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2015Printable Drug ListHumana FormularyThis is a partial list of covered drugsHDHP TraditionalDrug ListPlease read: This document containsinformation about the drugs we coverin this plan.Instructions for getting information about allcovered drugs are inside.Humana.comGCHHQ7XESAPDL0015B
Welcome to HumanaWWhat is the formulary?A formulary is a list of covered drugs selected by Humana.* Humana worked with a team of healthcare providers tomake sure the drugs on the formulary are safe and effective. Humana will cover the drugs listed in our formularyas long as the drug is medically necessary, the prescription is filled at a Humana network pharmacy and other planrules are followed. For more information on how to fill your prescriptions, please review your Certificate ofCoverage/Insurance or Summary Plan Description or Policy of Insurance.Can the formulary change?The Humana Pharmacy & Therapeutics (P&T) Committee reviews and updates the formulary regularly. New drugsare added as needed, and drugs that are deemed unsafe by the Food and Drug Administration (FDA) or a drug'smanufacturer are immediately removed. Members taking a drug removed from the formulary will be notified.We communicate changes to the formulary to members based on the drug list notification requirementsestablished by each state. You can view the most up-to-date formulary on Humana.com.The enclosed formulary is effective as of January 1, 2015. ** This is a partial formulary and includes the mostcommonly prescribed drugs.To get updated information about the drugs that Humana covers and estimated costs, please visit Humana.comand sign into MyHumana. You can access the drug search tool through “Drug Pricing” under “Plan Tools” at thebottom of the page. The search tool lets you search for your drug by name or by your condition.How do I use the formulary?Drugs are listed in the formulary alphabetically.How much will I pay for covered drugs?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.Are there any restrictions on my coverage?Some covered drugs 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 yourpharmacy plan. For these medicines to be covered, your doctor must get approval from Humana. Your planbenefits won't cover this drug without prior authorization. You'll pay the entire cost of the drug if you buy itwithout first obtaining a prior authorization. Quantity limits (QL): You may have a limit on how much you can get of some drugs at one time. Theselimits can be placed on some drugs because of safety or health care concerns and help prevent misuse ofthese drugs. If your prescription is over the limit there are two choices:––You can get the amount of drug that’s covered by your plan, and then pay for any drug that's overthe limit.OrIf your doctor thinks you need more than the amount allowed, he or she can ask for prior authorizationfrom Humana for the amount of the drug that goes over the limit.ABBREVIATED FORMULARY Updated 08/2014 - 3
Step therapy (ST): Sometimes there's more than one drug that works to treat a health condition. Somedrugs may cost less but still work for you. Before a prescription is filled for a drug that costs more, you maybe asked to try at least one other drug first.Talk to your doctor or health care provider if your drug has an additional requirement. Ask your doctor or healthcare provider to contact Humana Clinical Pharmacy Review (HCPR) to ask for approval for a drug that requires priorauthorization. Your doctor can contact HCPR at 