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2021 HDHP Traditional Drug ListThis is a list of covered medicines.This document contains information about the medicines we cover in this plan.Buscando o español? Haga clic aqui.2021HDHPTCPDL0009
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 by Humanaas long as the medicine is medically necessary, the prescription is filled at a Humana in-network pharmacy and otherplan rules are followed.If you have insurance through your employer and live in Texas, Louisiana, Illinois, or Puerto Rico: You will continue touse the 2020 version of this Drug List until your plan's renewal date in 2021. Otherwise, this Drug List is effective as ofJanuary 1, 2021. 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 Humana Clinical Pharmacy Review (HCPR) at 1-800-555-2546 between 8 a.m. –8 p.m. EST, Monday – Friday. For a member in Puerto Rico, your health care provider can contact HCPR in Puerto Rico at1-866-488-5991 between 8:00 a.m. - 8:00 p.m. local time, 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 provider prescribesa supply for 30, 60, or 90 days. These limits help prevent misuse of medicines. If your prescription is over the limitthere are two choices:– You can get the amount of medicine that's covered by your plan.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, you maybe asked to try at least one other medicine first.2 - DRUG LIST Updated 12/2020
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 24-72 hours for Humana to review and provide a responseback to your health care provider. For a member in Puerto Rico, your health care provider can contact HCPR in PuertoRico at 1-866-488-5991 between 8:00 a.m. - 8:00 p.m. local time, Monday-Friday.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, coverage determination may be needed.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 (also knownas prior authorization). Please follow the instructions on page 3 to get information on specific medicine coverage.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 medicine'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 plan deductibleis reached. You pay a copayment or a coinsurance amount after you have met your plan deductible. Click here to finda list of women's preventive medicines that are covered at no cost to you. You must have a prescription from yourhealth care provider and fill at a pharmacy in your plan's pharmacy network. Some contraceptive medicines coveredon the Drug List may be available to you at no cost if medically necessary. To ask for a medical necessity review toreceive your contraceptive medicine at no cost, your health care provider can contact Humana Clinical PharmacyReview (HCPR) at 1-800-555-2546 between 8 a.m. – 8 p.m. EST, Monday – Friday. For a member in Puerto Rico, yourhealth care provider can contact HCPR in Puerto Rico at 1-866-488-5991 between 8:00 a.m. - 8:00 p.m. local time,Monday-Friday.For specific coverage and cost information for existing members: Visit Humana.com and log into MyHumana.Access the drug search tool by clicking "Pharmacy".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 wait untilafter your plan's 2021 renewal date to see your new benefit information.-DRUG LIST Updated 12/2020 - 3
