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2008
Prescription Drug Guide
C0006_PDG_TEMP_FINAL_15 KC0807M0006_PDG_TEMP_FINAL_15 KC0807 GN18658RR_PDG_NA_08
Humana
FormularyComprehensive List of Covered Drugs
This document applies toall Prescription Drug Plans (PDP).
PLEASE READ:THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
Welcome to Humana!
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 1
PLEASE READ: THIS DOCUMENT CONTAINSINFORMATION ABOUT THE DRUGS WE COVER IN THESEPLANS.
Note to existing members: This formulary has changedsince last year. Please review this document to make surethat it still contains the drugs you take.
What is the Humana Formulary?A formulary is a list of covered drugs selected by Humanain consultation with a team of health care providers,which represents the prescription therapies believed to bea necessary part of a quality treatment program. Humanawill generally cover the drugs listed in our formulary aslong as the drug is medically necessary, the prescription isfilled at a Humana network pharmacy, and other plan rulesare followed. For more information on how to fill yourprescriptions, please review your Evidence of Coverage.
Can the Formulary change?Generally, if you are taking a drug on our 2008 formularythat was covered at the beginning of the year, we will notdiscontinue or reduce coverage of the drug during the2008 coverage year except when new adverse informationabout the safety or effectiveness of a drug is released.Other types of formulary changes, such as removing a drugfrom our formulary, will not affect members who arecurrently taking the drug. It will remain available at thesame level of cost-sharing for those members taking it forthe remainder of the coverage year. We feel it is importantthat you have continued access for the remainder of thecoverage year to the formulary drugs that were availablewhen you chose our plan, except for cases in which youcan save additional money or improve the safety of yourdrugs.
If we remove drugs from our formulary, or add priorauthorization, quantity limits and/or step therapyrestrictions on a drug or move a drug to a highercost-sharing tier, we must notify affected members of thechange at least 60 days before the change becomeseffective, or at the time the member requests a refill of thedrug, at which time the member will receive a 60-daysupply of the drug. If the Food and Drug Administrationdeems a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary andprovide notice to members who take the drug. Theenclosed formulary is current as of January 2008.
To get updated information about the drugs covered byHumana, please visit our Website at Humana.com.
You can also call Customer Care at the number listed onthe back of your member ID card for a better customerexperience. If you don’t have your member ID card readilyavailable call us at 1-800-281-6918 (TTY users may call1-800-833-3301).
Customer care representatives are available Sundaythrough Saturday 8 a.m. to 8 p.m.
From March 2, 2008 through your next Annual ElectionPeriod (AEP), for Saturdays, Sundays, and Holidays,alternative technical assistance will be available to returnyour call in one business day.
How do I use the Humana formulary?Alphabetical Listing
formulary are listed in alphabetical order. The formularyalso lists the Tier, Utilization Management Requirement,and Therapeutic Category.
Drugs are grouped into one of four tiers – 1, 2, 3, or 4• Tier 1 – Preferred Generic• Tier 2 – Preferred Brand• Tier 3 – Non-preferred Brand• Tier 4 – Specialty
Here’s how to read the Utilization ManagementRequirement codes:PA – Prior AuthorizationQL – Quantity LimitsST – Step Therapy
Requirements.
What are generic drugs?
The formulary begins on page 7. The drugs in this
See page 2 for more details on Utilization Management
2 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
Humana covers both brand drugs and generic drugs. Ageneric drug has the same active-ingredient as the branddrug. Generic drugs usually cost less than brand drugs, arerated to be as safe and effective as brand drugs, and areapproved by the Food and Drug Administration (FDA).
How much will I pay for Humana Covered Drugs?If you qualified for extra help with your drug costs, yourcosts may be different than those described below. Pleaserefer to your Evidence of Coverage or call Customer Careto find out what your costs are. Humana pays part of thecosts for your covered drugs and you pay part of the costsas well.
The amount you pay depends on which drug category yourdrug falls under in the formulary and whether you fill yourprescription at a network pharmacy.
Drug categories• Preferred Generic – drugs that have the same active
ingredients as brand drugs and are prescribed for thesame reasons. The Food and Drug Administration (FDA)requires generic drugs to have the same quality,strength, purity, and stability as brand drugs. Your costfor generic drugs is usually lower than your cost forbrand drugs.
• Preferred Brand – Brand prescription drugs thatHumana offers at a lower cost to you than non-preferreddrugs.
• Non-preferred Brand – More expensive brandprescription drugs that Humana offers at a higher cost toyou than preferred drugs.
• Specialty – Some injectables and other high-cost drugs.
Are there any other restrictions on coverage?Some covered drugs may have additional utilizationmanagement requirements or limits on coverage. Theserequirements and limits may include:
• Prior Authorization: Humana requires you to get priorauthorization for certain drugs. This means that you willneed to get approval from Humana before you fill yourprescriptions. If you don’t get approval, Humana maynot cover the drug.
• Quantity Limits: For certain drugs, Humana limits theamount of the drug that Humana will cover.
For example, Humana provides 30 tablets perprescription for simvastatin. This may be in addition to astandard 30- or 90-day supply. Specialty drugs arelimited to a 30-day supply.
• Step Therapy: In some cases, Humana requires you tofirst try certain drugs to treat your medical conditionbefore we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medicalcondition, Humana may not cover Drug B unless you tryDrug A first. If Drug A does not work for you, Humanawill then cover Drug B.
For drugs that require prior authorization, step therapy, orfall outside of the noted quantity limits, the doctor mustcall Humana at 1-800-555-2546. (Representatives areavailable Monday through Friday, 8 a.m. to 6 p.m.)
You can find out if your drug has any additionalrequirements or limits by looking on the formulary that
exception to these restrictions or limits. See the section,“How do I request an exception to the Humanaformulary?” for information on requesting an exception.
What if my drug is not on the Formulary?If your drug is not included in this formulary, you shouldfirst contact Customer Care and ask if your drug iscovered.
If you learn that Humana does not cover your drug, youhave two options:
• You can ask Customer Care for a list of similar drugsthat are covered by Humana. When you receive the list,show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Humana.
• You can ask Humana to make an exception and coveryour drug. See below for information about how torequest an exception.
Note: Due to a change in Medicare as of January 1, 2007,most Medicare Part D Plans will no longer cover erectiledysfunction drugs like Viagra, Cialis, Levitra, andCaverject. Call Customer Care for more information.
How do I request an exception to the HumanaFormulary?
begins on page 7. You can ask Humana to make an
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 3
You can ask Humana to make an exception to ourcoverage rules. There are several types of exceptions thatyou can ask us to make:
• You can ask us to cover your drug even if it is not on ourformulary.
• You can ask us to waive coverage restrictions or limitson your drug. For example, for certain drugs, Humanalimits the amount of the drug that we will cover. If yourdrug has a quantity limit, you can ask us to waive thelimit and cover more.
• You can ask us to provide a higher level of coverage foryour drug. For example, if your drug is usuallyconsidered a non-preferred drug, you can ask us to coverit as a preferred instead. This would lower the amountyou pay for your drug. Please note, if we grant yourrequest to cover a drug that is not on our formulary, youmay not ask us to provide a higher level of coverage forthe drug.
Generally, Humana will only approve your request for anexception if the alternative drugs are not included on theplan’s formulary, the lower tiered drug or additionalutilization restrictions would not be as effective in treatingyour condition and/or would cause you to have adversemedical effects.
You may contact us to ask us for an initial coveragedecision for a formulary, tiering, or utilization restrictionexception. When you are requesting a formulary, tiering orutilization restriction exception, submit a statement fromyour physician supporting your request. Generally, wemust make our decision within 72 hours of getting yourprescribing physician’s supporting statement. You canrequest an expedited (fast) exception if you or your doctorbelieve that your health could be seriously harmed bywaiting up to 72 hours for a decision. If your request toexpedite is granted, we must give you a decision no laterthan 24 hours after we get your prescribing physician’ssupporting statement.
What do I do before I can talk to my doctor aboutchanging my drugs or requesting an exception?As a new or continuing member in our plan you may betaking drugs that are not on our formulary. Or, you may betaking a drug that is on our formulary but your ability toget it is limited. For example, you may need a priorauthorization from us before you can fill your prescription.
You should talk to your doctor to decide if you shouldswitch to an appropriate drug that we cover or request aformulary exception so that we will cover the drug youtake. While you talk to your doctor to determine the rightcourse of action for you, we may cover your drug in certaincases during the first 90 days you are a member of ourplan.
For each of your drugs that is not on our formulary or ifyour ability to get your drugs is limited, we will cover atemporary 30-day supply (unless you have a prescriptionwritten for fewer days) when you go to a networkpharmacy. After your first 30-day supply, we will not payfor these drugs, even if you have been a member of theplan less than 90 days.
If you are a resident of a long-term care facility, we willcover a temporary 34-day transition supply (unless youhave a prescription written for fewer days). We will covermore than one refill of these drugs for the first 90 days youare a member of our plan. If you need a drug that is not onour formulary or your ability to get your drugs is limited,but you are past the first 90 days of membership in ourplan, we will cover a 34-day emergency supply of thatdrug (unless you have a prescription for fewer days) whileyou pursue a formulary exception.
Throughout the plan year, you may have a change in yourtreatment setting due to the level of care you require. Suchtransitions include:• Members who are discharged from a hospital or skilled
nursing facility to a home setting.
• Members who are admitted to a hospital or skillednursing facility from a home setting.
• Members who transfer from one skilled nursing facilityto another and are serviced by a different pharmacy.
• Members who end their skilled nursing facility MedicarePart A stay (where payments include all pharmacycharges) and who need to now use their Part D planbenefit.
• Members who give up Hospice Status and revert back tostandard Medicare Part A and B coverage.
• Members discharged from chronic psychiatric hospitalswith highly individualized drug regimens.
4 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
• Members currently requesting an appeal of an initialCoverage Determination and/or Exception.
For these changes in treatment settings, Humana willcover up to a 34 day temporary supply of a Part D covereddrug when your prescription is filled at a networkpharmacy. If you change treatment settings multiple timeswithin the same month, you may have to request anexception or prior authorization and receive approval forcontinued coverage of your drug. Humana will reviewthese requests for continuation of therapy on acase-by-case basis when you are stabilized on drugregimen, which if altered, is known to have risks.
Humana-Medicare.com — A Handy ToolFor help in selecting a health plan that’s right for you, useour online comparison tools at Humana-Medicare.com.
Research your coverage options; estimate costs for doctorsand hospitals, and use our Rx Calculator to estimate yourprescription drug costs. The Rx Calculator can help you:
• Estimate your monthly drug costs, and how long it willtake you to reach the various cost “stages” for yourprescription drug plan
• Get information about pricing, coverage, usage, dosage,interactions, and other details on more than 10,000drugs
• Find out whether a generic alternative might save youmoney.
For More InformationFor more detailed information about your Humanaprescription drug coverage, please review your Evidence ofCoverage booklet and other plan materials.
If you have questions about Humana, please visit ourWebsite at Humana.com.
You can also call Customer Care at the number listed onthe back of your member ID card for a better customerexperience. If you don’t have your member ID card readilyavailable call us at 1-800-281-6918 (TTY users may call1-800-833-3301).
Customer care representatives are available Sundaythrough Saturday 8 a.m. to 8 p.m.
From March 2, 2008 through your next Annual ElectionPeriod (AEP), for Saturdays, Sundays, and Holidays,alternative technical assistance will be available to returnyour call in one business day.
If you have general questions about Medicare prescriptiondrug coverage, please call Medicare at 1-800-MEDICARE(1-800-633-4227) 24 hours a day, 7 days a week. TTYusers should call 1-877-486-2048. Or, visitwww.medicare.gov.
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 5
Humana’s FormularyThe formulary beginning on the next page gives youspecific information about some of the drugs covered byHumana.
If your prescription is not listed in this formulary, pleasevisit our Website at Humana.com.
You can also call Customer Care at the number listed onthe back of your member ID card for a better customerexperience. If you don’t have your member ID card readilyavailable call us at 1-800-281-6918 (TTY users may call1-800-833-3301).
Customer care representatives are available Sundaythrough Saturday 8 a.m. to 8 p.m.
From March 2, 2008 through your next Annual ElectionPeriod (AEP), for Saturdays, Sundays, and Holidays,alternative technical assistance will be available to returnyour call in one business day.
The first column of the chart lists the drug name inalphabetical order. The second column lists the tier of thedrug. The information in the Utilization ManagementRequirements column tells you whether Humana has anyspecial requirements for covering that drug. If the columnis blank, then the supply is based on benefits and whetheryour doctor prescribes a 30-, 60- or 90-day supply.
The last column lists the Therapeutic Category of the drug.
The formulary beginning on the next page givesyou specific information about some of the drugscovered by Humana.
If your prescription is not listed in this formulary,please visit our Website at Humana.com.
You can also call Customer Care at the numberlisted on the back of your member ID card for abetter customer experience. If you don’t have yourmember ID card readily available call us at1-800-281-6918 (TTY users may call1-800-281-6918).
Customer care representatives are available Sundaythrough Saturday 8 a.m. to 8 p.m., Eastern time..From Month, date, year through your next AnnualElection Period (AEP), for Saturdays, Sundays, andHolidays, alternative technical assistance will beavailable to return your call in one business day.
The first column of the chart lists the drug name inalphabetical order. The second column lists the tierof the drug. The information in the UtilizationManagement Requirements column tells youwhether Humana or CarePlus has any special
requirements for covering that drug. If the columnis blank, then the supply is based on benefits andwhether your doctor prescribes a 30-, 60- or 90-daysupply.
The last column lists the Therapeutic Category ofthe drug.
6 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
Formulary Start Cross Reference
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 7
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
8-MOP 10 MG CAPSULES 2 Skin And Mucous Membrane Agents
A-METHAPRED 125 MG SOLUTION 1 Hormones And Synthetic Substitutes
A-METHAPRED 40 MG SOLUTION 1 Hormones And Synthetic Substitutes
ABELCET 5 MG/ML SUSPENSION 4 Anti-Infective Agents
ABILIFY 1 MG/ML SOLUTION 2 Central Nervous Systems Agents
ABILIFY 9.75 MG/1.3ML SOLUTION 3 Central Nervous Systems Agents
ABILIFY 10 MG TABLET 2 QL Central Nervous Systems Agents
ABILIFY 15 MG TABLET 2 QL Central Nervous Systems Agents
ABILIFY 2 MG TABLET 2 QL Central Nervous Systems Agents
ABILIFY 20 MG TABLET 2 QL Central Nervous Systems Agents
ABILIFY 30 MG TABLET 2 QL Central Nervous Systems Agents
ABILIFY 5 MG TABLET 2 QL Central Nervous Systems Agents
ABILIFY DISCMELT 10 MG TABLET 2 QL Central Nervous Systems Agents
ABILIFY DISCMELT 15 MG TABLET 2 QL Central Nervous Systems Agents
ABRAXANE 100 MG SUSPENSION 4 Antineoplastic Agents
ACCOLATE 10 MG TABLET 3 QL Respiratory Tract Agents
ACCOLATE 20 MG TABLET 3 QL Respiratory Tract Agents
ACCUNEB 0.63 MG/3ML NEBULIZER 2 Autonomic Drugs
ACCUNEB 1.25 MG/3ML NEBULIZER 2 Autonomic Drugs
ACCUPRIL 10 MG TABLET 3 Cardiovascular Drugs
ACCUPRIL 20 MG TABLET 3 Cardiovascular Drugs
ACCUPRIL 40 MG TABLET 3 Cardiovascular Drugs
ACCUPRIL 5 MG TABLET 3 Cardiovascular Drugs
ACCURETIC 12.5 MG;10 MG TABLET 3 Cardiovascular Drugs
ACCURETIC 12.5 MG;20 MG TABLET 3 Cardiovascular Drugs
ACCURETIC 25 MG;20 MG TABLET 3 Cardiovascular Drugs
ACCUTANE 10 MG CAPSULES 4 QL Skin And Mucous Membrane Agents
ACCUTANE 20 MG CAPSULES 4 QL Skin And Mucous Membrane Agents
ACCUTANE 40 MG CAPSULES 4 QL Skin And Mucous Membrane Agents
ACEBUTOLOL HCL 200 MG CAPSULES 1 Cardiovascular Drugs
ACEBUTOLOL HCL 400 MG CAPSULES 1 Cardiovascular Drugs
ACEON 2 MG TABLET 3 Cardiovascular Drugs
ACEON 4 MG TABLET 3 Cardiovascular Drugs
ACEON 8 MG TABLET 3 Cardiovascular Drugs
ACETADOTE 200 MG/ML SOLUTION 3 Miscellaneous Therapeutic Agents
ACETAMINOPHEN-CODEINE #4 300 MG;60 MGTABLET
1 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
8 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ACETAMINOPHEN/CODEINE 120 MG/5ML;12MG/5ML SOLUTION
1 Central Nervous Systems Agents
ACETAMINOPHEN/CODEINE 300 MG;15 MG TABLET 1 QL Central Nervous Systems Agents
ACETAMINOPHEN/CODEINE 300 MG;60 MG TABLET 1 QL Central Nervous Systems Agents
ACETAMINOPHEN/CODEINE #2 300 MG;15 MGTABLET
1 QL Central Nervous Systems Agents
ACETAMINOPHEN/CODEINE #3 300 MG;30 MGTABLET
1 QL Central Nervous Systems Agents
ACETAMINOPHEN/CODEINE #4 300 MG;60 MGTABLET
1 QL Central Nervous Systems Agents
ACETAZOLAMIDE 125 MG TABLET 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ACETAZOLAMIDE 250 MG TABLET 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ACETAZOLAMIDE SODIUM 500 MG SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ACETIC ACID 0.02 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ACETIC ACID/HYDROCORTISON 2 %;1 % SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ACETYLCYSTEINE 0.1 SOLUTION 1 Respiratory Tract Agents
ACETYLCYSTEINE 0.2 SOLUTION 1 Respiratory Tract Agents
ACIPHEX 20 MG TABLET 3 QL, ST Gastrointestinal Drugs
ACLOVATE 0.0005 CREAM 3 Skin And Mucous Membrane Agents
ACLOVATE 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents
ACTHIB 0 SOLUTION 3 Serums, Toxoids, And Vaccines
ACTICIN 0.05 CREAM 1 Skin And Mucous Membrane Agents
ACTIGALL 300 MG CAPSULES 3 Gastrointestinal Drugs
ACTIMMUNE 2000000 UNIT/0.5ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
ACTIQ 1200 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
ACTIQ 1600 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
ACTIQ 200 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
ACTIQ 400 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
ACTIQ 600 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
ACTIQ 800 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
ACTIVELLA 1 MG;0.5 MG TABLET 3 Hormones And Synthetic Substitutes
ACTONEL 30 MG TABLET 2 QL Miscellaneous Therapeutic Agents
ACTONEL 35 MG TABLET 2 QL Miscellaneous Therapeutic Agents
ACTONEL 5 MG TABLET 2 QL Miscellaneous Therapeutic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 9
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ACTONEL 75 MG TABLET 2 QL Miscellaneous Therapeutic Agents
ACTONEL WITH CALCIUM 1250 MG;35 MG TABLET 2 QL Miscellaneous Therapeutic Agents
ACTOPLUS MET 500 MG;15 MG TABLET 2 QL Hormones And Synthetic Substitutes
ACTOPLUS MET 850 MG;15 MG TABLET 2 QL Hormones And Synthetic Substitutes
ACTOS 15 MG TABLET 2 QL Hormones And Synthetic Substitutes
ACTOS 30 MG TABLET 2 QL Hormones And Synthetic Substitutes
ACTOS 45 MG TABLET 2 QL Hormones And Synthetic Substitutes
ACULAR 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ACULAR LS 0.004 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ACULAR PF 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ACYCLOVIR 200 MG CAPSULES 1 Anti-Infective Agents
ACYCLOVIR 200 MG/5ML SUSPENSION 1 Anti-Infective Agents
ACYCLOVIR 400 MG TABLET 1 Anti-Infective Agents
ACYCLOVIR 800 MG TABLET 1 Anti-Infective Agents
ACYCLOVIR SODIUM 1000 MG SOLUTION 1 Anti-Infective Agents
ACYCLOVIR SODIUM 50 MG/ML SOLUTION 1 Anti-Infective Agents
ACYCLOVIR SODIUM 500 MG SOLUTION 1 Anti-Infective Agents
ADACEL 15.5 MCG/0.5ML;2 LF/0.5ML;5 LF/0.5MLSUSPENSION
3 Serums, Toxoids, And Vaccines
ADAGEN 250 UNIT/ML SOLUTION 4 Enzymes
ADALAT CC 30 MG TABLET 3 QL Cardiovascular Drugs
ADALAT CC 60 MG TABLET 3 QL Cardiovascular Drugs
ADALAT CC 90 MG TABLET 3 QL Cardiovascular Drugs
ADDERALL 1.25 MG;1.25 MG;1.25 MG;1.25 MGTABLET
3 Central Nervous Systems Agents
ADDERALL 1.875 MG;1.875 MG;1.875 MG;1.875 MGTABLET
3 Central Nervous Systems Agents
ADDERALL 2.5 MG;2.5 MG;2.5 MG;2.5 MG TABLET 3 Central Nervous Systems Agents
ADDERALL 3.125 MG;3.125 MG;3.125 MG;3.125 MGTABLET
3 Central Nervous Systems Agents
ADDERALL 3.75 MG;3.75 MG;3.75 MG;3.75 MGTABLET
3 Central Nervous Systems Agents
ADDERALL 5 MG;5 MG;5 MG;5 MG TABLET 3 Central Nervous Systems Agents
ADDERALL 7.5 MG;7.5 MG;7.5 MG;7.5 MG TABLET 3 Central Nervous Systems Agents
ADDERALL XR 1.25 MG;1.25 MG;1.25 MG;1.25 MGCAPSULES
3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
10 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ADDERALL XR 2.5 MG;2.5 MG;2.5 MG;2.5 MGCAPSULES
3 QL Central Nervous Systems Agents
ADDERALL XR 3.75 MG;3.75 MG;3.75 MG;3.75 MGCAPSULES
3 QL Central Nervous Systems Agents
ADDERALL XR 5 MG;5 MG;5 MG;5 MG CAPSULES 3 QL Central Nervous Systems Agents
ADDERALL XR 6.25 MG;6.25 MG;6.25 MG;6.25 MGCAPSULES
3 QL Central Nervous Systems Agents
ADDERALL XR 7.5 MG;7.5 MG;7.5 MG;7.5 MGCAPSULES
3 QL Central Nervous Systems Agents
ADOXA 100 MG TABLET 3 Anti-Infective Agents
ADOXA 50 MG TABLET 3 Anti-Infective Agents
ADOXA 75 MG TABLET 3 Anti-Infective Agents
ADOXA PAK 1/100 100 MG TABLET 3 Anti-Infective Agents
ADOXA PAK 1/150 150 MG TABLET 3 Anti-Infective Agents
ADOXA PAK 1/75 75 MG TABLET 3 Anti-Infective Agents
ADOXA PAK 2/100 100 MG TABLET 3 Anti-Infective Agents
ADRENALIN 0.001 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ADRENALIN 1 MG/ML SOLUTION 1 Autonomic Drugs
ADRIAMYCIN 10 MG SOLUTION 1 Antineoplastic Agents
ADRIAMYCIN 2 MG/ML SOLUTION 1 Antineoplastic Agents
ADRIAMYCIN 20 MG SOLUTION 1 Antineoplastic Agents
ADRIAMYCIN 50 MG SOLUTION 1 Antineoplastic Agents
ADVAIR DISKUS 100 MCG/DOSE;50 MCG/DOSE MISC 2 QL Autonomic Drugs
ADVAIR DISKUS 250 MCG/DOSE;50 MCG/DOSE MISC 2 QL Autonomic Drugs
ADVAIR DISKUS 500 MCG/DOSE;50 MCG/DOSE MISC 2 QL Autonomic Drugs
ADVAIR HFA 115 MCG/ACT;21 MCG/ACT AEROSOL 2 QL Autonomic Drugs
ADVAIR HFA 230 MCG/ACT;21 MCG/ACT AEROSOL 2 QL Autonomic Drugs
ADVAIR HFA 45 MCG/ACT;21 MCG/ACT AEROSOL 2 QL Autonomic Drugs
ADVICOR 20 MG;1000 MG TABLET 2 QL Cardiovascular Drugs
ADVICOR 20 MG;500 MG TABLET 2 QL Cardiovascular Drugs
ADVICOR 20 MG;750 MG TABLET 2 QL Cardiovascular Drugs
ADVICOR 40 MG;1000 MG TABLET 2 QL Cardiovascular Drugs
AEROBID 250 MCG/ACT AEROSOL SOLUTION 3 QL, ST Hormones And Synthetic Substitutes
AEROBID-M 250 MCG/ACT AEROSOL SOLUTION 3 QL, ST Hormones And Synthetic Substitutes
AFEDITAB CR 30 MG TABLET 1 QL Cardiovascular Drugs
AFEDITAB CR 60 MG TABLET 1 QL Cardiovascular Drugs
AGENERASE 50 MG CAPSULES 2 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 11
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AGENERASE 15 MG/ML SOLUTION 2 Anti-Infective Agents
AGGRENOX 25 MG;200 MG CAPSULES 2 Cardiovascular Drugs
AGRYLIN 0.5 MG CAPSULES 4 Miscellaneous Therapeutic Agents
AGRYLIN 1 MG CAPSULES 4 Miscellaneous Therapeutic Agents
AIRET 0.00083 NEBULIZER 3 Autonomic Drugs
AK-CON 0.001 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
AK-POLY-BAC 500 UNIT/GM;10000 UNIT/GMOINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
AK-TOB 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
AKINETON 2 MG TABLET 3 Autonomic Drugs
AKNE-MYCIN 0.02 OINTMENT 3 Skin And Mucous Membrane Agents
ALA-CORT 0.01 CREAM 1 Skin And Mucous Membrane Agents
ALA-CORT 0.01 LOTION 1 Skin And Mucous Membrane Agents
ALA-SCALP 0.02 LOTION 1 Skin And Mucous Membrane Agents
ALAMAST 0.001 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ALBALON 0.001 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ALBENZA 200 MG TABLET 3 Anti-Infective Agents
ALBUTEROL 90 MCG/ACT AEROSOL SOLUTION 1 QL Autonomic Drugs
ALBUTEROL SULFATE 0.00083 NEBULIZER 1 Autonomic Drugs
ALBUTEROL SULFATE 0.005 NEBULIZER 1 Autonomic Drugs
ALBUTEROL SULFATE 1.25 MG/3ML NEBULIZER 1 Autonomic Drugs
ALBUTEROL SULFATE 2 MG/5ML SYRUP 1 Autonomic Drugs
ALBUTEROL SULFATE 2 MG TABLET 1 Autonomic Drugs
ALBUTEROL SULFATE 4 MG TABLET 1 Autonomic Drugs
ALBUTEROL SULFATE ER 4 MG TABLET 1 Autonomic Drugs
ALBUTEROL SULFATE ER 8 MG TABLET 1 Autonomic Drugs
ALCAINE 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ALCLOMETASONE DIPROPIONAT 0.0005 CREAM 1 Skin And Mucous Membrane Agents
ALCLOMETASONE DIPROPIONAT 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
ALCOHOL 5%/DEXTROSE 5% 5 %;5 % SOLUTION 3 Electrolytic, Caloric, And Water Balance
ALCOHOL SWABS 0.7 PADS 1 Skin And Mucous Membrane Agents
ALDACTAZIDE 25 MG;25 MG TABLET 3 Cardiovascular Drugs
ALDACTAZIDE 50 MG;50 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
12 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ALDACTONE 100 MG TABLET 3 Cardiovascular Drugs
ALDACTONE 25 MG TABLET 3 Cardiovascular Drugs
ALDACTONE 50 MG TABLET 3 Cardiovascular Drugs
ALDARA 0.05 CREAM 3 QL Skin And Mucous Membrane Agents
ALDURAZYME 2.9 MG/5ML SOLUTION 4 Enzymes
ALESSE-28 20 MCG;0.1 MG TABLET 3 Hormones And Synthetic Substitutes
ALFERON N 5 MU/ML SOLUTION 4 QL Anti-Infective Agents
ALIMTA 500 MG SOLUTION 4 QL Antineoplastic Agents
ALINIA 100 MG/5ML SUSPENSION 3 QL Anti-Infective Agents
ALINIA 500 MG TABLET 3 QL Anti-Infective Agents
ALKERAN 50 MG SOLUTION 4 Antineoplastic Agents
ALLEGRA 30 MG/5ML SUSPENSION 3 QL, ST Antihistamine Drugs
ALLEGRA 180 MG TABLET 3 QL, ST Antihistamine Drugs
ALLEGRA 30 MG TABLET 3 QL, ST Antihistamine Drugs
ALLEGRA 60 MG TABLET 3 QL, ST Antihistamine Drugs
ALLEGRA-D 12 HOUR 60 MG;120 MG TABLET 3 QL, ST Antihistamine Drugs
ALLEGRA-D 24 HOUR 180 MG;240 MG TABLET 3 QL, ST Antihistamine Drugs
ALLOPURINOL 100 MG TABLET 1 Miscellaneous Therapeutic Agents
ALLOPURINOL 300 MG TABLET 1 Miscellaneous Therapeutic Agents
ALLOPURINOL SODIUM 500 MG SOLUTION 1 Miscellaneous Therapeutic Agents
ALOCRIL 0.02 SOLUTION 3 Respiratory Tract Agents
ALOMIDE 0.001 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ALOPRIM 500 MG SOLUTION 3 Miscellaneous Therapeutic Agents
ALORA 0.025 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ALORA 0.05 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ALORA 0.075 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ALORA 0.1 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ALOXI 0.25 MG/5ML SOLUTION 4 Gastrointestinal Drugs
ALPHAGAN P 0.001 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
ALPHAGAN P 0.0015 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
ALPHATREX 0.0005 GEL 1 Skin And Mucous Membrane Agents
ALREX 0.002 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ALTACE 1.25 MG CAPSULES 2 Cardiovascular Drugs
ALTACE 10 MG CAPSULES 2 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 13
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ALTACE 2.5 MG CAPSULES 2 Cardiovascular Drugs
ALTACE 5 MG CAPSULES 2 Cardiovascular Drugs
ALTOPREV 20 MG TABLET 3 QL, ST Cardiovascular Drugs
ALTOPREV 40 MG TABLET 3 QL, ST Cardiovascular Drugs
ALTOPREV 60 MG TABLET 3 QL, ST Cardiovascular Drugs
ALUPENT 0.65 MG/ACT AEROSOL POWDER 3 QL Autonomic Drugs
AMANTADINE HCL 100 MG CAPSULES 1 Central Nervous Systems Agents
AMANTADINE HCL 50 MG/5ML SYRUP 1 Central Nervous Systems Agents
AMANTADINE HCL 100 MG TABLET 1 Central Nervous Systems Agents
AMARYL 1 MG TABLET 3 Hormones And Synthetic Substitutes
AMARYL 2 MG TABLET 3 Hormones And Synthetic Substitutes
AMARYL 4 MG TABLET 3 Hormones And Synthetic Substitutes
AMBIEN 10 MG TABLET 3 QL, ST Central Nervous Systems Agents
AMBIEN 5 MG TABLET 3 QL, ST Central Nervous Systems Agents
AMBIEN CR 12.5 MG TABLET 3 QL, ST Central Nervous Systems Agents
AMBIEN CR 6.25 MG TABLET 3 QL, ST Central Nervous Systems Agents
AMBISOME 50 MG SUSPENSION 3 Anti-Infective Agents
AMCINONIDE 0.001 CREAM 1 Skin And Mucous Membrane Agents
AMCINONIDE 0.001 LOTION 1 Skin And Mucous Membrane Agents
AMCINONIDE 0.001 OINTMENT 1 Skin And Mucous Membrane Agents
AMERGE 1 MG TABLET 3 QL Central Nervous Systems Agents
AMERGE 2.5 MG TABLET 3 QL Central Nervous Systems Agents
AMEVIVE 15 MG SOLUTION 4 QL, PA Skin And Mucous Membrane Agents
AMIKACIN SULFATE 250 MG/ML SOLUTION 1 Anti-Infective Agents
AMIKACIN SULFATE 50 MG/ML SOLUTION 1 Anti-Infective Agents
AMIKIN 250 MG/ML SOLUTION 1 Anti-Infective Agents
AMIKIN 50 MG/ML SOLUTION 1 Anti-Infective Agents
AMILORIDE HCL 5 MG TABLET 1 Electrolytic, Caloric, And Water Balance
AMILORIDE/HYDROCHLOROTHIA 5 MG;50 MGTABLET
1 Electrolytic, Caloric, And Water Balance
AMINESS 0.052 SOLUTION 3 Electrolytic, Caloric, And Water Balance
AMINOPHYLLINE 25 MG/ML SOLUTION 1 Smooth Muscle Relaxants
AMINOPHYLLINE 100 MG TABLET 1 Smooth Muscle Relaxants
AMINOPHYLLINE 200 MG TABLET 1 Smooth Muscle Relaxants
AMINOSYN 148 MEQ/L;1280 MG/100ML;980MG/100ML;1280 MG/100ML;300 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
14 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AMINOSYN 50.3 MEQ/L;695 MG/100ML;713MG/100ML;490 MG/100ML;517 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN 51 MEQ/L;448 MG/100ML;343MG/100ML;448 MG/100ML;105 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN 86 MEQ/L;640 MG/100ML;490MG/100ML;640 MG/100ML;150 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN 90 MEQ/L;1100 MG/100ML;850MG/100ML;35 MEQ/L;1100 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN 7%/ELECTROLYTES 124 MEQ/L;900MG/100ML;690 MG/100ML;96 MEQ/L;900MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN 8.5%/ELECTROLYTE 142 MEQ/L;1100MG/100ML;850 MG/100ML;98 MEQ/L;1100MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 107.6 MEQ/L;1490 MG/100ML;1527MG/100ML;1050 MG/100ML;1107 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 50.3 MEQ/L;695 MG/100ML;713MG/100ML;490 MG/100ML;517 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 61.1 MEQ/L;844 MG/100ML;865MG/100ML;595 MG/100ML;627 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 71.8 MEQ/L;993 MG/100ML;1018MG/100ML;700 MG/100ML;738 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 3.5%/DEXTROSE 25.2 MEQ/L;348MG/100ML;356 MG/100ML;245 MG/100ML;25 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 3.5%/DEXTROSE 25.2 MEQ/L;348MG/100ML;356 MG/100ML;245 MG/100ML;5 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 3.5/DEXTROSE 25.2 MEQ/L;348MG/100ML;356 MG/100ML;245 MG/100ML;5 MEQ/LSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 4.25/DEXTROSE 30.6 MEQ/L;422MG/100ML;432 MG/100ML;298 MG/100ML;20 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 15
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AMINOSYN II 4.25/DEXTROSE 30.6 MEQ/L;422MG/100ML;432 MG/100ML;298 MG/100ML;25 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 4.25/DEXTROSE 30.6 MEQ/L;422MG/100ML;432 MG/100ML;298 MG/100ML;30.6MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 4.25/DEXTROSE 30.6 MEQ/L;422MG/100ML;432 MG/100ML;298 MG/100ML;5 MEQ/LSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 5/DEXTROSE 25 35.9 MEQ/L;496MG/100ML;509 MG/100ML;350 MG/100ML;25 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II 8.5%/ELECTROL 61 MEQ/L;844MG/100ML;865 MG/100ML;595 MG/100ML;86MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II M 3.5%/DEXTRO 25.1 MEQ/L;348MG/100ML;356 MG/100ML;245 MG/100ML;36.5MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN II M 4.25/DEXTRO 30.5 MEQ/L;422MG/100ML;432 MG/100ML;298 MG/100ML;36.5MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN M 65 MEQ/L;448 MG/100ML;343MG/100ML;40 MEQ/L;448 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN-HBC 7.2 MEQ/100ML;660MG/100ML;507 MG/100ML;4 MEQ/100ML;660MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN-HF 62 MEQ/L;770 MG/100ML;600MG/100ML;3 MEQ/L;20 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN-PF 46 MEQ/L;698 MG/100ML;1227MG/100ML;527 MG/100ML;820 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMINOSYN-PF 7% 32.5 MEQ/L;490 MG/100ML;861MG/100ML;370 MG/100ML;576 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
AMIODARONE HCL 50 MG/ML SOLUTION 1 Cardiovascular Drugs
AMIODARONE HCL 200 MG TABLET 1 Cardiovascular Drugs
AMIODARONE HCL 400 MG TABLET 1 Cardiovascular Drugs
AMITIZA 24 MCG CAPSULES 3 Gastrointestinal Drugs
AMITRIPTYLINE HCL 10 MG TABLET 1 Central Nervous Systems Agents
AMITRIPTYLINE HCL 100 MG TABLET 1 Central Nervous Systems Agents
AMITRIPTYLINE HCL 150 MG TABLET 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
16 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AMITRIPTYLINE HCL 25 MG TABLET 1 Central Nervous Systems Agents
AMITRIPTYLINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
AMITRIPTYLINE HCL 75 MG TABLET 1 Central Nervous Systems Agents
AMITRIPTYLINE/CHLORDIAZEP 25 MG;10 MG TABLET 1 Central Nervous Systems Agents
AMLODIPINE BESYLATE 10 MG TABLET 1 QL Cardiovascular Drugs
AMLODIPINE BESYLATE 2.5 MG TABLET 1 QL Cardiovascular Drugs
AMLODIPINE BESYLATE 5 MG TABLET 1 QL Cardiovascular Drugs
AMLODIPINE BESYLATE/BENAZ 10 MG;20 MGCAPSULES
1 QL Cardiovascular Drugs
AMLODIPINE BESYLATE/BENAZ 2.5 MG;10 MGCAPSULES
1 QL Cardiovascular Drugs
AMLODIPINE BESYLATE/BENAZ 5 MG;10 MGCAPSULES
1 QL Cardiovascular Drugs
AMLODIPINE BESYLATE/BENAZ 5 MG;20 MGCAPSULES
1 QL Cardiovascular Drugs
AMMONIUM CHLORIDE 5 MEQ/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
AMMONIUM LACTATE 0.12 CREAM 1 Skin And Mucous Membrane Agents
AMMONIUM LACTATE 0.12 LOTION 1 Skin And Mucous Membrane Agents
AMMONIUM LACTATE 0.12 LOTION 1 Skin And Mucous Membrane Agents
AMNESTEEM 10 MG CAPSULES 3 QL Skin And Mucous Membrane Agents
AMNESTEEM 20 MG CAPSULES 3 QL Skin And Mucous Membrane Agents
AMNESTEEM 40 MG CAPSULES 3 QL Skin And Mucous Membrane Agents
AMOCLAN 200 MG/5ML;28.5 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMOCLAN 400 MG/5ML;57 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMOXAPINE 100 MG TABLET 1 Central Nervous Systems Agents
AMOXAPINE 150 MG TABLET 1 Central Nervous Systems Agents
AMOXAPINE 25 MG TABLET 1 Central Nervous Systems Agents
AMOXAPINE 50 MG TABLET 1 Central Nervous Systems Agents
AMOXICILLIN 250 MG CAPSULES 1 Anti-Infective Agents
AMOXICILLIN 500 MG CAPSULES 1 Anti-Infective Agents
AMOXICILLIN 125 MG CHEWABLE 1 Anti-Infective Agents
AMOXICILLIN 200 MG CHEWABLE 1 Anti-Infective Agents
AMOXICILLIN 250 MG CHEWABLE 1 Anti-Infective Agents
AMOXICILLIN 400 MG CHEWABLE 1 Anti-Infective Agents
AMOXICILLIN 125 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMOXICILLIN 200 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMOXICILLIN 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 17
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AMOXICILLIN 400 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMOXICILLIN 500 MG TABLET 1 Anti-Infective Agents
AMOXICILLIN 875 MG TABLET 1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 200 MG;28.5 MGCHEWABLE
1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 400 MG;57 MGCHEWABLE
1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 200 MG/5ML;28.5MG/5ML SUSPENSION
1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 200 MG/5ML;28.5MG/5ML SUSPENSION
1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 400 MG/5ML;57MG/5ML SUSPENSION
1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 600 MG/5ML;42.9MG/5ML SUSPENSION
1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 250 MG;125 MGTABLET
1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 500 MG;125 MGTABLET
1 Anti-Infective Agents
AMOXICILLIN/CLAVULANATE P 875 MG;125 MGTABLET
1 Anti-Infective Agents
AMOXICILLIN/POTASSIUM CLA 200 MG;28.5 MGCHEWABLE
1 Anti-Infective Agents
AMOXICILLIN/POTASSIUM CLA 400 MG;57 MGCHEWABLE
1 Anti-Infective Agents
AMOXICILLIN/POTASSIUM CLA 200 MG/5ML;28.5MG/5ML SUSPENSION
1 Anti-Infective Agents
AMOXICILLIN/POTASSIUM CLA 400 MG/5ML;57MG/5ML SUSPENSION
1 Anti-Infective Agents
AMOXICILLIN/POTASSIUM CLA 500 MG;125 MGTABLET
1 Anti-Infective Agents
AMOXIL 500 MG CAPSULES 1 Anti-Infective Agents
AMOXIL 200 MG CHEWABLE 1 Anti-Infective Agents
AMOXIL 400 MG CHEWABLE 1 Anti-Infective Agents
AMOXIL 200 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMOXIL 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMOXIL 400 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMOXIL 50 MG/ML SUSPENSION 1 Anti-Infective Agents
AMOXIL 500 MG TABLET 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
18 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AMOXIL 875 MG TABLET 1 Anti-Infective Agents
AMPHETAMINE SALT COMBO 2.5 MG;2.5 MG;2.5MG;2.5 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALT COMBO 3.125 MG;3.125MG;3.125 MG;3.125 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALT COMBO 3.75 MG;3.75 MG;3.75MG;3.75 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALT COMBO 5 MG;5 MG;5 MG;5MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALT COMBO 7.5 MG;7.5 MG;7.5MG;7.5 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALTS COMBO 1.25 MG;1.25MG;1.25 MG;1.25 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALTS COMBO 1.875 MG;1.875MG;1.875 MG;1.875 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALTS COMBO 2.5 MG;2.5 MG;2.5MG;2.5 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALTS COMBO 3.125 MG;3.125MG;3.125 MG;3.125 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALTS COMBO 3.75 MG;3.75MG;3.75 MG;3.75 MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALTS COMBO 5 MG;5 MG;5 MG;5MG TABLET
1 Central Nervous Systems Agents
AMPHETAMINE SALTS COMBO 7.5 MG;7.5 MG;7.5MG;7.5 MG TABLET
1 Central Nervous Systems Agents
AMPHOCIN 50 MG SOLUTION 3 Anti-Infective Agents
AMPHOTEC 100 MG SUSPENSION 4 Anti-Infective Agents
AMPHOTEC 50 MG SUSPENSION 4 Anti-Infective Agents
AMPHOTERICIN B 50 MG SOLUTION 1 Anti-Infective Agents
AMPICILLIN 250 MG CAPSULES 1 Anti-Infective Agents
AMPICILLIN 500 MG CAPSULES 1 Anti-Infective Agents
AMPICILLIN 125 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMPICILLIN 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
AMPICILLIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
AMPICILLIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
AMPICILLIN SODIUM 10 GM SOLUTION 1 Anti-Infective Agents
AMPICILLIN SODIUM 125 MG SOLUTION 1 Anti-Infective Agents
AMPICILLIN SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
AMPICILLIN SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 19
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AMPICILLIN SODIUM 250 MG SOLUTION 1 Anti-Infective Agents
AMPICILLIN SODIUM 500 MG SOLUTION 1 Anti-Infective Agents
AMPICILLIN-SULBACTAM 1 GM;0.5 GM SOLUTION 1 Anti-Infective Agents
AMPICILLIN-SULBACTAM 10 GM;5 GM SOLUTION 1 Anti-Infective Agents
AMPICILLIN-SULBACTAM 2 GM;1 GM SOLUTION 1 Anti-Infective Agents
ANADROL-50 50 MG TABLET 4 Hormones And Synthetic Substitutes
ANAFRANIL 25 MG CAPSULES 3 Central Nervous Systems Agents
ANAFRANIL 50 MG CAPSULES 3 Central Nervous Systems Agents
ANAFRANIL 75 MG CAPSULES 3 Central Nervous Systems Agents
ANAGRELIDE HYDROCHLORIDE 0.5 MG CAPSULES 4 Miscellaneous Therapeutic Agents
ANAGRELIDE HYDROCHLORIDE 1 MG CAPSULES 4 Miscellaneous Therapeutic Agents
ANAPROX 275 MG TABLET 3 Central Nervous Systems Agents
ANAPROX DS 550 MG TABLET 3 Central Nervous Systems Agents
ANCOBON 250 MG CAPSULES 3 Anti-Infective Agents
ANCOBON 500 MG CAPSULES 3 Anti-Infective Agents
ANDRODERM 2.5 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ANDRODERM 5 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ANDROGEL 25 MG/2.5GM GEL 2 QL Hormones And Synthetic Substitutes
ANDROGEL 50 MG/5GM GEL 2 QL Hormones And Synthetic Substitutes
ANDROGEL PUMP 0.01 GEL 2 QL Hormones And Synthetic Substitutes
ANDROID 10 MG CAPSULES 1 Hormones And Synthetic Substitutes
ANDROXY 10 MG TABLET 3 Hormones And Synthetic Substitutes
ANEXSIA 325 MG;5 MG TABLET 1 QL Central Nervous Systems Agents
ANEXSIA 325 MG;7.5 MG TABLET 1 QL Central Nervous Systems Agents
ANGELIQ 0.5 MG;1 MG TABLET 3 Hormones And Synthetic Substitutes
ANSAID 100 MG TABLET 3 Central Nervous Systems Agents
ANTABUSE 250 MG TABLET 2 Miscellaneous Therapeutic Agents
ANTABUSE 500 MG TABLET 2 Miscellaneous Therapeutic Agents
ANTARA 130 MG CAPSULES 3 QL Cardiovascular Drugs
ANTARA 43 MG CAPSULES 3 QL Cardiovascular Drugs
ANTIBIOTIC EAR 1 %;3.5 MG/ML;10000 UNIT/MLSOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
ANTIBIOTIC EAR 1 %;3.5 MG/ML;10000 UNIT/MLSUSPENSION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
ANTIVERT 12.5 MG TABLET 3 Gastrointestinal Drugs
ANTIVERT 25 MG TABLET 3 Gastrointestinal Drugs
ANTIVERT 50 MG TABLET 3 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
20 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ANTIZOL 1 GM/ML SOLUTION 3 Miscellaneous Therapeutic Agents
ANUSOL-HC 0.025 CREAM 1 Skin And Mucous Membrane Agents
ANZEMET 20 MG/ML SOLUTION 3 Gastrointestinal Drugs
ANZEMET 100 MG TABLET 3 QL Gastrointestinal Drugs
ANZEMET 50 MG TABLET 3 QL Gastrointestinal Drugs
APHTHASOL 0.05 PASTE 3 Miscellaneous Therapeutic Agents
APIDRA 100 UNIT/ML SOLUTION 3 Hormones And Synthetic Substitutes
APIDRA OPTICLIK 100 UNIT/ML SOLUTION 3 Hormones And Synthetic Substitutes
APOKYN 10 MG/ML SOLUTION 4 QL Central Nervous Systems Agents
APRI 0.15 MG;30 MCG TABLET 1 Hormones And Synthetic Substitutes
APTIVUS 250 MG CAPSULES 2 Anti-Infective Agents
ARALAST 400 MG SOLUTION 4 QL, PA Enzymes
ARALAST 800 MG SOLUTION 4 QL, PA Enzymes
ARALEN 500 MG TABLET 3 Anti-Infective Agents
ARANELLE 0 TABLET 1 Hormones And Synthetic Substitutes
ARANESP 100 MCG/0.5ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 100 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 150 MCG/0.3ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 150 MCG/0.75ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 200 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 25 MCG/0.42ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 25 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 300 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 40 MCG/0.4ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 40 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 60 MCG/0.3ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP 60 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 21
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ARANESP ALBUMIN FREE 100 MCG/0.5ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 100 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 150 MCG/0.3ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 150 MCG/0.75MLSOLUTION
4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 200 MCG/0.4ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 200 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 25 MCG/0.42ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 25 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 300 MCG/0.6ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 300 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 40 MCG/0.4ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 40 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 500 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 60 MCG/0.3ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARANESP ALBUMIN FREE 60 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
ARAVA 10 MG TABLET 3 QL, PA Miscellaneous Therapeutic Agents
ARAVA 20 MG TABLET 3 QL, PA Miscellaneous Therapeutic Agents
AREDIA 30 MG SOLUTION 4 QL Miscellaneous Therapeutic Agents
AREDIA 90 MG SOLUTION 4 QL Miscellaneous Therapeutic Agents
ARESTIN 1 MG MISC 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ARICEPT 10 MG TABLET 2 QL Autonomic Drugs
ARICEPT 5 MG TABLET 2 QL Autonomic Drugs
ARICEPT ODT 10 MG TABLET 2 QL Autonomic Drugs
