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2022 HDHP 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.2022HDHPCPDL0006
Welcome to Humana-What is the Drug List?The Humana Drug List (also known as a formulary) is a list of covered medicines selected by Humana. This is acomprehensive list, but is subject to change throughout the year. The medicines in the Drug List are covered byHumana as long as the medicine is medically necessary and other plan rules are followed.When is the Drug List effective?The Drug List is effective on January 1st, except for Commercial Fully-Insured policies issued in Illinois, Louisiana,Puerto Rico, and Texas where Drug List changes are effective on a plan's renewal date. These States will continue touse the 2021 version of this Drug List until the plan's renewal date in 2022. You can find that Drug List atHumana.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 by clicking "Pharmacy". Medical coverage may apply for some medicines.If your medicine is not on the Drug List, your healthcare provider can request Humana to approve a coverageexception. To submit an exception request, your healthcare provider can: Obtain forms at Humana.com/PASubmit the request electronically by visiting Covermymeds.com/epa/HumanaSubmit the request by fax to 877-486-2621Call Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (800-555-2546) (TTY: 711) between 8 a.m – 8 p.mEastern time, Monday - Friday. For a member in Puerto Rico, your healthcare provider can contact HCPR in PuertoRico at 866-488-5991 between 8 a.m – 8 p.m local time, Monday - Friday.The coverage exception request will be reviewed and our decision communicated within 24-72 hours after the requestis received from the heathcare provider.What if my medicine has additional requirements or limits?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.2 - DRUG LIST Updated 09/2021
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.If your medicine has an additional requirement, your healthcare provider can request Humana to approve a medicinethat requires prior authorization, quantity limit, or step therapy. To submit a request, your healthcare provider can: Obtain forms at Humana.com/PASubmit the request electronically by visiting Covermymeds.com/epa/HumanaSubmit the request by fax to 877-486-2621Call Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (800-555-2546) (TTY: 711) between 8 a.m – 8 p.mEastern time, Monday - Friday. For a member in Puerto Rico, your healthcare provider can contact HCPR in PuertoRico at 866-488-5991 between 8 a.m – 8 p.m local time, Monday – Friday.The coverage request will be reviewed and our decision of the coverage determination communicated within 24-72hours after the request is received from the heathcare provider.You can find out if your medicine has any additional requirements or limits by looking in the Drug List that begins onpage 5.