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/Summary PlanDescription/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.-2021 HDHP Traditional Drug ListThe Drug List that begins on the next page provides coverage information about some of the medicines covered byHumana.How to read your Drug ListThe first column of the chart lists medicine names in alphabetical order. Brand medicines are listed in UPPER CASE andgeneric medicines are listed in lower case. Next to the medicine name you may see the following indicators to tell youabout 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 at specialtypharmacies. 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 thenumber on the back of your ID card for additional information. This list may not be all inclusive and is subject tochange.DL – This medicine has a dispensing limit and may be limited to a 30 day supply or less as additional restrictions maybe applied by state/federal law(s) or your pharmacy. Please speak to your doctor or pharmacist about your treatmentoptions.The second 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, quantity limits,or step therapy. See page 2 for more details on these requirements for your plan.4 - DRUG LIST Updated 12/2020
for PDL007DRUG NAME1ST TIER UNIFINE PENTIPS 29 GAUGE X 1/2" NEEDLEMM1ST TIER UNIFINE PENTIPS 31 GAUGE X 1/4" NEEDLEMM1ST TIER UNIFINE PENTIPS 31 GAUGE X 3/16" NEEDLEMM1ST TIER UNIFINE PENTIPS 31 GAUGE X 5/16" NEEDLEMM1ST TIER UNIFINE PENTIPS 32 GAUGE X 5/32" NEEDLEMM1ST TIER UNIFINE PENTIPS PLUS 29 GAUGE X 1/2" NEEDLEMM1ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 1/4" NEEDLEMM1ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 3/16" NEEDLEMM1ST TIER UNIFINE PENTIPS PLUS 31 GAUGE X 5/16" NEEDLEMM1ST TIER UNIFINE PENTIPS PLUS 32 GAUGE X 5/32" NEEDLEMM1ST TIER UNILET COMFORTOUCH LANCET 28 GAUGEMM1ST TIER UNILET COMFORTOUCH LANCET 30 GAUGEMM2-IN-1 LANCET DEVICE 30 GAUGEMM2TEK CONTROL (HIGH-NORMAL) SOLUTIONMM2TEK GLUCOSE/BLOOD PRESSURE KITMMabacavir 20 mg/ml solutionMMabacavir 300 mg tabletMMabacavir-lamivudine 600-300 mgMMabacavir-lamivudine-zidov tabMMABILIFY 10 MG TABLETMMABILIFY 15 MG TABLETMMABILIFY 2 MG TABLETMMABILIFY 20 MG TABLETMMABILIFY 30 MG TABLETMMABILIFY 5 MG TABLETMMABILIFY MAINTENA 300 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASEMM,SP,DLABILIFY MAINTENA 300 MG SUSPENSION,EXTENDED REL. INTRAMUSCULAR SYRINGEMM,SP,DLABILIFY