ARICEPT ODT 5 MG TABLET 2 QL Autonomic Drugs
ARIMIDEX 1 MG TABLET 2 QL Antineoplastic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
22 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ARISTOSPAN INTRA-ARTICULA 20 MG/MLSUSPENSION
3 Hormones And Synthetic Substitutes
ARISTOSPAN INTRALESIONAL 5 MG/ML SUSPENSION 3 Hormones And Synthetic Substitutes
ARIXTRA 10 MG/0.8ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
ARIXTRA 2.5 MG/0.5ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
ARIXTRA 5 MG/0.4ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
ARIXTRA 7.5 MG/0.6ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
AROMASIN 25 MG TABLET 3 Antineoplastic Agents
ARRANON 5 MG/ML SOLUTION 4 PA Antineoplastic Agents
ARTHROTEC 50 50 MG;200 MCG TABLET 3 Central Nervous Systems Agents
ARTHROTEC 75 75 MG;200 MCG TABLET 3 Central Nervous Systems Agents
ASACOL 400 MG TABLET 2 QL Gastrointestinal Drugs
ASCOMP/CODEINE 325 MG;50 MG;40 MG;30 MGCAPSULES
1 Central Nervous Systems Agents
ASMANEX 120 METERED DOSES 220 MCG/INHAEROSOL POWDER
2 QL Hormones And Synthetic Substitutes
ASMANEX 14 METERED DOSES 220 MCG/INHAEROSOL POWDER
2 QL Hormones And Synthetic Substitutes
ASMANEX 30 METERED DOSES 220 MCG/INHAEROSOL POWDER
2 QL Hormones And Synthetic Substitutes
ASMANEX 60 METERED DOSES 220 MCG/INHAEROSOL POWDER
2 QL Hormones And Synthetic Substitutes
ASPIRIN/CODEINE 325 MG;30 MG TABLET 1 Central Nervous Systems Agents
ASPIRIN/CODEINE 325 MG;60 MG TABLET 1 Central Nervous Systems Agents
ASTELIN 137 MCG/SPRAY SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT)Preparations
ASTRAMORPH 0.5 MG/ML SOLUTION 1 Central Nervous Systems Agents
ASTRAMORPH 1 MG/ML SOLUTION 1 Central Nervous Systems Agents
ATACAND 16 MG TABLET 3 QL Cardiovascular Drugs
ATACAND 32 MG TABLET 3 QL Cardiovascular Drugs
ATACAND 4 MG TABLET 3 QL Cardiovascular Drugs
ATACAND 8 MG TABLET 3 QL Cardiovascular Drugs
ATACAND HCT 16 MG;12.5 MG TABLET 3 QL Cardiovascular Drugs
ATACAND HCT 32 MG;12.5 MG TABLET 3 QL Cardiovascular Drugs
ATAMET 25 MG;100 MG TABLET 3 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 23
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ATAMET 25 MG;250 MG TABLET 3 Central Nervous Systems Agents
ATENOLOL 100 MG TABLET 1 Cardiovascular Drugs
ATENOLOL 25 MG TABLET 1 Cardiovascular Drugs
ATENOLOL 50 MG TABLET 1 Cardiovascular Drugs
ATENOLOL/CHLORTHALIDONE 100 MG;25 MGTABLET
1 Cardiovascular Drugs
ATENOLOL/CHLORTHALIDONE 50 MG;25 MG TABLET 1 Cardiovascular Drugs
ATGAM 50 MG/ML INJECTION 3 Miscellaneous Therapeutic Agents
ATREZA 0.4 MG TABLET 1 Autonomic Drugs
ATRIDOX 0.1 KIT 3 Anti-Infective Agents
ATRIPLA 600 MG;200 MG;300 MG TABLET 2 Anti-Infective Agents
ATROPINE SULFATE 0.01 OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ATROPINE SULFATE 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ATROPINE SULFATE 0.05 MG/ML SOLUTION 1 Autonomic Drugs
ATROPINE SULFATE 0.1 MG/ML SOLUTION 1 Autonomic Drugs
ATROPINE SULFATE 0.4 MG/ML SOLUTION 1 Autonomic Drugs
ATROPINE SULFATE 0.8 MG/ML SOLUTION 1 Autonomic Drugs
ATROPINE SULFATE 1 MG/ML SOLUTION 1 Autonomic Drugs
ATROVENT 0.0003 SOLUTION 3 QL Eye, Ear, Nose, And Throat (EENT)Preparations
ATROVENT 0.0006 SOLUTION 3 QL Eye, Ear, Nose, And Throat (EENT)Preparations
ATROVENT HFA 17 MCG/ACT AEROSOL SOLUTION 3 QL Autonomic Drugs
ATTENUVAX 0 INJECTION 3 Serums, Toxoids, And Vaccines
AUGMENTED BETAMETHASONE D 0.0005 CREAM 1 Skin And Mucous Membrane Agents
AUGMENTED BETAMETHASONE D 0.0005 GEL 1 Skin And Mucous Membrane Agents
AUGMENTED BETAMETHASONE D 0.05 % LOTION 1 Skin And Mucous Membrane Agents
AUGMENTED BETAMETHASONE D 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
AUGMENTIN 125 MG;31.25 MG CHEWABLE 3 Anti-Infective Agents
AUGMENTIN 200 MG;28.5 MG CHEWABLE 3 Anti-Infective Agents
AUGMENTIN 250 MG;62.5 MG CHEWABLE 3 Anti-Infective Agents
AUGMENTIN 400 MG;57 MG CHEWABLE 3 Anti-Infective Agents
AUGMENTIN 125 MG/5ML;31.25 MG/5MLSUSPENSION
3 Anti-Infective Agents
AUGMENTIN 200 MG/5ML;28.5 MG/5MLSUSPENSION
3 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
24 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AUGMENTIN 250 MG/5ML;62.5 MG/5MLSUSPENSION
3 Anti-Infective Agents
AUGMENTIN 400 MG/5ML;57 MG/5ML SUSPENSION 3 Anti-Infective Agents
AUGMENTIN 250 MG;125 MG TABLET 3 Anti-Infective Agents
AUGMENTIN 500 MG;125 MG TABLET 3 Anti-Infective Agents
AUGMENTIN 875 MG;125 MG TABLET 3 Anti-Infective Agents
AUGMENTIN ES-600 600 MG/5ML;42.9 MG/5MLSUSPENSION
3 Anti-Infective Agents
AUGMENTIN XR 1000 MG;62.5 MG TABLET 3 Anti-Infective Agents
AVALIDE 12.5 MG;150 MG TABLET 2 QL Cardiovascular Drugs
AVALIDE 12.5 MG;300 MG TABLET 2 QL Cardiovascular Drugs
AVALIDE 25 MG;300 MG TABLET 2 QL Cardiovascular Drugs
AVANDAMET 1000 MG;2 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDAMET 1000 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDAMET 500 MG;2 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDAMET 500 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDARYL 1 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDARYL 2 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDARYL 4 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDIA 2 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDIA 4 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVANDIA 8 MG TABLET 2 QL Hormones And Synthetic Substitutes
AVAPRO 150 MG TABLET 2 QL Cardiovascular Drugs
AVAPRO 300 MG TABLET 2 QL Cardiovascular Drugs
AVAPRO 75 MG TABLET 2 QL Cardiovascular Drugs
AVASTIN 100 MG/4ML SOLUTION 4 QL Antineoplastic Agents
AVASTIN 400 MG/16ML SOLUTION 4 QL Antineoplastic Agents
AVELOX 400 MG/250ML;0.8 % SOLUTION 3 Anti-Infective Agents
AVELOX 400 MG TABLET 3 Anti-Infective Agents
AVELOX ABC PACK 400 MG TABLET 3 Anti-Infective Agents
AVIANE 20 MCG;0.1 MG TABLET 1 Hormones And Synthetic Substitutes
AVINZA 120 MG CAPSULES 2 QL Central Nervous Systems Agents
AVINZA 30 MG CAPSULES 2 QL Central Nervous Systems Agents
AVINZA 60 MG CAPSULES 2 QL Central Nervous Systems Agents
AVINZA 90 MG CAPSULES 2 QL Central Nervous Systems Agents
AVITA 0.00025 CREAM 1 PA Skin And Mucous Membrane Agents
AVITA 0.00025 GEL 1 PA Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 25
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
AVODART 0.5 MG CAPSULES 2 QL Miscellaneous Therapeutic Agents
AVONEX 30 MCG/0.5ML KIT 4 QL, PA Miscellaneous Therapeutic Agents
AVONEX 30 MCG/VIAL KIT 4 QL, PA Miscellaneous Therapeutic Agents
AXERT 12.5 MG TABLET 3 QL Central Nervous Systems Agents
AXERT 6.25 MG TABLET 3 QL Central Nervous Systems Agents
AXID 150 MG CAPSULES 3 Gastrointestinal Drugs
AXID 300 MG CAPSULES 3 Gastrointestinal Drugs
AXID 15 MG/ML SOLUTION 3 Gastrointestinal Drugs
AYGESTIN 5 MG TABLET 3 Hormones And Synthetic Substitutes
AZACTAM 1 GM SOLUTION 3 Anti-Infective Agents
AZACTAM 2 GM SOLUTION 3 Anti-Infective Agents
AZACTAM IN DEXTROSE 1 GM;0 - SOLUTION 3 Anti-Infective Agents
AZACTAM IN DEXTROSE 2 GM;0 - SOLUTION 3 Anti-Infective Agents
AZASAN 100 MG TABLET 3 Miscellaneous Therapeutic Agents
AZASAN 75 MG TABLET 3 Miscellaneous Therapeutic Agents
AZASITE 1 % SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
AZATHIOPRINE 50 MG TABLET 1 Miscellaneous Therapeutic Agents
AZATHIOPRINE SODIUM 100 MG SOLUTION 1 Miscellaneous Therapeutic Agents
AZELEX 0.2 CREAM 3 Skin And Mucous Membrane Agents
AZILECT 0.5 MG TABLET 3 QL Central Nervous Systems Agents
AZILECT 1 MG TABLET 3 QL Central Nervous Systems Agents
AZITHROMYCIN 1 GM PACK 1 Anti-Infective Agents
AZITHROMYCIN 500 MG SOLUTION 1 Anti-Infective Agents
AZITHROMYCIN 100 MG/5ML SUSPENSION 1 Anti-Infective Agents
AZITHROMYCIN 200 MG/5ML SUSPENSION 1 Anti-Infective Agents
AZITHROMYCIN 250 MG TABLET 1 Anti-Infective Agents
AZITHROMYCIN 500 MG TABLET 1 Anti-Infective Agents
AZITHROMYCIN 600 MG TABLET 1 Anti-Infective Agents
AZMACORT 100 MCG/ACT AEROSOL SOLUTION 3 QL, ST Hormones And Synthetic Substitutes
AZOPT 0.01 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
AZULFIDINE 500 MG TABLET 3 QL Anti-Infective Agents
AZULFIDINE EN-TABS 500 MG TABLET 3 QL Anti-Infective Agents
BAC/POLY/NEOMY/HC 400 UNIT/GM;1 %;0.5%;10000 UNIT/GM OINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
BACIIM 50000 UNIT SOLUTION 3 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
26 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
BACITRACIN 500 UNIT/GM OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
BACITRACIN 50000 UNIT SOLUTION 1 Anti-Infective Agents
BACITRACIN/NEOMYCIN/POLYM 400 UNIT/GM;5MG/GM;10000 UNIT/GM OINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
BACITRACIN/POLYMYXIN B 500 UNIT/GM;10000UNIT/GM OINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
BACLOFEN 10 MG TABLET 1 Autonomic Drugs
BACLOFEN 20 MG TABLET 1 Autonomic Drugs
BACTOCILL IN DEXTROSE 0 -;1 GM/50ML SOLUTION 1 Anti-Infective Agents
BACTOCILL IN DEXTROSE 0 -;2 GM/50ML SOLUTION 1 Anti-Infective Agents
BACTRIM 400 MG;80 MG TABLET 3 Anti-Infective Agents
BACTRIM DS 800 MG;160 MG TABLET 3 Anti-Infective Agents
BACTROBAN 0.02 CREAM 3 Skin And Mucous Membrane Agents
BACTROBAN 0.02 OINTMENT 3 Skin And Mucous Membrane Agents
BACTROBAN NASAL 0.02 OINTMENT 3 Eye, Ear, Nose, And Throat (EENT)Preparations
BALACET 325 325 MG;100 MG TABLET 1 QL Central Nervous Systems Agents
BALZIVA 35 MCG;0.4 MG TABLET 1 Hormones And Synthetic Substitutes
BARACLUDE 0.05 MG/ML SOLUTION 4 Anti-Infective Agents
BARACLUDE 0.5 MG TABLET 4 Anti-Infective Agents
BARACLUDE 1 MG TABLET 4 Anti-Infective Agents
BECONASE AQ 0.00042 INHALER 3 QL, ST Eye, Ear, Nose, And Throat (EENT)Preparations
BENADRYL 25 MG CAPSULES 1 Antihistamine Drugs
BENADRYL 50 MG/ML SOLUTION 3 Antihistamine Drugs
BENAZEPRIL HCL 10 MG TABLET 1 Cardiovascular Drugs
BENAZEPRIL HCL 20 MG TABLET 1 Cardiovascular Drugs
BENAZEPRIL HCL 40 MG TABLET 1 Cardiovascular Drugs
BENAZEPRIL HCL 5 MG TABLET 1 Cardiovascular Drugs
BENAZEPRIL HCL/HYDROCHLOR 10 MG;12.5 MGTABLET
1 Cardiovascular Drugs
BENAZEPRIL HCL/HYDROCHLOR 20 MG;12.5 MGTABLET
1 Cardiovascular Drugs
BENAZEPRIL HCL/HYDROCHLOR 20 MG;25 MGTABLET
1 Cardiovascular Drugs
BENAZEPRIL HCL/HYDROCHLOR 5 MG;6.25 MGTABLET
1 Cardiovascular Drugs
BENICAR 20 MG TABLET 2 QL Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 27
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
BENICAR 40 MG TABLET 2 QL Cardiovascular Drugs
BENICAR 5 MG TABLET 2 QL Cardiovascular Drugs
BENICAR HCT 12.5 MG;20 MG TABLET 2 QL Cardiovascular Drugs
BENICAR HCT 12.5 MG;40 MG TABLET 2 QL Cardiovascular Drugs
BENICAR HCT 25 MG;40 MG TABLET 2 QL Cardiovascular Drugs
BENOQUIN 0.2 CREAM 3 Skin And Mucous Membrane Agents
BENTYL 10 MG CAPSULES 3 Autonomic Drugs
BENTYL 10 MG/ML SOLUTION 3 Autonomic Drugs
BENTYL 10 MG/5ML SYRUP 3 Autonomic Drugs
BENTYL 20 MG TABLET 3 Autonomic Drugs
BENZACLIN 5 %;1 % GEL 3 Skin And Mucous Membrane Agents
BENZAMYCIN 5 %;3 % GEL 3 Skin And Mucous Membrane Agents
BENZTROPINE MESYLATE 0.5 MG TABLET 1 Autonomic Drugs
BENZTROPINE MESYLATE 1 MG TABLET 1 Autonomic Drugs
BENZTROPINE MESYLATE 2 MG TABLET 1 Autonomic Drugs
BETA-VAL 0.001 CREAM 1 Skin And Mucous Membrane Agents
BETA-VAL 0.001 LOTION 1 Skin And Mucous Membrane Agents
BETAGAN 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
BETAGAN C CAP QD 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
BETAGAN WITHOUT C CAP 0.0025 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
BETAMETHASONE DIPROPIONAT 0.0005 CREAM 1 Skin And Mucous Membrane Agents
BETAMETHASONE DIPROPIONAT 0.0005 GEL 1 Skin And Mucous Membrane Agents
BETAMETHASONE DIPROPIONAT 0.0005 LOTION 1 Skin And Mucous Membrane Agents
BETAMETHASONE DIPROPIONAT 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
BETAMETHASONE VALERATE 0.001 CREAM 1 Skin And Mucous Membrane Agents
BETAMETHASONE VALERATE 0.001 LOTION 1 Skin And Mucous Membrane Agents
BETAMETHASONE VALERATE 0.001 OINTMENT 1 Skin And Mucous Membrane Agents
BETAPACE 120 MG TABLET 3 Cardiovascular Drugs
BETAPACE 160 MG TABLET 3 Cardiovascular Drugs
BETAPACE 240 MG TABLET 3 Cardiovascular Drugs
BETAPACE 80 MG TABLET 3 Cardiovascular Drugs
BETAPACE AF 120 MG TABLET 3 Cardiovascular Drugs
BETAPACE AF 160 MG TABLET 3 Cardiovascular Drugs
BETAPACE AF 80 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
28 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
BETASERON 0.3 MG SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
BETAXOLOL HCL 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
BETAXOLOL HCL 10 MG TABLET 1 Cardiovascular Drugs
BETAXOLOL HCL 20 MG TABLET 1 Cardiovascular Drugs
BETHANECHOL CHLORIDE 10 MG TABLET 1 Autonomic Drugs
BETHANECHOL CHLORIDE 25 MG TABLET 1 Autonomic Drugs
BETHANECHOL CHLORIDE 5 MG TABLET 1 Autonomic Drugs
BETHANECHOL CHLORIDE 50 MG TABLET 1 Autonomic Drugs
BETIMOL 0.0025 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
BETIMOL 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
BETOPTIC-S 0.0025 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
BEXXAR 14 MG/ML CONCENTRATION 4 Antineoplastic Agents
BIAXIN 125 MG/5ML SUSPENSION 3 Anti-Infective Agents
BIAXIN 250 MG/5ML SUSPENSION 3 Anti-Infective Agents
BIAXIN 250 MG TABLET 3 Anti-Infective Agents
BIAXIN 500 MG TABLET 3 Anti-Infective Agents
BIAXIN XL 500 MG TABLET 2 Anti-Infective Agents
BIAXIN XL PAC 500 MG TABLET 2 Anti-Infective Agents
BICILLIN C-R 300000 UNIT/ML;300000 UNIT/MLSUSPENSION
3 Anti-Infective Agents
BICILLIN C-R 900000 UNIT/ML;300000 UNIT/MLSUSPENSION
3 Anti-Infective Agents
BICILLIN L-A 1200000 UNIT/2ML SUSPENSION 3 Anti-Infective Agents
BICILLIN L-A 2400000 UNIT/4ML SUSPENSION 3 Anti-Infective Agents
BICILLIN L-A 600000 UNIT/ML SUSPENSION 3 Anti-Infective Agents
BICNU W/DILUENT ABSOLUTE 100 MG SOLUTION 3 Antineoplastic Agents
BIDIL 37.5 MG;20 MG TABLET 2 QL Cardiovascular Drugs
BILTRICIDE 600 MG TABLET 3 Anti-Infective Agents
BIO-STATIN 1000000 UNIT CAPSULES 3 Anti-Infective Agents
BIO-STATIN 500000 UNIT CAPSULES 3 Anti-Infective Agents
BISOPROLOL FUMARATE 10 MG TABLET 1 Cardiovascular Drugs
BISOPROLOL FUMARATE 5 MG TABLET 1 Cardiovascular Drugs
BISOPROLOL FUMARATE/HYDRO 10 MG;6.25 MGTABLET
1 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 29
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
BISOPROLOL FUMARATE/HYDRO 2.5 MG;6.25 MGTABLET
1 Cardiovascular Drugs
BISOPROLOL FUMARATE/HYDRO 5 MG;6.25 MGTABLET
1 Cardiovascular Drugs
BLENOXANE 15 UNIT SOLUTION 3 Antineoplastic Agents
BLENOXANE 30 UNIT SOLUTION 3 Antineoplastic Agents
BLEOMYCIN SULFATE 15 UNIT SOLUTION 1 Antineoplastic Agents
BLEOMYCIN SULFATE 30 UNIT SOLUTION 1 Antineoplastic Agents
BLEPH-10 0.1 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
BLEPHAMIDE 0.2 %;10 % SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
BLEPHAMIDE S.O.P. 0.2 %;10 % OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
BONIVA 3 MG/3ML KIT 3 QL Miscellaneous Therapeutic Agents
BONIVA 150 MG TABLET 3 QL Miscellaneous Therapeutic Agents
BONIVA 2.5 MG TABLET 3 QL Miscellaneous Therapeutic Agents
BOOSTRIX 18.5 MCG/0.5ML;2.5 LF/0.5ML;5 LF/0.5MLSUSPENSION
3 Serums, Toxoids, And Vaccines
BOROFAIR 2 %;0 - SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
BRETHINE 1 MG/ML SOLUTION 3 Autonomic Drugs
BRETHINE 2.5 MG TABLET 3 Autonomic Drugs
BRETHINE 5 MG TABLET 3 Autonomic Drugs
BREVICON-28 35 MCG;0.5 MG TABLET 3 Hormones And Synthetic Substitutes
BRIMONIDINE TARTRATE 0.002 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
BROMOCRIPTINE MESYLATE 5 MG CAPSULES 1 Miscellaneous Therapeutic Agents
BROMOCRIPTINE MESYLATE 2.5 MG TABLET 1 Miscellaneous Therapeutic Agents
BROVANA 15 MCG/2ML NEBULIZER 3 QL Autonomic Drugs
BUDEPRION SR 100 MG TABLET 1 QL Central Nervous Systems Agents
BUDEPRION SR 150 MG TABLET 1 QL Central Nervous Systems Agents
BUDEPRION XL 300 MG TABLET 1 QL Central Nervous Systems Agents
BUMETANIDE 0.25 MG/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
BUMETANIDE 0.5 MG TABLET 1 Electrolytic, Caloric, And Water Balance
BUMETANIDE 1 MG TABLET 1 Electrolytic, Caloric, And Water Balance
BUMETANIDE 2 MG TABLET 1 Electrolytic, Caloric, And Water Balance
BUMEX 0.5 MG TABLET 3 Electrolytic, Caloric, And Water Balance
BUMEX 1 MG TABLET 3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
30 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
BUMEX 2 MG TABLET 3 Electrolytic, Caloric, And Water Balance
BUPHENYL 0 POWDER 4 Electrolytic, Caloric, And Water Balance
BUPHENYL 500 MG TABLET 4 Electrolytic, Caloric, And Water Balance
BUPRENEX 0.324 MG/ML SOLUTION 3 Central Nervous Systems Agents
BUPRENORPHINE HCL 0.324 MG/ML SOLUTION 3 Central Nervous Systems Agents
BUPROBAN 150 MG TABLET 1 QL Central Nervous Systems Agents
BUPROPION HCL 100 MG TABLET 1 QL Central Nervous Systems Agents
BUPROPION HCL 75 MG TABLET 1 Central Nervous Systems Agents
BUPROPION HCL SR 100 MG TABLET 1 QL Central Nervous Systems Agents
BUPROPION HCL SR 150 MG TABLET 1 QL Central Nervous Systems Agents
BUPROPION HCL SR 150 MG TABLET 1 QL Central Nervous Systems Agents
BUPROPION HCL SR 200 MG TABLET 1 QL Central Nervous Systems Agents
BUSPAR 10 MG TABLET 3 Central Nervous Systems Agents
BUSPAR 15 MG TABLET 3 Central Nervous Systems Agents
BUSPAR 30 MG TABLET 3 Central Nervous Systems Agents
BUSPAR 5 MG TABLET 3 Central Nervous Systems Agents
BUSPIRONE HCL 10 MG TABLET 1 Central Nervous Systems Agents
BUSPIRONE HCL 15 MG TABLET 1 Central Nervous Systems Agents
BUSPIRONE HCL 30 MG TABLET 1 Central Nervous Systems Agents
BUSPIRONE HCL 5 MG TABLET 1 Central Nervous Systems Agents
BUSPIRONE HCL 7.5 MG TABLET 1 Central Nervous Systems Agents
BUSULFEX 6 MG/ML SOLUTION 3 Antineoplastic Agents
BUTAL/ASA/CAFF/COD 325 MG;50 MG;40 MG;30 MGCAPSULES
1 Central Nervous Systems Agents
BUTALBITAL/APAP/CAFFEINE/ 325 MG;50 MG;40MG;30 MG CAPSULES
1 QL Central Nervous Systems Agents
BUTORPHANOL TARTRATE 1 MG/ML SOLUTION 1 QL Central Nervous Systems Agents
BUTORPHANOL TARTRATE 10 MG/ML SOLUTION 1 QL Central Nervous Systems Agents
BUTORPHANOL TARTRATE 2 MG/ML SOLUTION 1 QL Central Nervous Systems Agents
BYETTA 250 MCG/ML SOLUTION 2 QL, ST Hormones And Synthetic Substitutes
BYETTA 250 MCG/ML;1.2 ML SOLUTION 2 QL, ST Hormones And Synthetic Substitutes
CABERGOLINE 0.5 MG TABLET 1 QL Miscellaneous Therapeutic Agents
CADUET 10 MG;10 MG TABLET 3 QL Cardiovascular Drugs
CADUET 10 MG;20 MG TABLET 3 QL Cardiovascular Drugs
CADUET 10 MG;40 MG TABLET 3 QL Cardiovascular Drugs
CADUET 10 MG;80 MG TABLET 3 QL Cardiovascular Drugs
CADUET 2.5 MG;10 MG TABLET 3 QL Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 31
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CADUET 2.5 MG;20 MG TABLET 3 QL Cardiovascular Drugs
CADUET 2.5 MG;40 MG TABLET 3 QL Cardiovascular Drugs
CADUET 5 MG;10 MG TABLET 3 QL Cardiovascular Drugs
CADUET 5 MG;20 MG TABLET 3 QL Cardiovascular Drugs
CADUET 5 MG;40 MG TABLET 3 QL Cardiovascular Drugs
CADUET 5 MG;80 MG TABLET 3 QL Cardiovascular Drugs
CAFERGOT 100 MG;1 MG TABLET 3 Autonomic Drugs
CALAN 120 MG TABLET 3 Cardiovascular Drugs
CALAN 40 MG TABLET 3 Cardiovascular Drugs
CALAN 80 MG TABLET 3 Cardiovascular Drugs
CALAN SR 120 MG TABLET 3 Cardiovascular Drugs
CALAN SR 180 MG TABLET 3 Cardiovascular Drugs
CALAN SR 240 MG TABLET 3 Cardiovascular Drugs
CALCIJEX 1 MCG/ML SOLUTION 3 Vitamins
CALCITRIOL 0.25 MCG CAPSULES 1 Vitamins
CALCITRIOL 0.5 MCG CAPSULES 1 Vitamins
CALCITRIOL 1 MCG/ML SOLUTION 1 Vitamins
CALCITRIOL 1 MCG/ML SOLUTION 1 Vitamins
CALCITRIOL 2 MCG/ML SOLUTION 1 Vitamins
CAMILA 0.35 MG TABLET 1 Hormones And Synthetic Substitutes
CAMPATH 10 MG/ML SOLUTION 4 QL Antineoplastic Agents
CAMPATH 30 MG/ML SOLUTION 4 QL Antineoplastic Agents
CAMPRAL 333 MG TABLET 3 QL Central Nervous Systems Agents
CAMPTOSAR 20 MG/ML SOLUTION 4 Antineoplastic Agents
CANASA 1000 MG SUPPOSITORY 3 QL Gastrointestinal Drugs
CANCIDAS 50 MG SOLUTION 4 Anti-Infective Agents
CANCIDAS 70 MG SOLUTION 4 Anti-Infective Agents
CANTIL 25 MG TABLET 3 Autonomic Drugs
CAPASTAT SULFATE 1 GM SOLUTION 3 Anti-Infective Agents
CAPEX 0.0001 SHAMPOO 3 Skin And Mucous Membrane Agents
CAPITAL/CODEINE 120 MG/5ML;12 MG/5MLSUSPENSION
1 Central Nervous Systems Agents
CAPOTEN 100 MG TABLET 3 Cardiovascular Drugs
CAPOTEN 12.5 MG TABLET 3 Cardiovascular Drugs
CAPOTEN 25 MG TABLET 3 Cardiovascular Drugs
CAPOTEN 50 MG TABLET 3 Cardiovascular Drugs
CAPOZIDE 25 MG;15 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
32 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CAPOZIDE 25 MG;25 MG TABLET 3 Cardiovascular Drugs
CAPOZIDE 50 MG;15 MG TABLET 3 Cardiovascular Drugs
CAPOZIDE 50 MG;25 MG TABLET 3 Cardiovascular Drugs
CAPTOPRIL 100 MG TABLET 1 Cardiovascular Drugs
CAPTOPRIL 12.5 MG TABLET 1 Cardiovascular Drugs
CAPTOPRIL 25 MG TABLET 1 Cardiovascular Drugs
CAPTOPRIL 50 MG TABLET 1 Cardiovascular Drugs
CAPTOPRIL/HYDROCHLOROTHIA 25 MG;15 MGTABLET
1 Cardiovascular Drugs
CAPTOPRIL/HYDROCHLOROTHIA 25 MG;25 MGTABLET
1 Cardiovascular Drugs
CAPTOPRIL/HYDROCHLOROTHIA 50 MG;15 MGTABLET
1 Cardiovascular Drugs
CAPTOPRIL/HYDROCHLOROTHIA 50 MG;25 MGTABLET
1 Cardiovascular Drugs
CARAC 0.005 CREAM 3 Skin And Mucous Membrane Agents
CARAFATE 1 GM/10ML SUSPENSION 3 PA Gastrointestinal Drugs
CARAFATE 1 GM TABLET 3 PA Gastrointestinal Drugs
CARBAMAZEPINE 100 MG CHEWABLE 1 Central Nervous Systems Agents
CARBAMAZEPINE 100 MG/5ML SUSPENSION 1 Central Nervous Systems Agents
CARBAMAZEPINE 200 MG TABLET 1 Central Nervous Systems Agents
CARBASTAT 0.0001 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
CARBATROL 100 MG CAPSULES 3 QL Central Nervous Systems Agents
CARBATROL 200 MG CAPSULES 3 QL Central Nervous Systems Agents
CARBATROL 300 MG CAPSULES 3 QL Central Nervous Systems Agents
CARBIDOPA/LEVODOPA 10 MG;100 MG TABLET 1 Central Nervous Systems Agents
CARBIDOPA/LEVODOPA 25 MG;100 MG TABLET 1 Central Nervous Systems Agents
CARBIDOPA/LEVODOPA 25 MG;250 MG TABLET 1 Central Nervous Systems Agents
CARBIDOPA/LEVODOPA CR 25 MG;100 MG TABLET 1 Central Nervous Systems Agents
CARBIDOPA/LEVODOPA ER 25 MG;100 MG TABLET 1 Central Nervous Systems Agents
CARBIDOPA/LEVODOPA ER 50 MG;200 MG TABLET 1 Central Nervous Systems Agents
CARBIDOPA/LEVODOPA SR 25 MG;100 MG TABLET 1 Central Nervous Systems Agents
CARBIDOPA/LEVODOPA SR 50 MG;200 MG TABLET 1 Central Nervous Systems Agents
CARBOPLATIN 10 MG/ML SOLUTION 3 Antineoplastic Agents
CARBOPLATIN 150 MG SOLUTION 3 Antineoplastic Agents
CARBOPLATIN 150 MG/15ML SOLUTION 3 Antineoplastic Agents
CARBOPLATIN 450 MG SOLUTION 3 Antineoplastic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 33
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CARBOPLATIN 450 MG/45ML SOLUTION 3 Antineoplastic Agents
CARBOPLATIN 50 MG SOLUTION 1 Antineoplastic Agents
CARBOPLATIN 50 MG/5ML SOLUTION 3 Antineoplastic Agents
CARBOPLATIN 600 MG/60ML SOLUTION 3 Antineoplastic Agents
CARDENE 20 MG CAPSULES 3 Cardiovascular Drugs
CARDENE 30 MG CAPSULES 3 Cardiovascular Drugs
CARDENE I.V. 2.5 MG/ML SOLUTION 3 Cardiovascular Drugs
CARDENE SR 30 MG CAPSULES 3 QL Cardiovascular Drugs
CARDENE SR 45 MG CAPSULES 3 QL Cardiovascular Drugs
CARDENE SR 60 MG CAPSULES 3 QL Cardiovascular Drugs
CARDIZEM 120 MG TABLET 3 Cardiovascular Drugs
CARDIZEM 30 MG TABLET 3 Cardiovascular Drugs
CARDIZEM 60 MG TABLET 3 Cardiovascular Drugs
CARDIZEM 90 MG TABLET 3 Cardiovascular Drugs
CARDIZEM CD 120 MG CAPSULES 3 QL, PA Cardiovascular Drugs
CARDIZEM CD 180 MG CAPSULES 3 QL, PA Cardiovascular Drugs
CARDIZEM CD 240 MG CAPSULES 3 QL, PA Cardiovascular Drugs
CARDIZEM CD 300 MG CAPSULES 3 QL, PA Cardiovascular Drugs
CARDIZEM CD 360 MG CAPSULES 3 QL, PA Cardiovascular Drugs
CARDIZEM LA 120 MG TABLET 2 QL Cardiovascular Drugs
CARDIZEM LA 180 MG TABLET 2 QL Cardiovascular Drugs
CARDIZEM LA 240 MG TABLET 2 QL Cardiovascular Drugs
CARDIZEM LA 300 MG TABLET 2 QL Cardiovascular Drugs
CARDIZEM LA 360 MG TABLET 2 QL Cardiovascular Drugs
CARDIZEM LA 420 MG TABLET 2 QL Cardiovascular Drugs
CARDURA 1 MG TABLET 3 Cardiovascular Drugs
CARDURA 2 MG TABLET 3 Cardiovascular Drugs
CARDURA 4 MG TABLET 3 Cardiovascular Drugs
CARDURA 8 MG TABLET 3 Cardiovascular Drugs
CARDURA XL 4 MG TABLET 3 QL Cardiovascular Drugs
CARDURA XL 8 MG TABLET 3 QL Cardiovascular Drugs
CARIMUNE 1 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
CARIMUNE 12 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
CARIMUNE NANOFILTERED 1 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
CARIMUNE NANOFILTERED 12 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
CARIMUNE NANOFILTERED 3 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
34 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CARIMUNE NANOFILTERED 6 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
CARISOPRODOL 350 MG TABLET 1 Autonomic Drugs
CARISOPRODOL/ASPIRIN 325 MG;200 MG TABLET 1 Autonomic Drugs
CARISOPRODOL/ASPIRIN/CODE 325 MG;200 MG;16MG TABLET
1 Autonomic Drugs
CARMOL-HC 1 %;10 % CREAM 1 Skin And Mucous Membrane Agents
CARNITOR 1 GM/10ML SOLUTION 3 Miscellaneous Therapeutic Agents
CARNITOR 200 MG/ML SOLUTION 1 Miscellaneous Therapeutic Agents
CARNITOR 330 MG TABLET 3 Miscellaneous Therapeutic Agents
CARTEOLOL HCL 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
CARTIA XT 120 MG CAPSULES 1 QL Cardiovascular Drugs
CARTIA XT 180 MG CAPSULES 1 QL Cardiovascular Drugs
CARTIA XT 240 MG CAPSULES 1 QL Cardiovascular Drugs
CARTIA XT 300 MG CAPSULES 1 QL Cardiovascular Drugs
CARTROL 2.5 MG TABLET 3 Cardiovascular Drugs
CARTROL 5 MG TABLET 3 Cardiovascular Drugs
CASODEX 50 MG TABLET 2 QL Antineoplastic Agents
CATAFLAM 50 MG TABLET 3 Central Nervous Systems Agents
CATAPRES 0.1 MG TABLET 3 Cardiovascular Drugs
CATAPRES 0.2 MG TABLET 3 Cardiovascular Drugs
CATAPRES 0.3 MG TABLET 3 Cardiovascular Drugs
CATAPRES-TTS-1 0.1 MG/24HR PATCH 3 QL Cardiovascular Drugs
CATAPRES-TTS-2 0.2 MG/24HR PATCH 3 QL Cardiovascular Drugs
CATAPRES-TTS-3 0.3 MG/24HR PATCH 3 QL Cardiovascular Drugs
CEDAX 400 MG CAPSULES 3 Anti-Infective Agents
CEDAX 90 MG/5ML SUSPENSION 3 Anti-Infective Agents
CEENU 10 MG CAPSULES 3 Antineoplastic Agents
CEENU 100 MG CAPSULES 3 Antineoplastic Agents
CEENU 300 MG CAPSULES 3 Antineoplastic Agents
CEENU 40 MG CAPSULES 3 Antineoplastic Agents
CEFACLOR 250 MG CAPSULES 1 Anti-Infective Agents
CEFACLOR 500 MG CAPSULES 1 Anti-Infective Agents
CEFACLOR 125 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFACLOR 187 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFACLOR 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFACLOR 375 MG/5ML SUSPENSION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 35
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CEFACLOR ER 500 MG TABLET 1 Anti-Infective Agents
CEFADROXIL 500 MG CAPSULES 1 Anti-Infective Agents
CEFADROXIL 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFADROXIL 500 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFADROXIL 1 GM TABLET 1 Anti-Infective Agents
CEFAZOLIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
CEFAZOLIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
CEFAZOLIN SODIUM 1 GM;5 % SOLUTION 1 Anti-Infective Agents
CEFAZOLIN SODIUM 10 GM SOLUTION 1 Anti-Infective Agents
CEFAZOLIN SODIUM 20 GM SOLUTION 1 Anti-Infective Agents
CEFAZOLIN SODIUM 500 MG SOLUTION 1 Anti-Infective Agents
CEFAZOLIN SODIUM 500 MG;5 % SOLUTION 1 Anti-Infective Agents
CEFAZOLIN SODIUM-DEXTROSE 1 GM;4 %SOLUTION
1 Anti-Infective Agents
CEFDINIR 300 MG CAPSULES 1 Anti-Infective Agents
CEFDINIR 125 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFDINIR 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFIZOX IN DEXTROSE 5% 1 GM/50ML;5 %SOLUTION
3 Anti-Infective Agents
CEFIZOX IN DEXTROSE 5% 2 GM/50ML;5 %SOLUTION
3 Anti-Infective Agents
CEFOTAXIME SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
CEFOTAXIME SODIUM 10 GM SOLUTION 1 Anti-Infective Agents
CEFOTAXIME SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
CEFOTAXIME SODIUM 20 GM SOLUTION 1 Anti-Infective Agents
CEFOTAXIME SODIUM 500 MG SOLUTION 1 Anti-Infective Agents
CEFOXITIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
CEFOXITIN SODIUM 10 GM SOLUTION 1 Anti-Infective Agents
CEFOXITIN SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
CEFPODOXIME PROXETIL 100 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFPODOXIME PROXETIL 50 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFPODOXIME PROXETIL 100 MG TABLET 1 Anti-Infective Agents
CEFPODOXIME PROXETIL 200 MG TABLET 1 Anti-Infective Agents
CEFPROZIL 125 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFPROZIL 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEFPROZIL 250 MG TABLET 1 Anti-Infective Agents
CEFPROZIL 500 MG TABLET 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
36 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CEFTIN 125 MG/5ML SUSPENSION 3 Anti-Infective Agents
CEFTIN 250 MG/5ML SUSPENSION 3 Anti-Infective Agents
CEFTIN 250 MG TABLET 3 Anti-Infective Agents
CEFTIN 500 MG TABLET 3 Anti-Infective Agents
CEFTRIAXONE IN ISO-OSMOTI 20 MG/ML;0 -SOLUTION
1 Anti-Infective Agents
CEFTRIAXONE IN ISO-OSMOTI 40 MG/ML;0 -SOLUTION
1 Anti-Infective Agents
CEFTRIAXONE SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
CEFTRIAXONE SODIUM 10 GM SOLUTION 1 Anti-Infective Agents
CEFTRIAXONE SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
CEFTRIAXONE SODIUM 250 MG SOLUTION 1 Anti-Infective Agents
CEFTRIAXONE SODIUM 500 MG SOLUTION 1 Anti-Infective Agents
CEFTRIAXONE/DEXTROSE 1 GM;3.74 % SOLUTION 1 Anti-Infective Agents
CEFTRIAXONE/DEXTROSE 2 GM;2.22 % SOLUTION 1 Anti-Infective Agents
CEFUROXIME AXETIL 250 MG TABLET 1 Anti-Infective Agents
CEFUROXIME AXETIL 500 MG TABLET 1 Anti-Infective Agents
CEFUROXIME SODIUM 1.5 GM SOLUTION 1 Anti-Infective Agents
CEFUROXIME SODIUM 7.5 GM SOLUTION 1 Anti-Infective Agents
CEFUROXIME SODIUM 750 MG SOLUTION 1 Anti-Infective Agents
CEFUROXIME/DEXTROSE 1.5 GM;2.9 % SOLUTION 1 Anti-Infective Agents
CEFUROXIME/DEXTROSE 750 MG;4.1 % SOLUTION 1 Anti-Infective Agents
CEFZIL 125 MG/5ML SUSPENSION 3 Anti-Infective Agents
CEFZIL 250 MG/5ML SUSPENSION 3 Anti-Infective Agents
CEFZIL 250 MG TABLET 3 Anti-Infective Agents
CEFZIL 500 MG TABLET 3 Anti-Infective Agents
CELEBREX 100 MG CAPSULES 2 QL, ST Central Nervous Systems Agents
CELEBREX 200 MG CAPSULES 2 QL, ST Central Nervous Systems Agents
CELEBREX 400 MG CAPSULES 2 QL, ST Central Nervous Systems Agents
CELEBREX 50 MG CAPSULES 2 QL, ST Central Nervous Systems Agents
CELESTONE 0.6 MG/5ML SOLUTION 3 Hormones And Synthetic Substitutes
CELEXA 10 MG/5ML SOLUTION 3 Central Nervous Systems Agents
CELEXA 10 MG TABLET 3 QL Central Nervous Systems Agents
CELEXA 20 MG TABLET 3 QL Central Nervous Systems Agents
CELEXA 40 MG TABLET 3 QL Central Nervous Systems Agents
CELLCEPT 250 MG CAPSULES 2 Miscellaneous Therapeutic Agents
CELLCEPT 200 MG/ML SUSPENSION 2 Miscellaneous Therapeutic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 37
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CELLCEPT 500 MG TABLET 2 Miscellaneous Therapeutic Agents
CELLCEPT INTRAVENOUS 500 MG SOLUTION 3 Miscellaneous Therapeutic Agents
CELONTIN 300 MG CAPSULES 3 Central Nervous Systems Agents
CENESTIN 0.3 MG TABLET 2 Hormones And Synthetic Substitutes
CENESTIN 0.45 MG TABLET 2 Hormones And Synthetic Substitutes
CENESTIN 0.625 MG TABLET 2 Hormones And Synthetic Substitutes
CENESTIN 0.9 MG TABLET 2 Hormones And Synthetic Substitutes
CENESTIN 1.25 MG TABLET 2 Hormones And Synthetic Substitutes
CEPHALEXIN 250 MG CAPSULES 1 Anti-Infective Agents
CEPHALEXIN 500 MG CAPSULES 1 Anti-Infective Agents
CEPHALEXIN 125 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEPHALEXIN 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
CEPHALEXIN 250 MG TABLET 1 Anti-Infective Agents
CEPHALEXIN 500 MG TABLET 1 Anti-Infective Agents
CEREBYX 50 MG PE/ML SOLUTION 3 Central Nervous Systems Agents
CEREDASE 10 UNIT/ML SOLUTION 4 QL Enzymes
CEREDASE 80 UNIT/ML SOLUTION 4 QL Enzymes
CEREZYME 200 UNIT SOLUTION 4 QL Enzymes
CEREZYME 400 UNIT SOLUTION 4 QL Enzymes
CERUBIDINE 20 MG SOLUTION 3 Antineoplastic Agents
CESAMET 1 MG CAPSULES 4 Gastrointestinal Drugs
CESIA 0 TABLET 1 Hormones And Synthetic Substitutes
CETACORT 0.01 LOTION 1 Skin And Mucous Membrane Agents
CHANTIX 0.5 MG TABLET 3 QL Autonomic Drugs
CHANTIX 1 MG TABLET 3 QL Autonomic Drugs
CHEMET 100 MG CAPSULES 3 Heavy Metal Antagonists
CHLORAMPHENICOL SODIUM SU 1 GM SOLUTION 1 Anti-Infective Agents
CHLORDIAZEPOXIDE/AMITRIPT 12.5 MG;5 MGTABLET
1 Central Nervous Systems Agents
CHLORDIAZEPOXIDE/AMITRIPT 25 MG;10 MGTABLET
1 Central Nervous Systems Agents
CHLORHEXADINE GLUCONATE 0.0012 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
CHLORHEXIDINE GLUCONATE 0.0012 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
CHLOROQUINE PHOSPHATE 250 MG TABLET 1 Anti-Infective Agents
CHLOROQUINE PHOSPHATE 500 MG TABLET 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
38 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CHLOROTHIAZIDE 250 MG TABLET 1 Electrolytic, Caloric, And Water Balance
CHLOROTHIAZIDE 500 MG TABLET 1 Electrolytic, Caloric, And Water Balance
CHLORPROMAZINE HCL 25 MG/ML SOLUTION 1 Central Nervous Systems Agents
CHLORPROMAZINE HCL 10 MG TABLET 1 Central Nervous Systems Agents
CHLORPROMAZINE HCL 100 MG TABLET 1 Central Nervous Systems Agents
CHLORPROMAZINE HCL 200 MG TABLET 1 Central Nervous Systems Agents
CHLORPROMAZINE HCL 25 MG TABLET 1 Central Nervous Systems Agents
CHLORPROMAZINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
CHLORPROPAMIDE 100 MG TABLET 1 Hormones And Synthetic Substitutes
CHLORPROPAMIDE 250 MG TABLET 1 Hormones And Synthetic Substitutes
CHLORTHALIDONE 100 MG TABLET 1 Electrolytic, Caloric, And Water Balance
CHLORTHALIDONE 25 MG TABLET 1 Electrolytic, Caloric, And Water Balance
CHLORTHALIDONE 50 MG TABLET 1 Electrolytic, Caloric, And Water Balance
CHLORZOXAZONE 250 MG TABLET 1 Autonomic Drugs
CHLORZOXAZONE 500 MG TABLET 1 Autonomic Drugs
CHOLESTYRAMINE 4 GM PACK 1 Cardiovascular Drugs
CHOLESTYRAMINE 4 GM/DOSE POWDER 1 Cardiovascular Drugs
CHOLESTYRAMINE LIGHT 4 GM PACK 1 Cardiovascular Drugs
CHOLESTYRAMINE LIGHT 4 GM/DOSE POWDER 1 Cardiovascular Drugs
CICLOPIROX 0.0077 SUSPENSION 1 Skin And Mucous Membrane Agents
CICLOPIROX OLAMINE 0.0077 CREAM 1 Skin And Mucous Membrane Agents
CILOSTAZOL 100 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
CILOSTAZOL 50 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
CILOXAN 0.003 OINTMENT 3 Eye, Ear, Nose, And Throat (EENT)Preparations
CILOXAN 0.003 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
CIMETIDINE 200 MG TABLET 1 Gastrointestinal Drugs
CIMETIDINE 300 MG TABLET 1 Gastrointestinal Drugs
CIMETIDINE 400 MG TABLET 1 Gastrointestinal Drugs
CIMETIDINE 800 MG TABLET 1 Gastrointestinal Drugs
CIMETIDINE HCL 150 MG/ML SOLUTION 1 Gastrointestinal Drugs
CIMETIDINE HCL 300 MG/5ML SOLUTION 1 Gastrointestinal Drugs
CIPRO 10 GM/100ML SUSPENSION 3 Anti-Infective Agents
CIPRO 5 GM/100ML SUSPENSION 3 Anti-Infective Agents
CIPRO 250 MG TABLET 3 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 39
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CIPRO 500 MG TABLET 3 Anti-Infective Agents
CIPRO 750 MG TABLET 3 Anti-Infective Agents
CIPRO HC 0.2 %;1 % SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
CIPRO I.V. 200 MG SOLUTION 3 Anti-Infective Agents
CIPRO I.V. 400 MG SOLUTION 3 Anti-Infective Agents
CIPRO I.V.-IN D5W 200 MG;5 % SOLUTION 3 Anti-Infective Agents
CIPRO I.V.-IN D5W 400 MG;5 % SOLUTION 3 Anti-Infective Agents
CIPRO XR 1000 MG;0 -;0 - TABLET 3 Anti-Infective Agents
CIPRO XR 500 MG;0 -;0 - TABLET 3 Anti-Infective Agents
CIPRODEX 0.3 %;0.1 % SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
CIPROFLOXACIN 400 MG SOLUTION 1 Anti-Infective Agents
CIPROFLOXACIN ER 1000 MG;0 - TABLET 1 Anti-Infective Agents
CIPROFLOXACIN EXTENDED-RE 500 MG;0 - TABLET 1 Anti-Infective Agents
CIPROFLOXACIN HCL 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
CIPROFLOXACIN HCL 100 MG TABLET 1 Anti-Infective Agents
CIPROFLOXACIN HCL 250 MG TABLET 1 Anti-Infective Agents
CIPROFLOXACIN HCL 500 MG TABLET 1 Anti-Infective Agents
CIPROFLOXACIN HCL 750 MG TABLET 1 Anti-Infective Agents
CISPLATIN 1 MG/ML SOLUTION 1 Antineoplastic Agents
CISPLATIN AQ 1 MG/ML SOLUTION 1 Antineoplastic Agents
CITALOPRAM HYDROBROMIDE 10 MG/5MLSOLUTION
1 Central Nervous Systems Agents
CITALOPRAM HYDROBROMIDE 10 MG TABLET 1 QL Central Nervous Systems Agents
CITALOPRAM HYDROBROMIDE 20 MG TABLET 1 QL Central Nervous Systems Agents
CITALOPRAM HYDROBROMIDE 40 MG TABLET 1 QL Central Nervous Systems Agents
CLADRIBINE 1 MG/ML SOLUTION 4 Antineoplastic Agents
CLAFORAN 1 GM SOLUTION 3 Anti-Infective Agents
CLAFORAN 1 GM SOLUTION 3 Anti-Infective Agents
CLAFORAN 10 GM SOLUTION 3 Anti-Infective Agents
CLAFORAN 2 GM SOLUTION 3 Anti-Infective Agents
CLAFORAN 2 GM SOLUTION 3 Anti-Infective Agents
CLAFORAN 500 MG SOLUTION 3 Anti-Infective Agents
CLAFORAN/D5W 1 GM/50ML;5 % SOLUTION 3 Anti-Infective Agents
CLAFORAN/D5W 2 GM/50ML;5 % SOLUTION 3 Anti-Infective Agents
CLARAVIS 10 MG CAPSULES 3 QL Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
40 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CLARAVIS 20 MG CAPSULES 3 QL Skin And Mucous Membrane Agents
CLARAVIS 30 MG CAPSULES 3 QL Skin And Mucous Membrane Agents
CLARAVIS 40 MG CAPSULES 3 QL Skin And Mucous Membrane Agents
CLARINEX 0.5 MG/ML SYRUP 3 QL, PA, ST Antihistamine Drugs
CLARINEX 5 MG TABLET 3 QL, PA, ST Antihistamine Drugs
CLARINEX REDITABS 2.5 MG TABLET 3 QL, ST Antihistamine Drugs
CLARINEX REDITABS 5 MG TABLET 3 QL, ST Antihistamine Drugs
CLARINEX-D 12 HOUR 2.5 MG;120 MG TABLET 3 QL, ST Antihistamine Drugs
CLARINEX-D 24 HOUR 5 MG;240 MG TABLET 3 QL, ST Antihistamine Drugs
CLARITHROMYCIN 125 MG/5ML SUSPENSION 1 Anti-Infective Agents
CLARITHROMYCIN 250 MG/5ML SUSPENSION 1 Anti-Infective Agents
CLARITHROMYCIN 250 MG TABLET 1 Anti-Infective Agents
CLARITHROMYCIN 500 MG TABLET 1 Anti-Infective Agents
CLARITHROMYCIN ER 500 MG TABLET 1 Anti-Infective Agents
CLEMASTINE FUMARATE 0.67 MG/5ML SYRUP 1 Antihistamine Drugs
CLEMASTINE FUMARATE 2.68 MG TABLET 1 Antihistamine Drugs
CLEOCIN 150 MG CAPSULES 3 Anti-Infective Agents
CLEOCIN 300 MG CAPSULES 3 Anti-Infective Agents
CLEOCIN 75 MG CAPSULES 3 Anti-Infective Agents
CLEOCIN 0.02 CREAM 3 Skin And Mucous Membrane Agents
CLEOCIN 300 MG/50ML;5 % SOLUTION 3 Anti-Infective Agents
CLEOCIN 600 MG/50ML;5 % SOLUTION 3 Anti-Infective Agents
CLEOCIN 900 MG/50ML;5 % SOLUTION 3 Anti-Infective Agents
CLEOCIN 100 MG SUPPOSITORY 3 Skin And Mucous Membrane Agents
CLEOCIN PEDIATRIC GRANULE 75 MG/5MLSOLUTION
3 Anti-Infective Agents
CLEOCIN PHOSPHATE 150 MG/ML SOLUTION 3 Anti-Infective Agents
CLEOCIN PHOSPHATE 150 MG/ML SOLUTION 3 Anti-Infective Agents
CLEOCIN-T 0.01 GEL 3 Skin And Mucous Membrane Agents
CLEOCIN-T 0.01 LOTION 3 Skin And Mucous Membrane Agents
CLEOCIN-T 0.01 SOLUTION 3 Skin And Mucous Membrane Agents
CLEOCIN-T 0.01 SWAB 3 Skin And Mucous Membrane Agents
CLIMARA 0.025 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
CLIMARA 0.05 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
CLIMARA 0.06 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
CLIMARA 0.075 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
CLIMARA 0.1 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 41
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CLIMARA 37.5 MCG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
CLIMARA PRO 0.045 MG/DAY;0.015 MG/DAY PATCH 3 QL Hormones And Synthetic Substitutes
CLIMIMIX E 4.25%/DEXTROSE 880 MG/100ML;489MG/100ML;33 MG/100ML;5 GM/100ML;204MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINDAGEL 0.01 GEL 3 Skin And Mucous Membrane Agents
CLINDAMYCIN HCL 150 MG CAPSULES 1 Anti-Infective Agents
CLINDAMYCIN HCL 300 MG CAPSULES 1 Anti-Infective Agents
CLINDAMYCIN PHOSPHATE 0.02 CREAM 1 Skin And Mucous Membrane Agents
CLINDAMYCIN PHOSPHATE 0.01 GEL 1 Skin And Mucous Membrane Agents
CLINDAMYCIN PHOSPHATE 0.01 LOTION 1 Skin And Mucous Membrane Agents
CLINDAMYCIN PHOSPHATE 0.01 SOLUTION 1 Skin And Mucous Membrane Agents
CLINDAMYCIN PHOSPHATE 150 MG/ML SOLUTION 1 Anti-Infective Agents
CLINDAMYCIN PHOSPHATE 150 MG/ML SOLUTION 1 Anti-Infective Agents
CLINDAMYCIN PHOSPHATE 0.01 SWAB 1 Skin And Mucous Membrane Agents
CLINDESSE 0.02 CREAM 3 Skin And Mucous Membrane Agents
CLINDETS 0.01 SWAB 1 Skin And Mucous Membrane Agents
CLINIMIX 2.75%/DEXTROSE 5 24 MEQ/1000ML;570MG/100ML;316 MG/100ML;11 MEQ/1000ML;5GM/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX 4.25%/DEXTROSE 1 37 MEQ/L;880MG/100ML;489 MG/100ML;17 MEQ/L;10 GM/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX 4.25%/DEXTROSE 2 37 MEQ/L;880MG/100ML;489 MG/100ML;17 MEQ/L;20 GM/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX 4.25%/DEXTROSE 2 37 MEQ/L;880MG/100ML;489 MG/100ML;17 MEQ/L;25 GM/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX 4.25%/DEXTROSE 5 37 MEQ/L;880MG/100ML;489 MG/100ML;17 MEQ/L;5 GM/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX 5%/DEXTROSE 15% 42 MEQ/1000ML;1035MG/100ML;575 MG/100ML;20 MEQ/1000ML;15GM/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX 5%/DEXTROSE 20% 42 MEQ/L;1035MG/100ML;575 MG/100ML;20 MEQ/L;20 GM/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
42 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CLINIMIX 5%/DEXTROSE 25% 42 MEQ/L;1035MG/100ML;575 MG/100ML;20 MEQ/L;25 GM/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX E 2.75%/DEXTROSE 570 MG/100ML;316MG/100ML;33 MG/100ML;10 GM/100ML;132MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX E 2.75%/DEXTROSE 570 MG/100ML;316MG/100ML;33 MG/100ML;5 GM/100ML;132MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX E 4.25%/DEXTROSE 880 MG/100ML;489MG/100ML;33 MG/100ML;25 GM/100ML;204MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX E 5%/DEXTROSE 15 1035 MG/100ML;575MG/100ML;33 MG/100ML;15 GM/100ML;240MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX E 5%/DEXTROSE 20 1035 MG/100ML;575MG/100ML;33 MG/100ML;20 GM/100ML;240MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX E 5%/DEXTROSE 25 1035 MG/100ML;575MG/100ML;33 MG/100ML;25 GM/100ML;240MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINIMIX E 5%/DEXTROSE 35 1035 MG/100ML;575MG/100ML;33 MG/100ML;35 GM/100ML;240MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINISOL SF 15% 151 MEQ/L;2170 MG/100ML;1470MG/100ML;434 MG/100ML;749 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
CLINORIL 200 MG TABLET 3 Central Nervous Systems Agents
CLOBETASOL PROPIONATE 0.0005 CREAM 1 Skin And Mucous Membrane Agents
CLOBETASOL PROPIONATE 0.0005 GEL 1 Skin And Mucous Membrane Agents
CLOBETASOL PROPIONATE 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
CLOBETASOL PROPIONATE 0.0005 SOLUTION 1 Skin And Mucous Membrane Agents
CLOBETASOL PROPIONATE E 0.0005 CREAM 1 Skin And Mucous Membrane Agents
CLOBETASOL PROPIONATE EMO 0.0005 CREAM 1 Skin And Mucous Membrane Agents
CLOBEVATE 0.0005 GEL 3 Skin And Mucous Membrane Agents
CLOBEX 0.0005 LIQUID 3 Skin And Mucous Membrane Agents
CLOBEX 0.0005 LOTION 3 Skin And Mucous Membrane Agents
CLOBEX 0.0005 SHAMPOO 3 Skin And Mucous Membrane Agents
CLODERM 0.001 CREAM 3 Skin And Mucous Membrane Agents
CLOLAR 1 MG/ML SOLUTION 4 Antineoplastic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 43
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CLOMIPRAMINE HCL 25 MG CAPSULES 1 Central Nervous Systems Agents
CLOMIPRAMINE HCL 50 MG CAPSULES 1 Central Nervous Systems Agents
CLOMIPRAMINE HCL 75 MG CAPSULES 1 Central Nervous Systems Agents
CLONIDINE HCL 0.1 MG TABLET 1 Cardiovascular Drugs
CLONIDINE HCL 0.2 MG TABLET 1 Cardiovascular Drugs
CLONIDINE HCL 0.3 MG TABLET 1 Cardiovascular Drugs
CLORPRES 15 MG;0.1 MG TABLET 3 Cardiovascular Drugs
CLORPRES 15 MG;0.2 MG TABLET 3 Cardiovascular Drugs
CLORPRES 15 MG;0.3 MG TABLET 3 Cardiovascular Drugs
CLOTRIMAZOLE 0.01 CREAM 1 Skin And Mucous Membrane Agents
CLOTRIMAZOLE 10 MG LOZENGE 1 Skin And Mucous Membrane Agents
CLOTRIMAZOLE 0.01 SOLUTION 1 Skin And Mucous Membrane Agents
CLOTRIMAZOLE 10 MG TROCHE 1 Skin And Mucous Membrane Agents
CLOTRIMAZOLE/BETAMETHASON 0.05 %;1 %CREAM
1 Skin And Mucous Membrane Agents
CLOTRIMAZOLE/BETAMETHASON 0.05 %;1 %LOTION
1 Skin And Mucous Membrane Agents
CLOZAPINE 100 MG TABLET 1 Central Nervous Systems Agents
CLOZAPINE 200 MG TABLET 1 Central Nervous Systems Agents
CLOZAPINE 25 MG TABLET 1 Central Nervous Systems Agents
CLOZAPINE 50 MG TABLET 1 Central Nervous Systems Agents
CLOZARIL 100 MG TABLET 3 Central Nervous Systems Agents
CLOZARIL 25 MG TABLET 3 Central Nervous Systems Agents
CO-GESIC 500 MG;5 MG TABLET 1 QL Central Nervous Systems Agents
COGENTIN 1 MG/ML SOLUTION 3 Autonomic Drugs
COGNEX 10 MG CAPSULES 3 Autonomic Drugs
COGNEX 20 MG CAPSULES 3 Autonomic Drugs
COGNEX 30 MG CAPSULES 3 Autonomic Drugs
COGNEX 40 MG CAPSULES 3 Autonomic Drugs
COLAZAL 750 MG CAPSULES 2 QL Gastrointestinal Drugs
COLCHICINE 0.5 MG/ML SOLUTION 1 Miscellaneous Therapeutic Agents
COLCHICINE 0.6 MG TABLET 1 Miscellaneous Therapeutic Agents
COLESTID 5 GM GRANULES 3 Cardiovascular Drugs
COLESTID 5 GM PACK 3 Cardiovascular Drugs
COLESTID 1 GM TABLET 3 Cardiovascular Drugs
COLESTID FLAVORED 5 GM GRANULES 3 Cardiovascular Drugs
COLESTID FLAVORED 5 GM/7.5GM PACK 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
44 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
COLESTIPOL HCL 5 GM GRANULES 1 Cardiovascular Drugs
COLESTIPOL HCL 1 GM TABLET 1 Cardiovascular Drugs
COLISTIMETHATE SODIUM 150 MG SOLUTION 1 Anti-Infective Agents
COLOCORT 100 MG/60ML ENEMA 1 Skin And Mucous Membrane Agents
COLY-MYCIN-M 150 MG SOLUTION 4 Anti-Infective Agents
COLY-MYCIN-S 3 MG/ML;1 %;5 MG/ML;0.05 %SUSPENSION
3 Eye, Ear, Nose, And Throat (EENT)Preparations
COLYTE 240 GM;2.98 GM;6.72 GM;5.84 GM;22.72GM SOLUTION
3 Gastrointestinal Drugs
COLYTE-FLAVOR PACKS 240 GM;2.98 GM;6.72GM;5.84 GM;22.72 GM SOLUTION
3 Gastrointestinal Drugs
COMBIPATCH 0.05 MG/DAY;0.14 MG/DAY PATCH 3 QL Hormones And Synthetic Substitutes
COMBIPATCH 0.05 MG/DAY;0.25 MG/DAY PATCH 3 QL Hormones And Synthetic Substitutes
COMBIVENT 103 MCG/ACT;18 MCG/ACT AEROSOL 2 QL Autonomic Drugs