1-800-555-2546 between 8 a.m. – 6 p.m., Monday – Friday torequest an exception. Please allow 24-48 hours for Humana to review and provide a response back to your doctor.You can find out if your drug has any additional requirements or limits by looking in the formulary that begins onpage 7.What if my drug is not on the formulary?If your drug isn’t included in this printed list of covered drugs, you should visit Humana.com to see if your drug iscovered. You can use the drug search tool by signing into MyHumana to view alternatives for your drug. You canaccess the drug search tool through “Drug Pricing” under “Plan Tools” at the bottom of the page.If Humana doesn’t cover your drug, your doctor can ask Humana to make an exception to cover your drug if it’s noton our formulary. Generally, Humana will only approve a request for an exception if the alternative covered drugswouldn’t be as effective in treating your health condition and/or would cause adverse medical effects. To ask foran exception, your doctor can contact HCPR at 1-800-555-2546 between 8 a.m. – 6 p.m., Monday – Friday.4 - ABBREVIATED FORMULARY Updated 08/2014
For More InformationW For More InformationFor more detailed information about your Humana prescription drug coverage, please review your Certificate ofInsurance/Summary Plan Description/Policy of Insurance and other plan materials.If you have questions:* Prospective members should call the Customer Care number listed in your enrollment materials* Current members should call the number on the back of your Humana member ID cardABBREVIATED FORMULARY Updated 08/2014 - 5
HDHP Traditional Drug ListwThe formulary that begins on the next page provides coverage information about some of the drugs coveredby Humana.How to read your formularyThe first column of the chart lists drug names in alphabetical order. Brand-name drugs are listed in UPPER CASEand generic drugs are listed in lower case. Next to the drug name you may see the following indicators to tell youabout additional coverage information for that drug:MM – Maintenance drugs are taken long-term such as drugs you take for high cholesterol, mental health, orhypertension. Coverage varies by plan and you may be required to fill your prescriptions using your plan’smail-order pharmacy.SP – Specialty medications are typically high cost/high-technology drugs that require special dispensing andmonitoring. Specialty drug coverage varies by plan.The second column shows the utilization management requirements for the drug. Utilization managementrequirements mean that Humana may have special rules for covering that drug. These can include priorauthorization, quantity limits, or step therapy requirements. The quantity limit for each drug is based on safety orhealth care concerns and whether your doctor prescribes a supply for 30, 60, or 90 days. See page 3 for moredetails on these requirements for your plan.6 - ABBREVIATED FORMULARY Updated 08/2014
for PDL007DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSACANYA 1.2 %-2.5 % TOPICAL GELACCU-CHEK ACTIVE GLUCOSE CONT COMBO PACKACCU-CHEK ACTIVE TEST STRIPSQLMMACCU-CHEK AVIVA CONTROL SOLN SOLUTIONACCU-CHEK AVIVA PLUS METERACCU-CHEK AVIVA PLUS TEST STRIPSACCU-CHEK AVIVA STRIPSQLMMQLMMACCU-CHEK COMFORT CURVE COMBO PACKACCU-CHEK COMFORT CURVE LINEAR COMBO PACKACCU-CHEK COMFORT CURVE SOLUTIONACCU-CHEK COMFORT CURVE TEST STRIPSMMQLACCU-CHEK COMPACT BLUE CONTROL, MID-HIGH SOLUTIONACCU-CHEK COMPACT GLUCOSE CONT COMBO PACKACCU-CHEK COMPACT PLUS CARE KITACCU-CHEK COMPACT PLUS CONTROL