MAINTENA 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASEMM,SP,DLABILIFY MAINTENA 400 MG SUSPENSION,EXTENDED REL. INTRAMUSCULAR SYRINGEMM,SP,DLABILIFY MYCITE 10 MG TABLET WITH SENSOR AND PATCHMM,SP,DLABILIFY MYCITE 15 MG TABLET WITH SENSOR AND PATCHMM,SP,DLABILIFY MYCITE 2 MG TABLET WITH SENSOR AND PATCHMM,SP,DLABILIFY MYCITE 20 MG TABLET WITH SENSOR AND PATCHMM,SP,DLABILIFY MYCITE 30 MG TABLET WITH SENSOR AND PATCHMM,SP,DLABILIFY MYCITE 5 MG TABLET WITH SENSOR AND PATCHMM,SP,DLabiraterone acetate 250 mg tabMM,SP,DLABOUTTIME PEN NEEDLE 30 GAUGE X 5/16"MMABOUTTIME PEN NEEDLE 31 GAUGE X 3/16"MMABOUTTIME PEN NEEDLE 31 GAUGE X 5/16"MMABOUTTIME PEN NEEDLE 32 GAUGE X 5/32"MMABSORICA 10 MG CAPSULEABSORICA 20 MG CAPSULEABSORICA 25 MG CAPSULESP,DLABSORICA 30 MG CAPSULEABSORICA 35 MG CAPSULESP,DLABSORICA 40 MG CAPSULEABSORICA LD 16 MG CAPSULESP,DLABSORICA LD 24 MG CAPSULESP,DLABSORICA LD 32 MG CAPSULESP,DLABSORICA LD 8 MG CAPSULESP,DLABSTRAL 100 MCG TAB SUBLINGUALSP,DLST - Step Therapy QL - Quantity Limit PA - Prior (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)QL(1 per 28 days)QL(1 per 28 days)QL(1 per 28 days)QL(1 per 28 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(120 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)ST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,QL(120 per 30 days)ST,QL(60 per 30 days)PA,QL(128 per 30 days)DRUG LIST Updated 12/2020 - 5
DRUG NAMEABSTRAL 200 MCG TAB SUBLINGUALSP,DLABSTRAL 300 MCG TAB SUBLINGUALSP,DLABSTRAL 400 MCG TAB SUBLINGUALSP,DLABSTRAL 600 MCG TAB SUBLINGUALSP,DLABSTRAL 800 MCG TAB SUBLINGUALSP,DLacamprosate calc dr 333 mg tabMMACANYA 1.2 %-2.5 % TOPICAL GEL WITH PUMPacarbose 100 mg tabletMMacarbose 25 mg tabletMMacarbose 50 mg tabletMMACCOLATE 10 MG TABLETMMACCOLATE 20 MG TABLETMMACCU-CHEK AVIVA CONTROL SOLN SOLUTIONMMACCU-CHEK AVIVA PLUS METERMMACCU-CHEK AVIVA PLUS TEST STRIPSMMACCU-CHEK COMPACT PLUS CONTROLMMACCU-CHEK COMPACT PLUS STRIPSMMACCU-CHEK FASTCLIX LANCET DRUMMMACCU-CHEK FASTCLIX LANCING DEVICE KITMMACCU-CHEK GUIDE GLUCOSE METERMMACCU-CHEK GUIDE L1-L2 CONTROL SOLUTIONMMACCU-CHEK GUIDE ME GLUCOSE METERMMACCU-CHEK GUIDE TEST STRIPSMMACCU-CHEK MULTICLIX LANCETMMACCU-CHEK MULTICLIX LANCET KITMMACCU-CHEK NANO SMARTVIEW METERMMACCU-CHEK SAFE-T-PRO 23 GAUGEMMACCU-CHEK SAFE-T-PRO PLUS 23 GAUGEMMACCU-CHEK SMARTVIEW CONTROL SOLUTIONMMACCU-CHEK SMARTVIEW TEST STRIPSMMACCU-CHEK SOFTCLIX LANCETSMMACCU-CHEK SOFTCLIX LANCING DEVICE LANCETS KITMMACCUPRIL 10 MG TABLETMMACCUPRIL 20 MG TABLETMMACCUPRIL 40 MG TABLETMMACCUPRIL 5 MG TABLETMMACCURETIC 10 MG-12.5 MG TABLETMMACCURETIC 20 MG-12.5 MG TABLETMMACCURETIC 20 MG-25 MG TABLETMMACCUTREND GLUCOSE CONTROL SOLUTIONMMACCUTREND GLUCOSE TEST STRIPSMMACE AEROSOL CLOUD ENHANCER SPACERacebutolol 200 mg capsuleMMacebutolol 400 mg capsuleMMacetamin-caf-dihydrocodein 325DLacetamin-codein 300-30 