COMBIVIR 150 MG;300 MG TABLET 2 Anti-Infective Agents
COMBUNOX 400 MG;5 MG TABLET 3 QL Central Nervous Systems Agents
COMPRO 25 MG SUPPOSITORY 1 Gastrointestinal Drugs
COMTAN 200 MG TABLET 2 QL Central Nervous Systems Agents
COMVAX 7.5 MCG/0.5ML;5 MCG/0.5MLSUSPENSION
3 Serums, Toxoids, And Vaccines
CONCERTA 18 MG TABLET 3 QL Central Nervous Systems Agents
CONCERTA 27 MG TABLET 3 QL Central Nervous Systems Agents
CONCERTA 36 MG TABLET 3 QL Central Nervous Systems Agents
CONCERTA 54 MG TABLET 3 QL Central Nervous Systems Agents
CONDYLOX 0.005 GEL 3 Skin And Mucous Membrane Agents
CONDYLOX 0.005 SOLUTION 3 Skin And Mucous Membrane Agents
CONSTULOSE 10 GM/15ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
COPAXONE 20 MG/ML KIT 4 QL, PA Miscellaneous Therapeutic Agents
COPEGUS 200 MG TABLET 4 QL, PA Anti-Infective Agents
CORDARONE 200 MG TABLET 3 Cardiovascular Drugs
CORDRAN 0.0005 LOTION 3 Skin And Mucous Membrane Agents
CORDRAN 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents
CORDRAN SP 0.0005 CREAM 3 Skin And Mucous Membrane Agents
CORDRAN TAPE 4 MCG/SQCM TAPE 3 Skin And Mucous Membrane Agents
COREG 12.5 MG TABLET 3 PA Cardiovascular Drugs
COREG 25 MG TABLET 3 PA Cardiovascular Drugs
COREG 3.125 MG TABLET 3 PA Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 45
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
COREG 6.25 MG TABLET 3 PA Cardiovascular Drugs
COREG CR 10 MG CAPSULES 3 QL, PA Cardiovascular Drugs
COREG CR 20 MG CAPSULES 3 QL, PA Cardiovascular Drugs
COREG CR 40 MG CAPSULES 3 QL, PA Cardiovascular Drugs
COREG CR 80 MG CAPSULES 3 QL, PA Cardiovascular Drugs
CORGARD 20 MG TABLET 3 Cardiovascular Drugs
CORGARD 40 MG TABLET 3 Cardiovascular Drugs
CORGARD 80 MG TABLET 3 Cardiovascular Drugs
CORMAX 0.0005 CREAM 1 Skin And Mucous Membrane Agents
CORMAX 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
CORMAX 0.0005 SOLUTION 1 Skin And Mucous Membrane Agents
CORTEF 10 MG TABLET 3 Hormones And Synthetic Substitutes
CORTEF 20 MG TABLET 3 Hormones And Synthetic Substitutes
CORTEF 5 MG TABLET 3 Hormones And Synthetic Substitutes
CORTIFOAM 90 MG FOAM 3 Skin And Mucous Membrane Agents
CORTISONE ACETATE 25 MG TABLET 1 Hormones And Synthetic Substitutes
CORTISPORIN 0.5 %;0.5 %;10000 UNIT/GM CREAM 3 Skin And Mucous Membrane Agents
CORTISPORIN 400 UNIT/GM;1 %;0.5 %;5000UNIT/GM OINTMENT
3 Skin And Mucous Membrane Agents
CORTISPORIN 1 %;3.5 MG/ML;10000 UNIT/MLSOLUTION
3 Eye, Ear, Nose, And Throat (EENT)Preparations
CORTISPORIN 1 %;3.5 MG/ML;10000 UNIT/MLSUSPENSION
3 Eye, Ear, Nose, And Throat (EENT)Preparations
CORTISPORIN 1 %;5 MG/ML;10000 UNIT/MLSUSPENSION
3 Eye, Ear, Nose, And Throat (EENT)Preparations
CORTISPORIN-TC 3 MG/ML;10 MG/ML;3.3MG/ML;0.5 MG/ML SUSPENSION
3 Eye, Ear, Nose, And Throat (EENT)Preparations
CORTOMYCIN 1 %;3.5 MG/ML;10000 UNIT/MLSOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
CORTOMYCIN 1 %;3.5 MG/ML;10000 UNIT/MLSUSPENSION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
CORZIDE 5 MG;40 MG TABLET 3 Cardiovascular Drugs
CORZIDE 5 MG;80 MG TABLET 3 Cardiovascular Drugs
COSMEGEN 0.5 MG SOLUTION 4 Antineoplastic Agents
COSOPT 2 %;0.5 % SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT)Preparations
COUMADIN 5 MG SOLUTION 3 Blood Formation, Coagulation, AndThrombosis
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
46 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
COUMADIN 1 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COUMADIN 10 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COUMADIN 2 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COUMADIN 2.5 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COUMADIN 3 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COUMADIN 4 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COUMADIN 5 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COUMADIN 6 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COUMADIN 7.5 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
COVERA-HS 180 MG TABLET 3 QL Cardiovascular Drugs
COVERA-HS 240 MG TABLET 3 QL Cardiovascular Drugs
COZAAR 100 MG TABLET 3 QL Cardiovascular Drugs
COZAAR 25 MG TABLET 3 QL Cardiovascular Drugs
COZAAR 50 MG TABLET 3 QL Cardiovascular Drugs
CREON 10 33200 UNIT;10000 UNIT;37500 UNITCAPSULES
3 Gastrointestinal Drugs
CREON 20 66400 UNIT;20000 UNIT;75000 UNITCAPSULES
3 Gastrointestinal Drugs
CREON 5 16600 UNIT;5000 UNIT;18750 UNITCAPSULES
3 Gastrointestinal Drugs
CRESTOR 10 MG TABLET 2 QL Cardiovascular Drugs
CRESTOR 20 MG TABLET 2 QL Cardiovascular Drugs
CRESTOR 40 MG TABLET 2 QL Cardiovascular Drugs
CRESTOR 5 MG TABLET 2 QL Cardiovascular Drugs
CRINONE 0.08 GEL 3 Hormones And Synthetic Substitutes
CRIXIVAN 100 MG CAPSULES 2 Anti-Infective Agents
CRIXIVAN 200 MG CAPSULES 2 Anti-Infective Agents
CRIXIVAN 333 MG CAPSULES 2 Anti-Infective Agents
CRIXIVAN 400 MG CAPSULES 2 Anti-Infective Agents
CROLOM 0.04 SOLUTION 1 Respiratory Tract Agents
CROMOLYN SODIUM 20 MG/2ML NEBULIZER 1 Respiratory Tract Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 47
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CROMOLYN SODIUM 0.04 SOLUTION 1 Respiratory Tract Agents
CRYSELLE-28 30 MCG;0.3 MG TABLET 1 Hormones And Synthetic Substitutes
CUBICIN 500 MG SOLUTION 4 Anti-Infective Agents
CUPRIMINE 125 MG CAPSULES 3 Heavy Metal Antagonists
CUPRIMINE 250 MG CAPSULES 3 Heavy Metal Antagonists
CUTIVATE 0.0005 CREAM 3 Skin And Mucous Membrane Agents
CUTIVATE 0.05% LOTION 3 Skin And Mucous Membrane Agents
CUTIVATE 0.05% OINTMENT 3 Skin And Mucous Membrane Agents
CYCLESSA 0 TABLET 3 Hormones And Synthetic Substitutes
CYCLOBENZAPRINE HCL 10 MG TABLET 1 Autonomic Drugs
CYCLOBENZAPRINE HCL 5 MG TABLET 1 Autonomic Drugs
CYCLOPHOSPHAMIDE 1 GM SOLUTION 1 Antineoplastic Agents
CYCLOPHOSPHAMIDE 2 GM SOLUTION 1 Antineoplastic Agents
CYCLOPHOSPHAMIDE 500 MG SOLUTION 1 Antineoplastic Agents
CYCLOPHOSPHAMIDE 25 MG TABLET 1 Antineoplastic Agents
CYCLOPHOSPHAMIDE 50 MG TABLET 1 Antineoplastic Agents
CYCLOSPORINE 100 MG CAPSULES 1 Miscellaneous Therapeutic Agents
CYCLOSPORINE 25 MG CAPSULES 1 Miscellaneous Therapeutic Agents
CYCLOSPORINE 100 MG/ML SOLUTION 1 Miscellaneous Therapeutic Agents
CYCLOSPORINE 50 MG/ML SOLUTION 1 Miscellaneous Therapeutic Agents
CYCLOSPORINE MODIFIED 100 MG CAPSULES 1 Miscellaneous Therapeutic Agents
CYCLOSPORINE MODIFIED 25 MG CAPSULES 1 Miscellaneous Therapeutic Agents
CYCLOSPORINE MODIFIED 50 MG CAPSULES 1 Miscellaneous Therapeutic Agents
CYCLOSPORINE MODIFIED 100 MG/ML SOLUTION 1 Miscellaneous Therapeutic Agents
CYKLOKAPRON 100 MG/ML SOLUTION 2 Blood Formation, Coagulation, AndThrombosis
CYMBALTA 20 MG CAPSULES 2 QL Central Nervous Systems Agents
CYMBALTA 30 MG CAPSULES 2 QL Central Nervous Systems Agents
CYMBALTA 60 MG CAPSULES 2 QL Central Nervous Systems Agents
CYPROHEPTADINE HCL 2 MG/5ML SYRUP 1 Antihistamine Drugs
CYPROHEPTADINE HCL 4 MG TABLET 1 Antihistamine Drugs
CYSTADANE 0 POWDER 3 Miscellaneous Therapeutic Agents
CYSTAGON 150 MG CAPSULES 3 Miscellaneous Therapeutic Agents
CYSTAGON 50 MG CAPSULES 3 Miscellaneous Therapeutic Agents
CYTARABINE 1 GM SOLUTION 1 Antineoplastic Agents
CYTARABINE 100 MG SOLUTION 1 Antineoplastic Agents
CYTARABINE 100 MG/ML SOLUTION 1 Antineoplastic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
48 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
CYTARABINE 2 GM SOLUTION 1 Antineoplastic Agents
CYTARABINE 20 MG/ML SOLUTION 1 Antineoplastic Agents
CYTARABINE 500 MG SOLUTION 1 Antineoplastic Agents
CYTOMEL 25 MCG TABLET 3 Hormones And Synthetic Substitutes
CYTOMEL 5 MCG TABLET 3 Hormones And Synthetic Substitutes
CYTOMEL 50 MCG TABLET 3 Hormones And Synthetic Substitutes
CYTOTEC 100 MCG TABLET 3 Gastrointestinal Drugs
CYTOTEC 200 MCG TABLET 3 Gastrointestinal Drugs
CYTOVENE 500 MG SOLUTION 4 Anti-Infective Agents
CYTOXAN 1 GM SOLUTION 3 Antineoplastic Agents
CYTOXAN 2 GM SOLUTION 3 Antineoplastic Agents
CYTOXAN 500 MG SOLUTION 3 Antineoplastic Agents
CYTOXAN 25 MG TABLET 3 Antineoplastic Agents
CYTOXAN 50 MG TABLET 3 Antineoplastic Agents
D.H.E. 45 1 MG/ML SOLUTION 4 Autonomic Drugs
DACARBAZINE 100 MG SOLUTION 1 Antineoplastic Agents
DACARBAZINE 200 MG SOLUTION 1 Antineoplastic Agents
DACOGEN 50 MG SOLUTION 4 PA Antineoplastic Agents
DANAZOL 100 MG CAPSULES 1 Hormones And Synthetic Substitutes
DANAZOL 200 MG CAPSULES 1 Hormones And Synthetic Substitutes
DANAZOL 50 MG CAPSULES 1 Hormones And Synthetic Substitutes
DANTRIUM 100 MG CAPSULES 3 Autonomic Drugs
DANTRIUM 25 MG CAPSULES 3 Autonomic Drugs
DANTRIUM 50 MG CAPSULES 3 Autonomic Drugs
DANTROLENE SODIUM 100 MG CAPSULES 1 Autonomic Drugs
DANTROLENE SODIUM 25 MG CAPSULES 1 Autonomic Drugs
DANTROLENE SODIUM 50 MG CAPSULES 1 Autonomic Drugs
DAPSONE 100 MG TABLET 1 Anti-Infective Agents
DAPSONE 25 MG TABLET 1 Anti-Infective Agents
DAPTACEL 10 MCG/0.5ML;15 LF/0.5ML;5 LF/0.5MLSUSPENSION
3 Serums, Toxoids, And Vaccines
DARAPRIM 25 MG TABLET 3 Anti-Infective Agents
DARVOCET A500 500 MG;100 MG TABLET 3 QL Central Nervous Systems Agents
DARVOCET-N 100 650 MG;100 MG TABLET 3 QL Central Nervous Systems Agents
DARVOCET-N 50 325 MG;50 MG TABLET 3 QL Central Nervous Systems Agents
DARVON 65 MG CAPSULES 3 Central Nervous Systems Agents
DARVON-N 100 MG TABLET 3 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 49
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DAUNORUBICIN HCL 5 MG/ML INJECTION 1 Antineoplastic Agents
DAUNORUBICIN HCL 20 MG SOLUTION 1 Antineoplastic Agents
DAUNOXOME 2 MG/ML INJECTION 3 Antineoplastic Agents
DAYPRO 600 MG TABLET 3 Central Nervous Systems Agents
DAYTRANA 10 MG/9HR PATCH 3 QL Central Nervous Systems Agents
DAYTRANA 15 MG/9HR PATCH 3 QL Central Nervous Systems Agents
DAYTRANA 20 MG/9HR PATCH 3 QL Central Nervous Systems Agents
DAYTRANA 30 MG/9HR PATCH 3 QL Central Nervous Systems Agents
DDAVP 0.0001 SOLUTION 3 Hormones And Synthetic Substitutes
DDAVP 4 MCG/ML SOLUTION 3 Hormones And Synthetic Substitutes
DDAVP 0.1 MG TABLET 3 QL Hormones And Synthetic Substitutes
DDAVP 0.2 MG TABLET 3 QL Hormones And Synthetic Substitutes
DECAVAC 2 LFU;5 LFU INJECTION 3 Serums, Toxoids, And Vaccines
DECLOMYCIN 150 MG TABLET 3 Anti-Infective Agents
DECLOMYCIN 300 MG TABLET 3 Anti-Infective Agents
DEL-BETA 0.0005 LOTION 1 Skin And Mucous Membrane Agents
DELESTROGEN 10 MG/ML OIL 3 Hormones And Synthetic Substitutes
DELESTROGEN 20 MG/ML OIL 3 Hormones And Synthetic Substitutes
DELESTROGEN 40 MG/ML OIL 3 Hormones And Synthetic Substitutes
DELFLEX-LC/1.5% DEXTROSE 2.5 MEQ/L;95MEQ/L;1.5 %/L;40 MEQ/L;0.5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
DELFLEX-LC/2.5% DEXTROSE 2.5 MEQ/L;95MEQ/L;2.5 %/L;40 MEQ/L;0.5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
DELFLEX-LC/4.25% DEXTROSE 2.5 MEQ/L;95MEQ/L;4.25 %/L;40 MEQ/L;0.5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
DELFLEX-LM/1.5% DEXTROSE 3.5 MEQ/1000ML;96MEQ/1000ML;1.5 %/1000ML;40 MEQ/1000ML;0.5MEQ/1000ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
DELFLEX-LM/2.5% DEXTROSE 3.5 MEQ/1000ML;96MEQ/1000ML;2.5 %/1000ML;40 MEQ/1000ML;0.5MEQ/1000ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
DELFLEX-LM/4.25% DEXTROSE 3.5 MEQ/L;96MEQ/L;4.25 %/L;40 MEQ/L;0.5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
DELFLEX-SM/1.5% DEXTROSE 3.5 MEQ/1000ML;102MEQ/1000ML;1.5 %/1000ML;35 MEQ/1000ML;1.5MEQ/1000ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
DELFLEX-SM/2.5% DEXTROSE 3.5 MEQ/1000ML;102MEQ/1000ML;2.5 %/1000ML;35 MEQ/1000ML;1.5MEQ/1000ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
50 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DELFLEX-SM/4.25% DEXTROSE 3.5 MEQ/L;102MEQ/L;4.25 %/L;35 MEQ/L;1.5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
DEMADEX 10 MG/ML SOLUTION 3 Electrolytic, Caloric, And Water Balance
DEMADEX 10 MG TABLET 3 Electrolytic, Caloric, And Water Balance
DEMADEX 100 MG TABLET 3 Electrolytic, Caloric, And Water Balance
DEMADEX 20 MG TABLET 3 Electrolytic, Caloric, And Water Balance
DEMADEX 5 MG TABLET 3 Electrolytic, Caloric, And Water Balance
DEMECLOCYCLINE HCL 150 MG TABLET 1 Anti-Infective Agents
DEMECLOCYCLINE HCL 300 MG TABLET 1 Anti-Infective Agents
DEMEROL 100 MG/ML SOLUTION 3 Central Nervous Systems Agents
DEMEROL 25 MG/ML SOLUTION 3 Central Nervous Systems Agents
DEMEROL 50 MG/ML SOLUTION 3 Central Nervous Systems Agents
DEMEROL 75 MG/1.5ML SOLUTION 3 Central Nervous Systems Agents
DEMEROL 75 MG/ML SOLUTION 3 Central Nervous Systems Agents
DEMEROL 50 MG/5ML SYRUP 3 Central Nervous Systems Agents
DEMEROL 100 MG TABLET 3 Central Nervous Systems Agents
DEMEROL 50 MG TABLET 3 Central Nervous Systems Agents
DEMSER 250 MG CAPSULES 3 Miscellaneous Therapeutic Agents
DENAVIR 0.01 CREAM 2 Skin And Mucous Membrane Agents
DEPACON 100 MG/ML SOLUTION 3 Central Nervous Systems Agents
DEPADE 50 MG TABLET 1 Central Nervous Systems Agents
DEPAKENE 250 MG CAPSULES 3 Central Nervous Systems Agents
DEPAKENE 250 MG/5ML SYRUP 3 Central Nervous Systems Agents
DEPAKOTE 125 MG TABLET 2 Central Nervous Systems Agents
DEPAKOTE 250 MG TABLET 2 Central Nervous Systems Agents
DEPAKOTE 500 MG TABLET 2 Central Nervous Systems Agents
DEPAKOTE ER 250 MG TABLET 2 QL Central Nervous Systems Agents
DEPAKOTE ER 500 MG TABLET 2 Central Nervous Systems Agents
DEPAKOTE SPRINKLES 125 MG SPRINKLE CAPSULES 2 Central Nervous Systems Agents
DEPEN TITRATABS 250 MG TABLET 3 Heavy Metal Antagonists
DEPO-ESTRADIOL 5 MG/ML OIL 1 Hormones And Synthetic Substitutes
DEPO-MEDROL 20 MG/ML SUSPENSION 3 Hormones And Synthetic Substitutes
DEPO-MEDROL 40 MG/ML SUSPENSION 3 Hormones And Synthetic Substitutes
DEPO-MEDROL 80 MG/ML SUSPENSION 3 Hormones And Synthetic Substitutes
DEPO-PROVERA 400 MG/ML SUSPENSION 3 Hormones And Synthetic Substitutes
DEPO-PROVERA CONTRACEPTIV 150 MG/MLSUSPENSION
3 QL Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 51
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DEPO-SUBQ PROVERA 104 104 MG/0.65MLSUSPENSION
3 QL Hormones And Synthetic Substitutes
DEPO-TESTOSTERONE 100 MG/ML OIL 1 Hormones And Synthetic Substitutes
DEPO-TESTOSTERONE 200 MG/ML OIL 1 Hormones And Synthetic Substitutes
DEPODUR 10 MG/ML SUSPENSION 3 Central Nervous Systems Agents
DEPODUR 15 MG/1.5ML SUSPENSION 3 Central Nervous Systems Agents
DEPODUR 20 MG/2ML SUSPENSION 3 Central Nervous Systems Agents
DERMA-SMOOTHE/FS BODY OIL 0.0001 OIL 3 Skin And Mucous Membrane Agents
DERMA-SMOOTHE/FS SCALP OI 0.0001 OIL 3 Skin And Mucous Membrane Agents
DERMATOP 0.001 CREAM 3 Skin And Mucous Membrane Agents
DERMATOP 0.001 OINTMENT 3 Skin And Mucous Membrane Agents
DERMOTIC 0.0001 OIL 2 Eye, Ear, Nose, And Throat (EENT)Preparations
DESIPRAMINE HCL 10 MG TABLET 1 Central Nervous Systems Agents
DESIPRAMINE HCL 100 MG TABLET 1 Central Nervous Systems Agents
DESIPRAMINE HCL 150 MG TABLET 1 Central Nervous Systems Agents
DESIPRAMINE HCL 25 MG TABLET 1 Central Nervous Systems Agents
DESIPRAMINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
DESIPRAMINE HCL 75 MG TABLET 1 Central Nervous Systems Agents
DESMOPRESSIN ACETATE 0.0001 SOLUTION 1 Hormones And Synthetic Substitutes
DESMOPRESSIN ACETATE 4 MCG/ML SOLUTION 1 Hormones And Synthetic Substitutes
DESMOPRESSIN ACETATE 0.1 MG TABLET 1 Hormones And Synthetic Substitutes
DESMOPRESSIN ACETATE 0.2 MG TABLET 1 Hormones And Synthetic Substitutes
DESOGEN 0.15 MG;30 MCG TABLET 3 Hormones And Synthetic Substitutes
DESONATE 0.0005 GEL 3 Skin And Mucous Membrane Agents
DESONIDE 0.0005 CREAM 1 Skin And Mucous Membrane Agents
DESONIDE 0.0005 LOTION 1 Skin And Mucous Membrane Agents
DESONIDE 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
DESOWEN 0.0005 CREAM 3 Skin And Mucous Membrane Agents
DESOWEN 0.0005 LOTION 3 Skin And Mucous Membrane Agents
DESOWEN 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents
DESOXIMETASONE 0.0005 CREAM 1 Skin And Mucous Membrane Agents
DESOXIMETASONE 0.0025 CREAM 1 Skin And Mucous Membrane Agents
DESOXIMETASONE 0.0005 GEL 1 Skin And Mucous Membrane Agents
DESOXIMETASONE 0.0025 OINTMENT 1 Skin And Mucous Membrane Agents
DESOXYN 5 MG TABLET 3 Central Nervous Systems Agents
DETROL 1 MG TABLET 2 Smooth Muscle Relaxants
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
52 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DETROL 2 MG TABLET 2 Smooth Muscle Relaxants
DETROL LA 2 MG CAPSULES 2 QL Smooth Muscle Relaxants
DETROL LA 4 MG CAPSULES 2 QL Smooth Muscle Relaxants
DEXAMETHASONE 0.5 MG/5ML ELIXIR 1 Hormones And Synthetic Substitutes
DEXAMETHASONE 0.5 MG/5ML SOLUTION 1 Hormones And Synthetic Substitutes
DEXAMETHASONE 0.5 MG TABLET 1 Hormones And Synthetic Substitutes
DEXAMETHASONE 0.75 MG TABLET 1 Hormones And Synthetic Substitutes
DEXAMETHASONE 1 MG TABLET 1 Hormones And Synthetic Substitutes
DEXAMETHASONE 1.5 MG TABLET 1 Hormones And Synthetic Substitutes
DEXAMETHASONE 2 MG TABLET 1 Hormones And Synthetic Substitutes
DEXAMETHASONE 4 MG TABLET 1 Hormones And Synthetic Substitutes
DEXAMETHASONE 6 MG TABLET 1 Hormones And Synthetic Substitutes
DEXAMETHASONE INTENSOL 1 MG/MLCONCENTRATION
1 Hormones And Synthetic Substitutes
DEXAMETHASONE SODIUM PHOS 0.001 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
DEXAMETHASONE SODIUM PHOS 4 MG/MLSOLUTION
1 Hormones And Synthetic Substitutes
DEXASOL 0.001 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
DEXASPORIN 0.1 %;0.5 %;10000 UNIT/MLSUSPENSION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
DEXCHLORPHENIRAMINE MALEA 2 MG/5ML SYRUP 1 Antihistamine Drugs
DEXEDRINE 10 MG CAPSULES 3 Central Nervous Systems Agents
DEXEDRINE 15 MG CAPSULES 3 Central Nervous Systems Agents
DEXEDRINE 5 MG CAPSULES 3 Central Nervous Systems Agents
DEXMETHYLPHENIDATE HCL 10 MG TABLET 1 Central Nervous Systems Agents
DEXMETHYLPHENIDATE HCL 2.5 MG TABLET 1 Central Nervous Systems Agents
DEXMETHYLPHENIDATE HCL 5 MG TABLET 1 Central Nervous Systems Agents
DEXPAK 13 DAY 1.5 MG TABLET 3 Hormones And Synthetic Substitutes
DEXRAZOXANE 250 MG SOLUTION 1 Miscellaneous Therapeutic Agents
DEXRAZOXANE 500 MG SOLUTION 1 Miscellaneous Therapeutic Agents
DEXTROAMPHETAMINE SULFATE 10 MG CAPSULES 1 Central Nervous Systems Agents
DEXTROAMPHETAMINE SULFATE 15 MG CAPSULES 1 Central Nervous Systems Agents
DEXTROAMPHETAMINE SULFATE 5 MG CAPSULES 1 Central Nervous Systems Agents
DEXTROAMPHETAMINE SULFATE 10 MG TABLET 1 Central Nervous Systems Agents
DEXTROAMPHETAMINE SULFATE 5 MG TABLET 1 Central Nervous Systems Agents
DEXTROSE 10% 0.1 SOLUTION 1 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 53
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DEXTROSE 10%/NACL 0.2% 10 %;0.2 % SOLUTION 1 Electrolytic, Caloric, And Water Balance
DEXTROSE 10%/NACL 0.45% 10 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 2.5% 0.025 SOLUTION 1 Electrolytic, Caloric, And Water Balance
DEXTROSE 2.5% 1.5 MEQ/L;55 MEQ/L;2.5 %;14MEQ/L;2 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 2.5%/NACL 0.45% 2.5 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 2.5%/SODIUM CHLO 2.5 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5% 0.05 SOLUTION 1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5% 24 MEQ/L;5 %;23 MEQ/L;3 MEQ/L;3MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5% 48 MEQ/L;5 %;20 MEQ/L;15 MEQ/L;35MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/LACTATED RING 2.7 MEQ/L;109MEQ/L;5 %;28 MEQ/L;4 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/NACL 0.2% 5 %;0.2 % SOLUTION 1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/NACL 0.225% 5 %;0.225 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/NACL 0.33% 5 %;0.33 % SOLUTION 1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/NACL 0.45% 5 %;0.45 % SOLUTION 1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/NACL 0.9% 5 %;0.9 % SOLUTION 1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/POTASSIUM CHL 5 %;0.075 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/POTASSIUM CHL 5 %;0.15 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/SODIUM CHLORI 5 %;0.2 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/SODIUM CHLORI 5 %;0.33 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/SODIUM CHLORI 5 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSE 5%/SODIUM CHLORI 5 %;0.9 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
DEXTROSTAT 10 MG TABLET 1 Central Nervous Systems Agents
DEXTROSTAT 5 MG TABLET 1 Central Nervous Systems Agents
DIABETA 1.25 MG TABLET 3 Hormones And Synthetic Substitutes
DIABETA 2.5 MG TABLET 3 Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
54 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DIABETA 5 MG TABLET 3 Hormones And Synthetic Substitutes
DIABETIC SUPPLIES, MISC 0 MISC 1 Devices
DIABETIC SUPPLIES, MISC 0 MISC 1 Devices
DIABETIC SUPPLIES, MISC 0 MISC 1 Devices
DIABETIC SUPPLIES, MISC 0 MISC 1 Devices
DIABETIC SUPPLIES, MISC 0 PADS 1 Pharmaceutical Aids
DIABINESE 100 MG TABLET 3 Hormones And Synthetic Substitutes
DIABINESE 250 MG TABLET 3 Hormones And Synthetic Substitutes
DIALYTE/2.5% DEXTROSE PAT 26 MG/100ML;2.5 %;5MG/100ML;530 MG/100ML;450 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
DIAMOX 500 MG CAPSULES 3 Eye, Ear, Nose, And Throat (EENT)Preparations
DIANEAL LOW CALCIUM/1.5% 18.3 MG/100ML;1.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
DIANEAL LOW CALCIUM/2.5% 18.3 MG/100ML;2.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
DIANEAL LOW CALCIUM/4.25% 18.3MG/100ML;4.25 %;5.08 MG/100ML;538MG/100ML;448 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
DIANEAL PD-2/1.5% DEXTROS 25.7 MG/100ML;1.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
DIANEAL PD-2/2.5% DEXTROS 25.7 MG/100ML;2.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
DIANEAL PD-2/3.5% DEXTROS 25.7 MG/100ML;3.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
DIANEAL PD-2/4.25% DEXTRO 25.7 MG/100ML;4.25%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
DIBENZYLINE 10 MG CAPSULES 3 Autonomic Drugs
DICLOFENAC POTASSIUM 50 MG TABLET 1 Central Nervous Systems Agents
DICLOFENAC SODIUM 50 MG TABLET 1 Central Nervous Systems Agents
DICLOFENAC SODIUM 75 MG TABLET 1 Central Nervous Systems Agents
DICLOFENAC SODIUM DR 50 MG TABLET 1 Central Nervous Systems Agents
DICLOFENAC SODIUM EC 25 MG TABLET 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 55
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DICLOFENAC SODIUM EC 50 MG TABLET 1 Central Nervous Systems Agents
DICLOFENAC SODIUM ER 100 MG TABLET 1 Central Nervous Systems Agents
DICLOFENAC SODIUM XR 100 MG TABLET 1 Central Nervous Systems Agents
DICLOXACILLIN SODIUM 250 MG CAPSULES 1 Anti-Infective Agents
DICLOXACILLIN SODIUM 500 MG CAPSULES 1 Anti-Infective Agents
DICYCLOMINE HCL 10 MG CAPSULES 1 Autonomic Drugs
DICYCLOMINE HCL 10 MG/5ML SOLUTION 1 Autonomic Drugs
DICYCLOMINE HCL 10 MG/ML SOLUTION 1 Autonomic Drugs
DICYCLOMINE HCL 20 MG TABLET 1 Autonomic Drugs
DIDANOSINE 200 MG CAPSULES 1 Anti-Infective Agents
DIDANOSINE 250 MG CAPSULES 1 Anti-Infective Agents
DIDANOSINE 400 MG CAPSULES 1 Anti-Infective Agents
DIDRONEL 200 MG TABLET 3 Miscellaneous Therapeutic Agents
DIDRONEL 400 MG TABLET 3 Miscellaneous Therapeutic Agents
DIFFERIN 0.001 CREAM 3 Skin And Mucous Membrane Agents
DIFFERIN 0.001 GEL 3 Skin And Mucous Membrane Agents
DIFFERIN 0.3 % GEL 3 Skin And Mucous Membrane Agents
DIFLORASONE DIACETATE 0.0005 CREAM 1 Skin And Mucous Membrane Agents
DIFLORASONE DIACETATE 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
DIFLUCAN 10 MG/ML SUSPENSION 3 Anti-Infective Agents
DIFLUCAN 40 MG/ML SUSPENSION 3 Anti-Infective Agents
DIFLUCAN 100 MG TABLET 3 Anti-Infective Agents
DIFLUCAN 150 MG TABLET 3 QL Anti-Infective Agents
DIFLUCAN 200 MG TABLET 3 Anti-Infective Agents
DIFLUCAN 50 MG TABLET 3 Anti-Infective Agents
DIFLUCAN IN ISO-OSMOTIC D 0 -;200 MG/100MLSOLUTION
3 Anti-Infective Agents
DIFLUCAN IN ISO-OSMOTIC D 0 -;400 MG/200MLSOLUTION
3 Anti-Infective Agents
DIFLUCAN IN NACL 200 MG/100ML;0.9 % SOLUTION 3 Anti-Infective Agents
DIFLUCAN IN NACL 400 MG/200ML;0.9 % SOLUTION 3 Anti-Infective Agents
DIFLUNISAL 500 MG TABLET 1 Central Nervous Systems Agents
DIGITEK 0.125 MG TABLET 1 Cardiovascular Drugs
DIGITEK 0.25 MG TABLET 1 Cardiovascular Drugs
DIGOXIN 0.05 MG/ML SOLUTION 1 Cardiovascular Drugs
DIGOXIN 0.25 MG/ML SOLUTION 1 Cardiovascular Drugs
DIGOXIN 0.125 MG TABLET 1 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
56 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DIGOXIN 0.25 MG TABLET 1 Cardiovascular Drugs
DIHYDROERGOTAMINE MESYLAT 1 MG/MLSOLUTION
1 Autonomic Drugs
DILACOR XR 120 MG CAPSULES 3 QL Cardiovascular Drugs
DILACOR XR 180 MG CAPSULES 3 QL Cardiovascular Drugs
DILACOR XR 240 MG CAPSULES 3 QL Cardiovascular Drugs
DILANTIN 100 MG CAPSULES 2 Central Nervous Systems Agents
DILANTIN 30 MG CAPSULES 2 Central Nervous Systems Agents
DILANTIN 125 MG/5ML SUSPENSION 2 Central Nervous Systems Agents
DILANTIN INFATABS 50 MG CHEWABLE 2 Central Nervous Systems Agents
DILATRATE SR 40 MG CAPSULES 3 Cardiovascular Drugs
DILAUDID 8 MG TABLET 3 Central Nervous Systems Agents
DILAUDID-5 1 MG/ML LIQUID 3 Central Nervous Systems Agents
DILAUDID-HP 10 MG/ML SOLUTION 3 Central Nervous Systems Agents
DILAUDID-HP 250 MG SOLUTION 3 Central Nervous Systems Agents
DILOR 250 MG/ML SOLUTION 1 Smooth Muscle Relaxants
DILT-CD 120 MG CAPSULES 1 QL Cardiovascular Drugs
DILT-CD 180 MG CAPSULES 1 QL Cardiovascular Drugs
DILT-CD 240 MG CAPSULES 1 QL Cardiovascular Drugs
DILT-CD 300 MG CAPSULES 1 QL Cardiovascular Drugs
DILT-XR 120 MG CAPSULES 1 QL Cardiovascular Drugs
DILT-XR 180 MG CAPSULES 1 QL Cardiovascular Drugs
DILT-XR 240 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIA XT 120 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIA XT 180 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIA XT 240 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM CD 120 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM CD 180 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM CD 240 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM CD 300 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL 120 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL 180 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL 240 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL 300 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL 360 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL 100 MG SOLUTION 1 Cardiovascular Drugs
DILTIAZEM HCL 5 MG/ML SOLUTION 1 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 57
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DILTIAZEM HCL 120 MG TABLET 1 Cardiovascular Drugs
DILTIAZEM HCL 30 MG TABLET 1 Cardiovascular Drugs
DILTIAZEM HCL 60 MG TABLET 1 Cardiovascular Drugs
DILTIAZEM HCL 90 MG TABLET 1 Cardiovascular Drugs
DILTIAZEM HCL ER 120 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL ER 120 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL ER 180 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL ER 240 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL ER 300 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL ER 360 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL ER 420 MG CAPSULES 1 QL Cardiovascular Drugs
DILTIAZEM HCL ER 60 MG CAPSULES 1 Cardiovascular Drugs
DILTIAZEM HCL ER 90 MG CAPSULES 1 Cardiovascular Drugs
DIOVAN 160 MG TABLET 2 QL Cardiovascular Drugs
DIOVAN 320 MG TABLET 2 QL Cardiovascular Drugs
DIOVAN 40 MG TABLET 2 QL Cardiovascular Drugs
DIOVAN 80 MG TABLET 2 QL Cardiovascular Drugs
DIOVAN HCT 12.5 MG;160 MG TABLET 2 QL Cardiovascular Drugs
DIOVAN HCT 12.5 MG;320 MG TABLET 2 QL Cardiovascular Drugs
DIOVAN HCT 12.5 MG;80 MG TABLET 2 QL Cardiovascular Drugs
DIOVAN HCT 25 MG;160 MG TABLET 2 QL Cardiovascular Drugs
DIOVAN HCT 25 MG;320 MG TABLET 2 QL Cardiovascular Drugs
DIPENTUM 250 MG CAPSULES 3 QL Gastrointestinal Drugs
DIPHENHYDRAMINE HCL 25 MG CAPSULES 1 Antihistamine Drugs
DIPHENHYDRAMINE HCL 50 MG CAPSULES 1 Antihistamine Drugs
DIPHENHYDRAMINE HCL 12.5 MG/5ML ELIXIR 1 Antihistamine Drugs
DIPHENHYDRAMINE HCL 50 MG/ML SOLUTION 1 Antihistamine Drugs
DIPHENOXYLATE/ATROPINE 0.025 MG/5ML;2.5MG/5ML LIQUID
1 Gastrointestinal Drugs
DIPHENOXYLATE/ATROPINE 0.025 MG;2.5 MGTABLET
1 Gastrointestinal Drugs
DIPIVEFRIN HCL 0.001 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
DIPROLENE 0.0005 LOTION 3 Skin And Mucous Membrane Agents
DIPROLENE 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents
DIPROLENE AF 0.0005 CREAM 3 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
58 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DIPTHERIA/TETANUS TOXOID 6.7 LFU/0.5ML;5LFU/0.5ML INJECTION
3 Serums, Toxoids, And Vaccines
DIPYRIDAMOLE 25 MG TABLET 1 Cardiovascular Drugs
DIPYRIDAMOLE 50 MG TABLET 1 Cardiovascular Drugs
DIPYRIDAMOLE 75 MG TABLET 1 Cardiovascular Drugs
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULES 1 Cardiovascular Drugs
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULES 1 Cardiovascular Drugs
DISOPYRAMIDE PHOSPHATE ER 150 MG CAPSULES 1 Cardiovascular Drugs
DISPERMOX 200 MG SOLUBLE TABLET 1 Anti-Infective Agents
DISPERMOX 400 MG SOLUBLE TABLET 1 Anti-Infective Agents
DISPERMOX 600 MG SOLUBLE TABLET 1 Anti-Infective Agents
DITROPAN 5 MG/5ML SYRUP 3 ST Smooth Muscle Relaxants
DITROPAN 5 MG TABLET 3 ST Smooth Muscle Relaxants
DITROPAN XL 10 MG TABLET 3 QL, PA, ST Smooth Muscle Relaxants
DITROPAN XL 15 MG TABLET 3 QL, PA, ST Smooth Muscle Relaxants
DITROPAN XL 5 MG TABLET 3 QL, PA, ST Smooth Muscle Relaxants
DIURIL 250 MG/5ML SUSPENSION 3 Electrolytic, Caloric, And Water Balance
DIURIL IV 500 MG SOLUTION 3 Electrolytic, Caloric, And Water Balance
DIVIGEL 0.25 MG/0.25GM GEL 3 Hormones And Synthetic Substitutes
DIVIGEL 0.5 MG/0.5GM GEL 3 Hormones And Synthetic Substitutes
DIVIGEL 1 MG/GM GEL 3 Hormones And Synthetic Substitutes
DOLACET 500 MG;5 MG CAPSULES 1 QL Central Nervous Systems Agents
DOLAGESIC 500 MG;5 MG CAPSULES 1 QL Central Nervous Systems Agents
DOLOPHINE 10 MG TABLET 1 Central Nervous Systems Agents
DOLOPHINE HCL 5 MG TABLET 1 Central Nervous Systems Agents
DOLOREX FORTE 500 MG;5 MG CAPSULES 3 QL Central Nervous Systems Agents
DORYX 100 MG TABLET 3 Anti-Infective Agents
DORYX 75 MG TABLET 3 Anti-Infective Agents
DOSTINEX 0.5 MG TABLET 3 QL Miscellaneous Therapeutic Agents
DOVONEX 0.005% CREAM 2 Skin And Mucous Membrane Agents
DOVONEX 0.005% OINTMENT 2 Skin And Mucous Membrane Agents
DOVONEX 0.005% SOLUTION 2 Skin And Mucous Membrane Agents
DOXAZOSIN MESYLATE 1 MG TABLET 1 Cardiovascular Drugs
DOXAZOSIN MESYLATE 2 MG TABLET 1 Cardiovascular Drugs
DOXAZOSIN MESYLATE 4 MG TABLET 1 Cardiovascular Drugs
DOXAZOSIN MESYLATE 8 MG TABLET 1 Cardiovascular Drugs
DOXEPIN HCL 10 MG CAPSULES 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 59
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DOXEPIN HCL 100 MG CAPSULES 1 Central Nervous Systems Agents
DOXEPIN HCL 150 MG CAPSULES 1 Central Nervous Systems Agents
DOXEPIN HCL 25 MG CAPSULES 1 Central Nervous Systems Agents
DOXEPIN HCL 50 MG CAPSULES 1 Central Nervous Systems Agents
DOXEPIN HCL 75 MG CAPSULES 1 Central Nervous Systems Agents
DOXEPIN HCL 10 MG/ML CONCENTRATION 1 Central Nervous Systems Agents
DOXIL 2 MG/ML INJECTION 4 Antineoplastic Agents
DOXORUBICIN HCL 10 MG SOLUTION 1 Antineoplastic Agents
DOXORUBICIN HCL 2 MG/ML SOLUTION 1 Antineoplastic Agents
DOXORUBICIN HCL 50 MG SOLUTION 1 Antineoplastic Agents
DOXY-CAPS 100 MG CAPSULES 1 Anti-Infective Agents
DOXYCYCLINE HYCLATE 100 MG CAPSULES 1 Anti-Infective Agents
DOXYCYCLINE HYCLATE 100 MG CAPSULES 1 Anti-Infective Agents
DOXYCYCLINE HYCLATE 50 MG CAPSULES 1 Anti-Infective Agents
DOXYCYCLINE HYCLATE 75 MG CAPSULES 1 Anti-Infective Agents
DOXYCYCLINE HYCLATE 100 MG SOLUTION 1 Anti-Infective Agents
DOXYCYCLINE HYCLATE 100 MG TABLET 1 Anti-Infective Agents
DOXYCYCLINE HYCLATE 20 MG TABLET 1 Eye, Ear, Nose, And Throat (EENT)Preparations
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULES 1 Anti-Infective Agents
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULES 1 Anti-Infective Agents
DOXYCYCLINE MONOHYDRATE 100 MG TABLET 1 Anti-Infective Agents
DOXYCYCLINE MONOHYDRATE 50 MG TABLET 1 Anti-Infective Agents
DOXYCYCLINE MONOHYDRATE 75 MG TABLET 1 Anti-Infective Agents
DROXIA 200 MG CAPSULES 3 Antineoplastic Agents
DROXIA 300 MG CAPSULES 3 Antineoplastic Agents
DROXIA 400 MG CAPSULES 3 Antineoplastic Agents
DTIC-DOME 200 MG SOLUTION 3 Antineoplastic Agents
DUAC 5 %;1 % GEL 3 Skin And Mucous Membrane Agents
DUETACT 2 MG;30 MG TABLET 3 QL Hormones And Synthetic Substitutes
DUETACT 4 MG;30 MG TABLET 3 QL Hormones And Synthetic Substitutes
DUONEB 2.5 MG/3ML;0.5 MG/3ML SOLUTION 2 Autonomic Drugs
DURACLON 100 MCG/ML SOLUTION 3 Central Nervous Systems Agents
DURACLON 500 MCG/ML SOLUTION 3 Central Nervous Systems Agents
DURAGESIC 100 MCG/HR PATCH 3 QL Central Nervous Systems Agents
DURAGESIC 12.5 MCG/HR PATCH 3 QL Central Nervous Systems Agents
DURAGESIC 25 MCG/HR PATCH 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
60 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
DURAGESIC 50 MCG/HR PATCH 3 QL Central Nervous Systems Agents
DURAGESIC 75 MCG/HR PATCH 3 QL Central Nervous Systems Agents
DURAMORPH 0.5 MG/ML SOLUTION 1 Central Nervous Systems Agents
DURAMORPH 1 MG/ML SOLUTION 1 Central Nervous Systems Agents
DURICEF 250 MG/5ML SUSPENSION 3 Anti-Infective Agents
DURICEF 500 MG/5ML SUSPENSION 3 Anti-Infective Agents
DYAZIDE 25 MG;37.5 MG CAPSULES 3 Electrolytic, Caloric, And Water Balance
DYGASE 30000 UNIT;2400 UNIT;30000 UNITCAPSULES
1 Gastrointestinal Drugs
DYNABAC D5-PAK 250 MG TABLET 3 Anti-Infective Agents
DYNACIN 100 MG CAPSULES 3 Anti-Infective Agents
DYNACIN 75 MG CAPSULES 3 Anti-Infective Agents
DYNACIN 100 MG TABLET 3 Anti-Infective Agents
DYNACIN 50 MG TABLET 3 Anti-Infective Agents
DYNACIN 75 MG TABLET 3 Anti-Infective Agents
DYNACIRC CR 10 MG TABLET 2 QL Cardiovascular Drugs
DYNACIRC-CR 5 MG TABLET 2 QL Cardiovascular Drugs
DYRENIUM 100 MG CAPSULES 3 Electrolytic, Caloric, And Water Balance
DYRENIUM 50 MG CAPSULES 3 Electrolytic, Caloric, And Water Balance
E.E.S. 200 200 MG/5ML SUSPENSION 3 Anti-Infective Agents
E.E.S. 400 400 MG/5ML SUSPENSION 3 Anti-Infective Agents
E.E.S. 400 400 MG TABLET 3 Anti-Infective Agents
E.E.S. GRANULES 200 MG/5ML SUSPENSION 3 Anti-Infective Agents
EC-NAPROSYN 375 MG TABLET 3 Central Nervous Systems Agents
EC-NAPROSYN 500 MG TABLET 3 Central Nervous Systems Agents
ECONAZOLE NITRATE 0.01 CREAM 1 Skin And Mucous Membrane Agents
ECONOPRED PLUS 0.01 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ED K+10 10 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
EDECRIN 25 MG TABLET 3 Electrolytic, Caloric, And Water Balance
EFFEXOR 100 MG TABLET 3 Central Nervous Systems Agents
EFFEXOR 25 MG TABLET 3 Central Nervous Systems Agents
EFFEXOR 37.5 MG TABLET 3 Central Nervous Systems Agents
EFFEXOR 50 MG TABLET 3 Central Nervous Systems Agents
EFFEXOR 75 MG TABLET 3 Central Nervous Systems Agents
EFFEXOR XR 150 MG CAPSULES 2 QL Central Nervous Systems Agents
EFFEXOR XR 37.5 MG CAPSULES 2 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 61
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
EFFEXOR XR 75 MG CAPSULES 2 QL Central Nervous Systems Agents
EFUDEX 0.05 CREAM 3 PA Skin And Mucous Membrane Agents
EFUDEX 0.02 SOLUTION 3 PA Skin And Mucous Membrane Agents
EFUDEX 0.05 SOLUTION 3 PA Skin And Mucous Membrane Agents
EFUDEX OCCLUSION PACK 0.05 KIT 3 Skin And Mucous Membrane Agents
ELAPRASE 6 MG/3ML SOLUTION 4 PA Enzymes
ELDEPRYL 5 MG CAPSULES 3 Central Nervous Systems Agents
ELESTAT 0.0005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ELESTRIN 0.06 % GEL 3 Hormones And Synthetic Substitutes
ELIDEL 0.01 CREAM 3 Skin And Mucous Membrane Agents
ELIGARD 22.5 MG KIT 3 QL, PA Antineoplastic Agents
ELIGARD 30 MG KIT 3 QL, PA Antineoplastic Agents
ELIGARD 45 MG KIT 3 QL, PA Antineoplastic Agents
ELIGARD 7.5 MG KIT 3 QL, PA Antineoplastic Agents
ELIMITE 0.05 CREAM 3 Skin And Mucous Membrane Agents
ELITEK 1.5 MG SOLUTION 3 Enzymes
ELITEK 7.5 MG SOLUTION 4 Enzymes
ELIXOPHYLLIN 80 MG/15ML ELIXIR 1 Smooth Muscle Relaxants
ELLENCE 2 MG/ML SOLUTION 4 Antineoplastic Agents
ELMIRON 100 MG CAPSULES 2 Miscellaneous Therapeutic Agents
ELOCON 0.001 CREAM 3 Skin And Mucous Membrane Agents
ELOCON 0.001 LOTION 3 Skin And Mucous Membrane Agents
ELOCON 0.001 OINTMENT 3 Skin And Mucous Membrane Agents
ELOXATIN 100 MG/20ML SOLUTION 4 Antineoplastic Agents
ELOXATIN 50 MG/10ML SOLUTION 4 Antineoplastic Agents
ELSPAR 10000 UNIT SOLUTION 3 Antineoplastic Agents
EMADINE 0.0005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
EMCYT 140 MG CAPSULES 2 Antineoplastic Agents
EMEND 125 MG CAPSULES 3 QL Gastrointestinal Drugs
EMEND 40 MG CAPSULES 3 QL Gastrointestinal Drugs
EMEND 80 MG CAPSULES 3 QL Gastrointestinal Drugs
EMEND 0 MISC 3 QL Gastrointestinal Drugs
EMLA 2.5 %;2.5 % CREAM 3 Skin And Mucous Membrane Agents
EMLA/TEGADERM 2.5 %;2.5 % KIT 3 Skin And Mucous Membrane Agents
EMSAM 12 MG/24HR PATCH 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
62 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
EMSAM 6 MG/24HR PATCH 3 QL Central Nervous Systems Agents
EMSAM 9 MG/24HR PATCH 3 QL Central Nervous Systems Agents
EMTRIVA 200 MG CAPSULES 2 Anti-Infective Agents
EMTRIVA 10 MG/ML SOLUTION 2 Anti-Infective Agents
ENABLEX 15 MG TABLET 3 QL, ST Smooth Muscle Relaxants
ENABLEX 7.5 MG TABLET 3 QL, ST Smooth Muscle Relaxants
ENALAPRIL MALEATE 10 MG TABLET 1 Cardiovascular Drugs
ENALAPRIL MALEATE 2.5 MG TABLET 1 Cardiovascular Drugs
ENALAPRIL MALEATE 20 MG TABLET 1 Cardiovascular Drugs
ENALAPRIL MALEATE 5 MG TABLET 1 Cardiovascular Drugs
ENALAPRIL MALEATE/HYDROCH 10 MG;25 MGTABLET
1 Cardiovascular Drugs
ENALAPRIL MALEATE/HYDROCH 5 MG;12.5 MGTABLET
1 Cardiovascular Drugs
ENBREL 25 MG KIT 4 QL, PA Miscellaneous Therapeutic Agents
ENBREL 50 MG/ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
ENBREL SURECLICK 50 MG/ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
ENDOCET 325 MG;10 MG TABLET 1 QL Central Nervous Systems Agents
ENDOCET 325 MG;5 MG TABLET 1 QL Central Nervous Systems Agents
ENDOCET 325 MG;7.5 MG TABLET 1 QL Central Nervous Systems Agents
ENDOCET 500 MG;7.5 MG TABLET 1 QL Central Nervous Systems Agents
ENDOCET 650 MG;10 MG TABLET 1 QL Central Nervous Systems Agents
ENDOMETRIN 100 MG INSERT 3 Hormones And Synthetic Substitutes
ENGERIX-B 10 MCG/0.5ML INJECTION 3 Serums, Toxoids, And Vaccines
ENGERIX-B 20 MCG/ML INJECTION 3 Serums, Toxoids, And Vaccines
ENGERIX-B 10 MCG/0.5ML SUSPENSION 3 Serums, Toxoids, And Vaccines
ENGERIX-B 20 MCG/ML SUSPENSION 3 Serums, Toxoids, And Vaccines
ENJUVIA 0.3 MG TABLET 2 Hormones And Synthetic Substitutes
ENJUVIA 0.45 MG TABLET 2 Hormones And Synthetic Substitutes
ENJUVIA 0.625 MG TABLET 2 Hormones And Synthetic Substitutes
ENJUVIA 1.25 MG TABLET 2 Hormones And Synthetic Substitutes
ENLON-PLUS 0.14 MG/ML;10 MG/ML SOLUTION 3 Diagnostic Agents
ENPRESSE-28 0 TABLET 1 Hormones And Synthetic Substitutes
ENTOCORT EC 3 MG CAPSULES 3 Hormones And Synthetic Substitutes
ENULOSE 10 GM/15ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
ENZYCAP 15000 UNIT;1200 UNIT;15000 UNITCAPSULES
1 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 63
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ENZYMAX 12500 UNIT;1000 UNIT;12500 UNITTABLET
3 Gastrointestinal Drugs
EPINEPHRINE HCL 0.1 MG/ML SOLUTION 1 Autonomic Drugs
EPINEPHRINE HCL 1 MG/ML SOLUTION 1 Autonomic Drugs
EPIPEN 2-PAK 0.73611111111 DEVICE 2 Autonomic Drugs
EPIPEN-JR 2-PAK 1.4305555556 DEVICE 2 Autonomic Drugs
EPIRUBICIN HYDROCHLORIDE 200 MG SOLUTION 4 Antineoplastic Agents
EPIRUBICIN HYDROCHLORIDE 50 MG SOLUTION 4 Antineoplastic Agents
EPITOL 200 MG TABLET 1 Central Nervous Systems Agents
EPIVIR 10 MG/ML SOLUTION 2 Anti-Infective Agents
EPIVIR 150 MG TABLET 2 Anti-Infective Agents
EPIVIR 300 MG TABLET 2 Anti-Infective Agents
EPIVIR HBV 5 MG/ML SOLUTION 2 Anti-Infective Agents
EPIVIR HBV 100 MG TABLET 2 Anti-Infective Agents
EPOGEN 10000 UNIT/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
EPOGEN 2000 UNIT/ML SOLUTION 3 QL, PA Blood Formation, Coagulation, AndThrombosis
EPOGEN 20000 UNIT/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
EPOGEN 3000 UNIT/ML SOLUTION 3 QL, PA Blood Formation, Coagulation, AndThrombosis
EPOGEN 4000 UNIT/ML SOLUTION 3 QL, PA Blood Formation, Coagulation, AndThrombosis
EPOGEN 40000 UNIT/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
EPZICOM 600 MG;300 MG TABLET 2 Anti-Infective Agents
EQUAGESIC 325 MG;200 MG TABLET 3 Central Nervous Systems Agents
EQUETRO 100 MG CAPSULES 3 Central Nervous Systems Agents
EQUETRO 200 MG CAPSULES 3 Central Nervous Systems Agents
EQUETRO 300 MG CAPSULES 3 Central Nervous Systems Agents
ERAXIS 50 MG SOLUTION 4 Anti-Infective Agents
ERBITUX 100 MG/50ML SOLUTION 4 QL Antineoplastic Agents
ERGOLOID MESYLATES 1 MG TABLET 1 Autonomic Drugs
ERGOMAR 2 MG SUBLINGUAL 1 Autonomic Drugs
ERGOTAMINE TARTRATE/CAFFE 100 MG;1 MGTABLET
1 Autonomic Drugs
ERRIN 0.35 MG TABLET 1 Hormones And Synthetic Substitutes
ERTACZO 0.02 CREAM 3 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
64 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ERY-TAB 250 MG TABLET 3 Anti-Infective Agents
ERY-TAB 333 MG TABLET 3 Anti-Infective Agents
ERY-TAB 500 MG TABLET 3 Anti-Infective Agents
ERYC 250 MG CAPSULES 3 Anti-Infective Agents
ERYDERM 0.02 SOLUTION 1 Skin And Mucous Membrane Agents
ERYGEL 0.02 GEL 3 Skin And Mucous Membrane Agents
ERYPED 100 MG/2.5ML SUSPENSION 3 Anti-Infective Agents
ERYPED 200 200 MG/5ML SUSPENSION 3 Anti-Infective Agents
ERYPED 400 400 MG/5ML SUSPENSION 3 Anti-Infective Agents
ERYTHROCIN 1000 MG SOLUTION 1 Anti-Infective Agents
ERYTHROCIN LACTOBIONATE 500 MG SOLUTION 1 Anti-Infective Agents
ERYTHROCIN STEARATE 250 MG TABLET 1 Anti-Infective Agents
ERYTHROCIN STEARATE 500 MG TABLET 1 Anti-Infective Agents
ERYTHROMYCIN 250 MG CAPSULES 1 Anti-Infective Agents
ERYTHROMYCIN 0.02 GEL 1 Skin And Mucous Membrane Agents
ERYTHROMYCIN 5 MG/GM OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ERYTHROMYCIN 0.02 PADS 1 Skin And Mucous Membrane Agents
ERYTHROMYCIN 0.02 SOLUTION 1 Skin And Mucous Membrane Agents
ERYTHROMYCIN BASE 250 MG TABLET 1 Anti-Infective Agents
ERYTHROMYCIN BASE 500 MG TABLET 1 Anti-Infective Agents
ERYTHROMYCIN ETHYLSUCCINA 200 MG/5MLSUSPENSION
1 Anti-Infective Agents
ERYTHROMYCIN ETHYLSUCCINA 400 MG/5MLSUSPENSION
1 Anti-Infective Agents
ERYTHROMYCIN ETHYLSUCCINA 400 MG TABLET 1 Anti-Infective Agents
ERYTHROMYCIN LACTOBIONATE 500 MG SOLUTION 1 Anti-Infective Agents
ERYTHROMYCIN/BENZOYL PERO 5 %;3 % GEL 1 Skin And Mucous Membrane Agents
ERYTHROMYCIN/SULFISOXAZOL 200 MG/5ML;600MG/5ML SUSPENSION
1 Anti-Infective Agents
ESCLIM 0.025 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ESCLIM 0.038 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ESCLIM 0.05 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ESCLIM 0.075 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ESCLIM 0.1 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ESTRACE 0.1 MG/GM CREAM 3 Hormones And Synthetic Substitutes
ESTRACE 0.5 MG TABLET 3 PA Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 65
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ESTRACE 1 MG TABLET 3 PA Hormones And Synthetic Substitutes
ESTRACE 2 MG TABLET 3 PA Hormones And Synthetic Substitutes
ESTRADERM 0.05 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ESTRADERM 0.1 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ESTRADIOL 0.025 MG/24HR PATCH 1 QL Hormones And Synthetic Substitutes
ESTRADIOL 0.05 MG/24HR PATCH 1 QL Hormones And Synthetic Substitutes
ESTRADIOL 0.06 MG/24HR PATCH 1 Hormones And Synthetic Substitutes
ESTRADIOL 0.075 MG/24HR PATCH 1 QL Hormones And Synthetic Substitutes
ESTRADIOL 0.1 MG/24HR PATCH 1 QL Hormones And Synthetic Substitutes
ESTRADIOL 37.5 MCG/24HR PATCH 1 Hormones And Synthetic Substitutes
ESTRADIOL 0.5 MG TABLET 1 Hormones And Synthetic Substitutes
ESTRADIOL 1 MG TABLET 1 Hormones And Synthetic Substitutes
ESTRADIOL 2 MG TABLET 1 Hormones And Synthetic Substitutes
ESTRASORB 4.35 MG/1.74GM EMULSION 3 QL Hormones And Synthetic Substitutes
ESTRING 2 MG RING 3 QL Hormones And Synthetic Substitutes
ESTROGEL 0.0006 GEL 3 QL Hormones And Synthetic Substitutes
ESTROPIPATE 0.75 MG TABLET 1 Hormones And Synthetic Substitutes
ESTROPIPATE 1.5 MG TABLET 1 Hormones And Synthetic Substitutes
ESTROPIPATE 3 MG TABLET 1 Hormones And Synthetic Substitutes
ESTROSTEP FE 0 -;75 MG;1 MG TABLET 3 Hormones And Synthetic Substitutes
ETH-OXYDOSE 20 MG/ML CONCENTRATION 1 Central Nervous Systems Agents
ETHAMBUTOL HCL 100 MG TABLET 1 Anti-Infective Agents
ETHAMBUTOL HCL 400 MG TABLET 1 Anti-Infective Agents
ETHMOZINE 200 MG TABLET 3 Cardiovascular Drugs
ETHMOZINE 250 MG TABLET 3 Cardiovascular Drugs
ETHMOZINE 300 MG TABLET 3 Cardiovascular Drugs
ETHOSUXIMIDE 250 MG CAPSULES 1 Central Nervous Systems Agents
ETHOSUXIMIDE 250 MG/5ML SOLUTION 1 Central Nervous Systems Agents
ETHYOL 500 MG SOLUTION 4 Miscellaneous Therapeutic Agents
ETIDRONATE DISODIUM 200 MG TABLET 1 Miscellaneous Therapeutic Agents
ETIDRONATE DISODIUM 400 MG TABLET 1 Miscellaneous Therapeutic Agents
ETODOLAC 200 MG CAPSULES 1 Central Nervous Systems Agents
ETODOLAC 300 MG CAPSULES 1 Central Nervous Systems Agents
ETODOLAC 400 MG TABLET 1 Central Nervous Systems Agents
ETODOLAC 500 MG TABLET 1 Central Nervous Systems Agents
ETODOLAC ER 400 MG TABLET 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
66 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ETODOLAC ER 500 MG TABLET 1 Central Nervous Systems Agents
ETODOLAC ER 600 MG TABLET 1 Central Nervous Systems Agents
ETODOLAC EXTENDED-RELEASE 500 MG TABLET 1 Central Nervous Systems Agents
ETOPOPHOS 100 MG SOLUTION 4 Antineoplastic Agents
ETOPOSIDE 20 MG/ML SOLUTION 3 Antineoplastic Agents
EURAX 0.1 CREAM 3 Skin And Mucous Membrane Agents
EURAX 0.1 LOTION 3 Skin And Mucous Membrane Agents
EVISTA 60 MG TABLET 2 Hormones And Synthetic Substitutes
EVOCLIN 0.01 FOAM 3 Skin And Mucous Membrane Agents
EVOXAC 30 MG CAPSULES 3 Autonomic Drugs