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 preventive medicines that are covered at no cost to you when prescribed for preventive purposes. You musthave a prescription from your health care provider and fill the medication at a pharmacy in your plan's pharmacynetwork. Some contraceptive medicines covered on the Drug List may be available to you at no cost if medicallynecessary. Other contraceptive medicines not on the Drug List may be available to you at no cost if medicallynecessary. To ask for a medical necessity review for a contraceptive medicine, your health care provider can contactHumana Clinical Pharmacy Review (HCPR) at 800-555-2546 (TTY: 711) between 8 a.m. – 8 p.m. Eastern time, Monday– Friday. For a member in Puerto Rico, your health care provider can contact HCPR in Puerto Rico at 866-488-5991between 8 a.m. - 8 p.m. local time, Monday-Friday.Humana Pharmacy makes it easy to manage your prescriptions with mail delivery solutions.You may be able to fill your medicines through Humana Pharmacy - Humana's mail-delivery pharmacy. You can haveyour maintenance medicines, specialty medicines, or supplies mailed to a place that's most convenient for you. Youshould get your new prescription by mail in 7 -10 days after Humana Pharmacy has received your prescription and allthe necessary information. Refills should arrive within 5-7 days. To get started or learn more, visithumanapharmacy.com. You can also call Humana Pharmacy at 800-379-0092 (TTY: 711) Monday - Friday, 8 a.m. to11 p.m., and Saturday, 8 a.m. to 6:30 p.m., Eastern time.Other pharmacies are available in our network.DRUG LIST Updated 09/2021 - 3
For specific coverage and cost information for existing members: You may call the number on the back of your Humana ID card, or 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 2022 renewal date to see your new benefit information.-For More Information-Not 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.-2022 HDHP Drug List-The 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.ACA – Affordable Care Act 0 Preventive Medication Coverage. These medicines are available to you at no cost whenprescribed for preventive purposes. You must have a prescription from your health care provider and fill themedication at an in-network pharmacy for us to process a claim for preventive medicines or products under yourpharmacy plan. This list may not apply to all healthcare plans and may change over time. Some restrictions mayapply.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 09/2021
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) SOLUTIONMMabacavir 20 mg/ml solutionMMabacavir 300 mg tabletMMabacavir-lamivudine 600-300 mgMMabacavir-lamivudine-zidov tabMMABILIFY 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,DLabiraterone 500 mg tabletMM,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"MMacamprosate calc dr 333 mg tabMMacarbose 100 mg tabletMMacarbose 25 mg tabletMMacarbose 50 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 SAFE-T-PRO 23 GAUGEMMACCU-CHEK SAFE-T-PRO PLUS 23 GAUGEMMACCU-CHEK SMARTVIEW CONTROL SOLUTIONMMACCU-CHEK SMARTVIEW TEST STRIPSMMACCU-CHEK SOFTCLIX LANCETSMMST - Step Therapy QL - Quantity Limit PA - Prior 60 per 30 days)QL(60 per 30 days)QL(30 per 30 days)QL(60 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(60 per 30 days)PA,QL(120 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)DRUG LIST Updated 09/2021 - 5