mg/12.5DLacetaminop-codeine 120-12 mg/5DLacetaminop-codeine 120-12 mg/5DLacetaminophen-cod #2 tabletDLacetaminophen-cod #3 tabletDLacetaminophen-cod #4 tabletDLacetamn-caf-dihydrcodein 320.5DLacetazolamide 125 mg tabletMMacetazolamide 250 mg tabletMMST - Step Therapy QL - Quantity Limit PA - Prior Authorization6 - DRUG LIST Updated 12/2020UTILIZATIONMANAGEMENTREQUIREMENTSPA,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)QL(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(2700 per 30 days)QL(2700 per 30 days)QL(2700 per 30 days)QL(390 per 30 days)QL(360 per 30 days)QL(180 per 30 days)QL(300 per 30 days)QL(120 per 30 days)QL(120 per 30 days)
DRUG NAMEacetazolamide er 500 mg capMMacetic acid 2% ear solutionacetylcysteine 10% vialacetylcysteine 20% vialACIPHEX 20 MG TABLET,DELAYED RELEASEMMACIPHEX SPRINKLE 10 MG CAPSULE,DELAYED RELEASEMMACIPHEX SPRINKLE 5 MG CAPSULE,DELAYED RELEASEMMacitretin 10 mg capsuleSP,DLacitretin 17.5 mg capsuleSP,DLacitretin 25 mg capsuleSP,DLACTEMRA 162 MG/0.9 ML SUBCUTANEOUS SYRINGEMM,SP,DLACTEMRA ACTPEN 162 MG/0.9 ML SUBCUTANEOUS PEN INJECTORMM,SP,DLACTHAR 80 UNIT/ML INJECTION GELSP,DLACTI-LANCE LANCETS 17 GAUGEMMACTI-LANCE LANCETS 23 GAUGEMMACTI-LANCE LANCETS 28 GAUGEMMACTICLATE 150 MG TABLETACTICLATE 75 MG TABLETACTIGALL 300 MG CAPSULEMMACTIMMUNE 100 MCG (2 MILLION UNIT)/0.5 ML SUBCUTANEOUS SOLUTIONSP,LD,DLACTIQ 1,200 MCG LOZENGE ON A HANDLEDLACTIQ 1,600 MCG LOZENGE ON A HANDLEDLACTIQ 200 MCG LOZENGE ON A HANDLEDLACTIQ 400 MCG LOZENGE ON A HANDLEDLACTIQ 600 MCG LOZENGE ON A HANDLEDLACTIQ 800 MCG LOZENGE ON A HANDLEDLACTIVE FE 75 MG IRON-1,250 MCG TABLETACTIVELLA 0.5-0.1 MG TABLETMMACTIVELLA 1 MG-0.5 MG TABLETMMACTONEL 150 MG TABLETMMACTONEL 35 MG TABLETMMACTONEL 5 MG TABLETMMACTOPLUS MET 15 MG-500 MG TABLETMMACTOPLUS MET 15 MG-850 MG TABLETMMACTOPLUS MET XR 15-1,000 MG TBMMACTOPLUS MET XR 30-1,000 MG TBMMACTOS 15 MG TABLETMMACTOS 30 MG TABLETMMACTOS 45 MG TABLETMMACULAR 0.5 % EYE DROPSACULAR LS 0.4 % EYE DROPSACUVAIL (PF) 0.45 % EYE DROPS IN A DROPPERETTEacyclovir 200 mg capsuleMMacyclovir 200 mg/5 ml suspMMacyclovir 400 mg tabletMMacyclovir 5% creamacyclovir 5% ointmentacyclovir 800 mg tabletMMACZONE 5 % TOPICAL GELACZONE 7.5 % TOPICAL GEL WITH PUMPADACEL (TDAP ADOLESN/ADULT)(PF)2 LF-(2.5-5-3-5)-5 LF/0.5 ML IM SYRINGEADACEL (TDAP ADOLESN/ADULT)(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSPADALAT CC 30 MG TABLET,EXTENDED RELEASEMMADALAT CC 60 MG TABLET,EXTENDED RELEASEMMADALAT CC 90 MG TABLET,EXTENDED RELEASEMMST - Step Therapy QL - Quantity Limit PA - Prior 0 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)PA,QL(3.6 per 28 days)PA,QL(30 per 30 days)ST,QL(30 per 30 days)ST,QL(60 per 30 days)PA,QL(12 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(4 per 28 days)QL(30 per 30 days)ST,QL(90 per 30 days)ST,QL(90 per 30 days)ST,QL(60 per 30 days)ST,QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)STSTSTPAPASTSTQL(60 per 30 days)QL(60 per 30 days)QL(60 per 30 days)DRUG LIST Updated 12/2020 - 7
