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2013

Prescription Drug Guide


Humana Formulary
List of covered drugs

Humana Gold Plus H4141-013 (HMO)

Athens Athens Metro Area

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Y0040_PDG13_595C CMS Approved

H4141013PDG1326713C_v6

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PDG014

Welcome to Humana!
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. What is the formulary? A formulary is a list of covered drugs selected by Humana, which worked with a team of healthcare providers, that represents the prescription therapies believed to be a necessary part of a quality treatment program. Humana will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Humana network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary change? Generally, if you take a drug on our 2013 formulary that was covered at the beginningof the year, we won't discontinue or reduce coverage of the drug during the 2013 coverage year. However, we may change the formulary when a new, less-expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released. We are required to notify members who are affected by the following changes to our formulary: We remove drugs from the formulary We add prior authorization, quantity limits or step-therapy restrictions on a drug We move a drug to a higher cost-sharing tier When one of these changes happens, we will notify members at least 60 days before the change or when the member requests a refill of the affected drug. If the Food and Drug Administration decides a drug on our formulary is unsafe or the drug's manufacturer removes the drug from the market, we'll immediately remove the drug from our formulary and notify members who take the drug. The enclosed formulary is current as of January 1, 2013. We will update our printed formularies each month, and they will be available on Humana.com . To get updated information about the drugs that Humana covers, please visit Humana.com . Select "Medicare Drug List" from the Humana Medicare Plans tab at the top left of the website. The Medicare Drug List search tool lets you search for your drug by name or drug type. For help and information, call Humana Customer Care at 1-800-457-4708. If you use a TTY, call 711. From Oct. 1 Feb. 14, you can call us seven days a week from 8 a.m. - 8 p.m. From Feb. 15 - Sept. 30, you can leave us a voicemail message after hours, Saturdays, Sundays and some public holidays. Just leave a message and select the reason for your call from the automated list. We'll call back by the end of the next business day. Please have your Humana ID card with you when you call.

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 3

How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 10. The drugs in this formulary are grouped into categories dependingon the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category "Cardiovascular Drugs." If you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug. The formulary also lists the Tier and Utilization Management Requirements for each drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 190. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. Prescription drugs are grouped into one of five tiers - Tier 1, Tier 2, Tier 3, Tier 4, or Tier 5. Generic drugs have the same active ingredientsas brand drugs and are prescribed for the same reasons. The Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength, purity, and stability as brand drugs. Your cost for generic drugs is usually lower than your cost for brand drugs. Tier 1 - Preferred Generic: Generic or brand drugs that are available at the lowest cost share for this plan Tier 2 - Non-Preferred Generic: Generic or brand drugs that the plan offers at a higher cost to you than Tier 1 Preferred Generic drugs Tier 3 - Preferred Brand: Generic or brand drugs that the plan offers at a lower cost to you than Tier 4 Non-Preferred Brand drugs Tier 4 - Non-Preferred Brand: Generic or brand drugs that the plan offers at a higher cost to you than Tier 3 Preferred Brand drugs Tier 5 - Specialty Tier: Some injectables and other high-cost drugs How much will I pay for Covered Drugs? The amount of money you pay depends on which drug tier your drug falls under in the formulary and whether you fill your prescription at a network pharmacy. Humana pays part of the costs for your covered drugs and you pay part of the costs, too. If you qualified for extra help with your drug costs, your costs may be different from those described above. Please refer to your Evidence of Coverage (EOC) or call Customer Care to find out what your costs are.

4 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization (PA): Humana requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Humana before you fill your prescriptions. If you don't get approval, Humana may not cover the drug. Quantity Limits (QL): For certain drugs, Humana limits the amount of the drug that we'll cover. Humana might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. Specialty drugs are limited to a 30-day supply regardless of tier placement. Step Therapy (ST): In some cases, Humana requires you to first try certain drugs to treat your medical condition before we'll cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Humana may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Humana will then cover Drug B. Part B versus Part D (B vs D): Some drugs may be covered under Medicare Part B or Part D dependingupon the circumstances. Information may need to be submitted describing the use and the place where you receive and take the drug so we can make the determination. For drugs that need prior authorization or step therapy or that fall outside of the noted quantity limits, your doctor can fax information about those drugs to Humana at 1-877-486-2621. Representatives are available Monday Friday, 8 a.m. - 6 p.m. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 10. You can also visit Humana.com to get more information about the restrictions applied to specific covered drugs. Just select "Medicare Drug List" from the Humana Medicare Plans tab at the top left of the website. The Medicare Drug List search tool lets you search for your drug by name or drug type. You can ask Humana to make an exception to these restrictions or limits. See the section "How do I request an exception to the formulary?" on page 6 for information about how to request an exception. Does healthcare reform impact my coverage? Medicare Coverage Gap Discount Program beginningin 2011: Starting Jan. 1, 2011, Medicare made changes to help with the cost of medicines while members are in the Prescription Drug Plan coverage gap, often called the "donut hole." The Centers for Medicare & Medicaid Services (CMS) work with the companies that make prescription medicines and health plans to give you nearly 52.5 percent off on many covered brand-name prescriptions while you are in the coverage gap. Remember that Medicare members who now receive the low-income subsidy ("Extra Help") or are covered by a qualified, commercial prescription plan through an employer will not receive this discount. Coverage in the "gap" for generic prescription medicines: Starting Jan. 1, 2011, Medicare made changes to help with the cost of medicines while members are in the Prescription Drug Plan coverage gap, often called the "donut hole." The Centers for Medicare & Medicaid Services (CMS) work with health plans to provide some generic drug coverage while you are in the coverage gap.

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 5

What if my drug is not on the formulary? If your drug isn't included in this list of covered drugs, you should visit Humana.com to see if your drug is covered. You can also contact Customer Care and ask if your drug is covered. If Humana doesn't cover your drug, you have two options: You can ask Customer Care for a list of similar drugs that are covered by Humana. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Humana. You can ask Humana to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the formulary? You can ask Humana to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it's not on our formulary. You can ask us not to apply coverage restrictions or limits on your drug. For example, if your drug has a quantity limit, you can ask us to not apply the limit and to cover more. You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a non-preferred drug, you can ask us to cover it as preferred instead. This would lower the amount of money you must pay for your drug. Please remember, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, Humana will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower-tiered drug or other restrictions wouldn't be as effective in treating your condition and/or would cause adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tier or utilization restriction exception. When you're requesting an exception, you should submit a statement from your doctor supporting your request. This is called a supporting statement. Generally, we must make our decision within 72 hours of getting your prescribing doctor's supporting statement. You can request a quicker, or expedited, exception if you or your doctor believe that your health could be seriously harmed by waiting as long as 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing doctor's supporting statement. What do I need to do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that aren't on our formulary. Or you may be taking a drug that is on our formulary, but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you can switch to an appropriate drug that we cover or if you should request a formulary exception so that we'll cover your drug. In certain cases, we may cover as much as a 30-day supply of your drug during the first 90 days you're a member of our plan while you talk to your doctor to decide the right steps for you to take. Here is what we will do for each of your current Part D drugs that aren't on our formulary, or if you have limited ability to get your drugs: We'll temporarily cover up to a 30-day supply of your medicine when you go to a pharmacy We won't pay for these drugs after your first 30-day supply, even if you have been a member of the plan for less than 90 days, unless we have granted you a formulary exception If you're a resident of a long-term care facility and you currently take Part D drugs that aren't on our formulary, we'll cover a temporary 98-day transition supply of your current drug therapy (unless you have a prescription written for fewer days). We'll cover more than one refill of these drugs for the first 90 days you're a member of our plan. We'll cover a 31-day emergency supply of your drug (unless you have a prescription for fewer days) while you ask for a formulary exception if: You need a drug that's not on our formulary or You have limited ability to get your drugs and 6 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

You're past the first 90 days of membership in our plan Throughout the plan year, you may have a change in your treatment setting (the place where you receive and take your medicine) because of the level of care you require. Such transitions include: Members who are discharged from a hospital or skilled-nursing facility to a home setting Members who are admitted to a hospital or skilled-nursing facility from a home setting Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit Members who give up Hospice Status and go back to standard Medicare Part A and B coverage Members discharged from chronic psychiatric hospitals with highly individualized drug regimens For these changes in treatment settings, Humana will cover as much as a 31-day temporary supply of a Part D-covered drug when you fill your prescription at a pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and receive approval for continued coverage of your drug. Humana will review these requests for continuation of therapy on a case-by-case basis when you're on a stabilized drug regimen that, if changed, is known to have risks. Transition Extension Humana makes arrangements on a case-by case basis to continue to provide necessary drugs to you with an extension of the transition period in the event your exception request or appeal has not been processed by the end of your transition period. A member Transition Policy is available on Humana's Medicare website, Humana.com , in the same area where the Prescription Drug Guides are displayed. Humana-Medicare.com - Find a Plan For help choosing the plan that's right for you, go to Humana-Medicare.com , enter your ZIP code, and click "Find a Plan" to use our online comparison tools. You can research your coverage options, compare benefits, and estimate your yearly costs with various plans. You can also estimate your monthly drug costs and get more information about your drugs.

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 7

For More Information


For more detailed information about your Humana prescription drug coverage, please review your Evidence of Coverage (EOC) and other plan materials. If you have questions about Humana, please visit our website at Humana.com . Select "Medicare Drug List" from the Humana Medicare Plans tab at the top left of the website. The Medicare Drug List search tool lets you search for your drug by name or drug type. You can also call Humana Customer Care at 1-800-457-4708. If you use a TTY, call 711. You can call seven days a week from 8 a.m. - 8 p.m. From Feb. 15 until the following Annual Election Period (AEP), you can leave us a voicemail message after hours, Saturdays, Sundays and some public holidays. Just leave a message and select the reason for your call from the automated list. We'll call back by the end of the next business day. Please have your Humana ID card with you when you call. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week. TTY users should call 1-877-486-2048. You can also visit www.medicare.gov.

8 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

Humana Formulary
The formulary that begins on the next page provides coverage information about some of the drugs covered by Humana. If you have trouble finding your drug in the list, turn to the Index that begins on page 190. How to read your formulary The first column of the chart lists categories of medical conditions in alphabetical order. The drug names are then listed in alphabetical order within each category. Brand-name drugs are CAPITALIZED and generic drugs are listed in lower case. Next to the drug name you may see an indicator to tell you about additional coverage information for that drug. You might see the following indicators: HI - Home Infusion drugs that are covered in the gap SP - Medicines that are typically available through a specialty pharmacy. Please contact your specialty pharmacy to make sure your drug is available MO - Drugs that are typically available through mail-order. Please contact your mail-order pharmacy to make sure your drug is available The second column lists the tier of the drug. See page 4 for more details on the drug tiers in your plan. The third column shows the Utilization Management Requirements for the drug. Humana may have special requirements for covering that drug. If the column is blank, then there are no utilization requirements for that drug. The supply for each drug is based on benefits and whether your doctor prescribes a supply for 30, 60, or 90 days. The amount of any quantity limits will also be in this column (Example: "QL - 30 for 30 days" means you can only get 30 doses every 30 days). See page 5 for more details on these requirements for your plan.

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 9

Formulary Start Cross Reference

DRUG NAME
ANTI-INFECTIVE AGENTS abacavir 300 mg tablet SP ABELCET 5 MG/ML IV MO acyclovir 200 mg capsule MO acyclovir 200 mg/5 ml susp MO acyclovir 400 mg tablet MO acyclovir 500 mg/10 ml vial MO acyclovir 800 mg tablet MO acyclovir sodium 1 gm vial MO acyclovir sodium 500 mg vial MO ALBENZA 200 MG TABLET MO ALINIA 100 MG/5 ML ORAL SUSP MO ALINIA 500 MG TABLET MO AMBISOME 50 MG IV SUSP MO amikacin (pf) 100 mg/2 ml MO amikacin 1,000 mg/4 ml vial MO amikacin 250 mg/ml disp syr MO amikacin 500 mg/2 ml HI,MO amikacin sulfate 100 mg/2 ml HI,MO amox tr-k clv 200-28.5 tab chw MO amox tr-k clv 200-28.5/5 susp MO amox tr-k clv 250-125 mg tab MO amox tr-k clv 250-62.5/5 susp MO amox tr-k clv 400-57 tab chew MO amox tr-k clv 400-57/5 susp MO amox tr-k clv 500-125 mg tab MO amox tr-k clv 600-42.9/5 susp MO amox tr-k clv 875-125 mg tab MO amoxicillin 125 mg tab chew MO amoxicillin 125 mg/5 ml susp MO amoxicillin 200 mg/5 ml susp MO amoxicillin 250 mg capsule MO amoxicillin 250 mg tab chew MO amoxicillin 250 mg/5 ml susp MO amoxicillin 400 mg/5 ml susp MO amoxicillin 500 mg capsule MO

TIER

UTILIZATION MANAGEMENT REQUIREMENTS


QL (60 per 30 days)

4 5 2 2 2 2 2 2 2 4 4 4 4 4 3 4 3 4 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1

QL (150 per 30 days) QL (40 per 30 days)

Need more information about the indicators displayed by the drug names? Please go to page 9. ST - Step Therapy QL - Quantity Limit PA - Prior Authorization B vs D - Part B versus Part D 10 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

DRUG NAME
amoxicillin 500 mg tablet MO amoxicillin 875 mg tablet MO amoxicillin-clav er 1,000-62.5 MO AMPHOTEC 100 MG VIAL MO AMPHOTEC 50 MG VIAL MO amphotericin b 50 mg vial MO ampicillin 1 gm a-v vial MO ampicillin 1 gm vial HI,MO ampicillin 10 gm vial HI,MO ampicillin 125 mg vial HI,MO ampicillin 125 mg/5 ml susp MO ampicillin 2 gm a-v vial MO ampicillin 2 gm vial MO ampicillin 250 mg vial MO ampicillin 250 mg/5 ml susp MO ampicillin 500 mg vial MO ampicillin tr 250 mg capsule MO ampicillin tr 500 mg capsule MO ampicillin-sulb 3 gm add vial MO ampicillin-sulbactam 1.5 gm vl MO ampicillin-sulbactam 15 gm vl HI,MO ampicillin-sulbactam 3 gm vial HI,MO ANCOBON 250 MG CAPSULE MO ANCOBON 500 MG CAPSULE MO APTIVUS 100 MG/ML ORAL SOLN SP APTIVUS 250 MG CAPSULE SP ARALEN 500 MG TABLET MO atovaquone-proguanil 250-100 MO atovaquone-proguanil 62.5-25 MO ATRIPLA 600 MG-200 MG-300 MG TABLET SP AVELOX IN SODIUM CHLORIDE (ISO-OSMOTIC) 400 MG/250 ML IV PIGGY BACK HI,MO AZACTAM 1 GRAM SOLUTION FOR INJECTION MO AZACTAM 2 GRAM SOLUTION FOR INJECTION HI,MO AZACTAM IN ISO-OSMOTIC DEXTROSE 1 GRAM/50 ML IV PIGGY BACK HI,MO

TIER
1 1 3 4 4 3 4 4 4 4 2 4 4 4 2 4 2 2 4 4 4 4 4 4 5 5 4 4 4 5 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (285 per 28 days) QL (120 per 30 days)

QL (30 per 30 days)

PA PA

Need more information about the indicators displayed by the drug names? Please go to page 9. ST - Step Therapy QL - Quantity Limit PA - Prior Authorization B vs D - Part B versus Part D 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 11

DRUG NAME
AZACTAM IN ISO-OSMOTIC DEXTROSE 2 GRAM/50 ML IV PIGGY BACK HI,MO azithromycin 1 gm pwd packet MO azithromycin 100 mg/5 ml susp MO azithromycin 2.5 gm bulk vial MO azithromycin 200 mg/5 ml susp MO azithromycin 250 mg tablet MO azithromycin 500 mg tablet MO azithromycin 600 mg tablet MO azithromycin i.v. 500 mg vial HI,MO aztreonam 1 gm vial MO aztreonam 2 gm vial MO AZULFIDINE 500 MG TABLET MO AZULFIDINE EN-TABS 500 MG TABLET,DELAYED RELEASE MO baciim 50,000 unit im MO bacitracin 50,000 units vial MO BACTRIM 400 MG-80 MG TABLET MO BACTRIM DS 800 MG-160 MG TABLET MO BARACLUDE 0.05 MG/ML ORAL SOLN SP BARACLUDE 0.5 MG TABLET SP BARACLUDE 1 MG TABLET SP BICILLIN C-R 1,200,000 UNIT/2 ML IM SYRINGE HI,MO BICILLIN C-R 900,000 UNIT-300K UNIT/2 ML IM SYRINGE HI,MO BICILLIN L-A 1,200,000 UNIT/2 ML IM SYRINGE MO BICILLIN L-A 2,400,000 UNIT/4 ML IM SYRINGE MO BICILLIN L-A 600,000 UNIT/ML IM SYRINGE MO BILTRICIDE 600 MG TABLET MO CANCIDAS 50 MG IV SOLUTION HI,MO CANCIDAS 70 MG IV SOLUTION HI,MO CAPASTAT 1 GRAM SOLUTION FOR INJECTION MO CAYSTON 75 MG/ML NEB SOLUTION MO CEDAX 180 MG/5 ML ORAL SUSP MO CEDAX 400 MG CAPSULE MO CEDAX 90 MG/5 ML ORAL SUSP MO cefaclor 250 mg capsule MO cefaclor 500 mg capsule MO

TIER
4 2 2 4 2 2 2 2 2 2 5 4 4 4 2 4 4 4 5 5 4 4 4 4 4 4 5 5 4 5 4 4 4 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (630 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

B vs D B vs D PA,QL (84 per 28 days)

Need more information about the indicators displayed by the drug names? Please go to page 9. ST - Step Therapy QL - Quantity Limit PA - Prior Authorization B vs D - Part B versus Part D 12 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

DRUG NAME
cefaclor er 500 mg tablet MO cefadroxil 1 gm tablet MO cefadroxil 250 mg/5 ml susp MO cefadroxil 500 mg capsule MO cefadroxil 500 mg/5 ml susp MO cefazolin 1 gm add-van vial MO cefazolin 1 gm vial HI,MO cefazolin 1 gm-d5w bag HI,MO cefazolin 10 gm vial MO cefazolin 2 gm-d5w bag MO cefazolin 20 gm bulk vial MO cefazolin 500 mg vial MO cefdinir 125 mg/5 ml susp MO cefdinir 250 mg/5 ml susp MO cefdinir 300 mg capsule MO cefepime 1 gm injection MO cefepime 2 gm injection MO cefepime hcl 1 gm vial HI,MO cefepime hcl 2 gram vial HI,MO cefepime-dextrose 1 gm/50 ml MO cefepime-dextrose 2 gm/50 ml MO cefotaxime sodium 1 gm vial HI,MO cefotaxime sodium 10 gm vial HI,MO cefotaxime sodium 2 gm vial HI,MO cefotaxime sodium 20 gm vial MO cefotaxime sodium 500 mg vial MO cefotetan 1 gm vial MO cefotetan 10 gm vial MO cefotetan 2 gm vial MO cefotetan-dextr 1 g duplex bag MO cefotetan-dextr 2 g duplex bag MO cefoxitin 1 gm piggyback bag MO cefoxitin 1 gm vial MO cefoxitin 10 gm vial MO cefoxitin 2 gm piggyback bag MO cefoxitin 2 gm vial MO

TIER
3 2 2 2 2 2 3 3 3 3 3 3 2 2 2 4 4 4 4 4 4 1 1 1 1 1 4 4 4 4 4 1 4 4 1 4

UTILIZATION MANAGEMENT REQUIREMENTS

Need more information about the indicators displayed by the drug names? Please go to page 9. ST - Step Therapy QL - Quantity Limit PA - Prior Authorization B vs D - Part B versus Part D 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 13

DRUG NAME
cefpodoxime 100 mg tablet MO cefpodoxime 100 mg/5 ml susp MO cefpodoxime 200 mg tablet MO cefpodoxime 50 mg/5 ml susp MO cefprozil 125 mg/5 ml susp MO cefprozil 250 mg tablet MO cefprozil 250 mg/5 ml susp MO cefprozil 500 mg tablet MO ceftazidime 1 gm piggyback MO ceftazidime 1 gm vial HI,MO ceftazidime 2 gm piggyback MO ceftazidime 2 gm vial HI,MO ceftazidime 500 mg vial MO ceftazidime 6 gm vial HI,MO ceftriaxone 1 gm piggyback MO ceftriaxone 1 gm vial HI,MO ceftriaxone 1 gm-d5w bag MO ceftriaxone 10 gm vial MO ceftriaxone 2 gm add vial HI,MO ceftriaxone 2 gm piggyback MO ceftriaxone 2 gm vial MO ceftriaxone 2 gm-d5w bag MO ceftriaxone 250 mg vial MO ceftriaxone 500 mg vial HI,MO cefuroxime 1.5g/50 ml bag MO cefuroxime 750 mg/50 ml bag MO cefuroxime axetil 250 mg tab MO cefuroxime axetil 500 mg tab MO cefuroxime sod 7.5 gm vial HI,MO cefuroxime sod 750 mg vial HI,MO cephalexin 125 mg/5 ml susp MO cephalexin 250 mg capsule MO cephalexin 250 mg tablet MO cephalexin 250 mg/5 ml susp MO cephalexin 500 mg capsule MO cephalexin 500 mg tablet MO

TIER
4 4 4 4 3 3 3 3 2 2 2 2 2 2 3 3 3 3 3 3 2 3 3 2 1 1 2 2 3 3 2 2 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

Need more information about the indicators displayed by the drug names? Please go to page 9. ST - Step Therapy QL - Quantity Limit PA - Prior Authorization B vs D - Part B versus Part D 14 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