DRUG NAMEACCU-CHEK SOFTCLIX LANCING DEVICE LANCETS KITMMaccutane 10 mg capsuleaccutane 20 mg capsuleaccutane 30 mg capsuleaccutane 40 mg capsuleACCUTREND GLUCOSE CONTROL SOLUTIONMMACCUTREND GLUCOSE TEST STRIPSMMACE AEROSOL CLOUD ENHANCER SPACERacebutolol 200 mg capsuleMMacebutolol 400 mg capsuleMMacetamin-codein 300-30 mg/12.5DLacetaminop-codeine 120-12 mg/5DLacetaminop-codeine 120-12 mg/5DLacetaminophen-cod #2 tabletDLacetaminophen-cod #3 tabletDLacetaminophen-cod #4 tabletDLacetazolamide 125 mg tabletMMacetazolamide 250 mg tabletMMacetazolamide er 500 mg capMMacetic acid 2% ear solutionacetylcysteine 10% vialacetylcysteine 20% vialacitretin 10 mg capsuleSP,DLacitretin 17.5 mg capsuleSP,DLacitretin 25 mg capsuleSP,DLACTHAR 80 UNIT/ML INJECTION GELSP,LD,DLACTI-LANCE LANCETS 17 GAUGEMMACTI-LANCE LANCETS 23 GAUGEMMACTI-LANCE LANCETS 28 GAUGEMMACTIMMUNE 100 MCG (2 MILLION UNIT)/0.5 ML SUBCUTANEOUS SOLUTIONSP,DLacyclovir 200 mg capsuleMMacyclovir 200 mg/5 ml suspMMacyclovir 400 mg tabletMMacyclovir 5% ointmentacyclovir 800 mg tabletMMADACEL (TDAP ADOLESN/ADULT)(PF)2 LF-(2.5-5-3-5)-5 LF/0.5 ML IM SYRINGEACAADACEL (TDAP ADOLESN/ADULT)(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSPACAadapalene 0.1% creamadapalene 0.1% geladapalene-bnzyl perox 0.1-2.5%adefovir dipivoxil 10 mg tabSP,DLADEMPAS 0.5 MG TABLETMM,SP,DLADEMPAS 1 MG TABLETMM,SP,DLADEMPAS 1.5 MG TABLETMM,SP,DLADEMPAS 2 MG TABLETMM,SP,DLADEMPAS 2.5 MG TABLETMM,SP,DLADJUSTABLE LANCING DEVICEADVAIR HFA 115 MCG-21 MCG/ACTUATION AEROSOL INHALERMMADVAIR HFA 230 MCG-21 MCG/ACTUATION AEROSOL INHALERMMADVAIR HFA 45 MCG-21 MCG/ACTUATION AEROSOL INHALERMMADVANCED LANCING DEVICE KITMMADVANCED TRAVEL LANCETS 28 GAUGEMMADVANCED TRAVEL LANCETS 30 GAUGEMMADVOCATE CONTROL SOLUTION HIGHMMADVOCATE LANCET 26 GAUGEMMST - Step Therapy QL - Quantity Limit PA - Prior Authorization6 - DRUG LIST Updated 09/2021UTILIZATIONMANAGEMENTREQUIREMENTSQL(60 per 30 days)QL(60 per 30 days)QL(60 per 30 days)QL(120 per 30 days)QL(150 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(120 per 30 days)QL(120 per 30 days)QL(60 per 30 days)PAPAPAPA,QL(30 per 30 days)PA,QL(12 per 30 days)PAPA,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(12 per 30 days)QL(12 per 30 days)QL(12 per 30 days)
