Agentdw.com

Level One – Includes low-cost generic and brand-name drugs.
Level Two – Includes higher cost generic and brand-name drugs.
Level Three – Includes high-cost, mostly brand-name drugs and some self-administered injectables. These drugs may have generic
or brand-name alternatives in Levels One or Two.
Level Four – Includes high technology drugs and self-administered injectable drugs, which are not available on other levels.
Listed below in alphabetical order are commonly prescribed drugs for each level. This is not a complete list. If there is a prescription
drug that is not on this list, go to Humana.com or call the Customer Service phone number on the back of the Humana member ID
card to see if it’s covered and into what level it falls.
* Specialty - plan specific copayments or cost share for high cost/high-technology drugs often requiring special dispensing conditions.
Specialty drug coverage varies by plan. Visit Humana.com and log in to MyHumana to view specific prescription drug benefits,
including copayments or cost share, limitations and exclusions. Note: The drugs in BOLD TYPE are generic drugs. The drugs in regular type are brand-name drugs.
IR = immediate release, SR = sustained release, ER = extended release, QL = quantity limit, PA = prior authorization,
ST = Step Therapy
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
ACARBOSE
ACEBUTOLOL HCL
ACETAZOLAMIDE
ACYCLOVIR
ADAPALENE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
ALBUTEROL SULFATE
ALENDRONATE SODIUM
ALLOPURINOL
ALPRAZOLAM
ALPRAZOLAM ER
ALPRAZOLAM ODT
ALPRAZOLAM XR
ALTAVERA
AMETHIA LO
AMETHYST
AMILORIDE HCL
AMIODARONE HCL
AMITRIPTYLINE HCL
AMLODIPINE BESYLATE
AMMONIUM LACTATE
AMNESTEEM
AMOXICILLIN
ANASTROZOLE
ANUCORT-HC
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
ATENOLOL
ATORVASTATIN CALCIUM
ATROPINE SULFATE
AZATHIOPRINE
AZELASTINE HCL
AZITHROMYCIN
AZURETTE
BACITRACIN
BACLOFEN
BALSALAZIDE DISODIUM
BENAZEPRIL HCL
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
BENZONATATE
BENZOYL PEROXIDE
BENZTROPINE MESYLATE
BETAMETHASONE VALERATE
BETHANECHOL CHLORIDE
BICALUTAMIDE
BRIMONIDINE TARTRATE
BROMFED DM
BROMOCRIPTINE MESYLATE
BUDEPRION SR
BUDEPRION XL
BUDESONIDE
BUMETANIDE
BUPRENORPHINE HCL
BUPROPION HCL
BUPROPION HCL SR
BUSPIRONE HCL
BUTORPHANOL TARTRATE
CABERGOLINE
CALCIPOTRIENE
CALCITONIN-SALMON
CALCITRIOL
CALCIUM ACETATE
CAMRESE LO
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
CAPTOPRIL
CARBAMAZEPINE
CARBAMAZEPINE ER
CARISOPRODOL
CARTIA XT
CARVEDILOL
CEFADROXIL
CEFDINIR
CEFPODOXIME PROXETIL
CEFPROZIL
CEFUROXIME AXETIL
CEPHALEXIN
CETIRIZINE HCL
CHLORDIAZEPOXIDE HCL
CHLORHEXIDINE GLUCONATE
CHLOROQUINE PHOSPHATE
CHLORPROMAZINE HCL
CHLORTHALIDONE
CHLORZOXAZONE
CHOLESTYRAMINE
CICLOPIROX
CILOSTAZOL
CIMETIDINE
CIPROFLOXACIN HCL
CLARAVIS
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
CLARITHROMYCIN
CLARITHROMYCIN ER
CLINDAMYCIN HCL
CLINDAMYCIN PALMITATE HCL
CLINDAMYCIN PHOSPHATE
CLOBETASOL PROPIONATE
CLOMIPRAMINE HCL
CLONAZEPAM
CLONIDINE PATCH
CLONIDINE HCL TAB
CLOPIDOGREL
CLORAZEPATE DIPOTASSIUM
CLOTRIMAZOLE
CLOZAPINE
CROMOLYN SODIUM
CYCLOBENZAPRINE HCL
CYCLOSPORINE MODIFIED
CYPROHEPTADINE HCL
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
DESIPRAMINE HCL
DESMOPRESSIN ACETATE
DESONIDE
DESOXIMETASONE
DEXAMETHASONE
DEXMETHYLPHENIDATE HCL
DEXTROAMPHETAMINE SULFATE
DIAZEPAM
DICLOFENAC POTASSIUM
DICLOXACILLIN SODIUM
DICYCLOMINE HCL
DIFLUNISAL
DILTIAZEM HCL
DIPHENHYDRAMINE HCL
DIPYRIDAMOLE
DISULFIRAM
DIVALPROEX SODIUM
DIVALPROEX SODIUM ER
DONEPEZIL HCL
DORZOLAMIDE HCL
DOXAZOSIN MESYLATE
DOXEPIN HCL
DOXYCYCLINE HYCLATE
DOXYCYCLINE MONOHYDRATE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
ECONAZOLE NITRATE
EMOQUETTE
ENALAPRIL MALEATE