DRUG NAME
chloramphen na succ 1 gm vl HI,MO chloroquine ph 250 mg tablet MO chloroquine ph 500 mg tablet MO ciprofloxacin 10 mg/ml vial MO ciprofloxacin 200 mg/20 ml vl MO ciprofloxacin 400 mg/40 ml vl HI,MO ciprofloxacin er 1,000 mg tab MO ciprofloxacin er 500 mg tablet MO ciprofloxacin hcl 100 mg tab MO ciprofloxacin hcl 250 mg tab MO ciprofloxacin hcl 500 mg tab MO ciprofloxacin hcl 750 mg tab MO ciprofloxacn-d5w 200 mg/100 ml MO ciprofloxacn-d5w 400 mg/200 ml MO CLAFORAN 1 GRAM SOLUTION FOR INJECTION MO CLAFORAN 10 GRAM SOLUTION FOR INJECTION MO CLAFORAN 2 GRAM SOLUTION FOR INJECTION MO CLAFORAN 500 MG SOLUTION FOR INJECTION MO clarithromycin 125 mg/5 ml sus MO clarithromycin 250 mg tablet MO clarithromycin 250 mg/5 ml sus MO clarithromycin 500 mg tablet MO clarithromycin er 500 mg tab MO CLEOCIN 150 MG CAPSULE MO CLEOCIN 150 MG/ML INJECTION HI,MO CLEOCIN 300 MG CAPSULE MO CLEOCIN 600 MG/4 ML IV MO CLEOCIN 75 MG CAPSULE MO CLEOCIN 900 MG/6 ML IV MO CLEOCIN IN D5W 300 MG/50 ML IV PIGGY BACK HI,MO CLEOCIN IN D5W 600 MG/50 ML IV PIGGY BACK HI,MO CLEOCIN IN D5W 900 MG/50 ML IV PIGGY BACK HI,MO clindamycin 150 mg/ml addvan MO clindamycin 75 mg/5 ml soln MO clindamycin hcl 150 mg capsule MO clindamycin hcl 300 mg capsule MO

TIER
3 2 2 2 2 2 2 2 1 1 1 1 2 2 4 4 4 4 2 2 2 2 2 4 4 4 4 4 4 4 4 4 2 4 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA PA

Need more information about the indicators displayed by the drug names? Please go to page 9. ST - Step Therapy QL - Quantity Limit PA - Prior Authorization B vs D - Part B versus Part D 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 15

DRUG NAME
clindamycin hcl 75 mg capsule MO clindamycin ph 900 mg/6 ml vl MO COARTEM 20 MG-120 MG TABLET MO colistimethate 150 mg vial MO COLY-MYCIN M PARENTERAL 150 MG SOLUTION FOR INJECTION MO COMPLERA 200 MG-25 MG-300 MG TABLET SP COPEGUS 200 MG TABLET SP CRIXIVAN 100 MG CAPSULE SP CRIXIVAN 200 MG CAPSULE SP CRIXIVAN 400 MG CAPSULE SP CUBICIN 500 MG IV SOLUTION HI,MO CYTOVENE 500 MG IV SOLUTION MO dapsone 100 mg tablet MO dapsone 25 mg tablet MO DARAPRIM 25 MG TABLET MO demeclocycline 150 mg tablet MO demeclocycline 300 mg tablet MO dicloxacillin 250 mg capsule MO dicloxacillin 500 mg capsule MO didanosine dr 125 mg capsule SP didanosine dr 200 mg capsule SP didanosine dr 250 mg capsule SP didanosine dr 400 mg capsule SP DIFICID 200 MG TABLET MO DIFLUCAN 10 MG/ML ORAL SUSP MO DIFLUCAN 100 MG TABLET MO DIFLUCAN 150 MG TABLET MO DIFLUCAN 200 MG TABLET MO DIFLUCAN 40 MG/ML ORAL SUSP MO DIFLUCAN 50 MG TABLET MO DIFLUCAN-DEXTR 400 MG/200 ML MO DIFLUCAN-SALINE 200 MG/100 ML MO DIFLUCAN-SALINE 400 MG/200 ML MO DORIBAX 250 MG IV SUSP MO DORIBAX 500 MG IV SUSP MO doxycycline hyc 100 mg vial MO

TIER
2 2 4 4 4 5 5 5 4 4 5 4 3 3 4 4 4 2 2 4 4 4 4 5 4 4 4 4 4 4 4 4 4 4 4 1

UTILIZATION MANAGEMENT REQUIREMENTS

QL (24 per 30 days)

QL (30 per 30 days) PA,QL (168 per 28 days) QL (720 per 30 days) QL (450 per 30 days) QL (270 per 30 days) B vs D

QL (90 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (20 per 10 days) PA QL (4 per 28 days) PA

Need more information about the indicators displayed by the drug names? Please go to page 9. ST - Step Therapy QL - Quantity Limit PA - Prior Authorization B vs D - Part B versus Part D 16 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

DRUG NAME
doxycycline hyc dr 100 mg cap MO doxycycline hyc dr 100 mg tab MO doxycycline hyc dr 75 mg tab MO doxycycline hyclate 100 mg cap MO doxycycline hyclate 100 mg tab MO doxycycline hyclate 50 mg cap MO doxycycline mono 100 mg cap MO doxycycline mono 100 mg tablet MO doxycycline mono 150 mg cap MO doxycycline mono 150 mg tablet MO doxycycline mono 50 mg cap MO doxycycline mono 50 mg tablet MO doxycycline mono 75 mg capsule MO doxycycline mono 75 mg tablet MO E.E.S. 400 400 MG TABLET MO E.E.S. GRANULES 200 MG/5 ML ORAL SUSP MO EDURANT 25 MG TABLET SP EMTRIVA 10 MG/ML ORAL SOLN SP EMTRIVA 200 MG CAPSULE SP EPIVIR 10 MG/ML ORAL SOLN SP EPIVIR 150 MG TABLET SP EPIVIR 300 MG TABLET SP EPIVIR HBV 100 MG TABLET SP EPIVIR HBV 25 MG/5 ML (5 MG/ML) ORAL SOLN SP EPZICOM 600 MG-300 MG TABLET SP ERAXIS(WATER DILUENT) 100 MG IV SOLUTION MO ERAXIS(WATER DILUENT) 50 MG IV SOLUTION MO ERY-TAB 250 MG TABLET,DELAYED RELEASE MO ERY-TAB 333 MG TABLET,DELAYED RELEASE MO ERY-TAB 500 MG TABLET,DELAYED RELEASE MO ERYPED 200 200 MG/5 ML ORAL SUSP MO ERYPED 400 400 MG/5 ML ORAL SUSP MO ERYTHROCIN 1,000 MG IV SOLUTION MO ERYTHROCIN 500 MG FILMTAB MO ERYTHROCIN 500 MG IV SOLUTION HI,MO ERYTHROCIN STEARATE 250 MG TABLET MO

TIER
1 2 2 2 2 2 4 4 5 4 4 2 3 2 4 4 4 4 4 4 4 4 4 4 5 4 4 4 4 4 4 4 1 1 1 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days)

QL (60 per 30 days) QL (30 per 30 days)

QL (30 per 30 days) QL (680 per 28 days) QL (30 per 30 days) QL (960 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (90 per 30 days) QL (1680 per 28 days) QL (30 per 30 days) B vs D B vs D

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DRUG NAME
erythromycin 250 mg filmtab MO erythromycin 500 mg filmtab MO erythromycin ec 250 mg cap MO erythromycin es 400 mg tab MO erythromycin-sulfisox susp MO ethambutol hcl 100 mg tablet MO ethambutol hcl 400 mg tablet MO FACTIVE 320 MG TABLET MO famciclovir 125 mg tablet MO famciclovir 250 mg tablet MO famciclovir 500 mg tablet MO fluconazole 10 mg/ml susp MO fluconazole 100 mg tablet MO fluconazole 150 mg tablet MO fluconazole 200 mg tablet MO fluconazole 40 mg/ml susp MO fluconazole 50 mg tablet MO fluconazole-dext 200 mg/100 ml MO fluconazole-dext 400 mg/200 ml HI,MO fluconazole-ns 100 mg/50 ml MO fluconazole-ns 200 mg/100 ml MO fluconazole-ns 400 mg/200 ml MO flucytosine 250 mg capsule MO flucytosine 500 mg capsule MO FLUMADINE 100 MG TABLET MO FORTAZ 1 GRAM IV SOLUTION MO FORTAZ 1 GRAM SOLUTION FOR INJECTION MO FORTAZ 2 GRAM IV SOLUTION MO FORTAZ 2 GRAM SOLUTION FOR INJECTION MO FORTAZ 500 MG SOLUTION FOR INJECTION MO FORTAZ 6 GRAM SOLUTION FOR INJECTION MO FORTAZ IN D5W 1 GRAM/50 ML IV PIGGY BACK HI,MO FORTAZ IN D5W 2 GRAM/50 ML IV PIGGY BACK HI,MO foscarnet 24 mg/ml infus bttl MO FOSCAVIR 24 MG/ML IV MO FUZEON 90 MG SUB-Q KIT SP

TIER
2 2 2 2 2 2 4 4 3 3 3 1 2 2 2 1 2 1 1 2 2 2 3 3 4 4 4 4 4 4 4 4 4 4 4 5

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

QL (4 per 28 days)

B vs D B vs D QL (60 per 30 days)

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DRUG NAME
FUZEON 90 MG SUB-Q SOLN MO ganciclovir 500 mg vial HI,MO gentamicin 10 mg/ml vial MO gentamicin 40 mg/ml vial HI,MO gentamicin 70 mg/ns 50 ml pb HI,MO gentamicin 80 mg/ns 50 ml pb HI,MO gentamicin 90 mg/ns 100 ml pb HI,MO gentamicin ped 10 mg/ml vial MO GRIFULVIN V 500 MG TABLET MO GRIS-PEG 125 MG TABLET MO GRIS-PEG 250 MG TABLET MO griseofulvin 125 mg/5 ml susp MO HELIDAC 250 MG-500 MG-262.4 MG ORAL PACK MO HEPSERA 10 MG TABLET SP HIPREX 1 GRAM TABLET MO hydroxychloroquine 200 mg tab MO imipenem-cilastatin 250 mg vl HI,MO imipenem-cilastatin 500 mg vl HI,MO INCIVEK 375 MG TABLET SP INFERGEN 15 MCG/0.5 ML SUB-Q SP INFERGEN 9 MCG/0.3 ML SUB-Q SP INTELENCE 100 MG TABLET SP INTELENCE 200 MG TABLET SP INTELENCE 25 MG TABLET MO INTRON A 10 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP INTRON A 10 MILLION UNIT/ML SP INTRON A 10 MILLION UNIT/ML INJECTION SP INTRON A 18 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP INTRON A 50 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP INTRON A 6 MILLION UNIT/ML INJECTION SP INVANZ 1 GRAM IV SOLUTION MO INVANZ 1 GRAM SOLUTION FOR INJECTION HI,MO INVIRASE 200 MG CAPSULE SP INVIRASE 500 MG TABLET SP ISENTRESS 400 MG TABLET SP iso gentamicin 100 mg/100 ml HI,MO

TIER
5 3 2 2 3 3 3 2 4 4 4 4 4 5 4 2 4 4 5 5 5 5 5 4 4 4 4 4 4 5 4 4 5 5 5 3

QL (60 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA

PA,QL (168 per 28 days) PA,QL (30 per 30 days) PA,QL (12 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (120 per 30 days) PA PA PA PA PA PA

QL (300 per 30 days) QL (120 per 30 days) QL (120 per 30 days)

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DRUG NAME
iso gentamicin 120 mg/100 ml MO isonarif 300 mg-150 mg capsule MO isoniazid 100 mg tablet MO isoniazid 100 mg/ml vial MO isoniazid 300 mg tablet MO isoniazid 50 mg/5 ml syrup MO isoton gentamicin 100 mg/50 ml MO isoton gentamicin 60 mg/100 ml MO isoton gentamicin 60 mg/50 ml HI,MO isoton gentamicin 80 mg/100 ml HI,MO itraconazole 100 mg capsule MO KALETRA 100 MG-25 MG TABLET SP KALETRA 200 MG-50 MG TABLET SP KALETRA 400 MG-100 MG/5 ML ORAL SOLN SP kanamycin 1 gm/3 ml vial MO KEFLEX 250 MG CAPSULE MO KEFLEX 500 MG CAPSULE MO KEFLEX 750 MG CAPSULE MO KETEK 300 MG TABLET MO KETEK 400 MG TABLET MO ketoconazole 200 mg tablet MO lamivudine 150 mg tablet SP lamivudine 300 mg tablet SP lamivudine-zidovudine tablet SP LEVAQUIN 250 MG/10 ML ORAL SOLN MO LEVAQUIN I.V. 25 MG/ML VIAL MO LEVAQUIN IN D5W 250 MG/50 ML IV PIGGY BACK MO LEVAQUIN IN D5W 500 MG/100 ML IV PIGGY BACK MO LEVAQUIN IN D5W 750 MG/150 ML IV PIGGY BACK HI,MO levofloxacin 25 mg/ml solution MO levofloxacin 250 mg tablet MO levofloxacin 500 mg tablet MO levofloxacin 500 mg/20 ml vial MO levofloxacin 750 mg tablet MO levofloxacin-d5w 250 mg/50 ml MO levofloxacin-d5w 500 mg/100 ml HI,MO

TIER
3 2 1 1 1 1 3 3 3 3 4 5 5 5 1 4 4 4 4 4 2 4 4 4 4 4 4 4 4 2 2 2 4 2 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (120 per 30 days) QL (300 per 30 days) QL (150 per 30 days)

PA PA

QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days)

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DRUG NAME
levofloxacin-d5w 750 mg/150 ml MO LEXIVA 50 MG/ML ORAL SUSP SP LEXIVA 700 MG TABLET SP LINCOCIN 300 MG/ML INJECTION HI,MO MALARONE 250 MG-100 MG TABLET MO MALARONE 62.5 MG-25 MG TABLET MO MAXIPIME 1 GM ADD-VANTAGE VL MO MAXIPIME 1 GRAM VIAL MO MAXIPIME 2 GM ADD-VANTAGE VL MO MAXIPIME 2 GRAM VIAL MO mebendazole 100 mg tab chew MO mefloquine hcl 250 mg tablet MO MEFOXIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK MO MEFOXIN IN DEXTROSE (ISO-OSMOTIC) 2 GRAM/50 ML IV PIGGY BACK MO MEPRON 750 MG/5 ML ORAL SUSP MO meropenem iv 1 gm vial MO meropenem iv 500 mg vial HI,MO MERREM 1 GRAM IV SOLUTION MO MERREM 500 MG IV SOLUTION MO methenamine hipp 1 gm tablet MO methenamine md 1 gm tablet MO methenamine md 500 mg tablet MO METRO I.V. 500 MG/100 ML PIGGY BACK MO metronidazole 250 mg tablet MO metronidazole 375 mg capsule MO metronidazole 500 mg tablet MO metronidazole 500 mg/100 ml HI,MO minocycline 100 mg capsule MO minocycline 50 mg capsule MO minocycline 75 mg capsule MO minocycline er 135 mg tablet MO minocycline er 45 mg tablet MO minocycline er 90 mg tablet MO minocycline hcl 100 mg tablet MO

TIER
4 3 5 4 4 4 4 4 4 4 2 4 1 1 5 4 4 4 4 4 4 4 4 1 1 1 4 2 2 2 3 3 3 2

UTILIZATION MANAGEMENT REQUIREMENTS


QL (1575 per 28 days) QL (120 per 30 days)

PA

PA

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
minocycline hcl 50 mg tablet MO minocycline hcl 75 mg tablet MO MONUROL 3 GRAM ORAL PACKET MO morgidox 100 mg capsule MO MYAMBUTOL 100 MG TABLET MO MYAMBUTOL 400 MG TABLET MO MYCAMINE 100 MG IV SOLUTION MO MYCAMINE 50 MG IV SOLUTION MO MYCOBUTIN 150 MG CAPSULE MO nafcillin 1 gm add-van vial MO nafcillin 1 gm vial HI,MO nafcillin 1 gm/ 50 ml inj HI,MO nafcillin 10 gm vial HI,MO nafcillin 2 gm add-vant vial MO nafcillin 2 gm vial MO nafcillin 2 gm/ 100 ml inj MO neo-fradin 25 mg/ml oral soln MO neomycin 500 mg tablet MO nevirapine 200 mg tablet SP nevirapine 50 mg/5 ml susp SP nitrofurantoin 25 mg/5 ml susp MO nitrofurantoin mcr 100 mg cap MO nitrofurantoin mcr 50 mg cap MO nitrofurantoin mono-mcr 100 mg MO NOROXIN 400 MG TABLET MO NORVIR 100 MG CAPSULE SP NORVIR 100 MG TABLET SP NORVIR 80 MG/ML ORAL SOLN SP NOXAFIL 200 MG/5 ML (40 MG/ML) ORAL SUSP MO nystatin 100,000 units/ml susp MO nystatin 150,000,000 units pwd MO nystatin 50,000,000 units pwd MO nystatin 500,000 unit oral tab MO nystatin 500,000,000 units pwd MO OCUDOX 50 MG KIT MO ofloxacin 200 mg tablet MO

TIER
2 2 4 2 4 4 5 5 4 5 5 5 5 5 5 5 2 2 3 4 4 4 4 4 4 4 4 4 5 2 2 2 2 2 1 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (1200 per 30 days) PA,QL (90 per 120 days) PA PA PA QL (360 per 30 days) QL (360 per 30 days) QL (480 per 30 days) PA,QL (840 per 28 days)

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DRUG NAME
ofloxacin 300 mg tablet MO ofloxacin 400 mg tablet MO oxacillin 1 gm add-vantage vl MO oxacillin 1 gm vial HI,MO oxacillin 1 gm/ 50 ml inj HI,MO oxacillin 10 gm vial HI,MO oxacillin 2 gm add-vantage vl MO oxacillin 2 gm vial MO oxacillin 2 gm/ 50 ml inj HI,MO paromomycin 250 mg capsule MO PASER 4 GRAM ORAL PACKET MO PCE 333 MG PARTICLES IN TABLET MO PCE 500 MG PARTICLES IN TABLET MO PEGASYS 180 MCG/0.5 ML SUB-Q SYRINGE SP PEGASYS 180 MCG/ML SUB-Q SP PEGASYS CONVENIENCE PACK 180 MCG/0.5 ML SUB-Q KIT SP PEGASYS PROCLICK 135 MCG/0.5 ML SUB-Q PEN INJECTOR SP PEGASYS PROCLICK 180 MCG/0.5 ML SUB-Q PEN INJECTOR SP PEGINTRON 120 MCG/0.5 ML SUB-Q KIT SP PEGINTRON 150 MCG/0.5 ML SUB-Q KIT SP PEGINTRON 50 MCG/0.5 ML SUB-Q KIT SP PEGINTRON 80 MCG/0.5 ML SUB-Q KIT SP PEGINTRON REDIPEN 120 MCG/0.5 ML SUBQ KIT SP PEGINTRON REDIPEN 150 MCG/0.5 ML SUBQ KIT SP PEGINTRON REDIPEN 50 MCG/0.5 ML SUBQ KIT SP PEGINTRON REDIPEN 80 MCG/0.5 ML SUBQ KIT SP pen g 1.2 million unit/2 ml MO pen g k 1 million unit/50 ml MO pen g k 2 million unit/50 ml HI,MO pen g k 3 million unit/50 ml HI,MO penicillin g 600,000 unit/1 ml MO penicillin g k 5 million unit HI,MO penicillin g na 5 million unit HI,MO penicillin gk 20 million unit MO penicillin vk 125 mg/5 ml sus MO penicillin vk 250 mg tablet MO

TIER
2 2 4 4 4 4 4 4 4 4 2 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 4 3 3 3 4 3 3 3 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA,QL (2 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (2 per 28 days) PA,QL (2 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days)

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DRUG NAME
penicillin vk 250 mg/5 ml soln MO penicillin vk 500 mg tablet MO PENTAM 300 MG SOLUTION FOR INJECTION MO pfizerpen-g 20 million unit solution for injection MO pfizerpen-g 5 million unit solution for injection MO phosphasal 81.6 mg-10.8 mg-40.8 mg tablet MO piperacil-tazobact 2.25 gm vl MO piperacil-tazobact 3.375 gm vl HI,MO piperacil-tazobact 4.5 gm vial HI,MO piperacil-tazobact 40.5 gram MO piperacillin 2 gm vial MO piperacillin 3 gm vial MO piperacillin 4 gm vial MO piperacillin 40 gm bulk vial MO polymyxin b sulfate vial HI,MO PREZISTA 150 MG TABLET SP PREZISTA 400 MG TABLET SP PREZISTA 600 MG TABLET SP PREZISTA 75 MG TABLET SP PRIFTIN 150 MG TABLET MO primaquine 26.3 mg tablet MO PRIMAXIN I.M. 500 MG VIAL MO PRIMAXIN IV 250 MG IV SOLUTION MO PRIMAXIN IV 500 MG IV SOLUTION MO PRIMSOL 50 MG/5 ML ORAL SOLN MO PYLERA 140 MG-125 MG-125 MG CAPSULE MO pyrazinamide 500 mg tablet MO QUALAQUIN 324 MG CAPSULE MO quinine sulfate 324 mg capsule MO REBETOL 200 MG CAPSULE SP REBETOL 40 MG/ML ORAL SOLN SP RELENZA DISKHALER 5 MG/ACTUATION FOR INHALATION MO RESCRIPTOR 100 MG DISPERSIBLE TABLET SP RESCRIPTOR 200 MG TABLET SP RETROVIR 10 MG/ML IV SP RETROVIR 10 MG/ML SYRUP SP

TIER
2 2 4 2 2 4 2 2 2 2 1 1 1 1 2 4 5 5 4 4 2 3 3 3 2 4 4 4 4 5 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D

PA

QL (240 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (480 per 30 days)

QL (144 per 30 days) PA,QL (42 per 7 days) PA,QL (42 per 7 days) PA,QL (168 per 28 days) PA,QL (1000 per 30 days) QL (60 per 180 days) QL (360 per 30 days) QL (180 per 30 days) QL (1680 per 28 days)

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DRUG NAME
RETROVIR 100 MG CAPSULE SP RETROVIR 300 MG TABLET SP REYATAZ 100 MG CAPSULE SP REYATAZ 150 MG CAPSULE SP REYATAZ 200 MG CAPSULE SP REYATAZ 300 MG CAPSULE SP RIBAPAK DOSE PACK 200 MG (28)-400 MG (28) TABLETS MO RIBAPAK DOSE PACK 200 MG (7)-400 MG (7) TABLETS MO RIBAPAK DOSE PACK 400 MG (28)-400 MG (28) TABLETS SP RIBAPAK DOSE PACK 400 MG (7)-400 MG (7) TABLETS MO RIBAPAK DOSE PACK 600 MG (28)-400 MG (28) TABLETS SP RIBAPAK DOSE PACK 600 MG (28)-600 MG (28) TABLETS SP RIBAPAK DOSE PACK 600 MG (7)-400 MG (7) TABLETS MO RIBAPAK DOSE PACK 600 MG (7)-600 MG (7) TABLETS MO ribasphere 200 mg capsule SP ribasphere 200 mg tablet SP ribasphere 400 mg tablet SP ribasphere 600 mg tablet SP RIBATAB DOSE PACK 400 MG (28)-400 MG (28) TABLETS SP RIBATAB DOSE PACK 600 MG (28)-400 MG (28) TABLETS SP RIBATAB DOSE PACK 600 MG (28)-600 MG (28) TABLETS SP ribavirin 200 mg capsule SP ribavirin 200 mg tablet SP RIFADIN 150 MG CAPSULE MO RIFADIN 300 MG CAPSULE MO RIFADIN 600 MG IV SOLUTION MO RIFAMATE 300 MG-150 MG CAPSULE MO rifampin 150 mg capsule MO rifampin 300 mg capsule MO rifampin iv 600 mg vial MO RIFATER 50 MG-120 MG-300 MG TABLET MO rimantadine hcl 100 mg tablet MO ROCEPHIN 1 GRAM SOLUTION FOR INJECTION MO ROCEPHIN 500 MG SOLUTION FOR INJECTION MO SELZENTRY 150 MG TABLET SP SELZENTRY 300 MG TABLET SP