DRUG NAMEADVOCATE 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 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"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 KITAEROTRACH PLUS SPACERAEROVENT PLUS SPACERAFINITOR 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 tabletMM,ACAAFLURIA QD 2021-22 (36 MOS UP)(PF)60 MCG (15 MCG X4)/0.5 ML IM SYRINGEACAAFLURIA QD 2021-22 (6-35 MOS)(PF) 30 MCG(7.5 MCGX4)/0.25 ML IM SYRINGEACAAFLURIA QUAD 2021-2022 60 MCG (15 MCG X 4)/0.5 ML INTRAMUSCULAR SUSP.ACAAGAMATRIX CONTROL HIGH SOLUTIONMMAGAMATRIX CONTROL NORM-HI SOLUTIONMMAIMOVIG AUTOINJECTOR 140 MG/ML SUBCUTANEOUS AUTO-INJECTORMMAIMOVIG AUTOINJECTOR 70 MG/ML SUBCUTANEOUS AUTO-INJECTORMMak-poly-bac 500 unit-10,000 unit/gram eye ointmentalbendazole 200 mg tabletalbuterol 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 tabMMST - Step Therapy QL - Quantity Limit PA - Prior L(30 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(1 per 30 days)PA,QL(2 per 30 days)QL(36 per 30 days)DRUG LIST Updated 09/2021 - 7
DRUG NAMEalbuterol sulfate er 8 mg tabMMALCAINE 0.5 % EYE DROPSalclometasone dipr 0.05% ointALECENSA 150 MG CAPSULEMM,SP,LD,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,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 tabletMMalosetron hcl 0.5 mg tabletSP,DLalosetron hcl 1 mg tabletSP,DLalprazolam 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 tabletDLaltavera (28) 0.15 mg-0.03 mg tabletMM,ACAALTERNATE SITE LANCET 26 GAUGEMMALTERNATE SITE LANCING DEVICEALUNBRIG 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,DLalyacen 1/35 (28) 1 mg-35 mcg tabletMM,ACAalyacen 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tabletMM,ACAalyq 20 mg tabletMMamabelz 0.5 mg-0.1 mg tabletMMamabelz 1 mg-0.5 mg tabletMMamantadine 100 mg capsuleMMamantadine 50 mg/5 ml solutionMMambrisentan 10 mg tabletMM,SP,DLambrisentan 5 mg tabletMM,SP,DLamethia 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose packMMamethia lo tabletMMamethyst (28) 90 mcg-20 mcg tabletMM,ACAamiloride hcl 5 mg tabletMMamiloride hcl-hctz 5-50 mg tabMMAMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONAMINOSYN 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONAMINOSYN II 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTIONAMINOSYN M 3.5 % INTRAVENOUS SOLUTIONST - Step Therapy QL - Quantity Limit PA - Prior Authorization8 - DRUG LIST Updated 09/2021UTILIZATIONMANAGEMENTREQUIREMENTSPA,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)PA,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)PA,QL(30 per 30 days)PA,QL(180 per 30 days)PA,QL(30 per 30 days)PA,QL(30 per 30 days)PA,QL(60 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)
DRUG NAMEAMINOSYN-HBC 7% INTRAVENOUS SOLUTIONamiodarone hcl 100 mg tabletMMamiodarone hcl 200 mg tabletMMamiodarone hcl 400 mg tabletMMamitriptyline hcl 10 mg tabMMamitriptyline hcl 100 mg tabMMamitriptyline hcl 150 mg tabMMamitriptyline hcl 25 mg tabMMamitriptyline hcl 50 mg tabMMamitriptyline hcl 75 mg tabMMamlodipine besylate 10 mg tabMMamlodipine besylate 2.5 mg tabMMamlodipine besylate 5 mg tabMMamlodipine-benazepril 10-20 mgMMamlodipine-benazepril 10-40 mgMMamlodipine-benazepril 2.5-10MMamlodipine-benazepril 5-10 mgMMamlodipine-benazepril 5-20 mgMMamlodipine-benazepril 5-40 mgMMamlodipine-valsartan 10-160 mgMMamlodipine-valsartan 10-320 mgMMamlodipine-valsartan 5-160 