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2008 Prescription Drug Guide C0006_PDG_TEMP_FINAL_15 KC0807 M0006_PDG_TEMP_FINAL_15 KC0807 GN18658RR_PDG_NA_08 Humana Formulary Comprehensive List of Covered Drugs
Transcript

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

Notes

PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY - 177

Notes

178 - PRESCRIPTION DRUG GUIDE / HUMANA FORMULARY

Blank

C0006_PDG_TEMP_FINAL_15 KC0807M0006_PDG_TEMP_FINAL_15 KC0807 GN18658RR_PDG_NA_08_092007

Medicare approved PDP plans available to anyone entitled to Part Aand/or enrolled in Part B of Medicare through age or disability. Must use network pharmacies.

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