TIER
4 4 5 5 5 5 5 5 5 5 5 5 5 5 4 4 4 5 5 5 5 3 3 4 4 4 4 3 3 2 4 3 4 4 5 5

QL (180 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) PA,QL (112 per 28 days) PA,QL (112 per 28 days) PA,QL (84 per 28 days) PA,QL (84 per 28 days) PA,QL (112 per 30 days) PA,QL (56 per 28 days) PA,QL (112 per 30 days) PA,QL (56 per 28 days) PA,QL (168 per 28 days) PA,QL (168 per 28 days) PA,QL (112 per 30 days) PA,QL (56 per 28 days) PA,QL (84 per 28 days) PA,QL (112 per 30 days) PA,QL (56 per 28 days) PA,QL (168 per 28 days) PA,QL (168 per 28 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (240 per 30 days) QL (120 per 30 days)

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DRUG NAME
SEPTRA 80-400 TABLET MO SEPTRA DS TABLET MO SEROMYCIN 250 MG CAPSULE MO stavudine 1 mg/ml solution SP stavudine 15 mg capsule SP stavudine 20 mg capsule SP stavudine 30 mg capsule SP stavudine 40 mg capsule SP streptomycin sulf 1 gm vial HI,MO STROMECTOL 3 MG TABLET MO sulfadiazine 500 mg tablet MO sulfamethoxazole-tmp ds tablet MO sulfamethoxazole-tmp ss tablet MO sulfamethoxazole-tmp susp MO sulfamethoxazole-tmp vial MO sulfasalazine 500 mg tablet MO sulfasalazine dr 500 mg tab MO sulfazine 500 mg tablet MO sulfazine ec 500 mg tablet,delayed release MO SUPRAX 100 MG/5 ML ORAL SUSP MO SUPRAX 200 MG/5 ML ORAL SUSP MO SUSTIVA 200 MG CAPSULE SP SUSTIVA 50 MG CAPSULE SP SUSTIVA 600 MG TABLET SP SYLATRON 296 MCG SUB-Q KIT SP SYLATRON 4-PACK 296 MCG SUB-Q KIT SP SYLATRON 4-PACK 444 MCG SUB-Q KIT SP SYLATRON 4-PACK 888 MCG SUB-Q KIT SP SYLATRON 444 MCG SUB-Q KIT SP SYLATRON 888 MCG SUB-Q KIT SP SYNERCID 500 MG IV SOLUTION HI,MO TAMIFLU 12 MG/ML SUSPENSION MO TAMIFLU 30 MG CAPSULE MO TAMIFLU 45 MG CAPSULE MO TAMIFLU 6 MG/ML ORAL SUSP MO TAMIFLU 75 MG CAPSULE MO

TIER
4 4 4 2 2 2 2 2 3 3 4 1 1 1 1 2 2 2 2 4 4 3 3 3 5 5 5 5 5 5 5 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (2400 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (30 per 30 days) QL (60 per 30 days)

QL (120 per 30 days) QL (480 per 30 days) QL (30 per 30 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) QL (350 per 365 days) QL (112 per 365 days) QL (56 per 365 days) QL (720 per 365 days) QL (56 per 365 days)

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DRUG NAME
tazicef 1 gram iv solution MO tazicef 1 gram solution for injection MO tazicef 2 gram iv solution MO tazicef 2 gram solution for injection MO tazicef 6 gram solution for injection MO TEFLARO 400 MG IV SOLUTION MO TEFLARO 600 MG IV SOLUTION MO terbinafine hcl 250 mg tablet MO TERRAMYCIN 250 MG/2 ML IM MO TERRAMYCIN IM 100 MG/2 ML IM MO tetracycline 250 mg capsule MO tetracycline 500 mg capsule MO TIMENTIN 3.1 G IV SOLUTION HI,MO TIMENTIN 3.1 G/100 ML IV PIGGY BACK MO TIMENTIN 31 G IV SOLUTION MO tinidazole 250 mg tablet MO tinidazole 500 mg tablet MO TOBI 300 MG/5 ML NEB SOLUTION MO tobramycin 1.2 gm vial MO tobramycin 10 mg/ml vial MO tobramycin 40 mg/ml syringe MO tobramycin 40 mg/ml vial HI,MO tobramycin 60 mg/50 ml ns HI,MO tobramycin 80 mg/100 ml ns HI,MO TRECATOR 250 MG TABLET MO trimethoprim 100 mg tablet MO TRIZIVIR 300 MG-150 MG-300 MG TABLET SP TRUVADA 200 MG-300 MG TABLET SP TYGACIL 50 MG IV SOLUTION HI,MO TYZEKA 600 MG TABLET SP URETRON D-S 120 MG-0.12 MG-10.8 MG TABLET MO URETRON D-S 81.6 MG-10.8 MG-40.8 MG TABLET MO urin ds 81.6 mg-10.8 mg-40.8 mg tablet MO UROQID-ACID NO.2 500 MG-500 MG TABLET MO ustell 120 mg-0.12 mg capsule MO utira-c tablet MO

TIER
3 3 3 3 3 4 4 2 4 4 1 1 4 4 4 3 3 5 2 1 1 1 2 2 4 2 5 5 4 4 4 4 4 4 2 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (90 per 365 days)

PA,QL (280 per 28 days)

QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) PA PA PA PA PA

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DRUG NAME
valacyclovir hcl 1 gram tablet MO valacyclovir hcl 500 mg tablet MO VALCYTE 450 MG TABLET MO VALCYTE 50 MG/ML ORAL SOLUTION MO VANCOCIN 125 MG CAPSULE MO VANCOCIN 250 MG CAPSULE MO vancomycin 1 gm vial HI,MO vancomycin 500 mg vial HI,MO vancomycin 750 mg/150 ml bag MO vancomycin hcl 10 gm vial HI,MO vancomycin hcl 125 mg capsule MO vancomycin hcl 1g/200 ml bag MO vancomycin hcl 250 mg capsule MO vancomycin hcl 5 gm vial MO vancomycin hcl 750 mg vial MO vancomycin-d5w 500 mg/100 ml MO VFEND 200 MG/5 ML (40 MG/ML) ORAL SUSP MO VFEND IV 200 MG SOLN HI,MO VIBATIV 250 MG IV SOLUTION HI,MO VIBATIV 750 MG IV SOLUTION HI,MO VIBRAMYCIN 100 MG CAPSULE MO VIBRAMYCIN 25 MG/5 ML ORAL SUSP MO VIBRAMYCIN 50 MG CAPSULE MO VIBRAMYCIN 50 MG/5 ML SYRUP MO VICTRELIS 200 MG CAPSULE SP VIDEX 2 GRAM PEDIATRIC 10 MG/ML (FINAL CONC.) ORAL SOLUTION SP VIDEX 4 GRAM PEDIATRIC 10 MG/ML (FINAL CONC.) ORAL SOLUTION SP VIDEX EC 125 MG CAPSULE,DELAYED RELEASE SP VIDEX EC 200 MG CAPSULE,DELAYED RELEASE SP VIDEX EC 250 MG CAPSULE,DELAYED RELEASE SP VIDEX EC 400 MG CAPSULE,DELAYED RELEASE SP VIRACEPT 250 MG TABLET SP VIRACEPT 625 MG TABLET SP VIRACEPT POWDER SP VIRAMUNE 200 MG TABLET SP VIRAMUNE 50 MG/5 ML ORAL SUSP SP

TIER
3 3 5 5 5 5 3 3 4 3 5 4 5 3 3 4 5 4 4 4 4 4 4 4 5 4 4 4 4 4 4 4 5 4 4 4

QL (90 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (1056 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D B vs D B vs D B vs D PA,QL (400 per 30 days) B vs D B vs D PA

PA,QL (336 per 28 days) QL (1200 per 30 days) QL (1200 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (300 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (1200 per 30 days)

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DRUG NAME
VIRAMUNE XR 400 MG TABLET,EXTENDED RELEASE SP VIRAZOLE 6 GRAM SOLUTION FOR INHALATION MO VIREAD 150 MG TABLET MO VIREAD 200 MG TABLET MO VIREAD 250 MG TABLET MO VIREAD 300 MG TABLET SP VIREAD 40 MG/SCOOP (40 MG/GRAM) ORAL POWDER MO visqid a-a tablet MO VISTIDE 75 MG/ML IV MO voriconazole 200 mg tablet MO voriconazole 200 mg vial MO voriconazole 50 mg tablet MO XIFAXAN 200 MG TABLET MO XIFAXAN 550 MG TABLET MO YODOXIN 210 MG TABLET MO YODOXIN 650 MG TABLET MO ZERIT 1 MG/ML ORAL SOLUTION SP ZERIT 15 MG CAPSULE SP ZERIT 20 MG CAPSULE SP ZERIT 30 MG CAPSULE SP ZERIT 40 MG CAPSULE SP ZIAGEN 20 MG/ML ORAL SOLN SP ZIAGEN 300 MG TABLET SP zidovudine 100 mg capsule SP zidovudine 300 mg tablet SP zidovudine 50 mg/5 ml syrup SP ZINACEF 1.5 GRAM IV SOLUTION MO ZINACEF 1.5 GRAM SOLUTION FOR INJECTION MO ZINACEF 7.5 GRAM IV SOLUTION MO ZINACEF 750 MG IV SOLUTION MO ZINACEF 750 MG SOLUTION FOR INJECTION MO ZINACEF IN DEXTROSE (ISO-OSMOTIC) 750 MG/50 ML IV PIGGY BACK
MO

TIER
4 5 4 4 4 5 4 1 5 5 4 5 4 5 4 4 4 4 4 4 4 4 4 2 2 2 4 4 4 4 4 4 4 4 4

QL (30 per 30 days) B vs D QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA,QL (120 per 30 days) PA,QL (120 per 30 days) PA,QL (9 per 30 days) PA,QL (60 per 30 days)

QL (2400 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (960 per 30 days) QL (60 per 30 days) QL (180 per 30 days) QL (60 per 30 days) QL (1680 per 28 days)

ZINACEF IN STERILE WATER 1.5 GRAM/50 ML IV PIGGY BACK MO ZITHROMAX 1 GRAM ORAL PACKET MO ZITHROMAX 250 MG TABLET MO

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DRUG NAME
ZITHROMAX 500 MG TABLET MO ZITHROMAX 600 MG TABLET MO ZITHROMAX TRI-PAK 500 MG TABLET MO ZITHROMAX Z-PAK 250 MG TABLET MO ZOSYN 2.25 GRAM IV SOLUTION MO ZOSYN 3.375 GRAM IV SOLUTION HI,MO ZOSYN 4.5 GRAM IV SOLUTION MO ZOSYN 40.5 GRAM IV SOLUTION MO ZOSYN IN DEXTROSE (ISO-OSMOTIC) 2.25 GRAM/50 ML IV PIGGY BACK HI,MO ZOSYN IN DEXTROSE (ISO-OSMOTIC) 3.375 GRAM/50 ML IV PIGGY BACK HI,MO ZOSYN IN DEXTROSE (ISO-OSMOTIC) 4.5 GRAM/100 ML IV PIGGY BACK MO ZYVOX 100 MG/5 ML ORAL SUSP MO ZYVOX 200 MG/100 ML IV MO ZYVOX 600 MG TABLET MO ZYVOX 600 MG/300 ML IV HI,MO ANTIHISTAMINE DRUGS cetirizine hcl 1 mg/ml syrup MO fexofenadine hcl 180 mg tablet MO fexofenadine hcl 30 mg tablet MO fexofenadine hcl 60 mg tablet MO fexofenadine-pse er 180-240 tb MO fexofenadine-pse er 60-120 tab MO levocetirizine 2.5 mg/5 ml sol MO levocetirizine 5 mg tablet MO NOREL SR TABLET MO phenadoz 12.5 mg rectal suppository MO phenadoz 25 mg rectal suppository MO PHENERGAN 25 MG/ML INJECTION MO PHENERGAN 50 MG/ML INJECTION MO promethegan 12.5 mg rectal suppository MO promethegan 25 mg rectal suppository MO promethegan 50 mg rectal suppository MO PROTID ER 8 MG-40 MG-500 MG TABLET,EXTENDED RELEASE MO RESPA-AR 8 MG-90 MG-0.24 MG TABLET,EXTENDED RELEASE MO

TIER
4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 2 3 3 3 3 3 4 2 4 2 2 4 4 2 2 3 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

PA PA PA

PA PA

QL (300 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (300 per 30 days) QL (30 per 30 days) PA PA PA PA PA PA PA

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DRUG NAME
ru-tuss tablet MO SEMPREX-D 8 MG-60 MG CAPSULE MO XYZAL 2.5 MG/5 ML ORAL SOLN MO ANTINEOPLASTIC AGENTS ABRAXANE 100 MG IV SOLUTION MO adriamycin 10 mg iv solution MO adriamycin 10 mg/5 ml iv MO adriamycin 20 mg iv solution MO adriamycin 20 mg/10 ml iv MO ADRIAMYCIN 50 MG IV SOLUTION MO adriamycin 50 mg/25 ml iv MO adriamycin pfs 2 mg/ml iv MO AFINITOR 10 MG TABLET SP AFINITOR 2.5 MG TABLET SP AFINITOR 5 MG TABLET SP AFINITOR 7.5 MG TABLET MO ALIMTA 100 MG IV SOLUTION MO ALIMTA 500 MG IV SOLUTION MO ALKERAN 2 MG TABLET MO ALKERAN 50 MG IV SOLUTION MO anastrozole 1 mg tablet MO ARRANON 250 MG/50 ML IV MO ARZERRA 1,000 MG/50 ML IV MO ARZERRA 100 MG/5 ML IV MO AVASTIN 25 MG/ML IV MO bicalutamide 50 mg tablet MO BICNU 100 MG IV SOLUTION MO bleomycin sulfate 15 unit vial MO bleomycin sulfate 30 unit vial MO BUSULFEX 60 MG/10 ML IV MO CAMPATH 30 MG/ML IV MO CAMPTOSAR 100 MG/5 ML IV MO CAMPTOSAR 300 MG/15 ML IV MO CAMPTOSAR 40 MG/2 ML IV MO CAPRELSA 100 MG TABLET SP CAPRELSA 300 MG TABLET SP

TIER
4 4 4 5 3 3 3 3 3 3 3 5 5 5 5 5 5 5 4 1 5 5 5 5 3 4 3 3 4 5 4 5 5 5 5

UTILIZATION MANAGEMENT REQUIREMENTS

QL (300 per 30 days) PA,QL (700 per 21 days) B vs D B vs D B vs D B vs D B vs D B vs D B vs D PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (60 per 21 days) PA,QL (60 per 21 days) B vs D B vs D QL (30 per 30 days) PA PA,QL (400 per 28 days) PA,QL (400 per 28 days) PA QL (30 per 30 days) B vs D B vs D B vs D B vs D PA,QL (12 per 28 days) B vs D B vs D B vs D PA,QL (60 per 30 days) PA,QL (30 per 30 days)

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DRUG NAME
carboplatin 150 mg vial MO carboplatin 50 mg/5 ml vial MO CASODEX 50 MG TABLET MO CEENU 10 MG CAPSULE SP CEENU 100 MG CAPSULE SP CEENU 40 MG CAPSULE SP CERUBIDINE 20 MG IV SOLUTION MO cisplatin 1 mg/ml vial MO cladribine 10 mg/10 ml vial MO CLOLAR 20 MG/20 ML IV MO COSMEGEN 0.5 MG IV SOLUTION MO cyclophosphamide 1 gm vial MO cyclophosphamide 2 gm vial MO cyclophosphamide 25 mg tab MO cyclophosphamide 50 mg tablet MO cyclophosphamide 500 mg vial MO cytarabine 1 gm vial MO cytarabine 100 mg vial MO cytarabine 100 mg/ml vial MO cytarabine 2 gm vial MO cytarabine 20 mg/ml vial MO cytarabine 500 mg vial MO dacarbazine 100 mg vial MO dacarbazine 200 mg vial MO DACOGEN 50 MG IV SOLUTION MO dactinomycin 0.5 mg vial MO daunorubicin 20 mg vial MO daunorubicin 50 mg/10 ml vial MO DAUNOXOME 2 MG/ML IV MO DEPOCYT (PF) 50 MG/5 ML (10 MG/ML) SUSP, INTRATHECAL MO DOCEFREZ 20 MG IV SOLUTION MO DOCEFREZ 80 MG IV SOLUTION MO docetaxel 160 mg/16 ml vial MO docetaxel 160 mg/8 ml vial MO docetaxel 20 mg/0.5 ml vial MO docetaxel 20 mg/2 ml vial MO

TIER
3 3 4 4 4 4 4 3 1 5 5 4 4 4 4 4 1 1 1 1 1 1 1 1 5 3 1 1 4 5 4 5 5 5 5 5

B vs D B vs D QL (30 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D PA B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D

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DRUG NAME
docetaxel 20 mg/ml vial MO docetaxel 80 mg/2 ml vial MO docetaxel 80 mg/4 ml vial MO docetaxel 80 mg/8 ml vial MO DOXIL 2 MG/ML IV MO doxorubicin 10 mg vial MO doxorubicin 10 mg/5 ml vial MO doxorubicin 150 mg/75 ml vial MO doxorubicin 20 mg/10 ml vial MO doxorubicin 50 mg vial MO doxorubicin 50 mg/25 ml vial MO DROXIA 200 MG CAPSULE MO DROXIA 300 MG CAPSULE MO DROXIA 400 MG CAPSULE MO ELIGARD 22.5 MG SUB-Q SYRINGE MO ELIGARD 30 MG SUB-Q SYRINGE MO ELIGARD 45 MG SUB-Q SYRINGE MO ELIGARD 7.5 MG SUB-Q SYRINGE MO ELLENCE 200 MG/100 ML IV MO ELLENCE 50 MG/25 ML IV MO ELOXATIN 100 MG/20 ML SOLN MO ELOXATIN 200 MG/40 ML SOLN MO ELOXATIN 50 MG/10 ML (5 MG/ML) SOLN MO ELSPAR 10,000 UNIT SOLUTION FOR INJECTION MO EMCYT 140 MG CAPSULE MO epirubicin 200 mg/100 ml vial MO epirubicin 50 mg/25 ml vial MO epirubicin hcl 200 mg vial MO epirubicin hcl 50 mg vial MO ERBITUX 100 MG/50 ML IV MO ERBITUX 200 MG/100 ML IV MO ERIVEDGE 150 MG CAPSULE MO ETOPOPHOS 100 MG IV SOLUTION MO etoposide 100 mg/5 ml vial MO etoposide 50 mg capsule MO exemestane 25 mg tablet MO

TIER
5 5 5 5 5 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 4 4 4 4 4 4 5 5 5 5 3 5 4

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D

PA PA PA PA PA PA PA PA PA B vs D PA PA B vs D B vs D PA PA PA,QL (28 per 28 days) B vs D

QL (60 per 30 days)

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DRUG NAME
FARESTON 60 MG TABLET MO FASLODEX 250 MG/5 ML IM SYRINGE MO FIRMAGON 120 MG SUB-Q SOLN MO FIRMAGON 80 MG SUB-Q SOLN MO floxuridine 500 mg vial MO FLUDARA 50 MG IV SOLUTION MO fludarabine 50 mg vial MO fludarabine 50 mg/2 ml vial MO fluorouracil 1,000 mg/20 ml vl MO fluorouracil 2,500 mg/50 ml vl MO fluorouracil 5,000 mg/100 ml MO fluorouracil 500 mg/10 ml vial MO flutamide 125 mg capsule MO FOLOTYN 20 MG/ML (1 ML) IV MO FOLOTYN 40 MG/2 ML (20 MG/ML) IV MO gemcitabine 1 gram/26.3 ml vl MO gemcitabine 2 gram/52.6 ml vl MO gemcitabine 200 mg/5.26 ml vl MO gemcitabine hcl 1 gram vial MO gemcitabine hcl 2 gram vial MO gemcitabine hcl 200 mg vial MO GEMZAR 1 GRAM IV SOLUTION MO GEMZAR 200 MG IV SOLUTION MO GLEEVEC 100 MG TABLET SP GLEEVEC 400 MG TABLET SP HALAVEN 1 MG/2 ML (0.5 MG/ML) IV MO HERCEPTIN 440 MG IV SOLUTION MO HEXALEN 50 MG CAPSULE MO HYCAMTIN 0.25 MG CAPSULE SP HYCAMTIN 1 MG CAPSULE SP HYCAMTIN 4 MG IV SOLUTION MO HYDREA 500 MG CAPSULE MO hydroxyurea 500 mg capsule MO IDAMYCIN PFS 1 MG/ML IV MO idarubicin pfs 10 mg/10 ml vl MO IFEX 1 GRAM IV SOLUTION MO

TIER
5 5 5 4 1 5 2 2 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4 2 5 5 4

QL (30 per 30 days) B vs D,QL (30 per 30 days) PA PA B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D PA PA B vs D B vs D B vs D B vs D B vs D B vs D PA PA PA,QL (180 per 30 days) PA,QL (60 per 30 days) PA,QL (10 per 21 days) PA B vs D B vs D B vs D

