (40.5 MG/2.5 GRAM) TRANSDERMAL GEL PACKET MMANDROGEL 20.25 MG/1.25 GRAM (1.62 %) TRANSDERMAL GEL PUMP MMandroxy 10 mg tablet MMANGELIQ 0.25 MG-0.5 MG TABLET MMANGELIQ 0.5 MG-1 MG TABLET MMANORO ELLIPTA 62.5 MCG-25 MCG/ACTUATION POWDER FOR INHALATION MManusol-hc 2.5 % topical cream with perineal applicatorANZEMET 100 MG TABLETANZEMET 50 MG TABLETAPOKYN 10 MG/ML SUBCUTANEOUS CARTRIDGE MM,SP,LDapraclonidine hcl 0.5% dropsaprepitant 125 mg capsuleaprepitant 125-80-80 mg packaprepitant 40 mg capsuleaprepitant 80 mg capsuleapri 0.15 mg-0.03 mg tablet MM,ACAAPRISO 0.375 GRAM CAPSULE,EXTENDED RELEASE MMAPTIOM 200 MG TABLET MM,SPAPTIOM 400 MG TABLET MM,SPAPTIOM 600 MG TABLET MM,SPAPTIOM 800 MG TABLET MM,SPAPTIVUS 100 MG/ML ORAL SOLUTION MM,SPAPTIVUS 250 MG CAPSULE MM,SPAQUA LANCE LANCING DEVICEARALAST NP 1,000 MG INTRAVENOUS SOLUTION MM,SP,LDARALAST NP 500 MG INTRAVENOUS SOLUTION MM,SP,LDaranelle (28) 0.5 mg/1 mg/0.5 mg-35 mcg tablet MM,ACAarbinoxa 4 mg tabletarbinoxa 4 mg/5 ml liquidaripiprazole 1 mg/ml solution MMaripiprazole 10 mg tablet MMaripiprazole 15 mg tablet MMaripiprazole 2 mg tablet MMaripiprazole 20 mg tablet MMaripiprazole 30 mg tablet MMaripiprazole 5 mg tablet MMaripiprazole odt 10 mg tablet MMaripiprazole odt 15 mg tablet MMarmodafinil 150 mg tablet MMarmodafinil 200 mg tablet MMDRUG 3334444UTILIZATIONMANAGEMENTREQUIREMENTSPA,QL(60 per 30 days)QL(30 per 30 days)PA,QL(37.5 per 30 days)PA,QL(150 per 30 days)PA,QL(176 per 30 days)QL(60 per 30 days)QL(4 per 28 days)QL(4 per 28 days)QL(84 per 28 days)PA,QL(2 per 28 days)PA,QL(6 per 28 days)PA,QL(2 per 28 days)PA,QL(4 per 28 days)QL(120 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(60 per 30 days)PA,QL(60 per 30 days)QL(285 per 28 days)QL(120 per 30 days)PA,QL(30000 per 28 days)PA,QL(30000 per 28 days)QL(750 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(60 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)ST - Step Therapy QL - Quantity Limit PA - Prior AuthorizationDRUG LIST Updated 10/2018 - 11