mgMMamlodipine-valsartan 5-320 mgMMammonium 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 tabletMMamoxapine 150 mg tabletMMamoxapine 25 mg tabletMMamoxapine 50 mg tabletMMamoxicillin 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 tabletamoxicillin 875 mg tabletampicillin 250 mg capsuleampicillin 500 mg capsuleanagrelide hcl 0.5 mg capsuleMManagrelide hcl 1 mg capsuleMMST - Step Therapy QL - Quantity Limit PA - Prior 0 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 LIST Updated 09/2021 - 9
DRUG NAMEanastrozole 1 mg tabletMM,ACAANGELIQ 0.25 MG-0.5 MG TABLETMMANGELIQ 0.5 MG-1 MG TABLETMMANORO ELLIPTA 62.5 MCG-25 MCG/ACTUATION POWDER FOR INHALATIONMManusol-hc 2.5 % topical cream with perineal applicatorapo-varenicline 0.5 mg tabletACAapo-varenicline 1 mg tabletACAapraclonidine hcl 0.5% dropsaprepitant 125 mg capsuleaprepitant 125-80-80 mg packaprepitant 40 mg capsuleaprepitant 80 mg capsuleapri 0.15 mg-0.03 mg tabletMM,ACAAPTIVUS 100 MG/ML SOLUTIONMM,SPAPTIVUS 250 MG CAPSULEMM,SPAQUA LANCE LANCING DEVICEaranelle (28) 0.5 mg/1 mg/0.5 mg-35 mcg tabletMMarformoterol 15 mcg/2 ml solnMM,SP,DLaripiprazole 1 mg/ml solutionMMaripiprazole 10 mg tabletMMaripiprazole 15 mg tabletMMaripiprazole 2 mg tabletMMaripiprazole 20 mg tabletMMaripiprazole 30 mg tabletMMaripiprazole 5 mg tabletMMARISTADA 1,064 MG/3.9 ML SUSPENSION, EXTEND.REL. IM SYRINGEMM,SPARISTADA 441 MG/1.6 ML SUSPENSION, EXTEND.REL. IM SYRINGEMM,SP,DLARISTADA 662 MG/2.4 ML SUSPENSION, EXTEND.REL. IM SYRINGEMM,SP,DLARISTADA 882 MG/3.2 ML SUSPENSION, EXTEND.REL. IM SYRINGEMM,SP,DLARISTADA INITIO 675 MG/2.4 ML SUSPENSION, EXTEND.REL. IM SYRINGESPARMOUR THYROID 120 MG TABLETMMARMOUR THYROID 15 MG TABLETMMARMOUR THYROID 180 MG TABLETMMARMOUR THYROID 240 MG TABLETMMARMOUR THYROID 30 MG TABLETMMARMOUR THYROID 300 MG TABLETMMARMOUR THYROID 60 MG TABLETMMARMOUR THYROID 90 MG TABLETMMARNUITY ELLIPTA 100 MCG/ACTUATION POWDER FOR INHALATIONMMARNUITY ELLIPTA 200 MCG/ACTUATION POWDER FOR INHALATIONMMARNUITY ELLIPTA 50 MCG/ACTUATION POWDER FOR INHALATIONMMashlyna 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose packMMaspirin-dipyridam er 25-200 mgMMASSURE 4 CONTROL SOLUTION COMBO PACKMMASSURE COMFORT 28G LANCETSMMASSURE DOSE NORMAL CONTROL SOLUTIONMMASSURE DOSE NORMAL-HIGH CONTROL SOLUTIONMMASSURE HAEMOLANCE PLUS 18 GAUGEMMASSURE HAEMOLANCE PLUS 21 GAUGEMMASSURE HAEMOLANCE PLUS 25 GAUGEMMASSURE HAEMOLANCE PLUS 28 GAUGEMMASSURE ID DUO-SHIELD 30 GAUGE X 3/16" NEEDLEMMASSURE ID DUO-SHIELD 30 GAUGE X 5/16" NEEDLEMMASSURE ID INSULIN SAFETY 0.5 ML 29 GAUGE X 1/2" SYRINGEMMST - Step Therapy QL - Quantity Limit PA - Prior Authorization10 - DRUG LIST Updated 09/2021UTILIZATIONMANAGEMENTREQUIREMENTSQL(30 per 30 days)QL(60 per 30 days)QL(56 per 28 days)QL(56 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(285 per 28 days)QL(120 per 30 days)PA,QL(120 per 30 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(3.9 per 56 days)QL(1.6 per 28 days)QL(2.4 per 28 days)QL(3.2 per 28 days)QL(2.4 per 42 days)QL(30 per 30 days)QL(30 per 30 days)QL(30 per 30 days)QL(91 per 90 days)ST