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D

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DRUG NAME
IFEX 3 GRAM IV SOLUTION MO ifosfamide 1 gm vial MO ifosfamide 1 gm/ 20 ml vial MO ifosfamide 3 gm vial MO ifosfamide 3 gm/ 60 ml vial MO ifosfamide-mesna kit MO INLYTA 1 MG TABLET MO INLYTA 5 MG TABLET MO IRESSA 250 MG TABLET SP irinotecan hcl 100 mg/5 ml vl MO irinotecan hcl 40 mg/2 ml vial MO irinotecan hcl 500 mg/25 ml vl MO ISTODAX 10 MG/2 ML IV SOLUTION MO IXEMPRA 15 MG IV SOLUTION MO IXEMPRA 45 MG IV SOLUTION MO JAKAFI 10 MG TABLET MO JAKAFI 15 MG TABLET MO JAKAFI 20 MG TABLET MO JAKAFI 25 MG TABLET MO JAKAFI 5 MG TABLET MO JEVTANA 10 MG/ML (FINAL CONC.) IV MO letrozole 2.5 mg tablet MO LEUKERAN 2 MG TABLET MO leuprolide 2wk 1 mg/0.2 ml kt MO LEUSTATIN 10 MG/10 ML VIAL MO lipodox 2 mg/ml iv MO lipodox 50 2 mg/ml iv MO LUPRON DEPOT (3 MONTH) 11.25 MG IM SYRINGE KIT MO LUPRON DEPOT (3 MONTH) 22.5 MG IM SYRINGE KIT MO LUPRON DEPOT (4 MONTH) 30 MG IM SYRINGE KIT MO LUPRON DEPOT (6 MONTH) 45 MG IM SYRINGE KIT MO LUPRON DEPOT 3.75 MG IM SYRINGE KIT MO LUPRON DEPOT 7.5 MG IM SYRINGE KIT MO LUPRON DEPOT-PED (3 MONTH) 11.25 MG IM SYRINGE KIT MO LUPRON DEPOT-PED (3 MONTH) 30 MG IM SYRINGE KIT MO LUPRON DEPOT-PED 11.25 MG IM KIT SP

TIER
4 3 3 3 3 3 5 5 5 4 4 4 5 5 5 5 5 5 5 5 5 2 3 3 5 5 5 4 4 4 5 4 5 4 5 5

B vs D B vs D B vs D B vs D B vs D B vs D PA,QL (180 per 30 days) PA,QL (60 per 30 days) QL (30 per 30 days) B vs D B vs D B vs D PA PA,QL (45 per 21 days) PA,QL (45 per 21 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (4 per 21 days) QL (30 per 30 days) PA,QL (3 per 14 days) B vs D B vs D B vs D PA,QL (1 per 90 days) PA,QL (1 per 90 days) PA,QL (1 per 120 days) PA,QL (1 per 180 days) PA,QL (1 per 30 days) PA,QL (1 per 30 days) PA,QL (1 per 90 days) PA,QL (1 per 90 days) PA,QL (1 per 28 days)

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
LUPRON DEPOT-PED 15 MG IM KIT SP LUPRON DEPOT-PED 7.5 MG (PED) IM KIT SP LYSODREN 500 MG TABLET MO MATULANE 50 MG CAPSULE SP megestrol 20 mg tablet MO megestrol 40 mg tablet MO megestrol acet 40 mg/ml susp MO melphalan hcl 50 mg vial MO mercaptopurine 50 mg tablet MO methotrexate 1 gm vial MO methotrexate 1 gm/40 ml vial MO methotrexate 2.5 mg tablet MO methotrexate 25 mg/ml vial MO mitomycin 20 mg vial MO mitomycin 40 mg vial MO mitomycin 5 mg vial MO mitoxantrone 25 mg/12.5 ml vl MO MUSTARGEN 10 MG SOLUTION FOR INJECTION MO MYLERAN 2 MG TABLET MO NEXAVAR 200 MG TABLET SP NILANDRON 150 MG TABLET MO NIPENT 10 MG IV SOLUTION MO NOVANTRONE 2 MG/ML VIAL MO OFORTA 10 MG TABLET SP ONCASPAR 750 UNIT/ML INJECTION MO ONTAK 150 MCG/ML IV MO onxol 6 mg/ml concentrate, iv MO oxaliplatin 100 mg vial MO oxaliplatin 100 mg/20 ml vial MO oxaliplatin 50 mg vial MO oxaliplatin 50 mg/10 ml vial MO paclitaxel 100 mg/16.7 ml vial MO pentostatin 10 mg vial MO PERJETA 420 MG/14 ML (30 MG/ML) IV MO PHOTOFRIN 75 MG IV SOLUTION MO PROLEUKIN 22 MILLION UNIT IV SOLUTION MO

TIER
5 5 3 5 3 3 3 1 3 2 2 2 2 4 3 3 3 4 4 5 4 5 5 5 5 5 5 2 2 2 2 3 1 5 5 5

PA,QL (1 per 28 days) PA,QL (1 per 28 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA PA PA B vs D

B vs D B vs D B vs D B vs D B vs D B vs D PA,QL (120 per 30 days) QL (60 per 30 days) B vs D B vs D B vs D PA,QL (108 per 21 days) B vs D B vs D PA B vs D PA B vs D B vs D PA,QL (14 per 21 days) B vs D

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DRUG NAME
PURINETHOL 50 MG TABLET MO REVLIMID 10 MG CAPSULE SP REVLIMID 15 MG CAPSULE SP REVLIMID 2.5 MG CAPSULE MO REVLIMID 25 MG CAPSULE SP REVLIMID 5 MG CAPSULE SP RHEUMATREX 2.5 MG TABLETS IN A DOSE PACK MO RITUXAN 10 MG/ML CONCENTRATE, IV MO SPRYCEL 100 MG TABLET SP SPRYCEL 140 MG TABLET SP SPRYCEL 20 MG TABLET SP SPRYCEL 50 MG TABLET SP SPRYCEL 70 MG TABLET SP SPRYCEL 80 MG TABLET SP SUTENT 12.5 MG CAPSULE SP SUTENT 25 MG CAPSULE SP SUTENT 50 MG CAPSULE SP TABLOID 40 MG TABLET MO tamoxifen 10 mg tablet MO tamoxifen 20 mg tablet MO TARCEVA 100 MG TABLET SP TARCEVA 150 MG TABLET SP TARCEVA 25 MG TABLET SP TARGRETIN 75 MG CAPSULE SP TASIGNA 150 MG CAPSULE SP TASIGNA 200 MG CAPSULE SP TAXOTERE 20 MG/0.5 ML VIAL MO TAXOTERE 20 MG/ML (1 ML) IV MO TAXOTERE 80 MG/4 ML (20 MG/ML) IV MO TAXOTERE 80 MG/8 ML (FINAL CONC.) IV MO TEMODAR 100 MG IV SOLUTION MO thiotepa 15 mg vial MO toposar 20 mg/ml iv MO topotecan hcl 4 mg vial MO topotecan hcl 4 mg/4 ml vial MO TORISEL 30 MG/3 ML (10 MG/ML) (FINAL) IV SOLUTION MO

TIER
4 5 5 5 5 5 4 5 5 5 5 5 5 5 5 5 5 4 2 2 5 5 5 5 5 5 5 5 5 5 5 1 4 5 5 5

UTILIZATION MANAGEMENT REQUIREMENTS


PA,QL (28 per 28 days) PA,QL (28 per 28 days) PA,QL (28 per 28 days) PA,QL (28 per 28 days) PA,QL (28 per 28 days) B vs D PA PA,QL (60 per 30 days) PA,QL (30 per 30 days) PA,QL (90 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (28 per 28 days) PA,QL (28 per 28 days) PA,QL (28 per 28 days)

PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (90 per 30 days) PA,QL (300 per 30 days) PA,QL (120 per 30 days) PA,QL (120 per 30 days) B vs D B vs D B vs D B vs D PA,QL (27 per 30 days) B vs D B vs D B vs D B vs D PA,QL (100 per 28 days)

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DRUG NAME
TREANDA 100 MG IV SOLUTION MO TREANDA 25 MG IV SOLUTION MO TRELSTAR 11.25 MG/2 ML IM SYRINGE MO TRELSTAR 22.5 MG IM SUSP MO TRELSTAR 22.5 MG/2 ML IM SYRINGE MO TRELSTAR 3.75 MG/2 ML IM SYRINGE MO TRELSTAR DEPOT 3.75 MG IM SUSP MO TRELSTAR LA 11.25 MG IM SUSP MO tretinoin 10 mg capsule SP TREXALL 10 MG TABLET MO TREXALL 15 MG TABLET MO TREXALL 5 MG TABLET MO TREXALL 7.5 MG TABLET MO TRISENOX 10 MG/10 ML IV MO TYKERB 250 MG TABLET SP VALSTAR 40 MG/ML INTRAVESICAL MO VANDETANIB 100 MG TABLET SP VANDETANIB 300 MG TABLET SP VECTIBIX 100 MG/5 ML (20 MG/ML) IV MO VECTIBIX 400 MG/20 ML (20 MG/ML) IV MO VELCADE 3.5 MG SOLUTION FOR INJECTION MO VIDAZA 100 MG SUB-Q SOLN MO vinblastine 1 mg/ml vial MO vinblastine sulf 10 mg vial MO vincasar pfs 2 mg/2 ml iv MO vincristine 1 mg/ml vial MO vincristine 2 mg/2 ml vial MO vinorelbine 10 mg/ml vial MO vinorelbine 50 mg/5 ml vial MO VOTRIENT 200 MG TABLET SP VUMON 10 MG/ML IV MO XALKORI 200 MG CAPSULE SP XALKORI 250 MG CAPSULE SP YERVOY 200 MG/40 ML (5 MG/ML) IV MO YERVOY 50 MG/10 ML (5 MG/ML) IV MO ZALTRAP 100 MG/4 ML (25 MG/ML) IV SP

TIER
5 5 4 4 4 4 4 4 3 4 4 4 4 4 5 5 5 5 5 5 5 5 1 1 1 1 1 5 4 5 4 5 5 5 5 5

PA,QL (600 per 21 days) PA,QL (300 per 21 days) PA PA PA PA PA,QL (1 per 28 days) PA,QL (1 per 84 days) B vs D B vs D B vs D B vs D B vs D PA,QL (150 per 30 days) PA,QL (80 per 28 days) PA,QL (60 per 30 days) PA,QL (30 per 30 days) PA PA PA,QL (14 per 21 days) PA B vs D B vs D B vs D B vs D B vs D B vs D PA,QL (120 per 30 days) B vs D PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (40 per 21 days) PA,QL (70 per 21 days) PA,QL (5 per 28 days)

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
ZALTRAP 200 MG/8 ML (25 MG/ML) IV SP ZANOSAR 1 GRAM IV SOLUTION MO ZELBORAF 240 MG TABLET SP ZOLADEX 10.8 MG SUBQ IMPLANT MO ZOLADEX 3.6 MG SUBQ IMPLANT MO ZOLINZA 100 MG CAPSULE SP ZYTIGA 250 MG TABLET SP AUTONOMIC DRUGS albuterol 0.083% inhal soln MO albuterol 2.5 mg/0.5 ml sol MO albuterol 5 mg/ml solution MO albuterol sul 0.63 mg/3 ml sol MO albuterol sul 1.25 mg/3 ml sol MO albuterol sulf 2 mg/5 ml syrup MO albuterol sulfate 2 mg tab MO albuterol sulfate 4 mg tab MO albuterol sulfate er 4 mg tab MO albuterol sulfate er 8 mg tab MO alfuzosin hcl er 10 mg tablet MO ANASPAZ 0.125 MG DISINTEGRATING TABLET MO atracurium 100 mg/10 ml vial MO atropine 0.05 mg/ml syringe MO atropine 0.1 mg/ml abboject MO atropine 0.4 mg/0.5 ml ampul MO atropine 0.4 mg/ml vial MO atropine 1 mg/ml vial MO ATROVENT HFA 17 MCG/ACTUATION AEROSOL INHALER MO baclofen 10 mg tablet MO baclofen 20 mg tablet MO bethanechol 10 mg tablet MO bethanechol 25 mg tablet MO bethanechol 5 mg tablet MO bethanechol 50 mg tablet MO BROVANA 15 MCG/2 ML NEB SOLUTION MO CAFERGOT 1 MG-100 MG TABLET MO CANTIL 25 MG TABLET MO

TIER
5 4 5 5 4 5 5 2 2 2 2 2 2 2 2 4 4 3 4 1 2 2 2 2 2 4 2 2 4 4 3 4 4 4 4

PA,QL (5 per 28 days) B vs D PA,QL (240 per 30 days) PA,QL (1 per 84 days) PA,QL (1 per 28 days) PA,QL (120 per 30 days) PA,QL (120 per 30 days) B vs D B vs D B vs D B vs D B vs D

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 30 days) PA

QL (30 per 30 days)

PA,QL (124 per 30 days)

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DRUG NAME
carisoprodol 250 mg tablet MO carisoprodol 350 mg tablet MO carisoprodol compound tab MO carisoprodol cpd-codeine tab MO CHANTIX 0.5 MG TABLET MO CHANTIX 1 MG TABLET MO CHANTIX CONTINUING MONTH BOX 1 MG TABLET MO CHANTIX CONTINUING MONTH PAK 1 MG TABLET MO CHANTIX STARTING MONTH BOX 0.5 MG (11)-1 MG (42) TABLETS IN DOSE PACK MO CHANTIX STARTING MONTH PAK 0.5 MG (11)-1 MG (42) TABLETS IN DOSE PACK MO cisatracurium 20 mg/10 ml vial MO cisatracurium 200 mg/20 ml vl MO COMBIVENT 18 MCG-103 MCG/ACTUATION AEROSOL INHALER MO COMBIVENT RESPIMAT 20 MCG-100 MCG/ACTUATION AEROSOL INHALER MO D.H.E.45 1 MG/ML INJECTION MO dantrolene sodium 100 mg cap MO dantrolene sodium 25 mg cap MO dantrolene sodium 50 mg cap MO dihydroergotamine 1 mg/ml am MO dobutamine 1 gm-d5w 250 ml MO dobutamine 12.5 mg/ml vial MO dobutamine 250 mg-d5w 250 ml MO dobutamine 250 mg-d5w 500 ml MO dobutamine 500 mg-d5w 250 ml MO dobutamine 500 mg-d5w 500 ml MO donepezil hcl 10 mg tablet MO donepezil hcl 5 mg tablet MO donepezil hcl odt 10 mg tablet MO donepezil hcl odt 5 mg tablet MO dopamine 160 mg/ml vial MO dopamine 200 mg-d5w 250 ml MO dopamine 40 mg/ml vial MO dopamine 400 mg-d5w 250 ml MO dopamine 400 mg-d5w 500 ml MO

TIER
2 2 4 4 4 4 4 4 4 4 4 4 4 4 5 4 3 4 4 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1

PA,QL (120 per 30 days) PA PA PA,QL (360 per 30 days) QL (56 per 28 days) QL (56 per 28 days) QL (56 per 28 days) QL (56 per 28 days) QL (56 per 28 days) QL (56 per 28 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 28 days) QL (4 per 20 days)

QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
dopamine 80 mg/ml vial MO dopamine 800 mg-d5w 250 ml MO dopamine 800 mg-d5w 500 ml MO DUONEB 0.5 MG-3 MG(2.5 MG BASE)/3 ML NEB SOLUTION MO ed-spaz 0.125 mg disintegrating tablet MO ephedrine su 50 mg/ml vial MO epinephrine 0.1 mg/ml syringe MO epinephrine 0.15 mg auto-injct MO epinephrine 0.3 mg auto-inject MO epinephrine 1 mg/ml ampul MO epinephrine 1 mg/ml vial MO EPIPEN 0.3 MG/0.3 ML (1:1,000) IM INJECTOR MO EPIPEN JR 0.15 MG/0.3 ML (1:2,000) IM INJECTOR MO ERGOMAR 2 MG SUBLINGUAL TABLET MO ergotamine-caffeine tablet MO EXELON 2 MG/ML ORAL SOLN MO EXELON 4.6 MG/24 HOUR TRANSDERM 24 HR PATCH MO EXELON 9.5 MG/24 HOUR TRANSDERM 24 HR PATCH MO FORADIL AEROLIZER 12 MCG CAPSULE WITH INHALATION DEVICE MO galantamine 4 mg/ml oral soln MO galantamine er 16 mg capsule MO galantamine er 24 mg capsule MO galantamine er 8 mg capsule MO galantamine hbr 12 mg tablet MO galantamine hbr 4 mg tablet MO galantamine hbr 8 mg tablet MO glycopyrrolate 0.2 mg/ml vial MO glycopyrrolate 1 mg tablet MO glycopyrrolate 2 mg tablet MO guanidine hcl 125 mg tablet MO iprat-albut 0.5-3(2.5) mg/3 ml MO ipratropium br 0.02% soln MO isoproterenol 0.2 mg/ml syrn MO ISUPREL 0.2 MG/ML INJECTION MO levalbuterol conc 1.25 mg/0.5 MO LEVOPHED 1 MG/ML IV MO

TIER
1 1 1 4 2 1 1 2 3 1 1 3 3 2 2 4 4 4 3 4 4 4 4 4 4 4 2 3 3 2 2 2 1 4 2 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D PA

QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (200 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

B vs D B vs D

B vs D

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DRUG NAME
LIORESAL 2,000 MCG/ML INTRATHECAL MO LIORESAL 50 MCG/ML INTRATHECAL MO LIORESAL 500 MCG/ML INTRATHECAL MO MAXAIR AUTOHALER 200 MCG/INHALATION BREATH ACTIVATED MO MESTINON TIMESPAN 180 MG TABLET,EXTENDED RELEASE MO metaproterenol 10 mg tablet MO metaproterenol 10 mg/5 ml syr MO metaproterenol 20 mg tablet MO metaxalone 800 mg tablet MO methocarbamol 500 mg tablet MO methocarbamol 750 mg tablet MO methscopolamine brom 2.5 mg tb MO methscopolamine brom 5 mg tab MO midodrine hcl 10 mg tablet MO midodrine hcl 2.5 mg tablet MO midodrine hcl 5 mg tablet MO migergot 2 mg-100 mg rectal suppository MO MIGRANAL 0.5 MG/PUMP ACT. (4 MG/ML) NASAL SPRAY MO MYTELASE 10 MG TABLET MO NEO-SYNEPHRINE 10 MG/ML INJECTION MO neostigmine 1:1,000 vial MO neostigmine 1:2,000 vial MO NICOTROL NS 10 MG/ML NASAL SPRAY MO NIMBEX 10 MG/ML IV MO NIMBEX 2 MG/ML IV MO norepinephrine 4 mg/4 ml ampul MO NORFLEX 60 MG/2 ML AMPUL MO nulev 0.125 mg disintegrating tablet MO orphenadrine 30 mg/ml ampule MO orphenadrine er 100 mg tablet MO pancuronium 1 mg/ml vial MO pancuronium 2 mg/ml vial MO PERFOROMIST 20 MCG/2 ML NEB SOLUTION MO phentolamine 5 mg vial MO phenylephrine 10 mg/ml vial MO pilocarpine hcl 5 mg tablet MO

TIER
5 4 4 4 4 2 1 4 4 2 2 3 3 4 4 4 3 4 4 4 2 2 4 4 4 1 4 4 3 3 1 1 4 2 1 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (14 per 30 days)

PA,QL (120 per 30 days) PA PA

QL (8 per 30 days)

PA PA PA PA

PA,QL (120 per 30 days)

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DRUG NAME
pilocarpine hcl 7.5 mg tablet MO PROAIR HFA 90 MCG/ACTUATION AEROSOL INHALER MO PROAMATINE 10 MG TABLET MO PROAMATINE 2.5 MG TABLET MO PROAMATINE 5 MG TABLET MO propantheline 15 mg tablet MO PROSTIGMIN 15 MG TABLET MO PROVENTIL HFA 90 MCG/ACTUATION AEROSOL INHALER MO pyridostigmine br 60 mg tablet MO RAPAFLO 4 MG CAPSULE MO RAPAFLO 8 MG CAPSULE MO REGONOL 5 MG/ML INJECTION MO revonto 20 mg iv solution MO rivastigmine 1.5 mg capsule MO rivastigmine 3 mg capsule MO rivastigmine 4.5 mg capsule MO rivastigmine 6 mg capsule MO ROBINUL 0.2 MG/ML INJECTION MO ROBINUL 1 MG TABLET MO ROBINUL FORTE 2 MG TABLET MO rocuronium 100 mg/10 ml vial MO SEREVENT DISKUS 50 MCG/DOSE FOR INHALATION MO SPIRIVA WITH HANDIHALER 18 MCG & INHALATION CAPSULES MO tamsulosin hcl 0.4 mg capsule MO terbutaline sulf 1 mg/ml vial MO terbutaline sulfate 2.5 mg tab MO terbutaline sulfate 5 mg tab MO tizanidine hcl 2 mg tablet MO tizanidine hcl 4 mg tablet MO tubocurarine cl 3 mg/ml syrn MO TWINJECT 0.15 MG AUTO-INJECTOR MO TWINJECT 0.3 MG AUTO-INJECTOR MO vecuronium 10 mg vial MO vecuronium 20 mg vial MO VENTOLIN HFA 90 MCG/ACTUATION AEROSOL INHALER MO ZEMURON 10 MG/ML IV MO

TIER
4 3 4 4 4 2 4 4 3 3 3 4 3 4 4 4 4 4 4 4 1 3 3 2 5 4 4 2 2 1 4 4 1 1 3 4

UTILIZATION MANAGEMENT REQUIREMENTS


QL (36 per 30 days)

PA QL (36 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

QL (90 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

PA QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days)

QL (36 per 30 days)

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DRUG NAME
BLOOD FORMATION,COAGULATION & THROMBOSIS ACTIVASE 100 MG SOLUTION MO ACTIVASE 50 MG SOLUTION MO ALPHANINE SD 1,000 (+/-) UNIT IV SOLUTION MO AMICAR 1,000 MG TABLET MO AMICAR 25% SOLUTION MO AMICAR 500 MG TABLET MO aminocaproic acid 1,000 mg tab MO aminocaproic acid 25% solution MO aminocaproic acid 250 mg/ml MO aminocaproic acid 500 mg tab MO anagrelide hcl 0.5 mg capsule MO anagrelide hcl 1 mg capsule MO argatroban 100 mg/ml vial MO CEPROTIN (BLUE BAR) 500 UNIT IV SOLUTION MO CEPROTIN (GREEN BAR) 1,000 UNIT IV SOLUTION MO cilostazol 100 mg tablet MO cilostazol 50 mg tablet MO clopidogrel 300 mg tablet MO clopidogrel 75 mg tablet MO COUMADIN 1 MG TABLET MO COUMADIN 10 MG TABLET MO COUMADIN 2 MG TABLET MO COUMADIN 2.5 MG TABLET MO COUMADIN 3 MG TABLET MO COUMADIN 4 MG TABLET MO COUMADIN 5 MG IV SOLUTION MO COUMADIN 5 MG TABLET MO COUMADIN 6 MG TABLET MO COUMADIN 7.5 MG TABLET MO CYKLOKAPRON 100 MG/ML IV MO EFFIENT 10 MG TABLET MO EFFIENT 5 MG TABLET MO enoxaparin 100 mg/ml syr HI,MO enoxaparin 120 mg/0.8 ml syr HI,MO enoxaparin 150 mg/ml syr HI,MO