SOLUTIONACCU-CHEK COMPACT PLUS TEST STRIPSACCU-CHEK COMPACT TEST STRIPSMMQLQLMMACCU-CHEK FASTCLIXACCU-CHEK FASTCLIX KITACCU-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 SOLUTIONACCU-CHEK SMARTVIEW TEST STRIPSMMQLACCU-CHEK SOFTCLIX LANCET DEVACCU-CHEK SOFTCLIX LANCETSACCU-CHEK SOFTCLIX LANCING DEVICE LANCETS KITACCU-CHEK VOICEMATE KITacetaminophen-cod #3 tabletQLACZONE 5 % TOPICAL GELADDERALL XR 10 MG CAPSULE,EXTENDED RELEASEQLADDERALL XR 15 MG CAPSULE,EXTENDED RELEASEQLST – Step Therapy QL – Quantity Limit PA – Prior AuthorizationABBREVIATED FORMULARY Updated 08/2014 - 7
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSADDERALL XR 20 MG CAPSULE,EXTENDED RELEASEQLADDERALL XR 25 MG CAPSULE,EXTENDED RELEASEQLADDERALL XR 30 MG CAPSULE,EXTENDED RELEASEQLADDERALL XR 5 MG CAPSULE,EXTENDED RELEASEQLallopurinol 300 mg tabletMMalprazolam 0.25 mg tabletQLalprazolam 0.5 mg tabletQLalprazolam 1 mg tabletQLALVESCO 160 MCG/ACTUATION AEROSOL INHALERALVESCO 80 MCG/ACTUATION AEROSOL INHALERAMITIZA 24 MCG CAPSULEAMITIZA 8 MCG CAPSULEQLMMQLMMQLMMQLMMamlodipine besylate 10 mg tabamlodipine besylate 5 mg tabQLMMQLMMamox tr-k clv 875-125 mg tabamoxicillin 400 mg/5 ml suspamoxicillin 500 mg capsuleamoxicillin 875 mg tabletamphetamine salt combo 10 mg tabletQLamphetamine salt combo 20 mg tabletQLamphetamine salt combo 30 mg tabletQLAMTURNIDE 150 MG-5 MG-12.5 MG TABLETAMTURNIDE 300 MG-10 MG-12.5 MG TABLETAMTURNIDE 300 MG-10 MG-25 MG TABLETAMTURNIDE 300 MG-5 MG-12.5 MG TABLETAMTURNIDE 300 MG-5 MG-25 MG TABLETQLMMQLMMQLMMQLMMQLMMANDROGEL 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKETANDROGEL 1 % (50 MG/5 GRAM) TRANSDERMAL GEL PACKETQLMMQLMMANDROGEL 1.25 GRAM/ACTUATION (1%) TRANSDERMAL GEL PUMPANDROGEL 1.62 % (20.25 MG/1.25 GRAM) TRANSDERMAL GEL PACKETANDROGEL 1.62 % (40.5 MG/2.5 GRAM) TRANSDERMAL GEL PACKETANDROGEL 20.25 MG/1.25 GRAM (1.62 %) TRANSDERMAL GEL PUMPAPRISO 0.375 GRAM CAPSULE,EXTENDED RELEASEST – Step Therapy QL – Quantity Limit PA – Prior Authorization8 - ABBREVIATED FORMULARY Updated 08/2014MMMMMMQLQLQLQLMMARCAPTA NEOHALER 75 MCG CAPSULE WITH INHALATION DEVICEQLMMMMQL
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSASMANEX TWISTHALER 110 MCG (30 DOSES) BREATH ACTIVATEDQLMMASMANEX TWISTHALER 220 MCG (120 DOSES) BREATH ACTIVATEDQLMMASMANEX TWISTHALER 220 MCG (14 DOSES) BREATH ACTIVATEDMMQLASMANEX TWISTHALER 220 MCG (30 DOSES) BREATH ACTIVATEDMMQLASMANEX TWISTHALER 220 MCG (60 DOSES) BREATH ACTIVATEDMMQLASTEPRO 0.15 % (205.5 MCG) NASAL SPRAYATELVIA 35 MG TABLET,DELAYED RELEASEatenolol 50 mg tabletQLMMQLMMMMAUBAGIO 14 MG TABLETAUBAGIO 7 MG TABLETQL,PASPQL,PASPAVONEX 30 MCG INTRAMUSCULAR KITQL,PASPAVONEX 30 MCG/0.5 ML INTRAMUSCULAR PEN KITQL,PASPAVONEX ADMINISTRATION PACK 30 MCG/0.5 ML INTRAMUSCULAR KITQL,PASPAXIRON 30 MG/ACTUATION (1.5 ML) TRANSDERM SOLUTION IN METERED PUMPAZASITE 1 % EYE DROPSMMQLQLazithromycin 250 mg tabletbenzonatate 100 mg capsulebenzonatate 200 mg capsuleBETASERON 0.3 MG SUBCUTANEOUS KITBEYAZ 3 MG-0.02 MG-0.451 MG (24) TABLETBRILINTA 90 MG TABLETQL,PASPMMQLMMbromfed dm 2 mg-30 mg-10 mg/5 ml syrupbupropion hcl sr 150 mg tabletMMQLbupropion hcl xl 150 mg tabletMMQLbupropion hcl xl 300 mg tabletMMQLBYDUREON 2 MG SUBCUTANEOUS EXTENDED RELEASE SUSPENSIONBYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTORBYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTORCAMBIA 50 MG ORAL POWDER PACKETCANASA 1,000 MG RECTAL SUPPOSITORYQL,STMMMMMMQL,STQL,STQLMMQLcefdinir 300 mg capsulecephalexin 500 mg capsulechlorhexidine 0.12% rinseciprofloxacin hcl 500 mg tabST – Step Therapy QL – Quantity Limit PA – Prior AuthorizationABBREVIATED FORMULARY Updated 08/2014 - 9