DRUG NAMEadapalene 0.1% creamadapalene 0.1% geladapalene 0.1% lotionadapalene 0.1% solutionSP,DLadapalene 0.1% swabadapalene 0.3% geladapalene 0.3% gel pumpadapalene-bnzyl perox 0.1-2.5%ADASUVE 10 MG BREATH ACTIVATEDSP,DLADCIRCA 20 MG TABLETMM,DLADDERALL 10 MG TABLETMMADDERALL 12.5 MG TABLETMMADDERALL 15 MG TABLETMMADDERALL 20 MG TABLETMMADDERALL 30 MG TABLETMMADDERALL 5 MG TABLETMMADDERALL 7.5 MG TABLETMMADDERALL XR 10 MG CAPSULE,EXTENDED RELEASEMMADDERALL XR 15 MG CAPSULE,EXTENDED RELEASEMMADDERALL XR 20 MG CAPSULE,EXTENDED RELEASEMMADDERALL XR 25 MG CAPSULE,EXTENDED RELEASEMMADDERALL XR 30 MG CAPSULE,EXTENDED RELEASEMMADDERALL XR 5 MG CAPSULE,EXTENDED RELEASEMMadefovir dipivoxil 10 mg tabSP,DLADEMPAS 0.5 MG TABLETMM,SP,LD,DLADEMPAS 1 MG TABLETMM,SP,LD,DLADEMPAS 1.5 MG TABLETMM,SP,LD,DLADEMPAS 2 MG TABLETMM,SP,LD,DLADEMPAS 2.5 MG TABLETMM,SP,LD,DLADHANSIA XR 25 MG CAPSULE,EXTENDED RELEASEMMADHANSIA XR 35 MG CAPSULE,EXTENDED RELEASEMMADHANSIA XR 45 MG CAPSULE,EXTENDED RELEASEMMADHANSIA XR 55 MG CAPSULE,EXTENDED RELEASEMMADHANSIA XR 70 MG CAPSULE,EXTENDED RELEASEMMADHANSIA XR 85 MG CAPSULE,EXTENDED RELEASEMMADJUSTABLE LANCING DEVICEADLYXIN 10 MCG/0.2 ML-20 MCG/0.2 ML SUBCUTANEOUS PEN INJECTORADLYXIN 20 MCG/0.2 ML SUBCUTANEOUS PEN INJECTORMMADMELOG SOLOSTAR U-100 INSULIN LISPRO 100 UNIT/ML SUBCUTANEOUS PENMMADMELOG U-100 INSULIN LISPRO 100 UNIT/ML SUBCUTANEOUS SOLUTIONMMADVAIR DISKUS 100 MCG-50 MCG/DOSE POWDER FOR INHALATIONMMADVAIR DISKUS 250 MCG-50 MCG/DOSE POWDER FOR INHALATIONMMADVAIR DISKUS 500 MCG-50 MCG/DOSE POWDER FOR INHALATIONMMADVAIR HFA 115 MCG-21 MCG/ACTUATION AEROSOL INHALERMMADVAIR HFA 230 MCG-21 MCG/ACTUATION AEROSOL INHALERMMADVAIR HFA 45 MCG-21 MCG/ACTUATION AEROSOL INHALERMMADVANCED GLUCOSE METERMMADVANCED GLUCOSE METER TEST STRIPSMMADVANCED LANCING DEVICE KITMMADVANCED TRAVEL LANCETS 28 GAUGEMMADVANCED TRAVEL LANCETS 30 GAUGEMMADVOCATE BLOOD GLUCOSE MONITORMMADVOCATE CONTROL SOLUTION HIGHMMADVOCATE DUO DEVICEST - Step Therapy QL - Quantity Limit PA - Prior Authorization8 - DRUG LIST Updated 30 per 30 days)STSTSTPA,QL(30 per 30 days)PA,QL(60 per 30 days)ST,QL(90 per 30 days)ST,QL(90 per 30 days)ST,QL(90 per 30 days)ST,QL(90 per 30 days)ST,QL(60 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)ST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,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(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)ST,QL(6 per 28 days)ST,QL(6 per 28 days)STSTST,QL(60 per 30 days)ST,QL(60 per 30 days)ST,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)STST