EXELDERM 0.01 CREAM 3 Skin And Mucous Membrane Agents
EXELDERM 0.01 SOLUTION 3 Skin And Mucous Membrane Agents
EXELON 1.5 MG CAPSULES 2 QL Autonomic Drugs
EXELON 3 MG CAPSULES 2 QL Autonomic Drugs
EXELON 4.5 MG CAPSULES 2 QL Autonomic Drugs
EXELON 6 MG CAPSULES 2 QL Autonomic Drugs
EXELON 2 MG/ML SOLUTION 2 QL Autonomic Drugs
EXFORGE 10 MG;160 MG TABLET 2 QL Cardiovascular Drugs
EXFORGE 10 MG;320 MG TABLET 2 QL Cardiovascular Drugs
EXFORGE 5 MG;160 MG TABLET 2 QL Cardiovascular Drugs
EXFORGE 5 MG;320 MG TABLET 2 QL Cardiovascular Drugs
EXJADE 125 MG SOLUBLE TABLET 4 QL Heavy Metal Antagonists
EXJADE 250 MG SOLUBLE TABLET 4 QL Heavy Metal Antagonists
EXJADE 500 MG SOLUBLE TABLET 4 QL Heavy Metal Antagonists
EXUBERA COMBINATION PACK 0 POWDER 3 QL, PA Hormones And Synthetic Substitutes
EXUBERA KIT 0 POWDER 3 QL, PA Hormones And Synthetic Substitutes
FABRAZYME 35 MG SOLUTION 4 QL Enzymes
FABRAZYME 5 MG SOLUTION 4 QL Enzymes
FACTIVE 320 MG TABLET 3 Anti-Infective Agents
FAMOTIDINE 10 MG/ML SOLUTION 1 Gastrointestinal Drugs
FAMOTIDINE 20 MG TABLET 1 Gastrointestinal Drugs
FAMOTIDINE 40 MG TABLET 1 Gastrointestinal Drugs
FAMOTIDINE PREMIXED 0.4 MG/ML;0.9 % SOLUTION 1 Gastrointestinal Drugs
FAMVIR 125 MG TABLET 2 QL Anti-Infective Agents
FAMVIR 250 MG TABLET 2 QL Anti-Infective Agents
FAMVIR 500 MG TABLET 2 QL Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 67
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
FANSIDAR 25 MG;500 MG TABLET 3 Anti-Infective Agents
FARESTON 60 MG TABLET 3 Antineoplastic Agents
FASLODEX 125 MG/2.5ML SOLUTION 4 Antineoplastic Agents
FASLODEX 250 MG/5ML SOLUTION 4 Antineoplastic Agents
FAZACLO 100 MG TABLET 3 Central Nervous Systems Agents
FAZACLO 25 MG TABLET 3 Central Nervous Systems Agents
FELBATOL 600 MG/5ML SUSPENSION 3 Central Nervous Systems Agents
FELBATOL 400 MG TABLET 3 Central Nervous Systems Agents
FELBATOL 600 MG TABLET 3 Central Nervous Systems Agents
FELDENE 10 MG CAPSULES 3 Central Nervous Systems Agents
FELDENE 20 MG CAPSULES 3 Central Nervous Systems Agents
FELODIPINE ER 10 MG TABLET 1 QL Cardiovascular Drugs
FELODIPINE ER 2.5 MG TABLET 1 QL Cardiovascular Drugs
FELODIPINE ER 5 MG TABLET 1 QL Cardiovascular Drugs
FEMARA 2.5 MG TABLET 3 Antineoplastic Agents
FEMCON FE 35 MCG;0 -;0.4 MG CHEWABLE 3 Hormones And Synthetic Substitutes
FEMHRT 1/5 5 MCG;1 MG TABLET 3 Hormones And Synthetic Substitutes
FEMHRT LOW DOSE 2.5 MCG;0.5 MG TABLET 3 Hormones And Synthetic Substitutes
FEMRING 0.05 MG/24HR RING 3 QL Hormones And Synthetic Substitutes
FEMRING 0.1 MG/24HR RING 3 QL Hormones And Synthetic Substitutes
FEMTRACE 0.45 MG TABLET 3 Hormones And Synthetic Substitutes
FEMTRACE 0.9 MG TABLET 3 Hormones And Synthetic Substitutes
FEMTRACE 1.8 MG TABLET 3 Hormones And Synthetic Substitutes
FENOFIBRATE 134 MG CAPSULES 1 QL Cardiovascular Drugs
FENOFIBRATE 200 MG CAPSULES 1 QL Cardiovascular Drugs
FENOFIBRATE 67 MG CAPSULES 1 QL Cardiovascular Drugs
FENOFIBRATE 160 MG TABLET 1 QL Cardiovascular Drugs
FENOFIBRATE 54 MG TABLET 1 QL Cardiovascular Drugs
FENOPROFEN CALCIUM 600 MG TABLET 1 Central Nervous Systems Agents
FENTANYL 100 MCG/HR PATCH 1 QL Central Nervous Systems Agents
FENTANYL 12.5 MCG/HR PATCH 1 QL Central Nervous Systems Agents
FENTANYL 25 MCG/HR PATCH 1 QL Central Nervous Systems Agents
FENTANYL 50 MCG/HR PATCH 1 QL Central Nervous Systems Agents
FENTANYL 75 MCG/HR PATCH 1 QL Central Nervous Systems Agents
FENTANYL CITRATE 0.05 MG/ML SOLUTION 1 Central Nervous Systems Agents
FENTANYL CITRATE ORAL TRA 1200 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
68 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
FENTANYL CITRATE ORAL TRA 1600 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
FENTANYL CITRATE ORAL TRA 200 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
FENTANYL CITRATE ORAL TRA 400 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
FENTANYL CITRATE ORAL TRA 600 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
FENTANYL CITRATE ORAL TRA 800 MCG LOLLIPOP 4 QL, PA Central Nervous Systems Agents
FENTORA 100 MCG TABLET 4 QL, PA Central Nervous Systems Agents
FENTORA 200 MCG TABLET 4 QL, PA Central Nervous Systems Agents
FENTORA 400 MCG TABLET 4 QL, PA Central Nervous Systems Agents
FENTORA 600 MCG TABLET 4 QL, PA Central Nervous Systems Agents
FENTORA 800 MCG TABLET 4 QL, PA Central Nervous Systems Agents
FEXOFENADINE HCL 180 MG TABLET 1 QL Antihistamine Drugs
FEXOFENADINE HCL 30 MG TABLET 1 QL Antihistamine Drugs
FEXOFENADINE HCL 60 MG TABLET 1 QL Antihistamine Drugs
FINACEA 0.15 GEL 3 Skin And Mucous Membrane Agents
FINASTERIDE 5 MG TABLET 1 QL Miscellaneous Therapeutic Agents
FIORICET/CODEINE 325 MG;50 MG;40 MG;30 MGCAPSULES
3 QL Central Nervous Systems Agents
FIORINAL/CODEINE #3 325 MG;50 MG;40 MG;30 MGCAPSULES
3 Central Nervous Systems Agents
FLAGYL 375 MG CAPSULES 3 Anti-Infective Agents
FLAGYL 250 MG TABLET 3 Anti-Infective Agents
FLAGYL 500 MG TABLET 3 Anti-Infective Agents
FLAGYL ER 750 MG TABLET 3 Anti-Infective Agents
FLAREX 0.001 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
FLAVOXATE HCL 100 MG TABLET 1 Smooth Muscle Relaxants
FLEBOGAMMA 0.05 INJECTION 4 PA Serums, Toxoids, And Vaccines
FLECAINIDE ACETATE 100 MG TABLET 1 Cardiovascular Drugs
FLECAINIDE ACETATE 150 MG TABLET 1 Cardiovascular Drugs
FLECAINIDE ACETATE 50 MG TABLET 1 Cardiovascular Drugs
FLEXERIL 10 MG TABLET 3 PA Autonomic Drugs
FLEXERIL 5 MG TABLET 3 PA Autonomic Drugs
FLOMAX 0.4 MG CAPSULES 2 QL Miscellaneous Therapeutic Agents
FLONASE 50 MCG/ACT SUSPENSION 3 QL, PA, ST Eye, Ear, Nose, And Throat (EENT)Preparations
FLORINEF 0.1 MG TABLET 3 Hormones And Synthetic Substitutes
FLOVENT HFA 110 MCG/ACT AEROSOL 2 QL Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 69
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
FLOVENT HFA 220 MCG/ACT AEROSOL 2 QL Hormones And Synthetic Substitutes
FLOVENT HFA 44 MCG/ACT AEROSOL 2 QL Hormones And Synthetic Substitutes
FLOXIN OTIC 0.003 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
FLOXIN OTIC SINGLES 0.003 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
FLOXURIDINE 0.5 GM SOLUTION 1 Antineoplastic Agents
FLUCONAZOLE 10 MG/ML SUSPENSION 1 Anti-Infective Agents
FLUCONAZOLE 40 MG/ML SUSPENSION 1 Anti-Infective Agents
FLUCONAZOLE 100 MG TABLET 1 Anti-Infective Agents
FLUCONAZOLE 150 MG TABLET 1 QL Anti-Infective Agents
FLUCONAZOLE 200 MG TABLET 1 Anti-Infective Agents
FLUCONAZOLE 50 MG TABLET 1 Anti-Infective Agents
FLUCONAZOLE IN DEXTROSE 0 -;200 MG/100MLSOLUTION
1 Anti-Infective Agents
FLUCONAZOLE IN DEXTROSE 0 -;400 MG/200MLSOLUTION
1 Anti-Infective Agents
FLUCONAZOLE IN NACL 200 MG/100ML;0.9 %SOLUTION
1 Anti-Infective Agents
FLUCONAZOLE IN NACL 400 MG/200ML;0.9 %SOLUTION
1 Anti-Infective Agents
FLUDARA 50 MG SOLUTION 4 Antineoplastic Agents
FLUDARABINE PHOSPHATE 50 MG SOLUTION 4 Antineoplastic Agents
FLUDARABINE PHOSPHATE 50 MG/2ML SOLUTION 4 Antineoplastic Agents
FLUDROCORTISONE ACETATE 0.1 MG TABLET 1 Hormones And Synthetic Substitutes
FLUMADINE 50 MG/5ML SYRUP 3 Anti-Infective Agents
FLUMADINE 100 MG TABLET 3 Anti-Infective Agents
FLUNISOLIDE 0.00025 SOLUTION 1 QL Eye, Ear, Nose, And Throat (EENT)Preparations
FLUOCINOLONE ACETONIDE 0.0001 CREAM 1 Skin And Mucous Membrane Agents
FLUOCINOLONE ACETONIDE 0.00025 CREAM 1 Skin And Mucous Membrane Agents
FLUOCINOLONE ACETONIDE 0.00025 OINTMENT 1 Skin And Mucous Membrane Agents
FLUOCINOLONE ACETONIDE 0.0001 SOLUTION 1 Skin And Mucous Membrane Agents
FLUOCINONIDE 0.0005 CREAM 1 Skin And Mucous Membrane Agents
FLUOCINONIDE 0.0005 GEL 1 Skin And Mucous Membrane Agents
FLUOCINONIDE 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
FLUOCINONIDE 0.0005 SOLUTION 1 Skin And Mucous Membrane Agents
FLUOCINONIDE EMOLLIENT BA 0.0005 CREAM 1 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
70 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
FLUOCINONIDE-E 0.0005 CREAM 1 Skin And Mucous Membrane Agents
FLUOR-OP 0.001 SUSPENSION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
FLUOROMETHOLONE 0.001 SUSPENSION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
FLUOROPLEX 0.01 CREAM 2 Skin And Mucous Membrane Agents
FLUOROURACIL 0.02 SOLUTION 1 Skin And Mucous Membrane Agents
FLUOROURACIL 0.05 SOLUTION 1 Skin And Mucous Membrane Agents
FLUOROURACIL 50 MG/ML SOLUTION 1 Antineoplastic Agents
FLUOXETINE HCL 10 MG CAPSULES 1 QL Central Nervous Systems Agents
FLUOXETINE HCL 20 MG CAPSULES 1 QL Central Nervous Systems Agents
FLUOXETINE HCL 40 MG CAPSULES 1 QL Central Nervous Systems Agents
FLUOXETINE HCL 20 MG/5ML SOLUTION 1 Central Nervous Systems Agents
FLUOXETINE HCL 10 MG TABLET 1 QL Central Nervous Systems Agents
FLUOXETINE HCL 20 MG TABLET 1 QL Central Nervous Systems Agents
FLUPHENAZINE DECANOATE 25 MG/ML SOLUTION 1 Central Nervous Systems Agents
FLUPHENAZINE HCL 5 MG/ML CONCENTRATION 1 Central Nervous Systems Agents
FLUPHENAZINE HCL 2.5 MG/5ML ELIXIR 1 Central Nervous Systems Agents
FLUPHENAZINE HCL 2.5 MG/ML SOLUTION 1 Central Nervous Systems Agents
FLUPHENAZINE HCL 1 MG TABLET 1 Central Nervous Systems Agents
FLUPHENAZINE HCL 10 MG TABLET 1 Central Nervous Systems Agents
FLUPHENAZINE HCL 2.5 MG TABLET 1 Central Nervous Systems Agents
FLUPHENAZINE HCL 5 MG TABLET 1 Central Nervous Systems Agents
FLURBIPROFEN 100 MG TABLET 1 Central Nervous Systems Agents
FLURBIPROFEN 50 MG TABLET 1 Central Nervous Systems Agents
FLURBIPROFEN SODIUM 0.0003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
FLUTAMIDE 125 MG CAPSULES 1 Antineoplastic Agents
FLUTICASONE PROPIONATE 0.0005 CREAM 1 Skin And Mucous Membrane Agents
FLUTICASONE PROPIONATE 0.005% OINTMENT 1 Skin And Mucous Membrane Agents
FLUTICASONE PROPIONATE 50 MCG/ACTSUSPENSION
1 QL Eye, Ear, Nose, And Throat (EENT)Preparations
FLUVOXAMINE MALEATE 100 MG TABLET 1 QL Central Nervous Systems Agents
FLUVOXAMINE MALEATE 25 MG TABLET 1 QL Central Nervous Systems Agents
FLUVOXAMINE MALEATE 50 MG TABLET 1 QL Central Nervous Systems Agents
FML FORTE 0.0025 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 71
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
FML LIQUIFILM 0.001 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
FML S.O.P. 0.001 OINTMENT 3 Eye, Ear, Nose, And Throat (EENT)Preparations
FOCALIN 10 MG TABLET 3 Central Nervous Systems Agents
FOCALIN 2.5 MG TABLET 3 Central Nervous Systems Agents
FOCALIN 5 MG TABLET 3 Central Nervous Systems Agents
FOCALIN XR 10 MG CAPSULES 3 QL Central Nervous Systems Agents
FOCALIN XR 15 MG CAPSULES 3 QL Central Nervous Systems Agents
FOCALIN XR 20 MG CAPSULES 3 QL Central Nervous Systems Agents
FOCALIN XR 5 MG CAPSULES 3 QL Central Nervous Systems Agents
FORADIL AEROLIZER 12 MCG CAPSULES 3 QL Autonomic Drugs
FORTAMET 1000 MG TABLET 3 QL Hormones And Synthetic Substitutes
FORTAMET 500 MG TABLET 3 QL Hormones And Synthetic Substitutes
FORTAZ 1 GM SOLUTION 3 Anti-Infective Agents
FORTAZ 1 GM SOLUTION 3 Anti-Infective Agents
FORTAZ 1 GM/50ML;5 % SOLUTION 3 Anti-Infective Agents
FORTAZ 2 GM SOLUTION 3 Anti-Infective Agents
FORTAZ 2 GM SOLUTION 3 Anti-Infective Agents
FORTAZ 2 GM/50ML;5 % SOLUTION 3 Anti-Infective Agents
FORTAZ 500 MG SOLUTION 3 Anti-Infective Agents
FORTAZ 6 GM SOLUTION 3 Anti-Infective Agents
FORTAZ INFUSION PACK 1 GM SOLUTION 3 Anti-Infective Agents
FORTEO 750 MCG/3ML SOLUTION 3 Hormones And Synthetic Substitutes
FORTICAL 200 UNIT/ACT SOLUTION 2 QL Hormones And Synthetic Substitutes
FOSAMAX 70 MG/75ML SOLUTION 2 QL Miscellaneous Therapeutic Agents
FOSAMAX 10 MG TABLET 2 QL Miscellaneous Therapeutic Agents
FOSAMAX 35 MG TABLET 2 QL Miscellaneous Therapeutic Agents
FOSAMAX 40 MG TABLET 2 QL Miscellaneous Therapeutic Agents
FOSAMAX 5 MG TABLET 2 QL Miscellaneous Therapeutic Agents
FOSAMAX 70 MG TABLET 2 QL Miscellaneous Therapeutic Agents
FOSAMAX PLUS D 70 MG;2800 UNIT TABLET 2 QL Miscellaneous Therapeutic Agents
FOSAMAX PLUS D 70 MG;5600 UNIT TABLET 2 QL Miscellaneous Therapeutic Agents
FOSCARNET SODIUM 24 MG/ML SOLUTION 4 Anti-Infective Agents
FOSCAVIR 24 MG/ML SOLUTION 4 Anti-Infective Agents
FOSINOPRIL SODIUM 10 MG TABLET 1 Cardiovascular Drugs
FOSINOPRIL SODIUM 20 MG TABLET 1 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
72 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
FOSINOPRIL SODIUM 40 MG TABLET 1 Cardiovascular Drugs
FOSINOPRIL SODIUM/HYDROCH 10 MG;12.5 MGTABLET
1 Cardiovascular Drugs
FOSINOPRIL SODIUM/HYDROCH 20 MG;12.5 MGTABLET
1 Cardiovascular Drugs
FOSRENOL 1000 MG CHEWABLE 3 ST Electrolytic, Caloric, And Water Balance
FOSRENOL 250 MG CHEWABLE 3 ST Electrolytic, Caloric, And Water Balance
FOSRENOL 500 MG CHEWABLE 3 ST Electrolytic, Caloric, And Water Balance
FOSRENOL 750 MG CHEWABLE 3 ST Electrolytic, Caloric, And Water Balance
FRAGMIN 10000 UNIT/ML INJECTION 3 QL Blood Formation, Coagulation, AndThrombosis
FRAGMIN 2500 UNIT/0.2ML INJECTION 3 QL Blood Formation, Coagulation, AndThrombosis
FRAGMIN 25000 UNIT/ML INJECTION 3 QL Blood Formation, Coagulation, AndThrombosis
FRAGMIN 5000 UNIT/0.2ML INJECTION 3 QL Blood Formation, Coagulation, AndThrombosis
FRAGMIN 7500 UNIT/0.3ML INJECTION 3 QL Blood Formation, Coagulation, AndThrombosis
FREAMINE HBC 6.9% 59.3 MEQ/L;400MG/100ML;580 MG/100ML;3 MEQ/L;14 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
FREAMINE III 72 MEQ/L;600 MG/100ML;810MG/100ML;3 MEQ/L;14 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
FREAMINE III 3% 44 MEQ/L;210 MG/100ML;290MG/100ML;41 MEQ/L;20 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
FREAMINE III 8.5% 125 MEQ/L;600 MG/100ML;810MG/100ML;60 MEQ/L;20 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
FREAMINE III 8.5%/DEXTROS 125 MEQ/L;600MG/100ML;810 MG/100ML;60 MEQ/L;20 MG/100MLKIT
3 Electrolytic, Caloric, And Water Balance
FROVA 2.5 MG TABLET 3 QL Central Nervous Systems Agents
FUDR 0.5 GM SOLUTION 1 Antineoplastic Agents
FURADANTIN 25 MG/5ML SUSPENSION 3 Anti-Infective Agents
FUROSEMIDE 10 MG/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
FUROSEMIDE 10 MG/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
FUROSEMIDE 8 MG/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
FUROSEMIDE 20 MG TABLET 1 Electrolytic, Caloric, And Water Balance
FUROSEMIDE 40 MG TABLET 1 Electrolytic, Caloric, And Water Balance
FUROSEMIDE 80 MG TABLET 1 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 73
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
FUZEON 90 MG KIT 4 QL Anti-Infective Agents
GABAPENTIN 100 MG CAPSULES 1 QL Central Nervous Systems Agents
GABAPENTIN 300 MG CAPSULES 1 QL Central Nervous Systems Agents
GABAPENTIN 400 MG CAPSULES 1 QL Central Nervous Systems Agents
GABAPENTIN 100 MG TABLET 1 QL Central Nervous Systems Agents
GABAPENTIN 300 MG TABLET 1 QL Central Nervous Systems Agents
GABAPENTIN 400 MG TABLET 1 QL Central Nervous Systems Agents
GABAPENTIN 600 MG TABLET 1 QL Central Nervous Systems Agents
GABAPENTIN 800 MG TABLET 1 QL Central Nervous Systems Agents
GABITRIL 12 MG TABLET 3 QL Central Nervous Systems Agents
GABITRIL 16 MG TABLET 3 QL Central Nervous Systems Agents
GABITRIL 2 MG TABLET 3 QL Central Nervous Systems Agents
GABITRIL 4 MG TABLET 3 QL Central Nervous Systems Agents
GAMASTAN S/D 0 INJECTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD LIQUID 0.1 SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD LIQUID 10 GM/100ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD LIQUID 2.5 GM/25ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD LIQUID 20 GM/200ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD LIQUID 5 GM/50ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD S/D 0.5 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD S/D 10 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD S/D 2.5 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMMAGARD S/D 5 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
GAMUNEX 0.1 INJECTION 4 PA Serums, Toxoids, And Vaccines
GANCICLOVIR 250 MG CAPSULES 4 Anti-Infective Agents
GANCICLOVIR 500 MG CAPSULES 4 Anti-Infective Agents
GANTRISIN PEDIATRIC 500 MG/5ML SUSPENSION 3 Anti-Infective Agents
GARDASIL 0 SUSPENSION 3 Serums, Toxoids, And Vaccines
GASTROCROM 100 MG/5ML CONCENTRATION 3 Respiratory Tract Agents
GEMFIBROZIL 600 MG TABLET 1 QL Cardiovascular Drugs
GEMZAR 1 GM SOLUTION 4 Antineoplastic Agents
GEMZAR 200 MG SOLUTION 4 Antineoplastic Agents
GENERLAC 10 GM/15ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
GENGRAF 100 MG CAPSULES 1 Miscellaneous Therapeutic Agents
GENGRAF 25 MG CAPSULES 1 Miscellaneous Therapeutic Agents
GENGRAF 100 MG/ML SOLUTION 1 Miscellaneous Therapeutic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
74 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
GENOPTIC 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
GENOTROPIN 13.8 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN 5.8 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 0.2 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 0.4 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 0.6 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 0.8 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 1 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 1.2 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 1.4 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 1.6 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 1.8 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENOTROPIN MINIQUICK 2 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
GENTAK 0.003 OINTMENT 3 Eye, Ear, Nose, And Throat (EENT)Preparations
GENTAK 0.003 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
GENTAMICIN SULFATE 0.001 CREAM 1 Skin And Mucous Membrane Agents
GENTAMICIN SULFATE 0.001 OINTMENT 1 Skin And Mucous Membrane Agents
GENTAMICIN SULFATE 0.003 OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
GENTAMICIN SULFATE 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
GENTAMICIN SULFATE 10 MG/ML SOLUTION 1 Anti-Infective Agents
GENTAMICIN SULFATE 10 MG/ML SOLUTION 1 Anti-Infective Agents
GENTAMICIN SULFATE 40 MG/ML SOLUTION 1 Anti-Infective Agents
GENTAMICIN SULFATE/0.9% S 0.8 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/0.9% S 0.9 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/0.9% S 1 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/0.9% S 1.2 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/0.9% S 1.4 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/0.9% S 1.6 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 75
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
GENTAMICIN SULFATE/SODIUM 0.6 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/SODIUM 0.8 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/SODIUM 1 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/SODIUM 1.2 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTAMICIN SULFATE/SODIUM 1.6 MG/ML;0.9 %SOLUTION
1 Anti-Infective Agents
GENTASOL 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
GEOCILLIN 382 MG TABLET 3 Anti-Infective Agents
GEODON 20 MG CAPSULES 2 QL Central Nervous Systems Agents
GEODON 40 MG CAPSULES 2 QL Central Nervous Systems Agents
GEODON 60 MG CAPSULES 2 QL Central Nervous Systems Agents
GEODON 80 MG CAPSULES 2 QL Central Nervous Systems Agents
GEODON 20 MG SOLUTION 3 Central Nervous Systems Agents
GLEEVEC 100 MG TABLET 4 QL, PA Antineoplastic Agents
GLEEVEC 400 MG TABLET 4 QL, PA Antineoplastic Agents
GLIMEPIRIDE 1 MG TABLET 1 Hormones And Synthetic Substitutes
GLIMEPIRIDE 2 MG TABLET 1 Hormones And Synthetic Substitutes
GLIMEPIRIDE 4 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE 10 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE 5 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE ER 10 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE ER 2.5 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE ER 5 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE XL 10 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE XL 2.5 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE XL 5 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE/METFORMIN HCL 2.5 MG;250 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE/METFORMIN HCL 2.5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes
GLIPIZIDE/METFORMIN HCL 5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes
GLUCAGEN HYPOKIT 1 MG SOLUTION 3 Hormones And Synthetic Substitutes
GLUCAGON EMERGENCY KIT 1 MG KIT 2 Hormones And Synthetic Substitutes
GLUCOPHAGE 1000 MG TABLET 3 Hormones And Synthetic Substitutes
GLUCOPHAGE 500 MG TABLET 3 Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
76 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
GLUCOPHAGE 850 MG TABLET 3 Hormones And Synthetic Substitutes
GLUCOPHAGE XR 500 MG TABLET 3 QL Hormones And Synthetic Substitutes
GLUCOPHAGE XR 750 MG TABLET 3 QL Hormones And Synthetic Substitutes
GLUCOTROL 10 MG TABLET 3 Hormones And Synthetic Substitutes
GLUCOTROL 5 MG TABLET 3 Hormones And Synthetic Substitutes
GLUCOTROL XL 10 MG TABLET 3 PA Hormones And Synthetic Substitutes
GLUCOTROL XL 2.5 MG TABLET 3 PA Hormones And Synthetic Substitutes
GLUCOTROL XL 5 MG TABLET 3 PA Hormones And Synthetic Substitutes
GLUCOVANCE 1.25 MG;250 MG TABLET 3 Hormones And Synthetic Substitutes
GLUCOVANCE 2.5 MG;500 MG TABLET 3 Hormones And Synthetic Substitutes
GLUCOVANCE 5 MG;500 MG TABLET 3 Hormones And Synthetic Substitutes
GLUMETZA 500 MG TABLET 3 QL, ST Hormones And Synthetic Substitutes
GLYBURIDE 1.25 MG TABLET 1 Hormones And Synthetic Substitutes
GLYBURIDE 2.5 MG TABLET 1 Hormones And Synthetic Substitutes
GLYBURIDE 5 MG TABLET 1 Hormones And Synthetic Substitutes
GLYBURIDE MICRONIZED 1.5 MG TABLET 1 Hormones And Synthetic Substitutes
GLYBURIDE MICRONIZED 3 MG TABLET 1 Hormones And Synthetic Substitutes
GLYBURIDE MICRONIZED 6 MG TABLET 1 Hormones And Synthetic Substitutes
GLYBURIDE/METFORMIN HCL 1.25 MG;250 MGTABLET
1 Hormones And Synthetic Substitutes
GLYBURIDE/METFORMIN HCL 2.5 MG;500 MGTABLET
1 Hormones And Synthetic Substitutes
GLYBURIDE/METFORMIN HCL 5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes
GLYCOLAX 0 PACK 1 QL Gastrointestinal Drugs
GLYCOLAX 0 POWDER 1 QL Gastrointestinal Drugs
GLYCOPYRROLATE 0.2 MG/ML SOLUTION 1 Autonomic Drugs
GLYCOPYRROLATE 1 MG TABLET 1 Autonomic Drugs
GLYCOPYRROLATE 2 MG TABLET 1 Autonomic Drugs
GLYCRON 1.5 MG TABLET 1 Hormones And Synthetic Substitutes
GLYCRON 3 MG TABLET 1 Hormones And Synthetic Substitutes
GLYCRON 4.5 MG TABLET 3 Hormones And Synthetic Substitutes
GLYCRON 6 MG TABLET 1 Hormones And Synthetic Substitutes
GLYNASE 1.5 MG TABLET 3 Hormones And Synthetic Substitutes
GLYNASE 3 MG TABLET 3 Hormones And Synthetic Substitutes
GLYNASE 6 MG TABLET 3 Hormones And Synthetic Substitutes
GLYSET 100 MG TABLET 2 Hormones And Synthetic Substitutes
GLYSET 25 MG TABLET 2 Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 77
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
GLYSET 50 MG TABLET 2 Hormones And Synthetic Substitutes
GOLYTELY 227.1 GM;2.82 GM;6.36 GM;5.53 GM;21.5GM SOLUTION
3 Gastrointestinal Drugs
GOLYTELY 236 GM;2.97 GM;6.74 GM;5.86 GM;22.74GM SOLUTION
3 Gastrointestinal Drugs
GRIFULVIN V 125 MG/5ML SUSPENSION 3 Anti-Infective Agents
GRIFULVIN V 500 MG TABLET 2 Anti-Infective Agents
GRIS-PEG 125 MG TABLET 3 Anti-Infective Agents
GRIS-PEG 250 MG TABLET 3 Anti-Infective Agents
GRISEOFULVIN MICROSIZE 125 MG/5MLSUSPENSION
1 Anti-Infective Agents
GUANABENZ ACETATE 4 MG TABLET 1 Cardiovascular Drugs
GUANABENZ ACETATE 8 MG TABLET 1 Cardiovascular Drugs
GUANFACINE HCL 1 MG TABLET 1 Cardiovascular Drugs
GUANFACINE HCL 2 MG TABLET 1 Cardiovascular Drugs
GUANIDINE HCL 125 MG TABLET 1 Autonomic Drugs
GYNAZOLE-1 0.02 CREAM 3 Skin And Mucous Membrane Agents
GYNODIOL 0.5 MG TABLET 3 Hormones And Synthetic Substitutes
GYNODIOL 1 MG TABLET 3 Hormones And Synthetic Substitutes
GYNODIOL 1.5 MG TABLET 3 Hormones And Synthetic Substitutes
GYNODIOL 2 MG TABLET 3 Hormones And Synthetic Substitutes
HALDOL 5 MG/ML SOLUTION 3 Central Nervous Systems Agents
HALDOL DECANOATE-100 100 MG/ML SOLUTION 3 QL Central Nervous Systems Agents
HALDOL DECANOATE-50 50 MG/ML SOLUTION 3 QL Central Nervous Systems Agents
HALFLYTELY BOWEL PREP KIT 5 MG;210 GM;0.74GM;2.86 GM;5.6 GM KIT
3 Gastrointestinal Drugs
HALOBETASOL PROPIONATE 0.0005 CREAM 1 Skin And Mucous Membrane Agents
HALOBETASOL PROPIONATE 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
HALOG 0.001 CREAM 3 Skin And Mucous Membrane Agents
HALOG 0.001 OINTMENT 3 Skin And Mucous Membrane Agents
HALOG 0.001 SOLUTION 3 Skin And Mucous Membrane Agents
HALOPERIDOL 2 MG/ML CONCENTRATION 1 Central Nervous Systems Agents
HALOPERIDOL 0.5 MG TABLET 1 Central Nervous Systems Agents
HALOPERIDOL 1 MG TABLET 1 Central Nervous Systems Agents
HALOPERIDOL 10 MG TABLET 1 Central Nervous Systems Agents
HALOPERIDOL 2 MG TABLET 1 Central Nervous Systems Agents
HALOPERIDOL 20 MG TABLET 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
78 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
HALOPERIDOL 5 MG TABLET 1 Central Nervous Systems Agents
HALOPERIDOL DECANOATE 100 MG/ML SOLUTION 1 QL Central Nervous Systems Agents
HALOPERIDOL DECANOATE 50 MG/ML SOLUTION 1 QL Central Nervous Systems Agents
HALOPERIDOL LACTATE 5 MG/ML SOLUTION 1 Central Nervous Systems Agents
HAVRIX 1440 ELU/ML SUSPENSION 3 Serums, Toxoids, And Vaccines
HAVRIX 720 ELU/0.5ML SUSPENSION 3 Serums, Toxoids, And Vaccines
HECTOROL 0.5 MCG CAPSULES 2 Vitamins
HECTOROL 2.5 MCG CAPSULES 2 Vitamins
HECTOROL 4 MCG/2ML SOLUTION 3 Vitamins
HELIDAC 0 MISC 3 Anti-Infective Agents
HEPARIN SODIUM 1000 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM 10000 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM 2000 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM 25000 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM 5000 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM DCU 20000 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM/D5W 5 %;100 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM/D5W 5 %;40 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM/D5W 5 %;50 UNIT/ML SOLUTION 1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM/NACL 0.45% 100 UNIT/ML;0.45 %SOLUTION
1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM/NACL 0.45% 50 UNIT/ML;0.45 %SOLUTION
1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM/NACL 0.9% 2 UNIT/ML;0.9 %SOLUTION
1 Blood Formation, Coagulation, AndThrombosis
HEPARIN SODIUM/SODIUM CHL 2 UNIT/ML;0.9 %SOLUTION
1 Blood Formation, Coagulation, AndThrombosis
HEPATAMINE 62 MEQ/L;770 MG/100ML;600MG/100ML;3 MEQ/L;20 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
HEPATASOL 0.77 GM/100ML;0.6 GM/100ML;0.02GM/100ML;0.9 GM/100ML;0.24 GM/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 79
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
HEPSERA 10 MG TABLET 4 Anti-Infective Agents
HERCEPTIN 440 MG SOLUTION 4 QL Antineoplastic Agents
HEXALEN 50 MG CAPSULES 4 Antineoplastic Agents
HIBTITER 25 MCG;10 MCG SOLUTION 3 Serums, Toxoids, And Vaccines
HIPREX 1 GM TABLET 3 Anti-Infective Agents
HUMALOG 100 UNIT/ML SOLUTION 2 QL Hormones And Synthetic Substitutes
HUMALOG MIX 50/50 50 %;50 % SUSPENSION 2 Hormones And Synthetic Substitutes
HUMALOG MIX 50/50 PEN 50 %;50 % SUSPENSION 2 Hormones And Synthetic Substitutes
HUMALOG MIX 75/25 25 %;75 % SUSPENSION 2 Hormones And Synthetic Substitutes
HUMALOG MIX 75/25 PEN 25 %;75 % SUSPENSION 2 Hormones And Synthetic Substitutes
HUMALOG PEN 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
HUMATIN 250 MG CAPSULES 1 Anti-Infective Agents
HUMATROPE 12 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
HUMATROPE 24 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
HUMATROPE 6 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
HUMATROPE COMBO PACK 5 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
HUMIRA 40 MG/0.8ML KIT 4 QL, PA Miscellaneous Therapeutic Agents
HUMIRA PEN 40 MG/0.8ML KIT 4 QL, PA Miscellaneous Therapeutic Agents
HUMULIN 50/50 50 %;50 % SUSPENSION 2 Hormones And Synthetic Substitutes
HUMULIN 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes
HUMULIN 70/30 PEN 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes
HUMULIN N 100 UNIT/ML SUSPENSION 2 Hormones And Synthetic Substitutes
HUMULIN N U-100 PEN 100 UNIT/ML SUSPENSION 2 Hormones And Synthetic Substitutes
HUMULIN R 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
HUMULIN R 500 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
HYCAMTIN 4 MG SOLUTION 4 Antineoplastic Agents
HYCET 325 MG/15ML;7.5 MG/15ML SOLUTION 3 Central Nervous Systems Agents
HYDRALAZINE HCL 20 MG/ML SOLUTION 1 Cardiovascular Drugs
HYDRALAZINE HCL 10 MG TABLET 1 Cardiovascular Drugs
HYDRALAZINE HCL 100 MG TABLET 1 Cardiovascular Drugs
HYDRALAZINE HCL 25 MG TABLET 1 Cardiovascular Drugs
HYDRALAZINE HCL 50 MG TABLET 1 Cardiovascular Drugs
HYDREA 500 MG CAPSULES 3 Antineoplastic Agents
HYDROCET 500 MG;5 MG CAPSULES 1 QL Central Nervous Systems Agents
HYDROCHLOROTHIAZIDE 12.5 MG CAPSULES 1 Electrolytic, Caloric, And Water Balance
HYDROCHLOROTHIAZIDE 12.5 MG TABLET 1 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
80 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
HYDROCHLOROTHIAZIDE 25 MG TABLET 1 Electrolytic, Caloric, And Water Balance
HYDROCHLOROTHIAZIDE 50 MG TABLET 1 Electrolytic, Caloric, And Water Balance
HYDROCODONE BITARTRATE/AC 750 MG;10 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE BITARTRATE/AP 500 MG;10 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE-ACETAMINOPHEN 325 MG;5 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 500MG/15ML;7.5 MG/15ML SOLUTION
1 Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 325 MG;10 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 325 MG;5 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 325 MG;7.5 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 500 MG;10 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 500 MG;2.5 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 500 MG;5 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 500 MG;7.5 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 650 MG;10 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 650 MG;7.5 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 660 MG;10 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/ACETAMINOPHEN 750 MG;7.5 MGTABLET
1 QL Central Nervous Systems Agents
HYDROCODONE/APAP 325 MG;10 MG TABLET 1 QL Central Nervous Systems Agents
HYDROCODONE/IBUPROFEN 7.5 MG;200 MG TABLET 1 QL Central Nervous Systems Agents
HYDROCORTISONE 0.01 CREAM 1 Skin And Mucous Membrane Agents
HYDROCORTISONE 0.025 CREAM 1 Skin And Mucous Membrane Agents
HYDROCORTISONE 100 MG/60ML ENEMA 1 Skin And Mucous Membrane Agents
HYDROCORTISONE 0.01 LOTION 1 Skin And Mucous Membrane Agents
HYDROCORTISONE 0.025 LOTION 1 Skin And Mucous Membrane Agents
HYDROCORTISONE 0.01 OINTMENT 1 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 81
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
HYDROCORTISONE 0.025 OINTMENT 1 Skin And Mucous Membrane Agents
HYDROCORTISONE 20 MG TABLET 1 Hormones And Synthetic Substitutes
HYDROCORTISONE BUTYRATE 0.001 CREAM 1 Skin And Mucous Membrane Agents
HYDROCORTISONE BUTYRATE 0.001 OINTMENT 1 Skin And Mucous Membrane Agents
HYDROCORTISONE BUTYRATE 0.001 SOLUTION 1 Skin And Mucous Membrane Agents
HYDROCORTISONE IN ABSORBA 0.01 OINTMENT 1 Skin And Mucous Membrane Agents
HYDROCORTISONE VALERATE 0.002 CREAM 1 Skin And Mucous Membrane Agents
HYDROCORTISONE VALERATE 0.002 OINTMENT 1 Skin And Mucous Membrane Agents
HYDROMORPHONE HCL 10 MG/ML SOLUTION 1 Central Nervous Systems Agents
HYDROMORPHONE HCL 50 MG/5ML SOLUTION 1 Central Nervous Systems Agents
HYDROMORPHONE HCL 2 MG TABLET 1 Central Nervous Systems Agents
HYDROMORPHONE HCL 4 MG TABLET 1 Central Nervous Systems Agents
HYDROMORPHONE HCL 8 MG TABLET 1 Central Nervous Systems Agents
HYDROXYCHLOROQUINE SULFAT 200 MG TABLET 1 Anti-Infective Agents
HYDROXYUREA 500 MG CAPSULES 1 Antineoplastic Agents
HYDROXYZINE HCL 25 MG/ML SOLUTION 1 Central Nervous Systems Agents
HYDROXYZINE HCL 50 MG/ML SOLUTION 1 Central Nervous Systems Agents
HYDROXYZINE HCL 10 MG/5ML SYRUP 1 Central Nervous Systems Agents
HYDROXYZINE HCL 10 MG TABLET 1 Central Nervous Systems Agents
HYDROXYZINE HCL 25 MG TABLET 1 Central Nervous Systems Agents
HYDROXYZINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
HYDROXYZINE PAMOATE 100 MG CAPSULES 1 Central Nervous Systems Agents
HYDROXYZINE PAMOATE 25 MG CAPSULES 1 Central Nervous Systems Agents
HYDROXYZINE PAMOATE 50 MG CAPSULES 1 Central Nervous Systems Agents
HYTONE 0.025 CREAM 1 Skin And Mucous Membrane Agents
HYTRIN 1 MG CAPSULES 3 Cardiovascular Drugs
HYTRIN 10 MG CAPSULES 3 Cardiovascular Drugs
HYTRIN 2 MG CAPSULES 3 Cardiovascular Drugs
HYTRIN 5 MG CAPSULES 3 Cardiovascular Drugs
HYZAAR 12.5 MG;100 MG TABLET 3 QL Cardiovascular Drugs
HYZAAR 12.5 MG;50 MG TABLET 3 QL Cardiovascular Drugs
HYZAAR 25 MG;100 MG TABLET 3 QL Cardiovascular Drugs
IBUPROFEN 100 MG/5ML SUSPENSION 1 Central Nervous Systems Agents
IBUPROFEN 400 MG TABLET 1 Central Nervous Systems Agents
IBUPROFEN 600 MG TABLET 1 Central Nervous Systems Agents
IBUPROFEN 800 MG TABLET 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
82 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
IDAMYCIN PFS 1 MG/ML SOLUTION 4 Antineoplastic Agents
IDARUBICIN 1 MG/ML SOLUTION 4 Antineoplastic Agents
IFEX 1 GM SOLUTION 4 Antineoplastic Agents
IFEX 3 GM SOLUTION 4 Antineoplastic Agents
IFEX/MESNEX COMBO PACK 1 GM;1 GM KIT 4 Antineoplastic Agents
IFEX/MESNEX COMBO PACK 3000 MG;1000 MG KIT 4 Antineoplastic Agents
IFOSFAMIDE 1 GM SOLUTION 4 Antineoplastic Agents
IFOSFAMIDE 3 GM SOLUTION 4 Antineoplastic Agents
IFOSFAMIDE/MESNA 1 GM;1 GM KIT 4 Antineoplastic Agents
IFOSFAMIDE/MESNA 3000 MG;1000 MG KIT 4 Antineoplastic Agents
IMDUR 120 MG TABLET 3 Cardiovascular Drugs
IMDUR 30 MG TABLET 3 Cardiovascular Drugs
IMDUR 60 MG TABLET 3 Cardiovascular Drugs
IMIPRAMINE HCL 10 MG TABLET 1 Central Nervous Systems Agents
IMIPRAMINE HCL 25 MG TABLET 1 Central Nervous Systems Agents
IMIPRAMINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
IMIPRAMINE PAMOATE 100 MG CAPSULES 1 Central Nervous Systems Agents
IMIPRAMINE PAMOATE 125 MG CAPSULES 1 Central Nervous Systems Agents
IMIPRAMINE PAMOATE 150 MG CAPSULES 1 Central Nervous Systems Agents
IMIPRAMINE PAMOATE 75 MG CAPSULES 1 Central Nervous Systems Agents
IMITREX 20 MG/ACT SOLUTION 2 QL Central Nervous Systems Agents
IMITREX 5 MG/ACT SOLUTION 2 QL Central Nervous Systems Agents
IMITREX 6 MG/0.5ML SOLUTION 2 QL Central Nervous Systems Agents
IMITREX 100 MG TABLET 2 QL Central Nervous Systems Agents
IMITREX 25 MG TABLET 2 QL Central Nervous Systems Agents
IMITREX 50 MG TABLET 2 QL Central Nervous Systems Agents
IMITREX STATDOSE PEN 4 MG/0.5ML KIT 2 QL Central Nervous Systems Agents
IMITREX STATDOSE PEN 6 MG/0.5ML KIT 2 QL Central Nervous Systems Agents
IMITREX STATDOSE REFILL 4 MG/0.5ML KIT 2 QL Central Nervous Systems Agents
IMITREX STATDOSE REFILL 6 MG/0.5ML KIT 2 QL Central Nervous Systems Agents
IMMUNE GLOBULIN 0 INJECTION 4 PA Serums, Toxoids, And Vaccines
IMOVAX RABIES (H.D.C.V.) 2.5 UNIT/ML INJECTION 2 Serums, Toxoids, And Vaccines
IMURAN 50 MG TABLET 3 Miscellaneous Therapeutic Agents
INCRELEX 40 MG/4ML SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
INDAPAMIDE 1.25 MG TABLET 1 Electrolytic, Caloric, And Water Balance
INDAPAMIDE 2.5 MG TABLET 1 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 83
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
INDERAL 60 MG TABLET 3 Cardiovascular Drugs
INDERAL LA 120 MG CAPSULES 3 PA Cardiovascular Drugs
INDERAL LA 160 MG CAPSULES 3 PA Cardiovascular Drugs
INDERAL LA 60 MG CAPSULES 3 PA Cardiovascular Drugs
INDERAL LA 80 MG CAPSULES 3 PA Cardiovascular Drugs
INDERIDE 40/25 25 MG;40 MG TABLET 3 Cardiovascular Drugs
INDOCIN 25 MG/5ML SUSPENSION 3 Central Nervous Systems Agents
INDOCIN SR 75 MG CAPSULES 3 Central Nervous Systems Agents
INDOMETHACIN 25 MG CAPSULES 1 Central Nervous Systems Agents
INDOMETHACIN 50 MG CAPSULES 1 Central Nervous Systems Agents
INDOMETHACIN ER 75 MG CAPSULES 1 Central Nervous Systems Agents
INFANRIX 58 MCG/0.5ML;25 LFU/0.5ML;10LFU/0.5ML SUSPENSION
3 Serums, Toxoids, And Vaccines
INFERGEN 15 MCG/0.5ML INJECTION 4 QL, PA Anti-Infective Agents
INFERGEN 9 MCG/0.3ML INJECTION 4 QL, PA Anti-Infective Agents
INFUMORPH 200 10 MG/ML SOLUTION 3 Central Nervous Systems Agents
INFUMORPH 500 25 MG/ML SOLUTION 3 Central Nervous Systems Agents
INNOHEP 20000 UNIT/ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
INNOPRAN XL 120 MG CAPSULES 2 Cardiovascular Drugs
INNOPRAN XL 80 MG CAPSULES 2 Cardiovascular Drugs
INPERSOL-LM/1.5% DEXTROSE 3.5 MEQ/L;99MEQ/L;1.5 %;35 MEQ/L;1.15 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
INPERSOL-LM/2.5% DEXTROSE 3.5 MEQ/L;99MEQ/L;2.5 %;35 MEQ/L;1.15 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
INPERSOL-LM/4.25% DEXTROS 3.5 MEQ/L;99MEQ/L;4.25 %;35 MEQ/L;1.15 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
INPERSOL/DEXTROSE 3.5 MEQ/L;99 MEQ/L;1.5 %;35MEQ/L;1.15 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
INPERSOL/DEXTROSE 3.5 MEQ/L;99 MEQ/L;2.5 %;35MEQ/L;1.15 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
INPERSOL/DEXTROSE 3.5 MEQ/L;99 MEQ/L;4.25 %;35MEQ/L;1.15 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
INSPRA 25 MG TABLET 3 Cardiovascular Drugs
INSPRA 50 MG TABLET 3 Cardiovascular Drugs
INTAL 20 MG/2ML NEBULIZER 3 Respiratory Tract Agents
INTAL INHALER 800 MCG/ACT AEROSOL SOLUTION 3 QL Respiratory Tract Agents
INTRALIPID 1.7 %;1.2 %;30 % EMULSION 3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
84 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
INTRALIPID 2.25 %;1.2 %;10 % EMULSION 3 Electrolytic, Caloric, And Water Balance
INTRALIPID 2.5 %;1.2 %;20 % EMULSION 3 Electrolytic, Caloric, And Water Balance
INTRALIPID 20% 2.25 %;1.2 %;20 % EMULSION 3 Electrolytic, Caloric, And Water Balance
INTRON-A 10 MU/0.2ML KIT 4 QL, PA Anti-Infective Agents
INTRON-A 10 MU/ML KIT 4 QL, PA Anti-Infective Agents
INTRON-A 3 MU/0.2ML KIT 4 QL, PA Anti-Infective Agents
INTRON-A 5 MU/0.2ML KIT 4 QL, PA Anti-Infective Agents
INTRON-A 10 MU/ML SOLUTION 4 QL, PA Anti-Infective Agents
INTRON-A 6000000 UNIT/ML SOLUTION 4 QL, PA Anti-Infective Agents
INTRON-A W/DILUENT 10 MU SOLUTION 4 QL, PA Anti-Infective Agents
INTRON-A W/DILUENT 18 MU SOLUTION 4 QL, PA Anti-Infective Agents
INTRON-A W/DILUENT 50 MU SOLUTION 4 QL, PA Anti-Infective Agents
INVANZ 1 GM SOLUTION 3 Anti-Infective Agents
INVEGA 3 MG TABLET 2 QL Central Nervous Systems Agents
INVEGA 6 MG TABLET 2 QL Central Nervous Systems Agents
INVEGA 9 MG TABLET 2 QL Central Nervous Systems Agents
INVERSINE 2.5 MG TABLET 3 Cardiovascular Drugs
INVIRASE 200 MG CAPSULES 2 Anti-Infective Agents
INVIRASE 500 MG TABLET 2 Anti-Infective Agents
IONOSOL-B/DEXTROSE 5% 49 MEQ/L;5 %;25MEQ/L;5 MEQ/L;13 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
IONOSOL-MB/DEXTROSE 5% 22 MEQ/L;5 %;23MEQ/L;3 MEQ/L;3 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
IONOSOL-T/DEXTROSE 5% 40 MEQ/L;5 %;20MEQ/L;15 MEQ/L;35 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
IOPIDINE 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
IOPIDINE 0.01 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
IPLEX 36 MG/0.6ML SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
IPOL INACTIVATED IPV 0 INJECTION 3 Serums, Toxoids, And Vaccines
IPRATROPIUM BROMIDE 0.0002 SOLUTION 1 Autonomic Drugs
IPRATROPIUM BROMIDE 0.0003 SOLUTION 1 QL Eye, Ear, Nose, And Throat (EENT)Preparations
IPRATROPIUM BROMIDE 0.0006 SOLUTION 1 QL Eye, Ear, Nose, And Throat (EENT)Preparations
IRESSA 250 MG TABLET 4 QL Antineoplastic Agents
ISMO 20 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 85
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ISMOTIC 100 GM/220ML SOLUTION 3 Electrolytic, Caloric, And Water Balance
ISOCHRON 40 MG TABLET 3 Cardiovascular Drugs
ISOLYTE-H/DEXTROSE 5% 17 MEQ/L;39 MEQ/L;5 %;3MEQ/L;13 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
ISOLYTE-M/DEXTROSE 5% 20 MEQ/L;44 MEQ/L;5%;15 MEQ/L;35 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
ISOLYTE-P/DEXTROSE 5% 23 MEQ/L;23 MEQ/L;5 %;3MEQ/L;3 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
ISOLYTE-S 27 MEQ/L;98 MEQ/L;23 MEQ/L;3 MEQ/L;5MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
ISOLYTE-S PH 7.4 27 MEQ/1000ML;98MEQ/1000ML;23 MEQ/1000ML;3 MEQ/1000ML;1MEQ/1000ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
ISOLYTE-S/DEXTROSE 5% 30 MEQ/L;98 MEQ/L;5%;23 MEQ/L;3 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
ISONARIF 150 MG;300 MG CAPSULES 1 Anti-Infective Agents
ISONIAZID 100 MG/ML SOLUTION 1 Anti-Infective Agents
ISONIAZID 50 MG/5ML SYRUP 1 Anti-Infective Agents
ISONIAZID 100 MG TABLET 1 Anti-Infective Agents
ISONIAZID 300 MG TABLET 1 Anti-Infective Agents
ISOPTIN SR 120 MG TABLET 3 Cardiovascular Drugs
ISOPTIN SR 180 MG TABLET 3 Cardiovascular Drugs
ISOPTIN SR 240 MG TABLET 3 Cardiovascular Drugs
ISORDIL TITRADOSE 40 MG TABLET 3 Cardiovascular Drugs
ISORDIL TITRADOSE 5 MG TABLET 3 Cardiovascular Drugs
ISOSORBIDE DINITRATE 2.5 MG SUBLINGUAL 1 Cardiovascular Drugs
ISOSORBIDE DINITRATE 5 MG SUBLINGUAL 1 Cardiovascular Drugs
ISOSORBIDE DINITRATE 10 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE DINITRATE 20 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE DINITRATE 30 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE DINITRATE 5 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE DINITRATE ER 40 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE MONONITRATE 10 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE MONONITRATE 20 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE MONONITRATE ER 120 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE MONONITRATE ER 30 MG TABLET 1 Cardiovascular Drugs
ISOSORBIDE MONONITRATE ER 60 MG TABLET 1 Cardiovascular Drugs
ISOTONIC GENTAMICIN 0.6 MG/ML;0.9 % SOLUTION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
86 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ISOTONIC GENTAMICIN 0.8 MG/ML;0.9 % SOLUTION 1 Anti-Infective Agents
ISOTONIC GENTAMICIN 1 MG/ML;0.9 % SOLUTION 1 Anti-Infective Agents
ISOTONIC GENTAMICIN 1.2 MG/ML;0.9 % SOLUTION 1 Anti-Infective Agents
ISOTONIC GENTAMICIN 1.6 MG/ML;0.9 % SOLUTION 1 Anti-Infective Agents
ISOVATE 0.0005 CREAM 3 Skin And Mucous Membrane Agents
ISRADIPINE 2.5 MG CAPSULES 1 Cardiovascular Drugs
ISRADIPINE 5 MG CAPSULES 1 Cardiovascular Drugs
ISTALOL 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ISUPREL 0.2 MG/ML SOLUTION 3 Autonomic Drugs
ITRACONAZOLE 0 -;0 -;0 -;0 -;100 MG CAPSULES 1 QL, PA Anti-Infective Agents
ITRACONAZOLE 100 MG CAPSULES 1 QL, PA Anti-Infective Agents
IVEEGAM EN 5 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
JANTOVEN 1 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANTOVEN 10 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANTOVEN 2 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANTOVEN 2.5 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANTOVEN 3 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANTOVEN 4 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANTOVEN 5 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANTOVEN 6 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANTOVEN 7.5 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
JANUMET 1000 MG;50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes
JANUMET 500 MG;50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes
JANUVIA 100 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes
JANUVIA 25 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes
JANUVIA 50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes
JE-VAX 0 SOLUTION 3 Serums, Toxoids, And Vaccines
JOLESSA 0.03 MG;0.15 MG TABLET 1 QL Hormones And Synthetic Substitutes
JOLIVETTE 0.35 MG TABLET 1 Hormones And Synthetic Substitutes
JUNEL 1.5/30 30 MCG;1.5 MG TABLET 1 Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 87
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
JUNEL 1/20 20 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
JUNEL FE 1.5/30 30 MCG;75 MG;1.5 MG TABLET 1 Hormones And Synthetic Substitutes
JUNEL FE 1/20 20 MCG;75 MG;1 MG TABLET 1 Hormones And Synthetic Substitutes
K-TABS 10 MEQ TABLET 3 Electrolytic, Caloric, And Water Balance
K-VESCENT 20 MEQ PACK 1 Electrolytic, Caloric, And Water Balance
KADIAN 100 MG CAPSULES 2 QL Central Nervous Systems Agents
KADIAN 20 MG CAPSULES 2 QL Central Nervous Systems Agents
KADIAN 200 MG CAPSULES 2 QL Central Nervous Systems Agents
KADIAN 30 MG CAPSULES 2 QL Central Nervous Systems Agents
KADIAN 50 MG CAPSULES 2 QL Central Nervous Systems Agents
KADIAN 60 MG CAPSULES 2 QL Central Nervous Systems Agents
KADIAN 80 MG CAPSULES 2 QL Central Nervous Systems Agents
KALETRA 133.3 MG;33.3 MG CAPSULES 2 Anti-Infective Agents
KALETRA 400 MG/5ML;100 MG/5ML SOLUTION 2 Anti-Infective Agents
KALETRA 200 MG;50 MG TABLET 2 Anti-Infective Agents
KANAMYCIN SULFATE 333 MG/ML SOLUTION 1 Anti-Infective Agents
KAON-CL-10 10 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
KARIVA 0 TABLET 1 Hormones And Synthetic Substitutes
KAYEXALATE 0 POWDER 3 Electrolytic, Caloric, And Water Balance
KCL 0.075%/D5W/NACL 0.2% 5 %;0.075 %;0.2 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.075%/D5W/NACL 0.225 5 %;0.075 %;0.225 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.075%/D5W/NACL 0.45% 5 %;0.075 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.15%/D10W/NACL 0.2% 10 %;0.15 %;0.2 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.15%/D5W/ NACL 0.3% 5 %;0.15 %;0.33 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.15%/D5W/LR 3 MEQ/L;149 MEQ/L;5 %;28MEQ/L;24 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.15%/D5W/NACL 0.2% 5 %;0.15 %;0.2 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.15%/D5W/NACL 0.225% 5 %;0.15 %;0.225 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.15%/D5W/NACL 0.45% 5 %;0.15 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