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTScitalopram hbr 20 mg tabletMMQLcitalopram hbr 40 mg tabletMMQLCLIMARA PRO 0.045 MG-0.015 MG/24 HR TRANSDERMAL PATCHQLMMclindamycin hcl 300 mg capsuleclonazepam 0.5 mg tabletclonazepam 1 mg tabletCOLCRYS 0.6 MG TABLETMMMMQLMMCOPAXONE 20 MG/ML SUBCUTANEOUS SYRINGE KITQL,PASPCOPAXONE 40 MG/ML SUBCUTANEOUS SYRINGESPQL,PACOREG CR 10 MG CAPSULE, EXTENDED RELEASEMMQLCOREG CR 20 MG CAPSULE, EXTENDED RELEASEMMQLCOREG CR 40 MG CAPSULE, EXTENDED RELEASEMMQLCOREG CR 80 MG CAPSULE, EXTENDED RELEASEMMQLCREON 12,000-38,000-60,000 UNIT CAPSULE,DELAYED RELEASEMMCREON 24,000-76,000-120,000 UNIT CAPSULE,DELAYED RELEASECREON 3,000-9,500-15,000 UNIT CAPSULE,DELAYED RELEASEMMMMCREON 36,000-114,000-180,000 UNIT CAPSULE,DELAYED RELEASECREON 6,000-19,000-30,000 UNIT CAPSULE,DELAYED RELEASEMMMMCRESTOR 10 MG TABLETMMQLCRESTOR 20 MG TABLETMMQLCRESTOR 40 MG TABLETMMQLCRESTOR 5 MG TABLETQLMMCRIXIVAN 400 MG CAPSULEQLSPcyclobenzaprine 10 mg tabletdiazepam 5 mg tabletQLdoxycycline hyclate 100 mg capQLDULERA 100 MCG-5 MCG/ACTUATION HFA AEROSOL INHALERMMQLDULERA 200 MCG-5 MCG/ACTUATION HFA AEROSOL INHALERMMQLDYMISTA 137 MCG-50 MCG/SPRAY NASAL SPRAYEFFIENT 10 MG TABLETEFFIENT 5 MG TABLETQLQLMMQLMMENBREL 25 MG (1 ML) SUBCUTANEOUS KITQL,STQLMMMMELIQUIS 2.5 MG TABLETELIQUIS 5 MG TABLETMMSPST – Step Therapy QL – Quantity Limit PA – Prior Authorization10 - ABBREVIATED FORMULARY Updated 08/2014QL,PA
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSENBREL 25 MG/0.5 ML (0.51 ML) SUBCUTANEOUS SYRINGEENBREL 50 MG/ML (0.98 ML) SUBCUTANEOUS SYRINGEQL,PASPQL,PASPENBREL SURECLICK 50 MG/ML (0.98 ML) SUBCUTANEOUS PEN INJECTORSPQL,PAEPIDUO 0.1 %-2.5 % TOPICAL GELEPIDUO 0.1 %-2.5 % TOPICAL GEL WITH PUMPEPIPEN 2-PAK 0.3 MG/0.3 ML (1:1,000) INJECTION,AUTO-INJECTOREPIPEN JR 2-PAK 0.15 MG/0.3 ML (1:2,000) INJECTION,AUTO-INJECTORestradiol 1 mg tabletMMFINACEA 15 % TOPICAL GELFLOVENT DISKUS 100 MCG/ACTUATION POWDER FOR INHALATIONMMQLFLOVENT DISKUS 250 MCG/ACTUATION POWDER FOR INHALATIONMMQLFLOVENT DISKUS 50 MCG/ACTUATION POWDER FOR INHALATIONMMQLFLOVENT HFA 110 MCG/ACTUATION AEROSOL INHALERMMQLFLOVENT HFA 220 MCG/ACTUATION AEROSOL INHALERMMQLFLOVENT HFA 44 MCG/ACTUATION AEROSOL INHALERQLMMfluconazole 150 mg tabletfluoxetine hcl 20 mg capsuleQLMMfluticasone prop 50 mcg sprayQLMMFORADIL AEROLIZER 12 MCG CAPSULE WITH INHALATION DEVICEfurosemide 40 mg tabletMMQLMMgabapentin 300 mg capsuleQLMMGENOTROPIN 12 MG/ML (36 UNIT/ML) SUBCUTANEOUS CARTRIDGEGENOTROPIN 5 MG/ML (15 UNIT/ML) SUBCUTANEOUS CARTRIDGESPQL,PAQL,PASPGENOTROPIN MINIQUICK 0.2 MG/0.25 ML SUBCUTANEOUS SYRINGESPQL,PAGENOTROPIN MINIQUICK 0.4 MG/0.25 ML SUBCUTANEOUS SYRINGESPQL,PAGENOTROPIN MINIQUICK 0.6 MG/0.25 ML SUBCUTANEOUS SYRINGESPQL,PAGENOTROPIN MINIQUICK 0.8 MG/0.25 ML SUBCUTANEOUS SYRINGESPQL,PAGENOTROPIN MINIQUICK 1 MG/0.25 ML SUBCUTANEOUS SYRINGEQL,PASPGENOTROPIN MINIQUICK 1.2 MG/0.25 ML SUBCUTANEOUS SYRINGESPQL,PAGENOTROPIN MINIQUICK 1.4 MG/0.25 ML SUBCUTANEOUS SYRINGESPQL,PAGENOTROPIN MINIQUICK 1.6 MG/0.25 ML SUBCUTANEOUS SYRINGESPQL,PAGENOTROPIN MINIQUICK 1.8 MG/0.25 ML SUBCUTANEOUS SYRINGESPQL,PAGENOTROPIN MINIQUICK 2 MG/0.25 ML SUBCUTANEOUS SYRINGEGIANVI (28) 3 MG-20 MCG TABLETSPQL,PAMMST – Step Therapy QL – Quantity Limit PA – Prior AuthorizationABBREVIATED FORMULARY Updated 08/2014 - 11