DRUG NAMEarmodafinil 250 mg tablet MMarmodafinil 50 mg tablet MMARMOUR THYROID 120 MG TABLET MMARMOUR THYROID 15 MG TABLET MMARMOUR THYROID 180 MG TABLET MMARMOUR THYROID 240 MG TABLET MMARMOUR THYROID 30 MG TABLET MMARMOUR THYROID 300 MG TABLET MMARMOUR THYROID 60 MG TABLET MMARMOUR THYROID 90 MG TABLET MMARNUITY ELLIPTA 100 MCG/ACTUATION POWDER FOR INHALATION MMARNUITY ELLIPTA 200 MCG/ACTUATION POWDER FOR INHALATION MMARNUITY ELLIPTA 50 MCG/ACTUATION POWDER FOR INHALATION MMARZERRA 1,000 MG/50 ML INTRAVENOUS SOLUTION SP,LDARZERRA 100 MG/5 ML INTRAVENOUS SOLUTION SP,LDashlyna 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack MM,ACAaspirin-caff-dihydrocodein capaspirin-dipyridam er 25-200 mg MMASSURE 4 CONTROL SOLUTION COMBO PACK MMASSURE COMFORT 28G LANCETSASSURE DOSE NORMAL CONTROL SOLUTION MMASSURE DOSE NORMAL-HIGH CONTROL SOLUTION MMASSURE HAEMOLANCE PLUS 1.2 MMASSURE HAEMOLANCE PLUS 18 GAUGEASSURE HAEMOLANCE PLUS 21 GAUGEASSURE HAEMOLANCE PLUS 25 GAUGEASSURE HAEMOLANCE PLUS 28 GAUGEASSURE ID INSULIN SAFETY 0.5 ML 29 GAUGE X 1/2" SYRINGE MMASSURE ID INSULIN SAFETY 1 ML 29 GAUGE X 1/2" SYRINGE MMASSURE ID PEN NEEDLE 30 GAUGE X 3/16"ASSURE ID PEN NEEDLE 30 GAUGE X 5/16"ASSURE ID PEN NEEDLE 31 GAUGE X 3/16"ASSURE LANCE 25 GAUGEASSURE LANCE 28 GAUGEASSURE LANCE PLUS 21 GAUGEASSURE LANCE PLUS 25 GAUGEASSURE LANCE PLUS 30 GAUGEASSURE PRISM CONTROL 1-2 SOLUTION MMASTAGRAF XL 0.5 MG CAPSULE,EXTENDED RELEASE MMASTAGRAF XL 1 MG CAPSULE,EXTENDED RELEASE MMASTAGRAF XL 5 MG CAPSULE,EXTENDED RELEASE MMASTHMAPACK CHILDREN'S KITATABEX EC 29 MG-1 MG-50 MG TABLET,DELAYED RELEASE MMatazanavir sulfate 150 mg cap MM,SPatazanavir sulfate 200 mg cap MM,SPatazanavir sulfate 300 mg cap MM,SPatenolol 100 mg tablet MMatenolol 25 mg tablet MMatenolol 50 mg tablet MMatenolol-chlorthalidone 100-25 MMatenolol-chlorthalidone 50-25 MMATGAM 50 MG/ML INTRAVENOUS SOLUTION SPST - Step Therapy QL - Quantity Limit PA - Prior Authorization12 - DRUG LIST Updated 10/2018DRUG *11111*UTILIZATIONMANAGEMENTREQUIREMENTSPA,QL(30 per 30 days)PA,QL(60 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)PA,QL(400 per 28 days)PA,QL(400 per 28 days)QL(91 per 90 days)QL(330 per 30 days)STQL(60 per 30 days)QL(60 per 30 days)QL(30 per 30 days)PA,QL(1050 per 28 days)

DRUG NAMEatomoxetine hcl 10 mg capsule MMatomoxetine hcl 100 mg capsule MMatomoxetine hcl 18 mg capsule MMatomoxetine hcl 25 mg capsule MMatomoxetine hcl 40 mg capsule MMatomoxetine hcl 60 mg capsule MMatomoxetine hcl 80 mg capsule MMatorvastatin 10 mg tablet MM,ACAatorvastatin 20 mg tablet MM,ACAatorvastatin 40 mg tablet MM,ACAatorvastatin 80 mg tablet MM,ACAatovaquone 750 mg/5 ml susp SPatovaquone-proguanil 250-100atovaquone-proguanil 62.5-25ATRIPLA 600 MG-200 MG-300 MG TABLET MM,SPatropine 1 mg/ml vialatropine 1% eye drops MMATROVENT HFA 17 MCG/ACTUATION AEROSOL INHALER MMaubra 0.1 mg-20 mcg tablet MM,ACAaubra eq 0.1 mg-20 mcg tablet MM,ACAAURYXIA 210 MG IRON TABLET MMAUSTEDO 12 MG TABLET MM,SPAUSTEDO 6 MG TABLET MM,SPAUSTEDO 9 MG TABLET MM,SPAUTO-LANCET MINIAUTOJECT 2 INJECTION DEVICE SUBCUTANEOUS INSULIN PEN MMAUTOLET IMPRESSION LANCING DEVICE KITAUTOLET LANCING DEVICEAUTOLET PLUS LANCING DEVICEAUTOPEN 1 TO 21 UNITS SUBCUTANEOUS MMAUTOPEN 2 TO 42 UNITS SUBCUTANEOUS MMAVANDIA 2 MG TABLET MMAVANDIA 4 MG TABLET MMaviane 0.

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

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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

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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

Director of Army Safety Background A rmy motorcycle mishaps are on the rise. Motorcycle mishaps resulted in 155 Soldier fatalities from FY02 through FY06. Collected accident data revealed that over half of motorcycle fatalities were the result of single vehicle accidents that involved riders exercising poor risk decisions and judgment. Males between the ages of 18 and 25 years are historically .