88 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
KCL 0.15%/D5W/NACL 0.9% 5 %;0.15 %;0.9 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.224%/D5W/NACL 0.2% 5 %;0.224 %;0.2 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.224%/D5W/NACL 0.225 5 %;0.224 %;0.225 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.224%/D5W/NACL 0.45% 5 %;0.224 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.3%/D5W/LR 3 MEQ/L;149 MEQ/L;5 %;28MEQ/L;44 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.3%/D5W/LR IV LAC RI 3 MEQ/L;149 MEQ/L;5%;28 MEQ/L;44 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.3%/D5W/NACL 0.2% 5 %;0.3 %;0.2 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.3%/D5W/NACL 0.225% 5 %;0.3 %;0.225 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.3%/D5W/NACL 0.45% 5 %;0.3 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KCL 0.3%/D5W/NACL 0.9% 5 %;0.3 %;0.9 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
KEFLEX 250 MG CAPSULES 3 Anti-Infective Agents
KEFLEX 500 MG CAPSULES 3 Anti-Infective Agents
KEFLEX 750 MG CAPSULES 3 Anti-Infective Agents
KEFLEX 125 MG/5ML SUSPENSION 3 Anti-Infective Agents
KEFLEX 250 MG/5ML SUSPENSION 3 Anti-Infective Agents
KELNOR 1/35 35 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
KEMADRIN 5 MG TABLET 3 Autonomic Drugs
KENALOG 0 AEROSOL SOLUTION 3 Skin And Mucous Membrane Agents
KENALOG 0.001 CREAM 3 Skin And Mucous Membrane Agents
KENALOG 0.005 CREAM 3 Skin And Mucous Membrane Agents
KENALOG 0.001 LOTION 3 Skin And Mucous Membrane Agents
KENALOG 0.001 OINTMENT 3 Skin And Mucous Membrane Agents
KENALOG-10 10 MG/ML SUSPENSION 3 Hormones And Synthetic Substitutes
KENALOG-40 40 MG/ML SUSPENSION 3 Hormones And Synthetic Substitutes
KEPIVANCE 6.25 MG SOLUTION 4 Skin And Mucous Membrane Agents
KEPPRA 100 MG/ML SOLUTION 2 QL Central Nervous Systems Agents
KEPPRA 500 MG/5ML SOLUTION 2 QL Central Nervous Systems Agents
KEPPRA 1000 MG TABLET 2 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 89
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
KEPPRA 250 MG TABLET 2 QL Central Nervous Systems Agents
KEPPRA 500 MG TABLET 2 QL Central Nervous Systems Agents
KEPPRA 750 MG TABLET 2 QL Central Nervous Systems Agents
KERLONE 10 MG TABLET 3 Cardiovascular Drugs
KERLONE 20 MG TABLET 3 Cardiovascular Drugs
KETEK 300 MG TABLET 3 Anti-Infective Agents
KETEK 400 MG TABLET 3 Anti-Infective Agents
KETEK PAK 400 MG TABLET 3 Anti-Infective Agents
KETOCONAZOLE 0.02 CREAM 1 Skin And Mucous Membrane Agents
KETOCONAZOLE 0.02 SHAMPOO 1 Skin And Mucous Membrane Agents
KETOCONAZOLE 200 MG TABLET 1 Anti-Infective Agents
KETOPROFEN 50 MG CAPSULES 1 Central Nervous Systems Agents
KETOPROFEN 75 MG CAPSULES 1 Central Nervous Systems Agents
KETOPROFEN ER 200 MG CAPSULES 1 Central Nervous Systems Agents
KETOROLAC TROMETHAMINE 15 MG/ML SOLUTION 1 Central Nervous Systems Agents
KETOROLAC TROMETHAMINE 30 MG/ML SOLUTION 1 Central Nervous Systems Agents
KETOROLAC TROMETHAMINE 30 MG/ML SOLUTION 1 Central Nervous Systems Agents
KETOROLAC TROMETHAMINE 10 MG TABLET 1 QL Central Nervous Systems Agents
KETOTIFEN FUMARATE 0.00025 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
KINERET 100 MG/0.67ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
KIONEX 0 POWDER 1 Electrolytic, Caloric, And Water Balance
KLARON 0.1 LOTION 3 Skin And Mucous Membrane Agents
KLOR-CON 10 10 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
KLOR-CON 8 8 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
KLOR-CON M10 10 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
KLOR-CON M15 15 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
KLOR-CON M20 20 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
KLOTRIX 10 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
KRISTALOSE 10 GM PACK 3 Electrolytic, Caloric, And Water Balance
KRISTALOSE 20 GM PACK 3 Electrolytic, Caloric, And Water Balance
KU-ZYME 15000 UNIT;1200 UNIT;15000 UNITCAPSULES
3 Gastrointestinal Drugs
KU-ZYME HP 30000 UNIT;8000 UNIT;30000 UNITCAPSULES
3 Gastrointestinal Drugs
KURIC 0.02 CREAM 1 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
90 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
KUTRASE 30000 UNIT;2400 UNIT;30000 UNITCAPSULES
3 Gastrointestinal Drugs
KYTRIL 0.1 MG/ML SOLUTION 4 Gastrointestinal Drugs
KYTRIL 1 MG/ML SOLUTION 4 Gastrointestinal Drugs
KYTRIL 2 MG/10ML SOLUTION 4 Gastrointestinal Drugs
KYTRIL 1 MG TABLET 4 QL Gastrointestinal Drugs
LABETALOL HCL 5 MG/ML SOLUTION 1 Cardiovascular Drugs
LABETALOL HCL 100 MG TABLET 1 Cardiovascular Drugs
LABETALOL HCL 200 MG TABLET 1 Cardiovascular Drugs
LABETALOL HCL 300 MG TABLET 1 Cardiovascular Drugs
LAC-HYDRIN 0.12 CREAM 3 Skin And Mucous Membrane Agents
LAC-HYDRIN 0.12 LOTION 3 Skin And Mucous Membrane Agents
LACCREAM 0.12 CREAM 1 Skin And Mucous Membrane Agents
LACLOTION 0.12 LOTION 1 Skin And Mucous Membrane Agents
LACRISERT 5 MG INSERT 2 Eye, Ear, Nose, And Throat (EENT)Preparations
LACTATED RINGER’S DEXTROS 2.7 MEQ/L;109MEQ/L;5 %;28 MEQ/L;4 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
LACTATED RINGER’S IRRIGAT 3 MEQ/L;109 MEQ/L;28MEQ/L;4 MEQ/L;130 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
LACTATED RINGER’S VIAFLEX 3 MEQ/L;109 MEQ/L;28MEQ/L;4 MEQ/L;130 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
LACTICARE-HC 0.01 LOTION 3 Skin And Mucous Membrane Agents
LACTICARE-HC 0.025 LOTION 3 Skin And Mucous Membrane Agents
LACTULOSE 0 SOLUTION 1 Electrolytic, Caloric, And Water Balance
LACTULOSE 10 GM/15ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
LAMICTAL 100 MG TABLET 2 QL Central Nervous Systems Agents
LAMICTAL 150 MG TABLET 2 QL Central Nervous Systems Agents
LAMICTAL 200 MG TABLET 2 QL Central Nervous Systems Agents
LAMICTAL 25 MG TABLET 2 QL Central Nervous Systems Agents
LAMICTAL CHEWABLE DISPERS 25 MG TABLET 2 QL Central Nervous Systems Agents
LAMICTAL CHEWABLE DISPERS 5 MG TABLET 2 QL Central Nervous Systems Agents
LAMICTAL STARTER/NOT TAKI 0 KIT 2 Central Nervous Systems Agents
LAMICTAL STARTER/TAKING C 0 KIT 2 Central Nervous Systems Agents
LAMICTAL STARTER/TAKING V 25 MG KIT 2 Central Nervous Systems Agents
LAMISIL 0.01 SOLUTION 3 PA Skin And Mucous Membrane Agents
LAMISIL 250 MG TABLET 3 QL, PA Anti-Infective Agents
LAMOTRIGINE CHEWABLE DISP 25 MG TABLET 1 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 91
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LAMOTRIGINE CHEWABLE DISP 5 MG TABLET 1 QL Central Nervous Systems Agents
LANOXICAPS 0.1 MG CAPSULES 3 Cardiovascular Drugs
LANOXICAPS 0.2 MG CAPSULES 3 Cardiovascular Drugs
LANOXIN 0.1 MG/ML SOLUTION 3 Cardiovascular Drugs
LANOXIN 0.25 MG/ML SOLUTION 3 Cardiovascular Drugs
LANOXIN 0.125 MG TABLET 3 Cardiovascular Drugs
LANOXIN 0.25 MG TABLET 3 Cardiovascular Drugs
LANTUS 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
LANTUS OPTICLIK 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
LAPASE 15000 UNIT;1200 UNIT;15000 UNITCAPSULES
1 Gastrointestinal Drugs
LARIAM 250 MG TABLET 3 Anti-Infective Agents
LASIX 20 MG TABLET 3 Electrolytic, Caloric, And Water Balance
LASIX 40 MG TABLET 3 Electrolytic, Caloric, And Water Balance
LASIX 80 MG TABLET 3 Electrolytic, Caloric, And Water Balance
LEENA 0 TABLET 1 Hormones And Synthetic Substitutes
LEFLUNOMIDE 10 MG TABLET 1 QL, PA Miscellaneous Therapeutic Agents
LEFLUNOMIDE 20 MG TABLET 1 QL, PA Miscellaneous Therapeutic Agents
LESCOL 20 MG CAPSULES 2 QL Cardiovascular Drugs
LESCOL 40 MG CAPSULES 2 QL Cardiovascular Drugs
LESCOL XL 80 MG TABLET 2 QL Cardiovascular Drugs
LESSINA-28 20 MCG;0.1 MG TABLET 1 Hormones And Synthetic Substitutes
LETAIRIS 10 MG TABLET 4 QL, PA Cardiovascular Drugs
LETAIRIS 5 MG TABLET 4 QL, PA Cardiovascular Drugs
LEUCOVORIN CALCIUM 10 MG/ML SOLUTION 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 100 MG SOLUTION 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 200 MG SOLUTION 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 350 MG SOLUTION 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 50 MG SOLUTION 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 500 MG SOLUTION 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 10 MG TABLET 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 15 MG TABLET 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 25 MG TABLET 1 Miscellaneous Therapeutic Agents
LEUCOVORIN CALCIUM 5 MG TABLET 1 Miscellaneous Therapeutic Agents
LEUKERAN 2 MG TABLET 2 Antineoplastic Agents
LEUKINE 250 MCG SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
92 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LEUKINE 500 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
LEUKINE 500 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
LEUPROLIDE ACETATE 1 MG/0.2ML KIT 4 QL, PA Antineoplastic Agents
LEUPROLIDE ACETATE 5 MG/ML KIT 3 QL, PA Antineoplastic Agents
LEUPROLIDE ACETATE 1 MG/0.2ML SOLUTION 4 QL, PA Antineoplastic Agents
LEUSTATIN 1 MG/ML SOLUTION 4 Antineoplastic Agents
LEVAQUIN 25 MG/ML SOLUTION 3 Anti-Infective Agents
LEVAQUIN 25 MG/ML SOLUTION 3 Anti-Infective Agents
LEVAQUIN 5 %;750 MG/150ML SOLUTION 3 Anti-Infective Agents
LEVAQUIN 250 MG TABLET 2 Anti-Infective Agents
LEVAQUIN 500 MG TABLET 2 Anti-Infective Agents
LEVAQUIN 750 MG TABLET 2 Anti-Infective Agents
LEVAQUIN LEVA-PAK 750 MG TABLET 2 Anti-Infective Agents
LEVAQUIN PREMIX 5 %;250 MG/50ML SOLUTION 3 Anti-Infective Agents
LEVATOL 20 MG TABLET 3 Cardiovascular Drugs
LEVEMIR 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
LEVEMIR FLEXPEN 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
LEVLITE-28 20 MCG;0.1 MG TABLET 1 Hormones And Synthetic Substitutes
LEVO DROMORAN 2 MG/ML SOLUTION 3 Central Nervous Systems Agents
LEVO-DROMORAN 2 MG TABLET 3 Central Nervous Systems Agents
LEVOBUNOLOL HCL 0.0025 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
LEVOBUNOLOL HCL 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
LEVOCARNITINE 1 GM/10ML SOLUTION 1 Miscellaneous Therapeutic Agents
LEVOCARNITINE 200 MG/ML SOLUTION 1 Miscellaneous Therapeutic Agents
LEVOCARNITINE 330 MG TABLET 1 Miscellaneous Therapeutic Agents
LEVORA 0.15/30-28 30 MCG;0.15 MG TABLET 1 Hormones And Synthetic Substitutes
LEVORPHANOL TARTRATE 2 MG TABLET 1 Central Nervous Systems Agents
LEVOTHROID 100 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 112 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 125 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 137 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 150 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 175 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 200 MCG TABLET 1 Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 93
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LEVOTHROID 25 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 300 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 50 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 75 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHROID 88 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 200 MCG SOLUTION 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 500 MCG SOLUTION 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 100 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 112 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 125 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 137 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 150 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 175 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 200 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 25 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 300 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 50 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 75 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOTHYROXINE SODIUM 88 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 100 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 112 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 125 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 137 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 150 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 175 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 200 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 25 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 50 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 75 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVOXYL 88 MCG TABLET 1 Hormones And Synthetic Substitutes
LEVULAN KERASTICK 0.2 SOLUTION 4 Skin And Mucous Membrane Agents
LEXAPRO 5 MG/5ML SOLUTION 2 QL Central Nervous Systems Agents
LEXAPRO 10 MG TABLET 2 QL Central Nervous Systems Agents
LEXAPRO 20 MG TABLET 2 QL Central Nervous Systems Agents
LEXAPRO 5 MG TABLET 2 QL Central Nervous Systems Agents
LEXIVA 700 MG TABLET 2 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
94 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LEXXEL 5 MG;5 MG TABLET 3 Cardiovascular Drugs
LIALDA 1.2 GM TABLET 3 QL Gastrointestinal Drugs
LIDEX 0.0005 CREAM 3 Skin And Mucous Membrane Agents
LIDEX 0.0005 GEL 3 Skin And Mucous Membrane Agents
LIDEX 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents
LIDEX 0.0005 SOLUTION 3 Skin And Mucous Membrane Agents
LIDEX-E 0.0005 CREAM 3 Skin And Mucous Membrane Agents
LIDOCAINE 0.05 OINTMENT 1 Skin And Mucous Membrane Agents
LIDOCAINE HCL 0.02 GEL 1 Eye, Ear, Nose, And Throat (EENT)Preparations
LIDOCAINE HCL 0.005 SOLUTION 1 Local Anesthetics
LIDOCAINE HCL 0.01 SOLUTION 1 Local Anesthetics
LIDOCAINE HCL 0.015 SOLUTION 1 Local Anesthetics
LIDOCAINE HCL 0.02 SOLUTION 1 Local Anesthetics
LIDOCAINE HCL 0.04 SOLUTION 1 Local Anesthetics
LIDOCAINE HCL 0.04 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
LIDOCAINE HCL 10 MG/ML SOLUTION 1 Cardiovascular Drugs
LIDOCAINE HCL 20 MG/ML SOLUTION 1 Cardiovascular Drugs
LIDOCAINE HCL JELLY 0.02 GEL 1 Eye, Ear, Nose, And Throat (EENT)Preparations
LIDOCAINE/PRILOCAINE 2.5 %;2.5 % CREAM 1 Skin And Mucous Membrane Agents
LIDODERM 0.05 PATCH 2 QL Skin And Mucous Membrane Agents
LIDOMAR VISCOUS 0.02 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
LIMBITROL 12.5 MG;5 MG TABLET 3 Central Nervous Systems Agents
LIMBITROL DS 25 MG;10 MG TABLET 3 Central Nervous Systems Agents
LINCOCIN 300 MG/ML SOLUTION 3 Anti-Infective Agents
LINDANE 0.01 LOTION 1 Skin And Mucous Membrane Agents
LINDANE 0.01 SHAMPOO 1 Skin And Mucous Membrane Agents
LIOTHYRONINE SODIUM 10 MCG/ML SOLUTION 1 Hormones And Synthetic Substitutes
LIPITOR 10 MG TABLET 2 QL Cardiovascular Drugs
LIPITOR 20 MG TABLET 2 QL Cardiovascular Drugs
LIPITOR 40 MG TABLET 2 QL Cardiovascular Drugs
LIPITOR 80 MG TABLET 2 QL Cardiovascular Drugs
LIPOSYN II 2.5 %;1.2 %;10 %;10 % EMULSION 1 Electrolytic, Caloric, And Water Balance
LIPOSYN II 2.5 %;1.2 %;5 %;5 % EMULSION 1 Electrolytic, Caloric, And Water Balance
LIPOSYN III 2.5 %;1.2 %;10 % EMULSION 1 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 95
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LIPOSYN III 2.5 %;1.2 %;20 % EMULSION 1 Electrolytic, Caloric, And Water Balance
LIPOSYN III 2.5 %;1.8 %;30 % EMULSION 1 Electrolytic, Caloric, And Water Balance
LIPRAM 4500 20000 UNIT;4500 UNIT;25000 UNITCAPSULES
1 Gastrointestinal Drugs
LIPRAM-PN10 30000 UNIT;10000 UNIT;30000 UNITCAPSULES
1 Gastrointestinal Drugs
LIPRAM-PN16 48000 UNIT;16000 UNIT;48000 UNITCAPSULES
1 Gastrointestinal Drugs
LIPRAM-PN20 56000 UNIT;20000 UNIT;44000 UNITCAPSULES
1 Gastrointestinal Drugs
LIPRAM-UL12 39000 UNIT;12000 UNIT;39000 UNITCAPSULES
1 Gastrointestinal Drugs
LIPRAM-UL18 58500 UNIT;18000 UNIT;58500 UNITCAPSULES
1 Gastrointestinal Drugs
LIPRAM-UL20 65000 UNIT;20000 UNIT;65000 UNITCAPSULES
1 Gastrointestinal Drugs
LISINOPRIL 10 MG TABLET 1 Cardiovascular Drugs
LISINOPRIL 2.5 MG TABLET 1 Cardiovascular Drugs
LISINOPRIL 20 MG TABLET 1 Cardiovascular Drugs
LISINOPRIL 30 MG TABLET 1 Cardiovascular Drugs
LISINOPRIL 40 MG TABLET 1 Cardiovascular Drugs
LISINOPRIL 5 MG TABLET 1 Cardiovascular Drugs
LISINOPRIL/HYDROCHLOROTHI 12.5 MG;10 MGTABLET
1 Cardiovascular Drugs
LISINOPRIL/HYDROCHLOROTHI 12.5 MG;20 MGTABLET
1 Cardiovascular Drugs
LISINOPRIL/HYDROCHLOROTHI 25 MG;20 MGTABLET
1 Cardiovascular Drugs
LITHIUM CARBONATE 150 MG CAPSULES 1 Central Nervous Systems Agents
LITHIUM CARBONATE 300 MG CAPSULES 1 Central Nervous Systems Agents
LITHIUM CARBONATE 600 MG CAPSULES 1 Central Nervous Systems Agents
LITHIUM CARBONATE 300 MG TABLET 1 Central Nervous Systems Agents
LITHIUM CARBONATE ER 300 MG TABLET 1 Central Nervous Systems Agents
LITHIUM CARBONATE ER 450 MG TABLET 1 Central Nervous Systems Agents
LITHIUM CITRATE 8 MEQ/5ML SYRUP 1 Central Nervous Systems Agents
LITHOBID 300 MG TABLET 3 Central Nervous Systems Agents
LITHOSTAT 250 MG TABLET 3 Electrolytic, Caloric, And Water Balance
LO/OVRAL-28 30 MCG;0.3 MG TABLET 3 Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
96 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LOCOID 0.001 CREAM 3 Skin And Mucous Membrane Agents
LOCOID 0.001 OINTMENT 3 Skin And Mucous Membrane Agents
LOCOID 0.001 SOLUTION 3 Skin And Mucous Membrane Agents
LOCOID LIPOCREAM 0.001 CREAM 3 Skin And Mucous Membrane Agents
LODOSYN 25 MG TABLET 3 Central Nervous Systems Agents
LOESTRIN 1.5/30-21 30 MCG;1.5 MG TABLET 3 Hormones And Synthetic Substitutes
LOESTRIN 1/20-21 20 MCG;1 MG TABLET 3 Hormones And Synthetic Substitutes
LOESTRIN 24 FE 20 MCG;75 MG;1 MG TABLET 3 Hormones And Synthetic Substitutes
LOESTRIN FE 1.5/30 30 MCG;75 MG;1.5 MG TABLET 3 Hormones And Synthetic Substitutes
LOESTRIN FE 1/20 20 MCG;75 MG;1 MG TABLET 3 Hormones And Synthetic Substitutes
LOFENE 0.025 MG;2.5 MG TABLET 1 Gastrointestinal Drugs
LOFIBRA 134 MG CAPSULES 3 QL Cardiovascular Drugs
LOFIBRA 200 MG CAPSULES 3 QL Cardiovascular Drugs
LOFIBRA 67 MG CAPSULES 3 QL Cardiovascular Drugs
LOFIBRA 160 MG TABLET 3 QL Cardiovascular Drugs
LOFIBRA 54 MG TABLET 3 QL Cardiovascular Drugs
LOKARA 0.0005 LOTION 1 Skin And Mucous Membrane Agents
LOMOTIL 0.025 MG/5ML;2.5 MG/5ML LIQUID 3 Gastrointestinal Drugs
LOMOTIL 0.025 MG;2.5 MG TABLET 3 Gastrointestinal Drugs
LONOX 0.025 MG;2.5 MG TABLET 1 Gastrointestinal Drugs
LOPERAMIDE HCL 2 MG CAPSULES 1 Gastrointestinal Drugs
LOPID 600 MG TABLET 3 QL Cardiovascular Drugs
LOPRESSOR 1 MG/ML SOLUTION 3 Cardiovascular Drugs
LOPRESSOR 100 MG TABLET 3 Cardiovascular Drugs
LOPRESSOR 50 MG TABLET 3 Cardiovascular Drugs
LOPRESSOR HCT 25 MG;100 MG TABLET 3 Cardiovascular Drugs
LOPRESSOR HCT 25 MG;50 MG TABLET 3 Cardiovascular Drugs
LOPRESSOR HCT 50 MG;100 MG TABLET 3 Cardiovascular Drugs
LOPROX 0.0077 CREAM 3 Skin And Mucous Membrane Agents
LOPROX 0.0077 GEL 3 Skin And Mucous Membrane Agents
LOPROX 0.0077 SUSPENSION 3 Skin And Mucous Membrane Agents
LOPROX SHAMPOO 0.01 SHAMPOO 3 Skin And Mucous Membrane Agents
LORCET 10/650 650 MG;10 MG TABLET 3 QL Central Nervous Systems Agents
LORCET PLUS 650 MG;7.5 MG TABLET 3 QL Central Nervous Systems Agents
LORTAB 500 MG/15ML;7.5 MG/15ML ELIXIR 3 Central Nervous Systems Agents
LORTAB 10 500 MG;10 MG TABLET 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 97
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LORTAB 2.5 500 MG;2.5 MG TABLET 3 QL Central Nervous Systems Agents
LORTAB 5 500 MG;5 MG TABLET 3 QL Central Nervous Systems Agents
LORTAB 7.5 500 MG;7.5 MG TABLET 3 QL Central Nervous Systems Agents
LOTEMAX 0.005 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
LOTENSIN 10 MG TABLET 3 Cardiovascular Drugs
LOTENSIN 20 MG TABLET 3 Cardiovascular Drugs
LOTENSIN 40 MG TABLET 3 Cardiovascular Drugs
LOTENSIN 5 MG TABLET 3 Cardiovascular Drugs
LOTENSIN HCT 10 MG;12.5 MG TABLET 3 Cardiovascular Drugs
LOTENSIN HCT 20 MG;12.5 MG TABLET 3 Cardiovascular Drugs
LOTENSIN HCT 20 MG;25 MG TABLET 3 Cardiovascular Drugs
LOTENSIN HCT 5 MG;6.25 MG TABLET 3 Cardiovascular Drugs
LOTREL 10 MG;20 MG CAPSULES 3 QL, PA Cardiovascular Drugs
LOTREL 10 MG;40 MG CAPSULES 2 QL Cardiovascular Drugs
LOTREL 2.5 MG;10 MG CAPSULES 3 QL, PA Cardiovascular Drugs
LOTREL 5 MG;10 MG CAPSULES 3 QL, PA Cardiovascular Drugs
LOTREL 5 MG;20 MG CAPSULES 3 QL, PA Cardiovascular Drugs
LOTREL 5 MG;40 MG CAPSULES 2 QL Cardiovascular Drugs
LOTRISONE 0.05 %;1 % CREAM 3 Skin And Mucous Membrane Agents
LOTRISONE 0.05 %;1 % LOTION 3 Skin And Mucous Membrane Agents
LOTRONEX 0.5 MG TABLET 3 QL Gastrointestinal Drugs
LOTRONEX 1 MG TABLET 3 QL Gastrointestinal Drugs
LOVASTATIN 10 MG TABLET 1 QL Cardiovascular Drugs
LOVASTATIN 20 MG TABLET 1 QL Cardiovascular Drugs
LOVASTATIN 40 MG TABLET 1 QL Cardiovascular Drugs
LOVAZA 375 MG;465 MG;1 GM CAPSULES 3 QL Cardiovascular Drugs
LOVENOX 100 MG/ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
LOVENOX 120 MG/0.8ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
LOVENOX 150 MG/ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
LOVENOX 30 MG/0.3ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
LOVENOX 300 MG/3ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
LOVENOX 40 MG/0.4ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
98 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LOVENOX 60 MG/0.6ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
LOVENOX 80 MG/0.8ML SOLUTION 3 QL Blood Formation, Coagulation, AndThrombosis
LOW-OGESTREL 30 MCG;0.3 MG TABLET 1 Hormones And Synthetic Substitutes
LOXAPINE SUCCINATE 10 MG CAPSULES 1 Central Nervous Systems Agents
LOXAPINE SUCCINATE 25 MG CAPSULES 1 Central Nervous Systems Agents
LOXAPINE SUCCINATE 5 MG CAPSULES 1 Central Nervous Systems Agents
LOXAPINE SUCCINATE 50 MG CAPSULES 1 Central Nervous Systems Agents
LOXITANE 10 MG CAPSULES 1 Central Nervous Systems Agents
LOXITANE 25 MG CAPSULES 1 Central Nervous Systems Agents
LOXITANE 5 MG CAPSULES 1 Central Nervous Systems Agents
LOXITANE 50 MG CAPSULES 1 Central Nervous Systems Agents
LUFYLLIN 200 MG TABLET 1 Smooth Muscle Relaxants
LUFYLLIN 400 MG TABLET 1 Smooth Muscle Relaxants
LUMIGAN 0.0003 SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT)Preparations
LUNESTA 1 MG TABLET 3 QL, ST Central Nervous Systems Agents
LUNESTA 2 MG TABLET 3 QL, ST Central Nervous Systems Agents
LUNESTA 3 MG TABLET 3 QL, ST Central Nervous Systems Agents
LUPRON 2 WEEK SUPPLY 5 MG/ML KIT 4 QL, PA Antineoplastic Agents
LUPRON 6-PACK 5 MG/ML SOLUTION 4 QL, PA Antineoplastic Agents
LUPRON DEPOT 11.25 MG KIT 3 QL, PA Antineoplastic Agents
LUPRON DEPOT 22.5 MG KIT 4 QL, PA Antineoplastic Agents
LUPRON DEPOT 3.75 MG KIT 3 QL, PA Antineoplastic Agents
LUPRON DEPOT 30 MG KIT 4 QL, PA Antineoplastic Agents
LUPRON DEPOT 7.5 MG KIT 4 QL, PA Antineoplastic Agents
LUPRON DEPOT-PED 11.25 MG KIT 4 QL, PA Antineoplastic Agents
LUPRON DEPOT-PED 15 MG KIT 4 QL, PA Antineoplastic Agents
LUPRON DEPOT-PED 7.5 MG KIT 4 QL, PA Antineoplastic Agents
LUTERA 20 MCG;0.1 MG TABLET 1 Hormones And Synthetic Substitutes
LUXIQ 0.0012 FOAM 3 Skin And Mucous Membrane Agents
LYBREL 20 MCG;90 MCG TABLET 3 Hormones And Synthetic Substitutes
LYNOX 300 MG;10 MG TABLET 3 QL Central Nervous Systems Agents
LYNOX 300 MG;2.5 MG TABLET 3 QL Central Nervous Systems Agents
LYNOX 300 MG;5 MG TABLET 3 QL Central Nervous Systems Agents
LYNOX 300 MG;7.5 MG TABLET 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 99
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
LYRICA 100 MG CAPSULES 3 QL Central Nervous Systems Agents
LYRICA 150 MG CAPSULES 3 QL Central Nervous Systems Agents
LYRICA 200 MG CAPSULES 3 QL Central Nervous Systems Agents
LYRICA 225 MG CAPSULES 3 QL Central Nervous Systems Agents
LYRICA 25 MG CAPSULES 3 QL Central Nervous Systems Agents
LYRICA 300 MG CAPSULES 3 QL Central Nervous Systems Agents
LYRICA 50 MG CAPSULES 3 QL Central Nervous Systems Agents
LYRICA 75 MG CAPSULES 3 QL Central Nervous Systems Agents
LYSODREN 500 MG TABLET 4 Antineoplastic Agents
M-M-R II W/DILUENT 1 DOSE 0 INJECTION 3 Serums, Toxoids, And Vaccines
M-M-R II W/DILUENT 10 DOS 0 INJECTION 3 Serums, Toxoids, And Vaccines
M-R-VAX II 0 INJECTION 3 Serums, Toxoids, And Vaccines
MACROBID 100 MG CAPSULES 3 Anti-Infective Agents
MACRODANTIN 100 MG CAPSULES 3 Anti-Infective Agents
MACRODANTIN 25 MG CAPSULES 3 Anti-Infective Agents
MACRODANTIN 50 MG CAPSULES 3 Anti-Infective Agents
MAGNESIUM SULFATE 0.5 SOLUTION 1 Central Nervous Systems Agents
MAGNESIUM SULFATE 40 MG/ML SOLUTION 1 Central Nervous Systems Agents
MAGNESIUM SULFATE 80 MG/ML SOLUTION 1 Central Nervous Systems Agents
MAGNESIUM SULFATE IN D5W 5 %;10 MG/MLSOLUTION
1 Central Nervous Systems Agents
MALARONE 250 MG;100 MG TABLET 2 QL Anti-Infective Agents
MALARONE 62.5 MG;25 MG TABLET 2 QL Anti-Infective Agents
MAPROTILINE HCL 25 MG TABLET 1 Central Nervous Systems Agents
MAPROTILINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
MAPROTILINE HCL 75 MG TABLET 1 Central Nervous Systems Agents
MARGESIC-H 500 MG;5 MG CAPSULES 1 QL Central Nervous Systems Agents
MARINOL 10 MG CAPSULES 3 Gastrointestinal Drugs
MARINOL 2.5 MG CAPSULES 3 Gastrointestinal Drugs
MARINOL 5 MG CAPSULES 3 Gastrointestinal Drugs
MARPLAN 10 MG TABLET 3 Central Nervous Systems Agents
MATULANE 50 MG CAPSULES 4 Antineoplastic Agents
MAVIK 1 MG TABLET 3 PA Cardiovascular Drugs
MAVIK 2 MG TABLET 3 PA Cardiovascular Drugs
MAVIK 4 MG TABLET 3 PA Cardiovascular Drugs
MAXALT 10 MG TABLET 3 QL Central Nervous Systems Agents
MAXALT 5 MG TABLET 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
100 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
MAXALT-MLT 10 MG TABLET 3 QL Central Nervous Systems Agents
MAXALT-MLT 5 MG TABLET 3 QL Central Nervous Systems Agents
MAXIDEX 0.001 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
MAXIDONE 750 MG;10 MG TABLET 3 QL Central Nervous Systems Agents
MAXIPIME 1 GM SOLUTION 3 Anti-Infective Agents
MAXIPIME 1 GM SOLUTION 3 Anti-Infective Agents
MAXIPIME 2 GM SOLUTION 3 Anti-Infective Agents
MAXIPIME 2 GM SOLUTION 3 Anti-Infective Agents
MAXIPIME 500 MG SOLUTION 3 Anti-Infective Agents
MAXITROL 0.1 %;5 MG/GM;10000 UNIT/GMOINTMENT
3 Eye, Ear, Nose, And Throat (EENT)Preparations
MAXITROL 0.1 %;5 MG/ML;10000 UNIT/MLSUSPENSION
3 Eye, Ear, Nose, And Throat (EENT)Preparations
MAXZIDE 50 MG;75 MG TABLET 3 Electrolytic, Caloric, And Water Balance
MAXZIDE-25 25 MG;37.5 MG TABLET 3 Electrolytic, Caloric, And Water Balance
MEBENDAZOLE 100 MG CHEWABLE 1 Anti-Infective Agents
MECLIZINE HCL 12.5 MG TABLET 1 Gastrointestinal Drugs
MECLIZINE HCL 25 MG TABLET 1 Gastrointestinal Drugs
MECLOFENAMATE SODIUM 100 MG CAPSULES 1 Central Nervous Systems Agents
MECLOFENAMATE SODIUM 50 MG CAPSULES 1 Central Nervous Systems Agents
MEDROL 16 MG TABLET 3 Hormones And Synthetic Substitutes
MEDROL 2 MG TABLET 3 Hormones And Synthetic Substitutes
MEDROL 32 MG TABLET 3 Hormones And Synthetic Substitutes
MEDROL 4 MG TABLET 3 Hormones And Synthetic Substitutes
MEDROL 8 MG TABLET 3 Hormones And Synthetic Substitutes
MEDROL DOSEPAK 4 MG TABLET 3 Hormones And Synthetic Substitutes
MEDROXYPROGESTERONE ACETA 150 MG/MLSUSPENSION
1 QL Hormones And Synthetic Substitutes
MEDROXYPROGESTERONE ACETA 10 MG TABLET 1 Hormones And Synthetic Substitutes
MEDROXYPROGESTERONE ACETA 2.5 MG TABLET 1 Hormones And Synthetic Substitutes
MEDROXYPROGESTERONE ACETA 5 MG TABLET 1 Hormones And Synthetic Substitutes
MEFLOQUINE HCL 250 MG TABLET 1 Anti-Infective Agents
MEFOXIN 1 GM SOLUTION 3 Anti-Infective Agents
MEFOXIN 10 GM SOLUTION 3 Anti-Infective Agents
MEFOXIN 2 GM SOLUTION 3 Anti-Infective Agents
MEFOXIN ADD-VANTAGE 1 GM SOLUTION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 101
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
MEFOXIN ADD-VANTAGE 2 GM SOLUTION 1 Anti-Infective Agents
MEFOXIN IN DEXTROSE 2.2% 2 GM/50ML;2.2 %SOLUTION
1 Anti-Infective Agents
MEFOXIN IN DEXTROSE 3.9% 1 GM/50ML;3.9 %SOLUTION
3 Anti-Infective Agents
MEGACE ES 625 MG/5ML SUSPENSION 3 ST Antineoplastic Agents
MEGACE ORAL 40 MG/ML SUSPENSION 3 ST Antineoplastic Agents
MEGESTROL ACETATE 40 MG/ML SUSPENSION 1 Antineoplastic Agents
MEGESTROL ACETATE 20 MG TABLET 1 Antineoplastic Agents
MEGESTROL ACETATE 40 MG TABLET 1 Antineoplastic Agents
MELOXICAM 7.5 MG/5ML SUSPENSION 1 QL Central Nervous Systems Agents
MELOXICAM 15 MG TABLET 1 QL Central Nervous Systems Agents
MELOXICAM 7.5 MG TABLET 1 QL Central Nervous Systems Agents
MENACTRA 0 INJECTION 3 Serums, Toxoids, And Vaccines
MENEST 0.3 MG TABLET 2 Hormones And Synthetic Substitutes
MENEST 0.625 MG TABLET 2 Hormones And Synthetic Substitutes
MENEST 1.25 MG TABLET 2 Hormones And Synthetic Substitutes
MENEST 2.5 MG TABLET 2 Hormones And Synthetic Substitutes
MENOMUNE-A/C/Y/W-135 0 INJECTION 3 Serums, Toxoids, And Vaccines
MENOSTAR 14 MCG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
MENTAX 0.01 CREAM 3 Skin And Mucous Membrane Agents
MEPERIDINE HCL 10 MG/ML SOLUTION 1 Central Nervous Systems Agents
MEPERIDINE HCL 100 MG/ML SOLUTION 1 Central Nervous Systems Agents
MEPERIDINE HCL 25 MG/ML SOLUTION 1 Central Nervous Systems Agents
MEPERIDINE HCL 50 MG/5ML SOLUTION 1 Central Nervous Systems Agents
MEPERIDINE HCL 50 MG/ML SOLUTION 1 Central Nervous Systems Agents
MEPERIDINE HCL 75 MG/ML SOLUTION 1 Central Nervous Systems Agents
MEPERIDINE HCL 100 MG TABLET 1 Central Nervous Systems Agents
MEPERIDINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
MEPERITAB 100 MG TABLET 1 Central Nervous Systems Agents
MEPERITAB 50 MG TABLET 1 Central Nervous Systems Agents
MEPROBAMATE 200 MG TABLET 1 Central Nervous Systems Agents
MEPROBAMATE 400 MG TABLET 1 Central Nervous Systems Agents
MEPRON 750 MG/5ML SUSPENSION 4 QL Anti-Infective Agents
MERCAPTOPURINE 50 MG TABLET 1 Antineoplastic Agents
MERREM 1 GM SOLUTION 4 Anti-Infective Agents
MERREM 500 MG SOLUTION 4 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
102 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
MERUVAX II W/DILUENT 1 DO 0 INJECTION 3 Serums, Toxoids, And Vaccines
MERUVAX II W/DILUENT 10 D 0 INJECTION 3 Serums, Toxoids, And Vaccines
MESALAMINE 4 GM ENEMA 1 Gastrointestinal Drugs
MESNA 100 MG/ML SOLUTION 4 Miscellaneous Therapeutic Agents
MESNEX 100 MG/ML SOLUTION 4 Miscellaneous Therapeutic Agents
MESNEX 400 MG TABLET 4 Miscellaneous Therapeutic Agents
MESTINON 60 MG/5ML SYRUP 3 Autonomic Drugs
MESTINON 60 MG TABLET 3 Autonomic Drugs
MESTINON TIMESPAN 180 MG TABLET 3 Autonomic Drugs
METADATE CD 0 -;20 MG CAPSULES 3 QL Central Nervous Systems Agents
METADATE CD 0 -;30 MG CAPSULES 3 QL Central Nervous Systems Agents
METADATE CD 10 MG CAPSULES 3 QL Central Nervous Systems Agents
METADATE CD 40 MG CAPSULES 3 QL Central Nervous Systems Agents
METADATE CD 50 MG CAPSULES 3 QL Central Nervous Systems Agents
METADATE CD 60 MG CAPSULES 3 QL Central Nervous Systems Agents
METADATE ER 10 MG TABLET 1 Central Nervous Systems Agents
METADATE ER 20 MG TABLET 1 Central Nervous Systems Agents
METAGLIP 2.5 MG;250 MG TABLET 3 Hormones And Synthetic Substitutes
METAGLIP 2.5 MG;500 MG TABLET 3 Hormones And Synthetic Substitutes
METAGLIP 5 MG;500 MG TABLET 3 Hormones And Synthetic Substitutes
METAPROTERENOL SULFATE 0.004 NEBULIZER 1 Autonomic Drugs
METAPROTERENOL SULFATE 0.006 NEBULIZER 1 Autonomic Drugs
METAPROTERENOL SULFATE 10 MG/5ML SYRUP 1 Autonomic Drugs
METAPROTERENOL SULFATE 10 MG TABLET 1 Autonomic Drugs
METAPROTERENOL SULFATE 20 MG TABLET 1 Autonomic Drugs
METFORMIN HCL 1000 MG TABLET 1 Hormones And Synthetic Substitutes
METFORMIN HCL 500 MG TABLET 1 Hormones And Synthetic Substitutes
METFORMIN HCL 850 MG TABLET 1 Hormones And Synthetic Substitutes
METFORMIN HCL ER 500 MG TABLET 1 QL Hormones And Synthetic Substitutes
METFORMIN HCL ER 750 MG TABLET 1 QL Hormones And Synthetic Substitutes
METHADONE HCL 10 MG/ML CONCENTRATION 1 Central Nervous Systems Agents
METHADONE HCL 10 MG/5ML SOLUTION 1 Central Nervous Systems Agents
METHADONE HCL 10 MG/ML SOLUTION 1 Central Nervous Systems Agents
METHADONE HCL 5 MG/5ML SOLUTION 1 Central Nervous Systems Agents
METHADONE HCL 10 MG TABLET 1 Central Nervous Systems Agents
METHADONE HCL 5 MG TABLET 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 103
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
METHADOSE 10 MG TABLET 1 Central Nervous Systems Agents
METHADOSE 5 MG TABLET 1 Central Nervous Systems Agents
METHAZOLAMIDE 25 MG TABLET 1 Eye, Ear, Nose, And Throat (EENT)Preparations
METHAZOLAMIDE 50 MG TABLET 1 Eye, Ear, Nose, And Throat (EENT)Preparations
METHENAMINE HIPPURATE 1 GM TABLET 1 Anti-Infective Agents
METHERGINE 0.2 MG/ML SOLUTION 3 Oxytocics
METHERGINE 0.2 MG TABLET 3 Oxytocics
METHIMAZOLE 10 MG TABLET 1 Hormones And Synthetic Substitutes
METHIMAZOLE 5 MG TABLET 1 Hormones And Synthetic Substitutes
METHITEST 10 MG TABLET 3 Hormones And Synthetic Substitutes
METHOCARBAMOL 500 MG TABLET 1 Autonomic Drugs
METHOCARBAMOL 750 MG TABLET 1 Autonomic Drugs
METHOTREXATE 2.5 MG TABLET 1 Antineoplastic Agents
METHOTREXATE SODIUM 1 GM SOLUTION 1 Antineoplastic Agents
METHOTREXATE SODIUM 25 MG/ML SOLUTION 1 Antineoplastic Agents
METHSCOPOLAMINE BROMIDE 2.5 MG TABLET 1 Autonomic Drugs
METHSCOPOLAMINE BROMIDE 5 MG TABLET 1 Autonomic Drugs
METHYCLOTHIAZIDE 5 MG TABLET 1 Electrolytic, Caloric, And Water Balance
METHYLDOPA 250 MG TABLET 1 Cardiovascular Drugs
METHYLDOPA 500 MG TABLET 1 Cardiovascular Drugs
METHYLDOPA/HYDROCHLOROTHI 15 MG;250 MGTABLET
1 Cardiovascular Drugs
METHYLDOPA/HYDROCHLOROTHI 25 MG;250 MGTABLET
1 Cardiovascular Drugs
METHYLDOPATE HCL 250 MG/5ML SOLUTION 1 Cardiovascular Drugs
METHYLIN 10 MG CHEWABLE 1 Central Nervous Systems Agents
METHYLIN 2.5 MG CHEWABLE 1 Central Nervous Systems Agents
METHYLIN 5 MG CHEWABLE 1 Central Nervous Systems Agents
METHYLIN 10 MG/5ML SOLUTION 1 Central Nervous Systems Agents
METHYLIN 5 MG/5ML SOLUTION 1 Central Nervous Systems Agents
METHYLIN 10 MG TABLET 1 Central Nervous Systems Agents
METHYLIN 20 MG TABLET 1 Central Nervous Systems Agents
METHYLIN 5 MG TABLET 1 Central Nervous Systems Agents
METHYLIN ER 10 MG TABLET 1 Central Nervous Systems Agents
METHYLIN ER 20 MG TABLET 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
104 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
METHYLPHENIDATE HCL 10 MG TABLET 1 Central Nervous Systems Agents
METHYLPHENIDATE HCL 20 MG TABLET 1 Central Nervous Systems Agents
METHYLPHENIDATE HCL 20 MG TABLET 1 Central Nervous Systems Agents
METHYLPHENIDATE HCL 5 MG TABLET 1 Central Nervous Systems Agents
METHYLPHENIDATE HCL ER 20 MG TABLET 1 Central Nervous Systems Agents
METHYLPREDNISOLONE 4 MG TABLET 1 Hormones And Synthetic Substitutes
METHYLPREDNISOLONE 8 MG TABLET 1 Hormones And Synthetic Substitutes
METHYLPREDNISOLONE ACETAT 40 MG/MLSUSPENSION
1 Hormones And Synthetic Substitutes
METHYLPREDNISOLONE ACETAT 80 MG/MLSUSPENSION
1 Hormones And Synthetic Substitutes
METHYLPREDNISOLONE SODIUM 1000 MGSOLUTION
1 Hormones And Synthetic Substitutes
METHYLPREDNISOLONE SODIUM 125 MG SOLUTION 1 Hormones And Synthetic Substitutes
METHYLPREDNISOLONE SODIUM 40 MG SOLUTION 1 Hormones And Synthetic Substitutes
METIPRANOLOL 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
METOCLOPRAMIDE HCL 5 MG/ML SOLUTION 1 Gastrointestinal Drugs
METOCLOPRAMIDE HCL 5 MG/5ML SYRUP 1 Gastrointestinal Drugs
METOCLOPRAMIDE HCL 10 MG TABLET 1 Gastrointestinal Drugs
METOCLOPRAMIDE HCL 5 MG TABLET 1 Gastrointestinal Drugs
METOLAZONE 10 MG TABLET 1 Electrolytic, Caloric, And Water Balance
METOLAZONE 2.5 MG TABLET 1 Electrolytic, Caloric, And Water Balance
METOLAZONE 5 MG TABLET 1 Electrolytic, Caloric, And Water Balance
METOPROLOL SUCCINATE ER 25 MG TABLET 1 QL Cardiovascular Drugs
METOPROLOL TARTRATE 1 MG/ML SOLUTION 1 Cardiovascular Drugs
METOPROLOL TARTRATE 100 MG TABLET 1 Cardiovascular Drugs
METOPROLOL TARTRATE 25 MG TABLET 1 Cardiovascular Drugs
METOPROLOL TARTRATE 50 MG TABLET 1 Cardiovascular Drugs
METOPROLOL/HYDROCHLOROTHI 25 MG;100 MGTABLET
1 Cardiovascular Drugs
METOPROLOL/HYDROCHLOROTHI 25 MG;50 MGTABLET
1 Cardiovascular Drugs
METOPROLOL/HYDROCHLOROTHI 50 MG;100 MGTABLET
1 Cardiovascular Drugs
METRO IV 500 MG/100ML;0.74 % SOLUTION 3 Anti-Infective Agents
METROCREAM 0.0075 CREAM 3 Skin And Mucous Membrane Agents
METROGEL 0.01 GEL 3 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 105
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
METROGEL VAGINAL 0.0075 GEL 3 Skin And Mucous Membrane Agents
METROLOTION 0.0075 LOTION 3 Skin And Mucous Membrane Agents
METRONIDAZOLE 375 MG CAPSULES 1 Anti-Infective Agents
METRONIDAZOLE 0.0075 CREAM 1 Skin And Mucous Membrane Agents
METRONIDAZOLE 0.0075 GEL 1 Skin And Mucous Membrane Agents
METRONIDAZOLE 0.0075 LOTION 1 Skin And Mucous Membrane Agents
METRONIDAZOLE 250 MG TABLET 1 Anti-Infective Agents
METRONIDAZOLE 500 MG TABLET 1 Anti-Infective Agents
METRONIDAZOLE IN NACL 0.7 5 MG/ML;0.79 %SOLUTION
1 Anti-Infective Agents
METRONIDAZOLE VAGINAL 0.0075 GEL 1 Skin And Mucous Membrane Agents
MEVACOR 10 MG TABLET 3 QL Cardiovascular Drugs
MEVACOR 20 MG TABLET 3 QL Cardiovascular Drugs
MEVACOR 40 MG TABLET 3 QL Cardiovascular Drugs
MEXILETINE HCL 150 MG CAPSULES 1 Cardiovascular Drugs
MEXILETINE HCL 200 MG CAPSULES 1 Cardiovascular Drugs
MEXILETINE HCL 250 MG CAPSULES 1 Cardiovascular Drugs
MIACALCIN 200 UNIT/ACT SOLUTION 2 QL Hormones And Synthetic Substitutes
MIACALCIN 200 UNIT/ML SOLUTION 3 QL Hormones And Synthetic Substitutes
MICARDIS 20 MG TABLET 3 QL Cardiovascular Drugs
MICARDIS 40 MG TABLET 3 QL Cardiovascular Drugs
MICARDIS 80 MG TABLET 3 QL Cardiovascular Drugs
MICARDIS HCT 12.5 MG;40 MG TABLET 3 QL Cardiovascular Drugs
MICARDIS HCT 12.5 MG;80 MG TABLET 3 QL Cardiovascular Drugs
MICARDIS HCT 25 MG;80 MG TABLET 3 QL Cardiovascular Drugs
MICONAZOLE 3 200 MG SUPPOSITORY 1 Skin And Mucous Membrane Agents
MICRO-K 10 MEQ CAPSULES 3 Electrolytic, Caloric, And Water Balance
MICRO-K 8 MEQ CAPSULES 3 Electrolytic, Caloric, And Water Balance
MICROGESTIN 1.5/30 30 MCG;1.5 MG TABLET 1 Hormones And Synthetic Substitutes
MICROGESTIN 1/20 20 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
MICROGESTIN FE 20 MCG;75 MG;1 MG TABLET 1 Hormones And Synthetic Substitutes
MICROGESTIN FE 1.5/30 30 MCG;75 MG;1.5 MGTABLET
1 Hormones And Synthetic Substitutes
MICRONASE 1.25 MG TABLET 3 Hormones And Synthetic Substitutes
MICRONASE 2.5 MG TABLET 3 Hormones And Synthetic Substitutes
MICRONASE 5 MG TABLET 3 Hormones And Synthetic Substitutes
MICROZIDE 12.5 MG CAPSULES 3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
106 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
MIDODRINE HCL 10 MG TABLET 1 Autonomic Drugs
MIDODRINE HCL 2.5 MG TABLET 1 Autonomic Drugs
MIDODRINE HCL 5 MG TABLET 1 Autonomic Drugs
MIGERGOT 100 MG;2 MG SUPPOSITORY 1 Autonomic Drugs
MIGRANAL 4 MG/ML SOLUTION 3 QL Autonomic Drugs
MINIPRESS 1 MG CAPSULES 3 Cardiovascular Drugs
MINIPRESS 2 MG CAPSULES 3 Cardiovascular Drugs
MINIPRESS 5 MG CAPSULES 3 Cardiovascular Drugs
MINIRIN 0.1 MG/ML SOLUTION 3 Hormones And Synthetic Substitutes
MINITRAN 0.1 MG/HR PATCH 2 QL Cardiovascular Drugs
MINITRAN 0.2 MG/HR PATCH 2 QL Cardiovascular Drugs
MINITRAN 0.4 MG/HR PATCH 2 QL Cardiovascular Drugs
MINITRAN 0.6 MG/HR PATCH 2 QL Cardiovascular Drugs
MINOCIN 100 MG CAPSULES 3 Anti-Infective Agents
MINOCIN 50 MG CAPSULES 3 Anti-Infective Agents
MINOCIN PAC 0 KIT 3 Anti-Infective Agents
MINOCYCLINE HCL 100 MG CAPSULES 1 Anti-Infective Agents
MINOCYCLINE HCL 50 MG CAPSULES 1 Anti-Infective Agents
MINOCYCLINE HCL 75 MG CAPSULES 1 Anti-Infective Agents
MINOCYCLINE HCL 100 MG TABLET 1 Anti-Infective Agents
MINOCYCLINE HCL 50 MG TABLET 1 Anti-Infective Agents
MINOCYCLINE HCL 75 MG TABLET 1 Anti-Infective Agents
MINOXIDIL 10 MG TABLET 1 Cardiovascular Drugs
MINOXIDIL 2.5 MG TABLET 1 Cardiovascular Drugs
MINTEZOL 500 MG CHEWABLE 3 Anti-Infective Agents
MINTEZOL 500 MG/5ML SUSPENSION 3 Anti-Infective Agents
MIOSTAT 0.0001 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
MIRAPEX 0.125 MG TABLET 2 Central Nervous Systems Agents
MIRAPEX 0.25 MG TABLET 2 Central Nervous Systems Agents
MIRAPEX 0.5 MG TABLET 2 Central Nervous Systems Agents
MIRAPEX 1 MG TABLET 2 Central Nervous Systems Agents
MIRAPEX 1.5 MG TABLET 2 Central Nervous Systems Agents
MIRTAZAPINE 15 MG TABLET 1 Central Nervous Systems Agents
MIRTAZAPINE 15 MG TABLET 1 Central Nervous Systems Agents
MIRTAZAPINE 30 MG TABLET 1 Central Nervous Systems Agents
MIRTAZAPINE 30 MG TABLET 1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 107
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
MIRTAZAPINE 45 MG TABLET 1 Central Nervous Systems Agents
MIRTAZAPINE 45 MG TABLET 1 Central Nervous Systems Agents
MIRTAZAPINE 7.5 MG TABLET 1 Central Nervous Systems Agents
MISOPROSTOL 100 MCG TABLET 1 Gastrointestinal Drugs
MISOPROSTOL 200 MCG TABLET 1 Gastrointestinal Drugs
MITOMYCIN 20 MG SOLUTION 3 Antineoplastic Agents
MITOMYCIN 40 MG SOLUTION 3 Antineoplastic Agents
MITOMYCIN 5 MG SOLUTION 3 Antineoplastic Agents
MITOXANTRONE HCL 2 MG/ML CONCENTRATION 4 Antineoplastic Agents
MOBAN 10 MG TABLET 3 Central Nervous Systems Agents
MOBAN 25 MG TABLET 3 Central Nervous Systems Agents
MOBAN 5 MG TABLET 3 Central Nervous Systems Agents
MOBAN 50 MG TABLET 3 Central Nervous Systems Agents
MOBIC 7.5 MG/5ML SUSPENSION 3 QL, PA, ST Central Nervous Systems Agents
MOBIC 15 MG TABLET 3 QL, PA, ST Central Nervous Systems Agents
MOBIC 7.5 MG TABLET 3 QL, PA, ST Central Nervous Systems Agents
MODICON-28 35 MCG;0.5 MG TABLET 3 Hormones And Synthetic Substitutes
MOEXIPRIL HCL 15 MG TABLET 1 Cardiovascular Drugs
MOEXIPRIL HCL 7.5 MG TABLET 1 Cardiovascular Drugs
MOEXIPRIL/HYDROCHLOROTHIA 12.5 MG;15 MGTABLET
1 Cardiovascular Drugs
MOEXIPRIL/HYDROCHLOROTHIA 12.5 MG;7.5 MGTABLET
1 Cardiovascular Drugs
MOEXIPRIL/HYDROCHLOROTHIA 25 MG;15 MGTABLET
1 Cardiovascular Drugs
MOMETASONE FUROATE 0.001 CREAM 1 Skin And Mucous Membrane Agents
MOMETASONE FUROATE 0.001 OINTMENT 1 Skin And Mucous Membrane Agents
MOMETASONE FUROATE 0.001 SOLUTION 1 Skin And Mucous Membrane Agents
MONISTAT 7 COMBINATION PA 0 KIT 3 Skin And Mucous Membrane Agents
MONODOX 100 MG CAPSULES 3 Anti-Infective Agents
MONODOX 50 MG CAPSULES 3 Anti-Infective Agents
MONOKET 10 MG TABLET 3 Cardiovascular Drugs
MONOKET 20 MG TABLET 3 Cardiovascular Drugs
MONONESSA 35 MCG;0.25 MG TABLET 1 Hormones And Synthetic Substitutes
MONOPRIL 10 MG TABLET 3 Cardiovascular Drugs
MONOPRIL 20 MG TABLET 3 Cardiovascular Drugs
MONOPRIL 40 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
108 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
MONOPRIL HCT 10 MG;12.5 MG TABLET 3 Cardiovascular Drugs
MONOPRIL HCT 20 MG;12.5 MG TABLET 3 Cardiovascular Drugs
MONUROL 5.631 GM PACK 3 Anti-Infective Agents
MORPHINE SULFATE 0.5 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 1 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 1 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 10 MG/5ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 10 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 15 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 2 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 20 MG/10ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 20 MG/5ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 20 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 25 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 4 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 5 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 50 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 8 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE 10 MG SUPPOSITORY 1 Central Nervous Systems Agents
MORPHINE SULFATE 20 MG SUPPOSITORY 1 Central Nervous Systems Agents
MORPHINE SULFATE 30 MG SUPPOSITORY 1 Central Nervous Systems Agents
MORPHINE SULFATE 5 MG SUPPOSITORY 1 Central Nervous Systems Agents
MORPHINE SULFATE 15 MG TABLET 1 Central Nervous Systems Agents
MORPHINE SULFATE 30 MG TABLET 1 Central Nervous Systems Agents
MORPHINE SULFATE ADD-VANT 25 MG/MLSOLUTION
1 Central Nervous Systems Agents
MORPHINE SULFATE DILUTE-A 25 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE ER 100 MG TABLET 1 Central Nervous Systems Agents
MORPHINE SULFATE ER 15 MG TABLET 1 Central Nervous Systems Agents
MORPHINE SULFATE ER 200 MG TABLET 1 Central Nervous Systems Agents
MORPHINE SULFATE ER 30 MG TABLET 1 Central Nervous Systems Agents
MORPHINE SULFATE ER 60 MG TABLET 1 Central Nervous Systems Agents
MORPHINE SULFATE IN DEXTR 5 %;1 MG/MLSOLUTION
1 Central Nervous Systems Agents
MORPHINE SULFATE STICK-GA 1 MG/ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE SULFATE/D5W 5 %;100 MG/100MLSOLUTION
1 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 109
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
MORPHINE SULFATE/D5W 5 %;250 MG/250MLSOLUTION
1 Central Nervous Systems Agents
MORPHINE SULFATE/NS 10 MG/100ML;0.9 %SOLUTION
1 Central Nervous Systems Agents
MORPHINE SULFATE/NS 100 MG/100ML;0.9 %SOLUTION
1 Central Nervous Systems Agents
MORPHINE SULFATE/NS 250 MG/250ML;0.9 %SOLUTION
1 Central Nervous Systems Agents
MORPHINE SULFATE/NS 50 MG/50ML;0.9 %SOLUTION
1 Central Nervous Systems Agents
MORPHINE/D5W 5 %;100 MG/50ML SOLUTION 1 Central Nervous Systems Agents
MORPHINE/D5W 5 %;50 MG/25ML SOLUTION 1 Central Nervous Systems Agents
MOTOFEN 0.025 MG;1 MG TABLET 3 Gastrointestinal Drugs
MOTRIN 600 MG TABLET 3 Central Nervous Systems Agents
MOTRIN 800 MG TABLET 3 Central Nervous Systems Agents
MOVIPREP 4.7 GM;100 GM;1.015 GM;5.9 GM;2.691GM SOLUTION
3 Gastrointestinal Drugs
MS CONTIN 100 MG TABLET 3 Central Nervous Systems Agents
MS CONTIN 15 MG TABLET 3 Central Nervous Systems Agents
MS CONTIN 200 MG TABLET 3 Central Nervous Systems Agents
MS CONTIN 30 MG TABLET 3 Central Nervous Systems Agents
MS CONTIN 60 MG TABLET 3 Central Nervous Systems Agents
MST 600 600 MG TABLET 1 Central Nervous Systems Agents
MUCOMYST-10 0.1 SOLUTION 3 Respiratory Tract Agents
MUMPSVAX W/DILUENT 1 DOSE 0 INJECTION 3 Serums, Toxoids, And Vaccines
MUMPSVAX W/DILUENT 10 DOS 0 INJECTION 3 Serums, Toxoids, And Vaccines
MUPIROCIN 0.02 OINTMENT 1 Skin And Mucous Membrane Agents