DRUG NAMEADVOCATE DUO METER KITMMADVOCATE LANCET 26 GAUGEMMADVOCATE LANCET 30 GAUGEMMADVOCATE LANCING DEVICEADVOCATE LOW CONTROL SOLUTIONMMADVOCATE 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 MONITORMMADVOCATE REDI-CODE GLUCOSE MONITOR KITMMADVOCATE REDI-CODE PLUSMMADVOCATE REDI-CODE PLUS STRIPSMMADVOCATE REDI-CODE STRIPSMMADVOCATE REDI-CODE CTRL HIGH SOLUTIONMMADVOCATE REDI-CODE CTRL LOW SOLUTIONMMADVOCATE 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 30 GAUGE X 5/16"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 TEST STRIPSMMADZENYS ER 1.25 MG/ML SUSPENSION, EXTENDED RELEASE 24HRMMADZENYS XR-ODT 12.5 MG EXTENDED RELEASE DISINTEGRATING TABLETMMADZENYS XR-ODT 15.7 MG EXTENDED RELEASE DISINTEGRATING TABLETMMADZENYS XR-ODT 18.8 MG EXTENDED RELEASE DISINTEGRATING TABLETMMADZENYS XR-ODT 3.1 MG EXTENDED RELEASE DISINTEGRATING TABLETMMADZENYS XR-ODT 6.3 MG EXTENDED RELEASE DISINTEGRATING TABLETMMADZENYS XR-ODT 9.4 MG EXTENDED RELEASE DISINTEGRATING TABLETMMAEMCOLO 194 MG TABLET,DELAYED RELEASEAEROCHAMBER 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 SPACERAEROVENT PLUS SPACERafeditab cr 30 mg tabletMMafeditab cr 60 mg tabletMMAFINITOR 10 MG TABLETMM,SP,DLAFINITOR 2.5 MG TABLETMM,SP,DLST - Step Therapy QL - Quantity Limit PA - Prior STSTSTST,QL(150 per 30 days)ST,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)PA,QL(12 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)DRUG LIST Updated 12/2020 - 9
DRUG NAMEAFINITOR 5 MG TABLETMM,SP,DLAFINITOR 7.5 MG TABLETMM,SP,DLAFINITOR DISPERZ 2 MG TABLET FOR ORAL SUSPENSIONMM,SP,DLAFINITOR DISPERZ 3 MG TABLET FOR ORAL SUSPENSIONMM,SP,DLAFINITOR DISPERZ 5 MG TABLET FOR ORAL SUSPENSIONMM,SP,DLafirmelle 0.1 mg-20 mcg tabletMMAFLURIA QD 2020-21 (36 MOS UP)(PF)60 MCG (15 MCG X4)/0.5 ML IM SYRINGEAFLURIA QD 2020-21 (6-35 MOS)(PF) 30 MCG(7.5 MCGX4)/0.25 ML IM SYRINGEAFLURIA QUAD 2020-2021 60 MCG (15 MCG X 4)/0.5 ML INTRAMUSCULAR SUSP.AFREZZA (REGULAR INSULIN) 8 UNIT (90)/12 UNIT (90) CARTRIDGE,INHALERMMAFREZZA 12 UNIT CARTRIDGE WITH INHALERMMAFREZZA 4 UNIT (60)/8 UNIT (60)/12 UNIT (60) CARTRIDGE WITH INHALERMMAFREZZA 4 UNIT (90)/8 UNIT (90) CARTRIDGE WITH INHALERMMAFREZZA 4 UNIT CARTRIDGE WITH INHALERMMAFREZZA 8 UNIT CARTRIDGE WITH INHALERMMAGAMATRIX AMP GLUCOSE MONITORING SYSTEMMMAGAMATRIX AMP TEST STRIPSMMAGAMATRIX CONTROL HIGH SOLUTIONMMAGAMATRIX CONTROL NORM-HI SOLUTIONMMAGAMATRIX PRESTO TEST STRIPSMMAGGRENOX 25 MG-200 MG CAPSULEMMAGRYLIN 0.5 MG CAPSULEMMAIMOVIG 140 MG DOSE-2 AUTOINJMMAIMOVIG AUTOINJECTOR 140 MG/ML SUBCUTANEOUS AUTO-INJECTORMMAIMOVIG AUTOINJECTOR 70 MG/ML SUBCUTANEOUS AUTO-INJECTORMMAIRDUO DIGIHALER 113 MCG-14 MCG/ACTUATION BREATH ACT,POWDER SENSORMMAIRDUO DIGIHALER 232 MCG-14 MCG/ACTUATION BREATH ACT,POWDER SENSORMMAIRDUO DIGIHALER 55 MCG-14 MCG/ACTUATION BREATH ACT,POWDER SENSORMMAIRDUO RESPICLICK 113 MCG-14 MCG/ACTUATION BREATH ACTIVATEDMMAIRDUO RESPICLICK 232 MCG-14 MCG/ACTUATION BREATH ACTIVATEDMMAIRDUO RESPICLICK 