ENOXAPARIN SODIUM
EPLERENONE
ERYTHROMYCIN
ESCITALOPRAM OXALATE
ESTAZOLAM
ESTRADIOL
ESTROPIPATE
ETHOSUXIMIDE
ETODOLAC
EXEMESTANE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
FAMCICLOVIR
FAMOTIDINE
FELODIPINE ER
FENOFIBRATE
FENTANYL PATCH
FENTANYL CITRATE VIAL
FEXOFENADINE HCL
FINASTERIDE
FIORICET
FLECAINIDE ACETATE
FLUCONAZOLE
FLUDROCORTISONE ACETATE
FLUNISOLIDE
FLUOCINOLONE ACETONIDE
FLUOCINONIDE
FLUOROURACIL
FLUOXETINE HCL
FLURAZEPAM HCL
FLURBIPROFEN
FLUTICASONE PROPIONATE
FLUVASTATIN
FLUVOXAMINE MALEATE
FOLIC ACID
FOSINOPRIL SODIUM
FUROSEMIDE
GABAPENTIN
GEMFIBROZIL
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
GENERLAC
GENTAMICIN SULFATE
GILTUSS TR
GLIMEPIRIDE
GLIPIZIDE
GLIPIZIDE ER
GLIPIZIDE XL
GLYBURIDE
GLYBURIDE MICRONIZED
GLYCOPYRROLATE
GUANFACINE HCL
HALOBETASOL PROPIONATE
HALOPERIDOL
HYDRALAZINE HCL
HYDROCHLOROTHIAZIDE
HYDROCORTISONE
HYDROCORTISONE BUTYRATE
HYDROCORTISONE VALERATE
HYDROMET
HYDROMORPHONE HCL
HYDROXYUREA
HYDROXYZINE HCL
HYDROXYZINE PAMOATE
HYOSCYAMINE SULFATE
IBANDRONATE SODIUM
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
IBUPROFEN
IMIPRAMINE HCL
IMIQUIMOD
INDAPAMIDE
INDOMETHACIN
INTROVALE
IPRATROPIUM BROMIDE
IRBESARTAN
ISONIAZID
ISOSORBIDE DINITRATE
ISOSORBIDE MONONITRATE ER
JANTOVEN
JEVANTIQUE
JOLIVETTE
KENALOG OINT
KETOCONAZOLE
KETOPROFEN
KETOROLAC TROMETHAMINE
KLOR-CON M10
KLOR-CON M20
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
LABETALOL HCL
LACTULOSE
LAMOTRIGINE
LANSOPRAZOLE
LATANOPROST
LEFLUNOMIDE
LETROZOLE
LEUCOVORIN CALCIUM
LEVETIRACETAM
LEVOCARNITINE
LEVOFLOXACIN
LEVOTHYROXINE SODIUM
LIDOCAINE
LIDOCAINE HCL VIAL
LIOTHYRONINE SODIUM
LISINOPRIL
LITHIUM CARBONATE ER
L-METHYLFOLATE CALCIUM
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
LORAZEPAM
LOSARTAN POTASSIUM
LOVASTATIN
LOW-OGESTREL
MATZIM LA
MEBENDAZOLE
MECLIZINE HCL
MEFLOQUINE HCL
MEGESTROL ACETATE
MELOXICAM
MEPERIDINE HCL
MEPERITAB
MERCAPTOPURINE
MESALAMINE
METAXALONE
METFORMIN HCL
METFORMIN HCL ER
METHADONE HCL
METHIMAZOLE
METHOCARBAMOL
METHOTREXATE TAB
METHOTREXATE VIAL
METHSCOPOLAMINE BROMIDE
METHYLDOPA
METHYLERGONOVINE MALEATE
METHYLPHENIDATE HCL
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
METHYLPREDNISOLONE
METOCLOPRAMIDE HCL
METOLAZONE
METOPROLOL TARTRATE
METRONIDAZOLE
MICROGESTIN FE
MIDODRINE HCL
MILLIPRED
MINOCYCLINE HCL
MINOXIDIL
MIRTAZAPINE
MISOPROSTOL
MODAFINIL
MOEXIPRIL HCL
MOMETASONE FUROATE
MONONESSA
MORPHINE SULFATE
MORPHINE SULFATE ER
MUPIROCIN
MYCOPHENOLATE MOFETIL
NABUMETONE
NALTREXONE HCL
NAPROXEN
NAPROXEN SODIUM
NARATRIPTAN HCL
NATEGLINIDE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
NEFAZODONE HCL
NIFEDIAC CC
NIFEDICAL XL
NIFEDIPINE
NIFEDIPINE ER
NISOLDIPINE
NIZATIDINE
NORETHINDRONE
NORETHINDRONE ACETATE
NORTRIPTYLINE HCL
NYSTATIN
OFLOXACIN
OGESTREL
OLANZAPINE
OMEPRAZOLE
ONDANSETRON HCL
ONDANSETRON ODT
ORPHENADRINE CITRATE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
ORSYTHIA
OXAZEPAM
OXCARBAZEPINE
OXYBUTYNIN CHLORIDE
OXYBUTYNIN CHLORIDE ER
OXYCODONE HCL
PANTOPRAZOLE SODIUM
PAROXETINE HCL
PENICILLIN V POTASSIUM
PERMETHRIN
PHENAZOPYRIDINE HCL
PHENOBARBITAL
PHENYTOIN SODIUM EXTENDED
PIROXICAM CAP
POLYETHYLENE GLYCOL 3350
POTASSIUM CITRATE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
PRASCION
PRAVASTATIN SODIUM
PRAZOSIN HCL
PREDNISOLONE
PREDNISONE
PRENAPLUS
PRENATAL 19
PRENATAL PLUS
PREVIFEM
PRIMIDONE
PROBENECID
PROCHLORPERAZINE MALEATE
PROCTOZONE-HC
PROGESTERONE
PROMETHAZINE HCL
PROMETHAZINE-DM
PROMETHEGAN
PROPAFENONE HCL
PROPRANOLOL HCL VIAL
PROPRANOLOL HCL CAP
PROPRANOLOL HCL TAB
PROPYLTHIOURACIL
PYRIDOSTIGMINE BROMIDE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
QUASENSE
QUETIAPINE FUMARATE
QUINAPRIL HCL
RAMIPRIL
RANITIDINE HCL
RECLIPSEN