DRUG NAMEASSURE ID INSULIN SAFETY 0.5 ML 31 GAUGE X 15/64" SYRINGEMMASSURE ID INSULIN SAFETY 1 ML 29 GAUGE X 1/2" SYRINGEMMASSURE ID INSULIN SAFETY 1 ML 31 GAUGE X 15/64" SYRINGEMMASSURE ID PEN NEEDLE 30 GAUGE X 3/16"MMASSURE ID PEN NEEDLE 30 GAUGE X 5/16"MMASSURE ID PEN NEEDLE 31 GAUGE X 3/16"MMASSURE LANCE 25 GAUGEMMASSURE LANCE 28 GAUGEMMASSURE LANCE PLUS 21 GAUGEMMASSURE LANCE PLUS 25 GAUGEMMASSURE LANCE PLUS 30 GAUGEMMASSURE PRISM CONTROL 1-2 SOLUTIONMMASTAGRAF XL 0.5 MG CAPSULE,EXTENDED RELEASEMMASTAGRAF XL 1 MG CAPSULE,EXTENDED RELEASEMMASTAGRAF XL 5 MG CAPSULE,EXTENDED RELEASEMMASTHMAPACK CHILDREN'S KITatazanavir sulfate 150 mg capMMatazanavir sulfate 200 mg capMMatazanavir sulfate 300 mg capMMatenolol 100 mg tabletMMatenolol 25 mg tabletMMatenolol 50 mg tabletMMatenolol-chlorthalidone 100-25MMatenolol-chlorthalidone 50-25MMatomoxetine hcl 10 mg capsuleMMatomoxetine hcl 100 mg capsuleMMatomoxetine hcl 18 mg capsuleMMatomoxetine hcl 25 mg capsuleMMatomoxetine hcl 40 mg capsuleMMatomoxetine hcl 60 mg capsuleMMatomoxetine hcl 80 mg capsuleMMatorvastatin 10 mg tabletMM,ACAatorvastatin 20 mg tabletMM,ACAatorvastatin 40 mg tabletMM,ACAatorvastatin 80 mg tabletMM,ACAatovaquone 750 mg/5 ml suspSP,DLatovaquone-proguanil 250-100atovaquone-proguanil 62.5-25atropine 1% eye dropsMMaubra 0.1 mg-20 mcg tabletMM,ACAaubra eq 0.1 mg-20 mcg tabletMM,ACAaurovela 1.5/30 (21) 1.5 mg-30 mcg tabletMM,ACAaurovela 1/20 (21) 1 mg-20 mcg tabletMM,ACAaurovela 24 fe 1 mg-20 mcg (24)/75 mg (4) tabletMM,ACAaurovela fe 1-20 (28) 1 mg-20 mcg (21)/75 mg (7) tabletMM,ACAaurovela fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) tabletMM,ACAAUSTEDO 12 MG TABLETMM,SP,LD,DLAUSTEDO 6 MG TABLETMM,SP,LD,DLAUSTEDO 9 MG TABLETMM,SP,LD,DLAUTO-LANCET MINIAUTOJECT 2 INJECTION DEVICE SUBCUTANEOUS INSULIN PENMMAUTOLET IMPRESSION LANCING DEVICE KITMMAUTOLET LANCING DEVICEAUTOLET PLUS LANCING DEVICEST - Step Therapy QL - Quantity Limit PA - Prior 0 per 30 days)QL(60 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(600 per 30 days)QL(30 per 30 days)QL(30 per 30 days)PA,QL(120 per 30 days)PA,QL(60 per 30 days)PA,QL(120 per 30 days)DRUG LIST Updated 09/2021 - 11
DRUG NAMEAUTOPEN 1 TO 21 UNITS SUBCUTANEOUSMMAUTOPEN 2 TO 42 UNITS SUBCUTANEOUSMMaviane 0.1 mg-20 mcg tabletMM,ACAavidoxy 100 mg tabletAVONEX 30 MCG VIAL KITMM,SP,DLAVONEX 30 MCG/0.5 ML INTRAMUSCULAR PEN KITMM,SP,DLAVONEX 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE KITMM,SP,DLayuna 0.15 mg-0.03 mg tabletMM,ACAazathioprine 50 mg tabletMMazelastine 0.1% (137 mcg) spryMMazelastine 0.15% nasal sprayMMazelastine hcl 0.05% dropsazithromycin 1 gm pwd packetazithromycin 100 mg/5 ml suspazithromycin 200 mg/5 ml suspazithromycin 250 mg tabletazithromycin 500 mg tabletazithromycin 600 mg tabletazurette (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tabletMM,ACAbacitracin 500 unit/gm ophthbacitracin-polymyxin eye ointbaclofen 10 mg tabletMMbaclofen 