MUSTARGEN 10 MG SOLUTION 3 Antineoplastic Agents
MUTAMYCIN 20 MG SOLUTION 4 Antineoplastic Agents
MUTAMYCIN 40 MG SOLUTION 4 Antineoplastic Agents
MUTAMYCIN 5 MG SOLUTION 4 Antineoplastic Agents
MYAMBUTOL 100 MG TABLET 3 Anti-Infective Agents
MYAMBUTOL 400 MG TABLET 3 Anti-Infective Agents
MYCAMINE 100 MG SOLUTION 4 Anti-Infective Agents
MYCAMINE 50 MG SOLUTION 4 Anti-Infective Agents
MYCELEX 10 MG TROCHE 3 Skin And Mucous Membrane Agents
MYCOBUTIN 150 MG CAPSULES 3 Anti-Infective Agents
MYCOSTATIN 100000 UNIT/GM CREAM 3 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
110 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
MYCOSTATIN 100000 UNIT/GM POWDER 3 Skin And Mucous Membrane Agents
MYDRAL 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
MYDRAL 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
MYDRIACYL 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
MYFORTIC 180 MG TABLET 3 Miscellaneous Therapeutic Agents
MYFORTIC 360 MG TABLET 3 Miscellaneous Therapeutic Agents
MYLOTARG 5 MG SOLUTION 4 Antineoplastic Agents
MYOBLOC 10000 UNIT/2ML SOLUTION 3 Miscellaneous Therapeutic Agents
MYOBLOC 2500 UNIT/0.5ML SOLUTION 3 Miscellaneous Therapeutic Agents
MYOBLOC 5000 UNIT/ML SOLUTION 3 Miscellaneous Therapeutic Agents
MYOZYME 50 MG SOLUTION 4 Enzymes
MYRAC 100 MG TABLET 1 Anti-Infective Agents
MYRAC 50 MG TABLET 1 Anti-Infective Agents
MYRAC 75 MG TABLET 1 Anti-Infective Agents
MYSOLINE 250 MG TABLET 3 Central Nervous Systems Agents
MYSOLINE 50 MG TABLET 3 Central Nervous Systems Agents
MYTELASE 10 MG TABLET 3 Autonomic Drugs
NABUMETONE 500 MG TABLET 1 Central Nervous Systems Agents
NABUMETONE 750 MG TABLET 1 Central Nervous Systems Agents
NADOLOL 160 MG TABLET 1 Cardiovascular Drugs
NADOLOL 20 MG TABLET 1 Cardiovascular Drugs
NADOLOL 40 MG TABLET 1 Cardiovascular Drugs
NADOLOL 80 MG TABLET 1 Cardiovascular Drugs
NAFCILLIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
NAFCILLIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
NAFCILLIN SODIUM 10 GM SOLUTION 1 Anti-Infective Agents
NAFCILLIN SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
NAFTIN 0.01 CREAM 3 Skin And Mucous Membrane Agents
NAFTIN 0.01 GEL 3 Skin And Mucous Membrane Agents
NAFTIN-MP 0.01 CREAM 3 Skin And Mucous Membrane Agents
NAGLAZYME 1 MG/ML SOLUTION 4 Enzymes
NALBUPHINE HCL 10 MG/ML SOLUTION 1 Central Nervous Systems Agents
NALBUPHINE HCL 20 MG/ML SOLUTION 1 Central Nervous Systems Agents
NALFON 200 MG CAPSULES 3 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 111
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
NALLPEN ISO-OSMOTIC IN DE 0 -;2 GM/100MLSOLUTION
3 Anti-Infective Agents
NALLPEN/DEXTROSE 0 -;1 GM/50ML SOLUTION 3 Anti-Infective Agents
NALLPEN/DEXTROSE 0 -;2 GM/50ML SOLUTION 3 Anti-Infective Agents
NALOXONE HCL 0.4 MG/ML SOLUTION 1 Central Nervous Systems Agents
NALOXONE HCL 1 MG/ML SOLUTION 1 Central Nervous Systems Agents
NALTREXONE HCL 50 MG TABLET 1 Central Nervous Systems Agents
NAMENDA 10 MG/5ML SOLUTION 2 QL Central Nervous Systems Agents
NAMENDA 10 MG TABLET 2 QL Central Nervous Systems Agents
NAMENDA 5 MG TABLET 2 QL Central Nervous Systems Agents
NAMENDA TITRATION PAK 0 TABLET 2 QL Central Nervous Systems Agents
NANDROLONE DECANOATE 200 MG/ML OIL 1 Hormones And Synthetic Substitutes
NAPHAZOLINE HCL 0.001 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
NAPRELAN 375 MG TABLET 3 Central Nervous Systems Agents
NAPRELAN 500 MG TABLET 3 Central Nervous Systems Agents
NAPROSYN 125 MG/5ML SUSPENSION 3 Central Nervous Systems Agents
NAPROSYN 250 MG TABLET 3 Central Nervous Systems Agents
NAPROSYN 375 MG TABLET 3 Central Nervous Systems Agents
NAPROSYN 500 MG TABLET 3 Central Nervous Systems Agents
NAPROXEN 125 MG/5ML SUSPENSION 1 Central Nervous Systems Agents
NAPROXEN 250 MG TABLET 1 Central Nervous Systems Agents
NAPROXEN 375 MG TABLET 1 Central Nervous Systems Agents
NAPROXEN 500 MG TABLET 1 Central Nervous Systems Agents
NAPROXEN DR 375 MG TABLET 1 Central Nervous Systems Agents
NAPROXEN DR 500 MG TABLET 1 Central Nervous Systems Agents
NAPROXEN SODIUM 275 MG TABLET 1 Central Nervous Systems Agents
NAPROXEN SODIUM 500 MG TABLET 1 Central Nervous Systems Agents
NAPROXEN SODIUM 550 MG TABLET 1 Central Nervous Systems Agents
NARCAN 0.4 MG/ML SOLUTION 3 Central Nervous Systems Agents
NARDIL 15 MG TABLET 2 Central Nervous Systems Agents
NARVOX 500 MG;10 MG TABLET 1 QL Central Nervous Systems Agents
NASACORT AQ 55 MCG/ACT AEROSOL SOLUTION 3 QL, ST Eye, Ear, Nose, And Throat (EENT)Preparations
NASAREL 29 MCG/ACT SOLUTION 3 QL, ST Eye, Ear, Nose, And Throat (EENT)Preparations
NASONEX 50 MCG/ACT SUSPENSION 2 QL Eye, Ear, Nose, And Throat (EENT)Preparations
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
112 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
NATACYN 0.05 SUSPENSION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
NAVANE 10 MG CAPSULES 3 Central Nervous Systems Agents
NAVANE 2 MG CAPSULES 3 Central Nervous Systems Agents
NAVANE 20 MG CAPSULES 3 Central Nervous Systems Agents
NAVANE 5 MG CAPSULES 3 Central Nervous Systems Agents
NAVELBINE 10 MG/ML SOLUTION 4 Antineoplastic Agents
NEBUPENT 300 MG SOLUTION 2 Anti-Infective Agents
NECON 0.5/35-28 35 MCG;0.5 MG TABLET 1 Hormones And Synthetic Substitutes
NECON 1/35-28 35 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
NECON 1/50-28 50 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
NECON 10/11-28 35 MCG;0 - TABLET 1 Hormones And Synthetic Substitutes
NECON 7/7/7 0 TABLET 1 Hormones And Synthetic Substitutes
NEFAZODONE HCL 100 MG TABLET 1 Central Nervous Systems Agents
NEFAZODONE HCL 150 MG TABLET 1 Central Nervous Systems Agents
NEFAZODONE HCL 200 MG TABLET 1 Central Nervous Systems Agents
NEFAZODONE HCL 250 MG TABLET 1 Central Nervous Systems Agents
NEFAZODONE HCL 50 MG TABLET 1 Central Nervous Systems Agents
NEO-FRADIN 25 MG/ML SOLUTION 1 Anti-Infective Agents
NEO/POLY/BAC/HC 400 UNIT/GM;1 %;0.5 %;10000UNIT/GM OINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOCIN 400 UNIT/GM;5 MG/GM;10000 UNIT/GMOINTMENT
3 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOCIN-PG 0.025 MG/ML;2.5 MG/ML;10000UNIT/ML SOLUTION
3 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN SULFATE 500 MG TABLET 1 Anti-Infective Agents
NEOMYCIN/BACITRACIN ZN/PO 400 UNIT/GM;5MG/GM;10000 UNIT/GM OINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN/BACITRACIN/POLYM 400 UNIT/GM;5MG/GM;10000 UNIT/GM OINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN/POLYMYXIN B SULF 40 MG/ML;200000UNIT/ML SOLUTION
1 Skin And Mucous Membrane Agents
NEOMYCIN/POLYMYXIN/DEXAME 0.1 %;0.35%;10000 UNIT/GM OINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN/POLYMYXIN/DEXAME 0.1 %;5MG/GM;10000 UNIT/GM OINTMENT
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN/POLYMYXIN/DEXAME 0.1 %;5MG/ML;10000 UNIT/ML SUSPENSION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 113
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
NEOMYCIN/POLYMYXIN/GRAMIC 0.025 MG/ML;2.5MG/ML;10000 UNIT/ML SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN/POLYMYXIN/HC 1 %;3.5 MG/ML;10000UNIT/ML SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN/POLYMYXIN/HYDROC 1 %;3.5MG/ML;10000 UNIT/ML SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN/POLYMYXIN/HYDROC 1 %;3.5MG/ML;10000 UNIT/ML SUSPENSION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEOMYCIN/POLYMYXIN/HYDROC 1 %;3.5MG/ML;10000 UNIT/ML SUSPENSION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEORAL 100 MG CAPSULES 3 Miscellaneous Therapeutic Agents
NEORAL 25 MG CAPSULES 3 Miscellaneous Therapeutic Agents
NEORAL 100 MG/ML SOLUTION 3 Miscellaneous Therapeutic Agents
NEOSPORIN 0.025 MG/ML;2.5 MG/ML;10000UNIT/ML SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
NEPHRAMINE 44 MEQ/L;20 MG/100ML;250MG/100ML;560 MG/100ML;880 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
NEULASTA 6 MG/0.6ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
NEUMEGA 5 MG SOLUTION 4 Miscellaneous Therapeutic Agents
NEUPOGEN 300 MCG/0.5ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
NEUPOGEN 300 MCG/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
NEUPOGEN 480 MCG/0.8ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
NEUPOGEN 480 MCG/1.6ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
NEURONTIN 100 MG CAPSULES 3 QL, PA Central Nervous Systems Agents
NEURONTIN 300 MG CAPSULES 3 QL, PA Central Nervous Systems Agents
NEURONTIN 400 MG CAPSULES 3 QL, PA Central Nervous Systems Agents
NEURONTIN 250 MG/5ML SOLUTION 3 Central Nervous Systems Agents
NEURONTIN 600 MG TABLET 3 QL, PA Central Nervous Systems Agents
NEURONTIN 800 MG TABLET 3 QL, PA Central Nervous Systems Agents
NEUTREXIN 200 MG SOLUTION 4 Anti-Infective Agents
NEUTREXIN 25 MG SOLUTION 4 Anti-Infective Agents
NEVANAC 0.001 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
NEXAVAR 200 MG TABLET 4 QL, PA Antineoplastic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
114 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
NEXIUM 20 MG CAPSULES 2 QL Gastrointestinal Drugs
NEXIUM 40 MG CAPSULES 2 QL Gastrointestinal Drugs
NEXIUM 20 MG PACK 2 QL Gastrointestinal Drugs
NEXIUM 40 MG PACK 2 QL Gastrointestinal Drugs
NEXIUM I.V. 20 MG SOLUTION 2 Gastrointestinal Drugs
NEXIUM I.V. 40 MG SOLUTION 2 Gastrointestinal Drugs
NIACOR 500 MG TABLET 1 Cardiovascular Drugs
NIASPAN 1000 MG TABLET 2 Cardiovascular Drugs
NIASPAN 500 MG TABLET 2 Cardiovascular Drugs
NIASPAN 750 MG TABLET 2 Cardiovascular Drugs
NICARDIPINE HCL 20 MG CAPSULES 1 Cardiovascular Drugs
NICARDIPINE HCL 30 MG CAPSULES 1 Cardiovascular Drugs
NICOTINE 14 MG/24HR PATCH 1 Autonomic Drugs
NICOTINE 21 MG/24HR PATCH 1 Autonomic Drugs
NICOTINE 7 MG/24HR PATCH 1 Autonomic Drugs
NICOTROL INHALER 10 MG INHALER 3 Autonomic Drugs
NICOTROL NS 10 MG/ML SOLUTION 3 Autonomic Drugs
NIFEDIAC CC 30 MG TABLET 1 QL Cardiovascular Drugs
NIFEDIAC CC 60 MG TABLET 1 QL Cardiovascular Drugs
NIFEDIAC CC 90 MG TABLET 1 QL Cardiovascular Drugs
NIFEDICAL XL 30 MG TABLET 1 QL Cardiovascular Drugs
NIFEDICAL XL 60 MG TABLET 1 QL Cardiovascular Drugs
NIFEDIPINE 10 MG CAPSULES 1 Cardiovascular Drugs
NIFEDIPINE 20 MG CAPSULES 1 Cardiovascular Drugs
NIFEDIPINE ER 30 MG TABLET 1 QL Cardiovascular Drugs
NIFEDIPINE ER 60 MG TABLET 1 QL Cardiovascular Drugs
NIFEDIPINE ER 90 MG TABLET 1 QL Cardiovascular Drugs
NILANDRON 150 MG TABLET 3 Antineoplastic Agents
NIMOTOP 30 MG CAPSULES 4 Cardiovascular Drugs
NIPENT 10 MG SOLUTION 4 Antineoplastic Agents
NITREK 0.2 MG/HR PATCH 1 Cardiovascular Drugs
NITREK 0.4 MG/HR PATCH 1 Cardiovascular Drugs
NITREK 0.6 MG/HR PATCH 1 Cardiovascular Drugs
NITRO-DUR 0.1 MG/HR PATCH 3 Cardiovascular Drugs
NITRO-DUR 0.2 MG/HR PATCH 3 Cardiovascular Drugs
NITRO-DUR 0.3 MG/HR PATCH 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 115
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
NITRO-DUR 0.4 MG/HR PATCH 3 Cardiovascular Drugs
NITRO-DUR 0.6 MG/HR PATCH 3 Cardiovascular Drugs
NITRO-DUR 0.8 MG/HR PATCH 3 Cardiovascular Drugs
NITRO-TIME 2.5 MG CAPSULES 1 Cardiovascular Drugs
NITRO-TIME 9 MG CAPSULES 1 Cardiovascular Drugs
NITROBID 0.02 OINTMENT 3 Cardiovascular Drugs
NITROFURANTOIN MACROCRYST 100 MG CAPSULES 1 Anti-Infective Agents
NITROFURANTOIN MACROCRYST 50 MG CAPSULES 1 Anti-Infective Agents
NITROFURANTOIN MONOHYDRAT 100 MGCAPSULES
1 Anti-Infective Agents
NITROGLYCERIN 0.2 MG/HR PATCH 1 Cardiovascular Drugs
NITROGLYCERIN 0.4 MG/HR PATCH 1 Cardiovascular Drugs
NITROGLYCERIN 0.6 MG/HR PATCH 1 Cardiovascular Drugs
NITROGLYCERIN 5 MG/ML SOLUTION 1 Cardiovascular Drugs
NITROGLYCERIN CR 9 MG CAPSULES 1 Cardiovascular Drugs
NITROGLYCERIN TD 9 MG CAPSULES 1 Cardiovascular Drugs
NITROGLYCERIN TRANSDERMAL 0.1 MG/HR PATCH 1 Cardiovascular Drugs
NITROGLYCERIN TRANSDERMAL 0.2 MG/HR PATCH 1 Cardiovascular Drugs
NITROGLYCERIN TRANSDERMAL 0.4 MG/HR PATCH 1 Cardiovascular Drugs
NITROGLYCERIN TRANSDERMAL 0.6 MG/HR PATCH 1 Cardiovascular Drugs
NITROLINGUAL PUMPSPRAY 0.4 MG/SPRAYSOLUTION
2 Cardiovascular Drugs
NITROSTAT 0.3 MG SUBLINGUAL 3 Cardiovascular Drugs
NITROSTAT 0.4 MG SUBLINGUAL 3 Cardiovascular Drugs
NITROSTAT 0.6 MG SUBLINGUAL 3 Cardiovascular Drugs
NIZATIDINE 150 MG CAPSULES 1 Gastrointestinal Drugs
NIZATIDINE 300 MG CAPSULES 1 Gastrointestinal Drugs
NIZORAL 0.02 SHAMPOO 3 Skin And Mucous Membrane Agents
NIZORAL 200 MG TABLET 3 Anti-Infective Agents
NOR-QD 0.35 MG TABLET 3 Hormones And Synthetic Substitutes
NORA-BE 0.35 MG TABLET 1 Hormones And Synthetic Substitutes
NORCO 325 MG;10 MG TABLET 3 QL Central Nervous Systems Agents
NORCO 325 MG;5 MG TABLET 3 QL Central Nervous Systems Agents
NORCO 325 MG;7.5 MG TABLET 3 QL Central Nervous Systems Agents
NORDETTE-28 30 MCG;0.15 MG TABLET 3 Hormones And Synthetic Substitutes
NORDITROPIN CARTRIDGE 15 MG/1.5ML SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
NORDITROPIN CARTRIDGE 5 MG/1.5ML SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
116 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
NORDITROPIN NORDIFLEX 10 MG/1.5ML SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
NORDITROPIN NORDIFLEX PEN 15 MG/1.5MLSOLUTION
4 QL, PA Hormones And Synthetic Substitutes
NORDITROPIN NORDIFLEX PEN 5 MG/1.5MLSOLUTION
4 QL, PA Hormones And Synthetic Substitutes
NORETHINDRONE ACETATE 5 MG TABLET 1 Hormones And Synthetic Substitutes
NORFLEX 30 MG/ML SOLUTION 3 Autonomic Drugs
NORINYL 1+35 35 MCG;1 MG TABLET 3 Hormones And Synthetic Substitutes
NORITATE 0.01 CREAM 3 Skin And Mucous Membrane Agents
NORMOSOL -R 27 MEQ/L;98 MEQ/L;23 MEQ/L;3MEQ/L;5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
NORMOSOL-M IN D5W 16 MEQ/L;40 MEQ/L;5 %;3MEQ/L;13 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
NORMOSOL-R 27 MEQ/L;98 MEQ/L;23 MEQ/L;3MEQ/L;5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
NORMOSOL-R IN D5W 27 MEQ/L;98 MEQ/L;5 %;23MEQ/L;3 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
NOROXIN 400 MG TABLET 3 Anti-Infective Agents
NORPACE 100 MG CAPSULES 3 Cardiovascular Drugs
NORPACE 150 MG CAPSULES 3 Cardiovascular Drugs
NORPACE CR 100 MG CAPSULES 3 Cardiovascular Drugs
NORPACE CR 150 MG CAPSULES 3 Cardiovascular Drugs
NORPRAMIN 10 MG TABLET 3 Central Nervous Systems Agents
NORPRAMIN 100 MG TABLET 3 Central Nervous Systems Agents
NORPRAMIN 150 MG TABLET 3 Central Nervous Systems Agents
NORPRAMIN 25 MG TABLET 3 Central Nervous Systems Agents
NORPRAMIN 50 MG TABLET 3 Central Nervous Systems Agents
NORPRAMIN 75 MG TABLET 3 Central Nervous Systems Agents
NORTREL 0.5/35 (28) 35 MCG;0.5 MG TABLET 1 Hormones And Synthetic Substitutes
NORTREL 1/35 (21) 35 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
NORTREL 1/35 (28) 35 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
NORTREL 7/7/7 0 TABLET 1 Hormones And Synthetic Substitutes
NORTRIPTYLINE HCL 10 MG CAPSULES 1 Central Nervous Systems Agents
NORTRIPTYLINE HCL 25 MG CAPSULES 1 Central Nervous Systems Agents
NORTRIPTYLINE HCL 50 MG CAPSULES 1 Central Nervous Systems Agents
NORTRIPTYLINE HCL 75 MG CAPSULES 1 Central Nervous Systems Agents
NORTRIPTYLINE HCL 10 MG/5ML SOLUTION 1 Central Nervous Systems Agents
NORVASC 10 MG TABLET 3 QL, PA Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 117
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
NORVASC 2.5 MG TABLET 3 QL, PA Cardiovascular Drugs
NORVASC 5 MG TABLET 3 QL, PA Cardiovascular Drugs
NORVIR 100 MG CAPSULES 2 Anti-Infective Agents
NORVIR 80 MG/ML SOLUTION 2 Anti-Infective Agents
NOVAMINE 151 MEQ/L;2170 MG/100ML;1470MG/100ML;434 MG/100ML;749 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
NOVANTRONE 2 MG/ML CONCENTRATION 4 Antineoplastic Agents
NOVOLIN 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes
NOVOLIN 70/30 INNOLET 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes
NOVOLIN 70/30 PENFILL 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes
NOVOLIN N 100 UNIT/ML SUSPENSION 2 Hormones And Synthetic Substitutes
NOVOLIN N INNOLET 100 UNIT/ML SUSPENSION 2 Hormones And Synthetic Substitutes
NOVOLIN N U-100 PENFILL 100 UNIT/MLSUSPENSION
2 Hormones And Synthetic Substitutes
NOVOLIN R 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
NOVOLIN R INNOLET 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
NOVOLIN R U-100 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
NOVOLIN R U-100 PENFILL 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
NOVOLOG 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
NOVOLOG FLEXPEN 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
NOVOLOG MIX 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes
NOVOLOG MIX 70/30 PENFILL 30 %;70 %SUSPENSION
2 Hormones And Synthetic Substitutes
NOVOLOG MIX 70/30 PREFILL 30 %;70 %SUSPENSION
2 Hormones And Synthetic Substitutes
NOVOLOG PENFILL 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
NOXAFIL 40 MG/ML SUSPENSION 4 PA Anti-Infective Agents
NUBAIN 10 MG/ML SOLUTION 3 Central Nervous Systems Agents
NUBAIN 20 MG/ML SOLUTION 3 Central Nervous Systems Agents
NULYTELY 420 GM;1.48 GM;5.72 GM;11.2 GMSOLUTION
3 Gastrointestinal Drugs
NUMORPHAN 1 MG/ML SOLUTION 3 Central Nervous Systems Agents
NUTROPIN 10 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
NUTROPIN 5 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
NUTROPIN AQ 10 MG/2ML SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
NUTROPIN AQ PEN 10 MG/2ML SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
NUVARING 0.015 MG/24HR;0.12 MG/24HR RING 3 QL Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
118 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
NYAMYC 100000 UNIT/GM POWDER 1 Skin And Mucous Membrane Agents
NYDRAZID 100 MG/ML SOLUTION 3 Anti-Infective Agents
NYSTATIN 100000 UNIT/GM CREAM 1 Skin And Mucous Membrane Agents
NYSTATIN 100000 UNIT/GM OINTMENT 1 Skin And Mucous Membrane Agents
NYSTATIN 100000 UNIT/GM POWDER 1 Skin And Mucous Membrane Agents
NYSTATIN 100000 UNIT/ML SUSPENSION 1 Anti-Infective Agents
NYSTATIN 100000 UNIT TABLET 1 Skin And Mucous Membrane Agents
NYSTATIN 500000 UNIT TABLET 1 Anti-Infective Agents
NYSTATIN/TRIAMCINOLONE 100000 UNIT/GM;0.1 %CREAM
1 Skin And Mucous Membrane Agents
NYSTATIN/TRIAMCINOLONE 100000 UNIT/GM;0.1 %OINTMENT
1 Skin And Mucous Membrane Agents
NYSTOP 100000 UNIT/GM POWDER 1 Skin And Mucous Membrane Agents
OCTAGAM 1 GM/20ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
OCTAGAM 10 GM/200ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
OCTAGAM 2.5 GM/50ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
OCTAGAM 5 GM/100ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
OCTREOTIDE ACETATE 0.05 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
OCTREOTIDE ACETATE 0.1 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
OCTREOTIDE ACETATE 0.2 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
OCTREOTIDE ACETATE 0.5 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
OCTREOTIDE ACETATE 1 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
OCUFEN 0.0003 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
OCUFLOX 0.003 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
OCUSULF-10 0.1 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
OFLOXACIN 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
OFLOXACIN 200 MG TABLET 1 Anti-Infective Agents
OFLOXACIN 300 MG TABLET 1 Anti-Infective Agents
OFLOXACIN 400 MG TABLET 1 Anti-Infective Agents
OGEN 0.75 MG TABLET 1 Hormones And Synthetic Substitutes
OGEN 1.5 MG TABLET 1 Hormones And Synthetic Substitutes
OGEN 3 MG TABLET 1 Hormones And Synthetic Substitutes
OGESTREL 50 MCG;0.5 MG TABLET 1 Hormones And Synthetic Substitutes
OLUX 0.0005 FOAM 3 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 119
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
OLUX-E 0.0005 FOAM 3 Skin And Mucous Membrane Agents
OMACOR 375 MG;465 MG;1 GM CAPSULES 3 QL Cardiovascular Drugs
OMEPRAZOLE 10 MG CAPSULES 1 QL Gastrointestinal Drugs
OMEPRAZOLE 20 MG CAPSULES 1 QL Gastrointestinal Drugs
OMNI-PAC 300 MG CAPSULES 2 Anti-Infective Agents
OMNICEF 300 MG CAPSULES 2 Anti-Infective Agents
OMNICEF 125 MG/5ML SUSPENSION 2 Anti-Infective Agents
OMNICEF 250 MG/5ML SUSPENSION 2 Anti-Infective Agents
ONCASPAR 750 UNIT/ML SOLUTION 4 Antineoplastic Agents
ONDANSETRON HCL 2 MG/ML SOLUTION 1 Gastrointestinal Drugs
ONDANSETRON HCL 32 MG/50ML SOLUTION 1 Gastrointestinal Drugs
ONDANSETRON HCL 4 MG/5ML SOLUTION 1 Gastrointestinal Drugs
ONDANSETRON HCL 24 MG TABLET 1 QL Gastrointestinal Drugs
ONDANSETRON HCL 4 MG TABLET 1 QL Gastrointestinal Drugs
ONDANSETRON HCL 8 MG TABLET 1 QL Gastrointestinal Drugs
ONDANSETRON ODT 4 MG TABLET 1 QL Gastrointestinal Drugs
ONDANSETRON ODT 8 MG TABLET 1 QL Gastrointestinal Drugs
ONTAK 150 MCG/ML SOLUTION 4 Antineoplastic Agents
ONXOL 6 MG/ML CONCENTRATION 4 Antineoplastic Agents
OPANA 10 MG TABLET 3 Central Nervous Systems Agents
OPANA 5 MG TABLET 3 Central Nervous Systems Agents
OPANA ER 10 MG TABLET 2 QL Central Nervous Systems Agents
OPANA ER 20 MG TABLET 2 QL Central Nervous Systems Agents
OPANA ER 40 MG TABLET 2 QL Central Nervous Systems Agents
OPANA ER 5 MG TABLET 2 QL Central Nervous Systems Agents
OPIUM TINCTURE 0.1 TINCTURE 2 Gastrointestinal Drugs
OPTIPRANOLOL 0.003 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
OPTIVAR 0.0005 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
ORACEA 40 MG CAPSULES 3 QL Anti-Infective Agents
ORAMORPH SR 100 MG TABLET 1 Central Nervous Systems Agents
ORAMORPH SR 15 MG TABLET 1 Central Nervous Systems Agents
ORAMORPH SR 30 MG TABLET 1 Central Nervous Systems Agents
ORAMORPH SR 60 MG TABLET 1 Central Nervous Systems Agents
ORAP 1 MG TABLET 3 Central Nervous Systems Agents
ORAP 2 MG TABLET 3 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
120 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ORAPRED 15 MG/5ML SOLUTION 3 Hormones And Synthetic Substitutes
ORAPRED ODT 10 MG TABLET 3 Hormones And Synthetic Substitutes
ORAPRED ODT 15 MG TABLET 3 Hormones And Synthetic Substitutes
ORAPRED ODT 30 MG TABLET 3 Hormones And Synthetic Substitutes
ORENCIA 250 MG SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
ORFADIN 10 MG CAPSULES 4 Miscellaneous Therapeutic Agents
ORFADIN 2 MG CAPSULES 4 Miscellaneous Therapeutic Agents
ORFADIN 5 MG CAPSULES 4 Miscellaneous Therapeutic Agents
ORPHENADRINE CITRATE 30 MG/ML SOLUTION 1 Autonomic Drugs
ORPHENADRINE CITRATE ER 100 MG TABLET 1 Autonomic Drugs
ORPHENADRINE COMPOUND 385 MG;30 MG;25 MGTABLET
1 Autonomic Drugs
ORPHENADRINE COMPOUND DS 770 MG;60 MG;50MG TABLET
1 Autonomic Drugs
ORPHENADRINE/ASA/CAFF 385 MG;30 MG;25 MGTABLET
1 Autonomic Drugs
ORPHENGESIC 385 MG;30 MG;25 MG TABLET 1 Autonomic Drugs
ORPHENGESIC FORTE 770 MG;60 MG;50 MG TABLET 1 Autonomic Drugs
ORTHO EVRA 20 MCG/24HR;150 MCG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
ORTHO MICRONOR 0.35 MG TABLET 3 Hormones And Synthetic Substitutes
ORTHO TRI-CYCLEN 0 TABLET 3 Hormones And Synthetic Substitutes
ORTHO TRI-CYCLEN LO 0 TABLET 3 Hormones And Synthetic Substitutes
ORTHO-CEPT-28 0.15 MG;30 MCG TABLET 3 Hormones And Synthetic Substitutes
ORTHO-CYCLEN-28 35 MCG;0.25 MG TABLET 3 Hormones And Synthetic Substitutes
ORTHO-EST 0.75 MG TABLET 1 Hormones And Synthetic Substitutes
ORTHO-EST 1.5 MG TABLET 1 Hormones And Synthetic Substitutes
ORTHO-NOVUM 1/35-28 35 MCG;1 MG TABLET 3 Hormones And Synthetic Substitutes
ORTHO-NOVUM 1/50-28 50 MCG;1 MG TABLET 3 Hormones And Synthetic Substitutes
ORTHO-NOVUM 7/7/7-28 0 TABLET 3 Hormones And Synthetic Substitutes
ORTHOCLONE OKT3 1 MG/ML INJECTION 4 Miscellaneous Therapeutic Agents
OSMOPREP 0.398 GM;1.102 GM TABLET 3 Gastrointestinal Drugs
OTICIN HC 1 %;3.5 MG/ML;10000 UNIT/MLSUSPENSION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
OVCON-35 35 MCG;0.4 MG TABLET 3 Hormones And Synthetic Substitutes
OVCON-50 28 50 MCG;1 MG TABLET 3 Hormones And Synthetic Substitutes
OVIDE 0.005 LOTION 3 Skin And Mucous Membrane Agents
OXACILLIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 121
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
OXACILLIN SODIUM 1 GM SOLUTION 1 Anti-Infective Agents
OXACILLIN SODIUM 10 GM SOLUTION 1 Anti-Infective Agents
OXACILLIN SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
OXACILLIN SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
OXANDRIN 10 MG TABLET 4 Hormones And Synthetic Substitutes
OXANDRIN 2.5 MG TABLET 4 Hormones And Synthetic Substitutes
OXANDROLONE 10 MG TABLET 3 Hormones And Synthetic Substitutes
OXANDROLONE 2.5 MG TABLET 3 Hormones And Synthetic Substitutes
OXAPROZIN 600 MG TABLET 1 Central Nervous Systems Agents
OXISTAT 0.01 CREAM 3 Skin And Mucous Membrane Agents
OXISTAT 0.01 LOTION 3 Skin And Mucous Membrane Agents
OXSORALEN 0.01 LOTION 3 Skin And Mucous Membrane Agents
OXSORALEN ULTRA 10 MG CAPSULES 4 Skin And Mucous Membrane Agents
OXYBUTYNIN CHLORIDE 5 MG/5ML SYRUP 1 Smooth Muscle Relaxants
OXYBUTYNIN CHLORIDE 5 MG TABLET 1 Smooth Muscle Relaxants
OXYBUTYNIN CHLORIDE ER 10 MG TABLET 1 Smooth Muscle Relaxants
OXYBUTYNIN CHLORIDE ER 15 MG TABLET 1 Smooth Muscle Relaxants
OXYBUTYNIN CHLORIDE ER 5 MG TABLET 1 Smooth Muscle Relaxants
OXYCODONE HCL 5 MG CAPSULES 1 Central Nervous Systems Agents
OXYCODONE HCL 20 MG/ML CONCENTRATION 1 Central Nervous Systems Agents
OXYCODONE HCL 5 MG/5ML SOLUTION 1 Central Nervous Systems Agents
OXYCODONE HCL 15 MG TABLET 1 Central Nervous Systems Agents
OXYCODONE HCL 30 MG TABLET 1 Central Nervous Systems Agents
OXYCODONE HCL 5 MG TABLET 1 Central Nervous Systems Agents
OXYCODONE HCL CR 10 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE HCL CR 20 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE HCL CR 40 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE HCL CR 80 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE HCL ER 10 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE HCL ER 20 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE HCL ER 40 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE HCL ER 80 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE-APAP 325 MG;10 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE-APAP 325 MG;7.5 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE/ACETAMINOPHEN 500 MG;5 MGCAPSULES
1 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
122 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
OXYCODONE/ACETAMINOPHEN 325 MG;5 MGTABLET
1 QL Central Nervous Systems Agents
OXYCODONE/APAP 500 MG;7.5 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE/APAP 650 MG;10 MG TABLET 1 QL Central Nervous Systems Agents
OXYCODONE/ASPIRIN 325 MG;4.5 MG;0.38 MGTABLET
1 Central Nervous Systems Agents
OXYCONTIN 10 MG TABLET 2 QL Central Nervous Systems Agents
OXYCONTIN 20 MG TABLET 2 QL Central Nervous Systems Agents
OXYCONTIN 40 MG TABLET 2 QL Central Nervous Systems Agents
OXYCONTIN 80 MG TABLET 2 QL Central Nervous Systems Agents
OXYFAST 20 MG/ML CONCENTRATION 3 Central Nervous Systems Agents
OXYIR 5 MG CAPSULES 3 Central Nervous Systems Agents
OXYTOCIN 10 UNIT/ML SOLUTION 1 Oxytocics
OXYTROL 3.9 MG/24HR PATCH 3 QL, ST Smooth Muscle Relaxants
PACERONE 100 MG TABLET 1 Cardiovascular Drugs
PACERONE 200 MG TABLET 1 Cardiovascular Drugs
PACERONE 300 MG TABLET 1 Cardiovascular Drugs
PACERONE 400 MG TABLET 1 Cardiovascular Drugs
PACLITAXEL 100 MG/16.7ML CONCENTRATION 3 Antineoplastic Agents
PACLITAXEL 30 MG/5ML CONCENTRATION 3 Antineoplastic Agents
PACLITAXEL 300 MG/50ML CONCENTRATION 3 Antineoplastic Agents
PACLITAXEL 6 MG/ML CONCENTRATION 3 Antineoplastic Agents
PALCAPS 10 33200 UNIT;10000 UNIT;37500 UNITCAPSULES
1 Gastrointestinal Drugs
PALCAPS 20 66400 UNIT;20000 UNIT;75000 UNITCAPSULES
1 Gastrointestinal Drugs
PALGIC 4 MG/5ML LIQUID 3 Antihistamine Drugs
PALGIC 4 MG TABLET 3 Antihistamine Drugs
PALIPASE 20000 UNIT;4500 UNIT;25000 UNITCAPSULES
1 Gastrointestinal Drugs
PALIPASE MT 16 48000 UNIT;16000 UNIT;48000 UNITCAPSULES
1 Gastrointestinal Drugs
PALIPASE MT 20 56000 UNIT;20000 UNIT;44000 UNITCAPSULES
1 Gastrointestinal Drugs
PALPEON DR 10 33200 UNIT;10000 UNIT;37500 UNITCAPSULES
1 Gastrointestinal Drugs
PALPEON DR 20 66400 UNIT;20000 UNIT;75000 UNITCAPSULES
1 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 123
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PALPEON MT 20 65000 UNIT;20000 UNIT;65000 UNITCAPSULES
1 Gastrointestinal Drugs
PALTRASE V8 30000 UNIT;8000 UNIT;30000 UNITTABLET
1 Gastrointestinal Drugs
PAMELOR 10 MG CAPSULES 3 Central Nervous Systems Agents
PAMELOR 25 MG CAPSULES 3 Central Nervous Systems Agents
PAMELOR 50 MG CAPSULES 3 Central Nervous Systems Agents
PAMELOR 75 MG CAPSULES 3 Central Nervous Systems Agents
PAMELOR 10 MG/5ML SOLUTION 3 Central Nervous Systems Agents
PAMIDRONATE DISODIUM 30 MG SOLUTION 1 QL Miscellaneous Therapeutic Agents
PAMIDRONATE DISODIUM 30 MG/10ML SOLUTION 1 QL Miscellaneous Therapeutic Agents
PAMIDRONATE DISODIUM 6 MG/ML SOLUTION 1 QL Miscellaneous Therapeutic Agents
PAMIDRONATE DISODIUM 90 MG SOLUTION 1 QL Miscellaneous Therapeutic Agents
PAMIDRONATE DISODIUM 90 MG/10ML SOLUTION 1 QL Miscellaneous Therapeutic Agents
PAMINE 2.5 MG TABLET 3 Autonomic Drugs
PAMINE FORTE 5 MG TABLET 3 Autonomic Drugs
PANCREASE MT 10 30000 UNIT;10000 UNIT;30000UNIT CAPSULES
3 Gastrointestinal Drugs
PANCREASE MT 16 48000 UNIT;16000 UNIT;48000UNIT CAPSULES
3 Gastrointestinal Drugs
PANCREASE MT 20 56000 UNIT;20000 UNIT;44000UNIT CAPSULES
3 Gastrointestinal Drugs
PANCREASE MT 4 12000 UNIT;4000 UNIT;12000UNIT CAPSULES
3 Gastrointestinal Drugs
PANCRECARB MS-16 52000 UNIT;16000 UNIT;52000UNIT CAPSULES
3 Gastrointestinal Drugs
PANCRECARB MS-4 25000 UNIT;4000 UNIT;25000UNIT CAPSULES
3 Gastrointestinal Drugs
PANCRECARB MS-8 40000 UNIT;8000 UNIT;45000UNIT CAPSULES
3 Gastrointestinal Drugs
PANCRELIPASE 20000 UNIT;4000 UNIT;25000 UNITCAPSULES
3 Gastrointestinal Drugs
PANCRELIPASE 20000 UNIT;4500 UNIT;25000 UNITCAPSULES
1 Gastrointestinal Drugs
PANCRELIPASE 30000 UNIT;8000 UNIT;30000 UNITTABLET
1 Gastrointestinal Drugs
PANCRELIPASE MST-16 48000 UNIT;16000UNIT;48000 UNIT CAPSULES
1 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
124 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PANCRON 10 33200 UNIT;10000 UNIT;37500 UNITCAPSULES
1 Gastrointestinal Drugs
PANCRON 20 66400 UNIT;20000 UNIT;75000 UNITCAPSULES
1 Gastrointestinal Drugs
PANDEL 0.001 CREAM 3 Skin And Mucous Membrane Agents
PANGESTYME CN 10 33200 UNIT;10000 UNIT;37500UNIT CAPSULES
1 Gastrointestinal Drugs
PANGESTYME CN 20 66400 UNIT;20000 UNIT;75000UNIT CAPSULES
1 Gastrointestinal Drugs
PANGESTYME EC 20000 UNIT;4500 UNIT;25000 UNITCAPSULES
1 Gastrointestinal Drugs
PANGESTYME MT 16 48000 UNIT;16000 UNIT;48000UNIT CAPSULES
1 Gastrointestinal Drugs
PANGESTYME UL 12 39000 UNIT;12000 UNIT;39000UNIT CAPSULES
1 Gastrointestinal Drugs
PANGESTYME UL 18 58500 UNIT;18000 UNIT;58500UNIT CAPSULES
1 Gastrointestinal Drugs
PANGESTYME UL 20 65000 UNIT;20000 UNIT;65000UNIT CAPSULES
1 Gastrointestinal Drugs
PANGLOBULIN 1 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
PANGLOBULIN 12 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
PANGLOBULIN 3 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
PANGLOBULIN NF 12 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
PANGLOBULIN NF 6 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
PANGLOBULIN. 6 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
PANIXINE DISPERDOSE 125 MG SOLUBLE TABLET 1 Anti-Infective Agents
PANIXINE DISPERDOSE 250 MG SOLUBLE TABLET 1 Anti-Infective Agents
PANLOR DC 356.4 MG;30 MG;16 MG CAPSULES 3 QL Central Nervous Systems Agents
PANLOR SS 712.8 MG;60 MG;32 MG TABLET 3 QL Central Nervous Systems Agents
PANOCAPS 20000 UNIT;4500 UNIT;25000 UNITCAPSULES
1 Gastrointestinal Drugs
PANOCAPS MT 16 48000 UNIT;16000 UNIT;48000UNIT CAPSULES
1 Gastrointestinal Drugs
PANOCAPS MT 20 56000 UNIT;20000 UNIT;44000UNIT CAPSULES
1 Gastrointestinal Drugs
PANOKASE 30000 UNIT;8000 UNIT;30000 UNITTABLET
1 Gastrointestinal Drugs
PANOKASE-16 60000 UNIT;16000 UNIT;60000 UNITTABLET
1 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 125
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PANRETIN 0.001 GEL 4 Skin And Mucous Membrane Agents
PAPAVERINE HCL 30 MG/ML SOLUTION 1 Cardiovascular Drugs
PARAFON FORTE DSC 500 MG TABLET 3 Autonomic Drugs
PARAPLATIN 150 MG SOLUTION 4 Antineoplastic Agents
PARAPLATIN 150 MG/15ML SOLUTION 4 Antineoplastic Agents
PARAPLATIN 450 MG SOLUTION 4 Antineoplastic Agents
PARAPLATIN 450 MG/45ML SOLUTION 4 Antineoplastic Agents
PARAPLATIN 50 MG SOLUTION 4 Antineoplastic Agents
PARAPLATIN 50 MG/5ML SOLUTION 4 Antineoplastic Agents
PARAPLATIN 600 MG/60ML SOLUTION 4 Antineoplastic Agents
PARCAINE 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
PARCOPA 10 MG;100 MG TABLET 3 Central Nervous Systems Agents
PARCOPA 25 MG;100 MG TABLET 3 Central Nervous Systems Agents
PARCOPA 25 MG;250 MG TABLET 3 Central Nervous Systems Agents
PAREGORIC 2 MG/5ML TINCTURE 1 Gastrointestinal Drugs
PARLODEL 5 MG CAPSULES 3 Miscellaneous Therapeutic Agents
PARLODEL 2.5 MG TABLET 3 Miscellaneous Therapeutic Agents
PARNATE 10 MG TABLET 3 Central Nervous Systems Agents
PAROMOMYCIN SULFATE 250 MG CAPSULES 1 Anti-Infective Agents
PAROXETINE HCL 10 MG/5ML SUSPENSION 1 Central Nervous Systems Agents
PAROXETINE HCL 10 MG TABLET 1 QL Central Nervous Systems Agents
PAROXETINE HCL 20 MG TABLET 1 QL Central Nervous Systems Agents
PAROXETINE HCL 30 MG TABLET 1 QL Central Nervous Systems Agents
PAROXETINE HCL 40 MG TABLET 1 QL Central Nervous Systems Agents
PASER 4 GM PACK 1 Anti-Infective Agents
PATADAY 0.2 % SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
PATANOL 0.001 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
PAXIL 10 MG/5ML SUSPENSION 3 Central Nervous Systems Agents
PAXIL 10 MG TABLET 3 QL Central Nervous Systems Agents
PAXIL 20 MG TABLET 3 QL Central Nervous Systems Agents
PAXIL 30 MG TABLET 3 QL Central Nervous Systems Agents
PAXIL 40 MG TABLET 3 QL Central Nervous Systems Agents
PAXIL CR 12.5 MG TABLET 3 QL Central Nervous Systems Agents
PAXIL CR 25 MG TABLET 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
126 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PAXIL CR 37.5 MG TABLET 3 QL Central Nervous Systems Agents
PCE 333 MG TABLET 3 Anti-Infective Agents
PCE 500 MG TABLET 3 Anti-Infective Agents
PEDI-DRI 100000 UNIT/GM POWDER 1 Skin And Mucous Membrane Agents
PEDIAPRED 6.7 MG/5ML LIQUID 3 Hormones And Synthetic Substitutes
PEDIARIX 58 MCG/0.5ML;25 LFU/0.5ML;10MCG/0.5ML;0 -;10 LFU/0.5ML SUSPENSION
3 Serums, Toxoids, And Vaccines
PEDIAZOLE 200 MG/5ML;600 MG/5ML SUSPENSION 3 Anti-Infective Agents
PEDIOTIC 1 %;3.5 MG/ML;10000 UNIT/MLSUSPENSION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
PEDVAX HIB 0 SOLUTION 3 Serums, Toxoids, And Vaccines
PEG 3350/ELECTROLYTES 240 GM;2.98 GM;6.72GM;5.84 GM;22.72 GM SOLUTION
1 Gastrointestinal Drugs
PEG-INTRON 120 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON 150 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON 50 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON 80 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON REDIPEN 120 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON REDIPEN 150 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON REDIPEN 50 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON REDIPEN 80 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON REDIPEN PAK 4 120 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON REDIPEN PAK 4 150 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON REDIPEN PAK 4 50 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEG-INTRON REDIPEN PAK 4 80 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PEGANONE 250 MG TABLET 3 Central Nervous Systems Agents
PEGASYS 180 MCG/0.5ML KIT 4 QL, PA Anti-Infective Agents
PENICILLIN G POTASSIUM 20 MU SOLUTION 1 Anti-Infective Agents
PENICILLIN G POTASSIUM 5 MU SOLUTION 1 Anti-Infective Agents
PENICILLIN G POTASSIUM IN 0 -;20000 UNIT/MLSOLUTION
1 Anti-Infective Agents
PENICILLIN G POTASSIUM IN 0 -;40000 UNIT/MLSOLUTION
1 Anti-Infective Agents
PENICILLIN G POTASSIUM IN 0 -;60000 UNIT/MLSOLUTION
1 Anti-Infective Agents
PENICILLIN G PROCAINE 600000 UNIT/MLSUSPENSION
1 Anti-Infective Agents
PENICILLIN G SODIUM 5000000 UNIT SOLUTION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 127
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PENICILLIN V POTASSIUM 125 MG/5ML SOLUTION 1 Anti-Infective Agents
PENICILLIN V POTASSIUM 250 MG/5ML SOLUTION 1 Anti-Infective Agents
PENICILLIN V POTASSIUM 250 MG TABLET 1 Anti-Infective Agents
PENICILLIN V POTASSIUM 500 MG TABLET 1 Anti-Infective Agents
PENLAC NAIL LACQUER 0.08 SOLUTION 3 PA Skin And Mucous Membrane Agents
PENTAM 300 300 MG SOLUTION 4 Anti-Infective Agents
PENTAMIDINE ISETHIONATE 300 MG SOLUTION 1 Anti-Infective Agents
PENTASA 250 MG CAPSULES 3 QL Gastrointestinal Drugs
PENTASA 500 MG CAPSULES 3 QL Gastrointestinal Drugs
PENTAZOCINE/ACETAMINOPHEN 650 MG;25 MGTABLET
1 QL Central Nervous Systems Agents
PENTAZOCINE/NALOXONE HCL 0.5 MG;50 MGTABLET
1 Central Nervous Systems Agents
PENTOPAK 400 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
PENTOXIFYLLINE CR 400 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
PENTOXIFYLLINE ER 400 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
PENTOXIL 400 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
PEPCID 40 MG/5ML SUSPENSION 3 Gastrointestinal Drugs
PEPCID 20 MG TABLET 3 Gastrointestinal Drugs
PEPCID 40 MG TABLET 3 Gastrointestinal Drugs
PEPCID PREMIXED 0.4 MG/ML;0.9 % SOLUTION 3 Gastrointestinal Drugs
PERCOCET 325 MG;10 MG TABLET 3 QL, PA Central Nervous Systems Agents
PERCOCET 325 MG;2.5 MG TABLET 3 QL, PA Central Nervous Systems Agents
PERCOCET 325 MG;5 MG TABLET 3 QL, PA Central Nervous Systems Agents
PERCOCET 325 MG;7.5 MG TABLET 3 QL, PA Central Nervous Systems Agents
PERCOCET 500 MG;7.5 MG TABLET 3 QL, PA Central Nervous Systems Agents
PERCOCET 650 MG;10 MG TABLET 3 QL, PA Central Nervous Systems Agents
PERCODAN 325 MG;4.5 MG;0.38 MG TABLET 3 Central Nervous Systems Agents
PERCOLONE 5 MG TABLET 3 Central Nervous Systems Agents
PERIDEX ORAL RINSE 0.0012 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PERIOGARD 0.0012 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
PERIOSTAT 20 MG TABLET 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
128 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PERLOXX 300 MG;10 MG TABLET 1 QL Central Nervous Systems Agents
PERLOXX 300 MG;2.5 MG TABLET 1 QL Central Nervous Systems Agents
PERLOXX 300 MG;5 MG TABLET 1 QL Central Nervous Systems Agents
PERLOXX 300 MG;7.5 MG TABLET 1 QL Central Nervous Systems Agents
PERMETHRIN 0.05 CREAM 1 Skin And Mucous Membrane Agents
PERPHENAZINE 16 MG TABLET 1 Central Nervous Systems Agents
PERPHENAZINE 2 MG TABLET 1 Central Nervous Systems Agents
PERPHENAZINE 4 MG TABLET 1 Central Nervous Systems Agents
PERPHENAZINE 8 MG TABLET 1 Central Nervous Systems Agents
PERPHENAZINE/AMITRIPTYLIN 10 MG;2 MG TABLET 1 Central Nervous Systems Agents
PERPHENAZINE/AMITRIPTYLIN 10 MG;4 MG TABLET 1 Central Nervous Systems Agents
PERPHENAZINE/AMITRIPTYLIN 25 MG;2 MG TABLET 1 Central Nervous Systems Agents
PERPHENAZINE/AMITRIPTYLIN 25 MG;4 MG TABLET 1 Central Nervous Systems Agents
PERPHENAZINE/AMITRIPTYLIN 50 MG;4 MG TABLET 1 Central Nervous Systems Agents
PERSANTINE 25 MG TABLET 3 Cardiovascular Drugs
PERSANTINE 50 MG TABLET 3 Cardiovascular Drugs
PERSANTINE 75 MG TABLET 3 Cardiovascular Drugs
PEXEVA 10 MG TABLET 3 QL Central Nervous Systems Agents
PEXEVA 20 MG TABLET 3 QL Central Nervous Systems Agents
PEXEVA 30 MG TABLET 3 QL Central Nervous Systems Agents
PEXEVA 40 MG TABLET 3 QL Central Nervous Systems Agents
PFIZERPEN-G 20 MU SOLUTION 1 Anti-Infective Agents
PFIZERPEN-G 5 MU SOLUTION 1 Anti-Infective Agents
PHENADOZ 12.5 MG SUPPOSITORY 1 Antihistamine Drugs
PHENADOZ 25 MG SUPPOSITORY 1 Antihistamine Drugs
PHENAZOPYRIDINE HCL 100 MG TABLET 1 Skin And Mucous Membrane Agents
PHENAZOPYRIDINE HCL 200 MG TABLET 1 Skin And Mucous Membrane Agents
PHENERGAN 25 MG/ML SOLUTION 3 Antihistamine Drugs
PHENERGAN 50 MG/ML SOLUTION 3 Antihistamine Drugs
PHENYTEK 200 MG CAPSULES 2 Central Nervous Systems Agents
PHENYTEK 300 MG CAPSULES 2 Central Nervous Systems Agents
PHENYTOIN 125 MG/5ML SUSPENSION 1 Central Nervous Systems Agents
PHENYTOIN SODIUM 50 MG/ML SOLUTION 1 Central Nervous Systems Agents
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULES 1 Central Nervous Systems Agents
PHOSLO 667 MG CAPSULES 2 Electrolytic, Caloric, And Water Balance
PHOSPHOLINE IODIDE 0.00125 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 129
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PHOTOFRIN 75 MG SOLUTION 4 Antineoplastic Agents
PHRENILIN W/CAFFEINE/CODE 325 MG;50 MG;40MG;30 MG CAPSULES
1 QL Central Nervous Systems Agents
PHYSIOLYTE 27 MEQ/1000ML;98 MEQ/1000ML;23MEQ/1000ML;3 MEQ/1000ML;5 MEQ/1000MLSOLUTION
1 Electrolytic, Caloric, And Water Balance
PHYSIOSOL IRRIGATION 30 MG/100ML;37MG/100ML;222 MG/100ML;526 MG/100ML;502MG/100ML SOLUTION
1 Electrolytic, Caloric, And Water Balance
PHYSIOSOL IRRIGATION PH 7 30 MG/100ML;37MG/100ML;222 MG/100ML;526 MG/100ML;502MG/100ML SOLUTION
1 Electrolytic, Caloric, And Water Balance
PILOCARPINE HCL 7.5 MG TABLET 1 Autonomic Drugs
PILOCARPINE HYDROCHLORIDE 5 MG TABLET 1 Autonomic Drugs
PILOPINE HS 0.04 GEL 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PINDOLOL 10 MG TABLET 1 Cardiovascular Drugs
PINDOLOL 5 MG TABLET 1 Cardiovascular Drugs
PIPERACILLIN SODIUM 2 GM SOLUTION 1 Anti-Infective Agents
PIPERACILLIN SODIUM 3 GM SOLUTION 1 Anti-Infective Agents
PIPERACILLIN SODIUM 4 GM SOLUTION 1 Anti-Infective Agents
PIPERACILLIN SODIUM 40 GM SOLUTION 1 Anti-Infective Agents
PIROXICAM 10 MG CAPSULES 1 Central Nervous Systems Agents
PIROXICAM 20 MG CAPSULES 1 Central Nervous Systems Agents
PITOCIN 10 UNIT/ML SOLUTION 1 Oxytocics
PLAN B 0.75 MG TABLET 3 Hormones And Synthetic Substitutes
PLAQUENIL 200 MG TABLET 3 Anti-Infective Agents
PLARETASE 8000 30000 UNIT;8000 UNIT;30000 UNITTABLET
1 Gastrointestinal Drugs
PLASMA-LYTE 56 16 MEQ/L;40 MEQ/L;3 MEQ/L;13MEQ/L;40 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
PLASMA-LYTE A 27 MEQ/L;98 MEQ/L;23 MEQ/L;3MEQ/L;5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
PLASMA-LYTE-148 27 MEQ/L;98 MEQ/L;23 MEQ/L;3MEQ/L;5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
PLASMA-LYTE-148/D5W 27 MEQ/L;98 MEQ/L;5 %;23MEQ/L;3 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
PLASMA-LYTE-56/D5W 16 MEQ/L;40 MEQ/L;5 %;3MEQ/L;13 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
130 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PLASMA-LYTE-R 47 MEQ/L;5 MEQ/L;103 MEQ/L;8MEQ/L;3 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
PLATINOL AQ 1 MG/ML SOLUTION 3 Antineoplastic Agents
PLAVIX 75 MG TABLET 2 QL Blood Formation, Coagulation, AndThrombosis
PLENAXIS 100 MG SUSPENSION 4 Antineoplastic Agents
PLENDIL 10 MG TABLET 3 QL Cardiovascular Drugs
PLENDIL 2.5 MG TABLET 3 QL Cardiovascular Drugs
PLENDIL 5 MG TABLET 3 QL Cardiovascular Drugs
PLETAL 100 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
PLETAL 50 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
PODOCON 25 IN BENZOIN TIN 0.25 SOLUTION 3 Skin And Mucous Membrane Agents
PODOFILOX 0.005 SOLUTION 1 Skin And Mucous Membrane Agents
POLY-DEX 0.1 %;0.5 %;10000 UNIT/GM OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
POLY-DEX 0.1 %;0.5 %;10000 UNIT/ML SUSPENSION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
POLY-PRED 0.35 %;10000 UNIT/ML;0.5 %SUSPENSION
3 Eye, Ear, Nose, And Throat (EENT)Preparations
POLYCIN B 500 UNIT/GM;10000 UNIT/GM OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
POLYETHYLENE GLYCOL 3350 0 PACK 1 QL Gastrointestinal Drugs
POLYETHYLENE GLYCOL 3350 0 POWDER 1 QL Gastrointestinal Drugs
POLYGAM S/D 0.5 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
POLYGAM S/D 10 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
POLYGAM S/D 2.5 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
POLYGAM S/D 5 GM SOLUTION 4 PA Serums, Toxoids, And Vaccines
POLYMYXIN B SULFATE 500000 UNIT SOLUTION 1 Anti-Infective Agents
POLYMYXIN B SULFATE/TRIME 10000 UNIT/ML;0.1 %SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
POLYTRIM 10000 UNIT/ML;0.1 % SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PONSTEL 250 MG CAPSULES 3 Central Nervous Systems Agents
PORTIA-28 0.03 MG;0.15 MG TABLET 1 Hormones And Synthetic Substitutes
POTASSIUM CHLORIDE 13.4 MEQ/GM PACK 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 20 MEQ PACK 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.1 MEQ/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 131
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
POTASSIUM CHLORIDE 0.4 MEQ/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 10 MEQ/50ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 2 MEQ/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 20 MEQ/100ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 20 MEQ/50ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 30 MEQ/100ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 40 MEQ/100ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.075% 5 %;0.075 %;0.2 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.15% 0.15 %;0.9 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.15% 20 MEQ/L;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.15% 5 %;0.15 %;0.33 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.15% 5 %;0.15 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.15%/ 0.15 %;0.9 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.15%/ 5 %;0.15 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.22% 5 %;0.22 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.224% 5 %;0.224 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.224% 5 %;0.224 %;0.33 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.224% 5 %;0.224 %;0.45 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.3%/ 0.3 %;0.9 % SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.3%/D 5 %;0.3 % SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE 0.3%/N 0.3 %;0.9 %SOLUTION