REMICADE (covered via medical benefits on most RIBASPHERE
RIBAVIRIN
RIFAMPIN
RISPERIDONE
ROPINIROLE HCL
ROPINIROLE HCL ER
SALSALATE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
SERTRALINE HCL
SILVER SULFADIAZINE
SIMVASTATIN
SODIUM SULFACETAMIDE
SOTALOL HCL
SPIRONOLACTONE
SUCRALFATE
SULFACETAMIDE SODIUM
SULFASALAZINE
SULINDAC
SUMATRIPTAN
SUMATRIPTAN SUCCINATE
TACROLIMUS
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
TAMOXIFEN CITRATE
TAMSULOSIN HCL
TARON-C DHA
TAZTIA XT
TEMAZEPAM
TERAZOSIN HCL
TERCONAZOLE
TIMOLOL MALEATE
TINIDAZOLE
TIZANIDINE HCL
TOBRAMYCIN SULFATE
TOPIRAMATE
TORSEMIDE
TRAMADOL HCL
TRAMADOL HCL ER
TRANDOLAPRIL
TRAZODONE HCL
TRETINOIN
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
TRIAMCINOLONE ACETONIDE
TRIAZOLAM
TRIHEXYPHENIDYL HCL
TRI-LEGEST FE
TRIMETHOPRIM
TRINESSA
TRI-PREVIFEM
TRI-SPRINTEC
TRIVORA-28
URSODIOL
VALPROIC ACID
VENLAFAXINE HCL
VENLAFAXINE HCL ER
VERAPAMIL HCL
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
VITACIRC-B
VITAMIN D2
WARFARIN SODIUM
ZAFIRLUKAST
ZALEPLON
ZATEAN-PN PLUS
ZENCHENT
ZENCHENT FE
ZIPRASIDONE HCL
ZOLPIDEM TARTRATE
ZOLPIDEM TARTRATE ER
ZONISAMIDE
Utilization
Maintenance
Management
Drug Name
Specialty
Medication
Requirements
Prior authorization: before coverage for the drugs requiring prior authorization is extended, the prescribing physician must obtain prior authorization from Humana. Unless the physician requests and receives this approval from Humana, the prescription may not be covered. To request prior authorization, the physician should call Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546). This number is for physician use only. Hours of operation are between 8 a.m. and 6:30 p.m. EST, Monday through Friday.
Save even more with Rx4!
To get the most from the Rx4 prescription drug benefits, Humana provides a discount for many noncovered oral prescription drugs.
Members can save an average of 20 percent on drugs for weight loss, impotence, hair growth and smoking cessation, for example.
The discount is available at all major pharmacy chains except those in Mississippi.
Members can check out the Rx4 Pharmacy Discount Program link on MyHumana for the details on this program. It is not necessary to
show the printable Discount Card (shown online) when purchasing noncovered oral prescription drugs.
Please Note: This is a partial list.
All lists are subject to change. Benefits vary by plan. This Drug List may not apply to all plans. Please check the Summary of Benefits or
Humana.com for the specific prescription drug benefit, including copayments, limitations and exclusions. You may also call a Humana
Customer Service representative at the phone number on the back of the Humana member ID card.
Go to Humana.com for a current Drug List
Visit Humana’s Website for the most up-to-date Drug List. The online list is updated regularly. You can also learn more about the
prescription drug benefit and copayments. It is suggested that before members go to the pharmacy, they go to Humana.com, and log
in to MyHumana or click on “Register Now” for access to this information and more. Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plans of Michigan, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. – A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # 00187-0009 or administered by Humana Insurance Company or Humana Health Plan, Inc. For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company or Humana Health Plan, Inc.
Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company providing your benefits.
Our health benefit plans have limitations and exclusions.
Humana.com

Source: http://agentdw.com/Humana-Drug-List-grps-2013rx4%20cb.pdf

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