TIER

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D B vs D

5 5 4 4 4 5 4 2 2 2 2 2 1 4 4 2 2 2 2 4 4 4 4 4 4 4 4 4 4 3 4 4 4 4 4

B vs D

QL (1 per 30 days) QL (30 per 30 days)

PA,QL (400 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (28 per 30 days) QL (28 per 30 days) QL (28 per 30 days)

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DRUG NAME
enoxaparin 30 mg/0.3 ml syr HI,MO enoxaparin 300 mg/3 ml vial MO enoxaparin 40 mg/0.4 ml syr HI,MO enoxaparin 60 mg/0.6 ml syr HI,MO enoxaparin 80 mg/0.8 ml syr HI,MO EPOGEN 10,000 UNIT/ML INJECTION SP EPOGEN 2,000 UNIT/ML INJECTION SP EPOGEN 20,000 UNIT/2 ML INJECTION SP EPOGEN 20,000 UNIT/ML INJECTION SP EPOGEN 3,000 UNIT/ML INJECTION SP EPOGEN 4,000 UNIT/ML INJECTION SP fe c plus 100 mg-250 mg-25 mcg-1 mg tablet MO fondaparinux 10 mg/0.8 ml syr HI,MO fondaparinux 2.5 mg/0.5 ml syr HI,MO fondaparinux 5 mg/0.4 ml syr HI,MO fondaparinux 7.5 mg/0.6 ml syr HI,MO FRAGMIN 10,000 UNIT/ML SUB-Q SYRINGE MO FRAGMIN 12,500 UNIT/0.5 ML SUB-Q SYRINGE MO FRAGMIN 15,000 UNIT/0.6 ML SUB-Q SYRINGE MO FRAGMIN 18,000 UNIT/0.72 ML SUB-Q SYRINGE MO FRAGMIN 2,500 UNIT/0.2 ML SUB-Q SYRINGE MO FRAGMIN 25,000 UNIT/ML SUB-Q MO FRAGMIN 5,000 UNIT/0.2 ML SUB-Q SYRINGE MO FRAGMIN 7,500 UNIT/0.3 ML SUB-Q SYRINGE MO heparin iv flush 10 unit/ml sy MO heparin iv flush 100 units/ml MO heparin lock flush (porcine) (pf) 10 unit/ml iv syringe MO heparin sod 1,000 unit/ml vial MO heparin sod 10,000 unit/ml vl HI,MO heparin sod 2,000 unit/ml vial MO heparin sod 2,500 unit/ml vial MO heparin sod 20,000 unit/ml vl HI,MO heparin sod 5,000 unit/ 0.5 ml MO heparin sod 5,000 unit/0.5 ml MO heparin sod 5,000 unit/ml syr MO heparin sod 5,000 unit/ml vial HI,MO

TIER
4 4 4 4 4 5 3 4 4 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3

QL (28 per 30 days) QL (28 per 30 days) QL (28 per 30 days) QL (28 per 30 days) QL (28 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) QL (14 per 30 days) QL (14 per 30 days) QL (14 per 30 days) QL (14 per 30 days) QL (14 per 30 days) QL (14 per 30 days) QL (14 per 30 days) QL (14 per 30 days) QL (14 per 30 days) QL (2 per 30 days) QL (14 per 30 days) QL (14 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D

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DRUG NAME
heparin-1/2ns 12,500 unit/250 MO heparin-1/2ns 25,000 unit/250 HI,MO heparin-1/2ns 25,000 unit/500 HI,MO heparin-d5w 12,500 unit/250 ml MO heparin-d5w 20,000 unit/500 ml MO heparin-d5w 25,000 unit/250 ml MO heparin-d5w 25,000 unit/500 ml MO heparin-ns 1,000 unit/500 ml MO heparin-ns 2,000 unit/1,000 ml HI,MO ICAR-C PLUS 100 MG-250 MG-25 MCG-1 MG TABLET MO INNOHEP 20,000 UNIT/ML VIAL MO INTEGRILIN 0.75 MG/ML IV MO INTEGRILIN 2 MG/ML IV MO jantoven 1 mg tablet MO jantoven 10 mg tablet MO jantoven 2 mg tablet MO jantoven 2.5 mg tablet MO jantoven 3 mg tablet MO jantoven 4 mg tablet MO jantoven 5 mg tablet MO jantoven 6 mg tablet MO jantoven 7.5 mg tablet MO LEUKINE 250 MCG SOLUTION FOR INJECTION SP LEUKINE 500 MCG/ML INJECTION SP monoject prefill (pf) 10 unit/ml iv syringe MO MOZOBIL 24 MG/1.2 ML (20 MG/ML) SUB-Q SP NEULASTA 6 MG/0.6 ML SUB-Q SYRINGE SP NEUMEGA 5 MG SUB-Q SOLN SP NEUPOGEN 300 MCG/0.5 ML SYRINGE SP NEUPOGEN 300 MCG/ML INJECTION SP NEUPOGEN 480 MCG/0.8 ML SYRINGE SP NEUPOGEN 480 MCG/1.6 ML INJECTION SP pentoxifylline er 400 mg tab MO PLETAL 100 MG TABLET MO PLETAL 50 MG TABLET MO PRADAXA 150 MG CAPSULE MO

TIER
1 1 1 1 1 1 1 1 1 4 4 4 4 2 2 2 2 2 2 2 2 2 5 5 3 5 5 5 5 5 5 5 3 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (14 per 30 days)

PA PA PA,QL (8 per 30 days) PA,QL (2 per 28 days) QL (42 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days)

QL (60 per 30 days)

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DRUG NAME
PRADAXA 75 MG CAPSULE MO PROCRIT 10,000 UNIT/ML INJECTION SP PROCRIT 2,000 UNIT/ML INJECTION SP PROCRIT 20,000 UNIT/2 ML INJECTION SP PROCRIT 20,000 UNIT/ML INJECTION SP PROCRIT 3,000 UNIT/ML INJECTION SP PROCRIT 4,000 UNIT/ML INJECTION SP PROCRIT 40,000 UNIT/ML INJECTION SP PROMACTA 12.5 MG TABLET MO PROMACTA 25 MG TABLET SP PROMACTA 50 MG TABLET SP PROMACTA 75 MG TABLET SP protamine 10 mg/ml vial MO REFLUDAN 50 MG IV SOLUTION MO REOPRO 10 MG/5 ML IV MO RIASTAP 1 GRAM (900 MG-1,300 MG) IV SOLUTION MO ticlopidine 250 mg tablet MO TNKASE 50 MG IV KIT MO tranexamic acid 1,000 mg/10 ml MO tranexamic acid 1000 mg/10 ml MO TRENTAL 400 MG TABLET,EXTENDED RELEASE MO warfarin sodium 1 mg tablet MO warfarin sodium 10 mg tablet MO warfarin sodium 2 mg tablet MO warfarin sodium 2.5 mg tablet MO warfarin sodium 3 mg tablet MO warfarin sodium 4 mg tablet MO warfarin sodium 5 mg tablet MO warfarin sodium 6 mg tablet MO warfarin sodium 7.5 mg tablet MO XARELTO 10 MG TABLET MO XARELTO 15 MG TABLET MO XARELTO 20 MG TABLET MO CARDIOVASCULAR DRUGS ACCUPRIL 10 MG TABLET MO ACCUPRIL 20 MG TABLET MO

TIER
4 4 3 4 5 3 3 5 5 5 5 5 1 5 5 4 3 5 3 3 4 1 1 1 1 1 1 1 1 1 4 4 4 4 4

QL (60 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (14 per 30 days) PA,QL (4 per 30 days) PA,QL (60 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days) B vs D B vs D

UTILIZATION MANAGEMENT REQUIREMENTS

PA

PA,QL (400 per 30 days)

QL (35 per 60 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
ACCUPRIL 40 MG TABLET MO ACCUPRIL 5 MG TABLET MO ACCURETIC 10 MG-12.5 MG TABLET MO ACCURETIC 20 MG-12.5 MG TABLET MO ACCURETIC 20 MG-25 MG TABLET MO acebutolol 200 mg capsule MO acebutolol 400 mg capsule MO ACEON 2 MG TABLET MO ACEON 4 MG TABLET MO ACEON 8 MG TABLET MO ADALAT CC 30 MG TABLET,EXTENDED RELEASE MO ADALAT CC 60 MG TABLET,EXTENDED RELEASE MO ADALAT CC 90 MG TABLET,EXTENDED RELEASE MO ADCIRCA 20 MG TABLET SP ADENOCARD 3 MG/ML IV SYRINGE MO adenosine 12 mg/4 ml syringe MO adenosine 12 mg/4 ml vial MO afeditab cr 30 mg tablet,extended release MO afeditab cr 60 mg tablet,extended release MO AGGRENOX 200 MG-25 MG CAPSULE, EXTENDED RELEASE MO ALDACTAZIDE 25 MG-25 MG TABLET MO ALDACTAZIDE 50 MG-50 MG TABLET MO ALDACTONE 100 MG TABLET MO ALDACTONE 25 MG TABLET MO ALDACTONE 50 MG TABLET MO amiodarone 150 mg/3 ml syringe MO amiodarone 900 mg/18 ml vial MO amiodarone hcl 200 mg tablet MO amiodarone hcl 400 mg tablet MO amlodipine besylate 10 mg tab MO amlodipine besylate 2.5 mg tab MO amlodipine besylate 5 mg tab MO amlodipine-atorvast 10-10 mg MO amlodipine-atorvast 10-20 mg MO amlodipine-atorvast 10-40 mg MO amlodipine-atorvast 10-80 mg MO

TIER
4 4 4 4 4 2 2 4 4 4 4 4 4 5 4 1 1 3 3 4 4 4 4 4 4 2 2 2 2 1 1 1 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA,QL (60 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) ST

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
amlodipine-atorvast 2.5-10 mg MO amlodipine-atorvast 2.5-20 mg MO amlodipine-atorvast 2.5-40 mg MO amlodipine-atorvast 5-10 mg MO amlodipine-atorvast 5-20 mg MO amlodipine-atorvast 5-40 mg MO amlodipine-atorvast 5-80 mg MO amlodipine-benazepril 10-20 mg MO amlodipine-benazepril 10-40 mg MO amlodipine-benazepril 2.5-10 MO amlodipine-benazepril 5-10 mg MO amlodipine-benazepril 5-20 mg MO amlodipine-benazepril 5-40 mg MO AMTURNIDE 150 MG-5 MG-12.5 MG TABLET MO AMTURNIDE 300 MG-10 MG-12.5 MG TABLET MO AMTURNIDE 300 MG-10 MG-25 MG TABLET MO AMTURNIDE 300 MG-5 MG-12.5 MG TABLET MO AMTURNIDE 300 MG-5 MG-25 MG TABLET MO amyl nitrite ampul MO ANTARA 130 MG CAPSULE MO ANTARA 43 MG CAPSULE MO atenolol 100 mg tablet MO atenolol 25 mg tablet MO atenolol 50 mg tablet MO atenolol-chlorthal 50-25 tb MO atenolol-chlorthalidone 100-25 MO atorvastatin 10 mg tablet MO atorvastatin 20 mg tablet MO atorvastatin 40 mg tablet MO atorvastatin 80 mg tablet MO benazepril hcl 10 mg tablet MO benazepril hcl 20 mg tablet MO benazepril hcl 40 mg tablet MO benazepril hcl 5 mg tablet MO benazepril-hctz 10-12.5 mg tab MO benazepril-hctz 20-12.5 mg tab MO

TIER
2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 2 4 4 1 1 1 2 2 2 2 2 2 1 1 1 1 2 2

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
benazepril-hctz 20-25 mg tab MO benazepril-hctz 5-6.25 mg tab MO betaxolol 10 mg tablet MO betaxolol 20 mg tablet MO BIDIL 20 MG-37.5 MG TABLET MO bisoprolol fumarate 10 mg tab MO bisoprolol fumarate 5 mg tab MO bisoprolol-hctz 10-6.25 mg tab MO bisoprolol-hctz 2.5-6.25 mg tb MO bisoprolol-hctz 5-6.25 mg tab MO BREVIBLOC 100 MG/10 ML (10 MG/ML) IV MO BREVIBLOC IN SODIUM CHLORIDE (ISO-OSM) 2,000 MG/100 ML (20 MG/ML) IV MO BREVIBLOC IN SODIUM CHLORIDE (ISO-OSM) 2,500 MG/250 ML (10 MG/ML) IV MO BYSTOLIC 10 MG TABLET MO BYSTOLIC 2.5 MG TABLET MO BYSTOLIC 20 MG TABLET MO BYSTOLIC 5 MG TABLET MO CALAN 120 MG TABLET MO CALAN 80 MG TABLET MO CALAN SR 120 MG TABLET,EXTENDED RELEASE MO CALAN SR 180 MG TABLET,EXTENDED RELEASE MO CALAN SR 240 MG TABLET,EXTENDED RELEASE MO captopril 100 mg tablet MO captopril 12.5 mg tablet MO captopril 25 mg tablet MO captopril 50 mg tablet MO captopril-hctz 25-15 mg tablet MO captopril-hctz 25-25 mg tablet MO captopril-hctz 50-15 mg tablet MO captopril-hctz 50-25 mg tablet MO CARDENE SR 30 MG CAPSULE,EXTENDED RELEASE MO CARDENE SR 60 MG CAPSULE,EXTENDED RELEASE MO cartia xt 120 mg capsule,extended release MO cartia xt 180 mg capsule,extended release MO

TIER
2 2 3 2 3 3 2 2 2 2 4 4 4 3 3 3 3 4 4 4 4 4 1 1 1 1 2 2 2 2 4 4 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (180 per 30 days)

QL (120 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

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DRUG NAME
cartia xt 240 mg capsule,extended release MO cartia xt 300 mg capsule,extended release MO carvedilol 12.5 mg tablet MO carvedilol 25 mg tablet MO carvedilol 3.125 mg tablet MO carvedilol 6.25 mg tablet MO cholestyramine light 4 gram oral powder MO cholestyramine light 4 gram packet MO cholestyramine packet MO cholestyramine powder MO clonidine 0.1 mg/day patch MO clonidine 0.2 mg/day patch MO clonidine 0.3 mg/day patch MO clonidine hcl 0.1 mg tablet MO clonidine hcl 0.2 mg tablet MO clonidine hcl 0.3 mg tablet MO clorpres 0.1 mg-15 mg tablet MO clorpres 0.2 mg-15 mg tablet MO clorpres 0.3 mg-15 mg tablet MO colestipol hcl 1 gm tablet MO colestipol hcl granules MO colestipol hcl granules packet MO colestipol micronized 1 gm tab MO COREG CR 10 MG CAPSULE, EXTENDED RELEASE MO COREG CR 20 MG CAPSULE, EXTENDED RELEASE MO COREG CR 40 MG CAPSULE, EXTENDED RELEASE MO COREG CR 80 MG CAPSULE, EXTENDED RELEASE MO CORLOPAM 10 MG/ML IV MO CORVERT 0.1 MG/ML IV MO CORZIDE 40 MG-5 MG TABLET MO CORZIDE 80 MG-5 MG TABLET MO COVERA-HS ER 180 MG TABLET MO COVERA-HS ER 240 MG TABLET MO CRESTOR 10 MG TABLET MO CRESTOR 20 MG TABLET MO CRESTOR 40 MG TABLET MO

TIER
2 2 1 1 1 1 4 4 4 4 2 2 2 2 2 2 4 4 4 4 3 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3

QL (60 per 30 days) QL (30 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days)

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

QL (90 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
CRESTOR 5 MG TABLET MO digoxin 0.25 mg/ml ampul MO digoxin 0.25 mg/ml syringe MO digoxin 125 mcg tablet MO digoxin 250 mcg tablet MO digoxin 50 mcg/ml solution MO DILACOR XR 240 MG CAPSULE, EXTENDED RELEASE MO DILATRATE-SR 40 MG CAPSULE,EXTENDED RELEASE MO dilt-cd 120 mg capsule,extended release MO dilt-cd 180 mg capsule,extended release MO dilt-cd 240 mg capsule,extended release MO dilt-cd 300 mg capsule,extended release MO dilt-xr 120 mg capsule, extended release MO dilt-xr 180 mg capsule, extended release MO dilt-xr 240 mg capsule, extended release MO diltia xt 120 mg capsule, extended release MO diltia xt 180 mg capsule, extended release MO diltia xt 240 mg capsule, extended release MO diltiazem 120 mg tablet MO diltiazem 24hr cd 120 mg cap MO diltiazem 24hr cd 180 mg cap MO diltiazem 24hr er 240 mg cap MO diltiazem 24hr er 300 mg cap MO diltiazem 25 mg/5 ml carpuject MO diltiazem 30 mg tablet MO diltiazem 50 mg/10 ml vial MO diltiazem 60 mg tablet MO diltiazem 90 mg tablet MO diltiazem er 120 mg 12-hr cap MO diltiazem er 120 mg capsule MO diltiazem er 180 mg capsule MO diltiazem er 240 mg capsule MO diltiazem er 60 mg 12-hr cap MO diltiazem er 90 mg 12-hr cap MO diltiazem hcl 100 mg vial MO diltiazem hcl er 240 mg cap MO

TIER
3 1 1 1 1 1 4 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 4 2

QL (30 per 30 days) PA QL (30 per 30 days) PA PA QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

QL (60 per 30 days)

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DRUG NAME
diltiazem hcl er 300 mg cap MO diltiazem hcl er 360 mg cap MO diltiazem hcl er 420 mg cap MO diltzac er 120 mg capsule,extended release MO diltzac er 180 mg capsule,extended release MO diltzac er 240 mg capsule,extended release MO diltzac er 300 mg capsule,extended release MO diltzac er 360 mg capsule,extended release MO DIOVAN 160 MG TABLET MO DIOVAN 320 MG TABLET MO DIOVAN 40 MG TABLET MO DIOVAN 80 MG TABLET MO DIOVAN HCT 160 MG-12.5 MG TABLET MO DIOVAN HCT 160 MG-25 MG TABLET MO DIOVAN HCT 320 MG-12.5 MG TABLET MO DIOVAN HCT 320 MG-25 MG TABLET MO DIOVAN HCT 80 MG-12.5 MG TABLET MO disopyramide 100 mg capsule MO disopyramide 150 mg cap sa MO disopyramide 150 mg capsule MO doxazosin mesylate 1 mg tab MO doxazosin mesylate 2 mg tab MO doxazosin mesylate 4 mg tab MO doxazosin mesylate 8 mg tab MO DYNACIRC CR 10 MG TABLET MO DYNACIRC CR 5 MG TABLET MO enalapril maleate 10 mg tab MO enalapril maleate 2.5 mg tab MO enalapril maleate 20 mg tab MO enalapril maleate 5 mg tablet MO enalapril-hctz 10-25 mg tablet MO enalapril-hctz 5-12.5 mg tab MO enalaprilat 1.25 mg/ml vial MO eplerenone 25 mg tablet MO eplerenone 50 mg tablet MO epoprostenol sodium 0.5 mg vl MO

TIER
2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 2 2 4 2 2 2 2 4 4 1 1 1 1 2 2 2 4 4 5

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) PA PA PA

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (90 per 30 days)

PA

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DRUG NAME
epoprostenol sodium 1.5 mg vl MO esmolol hcl 100 mg/10 ml vial MO EXFORGE 10 MG-160 MG TABLET MO EXFORGE 10 MG-320 MG TABLET MO EXFORGE 5 MG-160 MG TABLET MO EXFORGE 5 MG-320 MG TABLET MO EXFORGE HCT 10 MG-160 MG-12.5 MG TABLET MO EXFORGE HCT 10 MG-160 MG-25 MG TABLET MO EXFORGE HCT 10 MG-320 MG-25 MG TABLET MO EXFORGE HCT 5 MG-160 MG-12.5 MG TABLET MO EXFORGE HCT 5 MG-160 MG-25 MG TABLET MO felodipine er 10 mg tablet MO felodipine er 2.5 mg tablet MO felodipine er 5 mg tablet MO fenofibrate 134 mg capsule MO fenofibrate 160 mg tablet MO fenofibrate 200 mg capsule MO fenofibrate 54 mg tablet MO fenofibrate 67 mg capsule MO fenoldopam 10 mg/ml ampule MO flecainide acetate 100 mg tab MO flecainide acetate 150 mg tab MO flecainide acetate 50 mg tab MO fluvastatin sodium 20 mg cap MO fluvastatin sodium 40 mg cap MO fosinopril sodium 10 mg tab MO fosinopril sodium 20 mg tab MO fosinopril sodium 40 mg tab MO fosinopril-hctz 10-12.5 mg tab MO fosinopril-hctz 20-12.5 mg tab MO gemfibrozil 600 mg tablet MO guanfacine 1 mg tablet MO guanfacine 2 mg tablet MO hydralazine 10 mg tablet MO hydralazine 100 mg tablet MO hydralazine 20 mg/ml vial MO

TIER
5 1 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 2 3 1 3 3 3 3 3 2 2 2 3 3 2 2 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS


PA

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

QL (60 per 30 days) QL (60 per 30 days)

QL (60 per 30 days) PA PA

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DRUG NAME
hydralazine 25 mg tablet MO hydralazine 50 mg tablet MO ibutilide fum 1 mg/10 ml vial MO IMDUR 120 MG TABLET,EXTENDED RELEASE MO IMDUR 30 MG TABLET,EXTENDED RELEASE MO IMDUR 60 MG TABLET,EXTENDED RELEASE MO inamrinone 100 mg/20 ml vial MO irbesartan 150 mg tablet MO irbesartan 300 mg tablet MO irbesartan 75 mg tablet MO irbesartan-hctz 150-12.5 mg tb MO irbesartan-hctz 300-12.5 mg tb MO isoditrate 40 mg tablet,extended release MO ISOPTIN SR 120 MG TABLET MO ISOPTIN SR 180 MG TABLET MO ISOPTIN SR 240 MG TABLET MO ISORDIL 40 MG TABLET MO ISORDIL TITRADOSE 5 MG TABLET MO isosorbide dn 10 mg tablet MO isosorbide dn 2.5 mg tab sl MO isosorbide dn 20 mg tablet MO isosorbide dn 30 mg tablet MO isosorbide dn 5 mg tablet MO isosorbide dn 5 mg tablet sl MO isosorbide dn er 40 mg tablet MO isosorbide mn 10 mg tablet MO isosorbide mn 20 mg tablet MO isosorbide mn er 120 mg tab MO isosorbide mn er 30 mg tablet MO isosorbide mn er 60 mg tablet MO isradipine 2.5 mg capsule MO isradipine 5 mg capsule MO KAPVAY 0.1 MG TABLET,EXTENDED RELEASE MO labetalol hcl 100 mg tablet MO labetalol hcl 20 mg/4 ml crpj MO labetalol hcl 200 mg tablet MO