DRUG NAMEGILENYA 0.5 MG ALOG 100 UNIT/ML SUBCUTANEOUS CARTRIDGEHUMALOG 100 UNIT/ML SUBCUTANEOUS SOLUTIONHUMALOG KWIKPEN 100 UNIT/ML SUBCUTANEOUSQLMMQLMMMMHUMALOG MIX 50-50 100 UNIT/ML SUBCUTANEOUS SUSPENSIONMMHUMALOG MIX 50-50 KWIKPEN 100 UNIT/ML SUBCUTANEOUS PENHUMALOG MIX 75-25 100 UNIT/ML SUBCUTANEOUS SUSPENSIONMMMMHUMALOG MIX 75-25 KWIKPEN 100 UNIT/ML SUBCUTANEOUS INSULIN PENMMHUMIRA 20 MG/0.4 ML SUBCUTANEOUS KITSPQL,PAHUMIRA 40 MG/0.8 ML SUBCUTANEOUS KITSPQL,PAHUMIRA CROHN'S DISEASE STARTER PACK 40 MG/0.8 ML SUBCUTANEOUS PEN KITHUMIRA PEN 40 MG/0.8 ML SUBCUTANEOUSQL,PAQL,PASPHUMIRA PSORIASIS STARTER PACK 40 MG/0.8 ML SUBCUTANEOUS PEN KITHUMULIN 70-30 PENSPQL,PASPMMHUMULIN 70/30 100 UNIT/ML SUBCUTANEOUS SUSPENSIONHUMULIN N 100 UNIT/ML SUBCUTANEOUS SUSPENSIONHUMULIN N 100 UNITS/ML PENMMMMMMHUMULIN R 100 UNIT/ML INJECTION SOLUTIONMMHUMULIN R U-500 "CONCENTRATED" INSULIN 500 UNIT/ML SUBCUTANEOUS SOLNhydrochlorothiazide 25 mg tabMMMMhydrocodon-acetaminoph 7.5-325QLhydrocodon-acetaminoph 7.5-500QLhydrocodon-acetaminoph 7.5-750QLhydrocodon-acetaminophen 5-325QLhydrocodon-acetaminophen 5-500QLhydrocodon-acetaminophn 10-325QLhydrocodon-acetaminophn 10-500QLibuprofen 600 mg tabletMMibuprofen 800 mg tabletMMINLYTA 1 MG TABLETSPQL,PAINLYTA 5 MG TABLETSPQL,PAJANUMET 50 MG-1,000 MG TABLETJANUMET 50 MG-500 MG TABLETQL,STMMQL,STMMJANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASEMMST – Step Therapy QL – Quantity Limit PA – Prior Authorization12 - ABBREVIATED FORMULARY Updated 08/2014QL,ST
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSJANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASEJANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASEJANUVIA 100 MG TABLETQL,STMMQL,STMMQL,STMMJANUVIA 25 MG TABLETMMJANUVIA 50 MG TABLETMMQL,STQL,STJENTADUETO 2.5 MG-1,000 MG TABLETQL,STMMJENTADUETO 2.5 MG-500 MG TABLETMMQL,STJENTADUETO 2.5 MG-850 MG TABLETMMQL,STKOMBIGLYZE XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASEKOMBIGLYZE XR 5 MG-1,000 MG TABLET,EXTENDED RELEASEKOMBIGLYZE XR 5 MG-500 MG TABLET,EXTENDED RELEASELANTUS 100 UNIT/ML SUBCUTANEOUS SOLUTIONLETAIRIS 5 MG TABLETQL,STMMQL,STMMMMLANTUS SOLOSTAR 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PENLETAIRIS 10 MG TABLETQL,STMMMMQL,PASPQL,PASPLEVEMIR 100 UNIT/ML SUBCUTANEOUS SOLUTIONMMLEVEMIR FLEXPEN 100 UNIT/ML (3 ML) SOLUTION SUBCUTANEOUS INSULIN PENlevothyroxine 100 mcg tabletMMlevothyroxine 125 mcg tabletMMlevothyroxine 25 mcg tabletMMlevothyroxine 50 mcg tabletMMlevothyroxine 75 mcg tabletMMLIALDA 1.2 GRAM TABLET,DELAYED RELEASEMMQLMMLINZESS 145 MCG CAPSULEMMQLLINZESS 290 MCG CAPSULEMMQLlisinopril 10 mg tabletMMlisinopril 20 mg tabletMMlisinopril 40 mg tabletMMlisinopril 5 mg tabletMMlisinopril-hctz 10-12.5 mg tabMMlisinopril-hctz 20-12.5 mg tabMMlisinopril-hctz 20-25 mg tabMMlosartan potassium 100 mg tablosartan potassium 50 mg tabQLMMQLMMST – Step Therapy QL – Quantity Limit PA – Prior AuthorizationABBREVIATED FORMULARY Updated 08/2014 - 13
DRUG NAMElow-ogestrel (28) 0.3 mg-30 mcg tabletlutera (28) 0.1 mg-20 mcg tabletmeloxicam 15 mg formin hcl 1,000 mg tabletmetformin hcl 500 mg tabletMMMMmethylphenidate er 36 mg tabQLmethylprednisolone 4 mg dosepkmetoprolol succ er 100 mg tabQLMMmetoprolol succ er 25 mg tabMMQLmetoprolol succ er 50 mg tabMMQLmetoprolol tartrate 50 mg tabMMmetronidazole 500 mg tabletmicrogestin fe 1/20 (28) 1 mg-20 mcg tabletMONONESSA (28) 0.25 MG-35 MCG TABLETmontelukast sod 10 mg tabletMULTAQ 400 MG TABLETMMMMQLMMQLMMmupirocin 2% ointmentnaproxen 500 mg tabletMMNASONEX 50 MCG/ACTUATION SPRAYQLMMNATAZIA 3 MG/2 MG-2 MG/2 MG-3 MG/1 MG TABLETnecon 1/35 (28) 1 mg-35 mcg tabletMMMMnitrofurantoin