55 MCG-14 MCG/ACTUATION BREATH ACTIVATEDMMAJOVY 225 MG/1.5 ML SUBCUTANEOUS AUTO-INJECTORMMAJOVY SYRINGE 225 MG/1.5 ML SUBCUTANEOUSMMak-poly-bac 500 unit-10,000 unit/gram eye ointmentAKLIEF 0.005 % TOPICAL CREAMAKTEN (PF) 3.5 % EYE GELAKTIPAK 3%-5% GEL POUCHAKYNZEO (NETUPITANT) 300 MG-0.5 MG CAPSULEALA-CORT 1 % TOPICAL CREAMALA-SCALP 2 % LOTIONalbendazole 200 mg tabletDLALBENZA 200 MG TABLETDLalbuterol 2.5 mg/0.5 ml solMMalbuterol 5 mg/ml solutionMMalbuterol hfa 90 mcg inhalerMMalbuterol sul 0.63 mg/3 ml solMMalbuterol sul 1.25 mg/3 ml solMMalbuterol sul 2.5 mg/3 ml solnMMalbuterol sulf 2 mg/5 ml syrupMMalbuterol sulfate 2 mg tabMMalbuterol sulfate 4 mg tabMMalbuterol sulfate er 4 mg tabMMalbuterol sulfate er 8 mg tabMMALCAINE 0.5 % EYE DROPSalclometasone dipr 0.05% ointST - Step Therapy QL - Quantity Limit PA - Prior Authorization10 - DRUG LIST Updated 12/2020UTILIZATIONMANAGEMENTREQUIREMENTSPA,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(180 per 30 days)PA,QL(90 per 30 days)PA,QL(180 per 30 days)PA,QL(180 per 30 days)PA,QL(90 per 30 days)PA,QL(90 per 30 days)STST,QL(150 per 30 days)ST,QL(150 per 30 days)STPA,QL(2 per 30 days)PA,QL(1 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)ST,QL(1 per 30 days)ST,QL(1 per 30 days)ST,QL(1 per 30 days)PA,QL(1.5 per 30 days)PA,QL(1.5 per 30 days)PAPA,QL(4 per 28 days)QL(36 per 30 days)
DRUG NAMEalclometasone dipro 0.05% crmALCOHOL PADSALCOHOL PREP PADSALCOHOL SWABALCOHOL WIPESALDACTAZIDE 25 MG-25 MG TABLETMMALDACTAZIDE 50 MG-50 MG TABLETMMALDACTONE 100 MG TABLETMMALDACTONE 25 MG TABLETMMALDACTONE 50 MG TABLETMMALDARA 5 % TOPICAL CREAM PACKETALECENSA 150 MG CAPSULEMM,SP,DLalendronate sod 70 mg/75 mlMMalendronate sodium 10 mg tabMMalendronate sodium 35 mg tabMMalendronate sodium 40 mg tabMMalendronate sodium 5 mg tabletMMalendronate sodium 70 mg tabMMalfuzosin hcl er 10 mg tabletMMALINIA 100 MG/5 ML ORAL SUSPENSIONSP,DLALINIA 500 MG TABLETSP,DLaliskiren 150 mg tabletMMaliskiren 300 mg tabletMMALKERAN 2 MG TABLETSP,DLALKINDI SPRINKLE 0.5 MG CAPSULEMM,SP,DLALKINDI SPRINKLE 1 MG CAPSULEMM,SP,DLALKINDI SPRINKLE 2 MG CAPSULEMM,SP,DLALKINDI SPRINKLE 5 MG CAPSULEMM,SP,DLALLERGIST 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 tabletMMallopurinol 300 mg tabletMMALLZITAL 25 MG-325 MG TABLETSP,DLalmotriptan malate 12.5 mg tabalmotriptan malate 6.25 mg tabALOCRIL 2 % EYE DROPSalogliptin 12.5 mg tabletMMalogliptin 25 mg tabletMMalogliptin 6.25 mg tabletMMalogliptin-metformin 12.5-1000MMalogliptin-metformin 12.5-500MMalogliptin-pioglit 12.5-15 mgMMalogliptin-pioglit 12.5-30 mgMMalogliptin-pioglit 12.5-45 mgMMalogliptin-pioglit 25-15 mg tbMMalogliptin-pioglit 25-30 mg tbMMalogliptin-pioglit 25-45 mg tbMMALOMIDE 0.1 % EYE DROPSALORA 0.025 MG/24 HR TRANSDERMAL PATCHMMALORA 0.05 MG/24 HR TRANSDERMAL PATCHMMALORA 0.075 MG/24 HR TRANSDERMAL PATCHMMALORA 0.1 