TIER
2 2 1 4 4 4 1 3 3 3 3 3 1 4 4 4 4 4 2 1 2 2 2 2 3 2 2 2 2 2 4 4 4 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA PA PA QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

ST,QL (120 per 30 days)

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DRUG NAME
labetalol hcl 300 mg tablet MO labetalol hcl 5 mg/ml vial MO LANOXIN 125 MCG TABLET MO LANOXIN 250 MCG TABLET MO LANOXIN 250 MCG/ML INJECTION MO LANOXIN PEDIATRIC 100 MCG/ML INJECTION MO LETAIRIS 10 MG TABLET SP LETAIRIS 5 MG TABLET SP LEVATOL 20 MG TABLET MO lidocaine 0.4% in d5w soln MO lidocaine 0.8% in d5w soln MO lidocaine hcl 1% syringe MO lidocaine hcl 2% abboject MO lisinopril 10 mg tablet MO lisinopril 2.5 mg tablet MO lisinopril 20 mg tablet MO lisinopril 30 mg tablet MO lisinopril 40 mg tablet MO lisinopril 5 mg tablet MO lisinopril-hctz 10-12.5 mg tab MO lisinopril-hctz 20-12.5 mg tab MO lisinopril-hctz 20-25 mg tab MO LOPRESSOR 100 MG TABLET MO LOPRESSOR 5 MG/5 ML IV MO LOPRESSOR 50 MG TABLET MO LOPRESSOR HCT 100 MG-25 MG TABLET MO LOPRESSOR HCT 50 MG-25 MG TABLET MO losartan potassium 100 mg tab MO losartan potassium 25 mg tab MO losartan potassium 50 mg tab MO losartan-hctz 100-12.5 mg tab MO losartan-hctz 100-25 mg tab MO losartan-hctz 50-12.5 mg tab MO LOTENSIN 10 MG TABLET MO LOTENSIN 20 MG TABLET MO LOTENSIN 40 MG TABLET MO

TIER
2 2 4 4 4 4 5 5 4 1 1 1 1 1 1 1 1 1 1 1 1 1 4 4 4 4 4 1 1 1 1 1 1 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 30 days) PA PA PA PA,QL (30 per 30 days) PA,QL (30 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

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DRUG NAME
LOTENSIN HCT 10 MG-12.5 MG TABLET MO LOTENSIN HCT 20 MG-12.5 MG TABLET MO LOTENSIN HCT 20 MG-25 MG TABLET MO lovastatin 10 mg tablet MO lovastatin 20 mg tablet MO lovastatin 40 mg tablet MO LOVAZA 1 GRAM CAPSULE MO MAVIK 1 MG TABLET MO MAVIK 2 MG TABLET MO MAVIK 4 MG TABLET MO metoprolol 1 mg/ml carpuject MO metoprolol succ er 100 mg tab MO metoprolol succ er 200 mg tab MO metoprolol succ er 25 mg tab MO metoprolol succ er 50 mg tab MO metoprolol tart 5 mg/5 ml amp MO metoprolol tartrate 100 mg tab MO metoprolol tartrate 25 mg tab MO metoprolol tartrate 50 mg tab MO metoprolol-hctz 100-25 mg tab MO metoprolol-hctz 100-50 mg tab MO metoprolol-hctz 50-25 mg tab MO mexiletine 150 mg capsule MO mexiletine 200 mg capsule MO mexiletine 250 mg capsule MO milrinone lact 10 mg/10 ml vl MO milrinone-d5w 20 mg/100 ml MO milrinone-d5w 40 mg/200 ml MO MINIPRESS 1 MG CAPSULE MO MINIPRESS 2 MG CAPSULE MO MINIPRESS 5 MG CAPSULE MO minoxidil 10 mg tablet MO minoxidil 2.5 mg tablet MO moexipril hcl 15 mg tablet MO moexipril hcl 7.5 mg tablet MO moexipril-hctz 15-12.5 mg tab MO

TIER
4 4 4 2 2 2 3 4 4 4 1 2 2 2 2 1 1 1 1 3 3 3 4 4 4 2 1 1 4 4 4 2 2 3 3 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

PA

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DRUG NAME
moexipril-hctz 15-25 mg tablet MO moexipril-hctz 7.5-12.5 mg tab MO MONOKET 10 MG TABLET MO MONOKET 20 MG TABLET MO MULTAQ 400 MG TABLET MO nadolol 20 mg tablet MO nadolol 40 mg tablet MO nadolol 80 mg tablet MO nadolol-bendroflu 40-5 mg tab MO nadolol-bendroflu 80-5 mg tab MO NATRECOR 1.5 MG IV SOLUTION MO NEXTERONE 150 MG/100 ML (1.5 MG/ML) IV MO NEXTERONE 360 MG/200 ML (1.8 MG/ML) IV MO niacor 500 mg tablet MO NIASPAN EXTENDED-RELEASE 1,000 MG TABLET,EXTENDED RELEASE MO NIASPAN EXTENDED-RELEASE 500 MG TABLET,EXTENDED RELEASE MO NIASPAN EXTENDED-RELEASE 750 MG TABLET,EXTENDED RELEASE MO nicardipine 20 mg capsule MO nicardipine 25 mg/10 ml ampule MO nicardipine 30 mg capsule MO nifediac cc 30 mg tablet,extended release MO nifediac cc 60 mg tablet,extended release MO nifediac cc 90 mg tablet,extended release MO nifedical xl 30 mg tablet,extended release MO nifedical xl 60 mg tablet,extended release MO nifedipine er 30 mg tablet MO nifedipine er 60 mg tablet MO nifedipine er 90 mg tablet MO nimodipine 30 mg capsule MO nisoldipine er 17 mg tablet MO nisoldipine er 20 mg tablet MO nisoldipine er 25.5 mg tablet MO nisoldipine er 30 mg tablet MO nisoldipine er 34 mg tablet MO nisoldipine er 40 mg tablet MO

TIER
2 2 4 4 3 2 2 2 3 3 4 4 4 3 3 3 3 2 2 2 3 3 3 3 3 3 3 3 4 4 4 4 3 3 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
nisoldipine er 8.5 mg tablet MO NITRO-DUR 0.1 MG/HR TRANSDERM 24 HR PATCH MO NITRO-DUR 0.2 MG/HR TRANSDERM 24 HR PATCH MO NITRO-DUR 0.3 MG/HR TRANSDERM 24 HR PATCH MO NITRO-DUR 0.4 MG/HR TRANSDERM 24 HR PATCH MO NITRO-DUR 0.6 MG/HR TRANSDERM 24 HR PATCH MO NITRO-DUR 0.8 MG/HR TRANSDERM 24 HR PATCH MO nitroglycerin 0.1 mg/hr patch MO nitroglycerin 0.2 mg/hr patch MO nitroglycerin 0.3 mg tab sl MO nitroglycerin 0.4 mg tablet sl MO nitroglycerin 0.4 mg/hr patch MO nitroglycerin 0.6 mg tab sl MO nitroglycerin 0.6 mg/hr patch MO nitroglycerin 5 mg/ml vial MO nitroglycerin lingual 0.4 mg MO NITROLINGUAL 0.4 MG/DOSE SPRAY MO NITROPRESS 25 MG/ML IV MO NITROSTAT 0.3 MG SUBLINGUAL TABLET MO NITROSTAT 0.4 MG SUBLINGUAL TABLET MO NITROSTAT 0.6 MG SUBLINGUAL TABLET MO ntg 0.2 mg/ml in d5w MO ntg 100 mg/250 ml in d5w MO ntg 200 mg/500 ml in d5w MO ntg 25 mg/250 ml in d5w MO ntg 50 mg/500 ml in d5w MO PACERONE 100 MG TABLET MO pacerone 200 mg tablet MO PACERONE 400 MG TABLET MO papaverine 150 mg capsule sa MO papaverine 300 mg/10 ml vial MO perindopril erbumine 2 mg tab MO perindopril erbumine 4 mg tab MO perindopril erbumine 8 mg tab MO pindolol 10 mg tablet MO pindolol 5 mg tablet MO

TIER
4 4 4 4 4 4 4 2 2 2 2 2 2 2 2 4 4 4 3 3 3 2 2 2 2 2 3 2 3 4 2 3 2 2 3 3

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (30 per 30 days)

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DRUG NAME
pravastatin sodium 10 mg tab MO pravastatin sodium 20 mg tab MO pravastatin sodium 40 mg tab MO pravastatin sodium 80 mg tab MO prazosin 1 mg capsule MO prazosin 2 mg capsule MO prazosin 5 mg capsule MO prevalite 4 gram oral packet MO prevalite 4 gram oral powder MO PRINIVIL 10 MG TABLET MO PRINIVIL 20 MG TABLET MO PRINIVIL 5 MG TABLET MO PRINZIDE 10 MG-12.5 MG TABLET MO PRINZIDE 20 MG-12.5 MG TABLET MO procainamide 100 mg/ml vial MO procainamide 500 mg/ml vial MO PROGLYCEM 50 MG/ML ORAL SUSP MO propafenone hcl 150 mg tablet MO propafenone hcl 225 mg tab MO propafenone hcl 300 mg tab MO propafenone hcl er 225 mg cap MO propafenone hcl sr 325 mg cap MO propafenone hcl sr 425 mg cap MO propranolol 1 mg/ml vial MO propranolol 10 mg tablet MO propranolol 20 mg tablet MO propranolol 20 mg/5 ml soln MO propranolol 40 mg tablet MO propranolol 40 mg/5 ml soln MO propranolol 60 mg tablet MO propranolol 80 mg tablet MO propranolol er 120 mg capsule MO propranolol er 160 mg capsule MO propranolol er 60 mg capsule MO propranolol er 80 mg capsule MO propranolol-hctz 40-25 mg tab MO

TIER
2 2 2 2 2 2 2 4 4 4 4 4 4 4 1 1 4 3 3 3 4 4 3 1 2 2 1 2 1 2 2 4 4 4 4 2

QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
propranolol-hctz 80-25 mg tab MO QUESTRAN 4 GRAM PACKET MO QUESTRAN LIGHT 4 GRAM PACKET MO quinapril 10 mg tablet MO quinapril 20 mg tablet MO quinapril 40 mg tablet MO quinapril 5 mg tablet MO quinapril-hctz 10-12.5 mg tab MO quinapril-hctz 20-12.5 mg tab MO quinapril-hctz 20-25 mg tab MO quinidine gluc 80 mg/ml vial MO quinidine gluc er 324 mg tab MO quinidine sulf er 300 mg tab MO quinidine sulfate 200 mg tab MO quinidine sulfate 300 mg tab MO ramipril 1.25 mg capsule MO ramipril 10 mg capsule MO ramipril 2.5 mg capsule MO ramipril 5 mg capsule MO RANEXA 1,000 MG TABLET,EXTENDED RELEASE MO RANEXA 500 MG TABLET,EXTENDED RELEASE MO REMODULIN 1 MG/ML INJECTION MO REMODULIN 10 MG/ML INJECTION MO REMODULIN 2.5 MG/ML INJECTION MO REMODULIN 5 MG/ML INJECTION MO reserpine 0.1 mg tablet MO reserpine 0.25 mg tablet MO REVATIO 20 MG TABLET SP SIMCOR 1,000 MG-20 MG TABLET,EXTENDED RELEASE MO SIMCOR 1,000 MG-40 MG TABLET,EXTENDED RELEASE MO SIMCOR 500 MG-20 MG TABLET,EXTENDED RELEASE MO SIMCOR 500 MG-40 MG TABLET,EXTENDED RELEASE MO SIMCOR 750 MG-20 MG TABLET,EXTENDED RELEASE MO simvastatin 10 mg tablet MO simvastatin 20 mg tablet MO simvastatin 40 mg tablet MO

TIER
3 4 4 2 2 2 2 3 3 3 2 3 2 2 2 2 2 2 2 3 3 5 5 5 5 2 2 5 4 4 4 4 4 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS


PA PA

ST,QL (120 per 30 days) ST,QL (120 per 30 days) PA PA PA PA PA PA,QL (90 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
simvastatin 5 mg tablet MO simvastatin 80 mg tablet MO sorine 120 mg tablet MO sorine 160 mg tablet MO sorine 240 mg tablet MO sorine 80 mg tablet MO sotalol 120 mg tablet MO sotalol 160 mg tablet MO sotalol 240 mg tablet MO sotalol 80 mg tablet MO sotalol af 120 mg tablet MO sotalol af 160 mg tablet MO sotalol af 80 mg tablet MO sotalol hcl 150 mg/10 ml vial MO spironolactone 100 mg tablet MO spironolactone 25 mg tablet MO spironolactone 50 mg tablet MO spironolactone-hctz 25-25 tab MO taztia xt 120 mg capsule,extended release MO taztia xt 180 mg capsule,extended release MO taztia xt 240 mg capsule,extended release MO taztia xt 300 mg capsule,extended release MO taztia xt 360 mg capsule,extended release MO TEKAMLO 150 MG-10 MG TABLET MO TEKAMLO 150 MG-5 MG TABLET MO TEKAMLO 300 MG-10 MG TABLET MO TEKAMLO 300 MG-5 MG TABLET MO TEKTURNA 150 MG TABLET MO TEKTURNA 300 MG TABLET MO TEKTURNA HCT 150 MG-12.5 MG TABLET MO TEKTURNA HCT 150 MG-25 MG TABLET MO TEKTURNA HCT 300 MG-12.5 MG TABLET MO TEKTURNA HCT 300 MG-25 MG TABLET MO TENORETIC 100 100 MG-25 MG TABLET MO TENORETIC 50 50 MG-25 MG TABLET MO TENORMIN 100 MG TABLET MO

TIER
1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4

QL (30 per 30 days) QL (30 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) PA

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DRUG NAME
TENORMIN 25 MG TABLET MO TENORMIN 50 MG TABLET MO terazosin 1 mg capsule MO terazosin 10 mg capsule MO terazosin 2 mg capsule MO terazosin 5 mg capsule MO TIAZAC 120 MG CAPSULE,EXTENDED RELEASE MO TIAZAC 180 MG CAPSULE,EXTENDED RELEASE MO TIAZAC 240 MG CAPSULE,EXTENDED RELEASE MO TIAZAC 300 MG CAPSULE,EXTENDED RELEASE MO TIAZAC 360 MG CAPSULE,EXTENDED RELEASE MO TIAZAC 420 MG CAPSULE,EXTENDED RELEASE MO TIKOSYN 125 MCG CAPSULE SP TIKOSYN 250 MCG CAPSULE SP TIKOSYN 500 MCG CAPSULE SP timolol maleate 10 mg tablet MO timolol maleate 20 mg tablet MO timolol maleate 5 mg tablet MO TOPROL XL 100 MG TABLET,EXTENDED RELEASE MO TOPROL XL 200 MG TABLET,EXTENDED RELEASE MO TOPROL XL 25 MG TABLET,EXTENDED RELEASE MO TOPROL XL 50 MG TABLET,EXTENDED RELEASE MO TRACLEER 125 MG TABLET SP TRACLEER 62.5 MG TABLET SP TRANDATE 100 MG TABLET MO TRANDATE 200 MG TABLET MO TRANDATE 300 MG TABLET MO trandolapril 1 mg tablet MO trandolapril 2 mg tablet MO trandolapril 4 mg tablet MO TRICOR 145 MG TABLET MO TRICOR 48 MG TABLET MO TRILIPIX 135 MG CAPSULE,DELAYED RELEASE MO TRILIPIX 45 MG CAPSULE,DELAYED RELEASE MO UNIRETIC 15 MG-12.5 MG TABLET MO UNIRETIC 15 MG-25 MG TABLET MO

TIER
4 4 2 2 2 2 4 4 4 4 4 4 4 4 4 2 2 2 4 4 4 4 5 5 4 4 4 2 2 2 3 3 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (120 per 30 days) QL (60 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days)

QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) PA

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DRUG NAME
UNIRETIC 7.5 MG-12.5 MG TABLET MO UNIVASC 15 MG TABLET MO UNIVASC 7.5 MG TABLET MO VALTURNA 150-160 MG TABLET MO VALTURNA 300-320 MG TABLET MO VELETRI 1.5 MG IV SOLUTION MO VENTAVIS 10 MCG/ML NEB SOLUTION SP VENTAVIS 20 MCG/ML NEB SOLUTION SP verapamil 120 mg tablet MO verapamil 2.5 mg/ml syringe MO verapamil 2.5 mg/ml vial MO verapamil 360 mg cap pellet MO verapamil 40 mg tablet MO verapamil 80 mg tablet MO verapamil er 120 mg capsule MO verapamil er 120 mg tablet MO verapamil er 180 mg capsule MO verapamil er 180 mg tablet MO verapamil er 240 mg capsule MO verapamil er 240 mg tablet MO verapamil er pm 100 mg capsule MO verapamil er pm 200 mg capsule MO verapamil er pm 300 mg capsule MO VYTORIN 10-10 10 MG-10 MG TABLET MO VYTORIN 10-20 10 MG-20 MG TABLET MO VYTORIN 10-40 10 MG-40 MG TABLET MO VYTORIN 10-80 10 MG-80 MG TABLET MO WELCHOL 3.75 GRAM ORAL POWDER PACK MO WELCHOL 625 MG TABLET MO XYLOCAINE (CARDIAC) (PF) 20 MG/ML (2 %) IV MO ZETIA 10 MG TABLET MO ZIAC 10 MG-6.25 MG TABLET MO ZIAC 2.5 MG-6.25 MG TABLET MO ZIAC 5 MG-6.25 MG TABLET MO CENTRAL NERVOUS SYSTEM AGENTS ABILIFY 1 MG/ML ORAL SOLN MO

TIER
4 4 4 3 3 5 5 5 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 4 3 3 4 3 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 30 days) QL (30 per 30 days) PA PA,QL (270 per 30 days) PA,QL (270 per 30 days)

QL (60 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

QL (30 per 30 days) PA PA PA QL (750 per 30 days)

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DRUG NAME
ABILIFY 10 MG TABLET MO ABILIFY 15 MG TABLET MO ABILIFY 2 MG TABLET MO ABILIFY 20 MG TABLET MO ABILIFY 30 MG TABLET MO ABILIFY 5 MG TABLET MO ABILIFY 9.75 MG/1.3 ML IM MO ABILIFY DISCMELT 10 MG DISINTEGRATING TABLET MO ABILIFY DISCMELT 15 MG DISINTEGRATING TABLET MO acetaminoph-caff-dihydrocodein MO acetaminophen-cod #2 tablet MO acetaminophen-cod #3 tablet MO acetaminophen-cod #4 tablet MO acetaminophen-codeine elixir MO ACUFLEX CAPLET MO alfentanil 500 mcg/ml amp MO ali-flex tablet MO alprazolam 0.25 mg tablet MO alprazolam 0.5 mg tablet MO alprazolam 1 mg tablet MO alprazolam 2 mg tablet MO amantadine 100 mg capsule MO amantadine 100 mg tablet MO amantadine 50 mg/5 ml syrup MO amitriptyline hcl 10 mg tab MO amitriptyline hcl 100 mg tab MO amitriptyline hcl 150 mg tab MO amitriptyline hcl 25 mg tab MO amitriptyline hcl 50 mg tab MO amitriptyline hcl 75 mg tab MO amoxapine 100 mg tablet MO amoxapine 150 mg tablet MO amoxapine 25 mg tablet MO amoxapine 50 mg tablet MO anabar 20 mg-300 mg-200 mg tablet MO APOKYN 10 MG/ML SUBQ CARTRIDGE MO

TIER
4 4 4 4 4 4 4 4 4 4 3 3 3 3 4 3 2 3 3 3 3 2 2 2 1 1 1 1 1 1 2 2 2 2 1 5

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (180 per 30 days) QL (390 per 30 days) QL (390 per 30 days) QL (390 per 30 days) QL (5010 per 30 days) QL (450 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (240 per 30 days) QL (150 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA PA PA PA PA PA

QL (60 per 30 days)

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DRUG NAME
astramorph-pf 0.5 mg/ml injection MO astramorph-pf 1 mg/ml injection MO AVINZA 120 MG CAPSULE, EXTENDED RELEASE MO AVINZA 30 MG CAPSULE, EXTENDED RELEASE MO AVINZA 45 MG CAPSULE, EXTENDED RELEASE MO AVINZA 60 MG CAPSULE, EXTENDED RELEASE MO AVINZA 75 MG CAPSULE, EXTENDED RELEASE MO AVINZA 90 MG CAPSULE, EXTENDED RELEASE MO AZILECT 0.5 MG TABLET MO AZILECT 1 MG TABLET MO BANZEL 200 MG TABLET MO BANZEL 40 MG/ML ORAL SUSP MO BANZEL 400 MG TABLET MO be-flex plus capsule MO benztropine 2 mg/2 ml ampule MO benztropine mes 0.5 mg tab MO benztropine mes 1 mg tablet MO benztropine mes 2 mg tablet MO bioregesic tablet MO bp poly-650 tablet MO bromocriptine 2.5 mg tablet MO bromocriptine 5 mg capsule MO budeprion sr 100 mg tablet,extended release MO budeprion sr 150 mg tablet,extended release MO budeprion xl 150 mg tablet MO budeprion xl 300 mg 24 hr tablet, extended release MO BUPRENEX 0.3 MG/ML INJECTION MO buprenorphine 0.3 mg/ml syrn MO buprenorphine 0.3 mg/ml vial MO buprenorphine 2 mg tablet sl MO buprenorphine 8 mg tablet sl MO buproban 150 mg tablet,extended release MO bupropion hcl 100 mg tablet MO bupropion hcl 75 mg tablet MO bupropion hcl sr 100 mg tablet MO bupropion hcl sr 200 mg tab MO

TIER
1 1 3 3 3 3 3 3 3 3 4 4 4 2 1 2 2 2 1 2 4 4 3 3 3 3 5 4 4 4 4 3 3 3 3 3

QL (7200 per 30 days) QL (3600 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) PA,QL (480 per 30 days) PA,QL (2760 per 30 days) PA,QL (240 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA PA PA

QL (120 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) PA,QL (240 per 30 days) PA,QL (240 per 30 days) PA,QL (240 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days) QL (90 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (60 per 30 days)