1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE CR 10 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE CR 20 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE ER 10 MEQ CAPSULES 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE ER 10 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE ER 20 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE ER 8 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
132 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
POTASSIUM CHLORIDE MINI-V 2 MEQ/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE SA 8 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CHLORIDE SR 8 MEQ TABLET 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CITRATE EXTENDE 1080 MG TABLET 1 Electrolytic, Caloric, And Water Balance
POTASSIUM CITRATE EXTENDE 540 MG TABLET 1 Electrolytic, Caloric, And Water Balance
PRANDIN 0.5 MG TABLET 2 Hormones And Synthetic Substitutes
PRANDIN 1 MG TABLET 2 Hormones And Synthetic Substitutes
PRANDIN 2 MG TABLET 2 Hormones And Synthetic Substitutes
PRAVACHOL 10 MG TABLET 3 QL, PA Cardiovascular Drugs
PRAVACHOL 20 MG TABLET 3 QL, PA Cardiovascular Drugs
PRAVACHOL 40 MG TABLET 3 QL, PA Cardiovascular Drugs
PRAVACHOL 80 MG TABLET 3 QL, PA Cardiovascular Drugs
PRAVASTATIN SODIUM 10 MG TABLET 1 QL Cardiovascular Drugs
PRAVASTATIN SODIUM 20 MG TABLET 1 QL Cardiovascular Drugs
PRAVASTATIN SODIUM 40 MG TABLET 1 QL Cardiovascular Drugs
PRAVASTATIN SODIUM 80 MG TABLET 1 QL Cardiovascular Drugs
PRAZOSIN HCL 1 MG CAPSULES 1 Cardiovascular Drugs
PRAZOSIN HCL 2 MG CAPSULES 1 Cardiovascular Drugs
PRAZOSIN HCL 5 MG CAPSULES 1 Cardiovascular Drugs
PRECOSE 100 MG TABLET 2 Hormones And Synthetic Substitutes
PRECOSE 25 MG TABLET 2 Hormones And Synthetic Substitutes
PRECOSE 50 MG TABLET 2 Hormones And Synthetic Substitutes
PRED FORTE 0.01 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PRED MILD 0.0012 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PRED-G 0.3 %;1 % SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PRED-G S.O.P. 0.3 %;0.6 % OINTMENT 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PREDNICARBATE 0.001 CREAM 1 Skin And Mucous Membrane Agents
PREDNICARBATE 0.1 % OINTMENT 1 Skin And Mucous Membrane Agents
PREDNISOL 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
PREDNISOLONE 15 MG/5ML SYRUP 1 Hormones And Synthetic Substitutes
PREDNISOLONE 5 MG/5ML SYRUP 1 Hormones And Synthetic Substitutes
PREDNISOLONE 5 MG TABLET 1 Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 133
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PREDNISOLONE ACETATE 0.01 SUSPENSION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
PREDNISOLONE SODIUM PHOSP 6.7 MG/5ML LIQUID 1 Hormones And Synthetic Substitutes
PREDNISOLONE SODIUM PHOSP 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
PREDNISOLONE SODIUM PHOSP 15 MG/5MLSOLUTION
1 Hormones And Synthetic Substitutes
PREDNISONE 5 MG/5ML SOLUTION 1 Hormones And Synthetic Substitutes
PREDNISONE 1 MG TABLET 1 Hormones And Synthetic Substitutes
PREDNISONE 10 MG TABLET 1 Hormones And Synthetic Substitutes
PREDNISONE 2.5 MG TABLET 1 Hormones And Synthetic Substitutes
PREDNISONE 20 MG TABLET 1 Hormones And Synthetic Substitutes
PREDNISONE 5 MG TABLET 1 Hormones And Synthetic Substitutes
PREDNISONE 50 MG TABLET 1 Hormones And Synthetic Substitutes
PREDNISONE INTENSOL 5 MG/ML CONCENTRATION 1 Hormones And Synthetic Substitutes
PREFEST 0 TABLET 3 Hormones And Synthetic Substitutes
PRELONE 15 MG/5ML SYRUP 1 Hormones And Synthetic Substitutes
PREMARIN 25 MG SOLUTION 3 Hormones And Synthetic Substitutes
PREMARIN 0.3 MG TABLET 2 Hormones And Synthetic Substitutes
PREMARIN 0.45 MG TABLET 2 Hormones And Synthetic Substitutes
PREMARIN 0.625 MG TABLET 2 Hormones And Synthetic Substitutes
PREMARIN 0.9 MG TABLET 2 Hormones And Synthetic Substitutes
PREMARIN 1.25 MG TABLET 2 Hormones And Synthetic Substitutes
PREMARIN W/APPLICATOR 0.625 MG/GM CREAM 2 Hormones And Synthetic Substitutes
PREMASOL 52 MEQ/L;1760 MG/100ML;880MG/100ML;34 MEQ/L;1760 MG/100ML SOLUTION
1 Electrolytic, Caloric, And Water Balance
PREMASOL 56 MEQ/L;320 MG/100ML;730MG/100ML;190 MG/100ML;3 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
PREMPHASE 0.625 MG;5 MG TABLET 2 Hormones And Synthetic Substitutes
PREMPRO 0.3 MG;1.5 MG TABLET 2 Hormones And Synthetic Substitutes
PREMPRO 0.45 MG;1.5 MG TABLET 2 Hormones And Synthetic Substitutes
PREMPRO 0.625 MG;2.5 MG TABLET 2 Hormones And Synthetic Substitutes
PREMPRO 0.625 MG;5 MG TABLET 2 Hormones And Synthetic Substitutes
PREVACID 15 MG CAPSULES 2 QL Gastrointestinal Drugs
PREVACID 30 MG CAPSULES 2 QL Gastrointestinal Drugs
PREVACID 15 MG PACK 2 QL Gastrointestinal Drugs
PREVACID 30 MG PACK 2 QL Gastrointestinal Drugs
PREVACID I.V. 30 MG SOLUTION 2 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
134 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PREVACID NAPRAPAC 15 MG;500 MG KIT 2 QL Central Nervous Systems Agents
PREVACID SOLUTAB 15 MG TABLET 2 QL Gastrointestinal Drugs
PREVACID SOLUTAB 30 MG TABLET 2 QL Gastrointestinal Drugs
PREVALITE 4 GM PACK 1 Cardiovascular Drugs
PREVALITE 4 GM/DOSE POWDER 1 Cardiovascular Drugs
PREVIFEM 35 MCG;0.25 MG TABLET 1 Hormones And Synthetic Substitutes
PREVPAC 0 MISC 3 Gastrointestinal Drugs
PREZISTA 300 MG TABLET 2 Anti-Infective Agents
PRIALT 100 MCG/ML SOLUTION 4 Central Nervous Systems Agents
PRIALT 500 MCG/20ML SOLUTION 4 Central Nervous Systems Agents
PRIALT 500 MCG/5ML SOLUTION 4 Central Nervous Systems Agents
PRIFTIN 150 MG TABLET 3 Anti-Infective Agents
PRILOSEC 10 MG CAPSULES 3 QL, ST Gastrointestinal Drugs
PRILOSEC 20 MG CAPSULES 3 QL, ST Gastrointestinal Drugs
PRILOSEC 40 MG CAPSULES 3 QL, ST Gastrointestinal Drugs
PRIMAQUINE PHOSPHATE 26.3 MG TABLET 1 Anti-Infective Agents
PRIMAXIN I.M. 500 MG;500 MG SOLUTION 2 Anti-Infective Agents
PRIMAXIN I.M. 750 MG;750 MG SOLUTION 2 Anti-Infective Agents
PRIMAXIN IV 250 MG;250 MG SOLUTION 2 Anti-Infective Agents
PRIMAXIN IV 500 MG;500 MG SOLUTION 2 Anti-Infective Agents
PRIMAXIN IV ADD-VANTAGE 250 MG;250 MGSOLUTION
2 Anti-Infective Agents
PRIMAXIN IV ADD-VANTAGE 500 MG;500 MGSOLUTION
2 Anti-Infective Agents
PRIMIDONE 250 MG TABLET 1 Central Nervous Systems Agents
PRIMIDONE 50 MG TABLET 1 Central Nervous Systems Agents
PRIMSOL 50 MG/5ML SOLUTION 1 Anti-Infective Agents
PRINIVIL 10 MG TABLET 3 Cardiovascular Drugs
PRINIVIL 20 MG TABLET 3 Cardiovascular Drugs
PRINIVIL 5 MG TABLET 3 Cardiovascular Drugs
PRINZIDE 12.5 MG;10 MG TABLET 3 Cardiovascular Drugs
PRINZIDE 12.5 MG;20 MG TABLET 3 Cardiovascular Drugs
PRINZIDE 25 MG;20 MG TABLET 3 Cardiovascular Drugs
PRO-BANTHINE 7.5 MG TABLET 3 Autonomic Drugs
PROAIR HFA 108 MCG/ACT AEROSOL SOLUTION 2 QL Autonomic Drugs
PROAMATINE 10 MG TABLET 3 Autonomic Drugs
PROAMATINE 2.5 MG TABLET 3 Autonomic Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 135
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PROAMATINE 5 MG TABLET 3 Autonomic Drugs
PROBENECID 500 MG TABLET 1 Electrolytic, Caloric, And Water Balance
PROBENECID/COLCHICINE 0.5 MG;500 MG TABLET 1 Electrolytic, Caloric, And Water Balance
PROCAINAMIDE HCL 250 MG CAPSULES 1 Cardiovascular Drugs
PROCAINAMIDE HCL 500 MG CAPSULES 1 Cardiovascular Drugs
PROCAINAMIDE HCL 100 MG/ML SOLUTION 1 Cardiovascular Drugs
PROCAINAMIDE HCL 500 MG/ML SOLUTION 1 Cardiovascular Drugs
PROCAINAMIDE HCL ER 1000 MG TABLET 1 Cardiovascular Drugs
PROCAINAMIDE HCL ER 750 MG TABLET 1 Cardiovascular Drugs
PROCAINAMIDE HCL SR 500 MG TABLET 1 Cardiovascular Drugs
PROCALAMINE 47 MEQ/L;210 MG/100ML;290MG/100ML;3 MEQ/L;41 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
PROCANBID 1000 MG TABLET 3 Cardiovascular Drugs
PROCANBID 500 MG TABLET 3 Cardiovascular Drugs
PROCARDIA 10 MG CAPSULES 3 Cardiovascular Drugs
PROCARDIA XL 30 MG TABLET 3 QL Cardiovascular Drugs
PROCARDIA XL 60 MG TABLET 3 QL Cardiovascular Drugs
PROCARDIA XL 90 MG TABLET 3 QL Cardiovascular Drugs
PROCHIEVE 0.04 GEL 3 Hormones And Synthetic Substitutes
PROCHLORPERAZINE 25 MG SUPPOSITORY 1 Gastrointestinal Drugs
PROCHLORPERAZINE EDISYLAT 5 MG/ML SOLUTION 1 Gastrointestinal Drugs
PROCHLORPERAZINE MALEATE 10 MG TABLET 1 Gastrointestinal Drugs
PROCHLORPERAZINE MALEATE 5 MG TABLET 1 Gastrointestinal Drugs
PROCRIT 10000 UNIT/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
PROCRIT 2000 UNIT/ML SOLUTION 3 QL, PA Blood Formation, Coagulation, AndThrombosis
PROCRIT 20000 UNIT/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
PROCRIT 3000 UNIT/ML SOLUTION 3 QL, PA Blood Formation, Coagulation, AndThrombosis
PROCRIT 4000 UNIT/ML SOLUTION 3 QL, PA Blood Formation, Coagulation, AndThrombosis
PROCRIT 40000 UNIT/ML SOLUTION 4 QL, PA Blood Formation, Coagulation, AndThrombosis
PROCTO-KIT 0.025 CREAM 3 Skin And Mucous Membrane Agents
PROCTO-PAK 0.01 CREAM 1 Skin And Mucous Membrane Agents
PROCTOCORT 0.01 CREAM 1 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
136 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PROCTOCREAM-HC 0.025 CREAM 1 Skin And Mucous Membrane Agents
PROCTOSOL HC 0.025 CREAM 1 Skin And Mucous Membrane Agents
PROCTOZONE-HC 0.025 CREAM 1 Skin And Mucous Membrane Agents
PROGLYCEM 50 MG/ML SUSPENSION 3 Cardiovascular Drugs
PROGRAF 0.5 MG CAPSULES 3 Miscellaneous Therapeutic Agents
PROGRAF 1 MG CAPSULES 3 Miscellaneous Therapeutic Agents
PROGRAF 5 MG CAPSULES 3 Miscellaneous Therapeutic Agents
PROGRAF 5 MG/ML SOLUTION 3 Miscellaneous Therapeutic Agents
PROLASTIN 500 MG SOLUTION 4 QL, PA Enzymes
PROLASTIN 1000 MG SUSPENSION 4 QL, PA Enzymes
PROLEUKIN 22000000 UNIT SOLUTION 4 Antineoplastic Agents
PROMETHAZINE HCL 25 MG/ML SOLUTION 1 Antihistamine Drugs
PROMETHAZINE HCL 50 MG/ML SOLUTION 1 Antihistamine Drugs
PROMETHAZINE HCL 50 MG/ML SOLUTION 1 Antihistamine Drugs
PROMETHAZINE HCL 12.5 MG SUPPOSITORY 1 Antihistamine Drugs
PROMETHAZINE HCL 25 MG SUPPOSITORY 1 Antihistamine Drugs
PROMETHAZINE HCL 50 MG SUPPOSITORY 1 Antihistamine Drugs
PROMETHAZINE HCL 6.25 MG/5ML SYRUP 1 Antihistamine Drugs
PROMETHAZINE HCL 12.5 MG TABLET 1 Antihistamine Drugs
PROMETHAZINE HCL 25 MG TABLET 1 Antihistamine Drugs
PROMETHAZINE HCL 50 MG TABLET 1 Antihistamine Drugs
PROMETHAZINE HCL PLAIN 6.25 MG/5ML SYRUP 1 Antihistamine Drugs
PROMETHAZINE VC 5 MG/5ML;6.25 MG/5ML SYRUP 1 Antihistamine Drugs
PROMETHEGAN 12.5 MG SUPPOSITORY 1 Antihistamine Drugs
PROMETHEGAN 25 MG SUPPOSITORY 1 Antihistamine Drugs
PROMETHEGAN 50 MG SUPPOSITORY 1 Antihistamine Drugs
PROMETRIUM 100 MG CAPSULES 3 Hormones And Synthetic Substitutes
PROMETRIUM 200 MG CAPSULES 3 Hormones And Synthetic Substitutes
PRONESTYL 250 MG CAPSULES 3 Cardiovascular Drugs
PRONESTYL 375 MG CAPSULES 3 Cardiovascular Drugs
PRONESTYL 375 MG TABLET 3 Cardiovascular Drugs
PRONESTYL 500 MG TABLET 3 Cardiovascular Drugs
PRONESTYL SR 500 MG TABLET 1 Cardiovascular Drugs
PROPAFENONE HCL 150 MG TABLET 1 Cardiovascular Drugs
PROPAFENONE HCL 225 MG TABLET 1 Cardiovascular Drugs
PROPAFENONE HCL 300 MG TABLET 1 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 137
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PROPANTHELINE BROMIDE 15 MG TABLET 1 Autonomic Drugs
PROPARACAINE HCL 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
PROPINE 0.001 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
PROPOXYPHENE HCL 65 MG CAPSULES 1 Central Nervous Systems Agents
PROPOXYPHENE-N/ACETAMINOP 325 MG;50 MGTABLET
1 QL Central Nervous Systems Agents
PROPOXYPHENE-N/ACETAMINOP 500 MG;100 MGTABLET
1 QL Central Nervous Systems Agents
PROPOXYPHENE-N/ACETAMINOP 650 MG;100 MGTABLET
1 QL Central Nervous Systems Agents
PROPOXYPHENE/ACETAMINOPHE 650 MG;65 MGTABLET
1 QL Central Nervous Systems Agents
PROPRANOLOL HCL 1 MG/ML SOLUTION 1 Cardiovascular Drugs
PROPRANOLOL HCL 20 MG/5ML SOLUTION 1 Cardiovascular Drugs
PROPRANOLOL HCL 40 MG/5ML SOLUTION 1 Cardiovascular Drugs
PROPRANOLOL HCL 10 MG TABLET 1 Cardiovascular Drugs
PROPRANOLOL HCL 20 MG TABLET 1 Cardiovascular Drugs
PROPRANOLOL HCL 40 MG TABLET 1 Cardiovascular Drugs
PROPRANOLOL HCL 60 MG TABLET 1 Cardiovascular Drugs
PROPRANOLOL HCL 80 MG TABLET 1 Cardiovascular Drugs
PROPRANOLOL HCL ER 120 MG CAPSULES 1 Cardiovascular Drugs
PROPRANOLOL HCL ER 160 MG CAPSULES 1 Cardiovascular Drugs
PROPRANOLOL HCL ER 60 MG CAPSULES 1 Cardiovascular Drugs
PROPRANOLOL HCL ER 80 MG CAPSULES 1 Cardiovascular Drugs
PROPRANOLOL/HYDROCHLOROTH 25 MG;40 MGTABLET
1 Cardiovascular Drugs
PROPRANOLOL/HYDROCHLOROTH 25 MG;80 MGTABLET
1 Cardiovascular Drugs
PROPYLTHIOURACIL 50 MG TABLET 1 Hormones And Synthetic Substitutes
PROQUAD 0 INJECTION 3 Serums, Toxoids, And Vaccines
PROQUIN XR 500 MG TABLET 3 Anti-Infective Agents
PROSCAR 5 MG TABLET 3 QL, PA Miscellaneous Therapeutic Agents
PROTONIX 40 MG SOLUTION 3 ST Gastrointestinal Drugs
PROTONIX 20 MG TABLET 3 QL, ST Gastrointestinal Drugs
PROTONIX 40 MG TABLET 3 QL, ST Gastrointestinal Drugs
PROTOPIC 0.0003 OINTMENT 3 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
138 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
PROTOPIC 0.001 OINTMENT 3 Skin And Mucous Membrane Agents
PROVENTIL 90 MCG/ACT AEROSOL SOLUTION 3 QL Autonomic Drugs
PROVENTIL 0.00083 NEBULIZER 3 Autonomic Drugs
PROVENTIL HFA 108 MCG/ACT AEROSOL SOLUTION 2 QL Autonomic Drugs
PROVERA 10 MG TABLET 3 Hormones And Synthetic Substitutes
PROVERA 2.5 MG TABLET 3 Hormones And Synthetic Substitutes
PROVERA 5 MG TABLET 3 Hormones And Synthetic Substitutes
PROVIGIL 100 MG TABLET 3 QL, PA Central Nervous Systems Agents
PROVIGIL 200 MG TABLET 3 QL, PA Central Nervous Systems Agents
PROZAC 10 MG CAPSULES 3 QL Central Nervous Systems Agents
PROZAC 20 MG CAPSULES 3 QL Central Nervous Systems Agents
PROZAC 40 MG CAPSULES 3 QL Central Nervous Systems Agents
PROZAC 20 MG/5ML SOLUTION 3 Central Nervous Systems Agents
PROZAC 10 MG TABLET 3 QL Central Nervous Systems Agents
PROZAC WEEKLY 90 MG CAPSULES 3 QL Central Nervous Systems Agents
PSORCON E 0.0005 CREAM 3 Skin And Mucous Membrane Agents
PULMICORT 0.25 MG/2ML SUSPENSION 3 Hormones And Synthetic Substitutes
PULMICORT 0.5 MG/2ML SUSPENSION 3 Hormones And Synthetic Substitutes
PULMICORT FLEXHALER 180 MCG/ACT INHALER 3 QL Hormones And Synthetic Substitutes
PULMICORT FLEXHALER 90 MCG/ACT INHALER 3 QL Hormones And Synthetic Substitutes
PULMICORT TURBUHALER 200 MCG/INH AEROSOLPOWDER
3 ST Hormones And Synthetic Substitutes
PULMOZYME 1 MG/ML SOLUTION 4 QL Enzymes
PURINETHOL 50 MG TABLET 3 Antineoplastic Agents
PYLERA 140 MG;125 MG;125 MG CAPSULES 3 QL Anti-Infective Agents
PYRAZINAMIDE 500 MG TABLET 1 Anti-Infective Agents
PYRIDIUM 100 MG TABLET 3 Skin And Mucous Membrane Agents
PYRIDIUM 200 MG TABLET 3 Skin And Mucous Membrane Agents
PYRIDOSTIGMINE BROMIDE 60 MG TABLET 1 Autonomic Drugs
QUADRAMET 1850 MBQ/ML SOLUTION 2 Miscellaneous Therapeutic Agents
QUALAQUIN 324 MG CAPSULES 3 QL Anti-Infective Agents
QUASENSE 0.03 MG;0.15 MG TABLET 1 QL Hormones And Synthetic Substitutes
QUESTRAN 4 GM PACK 3 Cardiovascular Drugs
QUESTRAN 4 GM/DOSE POWDER 3 Cardiovascular Drugs
QUESTRAN LIGHT 4 GM PACK 3 Cardiovascular Drugs
QUESTRAN LIGHT 4 GM/DOSE POWDER 3 Cardiovascular Drugs
QUINAPRIL HCL 10 MG TABLET 1 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 139
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
QUINAPRIL HCL 20 MG TABLET 1 Cardiovascular Drugs
QUINAPRIL HCL 40 MG TABLET 1 Cardiovascular Drugs
QUINAPRIL HCL 5 MG TABLET 1 Cardiovascular Drugs
QUINAPRIL/HYDROCHLOROTHIA 12.5 MG;10 MGTABLET
1 Cardiovascular Drugs
QUINAPRIL/HYDROCHLOROTHIA 12.5 MG;20 MGTABLET
1 Cardiovascular Drugs
QUINAPRIL/HYDROCHLOROTHIA 25 MG;20 MGTABLET
1 Cardiovascular Drugs
QUINARETIC 12.5 MG;10 MG TABLET 1 Cardiovascular Drugs
QUINARETIC 12.5 MG;20 MG TABLET 1 Cardiovascular Drugs
QUINARETIC 25 MG;20 MG TABLET 1 Cardiovascular Drugs
QUINIDINE GLUCONATE 80 MG/ML SOLUTION 1 Cardiovascular Drugs
QUINIDINE GLUCONATE CR 324 MG TABLET 1 Cardiovascular Drugs
QUINIDINE GLUCONATE ER 324 MG TABLET 1 Cardiovascular Drugs
QUINIDINE GLUCONATE SA 324 MG TABLET 1 Cardiovascular Drugs
QUINIDINE SULFATE 200 MG TABLET 1 Cardiovascular Drugs
QUINIDINE SULFATE 300 MG TABLET 1 Cardiovascular Drugs
QUINIDINE SULFATE ER 300 MG TABLET 1 Cardiovascular Drugs
QUIXIN 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
QVAR 40 MCG/ACT AEROSOL SOLUTION 2 QL Hormones And Synthetic Substitutes
QVAR 80 MCG/ACT AEROSOL SOLUTION 2 QL Hormones And Synthetic Substitutes
RABAVERT 0 SUSPENSION 2 Serums, Toxoids, And Vaccines
RANEXA 500 MG TABLET 3 QL, ST Cardiovascular Drugs
RANICLOR 250 MG CHEWABLE 1 Anti-Infective Agents
RANICLOR 375 MG CHEWABLE 1 Anti-Infective Agents
RANITIDINE HCL 150 MG CAPSULES 1 Gastrointestinal Drugs
RANITIDINE HCL 300 MG CAPSULES 1 Gastrointestinal Drugs
RANITIDINE HCL 150 MG/6ML SOLUTION 1 Gastrointestinal Drugs
RANITIDINE HCL 25 MG/ML SOLUTION 1 Gastrointestinal Drugs
RANITIDINE HCL 50 MG/2ML SOLUTION 1 Gastrointestinal Drugs
RANITIDINE HCL 150 MG TABLET 1 Gastrointestinal Drugs
RANITIDINE HCL 300 MG TABLET 1 Gastrointestinal Drugs
RAPAMUNE 1 MG/ML SOLUTION 3 Miscellaneous Therapeutic Agents
RAPAMUNE 1 MG TABLET 3 Miscellaneous Therapeutic Agents
RAPAMUNE 2 MG TABLET 3 Miscellaneous Therapeutic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
140 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
RAPIFLUX 20 MG TABLET 3 QL Central Nervous Systems Agents
RAPTIVA 125 MG KIT 4 QL, PA Skin And Mucous Membrane Agents
RAUWOLFIA/BENDROFLUMETHIA 4 MG;50 MGTABLET
2 Miscellaneous Therapeutic Agents
RAZADYNE 4 MG/ML SOLUTION 2 QL Autonomic Drugs
RAZADYNE 12 MG TABLET 2 QL Autonomic Drugs
RAZADYNE 4 MG TABLET 2 QL Autonomic Drugs
RAZADYNE 8 MG TABLET 2 QL Autonomic Drugs
RAZADYNE ER 16 MG CAPSULES 2 QL Autonomic Drugs
RAZADYNE ER 24 MG CAPSULES 2 QL Autonomic Drugs
RAZADYNE ER 8 MG CAPSULES 2 QL Autonomic Drugs
REBETOL 200 MG CAPSULES 4 QL, PA Anti-Infective Agents
REBETOL 40 MG/ML SOLUTION 4 QL, PA Anti-Infective Agents
REBIF 22 MCG/0.5ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
REBIF 44 MCG/0.5ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
REBIF TITRATION PACK 0 SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents
RECLIPSEN 0.15 MG;30 MCG TABLET 1 Hormones And Synthetic Substitutes
RECOMBIVAX HB 40 MCG/ML INJECTION 3 Serums, Toxoids, And Vaccines
RECOMBIVAX HB 10 MCG/ML SUSPENSION 3 Serums, Toxoids, And Vaccines
RECOMBIVAX HB 5 MCG/0.5ML SUSPENSION 3 Serums, Toxoids, And Vaccines
REGLAN 5 MG/ML SOLUTION 3 Gastrointestinal Drugs
REGLAN 10 MG TABLET 3 Gastrointestinal Drugs
REGLAN 5 MG TABLET 3 Gastrointestinal Drugs
REGONOL 5 MG/ML SOLUTION 3 Autonomic Drugs
REGRANEX 0.0001 GEL 4 Skin And Mucous Membrane Agents
RELENZA DISKHALER 5 MG/BLISTER AEROSOLPOWDER
3 QL Anti-Infective Agents
RELION 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes
RELION 70/30 INNOLET 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes
RELION N 100 UNIT/ML SUSPENSION 2 Hormones And Synthetic Substitutes
RELION N INNOLET 100 UNIT/ML SUSPENSION 2 Hormones And Synthetic Substitutes
RELION R 100 UNIT/ML SOLUTION 2 Hormones And Synthetic Substitutes
RELPAX 20 MG TABLET 3 QL Central Nervous Systems Agents
RELPAX 40 MG TABLET 3 QL Central Nervous Systems Agents
REMERON 15 MG TABLET 3 QL Central Nervous Systems Agents
REMERON 30 MG TABLET 3 QL Central Nervous Systems Agents
REMERON 45 MG TABLET 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 141
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
REMERON SOLTAB 15 MG TABLET 3 QL Central Nervous Systems Agents
REMERON SOLTAB 30 MG TABLET 3 QL Central Nervous Systems Agents
REMERON SOLTAB 45 MG TABLET 3 QL Central Nervous Systems Agents
REMICADE 100 MG SOLUTION 4 PA Miscellaneous Therapeutic Agents
REMODULIN 1 MG/ML SOLUTION 4 PA Cardiovascular Drugs
REMODULIN 10 MG/ML SOLUTION 4 PA Cardiovascular Drugs
REMODULIN 2.5 MG/ML SOLUTION 4 PA Cardiovascular Drugs
REMODULIN 5 MG/ML SOLUTION 4 PA Cardiovascular Drugs
RENAGEL 400 MG TABLET 2 Electrolytic, Caloric, And Water Balance
RENAGEL 800 MG TABLET 2 Electrolytic, Caloric, And Water Balance
RENAMIN 0.065 SOLUTION 3 Electrolytic, Caloric, And Water Balance
REPREXAIN 5 MG;200 MG TABLET 3 Central Nervous Systems Agents
REQUIP 0.25 MG TABLET 2 QL Central Nervous Systems Agents
REQUIP 0.5 MG TABLET 2 QL Central Nervous Systems Agents
REQUIP 1 MG TABLET 2 QL Central Nervous Systems Agents
REQUIP 2 MG TABLET 2 QL Central Nervous Systems Agents
REQUIP 3 MG TABLET 2 QL Central Nervous Systems Agents
REQUIP 4 MG TABLET 2 QL Central Nervous Systems Agents
REQUIP 5 MG TABLET 2 QL Central Nervous Systems Agents
RESCRIPTOR 100 MG TABLET 2 Anti-Infective Agents
RESCRIPTOR 200 MG TABLET 2 Anti-Infective Agents
RESERPINE 0.1 MG TABLET 1 Cardiovascular Drugs
RESERPINE 0.25 MG TABLET 1 Cardiovascular Drugs
RESTASIS 0.0005 EMULSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
RETIN-A 0.00025 CREAM 3 PA Skin And Mucous Membrane Agents
RETIN-A 0.0005 CREAM 3 PA Skin And Mucous Membrane Agents
RETIN-A 0.001 CREAM 3 PA Skin And Mucous Membrane Agents
RETIN-A 0.0001 GEL 3 PA Skin And Mucous Membrane Agents
RETIN-A 0.00025 GEL 3 PA Skin And Mucous Membrane Agents
RETIN-A MICRO 0.0004 GEL 3 PA Skin And Mucous Membrane Agents
RETIN-A MICRO 0.001 GEL 3 PA Skin And Mucous Membrane Agents
RETROVIR 100 MG CAPSULES 2 Anti-Infective Agents
RETROVIR 10 MG/ML SYRUP 2 Anti-Infective Agents
RETROVIR 300 MG TABLET 2 Anti-Infective Agents
RETROVIR IV INFUSION 10 MG/ML SOLUTION 3 Anti-Infective Agents
REVATIO 20 MG TABLET 4 QL, PA Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
142 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
REVEX 1 MG/ML SOLUTION 3 Central Nervous Systems Agents
REVEX 100 MCG/ML SOLUTION 3 Central Nervous Systems Agents
REVIA 50 MG TABLET 3 Central Nervous Systems Agents
REVLIMID 10 MG CAPSULES 4 QL, PA Miscellaneous Therapeutic Agents
REVLIMID 15 MG CAPSULES 4 QL, PA Miscellaneous Therapeutic Agents
REVLIMID 25 MG CAPSULES 4 QL, PA Miscellaneous Therapeutic Agents
REVLIMID 5 MG CAPSULES 4 QL, PA Miscellaneous Therapeutic Agents
REYATAZ 100 MG CAPSULES 2 Anti-Infective Agents
REYATAZ 150 MG CAPSULES 2 Anti-Infective Agents
REYATAZ 200 MG CAPSULES 2 Anti-Infective Agents
REYATAZ 300 MG CAPSULES 2 Anti-Infective Agents
RHEUMATREX 2.5 MG TABLET 3 Antineoplastic Agents
RHINOCORT AQUA 32 MCG/ACT SUSPENSION 3 QL, ST Eye, Ear, Nose, And Throat (EENT)Preparations
RIBAPAK 0 MISC 4 QL, PA Anti-Infective Agents
RIBAPAK 400 MG TABLET 4 QL, PA Anti-Infective Agents
RIBAPAK 600 MG TABLET 4 QL, PA Anti-Infective Agents
RIBASPHERE 200 MG CAPSULES 4 QL, PA Anti-Infective Agents
RIBASPHERE 200 MG TABLET 4 QL, PA Anti-Infective Agents
RIBASPHERE 400 MG TABLET 4 QL, PA Anti-Infective Agents
RIBASPHERE 600 MG TABLET 4 QL, PA Anti-Infective Agents
RIBATAB 0 MISC 4 QL, PA Anti-Infective Agents
RIBATAB 400 MG TABLET 4 QL, PA Anti-Infective Agents
RIBATAB 600 MG TABLET 4 QL, PA Anti-Infective Agents
RIBAVIRIN 200 MG CAPSULES 4 QL, PA Anti-Infective Agents
RIBAVIRIN 200 MG TABLET 4 QL, PA Anti-Infective Agents
RIDAURA 3 MG CAPSULES 2 Gold Compounds
RIFADIN 150 MG CAPSULES 3 Anti-Infective Agents
RIFADIN 300 MG CAPSULES 3 Anti-Infective Agents
RIFADIN 600 MG SOLUTION 3 Anti-Infective Agents
RIFAMATE 150 MG;300 MG CAPSULES 1 Anti-Infective Agents
RIFAMPIN 150 MG CAPSULES 1 Anti-Infective Agents
RIFAMPIN 300 MG CAPSULES 1 Anti-Infective Agents
RIFAMPIN 600 MG SOLUTION 1 Anti-Infective Agents
RIFATER 50 MG;300 MG;120 MG TABLET 3 Anti-Infective Agents
RILUTEK 50 MG TABLET 2 Central Nervous Systems Agents
RIMANTADINE HCL 100 MG TABLET 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 143
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
RINGER’S INJECTION 4.5 MEQ/L;156 MEQ/L;4MEQ/L;147 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
RINGER’S IRRIGATION 4.5 MEQ/L;156 MEQ/L;4MEQ/L;147 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
RIOMET 500 MG/5ML SOLUTION 3 Hormones And Synthetic Substitutes
RISPERDAL 1 MG/ML SOLUTION 2 Central Nervous Systems Agents
RISPERDAL 0.25 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL 0.5 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL 1 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL 2 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL 3 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL 4 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL CONSTA 12.5 MG SUSPENSION 4 QL Central Nervous Systems Agents
RISPERDAL CONSTA 25 MG SUSPENSION 4 QL Central Nervous Systems Agents
RISPERDAL CONSTA 37.5 MG SUSPENSION 4 QL Central Nervous Systems Agents
RISPERDAL CONSTA 50 MG SUSPENSION 4 QL Central Nervous Systems Agents
RISPERDAL M-TAB 0.5 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL M-TAB 1 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL M-TAB 2 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL M-TAB 3 MG TABLET 2 QL Central Nervous Systems Agents
RISPERDAL M-TAB 4 MG TABLET 2 QL Central Nervous Systems Agents
RITALIN 10 MG TABLET 3 Central Nervous Systems Agents
RITALIN 20 MG TABLET 3 Central Nervous Systems Agents
RITALIN 5 MG TABLET 3 Central Nervous Systems Agents
RITALIN LA 10 MG CAPSULES 3 QL Central Nervous Systems Agents
RITALIN LA 20 MG CAPSULES 3 QL Central Nervous Systems Agents
RITALIN LA 30 MG CAPSULES 3 QL Central Nervous Systems Agents
RITALIN LA 40 MG CAPSULES 3 QL Central Nervous Systems Agents
RITALIN SR 20 MG TABLET 3 Central Nervous Systems Agents
RITUXAN 10 MG/ML CONCENTRATION 4 QL, PA Antineoplastic Agents
RMS 10 MG SUPPOSITORY 3 Central Nervous Systems Agents
RMS 20 MG SUPPOSITORY 3 Central Nervous Systems Agents
RMS 30 MG SUPPOSITORY 3 Central Nervous Systems Agents
RMS 5 MG SUPPOSITORY 3 Central Nervous Systems Agents
ROBAXIN 100 MG/ML SOLUTION 3 Autonomic Drugs
ROBAXIN 500 MG TABLET 3 Autonomic Drugs
ROBAXIN-750 750 MG TABLET 3 Autonomic Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
144 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ROBINUL 0.2 MG/ML SOLUTION 3 Autonomic Drugs
ROBINUL 1 MG TABLET 3 Autonomic Drugs
ROBINUL FORTE 2 MG TABLET 3 Autonomic Drugs
ROCALTROL 0.25 MCG CAPSULES 3 Vitamins
ROCALTROL 0.5 MCG CAPSULES 3 Vitamins
ROCALTROL 1 MCG/ML SOLUTION 3 Vitamins
ROCEPHIN 1 GM SOLUTION 3 Anti-Infective Agents
ROCEPHIN 1 GM SOLUTION 3 Anti-Infective Agents
ROCEPHIN 10 GM SOLUTION 3 Anti-Infective Agents
ROCEPHIN 2 GM SOLUTION 3 Anti-Infective Agents
ROCEPHIN 2 GM SOLUTION 3 Anti-Infective Agents
ROCEPHIN 250 MG SOLUTION 3 Anti-Infective Agents
ROCEPHIN 500 MG SOLUTION 3 Anti-Infective Agents
ROCEPHIN IN ISO-OSMOTIC D 20 MG/ML;0 -SOLUTION
2 Anti-Infective Agents
ROCEPHIN IN ISO-OSMOTIC D 40 MG/ML;0 -SOLUTION
1 Anti-Infective Agents
ROFERON-A 3 MU/0.5ML KIT 3 QL, PA Anti-Infective Agents
ROFERON-A 6 MU/0.5ML KIT 3 QL, PA Anti-Infective Agents
ROFERON-A 9 MU/0.5ML KIT 3 QL, PA Anti-Infective Agents
ROMYCIN 5 MG/GM OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
ROTATEQ 0 SUSPENSION 3 Serums, Toxoids, And Vaccines
ROWASA 4 GM ENEMA 3 QL Gastrointestinal Drugs
ROXANOL 20 MG/ML SOLUTION 3 Central Nervous Systems Agents
ROXICET 325 MG/5ML;5 MG/5ML SOLUTION 1 Central Nervous Systems Agents
ROXICET 325 MG;5 MG TABLET 1 QL Central Nervous Systems Agents
ROXICET 500 MG;5 MG TABLET 1 QL Central Nervous Systems Agents
ROXICODONE 5 MG/5ML SOLUTION 3 Central Nervous Systems Agents
ROXICODONE 15 MG TABLET 3 Central Nervous Systems Agents
ROXICODONE 30 MG TABLET 3 Central Nervous Systems Agents
ROXICODONE 5 MG TABLET 3 Central Nervous Systems Agents
ROXICODONE INTENSOL 20 MG/MLCONCENTRATION
3 Central Nervous Systems Agents
ROZEREM 8 MG TABLET 3 QL, ST Central Nervous Systems Agents
ROZEX 0.0075 EMULSION 3 Skin And Mucous Membrane Agents
RYTHMOL 150 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 145
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
RYTHMOL 225 MG TABLET 3 Cardiovascular Drugs
RYTHMOL 300 MG TABLET 3 Cardiovascular Drugs
RYTHMOL SR 225 MG CAPSULES 2 Cardiovascular Drugs
RYTHMOL SR 325 MG CAPSULES 2 Cardiovascular Drugs
RYTHMOL SR 425 MG CAPSULES 2 Cardiovascular Drugs
SAIZEN 5 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SAIZEN 8.8 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SAIZEN CLICK.EASY 8.8 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SALAGEN 5 MG TABLET 3 Autonomic Drugs
SALAGEN 7.5 MG TABLET 3 Autonomic Drugs
SANCTURA 20 MG TABLET 3 QL Smooth Muscle Relaxants
SANDIMMUNE 100 MG CAPSULES 3 Miscellaneous Therapeutic Agents
SANDIMMUNE 25 MG CAPSULES 3 Miscellaneous Therapeutic Agents
SANDIMMUNE 100 MG/ML SOLUTION 3 Miscellaneous Therapeutic Agents
SANDIMMUNE 50 MG/ML SOLUTION 3 Miscellaneous Therapeutic Agents
SANDOSTATIN 0.05 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
SANDOSTATIN 0.1 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
SANDOSTATIN 0.2 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
SANDOSTATIN 0.5 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
SANDOSTATIN 1 MG/ML SOLUTION 4 PA Miscellaneous Therapeutic Agents
SANDOSTATIN LAR DEPOT 10 MG KIT 4 PA Miscellaneous Therapeutic Agents
SANDOSTATIN LAR DEPOT 20 MG KIT 4 PA Miscellaneous Therapeutic Agents
SANDOSTATIN LAR DEPOT 30 MG KIT 4 PA Miscellaneous Therapeutic Agents
SANTYL 250 UNIT/GM OINTMENT 2 Skin And Mucous Membrane Agents
SARAFEM 10 MG CAPSULES 3 QL Central Nervous Systems Agents
SARAFEM 20 MG CAPSULES 3 QL Central Nervous Systems Agents
SEASONALE 0.03 MG;0.15 MG TABLET 3 QL Hormones And Synthetic Substitutes
SEASONIQUE 0 TABLET 3 QL Hormones And Synthetic Substitutes
SECTRAL 200 MG CAPSULES 3 Cardiovascular Drugs
SECTRAL 400 MG CAPSULES 3 Cardiovascular Drugs
SELEGILINE HCL 5 MG CAPSULES 1 Central Nervous Systems Agents
SELEGILINE HCL 5 MG TABLET 1 Central Nervous Systems Agents
SELENIUM SULFIDE 0.025 LOTION 1 Skin And Mucous Membrane Agents
SELSUN SHAMPOO 0.025 LOTION 1 Skin And Mucous Membrane Agents
SEMPREX-D 8 MG;60 MG CAPSULES 3 Antihistamine Drugs
SENSIPAR 30 MG TABLET 4 QL Miscellaneous Therapeutic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
146 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
SENSIPAR 60 MG TABLET 4 QL Miscellaneous Therapeutic Agents
SENSIPAR 90 MG TABLET 4 QL Miscellaneous Therapeutic Agents
SEPTRA 400 MG;80 MG TABLET 3 Anti-Infective Agents
SEPTRA DS 800 MG;160 MG TABLET 3 Anti-Infective Agents
SEREVENT DISKUS 50 MCG/DOSE AEROSOL POWDER 2 QL Autonomic Drugs
SEROMYCIN 250 MG CAPSULES 3 Anti-Infective Agents
SEROQUEL 100 MG TABLET 2 QL Central Nervous Systems Agents
SEROQUEL 200 MG TABLET 2 QL Central Nervous Systems Agents
SEROQUEL 25 MG TABLET 2 QL Central Nervous Systems Agents
SEROQUEL 300 MG TABLET 2 QL Central Nervous Systems Agents
SEROQUEL 400 MG TABLET 2 QL Central Nervous Systems Agents
SEROQUEL 50 MG TABLET 2 QL Central Nervous Systems Agents
SEROQUEL XR 200 MG TABLET 2 QL Central Nervous Systems Agents
SEROQUEL XR 300 MG TABLET 2 QL Central Nervous Systems Agents
SEROQUEL XR 400 MG TABLET 2 QL Central Nervous Systems Agents
SEROSTIM 4 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SEROSTIM 5 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SEROSTIM 6 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SERTRALINE HCL 20 MG/ML CONCENTRATION 1 QL Central Nervous Systems Agents
SERTRALINE HCL 100 MG TABLET 1 QL Central Nervous Systems Agents
SERTRALINE HCL 25 MG TABLET 1 QL Central Nervous Systems Agents
SERTRALINE HCL 50 MG TABLET 1 QL Central Nervous Systems Agents
SERTRALINE HYDROCHLORIDE 20 MG/MLCONCENTRATION
1 Central Nervous Systems Agents
SILVADENE 0.01 CREAM 3 Skin And Mucous Membrane Agents
SILVER SULFADIAZINE 0.01 CREAM 1 Skin And Mucous Membrane Agents
SIMULECT 10 MG SOLUTION 4 Miscellaneous Therapeutic Agents
SIMULECT 20 MG SOLUTION 4 Miscellaneous Therapeutic Agents
SIMVASTATIN 10 MG TABLET 1 QL Cardiovascular Drugs
SIMVASTATIN 20 MG TABLET 1 QL Cardiovascular Drugs
SIMVASTATIN 40 MG TABLET 1 QL Cardiovascular Drugs
SIMVASTATIN 5 MG TABLET 1 QL Cardiovascular Drugs
SIMVASTATIN 80 MG TABLET 1 QL Cardiovascular Drugs
SINEMET 10 MG;100 MG TABLET 3 Central Nervous Systems Agents
SINEMET 25 MG;100 MG TABLET 3 Central Nervous Systems Agents
SINEMET 25 MG;250 MG TABLET 3 Central Nervous Systems Agents
SINEMET CR 25 MG;100 MG TABLET 3 Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 147
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
SINEMET CR 50 MG;200 MG TABLET 3 Central Nervous Systems Agents
SINGULAIR 4 MG CHEWABLE 2 QL Respiratory Tract Agents
SINGULAIR 5 MG CHEWABLE 2 QL Respiratory Tract Agents
SINGULAIR 4 MG PACK 2 QL Respiratory Tract Agents
SINGULAIR 10 MG TABLET 2 QL Respiratory Tract Agents
SKELAXIN 800 MG TABLET 3 QL Autonomic Drugs
SKELID 240 MG TABLET 3 Miscellaneous Therapeutic Agents
SODIUM BICARBONATE 0.042 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM BICARBONATE 0.075 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM BICARBONATE 0.084 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE 0.009 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE 0.03 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE 0.05 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE 2.5 MEQ/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE 4 MEQ/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE 0.45% VIA 0.0045 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE 0.9% 0.009 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE 0.9% 0.009 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE BACTERIOS 0 -;0.9 % SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM CHLORIDE BACTERIOS 0.009 SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM EDECRIN 50 MG SOLUTION 3 Electrolytic, Caloric, And Water Balance
SODIUM LACTATE 167 MEQ/L SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM LACTATE 5 MEQ/ML SOLUTION 1 Electrolytic, Caloric, And Water Balance
SODIUM POLYSTYRENE SULFON 0 POWDER 1 Electrolytic, Caloric, And Water Balance
SODIUM POLYSTYRENE SULFON 15 GM/60MLSUSPENSION
1 Electrolytic, Caloric, And Water Balance
SODIUM POLYSTYRENE SULFON 30 GM/120MLSUSPENSION
1 Electrolytic, Caloric, And Water Balance
SODIUM POLYSTYRENE SULFON 50 GM/200MLSUSPENSION
1 Electrolytic, Caloric, And Water Balance
SODIUM SULFACETAMIDE 0.1 LOTION 1 Skin And Mucous Membrane Agents
SOLARAZE 0.03 GEL 2 Skin And Mucous Membrane Agents
SOLIA 0.15 MG;30 MCG TABLET 1 Hormones And Synthetic Substitutes
SOLODYN 135 MG TABLET 3 QL Anti-Infective Agents
SOLODYN 45 MG TABLET 3 QL Anti-Infective Agents
SOLODYN 90 MG TABLET 3 QL Anti-Infective Agents
SOLTAMOX 10 MG/5ML SOLUTION 3 Antineoplastic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
148 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
SOLU-CORTEF 100 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-CORTEF 1000 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-CORTEF 250 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-CORTEF 500 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-MEDROL 1000 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-MEDROL 125 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-MEDROL 2 GM SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-MEDROL 40 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-MEDROL 500 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOLU-MEDROL ACT-O-VIAL 500 MG SOLUTION 3 Hormones And Synthetic Substitutes
SOMA 350 MG TABLET 3 Autonomic Drugs
SOMA COMPOUND 325 MG;200 MG TABLET 3 Autonomic Drugs
SOMA COMPOUND/CODEINE 325 MG;200 MG;16MG TABLET
3 Autonomic Drugs
SOMAVERT 10 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SOMAVERT 15 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SOMAVERT 20 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
SONATA 10 MG CAPSULES 3 QL, ST Central Nervous Systems Agents
SONATA 5 MG CAPSULES 3 QL, ST Central Nervous Systems Agents
SORIATANE 10 MG CAPSULES 4 Skin And Mucous Membrane Agents
SORIATANE 25 MG CAPSULES 4 Skin And Mucous Membrane Agents
SORINE 120 MG TABLET 1 Cardiovascular Drugs
SORINE 160 MG TABLET 1 Cardiovascular Drugs
SORINE 240 MG TABLET 1 Cardiovascular Drugs
SORINE 80 MG TABLET 1 Cardiovascular Drugs
SOTALOL HCL 120 MG TABLET 1 Cardiovascular Drugs
SOTALOL HCL 160 MG TABLET 1 Cardiovascular Drugs
SOTALOL HCL 240 MG TABLET 1 Cardiovascular Drugs
SOTALOL HCL 80 MG TABLET 1 Cardiovascular Drugs
SOTALOL HCL (AF) 120 MG TABLET 1 Cardiovascular Drugs
SOTALOL HCL (AF) 160 MG TABLET 1 Cardiovascular Drugs
SOTALOL HCL (AF) 80 MG TABLET 1 Cardiovascular Drugs
SOTRET 10 MG CAPSULES 3 Skin And Mucous Membrane Agents
SOTRET 20 MG CAPSULES 3 Skin And Mucous Membrane Agents
SOTRET 30 MG CAPSULES 3 Skin And Mucous Membrane Agents
SOTRET 40 MG CAPSULES 3 Skin And Mucous Membrane Agents
SPECTRACEF 200 MG TABLET 3 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 149
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
SPIRIVA HANDIHALER 18 MCG CAPSULES 2 QL Autonomic Drugs
SPIRONOLACTONE 100 MG TABLET 1 Cardiovascular Drugs
SPIRONOLACTONE 25 MG TABLET 1 Cardiovascular Drugs
SPIRONOLACTONE 50 MG TABLET 1 Cardiovascular Drugs
SPIRONOLACTONE/HYDROCHLOR 25 MG;25 MGTABLET
1 Cardiovascular Drugs
SPORANOX 100 MG CAPSULES 3 QL, PA Anti-Infective Agents
SPORANOX 250 MG KIT 3 PA Anti-Infective Agents
SPORANOX 10 MG/ML SOLUTION 3 PA Anti-Infective Agents
SPORANOX PULSEPAK 100 MG CAPSULES 3 PA Anti-Infective Agents
SPRINTEC 28 35 MCG;0.25 MG TABLET 1 Hormones And Synthetic Substitutes
SPRYCEL 20 MG TABLET 4 QL, PA Antineoplastic Agents
SPRYCEL 50 MG TABLET 4 QL, PA Antineoplastic Agents
SPRYCEL 70 MG TABLET 4 QL, PA Antineoplastic Agents
SPS 15 GM/60ML SUSPENSION 1 Electrolytic, Caloric, And Water Balance
SPS 30 GM/120ML SUSPENSION 1 Electrolytic, Caloric, And Water Balance
SRONYX 20 MCG;0.1 MG TABLET 1 Hormones And Synthetic Substitutes
SSD 0.01 CREAM 1 Skin And Mucous Membrane Agents
SSD AF 0.01 CREAM 1 Skin And Mucous Membrane Agents
STADOL 2 MG/ML SOLUTION 3 QL Central Nervous Systems Agents
STAGESIC 500 MG;5 MG CAPSULES 1 QL Central Nervous Systems Agents
STALEVO 100 25 MG;200 MG;100 MG TABLET 2 Central Nervous Systems Agents
STALEVO 150 37.5 MG;200 MG;150 MG TABLET 2 Central Nervous Systems Agents
STALEVO 50 12.5 MG;200 MG;50 MG TABLET 2 Central Nervous Systems Agents
STARLIX 120 MG TABLET 2 Hormones And Synthetic Substitutes
STARLIX 60 MG TABLET 2 Hormones And Synthetic Substitutes
STERAPRED 5 MG TABLET 3 Hormones And Synthetic Substitutes
STERAPRED 12 DAY 5 MG TABLET 3 Hormones And Synthetic Substitutes
STERAPRED DS 10 MG TABLET 3 Hormones And Synthetic Substitutes
STERAPRED DS 12 DAY 10 MG TABLET 3 Hormones And Synthetic Substitutes
STERILE WATER IRRIGATION 0 SOLUTION 1 Electrolytic, Caloric, And Water Balance
STIMATE 1.5 MG/ML SOLUTION 4 Hormones And Synthetic Substitutes
STRATTERA 10 MG CAPSULES 3 QL Central Nervous Systems Agents
STRATTERA 100 MG CAPSULES 3 QL Central Nervous Systems Agents
STRATTERA 18 MG CAPSULES 3 QL Central Nervous Systems Agents
STRATTERA 25 MG CAPSULES 3 QL Central Nervous Systems Agents
STRATTERA 40 MG CAPSULES 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
150 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
STRATTERA 60 MG CAPSULES 3 QL Central Nervous Systems Agents
STRATTERA 80 MG CAPSULES 3 QL Central Nervous Systems Agents
STREPTOMYCIN SULFATE 1 GM SOLUTION 1 Anti-Infective Agents
STRIANT 30 MG MISC 3 Hormones And Synthetic Substitutes
STROMECTOL 3 MG TABLET 3 Anti-Infective Agents
STROMECTOL 6 MG TABLET 3 Anti-Infective Agents
SUBOXONE 2 MG;0.5 MG SUBLINGUAL 3 Central Nervous Systems Agents
SUBOXONE 8 MG;2 MG SUBLINGUAL 3 Central Nervous Systems Agents
SUBUTEX 2 MG SUBLINGUAL 3 Central Nervous Systems Agents
SUBUTEX 8 MG SUBLINGUAL 3 Central Nervous Systems Agents
SUCRAID 8500 UNIT/ML SOLUTION 4 Enzymes
SUCRALFATE 1 GM TABLET 1 Gastrointestinal Drugs
SULAR 10 MG TABLET 2 QL Cardiovascular Drugs
SULAR 20 MG TABLET 2 QL Cardiovascular Drugs
SULAR 30 MG TABLET 2 QL Cardiovascular Drugs
SULAR 40 MG TABLET 2 QL Cardiovascular Drugs
SULF-10 0.1 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
SULFACETAMIDE SODIUM 0.1 OINTMENT 1 Eye, Ear, Nose, And Throat (EENT)Preparations
SULFACETAMIDE SODIUM 0.1 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
SULFACETAMIDE SODIUM/PRED 0.23 %;10 %SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
SULFADIAZINE 500 MG TABLET 1 Anti-Infective Agents
SULFAMETHOXAZOLE/TRIMETHO 400 MG/5ML;80MG/5ML SOLUTION
1 Anti-Infective Agents
SULFAMETHOXAZOLE/TRIMETHO 200 MG/5ML;40MG/5ML SUSPENSION
1 Anti-Infective Agents
SULFAMETHOXAZOLE/TRIMETHO 400 MG;80 MGTABLET
1 Anti-Infective Agents
SULFAMETHOXAZOLE/TRIMETHO 800 MG;160 MGTABLET
1 Anti-Infective Agents
SULFAMYLON 85 MG/GM CREAM 3 Skin And Mucous Membrane Agents
SULFAMYLON 50 GM PACK 3 Skin And Mucous Membrane Agents
SULFASALAZINE 500 MG TABLET 1 Anti-Infective Agents
SULFASALAZINE 500 MG TABLET 1 Anti-Infective Agents
SULFATRIM 200 MG/5ML;40 MG/5ML SUSPENSION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 151
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
SULFAZINE 500 MG TABLET 1 Anti-Infective Agents
SULFAZINE EC 500 MG TABLET 1 Anti-Infective Agents
SULINDAC 150 MG TABLET 1 Central Nervous Systems Agents
SULINDAC 200 MG TABLET 1 Central Nervous Systems Agents
SUMYCIN 125 MG/5ML SYRUP 1 Anti-Infective Agents
SUMYCIN 250 MG TABLET 1 Anti-Infective Agents
SUMYCIN 500 MG TABLET 1 Anti-Infective Agents
SUPRAX 100 MG/5ML SUSPENSION 3 Anti-Infective Agents
SURMONTIL 100 MG CAPSULES 3 Central Nervous Systems Agents
SURMONTIL 25 MG CAPSULES 3 Central Nervous Systems Agents
SURMONTIL 50 MG CAPSULES 3 Central Nervous Systems Agents
SUSTIVA 100 MG CAPSULES 2 Anti-Infective Agents
SUSTIVA 200 MG CAPSULES 2 Anti-Infective Agents
SUSTIVA 50 MG CAPSULES 2 Anti-Infective Agents
SUSTIVA 600 MG TABLET 2 Anti-Infective Agents
SUTENT 12.5 MG CAPSULES 4 QL, PA Antineoplastic Agents
SUTENT 25 MG CAPSULES 4 QL, PA Antineoplastic Agents
SUTENT 50 MG CAPSULES 4 QL, PA Antineoplastic Agents
SYMBICORT 160 MCG/ACT;4.5 MCG/ACT AEROSOL 2 QL Hormones And Synthetic Substitutes
SYMBICORT 80 MCG/ACT;4.5 MCG/ACT AEROSOL 2 QL Hormones And Synthetic Substitutes
SYMBYAX 25 MG;12 MG CAPSULES 3 QL Central Nervous Systems Agents
SYMBYAX 25 MG;6 MG CAPSULES 3 QL Central Nervous Systems Agents
SYMBYAX 50 MG;12 MG CAPSULES 3 QL Central Nervous Systems Agents
SYMBYAX 50 MG;6 MG CAPSULES 3 QL Central Nervous Systems Agents
SYMLIN 0.6 MG/ML SOLUTION 3 QL, PA Hormones And Synthetic Substitutes
SYMMETREL 100 MG TABLET 3 Central Nervous Systems Agents
SYNAGIS 100 MG/ML SOLUTION 4 QL, PA Anti-Infective Agents
SYNAGIS 50 MG/0.5ML SOLUTION 4 QL, PA Anti-Infective Agents
SYNALAR 0.00025 CREAM 3 Skin And Mucous Membrane Agents
SYNALAR 0.00025 OINTMENT 3 Skin And Mucous Membrane Agents
SYNALAR 0.0001 SOLUTION 3 Skin And Mucous Membrane Agents
SYNALGOS-DC 356.4 MG;30 MG;16 MG CAPSULES 3 Central Nervous Systems Agents
SYNAREL 2 MG/ML SOLUTION 4 QL Hormones And Synthetic Substitutes
SYNERA 70 MG;70 MG PATCH 3 Skin And Mucous Membrane Agents
SYNERCID 350 MG;150 MG SOLUTION 4 Anti-Infective Agents
SYNTHROID 100 MCG TABLET 2 Hormones And Synthetic Substitutes
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
152 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
SYNTHROID 112 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 125 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 137 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 150 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 175 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 200 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 25 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 300 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 50 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 75 MCG TABLET 2 Hormones And Synthetic Substitutes
SYNTHROID 88 MCG TABLET 2 Hormones And Synthetic Substitutes
SYPRINE 250 MG CAPSULES 3 Heavy Metal Antagonists
TABLOID 40 MG TABLET 1 Antineoplastic Agents
TACLONEX 0.064 %;0.005 % OINTMENT 3 QL Skin And Mucous Membrane Agents
TAGAMET 400 MG TABLET 3 Gastrointestinal Drugs
TALACEN 650 MG;25 MG TABLET 3 QL Central Nervous Systems Agents
TALADINE 150 MG CAPSULES 3 Gastrointestinal Drugs
TALWIN 30 MG/ML SOLUTION 3 Central Nervous Systems Agents
TALWIN NX 0.5 MG;50 MG TABLET 3 Central Nervous Systems Agents
TAMBOCOR 100 MG TABLET 3 Cardiovascular Drugs
TAMBOCOR 150 MG TABLET 3 Cardiovascular Drugs
TAMBOCOR 50 MG TABLET 3 Cardiovascular Drugs
TAMIFLU 75 MG CAPSULES 3 QL Anti-Infective Agents
TAMIFLU 12 MG/ML SUSPENSION 3 QL Anti-Infective Agents
TAMOXIFEN CITRATE 10 MG TABLET 1 Antineoplastic Agents
TAMOXIFEN CITRATE 20 MG TABLET 1 Antineoplastic Agents
TAPAZOLE 10 MG TABLET 3 Hormones And Synthetic Substitutes
TAPAZOLE 5 MG TABLET 3 Hormones And Synthetic Substitutes
TARCEVA 100 MG TABLET 4 QL Antineoplastic Agents
TARCEVA 150 MG TABLET 4 QL Antineoplastic Agents
TARCEVA 25 MG TABLET 4 QL Antineoplastic Agents
TARGRETIN 75 MG CAPSULES 4 Antineoplastic Agents
TARGRETIN 0.01 GEL 4 Skin And Mucous Membrane Agents
TARKA 1 MG;240 MG TABLET 3 Cardiovascular Drugs
TARKA 2 MG;180 MG TABLET 3 Cardiovascular Drugs
TARKA 2 MG;240 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 153
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TARKA 4 MG;240 MG TABLET 3 Cardiovascular Drugs
TASMAR 100 MG TABLET 2 Central Nervous Systems Agents
TASMAR 200 MG TABLET 2 Central Nervous Systems Agents
TAXOL 6 MG/ML CONCENTRATION 4 Antineoplastic Agents
TAXOTERE 20 MG/0.5ML CONCENTRATION 4 Antineoplastic Agents
TAXOTERE 80 MG/2ML CONCENTRATION 4 Antineoplastic Agents
TAZICEF 1 GM SOLUTION 1 Anti-Infective Agents
TAZICEF 1 GM SOLUTION 1 Anti-Infective Agents
TAZICEF 1 GM/50ML;4.4 % SOLUTION 1 Anti-Infective Agents
TAZICEF 2 GM SOLUTION 1 Anti-Infective Agents
TAZICEF 2 GM SOLUTION 1 Anti-Infective Agents
TAZICEF 2 GM/50ML;3.2 % SOLUTION 1 Anti-Infective Agents
TAZICEF 6 GM SOLUTION 1 Anti-Infective Agents
TAZORAC 0.0005 CREAM 2 Skin And Mucous Membrane Agents
TAZORAC 0.001 CREAM 2 Skin And Mucous Membrane Agents
TAZORAC 0.0005 GEL 2 Skin And Mucous Membrane Agents
TAZORAC 0.001 GEL 2 Skin And Mucous Membrane Agents
