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
International Journal of Gynecology and Obstetrics (2008) 100, 4–9a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o mw w w. e l s e v i e r. c o m / l o c a t e / i j g oA systematic review of randomized controlled trials toreduce hemorrhage during myomectomy foruterine fibroids ☆E.J. Kongnyuy a,⁎, N. van den Broek a, C.S. Wiysonge ba Child and Reproductive Health Group,
Timothy M. Uyeki,* Yu-Hoi Chong,† Jacqueline M. Katz,* Wilina Lim,† Yuk-Yin Ho,† Sophia S. Wang,* Thomas H.F. Tsang,* Winnie Wan-Yee Au,† Shuk-Chi Chan,† Thomas Rowe,* Jean Hu-Primmer,* Jensa C. Bell,* William W. Thompson,* Carolyn Buxton Bridges,* Nancy J. Cox,* Kwok-Hang Mak,† and Keiji Fukuda* In April 1999, isolation of avian influenza A (H9N2) viruses from humans wa