MG/24 HR TRANSDERMAL PATCHMMST - Step Therapy QL - Quantity Limit PA - Prior 2 per 30 days)PA,QL(240 per 30 days)QL(300 per 28 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(30 per 30 days)QL(150 per 30 days)QL(40 per 30 days)ST,QL(30 per 30 days)ST,QL(30 per 30 days)QL(80 per 30 days)PAPAPAPAQL(360 per 30 days)ST,QL(9 per 30 days)ST,QL(9 per 30 days)STPA,QL(30 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)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)STQL(8 per 28 days)QL(8 per 28 days)QL(8 per 28 days)QL(8 per 28 days)DRUG LIST Updated 12/2020 - 11
DRUG NAMEalosetron hcl 0.5 mg tabletSP,DLalosetron hcl 1 mg tabletSP,DLALPHAGAN P 0.1 % EYE DROPSMMALPHAGAN P 0.15 % EYE DROPSMMalprazolam 0.25 mg tabletDLalprazolam 0.5 mg tabletDLalprazolam 1 mg tabletDLalprazolam 2 mg tabletDLalprazolam er 0.5 mg tabletDLalprazolam er 1 mg tabletDLalprazolam er 2 mg tabletDLalprazolam er 3 mg tabletDLalprazolam intensol 1 mg/ml oral concentrateDLalprazolam odt 0.25 mg tabDLalprazolam odt 0.5 mg tabDLalprazolam odt 1 mg tabDLalprazolam odt 2 mg tabDLALREX 0.2 % EYE DROPS,SUSPENSIONALTABAX 1 % TOPICAL OINTMENTALTACE 1.25 MG CAPSULEMMALTACE 10 MG CAPSULEMMALTACE 2.5 MG CAPSULEMMALTACE 5 MG CAPSULEMMaltavera (28) 0.15 mg-0.03 mg tabletMMALTERNATE SITE LANCET 26 GAUGEMMALTERNATE SITE LANCING DEVICEALTOPREV 20 MG TABLET,EXTENDED RELEASEMM,SP,DLALTOPREV 40 MG TABLET,EXTENDED RELEASEMM,SP,DLALTOPREV 60 MG TABLET,EXTENDED RELEASEMM,SP,DLALTRENO 0.05 % LOTIONALUNBRIG 180 MG TABLETMM,SP,DLALUNBRIG 30 MG TABLETMM,SP,DLALUNBRIG 90 MG (7)-180 MG (23) TABLETS IN A DOSE PACKSP,DLALUNBRIG 90 MG TABLETMM,SP,DLALVESCO 160 MCG/ACTUATION AEROSOL INHALERMMALVESCO 80 MCG/ACTUATION AEROSOL INHALERMMalyacen 1/35 (28) 1 mg-35 mcg tabletMMalyacen 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tabletMMalyq 20 mg tabletMM,DLamabelz 0.5 mg-0.1 mg tabletMMamabelz 1 mg-0.5 mg tabletMMamantadine 100 mg capsuleMMamantadine 100 mg tabletMMamantadine 50 mg/5 ml solutionMMAMARYL 1 MG TABLETMMAMARYL 2 MG TABLETMMAMARYL 4 MG TABLETMMAMBIEN 10 MG TABLETAMBIEN 5 MG TABLETAMBIEN CR 12.5 MG TABLET,EXTENDED RELEASEAMBIEN CR 6.25 MG TABLET,EXTENDED RELEASEambrisentan 10 mg tabletMM,SP,DLambrisentan 5 mg tabletMM,SP,DLamcinonide 0.1% creamST - Step Therapy QL - Quantity Limit PA - Prior Authorization12 - DRUG LIST Updated 12/2020UTILIZATIONMANAGEMENTREQUIREMENTSPA,QL(60 per 30 days)PA,QL(60 per 30 days)ST,QL(10 per 30 days)ST,QL(10 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)QL(120 per 30 days)QL(120 per 30 days)QL(120 per 30 days)QL(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)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)PA,QL(30 per 30 days)PA,QL(30 per 30 days)
DRUG NAMEamcinonide 0.1% lotionAMERGE 1 MG TABLETA
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 Drug List are covered by Humana