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DRUG NAME
bupropion hcl xl 150 mg tablet MO bupropion hcl xl 300 mg tablet MO bupropion sr 150 mg tablet MO buspirone hcl 10 mg tablet MO buspirone hcl 15 mg tablet MO buspirone hcl 30 mg tablet MO buspirone hcl 5 mg tablet MO buspirone hcl 7.5 mg tablet MO BUTISOL 30 MG TABLET MO BUTISOL 30 MG/5 ML ELIXIR MO BUTISOL 50 MG TABLET MO butorphanol 1 mg/ml syringe MO butorphanol 1 mg/ml vial MO butorphanol 10 mg/ml spray MO butorphanol 2 mg/ml syringe MO butorphanol 2 mg/ml vial MO cabergoline 0.5 mg tablet MO CAFCIT 60 MG/3 ML (20 MG/ML) IV MO CAFCIT 60 MG/3 ML (20 MG/ML) ORAL SOLN MO caff-sod benzoate 500 mg vl MO caffeine cit 60 mg/3 ml oral MO caffeine cit 60 mg/3 ml vial MO cafgesic capsule MO cafgesic forte tablet MO CAMPRAL 333 MG DOSE PAK MO CAMPRAL 333 MG TABLET,DELAYED RELEASE MO CAPITAL WITH CODEINE 120 MG-12 MG/5 ML ORAL SUSP MO carbamazepine 100 mg tab chew MO carbamazepine 100 mg/5 ml susp MO carbamazepine 200 mg tablet MO carbamazepine 200 mg/10 ml liq MO carbamazepine er 100 mg cap MO carbamazepine er 200 mg cap MO carbamazepine er 300 mg cap MO carbamazepine xr 200 mg tablet MO carbamazepine xr 400 mg tablet MO

TIER
3 3 3 2 2 2 2 2 4 4 4 3 3 3 3 3 4 4 4 1 1 1 2 2 4 4 4 2 2 2 2 4 4 4 2 2

QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA PA PA QL (960 per 30 days) QL (960 per 30 days) QL (5 per 28 days) QL (480 per 30 days) QL (480 per 30 days) QL (16 per 28 days)

QL (180 per 30 days) QL (5010 per 30 days)

QL (60 per 30 days) QL (240 per 30 days) QL (150 per 30 days)

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DRUG NAME
CARBATROL 100 MG CAPSULE, EXTENDED RELEASE MO CARBATROL 200 MG CAPSULE, EXTENDED RELEASE MO CARBATROL 300 MG CAPSULE, EXTENDED RELEASE MO carbidopa-levo 10-100 mg odt MO carbidopa-levo 25-100 mg odt MO carbidopa-levo 25-250 mg odt MO carbidopa-levo er 25-100 tab MO carbidopa-levo er 50-200 tab MO carbidopa-levodopa 10-100 tab MO carbidopa-levodopa 25-100 tab MO carbidopa-levodopa 25-250 tab MO carbidopa-levodopa-enta 100 mg MO carbidopa-levodopa-enta 125 mg MO carbidopa-levodopa-enta 150 mg MO carbidopa-levodopa-enta 200 mg MO carbidopa-levodopa-enta 50 mg MO carbidopa-levodopa-enta 75 mg MO CELEBREX 100 MG CAPSULE MO CELEBREX 200 MG CAPSULE MO CELEBREX 400 MG CAPSULE MO CELEBREX 50 MG CAPSULE MO CELONTIN 300 MG CAPSULE MO chlorpromazine 10 mg tablet MO chlorpromazine 100 mg tablet MO chlorpromazine 200 mg tablet MO chlorpromazine 25 mg tablet MO chlorpromazine 25 mg/ml amp MO chlorpromazine 50 mg tablet MO choline mag trisal 1 gm tab MO choline mag trisal 500 mg tb MO choline mag trisal 750 mg tb MO choline mag trisal liquid MO citalopram hbr 10 mg tablet MO citalopram hbr 10 mg/5 ml soln MO citalopram hbr 20 mg tablet MO citalopram hbr 40 mg tablet MO

TIER
4 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 2 3 2 2 2 2 1 1 1 1

QL (60 per 30 days) QL (240 per 30 days) QL (150 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) B vs D

B vs D

QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days)

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DRUG NAME
CLINORIL 200 MG TABLET MO clomipramine 25 mg capsule MO clomipramine 50 mg capsule MO clomipramine 75 mg capsule MO clonazepam 0.125 mg dis tab MO clonazepam 0.25 mg odt MO clonazepam 0.5 mg dis tablet MO clonazepam 0.5 mg tablet MO clonazepam 1 mg dis tablet MO clonazepam 1 mg tablet MO clonazepam 2 mg odt MO clonazepam 2 mg tablet MO clonidine 1000 mcg/10 ml vial MO clonidine 5,000 mcg/10 ml vial MO clorazepate 15 mg tablet MO clorazepate 3.75 mg tablet MO clorazepate 7.5 mg tablet MO clozapine 100 mg tablet MO clozapine 200 mg tablet MO clozapine 25 mg tablet MO clozapine 50 mg tablet MO codeine ph 15 mg/ml syringe MO codeine ph 30 mg/ml syringe MO codeine sulfate 15 mg tablet MO codeine sulfate 30 mg tablet MO codeine sulfate 60 mg tablet MO COGENTIN 2 MG/2 ML INJECTION MO COMTAN 200 MG TABLET MO CYMBALTA 20 MG CAPSULE,DELAYED RELEASE MO CYMBALTA 30 MG CAPSULE,DELAYED RELEASE MO CYMBALTA 60 MG CAPSULE,DELAYED RELEASE MO d-amphetamine er 10 mg capsule MO d-amphetamine er 15 mg capsule MO d-amphetamine er 5 mg capsule MO DEPACON 500 MG/5 ML (100 MG/ML) IV MO depade 50 mg tablet MO

TIER
4 2 2 2 4 4 4 3 4 3 4 3 1 1 4 4 4 3 3 3 3 1 1 3 3 3 4 3 3 3 3 4 4 3 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


PA PA PA

QL (360 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA QL (300 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA,QL (180 per 30 days) PA,QL (120 per 30 days) PA,QL (60 per 30 days)

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DRUG NAME
DEPAKENE 250 MG CAPSULE MO DEPAKENE 250 MG/5 ML ORAL SOLN MO desipramine 10 mg tablet MO desipramine 100 mg tablet MO desipramine 150 mg tablet MO desipramine 25 mg tablet MO desipramine 50 mg tablet MO desipramine 75 mg tablet MO dexmethylphenidate 10 mg tab MO dexmethylphenidate 2.5 mg tab MO dexmethylphenidate 5 mg tab MO dextroamphetamine 10 mg tab MO dextroamphetamine 5 mg tab MO diazepam 10 mg tablet MO diazepam 2 mg tablet MO diazepam 2.5 mg rectal gel MO diazepam 20 mg rectal gel MO diazepam 5 mg tablet MO diazepam 5 mg/5 ml solution MO diazepam 5-7.5-10 mg gel kit MO diazepam intensol 5 mg/ml oral concentrate MO diclofenac pot 50 mg tablet MO diclofenac sod ec 25 mg tab MO diclofenac sod ec 50 mg tab MO diclofenac sod ec 75 mg tab MO diclofenac sod er 100 mg tab MO diflunisal 500 mg tablet MO DILANTIN 30 MG CAPSULE MO DILANTIN EXTENDED 100 MG CAPSULE MO dilantin infatabs 50 mg chewable tablet MO DILANTIN-125 125 MG/5 ML ORAL SUSP MO divalproex sod dr 125 mg tab MO divalproex sod dr 250 mg tab MO divalproex sod dr 500 mg tab MO divalproex sod er 250 mg tab MO divalproex sod er 500 mg tab MO

TIER
4 4 4 4 4 4 4 4 2 2 2 4 4 4 4 4 4 4 4 4 4 3 2 2 2 3 4 4 4 4 4 2 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (180 per 30 days) PA,QL (150 per 30 days) QL (120 per 30 days) QL (90 per 30 days)

QL (90 per 30 days) QL (1200 per 30 days) QL (1200 per 30 days)

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DRUG NAME
divalproex sodium 125 mg cap MO dologesic capsule MO DOLOGESIC LIQUID MO DOLOPHINE 10 MG TABLET MO DOLOPHINE 5 MG TABLET MO DOLOREX SOFTGEL CAPSULE MO DOPRAM 20 MG/ML IV MO doxapram hcl 20 mg/ml vial MO doxepin 10 mg capsule MO doxepin 10 mg/ml oral conc MO doxepin 100 mg capsule MO doxepin 150 mg capsule MO doxepin 25 mg capsule MO doxepin 50 mg capsule MO doxepin 75 mg capsule MO droperidol 2.5 mg/ml vial MO DURABAC CAPSULE MO DURABAC FORTE TABLET MO DURACLON (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL MO DURACLON (PF) 5,000 MCG/10 ML EPIDURAL MO DURAMORPH (PF) 0.5 MG/ML INJECTION MO DURAMORPH (PF) 1 MG/ML INJECTION MO duraxin 20 mg-300 mg-200 mg capsule MO EC-NAPROSYN 375 MG TABLET,DELAYED RELEASE MO EC-NAPROSYN 500 MG TABLET,DELAYED RELEASE MO ed-flex capsule MO EMBEDA 100-4 MG CAPSULE MO EMBEDA 20-0.8 MG CAPSULE MO EMBEDA 30-1.2 MG CAPSULE MO EMBEDA 50-2 MG CAPSULE MO EMBEDA 60-2.4 MG CAPSULE MO EMBEDA 80-3.2 MG CAPSULE MO EMSAM 12 MG/24 HR TRANSDERM 24 HR PATCH MO EMSAM 6 MG/24 HR TRANSDERM 24 HR PATCH MO EMSAM 9 MG/24 HR TRANSDERM 24 HR PATCH MO endocet 10 mg-325 mg tablet MO

TIER
2 1 4 2 2 4 4 4 2 2 2 2 2 2 2 1 4 4 4 4 4 4 2 4 4 2 3 3 3 3 3 3 5 4 5 3

UTILIZATION MANAGEMENT REQUIREMENTS

QL (240 per 30 days) QL (480 per 30 days)

PA PA PA PA PA PA PA

QL (7200 per 30 days) QL (3600 per 30 days) PA PA QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (360 per 30 days)

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DRUG NAME
endocet 10 mg-650 mg tablet MO endocet 5 mg-325 mg tablet MO endocet 7.5 mg-325 mg tablet MO endocet 7.5 mg-500 mg tablet MO epitol 200 mg tablet MO EQUETRO 100 MG CAPSULE, EXTENDED RELEASE MO EQUETRO 200 MG CAPSULE, EXTENDED RELEASE MO EQUETRO 300 MG CAPSULE, EXTENDED RELEASE MO escitalopram 10 mg tablet MO escitalopram 20 mg tablet MO escitalopram 5 mg tablet MO escitalopram oxalate 5 mg/5 ml MO ethosuximide 250 mg capsule MO ethosuximide 250 mg/5 ml soln MO etodolac 200 mg capsule MO etodolac 300 mg capsule MO etodolac 400 mg tablet MO etodolac 500 mg tablet MO etodolac er 400 mg tablet MO etodolac er 500 mg tablet MO etodolac er 600 mg tablet MO EXALGO ER 12 MG TABLET,EXTENDED RELEASE MO EXALGO ER 16 MG TABLET,EXTENDED RELEASE MO EXALGO ER 8 MG TABLET,EXTENDED RELEASE MO FANAPT 1 MG TABLET MO FANAPT 10 MG TABLET MO FANAPT 12 MG TABLET MO FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK MO FANAPT 2 MG TABLET MO FANAPT 4 MG TABLET MO FANAPT 6 MG TABLET MO FANAPT 8 MG TABLET MO FAZACLO 100 MG DISINTEGRATING TABLET MO FAZACLO 12.5 MG DISINTEGRATING TABLET MO FAZACLO 150 MG DISINTEGRATING TABLET MO FAZACLO 200 MG DISINTEGRATING TABLET MO

TIER
3 3 3 3 2 4 4 4 3 3 3 3 2 2 2 2 2 2 4 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

QL (180 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (240 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (600 per 30 days)

QL (180 per 30 days) QL (120 per 30 days) QL (240 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) ST ST ST ST

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DRUG NAME
FAZACLO 25 MG DISINTEGRATING TABLET MO felbamate 400 mg tablet MO felbamate 600 mg tablet MO felbamate 600 mg/5 ml susp MO FELBATOL 400 MG TABLET MO FELBATOL 600 MG TABLET MO FELBATOL 600 MG/5 ML ORAL SUSP MO fenoprofen 600 mg tablet MO fentanyl 0.05 mg/ml ampul MO fentanyl 0.05 mg/ml syringe MO fentanyl 100 mcg/hr patch MO fentanyl 12 mcg/hr patch MO fentanyl 25 mcg/hr patch MO fentanyl 50 mcg/hr patch MO fentanyl 75 mcg/hr patch MO fentanyl cit otfc 1,200 mcg MO fentanyl cit otfc 1,600 mcg MO fentanyl citrate otfc 200 mcg MO fentanyl citrate otfc 400 mcg MO fentanyl citrate otfc 600 mcg MO fentanyl citrate otfc 800 mcg MO FLECTOR 1.3 % ADHESIVE PATCH MO FLEXTRA PLUS CAPSULE MO FLEXTRA-650 TABLET MO FLEXTRA-DS TABLET MO flumazenil 0.1 mg/ml vial MO fluoxetine 20 mg/5 ml solution MO fluoxetine dr 90 mg capsule MO fluoxetine hcl 10 mg capsule MO fluoxetine hcl 10 mg tablet MO fluoxetine hcl 20 mg capsule MO fluoxetine hcl 20 mg tablet MO fluoxetine hcl 40 mg capsule MO fluoxetine hcl 60 mg tablet MO fluphenazine 1 mg tablet MO fluphenazine 10 mg tablet MO

TIER
4 4 4 4 5 5 5 4 4 4 4 4 4 4 4 5 5 5 5 5 5 4 4 4 4 2 2 4 2 2 2 3 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS


ST

QL (720 per 30 days) QL (240 per 30 days) QL (20 per 30 days) QL (20 per 30 days) QL (20 per 30 days) QL (20 per 30 days) QL (20 per 30 days) PA,QL (120 per 30 days) PA,QL (120 per 30 days) PA,QL (120 per 30 days) PA,QL (120 per 30 days) PA,QL (120 per 30 days) PA,QL (120 per 30 days) QL (60 per 30 days)

QL (4 per 28 days) QL (60 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (30 per 30 days)

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DRUG NAME
fluphenazine 2.5 mg tablet MO fluphenazine 2.5 mg/5 ml elix MO fluphenazine 2.5 mg/ml vial MO fluphenazine 5 mg tablet MO fluphenazine 5 mg/ml conc MO fluphenazine dec 25 mg/ml vl MO flurbiprofen 100 mg tablet MO flurbiprofen 50 mg tablet MO fluvoxamine maleate 100 mg tab MO fluvoxamine maleate 25 mg tab MO fluvoxamine maleate 50 mg tab MO fosphenytoin 100 mg pe/2 ml vl MO fosphenytoin 500 mg pe/10 ml MO frenadol tablet MO gabapentin 100 mg capsule MO gabapentin 250 mg/5 ml soln MO gabapentin 300 mg capsule MO gabapentin 400 mg capsule MO gabapentin 600 mg tablet MO gabapentin 800 mg tablet MO GABITRIL 12 MG TABLET MO GABITRIL 16 MG TABLET MO GABITRIL 2 MG TABLET MO GABITRIL 4 MG TABLET MO GEODON 20 MG IM MO GRALISE 30-DAY STARTER PACK 300 MG (9)-600 MG (69) TABLET,EXT. RELEASE MO GRALISE 300 MG TABLET,EXTENDED RELEASE MO GRALISE 600 MG TABLET,EXTENDED RELEASE MO HALDOL 5 MG/ML INJECTION MO HALDOL DECANOATE 100 MG/ML IM MO HALDOL DECANOATE 50 MG/ML IM MO haloperidol 0.5 mg tablet MO haloperidol 1 mg tablet MO haloperidol 10 mg tablet MO haloperidol 2 mg tablet MO

TIER
2 2 2 2 2 4 2 2 3 3 3 1 1 1 2 3 2 2 2 2 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days)

QL (270 per 30 days) QL (270 per 30 days) QL (270 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (90 per 30 days)

ST,QL (78 per 30 days) ST,QL (30 per 30 days) ST,QL (90 per 30 days) PA

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DRUG NAME
haloperidol 20 mg tablet MO haloperidol 5 mg tablet MO haloperidol dec 100 mg/ml vial MO haloperidol dec 50 mg/ml vial MO haloperidol lac 2 mg/ml conc MO haloperidol lac 5 mg/ml vial MO HORIZANT ER 600 MG TABLET,EXTENDED RELEASE MO hydrocodon-acetaminoph 2.5-325 MO hydrocodon-acetaminoph 2.5-500 MO hydrocodon-acetaminoph 7.5-300 MO hydrocodon-acetaminoph 7.5-325 MO hydrocodon-acetaminoph 7.5-500 MO hydrocodon-acetaminoph 7.5-650 MO hydrocodon-acetaminoph 7.5-750 MO hydrocodon-acetaminophen 5-300 MO hydrocodon-acetaminophen 5-325 MO hydrocodon-acetaminophen 5-500 MO hydrocodon-acetaminophn 10-300 MO hydrocodon-acetaminophn 10-325 MO hydrocodon-acetaminophn 10-500 MO hydrocodon-acetaminophn 10-650 MO hydrocodon-acetaminophn 10-660 MO hydrocodon-acetaminophn 10-750 MO hydrocodone-ibuprofen 7.5-200 MO hydromorphone 1 mg/ml syringe MO hydromorphone 2 mg tablet MO hydromorphone 2 mg/ml syringe MO hydromorphone 2 mg/ml vial MO hydromorphone 3 mg suppos MO hydromorphone 4 mg tablet MO hydromorphone 4 mg/ml syrin MO hydromorphone 500 mg/50 ml via MO hydromorphone 8 mg tablet MO hydromorphone hcl 1 mg/ml amp MO hydromorphone hcl 2 mg/ml amp MO hydromorphone hcl 4 mg/ml amp MO

TIER
2 2 4 2 2 2 4 3 3 4 3 3 3 3 4 3 3 4 3 3 3 3 4 3 4 4 4 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

PA,QL (60 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (390 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (180 per 30 days) QL (150 per 30 days) QL (390 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (390 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (720 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (120 per 30 days) QL (360 per 30 days) QL (180 per 30 days) QL (144 per 30 days) QL (240 per 30 days) QL (720 per 30 days) QL (360 per 30 days) QL (180 per 30 days)

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DRUG NAME
ibuprofen 100 mg/5 ml susp MO ibuprofen 400 mg tablet MO ibuprofen 600 mg tablet MO ibuprofen 800 mg tablet MO imipramine hcl 10 mg tablet MO imipramine hcl 25 mg tablet MO imipramine hcl 50 mg tablet MO imipramine pamoate 100 mg cap MO imipramine pamoate 125 mg cap MO imipramine pamoate 150 mg cap MO imipramine pamoate 75 mg cap MO INDOCIN 1 MG IV SOLUTION MO INDOCIN 25 MG/5 ML ORAL SUSP MO INDOCIN 50 MG RECTAL SUPPOSITORY MO indomethacin 1 mg vial MO indomethacin 25 mg capsule MO indomethacin 50 mg capsule MO indomethacin er 75 mg capsule MO INFUMORPH P/F 10 MG/ML INJECTION MO INFUMORPH P/F 25 MG/ML INJECTION MO INVEGA 1.5 MG TABLET,EXTENDED RELEASE MO INVEGA 3 MG TABLET,EXTENDED RELEASE MO INVEGA 6 MG TABLET,EXTENDED RELEASE MO INVEGA 9 MG TABLET,EXTENDED RELEASE MO INVEGA SUSTENNA 117 MG/0.75 ML IM SYRINGE MO INVEGA SUSTENNA 156 MG/ML (1 ML) IM SYRINGE MO INVEGA SUSTENNA 234 MG/1.5 ML IM SYRINGE MO INVEGA SUSTENNA 39 MG/0.25 ML IM SYRINGE MO INVEGA SUSTENNA 78 MG/0.5 ML IM SYRINGE MO ketoprofen 50 mg capsule MO ketoprofen 75 mg capsule MO ketoprofen er 200 mg capsule MO LAGESIC CAPLET MO LAMICTAL 100 MG TABLET MO LAMICTAL 150 MG TABLET MO LAMICTAL 200 MG TABLET MO

TIER
1 1 1 1 2 2 2 4 4 4 4 4 4 4 1 2 2 4 4 4 4 4 4 4 5 5 5 4 4 2 2 3 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

PA PA PA PA PA PA PA

QL (360 per 30 days) QL (150 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days) ST,QL (60 per 30 days) ST,QL (30 per 30 days) QL (1 per 30 days) QL (1 per 30 days) QL (1 per 30 days) QL (1 per 30 days) QL (1 per 30 days)

QL (150 per 30 days) QL (90 per 30 days) QL (90 per 30 days)

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DRUG NAME
LAMICTAL 25 MG CHEWABLE DISPERSIBLE TABLET MO LAMICTAL 25 MG TABLET MO LAMICTAL 5 MG CHEWABLE DISPERSIBLE TABLET MO LAMICTAL ODT 100 MG DISINTEGRATING TABLET MO LAMICTAL ODT 200 MG DISINTEGRATING TABLET MO LAMICTAL ODT 25 MG DISINTEGRATING TABLET MO LAMICTAL ODT 50 MG DISINTEGRATING TABLET MO LAMICTAL ODT STARTER (BLUE) 25 MG (21)-50 MG (7) TABLET,DISINTEGRATING MO LAMICTAL ODT STARTER (GREEN) 50 MG (42)-100 MG (14) TAB,DISINTEGRATING MO LAMICTAL ODT STARTER (ORANGE) 25 MG(14)-50 MG(14)-100 MG(7) TAB,DISINT MO LAMICTAL STARTER (BLUE) KIT 25 MG (35) TABLETS IN A DOSE PACK MO LAMICTAL STARTER (GREEN) KIT 25 MG (84)-100 MG (14) TABLETS, DOSE PACK MO LAMICTAL STARTER (ORANGE) KIT 25 MG (42)-100 MG (7) TABLETS, DOSE PACK MO LAMICTAL XR 100 MG TABLET,EXTENDED RELEASE MO LAMICTAL XR 200 MG TABLET,EXTENDED RELEASE MO LAMICTAL XR 25 MG TABLET,EXTENDED RELEASE MO LAMICTAL XR 250 MG TABLET,EXTENDED RELEASE MO LAMICTAL XR 300 MG TABLET,EXTENDED RELEASE MO LAMICTAL XR 50 MG TABLET,EXTENDED RELEASE MO LAMICTAL XR STARTER (BLUE) 25 MG (21)-50 MG (7) TABLET,EXTEND RELEASE MO LAMICTAL XR STARTER (GREEN) 50 MG(14)-100 MG(14)-200MG(7) TAB,EXT.REL MO LAMICTAL XR STARTER (ORANGE) 25MG (14)-50MG (14)-100MG (7) TAB,EXT.REL MO lamotrigine 100 mg tablet MO lamotrigine 150 mg tablet MO lamotrigine 200 mg tablet MO lamotrigine 25 mg disper tab MO lamotrigine 25 mg tablet MO lamotrigine 25 mg tb start kit MO lamotrigine 5 mg disper tablet MO LATUDA 20 MG TABLET MO