mono-mcr 100 mgNOVOFINE 30 30 X 1/3" NEEDLENOVOFINE 32 32 X 1/4" NEEDLENOVOFINE AUTOCOVER 30 X 1/3" NEEDLENOVOTWIST 30 X 1/3" NEEDLENOVOTWIST 32 X 1/5" NEEDLENUEDEXTA 20 MG-10 MG CAPSULEQLNUTROPIN AQ 10 MG/2 ML (5 MG/ML) SUBCUTANEOUS CARTRIDGEQL,PASPNUTROPIN AQ 20 MG/2 ML (10 MG/ML) SUBCUTANEOUS CARTRIDGEQL,PASPNUTROPIN AQ NUSPIN 10 MG/2 ML (5 MG/ML) SUBCUTANEOUS CARTRIDGESPNUTROPIN AQ NUSPIN 20 MG/2 ML (10 MG/ML) SUBCUTANEOUS CARTRIDGENUTROPIN AQ NUSPIN 5 MG/2 ML (2.5 MG/ML) SUBCUTANEOUS CARTRIDGENUVARING 0.12 MG -0.015 MG/24 HR VAGINALMMST – Step Therapy QL – Quantity Limit PA – Prior Authorization14 - ABBREVIATED FORMULARY Updated 08/2014SPSPQL,PAQL,PAQL,PAQL
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSNUVIGIL 150 MG TABLETMMQL,PANUVIGIL 200 MG TABLETMMQL,PANUVIGIL 250 MG TABLETMMQL,PANUVIGIL 50 MG TABLETQL,PAMMOCELLA 3 MG-0.03 MG TABLETMMomeprazole dr 20 mg capsuleMMQLomeprazole dr 40 mg capsuleMMQLONGLYZA 2.5 MG TABLETONGLYZA 5 MG TABLETQL,STMMQL,STMMOPANA ER 10 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASEQLOPANA ER 15 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASEQLOPANA ER 20 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASEQLOPANA ER 30 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASEQLOPANA ER 40 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASEQLOPANA ER 5 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASEQLOPANA ER 7.5 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASEQLORACEA 40 MG CAPSULE, EXTENDED RELEASEQLORTHO TRI-CYCLEN LO (28) 0.18 MG/0.215 MG/0.25 MG-25 MCG TABLETMMoxycodone-acetaminophen 10-325QLoxycodone-acetaminophen 5-325QLpantoprazole sod dr 40 mg tabQLMMPEGASYS 180 MCG/0.5 ML SUBCUTANEOUS SYRINGEPEGASYS 180 MCG/ML SUBCUTANEOUS SOLUTIONQL,PASPQL,PASPPEGASYS PROCLICK 135 MCG/0.5 ML SUBCUTANEOUS PEN INJECTORSPQL,PAPEGASYS PROCLICK 180 MCG/0.5 ML SUBCUTANEOUS PEN INJECTORSPQL,PAPEGINTRON REDIPEN 120 MCG/0.5 ML SUBCUTANEOUS KITSPQL,PAPEGINTRON REDIPEN 150 MCG/0.5 ML SUBCUTANEOUS KITSPQL,PAPEGINTRON REDIPEN 50 MCG/0.5 ML SUBCUTANEOUS KITSPQL,PAPEGINTRON REDIPEN 80 MCG/0.5 ML SUBCUTANEOUS KITSPQL,PApenicillin vk 500 mg tabletPENTASA 250 MG CAPSULE,EXTENDED RELEASEMMQLPENTASA 500 MG CAPSULE,EXTENDED RELEASEMMQLPRADAXA 150 MG CAPSULEPRADAXA 75 MG CAPSULEQLMMQLMMST – Step Therapy QL – Quantity Limit PA – Prior AuthorizationABBREVIATED FORMULARY Updated 08/2014 - 15
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSpravastatin sodium 20 mg tabMMQLpravastatin sodium 40 mg tabMMQLprednisone 10 mg tabletprednisone 20 mg tabletPRISTIQ 100 MG TABLET,EXTENDED RELEASEPRISTIQ 50 MG TABLET,EXTENDED RELEASEQLMMQLMMPROAIR HFA 90 MCG/ACTUATION AEROSOL INHALERQLMMPROCRIT 10,000 UNIT/ML INJECTION SOLUTIONSPQL,PAPROCRIT 20,000 UNIT/ML INJECTION SOLUTIONSPQL,PAPROCRIT 4,000 UNIT/ML INJECTION SOLUTIONQL,PASPPROCRIT 40,000 UNIT/ML INJECTION SOLUTIONQL,PASPPRODIGY AUTOCODE METER KITPRODIGY LANCING DEVICEPRODIGY NO CODING STRIPSQLMMPRODIGY POCKET METER KITPRODIGY TWIST TOP LANCET 28 GAUGEpromethazine 25 mg tabletPROVENTIL HFA 90 MCG/ACTUATION AEROSOL INHALERQNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAYQLMMQLMMQVAR 40 MCG/ACTUATION METERED AEROSOL ORAL INHALERMMQLQVAR 80 MCG/ACTUATION METERED AEROSOL ORAL INHALERMMQLRANEXA 1,000 MG TABLET,EXTENDED RELEASERANEXA 500 MG TABLET,EXTENDED RELEASEQL,STMMQL,STMMREBIF (WITH ALBUMIN) 22 MCG/0.5 ML SUBCUTANEOUS SYRINGESPQL,PAREBIF (WITH ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGESPQL,PAREBIF REBIDOSE 22 MCG/0.5 ML SUBCUTANEOUS PEN INJECTORSPQL,PAREBIF REBIDOSE 44 MCG/0.5 ML SUBCUTANEOUS PEN INJECTORSPQL,PAREBIF REBIDOSE 8.8 MCG/0.2 ML-22 MCG/0.5 ML SUBCUTANEOUS PEN INJECTORreclipsen (28) 0.15 mg-30 mcg tabletSPQL,PAMMRESTASIS 0.05 % EYE DROPS IN A DROPPERETTEMMQLSANCUSO 3.1 MG/24 HOUR TRANSDERMAL PATCHQLSAVELLA 100 MG TABLETQLMMSAVELLA 12.5 MG (5)-25 MG(8)-50MG(42) TABLETS IN A DOSE PACKQLSAVELLA 12.5 MG TABLETQLMMST – Step Therapy QL – Quantity Limit PA – Prior Authorization16 - ABBREVIATED FORMULARY Updated 08/2014