20 mg tabletMMbaclofen 5 mg tabletMMBALCOLTRA 0.1 MG-0.02 MG(21)/36.5 MG(7) TABLETMMbalsalazide disodium 750 mg cpBALVERSA 3 MG TABLETMM,SP,DLBALVERSA 4 MG TABLETMM,SP,DLBALVERSA 5 MG TABLETMM,SP,DLbalziva (28) 0.4 mg-35 mcg tabletMM,ACABAQSIMI 3 MG/ACTUATION NASAL SPRAYBARACLUDE 0.05 MG/ML ORAL SOLUTIONMM,SP,DLBAXDELA 450 MG TABLETBD ALLERGIST TRAY REG BEVEL 1 ML 26 GAUGE X 1/2" SYRINGEBD ALLERGIST TRAY REG BEVEL 1 ML 27 X 1/2" SYRINGEBD ALLERGIST TRAY REG BEVEL 1/2 ML 27 X 1/2"BD AUTOSHIELD DUO PEN NEEDLE 30 GAUGE X 3/16"MMBD BLUNT NEEDLE 18GX1-1/2"BD ECLIPSE LUER-LOK 1 ML 30 GAUGE X 1/2" SYRINGEMMBD ECLIPSE NEEDLE 18GX1 1/2"BD FILTER NEEDLE-5 MICRON 19 X 1 1/2"BD INSULIN SYR 1 ML 28GX1/2"MMBD INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2"MMBD INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2"MMBD INSULIN SYRINGE 1 ML 25 GAUGE X 5/8"MMBD INSULIN SYRINGE 1 ML 25 X 1"MMBD INSULIN SYRINGE 1 ML 26 X 1/2"MMBD INSULIN SYRINGE 1 ML 27 GAUGE X 1/2"MMBD INSULIN SYRINGE 1 ML 28 GAUGE X 1/2"MMBD INSULIN SYRINGE 1 ML 29 GAUGE X 1/2"MMBD INSULIN SYRINGE MICRO-FINE 1 ML 28 GAUGE X 1/2"MMBD INSULIN SYRINGE SAFETY-LOK 1 ML 29 GAUGE X 1/2"MMBD INSULIN SYRINGE SLIP TIP 1 MLMMBD INSULIN SYRINGE U-500 1/2 ML 31 GAUGE X 15/64"BD INSULIN SYRINGE ULTRA-FINE (HALF UNIT) 0.3 ML 31 GAUGE X 5/16"MMST - Step Therapy QL - Quantity Limit PA - Prior Authorization12 - DRUG LIST Updated 09/2021UTILIZATIONMANAGEMENTREQUIREMENTSPA,QL(4 per 28 days)PA,QL(1 per 28 days)PA,QL(1 per 28 days)QL(30 per 25 days)QL(30 per 25 days)QL(16 per 60 days)QL(240 per 30 days)QL(120 per 30 days)QL(90 per 30 days)QL(270 per 30 days)PA,QL(90 per 30 days)PA,QL(60 per 30 days)PA,QL(30 per 30 days)QL(630 per 30 days)QL(28 per 14 days)
DRUG NAMEBD INSULIN SYRINGE ULTRA-FINE 0.3 ML 30 GAUGE X 1/2"MMBD INSULIN SYRINGE ULTRA-FINE 0.3 ML 31 GAUGE X 5/16"MMBD INSULIN SYRINGE ULTRA-FINE 0.5 ML 30 GAUGE X 1/2"MMBD INSULIN SYRINGE ULTRA-FINE 0.5 ML 31 GAUGE X 5/16"MMBD INSULIN SYRINGE ULTRA-FINE 1 ML 30 GAUGE X 1/2"MMBD INSULIN SYRINGE ULTRA-FINE 1 ML 31 GAUGE X 5/16"MMBD INTEGRA SYRINGE 3 ML 25 GAUGE X 1"BD LANCETS 33GMMBD LO-DOSE MICRO-FINE IV 1/2 ML 28 GAUGE X 1/2" SYRINGEMMBD LO-DOSE ULTRA-FINE 0.5 ML 29 GAUGE X 1/2" SYRINGEMMBD LUER-LOK SYRINGE 1 MLMMBD MICROTAINER LANCET 21 GAUGEMMBD MICROTAINER LANCET 30 GAUGEMMBD NANO 2ND GEN PEN NEEDLE 32 GAUGE X 5/32"MMBD SAFETYGLIDE ALLERGIST TRAY 1 ML 27 X 1/2" SYRINGEBD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2"MMBD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 31 GAUGE X 15/64"MMBD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16"MMBD SAFETYGLIDE INSULIN SYRINGE 0.5 ML 3
When is the Drug List effective? The Drug List is effective on January 1st, except for Commercial Fully-Insured policies issued in Illinois, Louisiana, Puerto Rico, and Texas where Drug List changes are effective on a plan's renewal date. These States will continue to use the 2021 version of this Drug List until the plan's renewal date in 2022.