TAZTIA XT 120 MG CAPSULES 1 QL Cardiovascular Drugs
TAZTIA XT 180 MG CAPSULES 1 QL Cardiovascular Drugs
TAZTIA XT 240 MG CAPSULES 1 QL Cardiovascular Drugs
TAZTIA XT 300 MG CAPSULES 1 QL Cardiovascular Drugs
TAZTIA XT 360 MG CAPSULES 1 QL Cardiovascular Drugs
TEGRETOL 100 MG CHEWABLE 3 Central Nervous Systems Agents
TEGRETOL 100 MG/5ML SUSPENSION 3 Central Nervous Systems Agents
TEGRETOL 200 MG TABLET 3 Central Nervous Systems Agents
TEGRETOL-XR 100 MG TABLET 3 QL Central Nervous Systems Agents
TEGRETOL-XR 200 MG TABLET 3 QL Central Nervous Systems Agents
TEGRETOL-XR 400 MG TABLET 3 QL Central Nervous Systems Agents
TEKTURNA 150 MG TABLET 3 QL, ST Cardiovascular Drugs
TEKTURNA 300 MG TABLET 3 QL, ST Cardiovascular Drugs
TEMOVATE 0.0005 CREAM 3 Skin And Mucous Membrane Agents
TEMOVATE 0.0005 GEL 3 Skin And Mucous Membrane Agents
TEMOVATE 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents
TEMOVATE 0.0005 SOLUTION 3 Skin And Mucous Membrane Agents
TEMOVATE E 0.0005 CREAM 3 Skin And Mucous Membrane Agents
TENEX 1 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
154 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TENEX 2 MG TABLET 3 Cardiovascular Drugs
TENORETIC 100 100 MG;25 MG TABLET 3 Cardiovascular Drugs
TENORETIC 50 50 MG;25 MG TABLET 3 Cardiovascular Drugs
TENORMIN 5 MG/10ML SOLUTION 3 Cardiovascular Drugs
TENORMIN 100 MG TABLET 3 Cardiovascular Drugs
TENORMIN 25 MG TABLET 3 Cardiovascular Drugs
TENORMIN 50 MG TABLET 3 Cardiovascular Drugs
TERAZOL 3 80 MG SUPPOSITORY 3 Skin And Mucous Membrane Agents
TERAZOL 3 W/APPLICATOR 0.008 CREAM 1 Skin And Mucous Membrane Agents
TERAZOL 7 0.004 CREAM 3 Skin And Mucous Membrane Agents
TERAZOSIN HCL 1 MG CAPSULES 1 Cardiovascular Drugs
TERAZOSIN HCL 10 MG CAPSULES 1 Cardiovascular Drugs
TERAZOSIN HCL 2 MG CAPSULES 1 Cardiovascular Drugs
TERAZOSIN HCL 5 MG CAPSULES 1 Cardiovascular Drugs
TERBINAFINE HCL 250 MG TABLET 1 QL, PA Anti-Infective Agents
TERBUTALINE SULFATE 1 MG/ML SOLUTION 1 Autonomic Drugs
TERBUTALINE SULFATE 2.5 MG TABLET 1 Autonomic Drugs
TERBUTALINE SULFATE 5 MG TABLET 1 Autonomic Drugs
TERCONAZOLE 0.004 CREAM 1 Skin And Mucous Membrane Agents
TERCONAZOLE 0.008 CREAM 1 Skin And Mucous Membrane Agents
TERCONAZOLE 80 MG SUPPOSITORY 1 Skin And Mucous Membrane Agents
TERCONAZOLE VAGINAL 0.008 CREAM 1 Skin And Mucous Membrane Agents
TESLAC 50 MG TABLET 3 Antineoplastic Agents
TESTIM 0.01 GEL 3 Hormones And Synthetic Substitutes
TESTOPEL 75 MG PELLET 3 Hormones And Synthetic Substitutes
TESTOSTERONE CYPIONATE 100 MG/ML OIL 1 Hormones And Synthetic Substitutes
TESTOSTERONE CYPIONATE 200 MG/ML OIL 1 Hormones And Synthetic Substitutes
TESTOSTERONE ENANTHATE 200 MG/ML OIL 1 Hormones And Synthetic Substitutes
TESTRED 10 MG CAPSULES 3 Hormones And Synthetic Substitutes
TETANUS TOXOID 5 LFU SOLUTION 2 Serums, Toxoids, And Vaccines
TETANUS TOXOID ADSORBED 5 LFU SOLUTION 2 Serums, Toxoids, And Vaccines
TETANUS/DIPHTHERIA TOXOID 2 LF/0.5ML;2LF/0.5ML SUSPENSION
2 Serums, Toxoids, And Vaccines
TETRACYCLINE HCL 250 MG CAPSULES 1 Anti-Infective Agents
TETRACYCLINE HCL 500 MG CAPSULES 1 Anti-Infective Agents
TEV-TROPIN 5 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
TEVETEN 400 MG TABLET 3 QL Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 155
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TEVETEN 600 MG TABLET 3 QL Cardiovascular Drugs
TEVETEN HCT 600 MG;12.5 MG TABLET 3 QL Cardiovascular Drugs
TEVETEN HCT 600 MG;25 MG TABLET 3 QL Cardiovascular Drugs
TEXACORT 0.01 SOLUTION 3 Skin And Mucous Membrane Agents
TEXACORT 0.025 SOLUTION 3 Skin And Mucous Membrane Agents
THALITONE 15 MG TABLET 3 Electrolytic, Caloric, And Water Balance
THALOMID 100 MG CAPSULES 4 QL, PA Miscellaneous Therapeutic Agents
THALOMID 200 MG CAPSULES 4 QL, PA Miscellaneous Therapeutic Agents
THALOMID 50 MG CAPSULES 4 QL, PA Miscellaneous Therapeutic Agents
THEO-24 100 MG CAPSULES 1 Smooth Muscle Relaxants
THEO-24 200 MG CAPSULES 1 Smooth Muscle Relaxants
THEO-24 300 MG CAPSULES 1 Smooth Muscle Relaxants
THEO-24 400 MG CAPSULES 1 Smooth Muscle Relaxants
THEOCAP 125 MG CAPSULES 3 Smooth Muscle Relaxants
THEOCAP 200 MG CAPSULES 3 Smooth Muscle Relaxants
THEOCAP 300 MG CAPSULES 3 Smooth Muscle Relaxants
THEOCHRON 100 MG TABLET 1 Smooth Muscle Relaxants
THEOCHRON 200 MG TABLET 1 Smooth Muscle Relaxants
THEOCHRON 300 MG TABLET 1 Smooth Muscle Relaxants
THEOCHRON 450 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE CR 100 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE CR 200 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE CR 300 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE ER 125 MG CAPSULES 1 Smooth Muscle Relaxants
THEOPHYLLINE ER 200 MG CAPSULES 1 Smooth Muscle Relaxants
THEOPHYLLINE ER 300 MG CAPSULES 1 Smooth Muscle Relaxants
THEOPHYLLINE ER 100 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE ER 200 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE ER 300 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE ER 450 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE TD 100 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE TD 200 MG TABLET 1 Smooth Muscle Relaxants
THEOPHYLLINE TD 300 MG TABLET 1 Smooth Muscle Relaxants
THERACYS 81 MG/VIAL;5 % SUSPENSION 3 Serums, Toxoids, And Vaccines
THERMAZENE 0.01 CREAM 1 Skin And Mucous Membrane Agents
THIOLA 100 MG TABLET 2 Miscellaneous Therapeutic Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
156 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
THIORIDAZINE HCL 10 MG TABLET 1 Central Nervous Systems Agents
THIORIDAZINE HCL 100 MG TABLET 1 Central Nervous Systems Agents
THIORIDAZINE HCL 25 MG TABLET 1 Central Nervous Systems Agents
THIORIDAZINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
THIOTEPA 15 MG SOLUTION 1 Antineoplastic Agents
THIOTHIXENE 1 MG CAPSULES 1 Central Nervous Systems Agents
THIOTHIXENE 10 MG CAPSULES 1 Central Nervous Systems Agents
THIOTHIXENE 2 MG CAPSULES 1 Central Nervous Systems Agents
THIOTHIXENE 5 MG CAPSULES 1 Central Nervous Systems Agents
THYMOGLOBULIN 25 MG SOLUTION 4 Miscellaneous Therapeutic Agents
THYROLAR-1 60 MG TABLET 1 Hormones And Synthetic Substitutes
THYROLAR-1/2 30 MG TABLET 1 Hormones And Synthetic Substitutes
THYROLAR-1/4 15 MG TABLET 1 Hormones And Synthetic Substitutes
THYROLAR-2 120 MG TABLET 1 Hormones And Synthetic Substitutes
THYROLAR-3 180 MG TABLET 1 Hormones And Synthetic Substitutes
TIAZAC 120 MG CAPSULES 3 QL Cardiovascular Drugs
TIAZAC 180 MG CAPSULES 3 QL Cardiovascular Drugs
TIAZAC 240 MG CAPSULES 3 QL Cardiovascular Drugs
TIAZAC 300 MG CAPSULES 3 QL Cardiovascular Drugs
TIAZAC 360 MG CAPSULES 3 QL Cardiovascular Drugs
TIAZAC 420 MG CAPSULES 3 QL Cardiovascular Drugs
TICE BCG 50 MG SUSPENSION 4 Serums, Toxoids, And Vaccines
TICLID 250 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
TICLOPIDINE HCL 250 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
TIGAN 300 MG CAPSULES 3 Gastrointestinal Drugs
TIGAN 100 MG/ML SOLUTION 3 Gastrointestinal Drugs
TIKOSYN 125 MCG CAPSULES 3 QL Cardiovascular Drugs
TIKOSYN 250 MCG CAPSULES 3 QL Cardiovascular Drugs
TIKOSYN 500 MCG CAPSULES 3 QL Cardiovascular Drugs
TILADE 1.75 MG/ACT AEROSOL SOLUTION 2 QL Respiratory Tract Agents
TIMENTIN 0.1 GM/100ML;3 GM/100ML SOLUTION 3 Anti-Infective Agents
TIMENTIN 0.1 GM;3 GM SOLUTION 3 Anti-Infective Agents
TIMENTIN 1 GM;30 GM SOLUTION 3 Anti-Infective Agents
TIMOLIDE 10/25 25 MG;10 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 157
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TIMOLOL MALEATE 0.0025 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOLOL MALEATE 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOLOL MALEATE 10 MG TABLET 1 Cardiovascular Drugs
TIMOLOL MALEATE 20 MG TABLET 1 Cardiovascular Drugs
TIMOLOL MALEATE 5 MG TABLET 1 Cardiovascular Drugs
TIMOLOL MALEATE OPHTHALMI 0.0025 GELFORMING SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOLOL MALEATE OPHTHALMI 0.005 GELFORMING SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOPTIC 0.0025 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOPTIC 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOPTIC OCUDOSE 0.0025 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOPTIC OCUDOSE 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOPTIC-XE 0.0025 GEL FORMING SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TIMOPTIC-XE 0.005 GEL FORMING SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TINDAMAX 250 MG TABLET 3 Anti-Infective Agents
TINDAMAX 500 MG TABLET 3 Anti-Infective Agents
TIS-U-SOL 4.5 MEQ/L;156 MEQ/L;4 MEQ/L;147 MEQ/LSOLUTION
1 Electrolytic, Caloric, And Water Balance
TIS-U-SOL VIAFLEX 4.5 MEQ/L;156 MEQ/L;4MEQ/L;147 MEQ/L SOLUTION
1 Electrolytic, Caloric, And Water Balance
TIZANIDINE HCL 2 MG TABLET 1 Autonomic Drugs
TIZANIDINE HCL 4 MG TABLET 1 Autonomic Drugs
TOBI 300 MG/5ML NEBULIZER 4 QL, PA Anti-Infective Agents
TOBRADEX 0.1 %;0.3 % OINTMENT 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TOBRADEX 0.1 %;0.3 % SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TOBRAMYCIN SULFATE 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TOBRAMYCIN SULFATE 1.2 GM SOLUTION 1 Anti-Infective Agents
TOBRAMYCIN SULFATE 10 MG/ML SOLUTION 1 Anti-Infective Agents
TOBRAMYCIN SULFATE 40 MG/ML SOLUTION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
158 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TOBRAMYCIN SULFATE 80 MG/2ML SOLUTION 1 Anti-Infective Agents
TOBRAMYCIN SULFATE ADD-VA 10 MG/MLSOLUTION
1 Anti-Infective Agents
TOBRAMYCIN SULFATE FLIPTO 40 MG/ML SOLUTION 1 Anti-Infective Agents
TOBRAMYCIN SULFATE/SODIUM 0.9 %;0.8 MG/MLSOLUTION
1 Anti-Infective Agents
TOBRAMYCIN SULFATE/SODIUM 0.9 %;1.2 MG/MLSOLUTION
1 Anti-Infective Agents
TOBRASOL 0.003 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TOBREX 0.003 OINTMENT 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TOBREX 0.003 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
TOFRANIL 10 MG TABLET 3 Central Nervous Systems Agents
TOFRANIL 25 MG TABLET 3 Central Nervous Systems Agents
TOFRANIL 50 MG TABLET 3 Central Nervous Systems Agents
TOFRANIL-PM 100 MG CAPSULES 3 Central Nervous Systems Agents
TOFRANIL-PM 125 MG CAPSULES 3 Central Nervous Systems Agents
TOFRANIL-PM 150 MG CAPSULES 3 Central Nervous Systems Agents
TOFRANIL-PM 75 MG CAPSULES 3 Central Nervous Systems Agents
TOLAZAMIDE 100 MG TABLET 1 Hormones And Synthetic Substitutes
TOLAZAMIDE 250 MG TABLET 1 Hormones And Synthetic Substitutes
TOLAZAMIDE 500 MG TABLET 1 Hormones And Synthetic Substitutes
TOLBUTAMIDE 500 MG TABLET 1 Hormones And Synthetic Substitutes
TOLMETIN SODIUM 400 MG CAPSULES 1 Central Nervous Systems Agents
TOLMETIN SODIUM 200 MG TABLET 1 Central Nervous Systems Agents
TOLMETIN SODIUM 600 MG TABLET 1 Central Nervous Systems Agents
TOPAMAX 100 MG TABLET 3 QL Central Nervous Systems Agents
TOPAMAX 200 MG TABLET 3 QL Central Nervous Systems Agents
TOPAMAX 25 MG TABLET 3 QL Central Nervous Systems Agents
TOPAMAX 50 MG TABLET 3 QL Central Nervous Systems Agents
TOPAMAX SPRINKLE 15 MG SPRINKLE CAPSULES 3 QL Central Nervous Systems Agents
TOPAMAX SPRINKLE 25 MG SPRINKLE CAPSULES 3 QL Central Nervous Systems Agents
TOPICORT 0.0025 CREAM 3 Skin And Mucous Membrane Agents
TOPICORT 0.0005 GEL 3 Skin And Mucous Membrane Agents
TOPICORT 0.0025 OINTMENT 3 Skin And Mucous Membrane Agents
TOPICORT LP 0.0005 CREAM 3 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 159
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TOPOSAR 20 MG/ML SOLUTION 3 Antineoplastic Agents
TOPROL XL 100 MG TABLET 3 QL Cardiovascular Drugs
TOPROL XL 200 MG TABLET 3 QL Cardiovascular Drugs
TOPROL XL 25 MG TABLET 3 QL Cardiovascular Drugs
TOPROL XL 50 MG TABLET 3 QL Cardiovascular Drugs
TORISEL 25 MG/ML SOLUTION 4 PA Antineoplastic Agents
TORSEMIDE 10 MG TABLET 1 Electrolytic, Caloric, And Water Balance
TORSEMIDE 100 MG TABLET 1 Electrolytic, Caloric, And Water Balance
TORSEMIDE 20 MG TABLET 1 Electrolytic, Caloric, And Water Balance
TORSEMIDE 5 MG TABLET 1 Electrolytic, Caloric, And Water Balance
TPN ELECTROLYTES FTV 29.5 MEQ/20ML;4.5MEQ/20ML;35 MEQ/20ML;5 MEQ/20ML;20MEQ/20ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRACLEER 125 MG TABLET 4 QL, PA Cardiovascular Drugs
TRACLEER 62.5 MG TABLET 4 QL, PA Cardiovascular Drugs
TRAMADOL HCL 50 MG TABLET 1 QL Central Nervous Systems Agents
TRAMADOL HYDROCHLORIDE/AC 325 MG;37.5 MGTABLET
1 QL Central Nervous Systems Agents
TRANDATE 100 MG TABLET 3 Cardiovascular Drugs
TRANDATE 200 MG TABLET 3 Cardiovascular Drugs
TRANDATE 300 MG TABLET 3 Cardiovascular Drugs
TRANDATE IV 5 MG/ML SOLUTION 3 Cardiovascular Drugs
TRANDOLAPRIL 1 MG TABLET 1 Cardiovascular Drugs
TRANDOLAPRIL 2 MG TABLET 1 Cardiovascular Drugs
TRANDOLAPRIL 4 MG TABLET 1 Cardiovascular Drugs
TRANSDERM-SCOP 1.5 MG PATCH 3 QL Gastrointestinal Drugs
TRANYLCYPROMINE SULFATE 10 MG TABLET 1 Central Nervous Systems Agents
TRAVASOL 43 MEQ/L;1140 MG/100ML;570MG/100ML;22 MEQ/L;1140 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 52 MEQ/L;1760 MG/100ML;880MG/100ML;34 MEQ/L;1760 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 67 MEQ/L;1760 MG/100ML;880MG/100ML;34 MEQ/L;1760 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 2.75%/DEXTROSE 1 570 MG/100ML;285MG/100ML;10 %;570 MG/100ML;120 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
160 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TRAVASOL 2.75%/DEXTROSE 5 570 MG/100ML;285MG/100ML;5 %;570 MG/100ML;120 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 3.5%/ELECTROLYTE 728 MG/100ML;364MG/100ML;728 MG/100ML;154 MG/100ML;168MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 4.25%/DEXTROSE 1 880 MG/100ML;440MG/100ML;10 %;880 MG/100ML;186 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 4.25%/DEXTROSE 2 880 MG/100ML;440MG/100ML;25 %;880 MG/100ML;186 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 4.25%/DEXTROSE 5 880 MG/100ML;440MG/100ML;5 %;880 MG/100ML;186 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 5.5%/DEXTROSE 10 44 MEQ/L;0 -;10%;250 MG/100ML;560 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 5.5%/DEXTROSE 20 44 MEQ/L;0 -;20%;250 MG/100ML;560 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 5.5%/ELECTROLYTE 101 MEQ/L;1140MG/100ML;570 MG/100ML;70 MEQ/L;1140MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 8.5%/DEXTROSE 10 90 MEQ/L;1100MG/100ML;850 MG/100ML;35 MEQ/L;10 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 8.5%/DEXTROSE 20 90 MEQ/L;1100MG/100ML;850 MG/100ML;35 MEQ/L;20 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 8.5%/DEXTROSE 50 90 MEQ/L;1100MG/100ML;850 MG/100ML;35 MEQ/L;50 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVASOL 8.5%/ELECTROLYTE 130 MEQ/L;1760MG/100ML;880 MG/100ML;70 MEQ/L;1760MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVATAN 0.004% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT)Preparations
TRAVATAN Z 0.004% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT)Preparations
TRAVERT 0.1 SOLUTION 3 Electrolytic, Caloric, And Water Balance
TRAVERT 10% 0.1 SOLUTION 3 Electrolytic, Caloric, And Water Balance
TRAVERT 10%-1/2NS-KCL 10 %;0.3 %;0.45 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 161
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TRAVERT 10%-NORMAL SALINE 10 %;0.9 %SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVERT 10%/ELECTROLYTE 2 56 MEQ/L;10 %;25MEQ/L;6 MEQ/L;12.5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAVERT 5%/ELECTROLYTE #2 56 MEQ/L;5 %;25MEQ/L;6 MEQ/L;12.5 MEQ/L SOLUTION
3 Electrolytic, Caloric, And Water Balance
TRAZODONE HCL 100 MG TABLET 1 Central Nervous Systems Agents
TRAZODONE HCL 150 MG TABLET 1 Central Nervous Systems Agents
TRAZODONE HCL 300 MG TABLET 1 Central Nervous Systems Agents
TRAZODONE HCL 50 MG TABLET 1 Central Nervous Systems Agents
TRECATOR 250 MG TABLET 3 Anti-Infective Agents
TRELSTAR DEPOT 3.75 MG SUSPENSION 3 QL, PA Antineoplastic Agents
TRELSTAR LA 11.25 MG SUSPENSION 3 QL, PA Antineoplastic Agents
TRENTAL 400 MG TABLET 3 Blood Formation, Coagulation, AndThrombosis
TRETINOIN 10 MG CAPSULES 4 Antineoplastic Agents
TRETINOIN 0.00025 CREAM 1 PA Skin And Mucous Membrane Agents
TRETINOIN 0.0005 CREAM 1 PA Skin And Mucous Membrane Agents
TRETINOIN 0.001 CREAM 1 PA Skin And Mucous Membrane Agents
TRETINOIN 0.0001 GEL 1 PA Skin And Mucous Membrane Agents
TRETINOIN 0.00025 GEL 1 PA Skin And Mucous Membrane Agents
TREXALL 10 MG TABLET 3 Antineoplastic Agents
TREXALL 15 MG TABLET 3 Antineoplastic Agents
TREXALL 5 MG TABLET 3 Antineoplastic Agents
TREXALL 7.5 MG TABLET 3 Antineoplastic Agents
TRI-LEVLEN 0 TABLET 3 Hormones And Synthetic Substitutes
TRI-LEVLEN CONTRACT PACK 0 TABLET 3 Hormones And Synthetic Substitutes
TRI-NORINYL 28 0 TABLET 3 Hormones And Synthetic Substitutes
TRI-PREVIFEM 0 TABLET 1 Hormones And Synthetic Substitutes
TRI-SPRINTEC 0 TABLET 1 Hormones And Synthetic Substitutes
TRIAMCINOLONE ACETONIDE 0.00025 CREAM 1 Skin And Mucous Membrane Agents
TRIAMCINOLONE ACETONIDE 0.001 CREAM 1 Skin And Mucous Membrane Agents
TRIAMCINOLONE ACETONIDE 0.005 CREAM 1 Skin And Mucous Membrane Agents
TRIAMCINOLONE ACETONIDE 0.00025 LOTION 1 Skin And Mucous Membrane Agents
TRIAMCINOLONE ACETONIDE 0.001 LOTION 1 Skin And Mucous Membrane Agents
TRIAMCINOLONE ACETONIDE 0.00025 OINTMENT 1 Skin And Mucous Membrane Agents
TRIAMCINOLONE ACETONIDE 0.001 OINTMENT 1 Skin And Mucous Membrane Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
162 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TRIAMCINOLONE ACETONIDE 0.005 OINTMENT 1 Skin And Mucous Membrane Agents
TRIAMCINOLONE ACETONIDE I 0.0005 OINTMENT 1 Skin And Mucous Membrane Agents
TRIAMCINOLONE IN ORABASE 0.001 PASTE 1 Skin And Mucous Membrane Agents
TRIAMTERENE/HYDROCHLOROTH 25 MG;50 MGCAPSULES
1 Electrolytic, Caloric, And Water Balance
TRIAMTERENE/HYDROCHLOROTH 25 MG;37.5 MGTABLET
1 Electrolytic, Caloric, And Water Balance
TRIAMTERENE/HYDROCHLOROTH 50 MG;75 MGTABLET
1 Electrolytic, Caloric, And Water Balance
TRICOR 145 MG TABLET 2 QL Cardiovascular Drugs
TRICOR 48 MG TABLET 2 QL Cardiovascular Drugs
TRIDERM 0.001 CREAM 1 Skin And Mucous Membrane Agents
TRIDERM 0.001 OINTMENT 1 Skin And Mucous Membrane Agents
TRIFLUOPERAZINE HCL 1 MG TABLET 1 Central Nervous Systems Agents
TRIFLUOPERAZINE HCL 10 MG TABLET 1 Central Nervous Systems Agents
TRIFLUOPERAZINE HCL 2 MG TABLET 1 Central Nervous Systems Agents
TRIFLUOPERAZINE HCL 5 MG TABLET 1 Central Nervous Systems Agents
TRIFLURIDINE 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TRIGLIDE 160 MG TABLET 3 QL Cardiovascular Drugs
TRIGLIDE 50 MG TABLET 3 QL Cardiovascular Drugs
TRIHEXYPHENIDYL HCL 0.4 MG/ML ELIXIR 1 Autonomic Drugs
TRIHEXYPHENIDYL HCL 2 MG TABLET 1 Autonomic Drugs
TRIHEXYPHENIDYL HCL 5 MG TABLET 1 Autonomic Drugs
TRIHIBIT 46.8 MCG;6.7 LFU;0 -;5 LFU KIT 3 Serums, Toxoids, And Vaccines
TRILEPTAL 300 MG/5ML SUSPENSION 3 Central Nervous Systems Agents
TRILEPTAL 150 MG TABLET 3 Central Nervous Systems Agents
TRILEPTAL 300 MG TABLET 3 Central Nervous Systems Agents
TRILEPTAL 600 MG TABLET 3 Central Nervous Systems Agents
TRILYTE 420 GM;1.48 GM;5.72 GM;11.2 GMSOLUTION
2 Gastrointestinal Drugs
TRIMETHOBENZAMIDE HCL 300 MG CAPSULES 1 Gastrointestinal Drugs
TRIMETHOBENZAMIDE HCL 100 MG/ML SOLUTION 1 Gastrointestinal Drugs
TRIMETHOPRIM 100 MG TABLET 1 Anti-Infective Agents
TRIMETHOPRIM SULFATE/POLY 10000 UNIT/ML;0.1% SOLUTION
1 Eye, Ear, Nose, And Throat (EENT)Preparations
TRIMETHOPRIM/SULFAMETHOXA 800 MG;160 MGTABLET
1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 163
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TRIMIPRAMINE MALEATE 25 MG CAPSULES 1 Central Nervous Systems Agents
TRIMIPRAMINE MALEATE 50 MG CAPSULES 1 Central Nervous Systems Agents
TRIMOX 500 MG CAPSULES 1 Anti-Infective Agents
TRINESSA 0 TABLET 1 Hormones And Synthetic Substitutes
TRIPEDIA 46.8 MCG/0.5ML;6.7 LFU/0.5ML;5LFU/0.5ML SUSPENSION
3 Serums, Toxoids, And Vaccines
TRIPHASIL 28 0 TABLET 3 Hormones And Synthetic Substitutes
TRISENOX 10 MG/10ML SOLUTION 4 Antineoplastic Agents
TRIVORA-28 0 TABLET 1 Hormones And Synthetic Substitutes
TRIZIVIR 300 MG;150 MG;300 MG TABLET 2 Anti-Infective Agents
TROPHAMINE 0 -;0.32 GM/100ML;0.73GM/100ML;0.19 GM/100ML;0.014 GM/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
TROPHAMINE 97 MEQ/L;0.54 GM/100ML;1.2GM/100ML;0.32 GM/100ML;0 - SOLUTION
3 Electrolytic, Caloric, And Water Balance
TROPICACYL 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TROPICACYL 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TROPICAMIDE 0.005 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TROPICAMIDE 0.01 SOLUTION 1 Eye, Ear, Nose, And Throat (EENT)Preparations
TRUSOPT 0.02 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
TRUVADA 200 MG;300 MG TABLET 2 Anti-Infective Agents
TWINJECT 0.15 MG/DOSE DEVICE 3 Autonomic Drugs
TWINJECT 0.3 MG/DOSE DEVICE 3 Autonomic Drugs
TWINRIX 720 ELU/ML;20 MCG/ML SUSPENSION 3 Serums, Toxoids, And Vaccines
TYGACIL 50 MG SOLUTION 3 Anti-Infective Agents
TYKERB 250 MG TABLET 4 QL, PA Antineoplastic Agents
TYLENOL/CODEINE #3 300 MG;30 MG TABLET 3 QL Central Nervous Systems Agents
TYLENOL/CODEINE #4 300 MG;60 MG TABLET 3 QL Central Nervous Systems Agents
TYLOX 500 MG;5 MG CAPSULES 3 QL Central Nervous Systems Agents
TYPHIM VI 25 MCG/0.5ML SOLUTION 3 Serums, Toxoids, And Vaccines
TYSABRI 300 MG/15ML CONCENTRATION 4 Miscellaneous Therapeutic Agents
TYZEKA 600 MG TABLET 3 QL Anti-Infective Agents
TYZINE 0.001 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT)Preparations
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
164 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
TYZINE PEDIATRIC NASAL DR 0.0005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
U-CORT 1 %;10 % CREAM 1 Skin And Mucous Membrane Agents
ULTRABAG/DIANEAL LOW CALC 18.3 MG/100ML;1.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
ULTRABAG/DIANEAL LOW CALC 18.3 MG/100ML;2.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
ULTRABAG/DIANEAL LOW CALC 18.3MG/100ML;4.25 %;5.08 MG/100ML;538MG/100ML;448 MG/100ML SOLUTION
3 Electrolytic, Caloric, And Water Balance
ULTRABAG/DIANEAL PD-2/1.5 25.7 MG/100ML;1.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
ULTRABAG/DIANEAL PD-2/2.5 25.7 MG/100ML;2.5%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
ULTRABAG/DIANEAL PD-2/4.2 25.7 MG/100ML;4.25%;5.08 MG/100ML;538 MG/100ML;448 MG/100MLSOLUTION
3 Electrolytic, Caloric, And Water Balance
ULTRACAPS MT 20 65000 UNIT;20000 UNIT;65000UNIT CAPSULES
1 Gastrointestinal Drugs
ULTRACET 325 MG;37.5 MG TABLET 3 QL Central Nervous Systems Agents
ULTRAM 50 MG TABLET 3 QL, PA Central Nervous Systems Agents
ULTRAM ER 100 MG TABLET 3 QL, ST Central Nervous Systems Agents
ULTRAM ER 200 MG TABLET 3 QL, ST Central Nervous Systems Agents
ULTRAM ER 300 MG TABLET 3 QL, ST Central Nervous Systems Agents
ULTRASE 20000 UNIT;4500 UNIT;25000 UNITCAPSULES
2 Gastrointestinal Drugs
ULTRASE MT 12 39000 UNIT;12000 UNIT;39000 UNITCAPSULES
2 Gastrointestinal Drugs
ULTRASE MT 18 58500 UNIT;18000 UNIT;58500 UNITCAPSULES
2 Gastrointestinal Drugs
ULTRASE MT 20 65000 UNIT;20000 UNIT;65000 UNITCAPSULES
2 Gastrointestinal Drugs
ULTRAVATE 0.0005 CREAM 3 Skin And Mucous Membrane Agents
ULTRAVATE 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents
UNASYN 1 GM;0.5 GM SOLUTION 3 Anti-Infective Agents
UNASYN 2 GM;1 GM SOLUTION 3 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 165
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
UNASYN ADD-VANTAGE 1 GM;0.5 GM SOLUTION 3 Anti-Infective Agents
UNASYN ADD-VANTAGE 2 GM;1 GM SOLUTION 3 Anti-Infective Agents
UNASYN BULK PACK 10 GM;5 GM SOLUTION 3 Anti-Infective Agents
UNASYN PIGGYBACK UNIT 1 GM;0.5 GM SOLUTION 3 Anti-Infective Agents
UNASYN PIGGYBACK UNIT 2 GM;1 GM SOLUTION 3 Anti-Infective Agents
UNI-OTIC 0.1 %;1 % LIQUID 1 Eye, Ear, Nose, And Throat (EENT)Preparations
UNIPHYL 400 MG TABLET 2 Smooth Muscle Relaxants
UNIPHYL 600 MG TABLET 2 Smooth Muscle Relaxants
UNIRETIC 12.5 MG;15 MG TABLET 3 Cardiovascular Drugs
UNIRETIC 12.5 MG;7.5 MG TABLET 3 Cardiovascular Drugs
UNIRETIC 25 MG;15 MG TABLET 3 Cardiovascular Drugs
UNITHROID 100 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 112 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 125 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 150 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 175 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 200 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 25 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 300 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 50 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 75 MCG TABLET 1 Hormones And Synthetic Substitutes
UNITHROID 88 MCG TABLET 1 Hormones And Synthetic Substitutes
UNIVASC 15 MG TABLET 3 Cardiovascular Drugs
UNIVASC 7.5 MG TABLET 3 Cardiovascular Drugs
URECHOLINE 10 MG TABLET 3 Autonomic Drugs
URECHOLINE 25 MG TABLET 3 Autonomic Drugs
URECHOLINE 5 MG TABLET 3 Autonomic Drugs
URECHOLINE 50 MG TABLET 3 Autonomic Drugs
UREX 1 GM TABLET 1 Anti-Infective Agents
URISPAS 100 MG TABLET 3 ST Smooth Muscle Relaxants
UROCIT-K 10 1080 MG TABLET 3 Electrolytic, Caloric, And Water Balance
UROCIT-K 5 540 MG TABLET 3 Electrolytic, Caloric, And Water Balance
UROXATRAL 10 MG TABLET 3 QL Miscellaneous Therapeutic Agents
URSO 250 250 MG TABLET 3 Gastrointestinal Drugs
URSO FORTE 500 MG TABLET 3 Gastrointestinal Drugs
URSODIOL 300 MG CAPSULES 1 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
166 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
UVADEX 20 MCG/ML SOLUTION 3 Skin And Mucous Membrane Agents
VAGIFEM 25 MCG TABLET 3 Hormones And Synthetic Substitutes
VALCYTE 450 MG TABLET 4 Anti-Infective Agents
VALPROATE SODIUM 100 MG/ML SOLUTION 1 Central Nervous Systems Agents
VALPROIC ACID 250 MG CAPSULES 1 Central Nervous Systems Agents
VALPROIC ACID 0 LIQUID 1 Central Nervous Systems Agents
VALPROIC ACID 250 MG/5ML SYRUP 1 Central Nervous Systems Agents
VALTREX 1 GM TABLET 2 QL Anti-Infective Agents
VALTREX 500 MG TABLET 2 QL Anti-Infective Agents
VANACET 500 MG;5 MG TABLET 1 QL Central Nervous Systems Agents
VANCOCIN HCL 125 MG CAPSULES 4 QL Anti-Infective Agents
VANCOCIN HCL 250 MG CAPSULES 4 QL Anti-Infective Agents
VANCOCIN HCL 0 -;1 GM/200ML SOLUTION 3 Anti-Infective Agents
VANCOCIN HCL ISO-OSMOTIC 0 -;500 MG/100MLSOLUTION
3 Anti-Infective Agents
VANCOMYCIN HCL 10 GM SOLUTION 1 Anti-Infective Agents
VANCOMYCIN HCL 1000 MG SOLUTION 1 Anti-Infective Agents
VANCOMYCIN HCL 500 MG SOLUTION 1 Anti-Infective Agents
VANCOMYCIN HCL 5000 MG SOLUTION 1 Anti-Infective Agents
VANDAZOLE 0.0075 GEL 1 Skin And Mucous Membrane Agents
VANOS 0.001 CREAM 3 Skin And Mucous Membrane Agents
VANSPAR 7.5 MG TABLET 3 Central Nervous Systems Agents
VANTAS 50 MG KIT 3 Antineoplastic Agents
VANTIN 100 MG/5ML SUSPENSION 3 Anti-Infective Agents
VANTIN 50 MG/5ML SUSPENSION 3 Anti-Infective Agents
VANTIN 100 MG TABLET 3 Anti-Infective Agents
VANTIN 200 MG TABLET 3 Anti-Infective Agents
VAQTA 25 UNIT/0.5ML INJECTION 3 Serums, Toxoids, And Vaccines
VAQTA 50 UNIT/ML INJECTION 3 Serums, Toxoids, And Vaccines
VARIVAX 1350 PFU/0.5ML INJECTION 2 Serums, Toxoids, And Vaccines
VASERETIC 10 MG;25 MG TABLET 3 Cardiovascular Drugs
VASOTEC 10 MG TABLET 3 Cardiovascular Drugs
VASOTEC 2.5 MG TABLET 3 Cardiovascular Drugs
VASOTEC 20 MG TABLET 3 Cardiovascular Drugs
VASOTEC 5 MG TABLET 3 Cardiovascular Drugs
VECTIBIX 200 MG/10ML SOLUTION 4 PA Antineoplastic Agents
VEETIDS 125 MG/5ML SOLUTION 1 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 167
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
VEETIDS 250 MG TABLET 1 Anti-Infective Agents
VEETIDS 500 MG TABLET 1 Anti-Infective Agents
VELCADE 3.5 MG SOLUTION 4 Antineoplastic Agents
VELIVET 0 TABLET 1 Hormones And Synthetic Substitutes
VENLAFAXINE HCL 100 MG TABLET 1 Central Nervous Systems Agents
VENLAFAXINE HCL 25 MG TABLET 1 Central Nervous Systems Agents
VENLAFAXINE HCL 37.5 MG TABLET 1 Central Nervous Systems Agents
VENLAFAXINE HCL 50 MG TABLET 1 Central Nervous Systems Agents
VENLAFAXINE HCL 75 MG TABLET 1 Central Nervous Systems Agents
VENOGLOBULIN-S 0.1 INJECTION 4 PA Serums, Toxoids, And Vaccines
VENTAVIS 10 MCG/ML SOLUTION 4 QL, PA Cardiovascular Drugs
VENTOLIN HFA 108 MCG/ACT AEROSOL SOLUTION 3 QL, ST Autonomic Drugs
VERAMYST 27.5 MCG/SPRAY SUSPENSION 3 QL, ST Eye, Ear, Nose, And Throat (EENT)Preparations
VERAPAMIL HCL 2.5 MG/ML SOLUTION 1 Cardiovascular Drugs
VERAPAMIL HCL 120 MG TABLET 1 Cardiovascular Drugs
VERAPAMIL HCL 40 MG TABLET 1 Cardiovascular Drugs
VERAPAMIL HCL 80 MG TABLET 1 Cardiovascular Drugs
VERAPAMIL HCL ER 120 MG CAPSULES 1 QL Cardiovascular Drugs
VERAPAMIL HCL ER 180 MG CAPSULES 1 QL Cardiovascular Drugs
VERAPAMIL HCL ER 240 MG CAPSULES 1 QL Cardiovascular Drugs
VERAPAMIL HCL ER 120 MG TABLET 1 Cardiovascular Drugs
VERAPAMIL HCL ER 180 MG TABLET 1 Cardiovascular Drugs
VERAPAMIL HCL ER 240 MG TABLET 1 Cardiovascular Drugs
VERAPAMIL HCL SR 120 MG TABLET 1 QL Cardiovascular Drugs
VERDESO 0.0005 FOAM 3 Skin And Mucous Membrane Agents
VERELAN 120 MG CAPSULES 3 QL Cardiovascular Drugs
VERELAN 180 MG CAPSULES 3 QL Cardiovascular Drugs
VERELAN 240 MG CAPSULES 3 QL Cardiovascular Drugs
VERELAN 360 MG CAPSULES 3 QL Cardiovascular Drugs
VERELAN PM 100 MG CAPSULES 3 QL Cardiovascular Drugs
VERELAN PM 200 MG CAPSULES 3 QL Cardiovascular Drugs
VERELAN PM 300 MG CAPSULES 3 QL Cardiovascular Drugs
VESANOID 10 MG CAPSULES 4 Antineoplastic Agents
VESICARE 10 MG TABLET 2 QL Smooth Muscle Relaxants
VESICARE 5 MG TABLET 2 QL Smooth Muscle Relaxants
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
168 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
VEXOL 0.01 SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
VFEND 40 MG/ML SUSPENSION 4 QL Anti-Infective Agents
VFEND 200 MG TABLET 4 QL Anti-Infective Agents
VFEND 50 MG TABLET 4 QL Anti-Infective Agents
VFEND IV 200 MG SOLUTION 4 Anti-Infective Agents
VIADUR 120 MCG/24HR KIT 3 QL, PA Antineoplastic Agents
VIBRAMYCIN 100 MG CAPSULES 3 Anti-Infective Agents
VIBRAMYCIN 25 MG/5ML SUSPENSION 3 Anti-Infective Agents
VIBRAMYCIN 50 MG/5ML SYRUP 3 Anti-Infective Agents
VIBRATAB 100 MG TABLET 3 Anti-Infective Agents
VICODIN 500 MG;5 MG TABLET 3 QL Central Nervous Systems Agents
VICODIN ES 750 MG;7.5 MG TABLET 3 QL Central Nervous Systems Agents
VICODIN HP 660 MG;10 MG TABLET 3 QL Central Nervous Systems Agents
VICOPROFEN 7.5 MG;200 MG TABLET 3 QL Central Nervous Systems Agents
VIDAZA 100 MG SUSPENSION 4 PA Antineoplastic Agents
VIDEX 2 GM SOLUTION 2 Anti-Infective Agents
VIDEX 4 GM SOLUTION 2 Anti-Infective Agents
VIDEX EC 125 MG CAPSULES 2 Anti-Infective Agents
VIDEX EC 200 MG CAPSULES 2 Anti-Infective Agents
VIDEX EC 250 MG CAPSULES 2 Anti-Infective Agents
VIDEX EC 400 MG CAPSULES 2 Anti-Infective Agents
VIGAMOX 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
VINBLASTINE SULFATE 1 MG/ML SOLUTION 1 Antineoplastic Agents
VINBLASTINE SULFATE 10 MG SOLUTION 1 Antineoplastic Agents
VINCASAR PFS 1 MG/ML SOLUTION 1 Antineoplastic Agents
VINCRISTINE SULFATE 1 MG/ML SOLUTION 1 Antineoplastic Agents
VINORELBINE TARTRATE 10 MG/ML SOLUTION 4 Antineoplastic Agents
VINORELBINE TARTRATE 50 MG/5ML SOLUTION 4 Antineoplastic Agents
VINORELBINE TARTRATE 50 MG/ML SOLUTION 4 Antineoplastic Agents
VIOKASE 70000 UNIT;16800 UNIT;70000 UNITPOWDER
3 Gastrointestinal Drugs
VIOKASE 16 60000 UNIT;16000 UNIT;60000 UNITTABLET
3 Gastrointestinal Drugs
VIOKASE 8 30000 UNIT;8000 UNIT;30000 UNITTABLET
3 Gastrointestinal Drugs
VIRACEPT 50 MG/GM POWDER 2 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 169
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
VIRACEPT 250 MG TABLET 2 Anti-Infective Agents
VIRACEPT 625 MG TABLET 2 Anti-Infective Agents
VIRAMUNE 50 MG/5ML SUSPENSION 2 Anti-Infective Agents
VIRAMUNE 200 MG TABLET 2 Anti-Infective Agents
VIRAZOLE 6 GM SOLUTION 4 QL Anti-Infective Agents
VIREAD 300 MG TABLET 2 Anti-Infective Agents
VIROPTIC 0.01 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
VISICOL 0.398 GM;1.102 GM TABLET 3 Gastrointestinal Drugs
VISTARIL 25 MG CAPSULES 3 Central Nervous Systems Agents
VISTARIL 50 MG CAPSULES 3 Central Nervous Systems Agents
VISTARIL 25 MG/5ML SUSPENSION 3 Central Nervous Systems Agents
VISTIDE 75 MG/ML SOLUTION 4 Anti-Infective Agents
VIVACTIL 10 MG TABLET 3 Central Nervous Systems Agents
VIVACTIL 5 MG TABLET 3 Central Nervous Systems Agents
VIVAGLOBIN 160 MG/ML SOLUTION 4 PA Serums, Toxoids, And Vaccines
VIVELLE 0.05 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
VIVELLE 0.1 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
VIVELLE-DOT 0.025 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
VIVELLE-DOT 0.038 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
VIVELLE-DOT 0.05 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
VIVELLE-DOT 0.075 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
VIVELLE-DOT 0.1 MG/24HR PATCH 3 QL Hormones And Synthetic Substitutes
VIVITROL 380 MG SUSPENSION 4 PA Central Nervous Systems Agents
VIVOTIF BERNA 0 CAPSULES 3 Serums, Toxoids, And Vaccines
VOLTAREN 0.001 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
VOLTAREN 75 MG TABLET 3 Central Nervous Systems Agents
VOLTAREN-XR 100 MG TABLET 3 Central Nervous Systems Agents
VOPAC 650 MG;30 MG TABLET 3 Central Nervous Systems Agents
VOSPIRE ER 4 MG TABLET 3 Autonomic Drugs
VOSPIRE ER 8 MG TABLET 3 Autonomic Drugs
VUMON 30 MG/ML;500 MG/ML;60 MG/ML;10MG/ML SOLUTION
3 Antineoplastic Agents
VYTORIN 10 MG;10 MG TABLET 2 QL Cardiovascular Drugs
VYTORIN 10 MG;20 MG TABLET 2 QL Cardiovascular Drugs
VYTORIN 10 MG;40 MG TABLET 2 QL Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
170 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
VYTORIN 10 MG;80 MG TABLET 2 QL Cardiovascular Drugs
VYVANSE 30 MG CAPSULES 3 QL Central Nervous Systems Agents
VYVANSE 50 MG CAPSULES 3 QL Central Nervous Systems Agents
VYVANSE 70 MG CAPSULES 3 QL Central Nervous Systems Agents
WARFARIN SODIUM 1 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WARFARIN SODIUM 10 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WARFARIN SODIUM 2 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WARFARIN SODIUM 2.5 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WARFARIN SODIUM 3 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WARFARIN SODIUM 4 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WARFARIN SODIUM 5 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WARFARIN SODIUM 6 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WARFARIN SODIUM 7.5 MG TABLET 1 Blood Formation, Coagulation, AndThrombosis
WELCHOL 625 MG TABLET 2 Cardiovascular Drugs
WELLBUTRIN 100 MG TABLET 3 Central Nervous Systems Agents
WELLBUTRIN 75 MG TABLET 3 Central Nervous Systems Agents
WELLBUTRIN SR 100 MG TABLET 3 QL Central Nervous Systems Agents
WELLBUTRIN SR 150 MG TABLET 3 QL Central Nervous Systems Agents
WELLBUTRIN SR 200 MG TABLET 3 QL Central Nervous Systems Agents
WELLBUTRIN XL 150 MG TABLET 2 QL Central Nervous Systems Agents
WELLBUTRIN XL 300 MG TABLET 2 QL Central Nervous Systems Agents
WESTCORT 0.002 CREAM 3 Skin And Mucous Membrane Agents
WESTCORT 0.002 OINTMENT 3 Skin And Mucous Membrane Agents
XALATAN 0.005% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT)Preparations
XIBROM 0.0009 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
XIFAXAN 200 MG TABLET 3 QL, ST Anti-Infective Agents
XODOL 300 MG;10 MG TABLET 3 QL Central Nervous Systems Agents
XODOL 300 MG;5 MG TABLET 3 QL Central Nervous Systems Agents
XODOL 300 MG;7.5 MG TABLET 3 QL Central Nervous Systems Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 171
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
XOLAIR 150 MG SOLUTION 4 QL, PA Respiratory Tract Agents
XOLEGEL 0.02 GEL 3 Skin And Mucous Membrane Agents
XOPENEX 0.31 MG/3ML NEBULIZER 3 Autonomic Drugs
XOPENEX 0.63 MG/3ML NEBULIZER 3 Autonomic Drugs
XOPENEX 1.25 MG/3ML NEBULIZER 3 Autonomic Drugs
XOPENEX CONCENTRATE 1.25 MG/0.5ML NEBULIZER 3 Autonomic Drugs
XOPENEX HFA 45 MCG/ACT AEROSOL 3 QL, ST Autonomic Drugs
XYLOCAINE 0.005 SOLUTION 3 Local Anesthetics
XYLOCAINE 0.01 SOLUTION 3 Local Anesthetics
XYLOCAINE 0.02 SOLUTION 3 Local Anesthetics
XYLOCAINE 0.04 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
XYLOCAINE 20 MG/ML SOLUTION 3 Cardiovascular Drugs
XYLOCAINE JELLY 0.02 GEL 3 Eye, Ear, Nose, And Throat (EENT)Preparations
XYLOCAINE VISCOUS 0.02 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
XYREM 500 MG/ML SOLUTION 4 Central Nervous Systems Agents
YASMIN 28 3 MG;0.03 MG TABLET 3 Hormones And Synthetic Substitutes
YAZ 3 MG;0.02 MG TABLET 3 Hormones And Synthetic Substitutes
YF-VAX 0 INJECTION 3 Serums, Toxoids, And Vaccines
Z-CLINZ 10 10 %;1 % KIT 3 Skin And Mucous Membrane Agents
Z-CLINZ 5 5 %;1 % KIT 3 Skin And Mucous Membrane Agents
ZANAFLEX 2 MG CAPSULES 3 ST Autonomic Drugs
ZANAFLEX 4 MG CAPSULES 3 ST Autonomic Drugs
ZANAFLEX 6 MG CAPSULES 3 ST Autonomic Drugs
ZANAFLEX 2 MG TABLET 3 PA Autonomic Drugs
ZANAFLEX 4 MG TABLET 3 PA Autonomic Drugs
ZANOSAR 1 GM SOLUTION 3 Antineoplastic Agents
ZANTAC 150 MG PACK 3 Gastrointestinal Drugs
ZANTAC 25 MG/ML SOLUTION 3 Gastrointestinal Drugs
ZANTAC 50 MG/50ML;0.45 % SOLUTION 3 Gastrointestinal Drugs
ZANTAC 15 MG/ML SYRUP 3 Gastrointestinal Drugs
ZANTAC 150 MG TABLET 3 Gastrointestinal Drugs
ZANTAC 150 MG TABLET 3 Gastrointestinal Drugs
ZANTAC 25 MG TABLET 3 Gastrointestinal Drugs
ZANTAC 300 MG TABLET 3 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
172 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ZARONTIN 250 MG CAPSULES 3 Central Nervous Systems Agents
ZARONTIN 250 MG/5ML SOLUTION 3 Central Nervous Systems Agents
ZAROXOLYN 10 MG TABLET 3 Electrolytic, Caloric, And Water Balance
ZAROXOLYN 2.5 MG TABLET 3 Electrolytic, Caloric, And Water Balance
ZAROXOLYN 5 MG TABLET 3 Electrolytic, Caloric, And Water Balance
ZAVESCA 100 MG CAPSULES 4 QL Miscellaneous Therapeutic Agents
ZAZOLE 0.004 CREAM 1 Skin And Mucous Membrane Agents
ZAZOLE 0.008 CREAM 1 Skin And Mucous Membrane Agents
ZAZOLE 80 MG SUPPOSITORY 1 Skin And Mucous Membrane Agents
ZEBETA 10 MG TABLET 3 Cardiovascular Drugs
ZEBETA 5 MG TABLET 3 Cardiovascular Drugs
ZEGERID 20 MG;1100 MG CAPSULES 3 QL Gastrointestinal Drugs
ZEGERID 40 MG;1100 MG CAPSULES 3 QL Gastrointestinal Drugs
ZELAPAR 1.25 MG TABLET 3 Central Nervous Systems Agents
ZEMAIRA 1000 MG SOLUTION 4 QL, PA Enzymes
ZEMPLAR 1 MCG CAPSULES 3 QL Vitamins
ZEMPLAR 2 MCG CAPSULES 3 QL Vitamins
ZEMPLAR 4 MCG CAPSULES 3 QL Vitamins
ZEMPLAR 2 MCG/ML SOLUTION 3 QL Vitamins
ZEMPLAR 5 MCG/ML SOLUTION 3 QL Vitamins
ZENAPAX 25 MG/5ML CONCENTRATION 4 Miscellaneous Therapeutic Agents
ZERIT 15 MG CAPSULES 2 Anti-Infective Agents
ZERIT 20 MG CAPSULES 2 Anti-Infective Agents
ZERIT 30 MG CAPSULES 2 Anti-Infective Agents
ZERIT 40 MG CAPSULES 2 Anti-Infective Agents
ZERIT 1 MG/ML SOLUTION 2 Anti-Infective Agents
ZERLOR 712.8 MG;60 MG;32 MG TABLET 1 QL Central Nervous Systems Agents
ZESTORETIC 12.5 MG;10 MG TABLET 3 Cardiovascular Drugs
ZESTORETIC 12.5 MG;20 MG TABLET 3 Cardiovascular Drugs
ZESTORETIC 25 MG;20 MG TABLET 3 Cardiovascular Drugs
ZESTRIL 10 MG TABLET 3 Cardiovascular Drugs
ZESTRIL 2.5 MG TABLET 3 Cardiovascular Drugs
ZESTRIL 20 MG TABLET 3 Cardiovascular Drugs
ZESTRIL 30 MG TABLET 3 Cardiovascular Drugs
ZESTRIL 40 MG TABLET 3 Cardiovascular Drugs
ZESTRIL 5 MG TABLET 3 Cardiovascular Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 173
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ZETIA 10 MG TABLET 2 QL Cardiovascular Drugs
ZIAC 10 MG;6.25 MG TABLET 3 Cardiovascular Drugs
ZIAC 2.5 MG;6.25 MG TABLET 3 Cardiovascular Drugs
ZIAC 5 MG;6.25 MG TABLET 3 Cardiovascular Drugs
ZIAGEN 20 MG/ML SOLUTION 2 Anti-Infective Agents
ZIAGEN 300 MG TABLET 2 Anti-Infective Agents
ZIANA 1.2 %;0.025 % GEL 3 Skin And Mucous Membrane Agents
ZIDOVUDINE 100 MG CAPSULES 1 Anti-Infective Agents
ZIDOVUDINE 50 MG/5ML SYRUP 1 Anti-Infective Agents
ZIDOVUDINE 300 MG TABLET 1 Anti-Infective Agents
ZINACEF 1.5 GM SOLUTION 3 Anti-Infective Agents
ZINACEF 1.5 GM SOLUTION 3 Anti-Infective Agents
ZINACEF 1.5 GM;0 - SOLUTION 3 Anti-Infective Agents
ZINACEF 7.5 GM SOLUTION 3 Anti-Infective Agents
ZINACEF 750 MG SOLUTION 3 Anti-Infective Agents
ZINACEF 750 MG SOLUTION 3 Anti-Infective Agents
ZINACEF 750 MG;0 - SOLUTION 3 Anti-Infective Agents
ZINACEF/D5W 1.5 GM/100ML;5 % SOLUTION 3 Anti-Infective Agents
ZINECARD 250 MG SOLUTION 4 Miscellaneous Therapeutic Agents
ZINECARD 500 MG SOLUTION 4 Miscellaneous Therapeutic Agents
ZITHROMAX 1 GM PACK 2 Anti-Infective Agents
ZITHROMAX 500 MG SOLUTION 3 Anti-Infective Agents
ZITHROMAX 100 MG/5ML SUSPENSION 2 Anti-Infective Agents
ZITHROMAX 200 MG/5ML SUSPENSION 2 Anti-Infective Agents
ZITHROMAX 250 MG TABLET 3 Anti-Infective Agents
ZITHROMAX 500 MG TABLET 3 Anti-Infective Agents
ZITHROMAX 600 MG TABLET 3 Anti-Infective Agents
ZITHROMAX TRI-PAK 500 MG TABLET 3 Anti-Infective Agents
ZITHROMAX Z-PAK 250 MG TABLET 3 Anti-Infective Agents
ZMAX 2 GM SUSPENSION 3 QL Anti-Infective Agents
ZOCOR 10 MG TABLET 3 QL, PA Cardiovascular Drugs
ZOCOR 20 MG TABLET 3 QL, PA Cardiovascular Drugs
ZOCOR 40 MG TABLET 3 QL, PA Cardiovascular Drugs
ZOCOR 5 MG TABLET 3 QL, PA Cardiovascular Drugs
ZOCOR 80 MG TABLET 3 QL, PA Cardiovascular Drugs
ZOFRAN 2 MG/ML SOLUTION 4 Gastrointestinal Drugs
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
174 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ZOFRAN 32 MG/50ML SOLUTION 4 Gastrointestinal Drugs
ZOFRAN 4 MG/5ML SOLUTION 4 Gastrointestinal Drugs
ZOFRAN 4 MG TABLET 4 QL, PA Gastrointestinal Drugs
ZOFRAN 8 MG TABLET 4 QL, PA Gastrointestinal Drugs
ZOFRAN ODT 4 MG TABLET 4 QL Gastrointestinal Drugs
ZOFRAN ODT 8 MG TABLET 4 QL, PA Gastrointestinal Drugs
ZOLADEX 10.8 MG IMPLANT 4 QL, PA Antineoplastic Agents
ZOLADEX 3.6 MG IMPLANT 4 QL, PA Antineoplastic Agents
ZOLINZA 100 MG CAPSULES 4 QL, PA Antineoplastic Agents
ZOLOFT 20 MG/ML CONCENTRATION 3 Central Nervous Systems Agents
ZOLOFT 100 MG TABLET 3 QL Central Nervous Systems Agents
ZOLOFT 25 MG TABLET 3 QL Central Nervous Systems Agents
ZOLOFT 50 MG TABLET 3 QL Central Nervous Systems Agents
ZOLPIDEM TARTRATE 10 MG TABLET 1 QL Central Nervous Systems Agents
ZOLPIDEM TARTRATE 5 MG TABLET 1 QL Central Nervous Systems Agents
ZOMETA 4 MG/5ML CONCENTRATION 4 QL Miscellaneous Therapeutic Agents
ZOMIG 5 MG SOLUTION 3 QL Central Nervous Systems Agents
ZOMIG 2.5 MG TABLET 3 QL Central Nervous Systems Agents
ZOMIG 5 MG TABLET 3 QL Central Nervous Systems Agents
ZOMIG ZMT 2.5 MG TABLET 3 QL Central Nervous Systems Agents
ZOMIG ZMT 5 MG TABLET 3 QL Central Nervous Systems Agents
ZONALON 0.05 CREAM 2 Skin And Mucous Membrane Agents
ZONEGRAN 100 MG CAPSULES 3 Central Nervous Systems Agents
ZONEGRAN 25 MG CAPSULES 3 Central Nervous Systems Agents
ZONISAMIDE 100 MG CAPSULES 1 Central Nervous Systems Agents
ZONISAMIDE 25 MG CAPSULES 1 Central Nervous Systems Agents
ZONISAMIDE 50 MG CAPSULES 1 Central Nervous Systems Agents
ZORBTIVE 8.8 MG SOLUTION 4 QL, PA Hormones And Synthetic Substitutes
ZOSTAVAX 19400 UNT/0.65ML SOLUTION 3 QL Serums, Toxoids, And Vaccines
ZOSYN 2 GM;0.25 GM SOLUTION 3 Anti-Infective Agents
ZOSYN 3 GM;0.375 GM SOLUTION 3 Anti-Infective Agents
ZOSYN 36 GM;4.5 GM SOLUTION 3 Anti-Infective Agents
ZOSYN 4 GM;0.5 GM SOLUTION 3 Anti-Infective Agents
ZOSYN 5 %;2 GM/50ML;0.25 GM/50ML SOLUTION 3 Anti-Infective Agents
ZOSYN 5 %;3 GM/50ML;0.375 GM/50ML SOLUTION 3 Anti-Infective Agents
ZOSYN 5 %;4 GM/100ML;0.5 GM/100ML SOLUTION 3 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 175
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ZOVIA 1/35E 35 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
ZOVIA 1/50E 50 MCG;1 MG TABLET 1 Hormones And Synthetic Substitutes
ZOVIRAX 200 MG CAPSULES 3 PA Anti-Infective Agents
ZOVIRAX 0.05 CREAM 3 PA Skin And Mucous Membrane Agents
ZOVIRAX 0.05 OINTMENT 3 PA Skin And Mucous Membrane Agents
ZOVIRAX 200 MG/5ML SUSPENSION 3 PA Anti-Infective Agents
ZOVIRAX 400 MG TABLET 3 PA Anti-Infective Agents
ZOVIRAX 800 MG TABLET 3 PA Anti-Infective Agents
ZYBAN 150 MG TABLET 3 QL Central Nervous Systems Agents
ZYDONE 400 MG;10 MG TABLET 3 QL Central Nervous Systems Agents
ZYDONE 400 MG;5 MG TABLET 3 QL Central Nervous Systems Agents
ZYDONE 400 MG;7.5 MG TABLET 3 QL Central Nervous Systems Agents
ZYFLO 600 MG TABLET 3 QL Respiratory Tract Agents
ZYLET 0.5 %;0.3 % SUSPENSION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ZYLOPRIM 100 MG TABLET 3 Miscellaneous Therapeutic Agents
ZYLOPRIM 300 MG TABLET 3 Miscellaneous Therapeutic Agents
ZYMAR 0.003 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT)Preparations
ZYPREXA 10 MG SOLUTION 3 QL Central Nervous Systems Agents
ZYPREXA 10 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA 15 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA 2.5 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA 20 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA 5 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA 7.5 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA ZYDIS 10 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA ZYDIS 15 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA ZYDIS 20 MG TABLET 2 QL Central Nervous Systems Agents
ZYPREXA ZYDIS 5 MG TABLET 2 QL Central Nervous Systems Agents
ZYRTEC 10 MG CHEWABLE 3 QL, ST Antihistamine Drugs
ZYRTEC 5 MG CHEWABLE 3 QL, ST Antihistamine Drugs
ZYRTEC 1 MG/ML SYRUP 3 QL, ST Antihistamine Drugs
ZYRTEC 10 MG TABLET 3 QL, PA, ST Antihistamine Drugs
ZYRTEC 5 MG TABLET 3 QL, PA, ST Antihistamine Drugs
ZYRTEC-D 5 MG;120 MG TABLET 3 QL, ST Antihistamine Drugs
ZYVOX 2 MG/ML SOLUTION 4 Anti-Infective Agents
PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy
176 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY
DRUG NAME TIERUTILIZATION
MANAGEMENTREQUIREMENTS
THERAPEUTIC CATEGORY
ZYVOX 100 MG/5ML SUSPENSION 4 QL Anti-Infective Agents
ZYVOX 600 MG TABLET 4 QL Anti-Infective Agents