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSSAVELLA 25 MG TABLETMMQLSAVELLA 50 MG TABLETMMQLSEREVENT DISKUS 50 MCG/DOSE POWDER FOR INHALATIONQLMMSEROQUEL XR 150 MG TABLET,EXTENDED RELEASEMMQLSEROQUEL XR 200 MG TABLET,EXTENDED RELEASEMMQLSEROQUEL XR 300 MG TABLET,EXTENDED RELEASEMMQLSEROQUEL XR 400 MG TABLET,EXTENDED RELEASEMMQLSEROQUEL XR 50 MG TABLET,EXTENDED RELEASEsertraline hcl 100 mg tabletsertraline hcl 50 mg tabletQLMMQLMMQLMMSIDEKICK BLOOD GLUCOSE SYSTEM KITMMSIMPONI 100 MG/ML SUBCUTANEOUS PEN INJECTORSIMPONI 100 MG/ML SUBCUTANEOUS SYRINGEQL,PASPQL,PASPsimvastatin 20 mg tabletMMQLsimvastatin 40 mg tabletMMQLSOFT TOUCH LANCETSSOLODYN 105 MG TABLET,EXTENDED RELEASEQLSOLODYN 115 MG TABLET,EXTENDED RELEASEQLSOLODYN 55 MG TABLET,EXTENDED RELEASEQLSOLODYN 65 MG TABLET,EXTENDED RELEASEQLSOLODYN 80 MG TABLET,EXTENDED RELEASEQLSOVALDI 400 MG TABLETQL,PASPSPIRIVA WITH HANDIHALER 18 MCG & INHALATION CAPSULESsprintec (28) 0.25 mg-35 mcg tabletMMQLMMSPRYCEL 100 MG TABLETSPQL,PASPRYCEL 140 MG TABLETSPQL,PASPRYCEL 20 MG TABLETSPQL,PASPRYCEL 50 MG TABLETSPQL,PASPRYCEL 70 MG TABLETSPQL,PASPRYCEL 80 MG TABLETSPQL,PASUBOXONE 12 MG-3 MG SUBLINGUAL FILMQL,PASUBOXONE 2 MG-0.5 MG SUBLINGUAL FILMQL,PASUBOXONE 4 MG-1 MG SUBLINGUAL FILMQL,PASUBOXONE 8 MG-2 MG SUBLINGUAL FILMQL,PAST – Step Therapy QL – Quantity Limit PA – Prior AuthorizationABBREVIATED FORMULARY Updated 08/2014 - 17
DRUG ole-tmp ds tabletSUTENT 12.5 MG CAPSULESUTENT 25 MG CAPSULEQL,PASPSUTENT 37.5 MG CAPSULESUTENT 50 MG CAPSULEQL,PASPQL,PASPQL,PASPSYMBICORT 160 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALERSYMBICORT 80 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALERtamsulosin hcl 0.4 mg capsuleMMQLQLMMQLMMTECFIDERA 120 MG (14)-240 MG (46) CAPSULE,DELAYED RELEASEQL,PASPTECFIDERA 120 MG CAPSULE,DELAYED RELEASESPQL,PATECFIDERA 240 MG CAPSULE,DELAYED RELEASESPQL,PATEKAMLO 150 MG-5 MG TABLETTEKAMLO 300 MG-10 MG TABLETTEKAMLO 300 MG-5 MG TABLETTEKTURNA 150 MG TABLETMMTEKTURNA 300 MG TABLETMMQLMMQLMMQLMMQLQLTEKTURNA HCT 150 MG-12.5 MG TABLETTEKTURNA HCT 150 MG-25 MG TABLETtizanidine hcl 4 mg tabletQLMMTEKTURNA HCT 300 MG-12.5 MG TABLETTEKTURNA HCT 300 MG-25 MG TABLETQLMMQLMMQLMMMMTOVIAZ 4 MG TABLET,EXTENDED RELEASEMMQLTOVIAZ 8 MG TABLET,EXTENDED RELEASEMMQLTRACLEER 125 MG TABLETTRACLEER 62.5 MG TABLETTRADJENTA 5 MG TABLETQL,PASPQL,PASPQL,STMMtramadol hcl 50 mg tablettrazodone 100 mg tablettrazodone 50 mg tabletQLMMMMTREXIMET 85 MG-500 MG TABLETQLtri-sprintec (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablettriamterene-hctz 37.5-25 mg tbMMMMTRINESSA (28) 0.18 MG(7)/0.215 MG(7)/0.25 MG(7)-35 MCG TABLETTRUE2GO BLOOD GLUCOSE SYSTEM KITST – Step Therapy QL – Quantity Limit PA – Prior Authorization18 - ABBREVIATED FORMULARY Updated 08/2014MM
DRUG NAMEUTILIZATIONMANAGEMENTREQUIREMENTSTRUECONTROL LEVEL 0 SOLUTIONTRUECONTROL LEVEL 1 SOLUTIONTRUETRACK BLOOD GLUCOSE SYSTEM KITTRUETRACK GLUCOSE CONTROLTRUETRACK GLUCOSE CONTROLTUDORZA PRESSAIR 400 MCG/ACTUATION BREATH ACTIVATEDQLMMULORIC 40 MG TABLETMMQL,STULORIC 80 MG TABLETMMQL,STvalacyclovir hcl 1 gram tabletQLMMvalacyclovir hcl 500 mg tabletMMQLvenlafaxine hcl er 150 mg capMMQLvenlafaxine hcl er 75 mg capQLMMVENTOLIN HFA 90 MCG/ACTUATION AEROSOL INHALERQLMMVICTOZA 2-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTORMMQL,STVICTOZA 3-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTORMMQL,STVICTRELIS 200 MG CAPSULESPvit d2 1.25 mg (50,000 unit)MMvitamin d2 50,000 unit capsuleVOLTAREN 1 % TOPICAL GELQL,PAMMMMVYVANSE 20 MG CAPSULEQLVYVANSE 30 MG CAPSULEQLVYVANSE 40 MG CAPSULEQLVYVANSE 50 MG CAPSULEQLVYVANSE 60 MG CAPSULEQLVYVANSE 70 MG CAPSULEQLXARELTO 10 MG TABLETQLXARELTO 15 MG TABLETMMQLXARELTO 20 MG TABLETMMQLZENPEP 10,000-34,000-55,000 UNIT CAPSULE,DELAYED RELEASEMMZENPEP 15,000-51,000-82,000 UNIT CAPSULE,DELAYED RELEASEMMZENPEP 20,000-68,000-109,000 UNIT CAPSULE,DELAYED RELEASEMMZENPEP 25,000-85,000-136,000 UNIT CAPSULE,DELAYED RELEASEMMZENPEP 3,000-10,000-16,000 UNIT CAPSULE,DELAYED RELEASEMMZENPEP 5,000-17,000-27,000 UNIT CAPSULE,DELAYED RELEASEMMST – Step Therapy QL – Quantity Limit PA – Prior AuthorizationABBREVIATED FORMULARY Updated 08/2014 - 19
DRUG NAMEZETIA 10 MG TABLETUTILIZATIONMANAGEMENTREQUIREMENTSQLMMZIANA 1.2 %-0.025 % TOPICAL GELzolpidem tartrate 10 mg tabletZYTIGA 250 MG TABLETSPST – Step Therapy QL – Quantity Limit PA – Prior Authorization20 - ABBREVIATED FORMULARY Updated 08/2014QLQL,PA
Notes
Notes
* Not all the drugs listed on this formulary are covered by all prescription drug benefit plans. For more informationabout the drugs covered by your prescription drug benefit plan, copayment or coinsurance amounts, you can callthe number on the back of your Humana member ID card or log into MyHumana.** For Commercial Fully-Insured and Individual policies issued in Texas, Louisiana, and Puerto Rico:formulary changes are effective on a plan’s renewal date.Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., HumanaHealth Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana HealthPlans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, orHumana Health Plan of Texas, Inc. - A Health Maintenance Organization, or insured by Humana Health InsuranceCompany of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., HumanaInsurance Company, Humana Insurance Company of Kentucky, Humana Insurance of Puerto Rico, Inc. License #00187-0009, or administered by Humana Insurance Company or Humana Health Plan, Inc.Statements in languages other than English contained in the advertisement do not necessarily reflect the exactcontents of the policy written in English, because of possible linguistic differences. In the event of a dispute, thepolicy as written in English is considered the controlling authority.For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Humana Insurance Company.Administered by Humana Insurance Company.Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) formore information on the company providing your benefits.Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued inforce or discontinued. For costs and complete details of the coverage, call or write your Humana insurance agentor broker.ASO products are administered by Humana Insurance Company or Humana Health Plan, Inc.Humana.comGCHHQ7XESA
Humana.com 2015 Printable Drug List Humana Formulary This is a partial list of covered drugs HDHP Traditional Drug List Instructions for getting information about all . You can access the drug search tool through fiDrug Pricingfl under fiPlan Toolsfl at the bottom of the page. The search tool lets you search for your drug by name or by .