TIER
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2 2 2 2 4

UTILIZATION MANAGEMENT REQUIREMENTS


QL (120 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (90 per 30 days)

QL (120 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (90 per 30 days)

QL (150 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (120 per 30 days)

PA,QL (30 per 30 days)

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DRUG NAME
LATUDA 40 MG TABLET MO LATUDA 80 MG TABLET MO LEVACET 500 MG-250 MG-150 MG-32.5 MG TABLET MO levetiraceta-nacl 1,000 mg/100 MO levetiraceta-nacl 1,500 mg/100 MO levetiracetam 1,000 mg tablet MO levetiracetam 100 mg/ml soln MO levetiracetam 250 mg tablet MO levetiracetam 500 mg tablet MO levetiracetam 500 mg/5 ml soln MO levetiracetam 500 mg/5 ml vial MO levetiracetam 750 mg tablet MO levetiracetam er 500 mg tablet MO levetiracetam er 750 mg tablet MO levetiracetam-nacl 500 mg/100 MO levorphanol 2 mg tablet MO LEXAPRO 5 MG/5 ML ORAL SOLN MO lithium 8 meq/5 ml solution MO lithium carbonate 150 mg cap MO lithium carbonate 300 mg cap MO lithium carbonate 300 mg tab MO lithium carbonate 600 mg cap MO lithium carbonate er 300 mg tb MO lithium er 450 mg tablet MO lorazepam 0.5 mg tablet MO lorazepam 1 mg tablet MO lorazepam 2 mg tablet MO loxapine 10 mg capsule MO loxapine 25 mg capsule MO loxapine 5 mg capsule MO loxapine 50 mg capsule MO LOXITANE 10 MG CAPSULE MO LOXITANE 25 MG CAPSULE MO LOXITANE 5 MG CAPSULE MO LOXITANE 50 MG CAPSULE MO LUNESTA 1 MG TABLET MO

TIER
4 4 4 2 2 2 2 2 2 2 2 2 2 2 2 3 4 2 2 2 2 2 2 2 3 3 3 3 3 3 3 4 3 4 3 4

PA,QL (30 per 30 days) PA,QL (60 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (120 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (900 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (240 per 30 days) PA,QL (600 per 30 days)

QL (90 per 30 days) QL (90 per 30 days) QL (150 per 30 days)

PA

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DRUG NAME
LUNESTA 2 MG TABLET MO LUNESTA 3 MG TABLET MO LUVOX CR 100 MG CAPSULE,EXTENDED RELEASE MO LUVOX CR 150 MG CAPSULE,EXTENDED RELEASE MO LYRICA 100 MG CAPSULE MO LYRICA 150 MG CAPSULE MO LYRICA 200 MG CAPSULE MO LYRICA 225 MG CAPSULE MO LYRICA 25 MG CAPSULE MO LYRICA 300 MG CAPSULE MO LYRICA 50 MG CAPSULE MO LYRICA 75 MG CAPSULE MO magnesium chl 200 mg/ml vial MO magnesium sulf 4% iv soln MO magnesium sulf 8% iv soln MO magnesium sulfate 50% syringe MO magnesium sulfate 50% vial MO magnesium-d5w 1 gm/100 ml soln MO maprotiline 25 mg tablet MO maprotiline 50 mg tablet MO maprotiline 75 mg tablet MO margesic h 5-500 capsule MO MARPLAN 10 MG TABLET MO MAXALT 10 MG TABLET MO MAXALT 5 MG TABLET MO MAXALT-MLT 10 MG DISINTEGRATING TABLET MO MAXALT-MLT 5 MG DISINTEGRATING TABLET MO MAXIDONE 10 MG-750 MG TABLET MO MEBARAL 100 MG TABLET MO MEBARAL 32 MG TABLET MO MEBARAL 50 MG TABLET MO meclofenamate 100 mg capsule MO meclofenamate 50 mg capsule MO meloxicam 15 mg tablet MO meloxicam 7.5 mg tablet MO meloxicam 7.5 mg/5 ml susp MO

TIER
4 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2 2 2 4 4 2 1 4 4 4 4 4 4 4 4 4 4 2 1 1 1

PA PA QL (60 per 30 days) QL (60 per 30 days) ST,QL (90 per 30 days) ST,QL (90 per 30 days) ST,QL (90 per 30 days) ST,QL (60 per 30 days) ST,QL (90 per 30 days) ST,QL (60 per 30 days) ST,QL (90 per 30 days) ST,QL (90 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (240 per 30 days) QL (12 per 30 days) QL (12 per 30 days) QL (12 per 30 days) QL (12 per 30 days) QL (150 per 30 days) PA PA PA

QL (30 per 30 days) QL (60 per 30 days) QL (300 per 30 days)

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DRUG NAME
methadone 10 mg/5 ml solution MO methadone 10 mg/ml oral conc MO methadone 5 mg/5 ml solution MO methadone hcl 10 mg tablet MO methadone hcl 10 mg/ml vial MO methadone hcl 5 mg tablet MO methadone intensol 10 mg/ml oral concentrate MO methadose 10 mg tablet MO METHADOSE 10 MG/ML ORAL CONCENTRATE MO methamphetamine 5 mg tablet MO methyl salicylate liquid MO methylphenidate 10 mg tablet MO methylphenidate 20 mg tablet MO methylphenidate 5 mg tablet MO mirtazapine 15 mg odt MO mirtazapine 15 mg tablet MO mirtazapine 30 mg odt MO mirtazapine 30 mg tablet MO mirtazapine 45 mg odt MO mirtazapine 45 mg tablet MO mirtazapine 7.5 mg tablet MO MOBAN 10 MG TABLET MO MOBAN 25 MG TABLET MO MOBAN 5 MG TABLET MO MOBAN 50 MG TABLET MO modafinil 100 mg tablet MO modafinil 200 mg tablet MO morphine 0.5 mg/ml vial MO morphine 1 mg/ml syringe MO morphine 1 mg/ml syringe MO morphine 1 mg/ml vial p-f MO morphine 1 mg/ml-d5w 100 ml MO morphine 1 mg/ml-d5w 250 ml MO morphine 10 mg/ml syringe MO morphine 10 mg/ml vial MO morphine 15 mg/ml syringe MO

TIER
2 2 2 2 2 2 2 2 3 5 1 2 2 2 2 2 4 2 4 2 2 4 4 4 4 4 5 3 3 3 3 3 3 3 3 3

QL (1800 per 30 days) QL (360 per 30 days) QL (3600 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (480 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (150 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA,QL (60 per 30 days) PA,QL (60 per 30 days) QL (7200 per 30 days) QL (3600 per 30 days) QL (3600 per 30 days) QL (3600 per 30 days) QL (3600 per 30 days) QL (3600 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (240 per 30 days)

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DRUG NAME
morphine 2 mg/ml syringe MO morphine 300 mg/20 ml vial MO morphine 4 mg/ml syringe MO morphine 5 mg/ml vial MO morphine 8 mg/ml syringe MO morphine 8 mg/ml vial MO morphine sulf 10 mg suppos MO morphine sulf 10 mg/5 ml soln MO morphine sulf 100 mg/5 ml soln MO morphine sulf 20 mg suppos MO morphine sulf 20 mg/5 ml soln MO morphine sulf 30 mg suppos MO morphine sulf 5 mg suppos MO morphine sulf er 100 mg tablet MO morphine sulf er 15 mg tablet MO morphine sulf er 200 mg tablet MO morphine sulf er 30 mg tablet MO morphine sulf er 60 mg tablet MO morphine sulfate 1 mg/ml vial MO morphine sulfate 25 mg/ml vial MO morphine sulfate 25 mg/ml vl MO morphine sulfate 50 mg/ml vial MO morphine sulfate er 100 mg cap MO morphine sulfate er 20 mg cap MO morphine sulfate er 30 mg cap MO morphine sulfate er 50 mg cap MO morphine sulfate er 60 mg cap MO morphine sulfate er 80 mg cap MO morphine sulfate ir 15 mg tab MO morphine sulfate ir 30 mg tab MO mst 600 600 mg tablet MO nabumetone 500 mg tablet MO nabumetone 750 mg tablet MO nalbuphine 100 mg/10 ml vial MO nalbuphine 200 mg/10 ml vial MO NALFON 200 MG PULVULE MO

TIER
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 4 4 4

QL (1800 per 30 days) QL (600 per 30 days) QL (900 per 30 days) QL (720 per 30 days) QL (450 per 30 days) QL (450 per 30 days) QL (180 per 30 days) QL (2700 per 30 days) QL (600 per 30 days) QL (180 per 30 days) QL (1350 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (3600 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (240 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (180 per 30 days) QL (180 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (240 per 30 days) QL (120 per 30 days)

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DRUG NAME
NALFON 400 MG CAPSULE MO naloxone 0.02 mg/ml vial MO naloxone 0.4 mg/ml syringe MO naloxone 0.4 mg/ml vial MO naloxone 2 mg/2 ml syringe MO naltrexone 50 mg tablet MO NAMENDA 10 MG TABLET MO NAMENDA 10 MG/5 ML ORAL SOLN MO NAMENDA 5 MG TABLET MO NAMENDA TITRATION PAK 5 MG-10 MG TABLETS IN A DOSE PACK MO naproxen 125 mg/5 ml suspen MO naproxen 250 mg tablet MO naproxen 375 mg tablet MO naproxen 500 mg tablet MO naproxen dr 375 mg tablet MO naproxen dr 500 mg tablet MO naproxen sodium 275 mg tab MO naproxen sodium 550 mg tab MO naratriptan hcl 1 mg tablet MO naratriptan hcl 2.5 mg tablet MO NARDIL 15 MG TABLET MO NAVANE 10 MG CAPSULE MO NAVANE 2 MG CAPSULE MO NAVANE 20 MG CAPSULE MO NAVANE 5 MG CAPSULE MO nefazodone hcl 100 mg tablet MO nefazodone hcl 150 mg tablet MO nefazodone hcl 200 mg tablet MO nefazodone hcl 250 mg tablet MO nefazodone hcl 50 mg tablet MO NEUPRO 1 MG/24 HOUR TRANSDERM 24 HR PATCH MO NEUPRO 2 MG/24 HOUR TRANSDERM 24 HR PATCH MO NEUPRO 3 MG/24 HOUR TRANSDERM 24 HR PATCH MO NEUPRO 4 MG/24 HOUR TRANSDERM 24 HR PATCH MO NEUPRO 6 MG/24 HOUR TRANSDERM 24 HR PATCH MO NEUPRO 8 MG/24 HOUR TRANSDERM 24 HR PATCH MO

TIER
4 2 2 2 2 2 3 3 3 3 2 2 2 2 2 2 2 2 4 4 4 4 4 4 4 4 4 4 4 2 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (360 per 30 days) QL (60 per 30 days) QL (98 per 30 days)

QL (9 per 30 days) QL (9 per 30 days)

PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days)

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DRUG NAME
NEURONTIN 250 MG/5 ML ORAL SOLN MO NORPRAMIN 10 MG TABLET MO NORPRAMIN 100 MG TABLET MO NORPRAMIN 150 MG TABLET MO NORPRAMIN 25 MG TABLET MO NORPRAMIN 50 MG TABLET MO NORPRAMIN 75 MG TABLET MO nortriptyline 10 mg/5 ml sol MO nortriptyline hcl 10 mg cap MO nortriptyline hcl 25 mg cap MO nortriptyline hcl 50 mg cap MO nortriptyline hcl 75 mg cap MO NUEDEXTA 20 MG-10 MG CAPSULE MO olanzapine 10 mg tablet MO olanzapine 10 mg vial MO olanzapine 15 mg tablet MO olanzapine 2.5 mg tablet MO olanzapine 20 mg tablet MO olanzapine 5 mg tablet MO olanzapine 7.5 mg tablet MO olanzapine odt 10 mg tablet MO olanzapine odt 15 mg tablet MO olanzapine odt 20 mg tablet MO olanzapine odt 5 mg tablet MO ONFI 10 MG TABLET MO ONFI 20 MG TABLET MO ONFI 5 MG TABLET MO OPANA ER 10 MG TABLET,EXTENDED RELEASE MO OPANA ER 20 MG TABLET,EXTENDED RELEASE MO OPANA ER 30 MG TABLET,EXTENDED RELEASE MO OPANA ER 40 MG TABLET,EXTENDED RELEASE MO OPANA ER 5 MG TABLET,EXTENDED RELEASE MO ORAP 1 MG TABLET MO ORAP 2 MG TABLET MO oxaprozin 600 mg tablet MO oxazepam 10 mg capsule MO

TIER
4 4 4 4 4 4 4 1 2 2 2 2 4 3 3 3 3 3 3 3 3 3 3 3 4 4 4 3 3 3 3 3 4 4 2 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

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DRUG NAME
oxazepam 15 mg capsule MO oxazepam 30 mg capsule MO oxcarbazepine 150 mg tablet MO oxcarbazepine 300 mg tablet MO oxcarbazepine 300 mg/5 ml susp MO oxcarbazepine 600 mg tablet MO oxycodon-acetaminophen 2.5-325 MO oxycodon-acetaminophen 7.5-325 MO oxycodon-acetaminophen 7.5-500 MO oxycodone conc 20 mg/ml soln MO oxycodone hcl 10 mg tablet MO oxycodone hcl 15 mg tablet MO oxycodone hcl 20 mg tablet MO oxycodone hcl 30 mg tablet MO oxycodone hcl 5 mg capsule MO oxycodone hcl 5 mg tablet MO oxycodone hcl 5 mg/5 ml sol MO oxycodone-acetaminophen 10-325 MO oxycodone-acetaminophen 10-650 MO oxycodone-acetaminophen 5-325 MO oxycodone-acetaminophen 5-500 MO oxycodone-asa 4.5-0.38-325 tab MO oxycodone-aspirin 4.83-325 mg MO oxycodone-ibuprofen 5-400 tab MO oxymorphone hcl er 15 mg tab MO oxymorphone hcl er 7.5 mg tab MO paroxetine cr 12.5 mg tablet MO paroxetine cr 25 mg tablet MO paroxetine er 37.5 mg tablet MO paroxetine hcl 10 mg tablet MO paroxetine hcl 10 mg/5 ml susp MO paroxetine hcl 20 mg tablet MO paroxetine hcl 30 mg tablet MO paroxetine hcl 40 mg tablet MO PAXIL 10 MG/5 ML ORAL SUSP MO PEGANONE 250 MG TABLET MO

TIER
4 4 3 3 2 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 4 4 4 4 2 2 2 2 2 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (360 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (270 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (5400 per 30 days) QL (360 per 30 days) QL (180 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

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DRUG NAME
PENNSAID 1.5 % TOPICAL DROPS MO perphen-amitrip 2 mg-10 mg tab MO perphen-amitrip 2 mg-25 mg tab MO perphen-amitrip 4 mg-10 mg tab MO perphen-amitrip 4 mg-25 mg tab MO perphen-amitrip 4 mg-50 mg tab MO perphenazine 16 mg tablet MO perphenazine 2 mg tablet MO perphenazine 4 mg tablet MO perphenazine 8 mg tablet MO phenelzine sulfate 15 mg tab MO phenobarbital 100 mg tablet MO phenobarbital 15 mg tablet MO phenobarbital 16.2 mg tablet MO phenobarbital 30 mg tablet MO phenobarbital 32.4 mg tablet MO phenobarbital 60 mg tablet MO phenobarbital 64.8 mg tablet MO phenobarbital 97.2 mg tablet MO PHENYTEK 200 MG CAPSULE MO PHENYTEK 300 MG CAPSULE MO phenytoin 100 mg/4 ml susp MO phenytoin 125 mg/5 ml susp MO phenytoin 50 mg/ml syringe MO phenytoin 50 mg/ml vial MO phenytoin sod ext 100 mg cap MO phenytoin sod ext 200 mg cap MO phenytoin sod ext 300 mg cap MO piroxicam 10 mg capsule MO piroxicam 20 mg capsule MO POTIGA 200 MG TABLET MO POTIGA 300 MG TABLET MO POTIGA 400 MG TABLET MO POTIGA 50 MG TABLET MO pramipexole 0.125 mg tablet MO pramipexole 0.25 mg tablet MO

TIER
4 2 2 2 2 2 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 3 3 4 4 4 4 2 2

UTILIZATION MANAGEMENT REQUIREMENTS


PA PA PA PA PA

PA,QL (60 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days) PA,QL (210 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days)

PA,QL (90 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days) PA,QL (270 per 30 days)

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DRUG NAME
pramipexole 0.5 mg tablet MO pramipexole 0.75 mg tablet MO pramipexole 1 mg tablet MO pramipexole 1.5 mg tablet MO PRECEDEX 200 MCG/2 ML IV MO PRIALT 100 MCG/ML INTRATHECAL MO PRIALT 25 MCG/ML INTRATHECAL MO primidone 250 mg tablet MO primidone 50 mg tablet MO PRISTIQ 100 MG TABLET,EXTENDED RELEASE MO PRISTIQ 50 MG TABLET,EXTENDED RELEASE MO protriptyline hcl 10 mg tablet MO protriptyline hcl 5 mg tablet MO quetiapine fumarate 100 mg tab MO quetiapine fumarate 200 mg tab MO quetiapine fumarate 25 mg tab MO quetiapine fumarate 300 mg tab MO quetiapine fumarate 400 mg tab MO quetiapine fumarate 50 mg tab MO RELAGESIC TABLET MO REQUIP XL 12 MG TABLET,EXTENDED RELEASE MO REQUIP XL 2 MG TABLET,EXTENDED RELEASE MO REQUIP XL 4 MG TABLET,EXTENDED RELEASE MO REQUIP XL 6 MG TABLET,EXTENDED RELEASE MO REQUIP XL 8 MG TABLET,EXTENDED RELEASE MO revia 50 mg tablet MO rhinoflex 50 mg-500 mg tablet MO rhinoflex-650 50 mg-650 mg tablet MO RILUTEK 50 MG TABLET MO RISPERDAL CONSTA 12.5 MG/2 ML IM SYRINGE MO RISPERDAL CONSTA 25 MG/2 ML IM SYRINGE MO RISPERDAL CONSTA 37.5 MG/2 ML IM SYRINGE MO RISPERDAL CONSTA 50 MG/2 ML IM SYRINGE MO RISPERDAL M-TAB 0.5 MG DISINTEGRATING TABLET MO RISPERDAL M-TAB 1 MG DISINTEGRATING TABLET MO RISPERDAL M-TAB 2 MG DISINTEGRATING TABLET MO

TIER
2 2 2 2 4 5 5 2 2 4 4 4 4 3 3 3 3 3 3 4 4 4 4 4 4 4 2 2 3 4 4 4 5 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 30 days) QL (30 per 30 days)

QL (90 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days)

QL (2 per 28 days) QL (2 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

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DRUG NAME
RISPERDAL M-TAB 3 MG DISINTEGRATING TABLET MO RISPERDAL M-TAB 4 MG DISINTEGRATING TABLET MO risperidone 0.25 mg odt MO risperidone 0.25 mg tablet MO risperidone 0.5 mg odt MO risperidone 0.5 mg tablet MO risperidone 1 mg odt MO risperidone 1 mg tablet MO risperidone 1 mg/ml solution MO risperidone 2 mg odt MO risperidone 2 mg tablet MO risperidone 3 mg odt MO risperidone 3 mg tablet MO risperidone 4 mg odt MO risperidone 4 mg tablet MO risperidone m-tab 0.5 mg disintegrating tablet MO risperidone m-tab 1 mg disintegrating tablet MO risperidone m-tab 2 mg disintegrating tablet MO risperidone m-tab 3 mg disintegrating tablet MO risperidone m-tab 4 mg disintegrating tablet MO ROMAZICON 0.1 MG/ML IV MO ropinirole hcl 0.25 mg tablet MO ropinirole hcl 0.5 mg tablet MO ropinirole hcl 1 mg tablet MO ropinirole hcl 2 mg tablet MO ropinirole hcl 3 mg tablet MO ropinirole hcl 4 mg tablet MO ropinirole hcl 5 mg tablet MO ropinirole hcl er 12 mg tablet MO ropinirole hcl er 2 mg tablet MO ropinirole hcl er 4 mg tablet MO ropinirole hcl er 6 mg tablet MO ropinirole hcl er 8 mg tablet MO roxicet 5 mg-325 mg tablet MO ROXICET 5 MG-325 MG/5 ML ORAL SOLN MO ROXICET 5-500 CAPLET MO

TIER
4 4 4 2 2 2 4 2 2 2 2 2 2 2 2 4 2 4 4 2 4 2 2 2 2 2 2 2 4 4 4 4 4 3 3 3

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (360 per 30 days) QL (1830 per 30 days) QL (240 per 30 days)

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DRUG NAME
SABRIL 500 MG ORAL POWDER IN PACKET MO SABRIL 500 MG TABLET MO salsalate 500 mg tablet MO salsalate 750 mg tablet MO SAPHRIS 10 MG SUBLINGUAL TABLET MO SAPHRIS 5 MG SUBLINGUAL TABLET MO SAVELLA 100 MG TABLET MO SAVELLA 12.5 MG (5)-25 MG(8)-50MG(42) TABLETS IN A DOSE PACK MO SAVELLA 12.5 MG TABLET MO SAVELLA 25 MG TABLET MO SAVELLA 50 MG TABLET MO selegiline hcl 5 mg capsule MO selegiline hcl 5 mg tablet MO SEROQUEL XR 150 MG TABLET,EXTENDED RELEASE MO SEROQUEL XR 200 MG TABLET,EXTENDED RELEASE MO SEROQUEL XR 300 MG TABLET,EXTENDED RELEASE MO SEROQUEL XR 400 MG TABLET,EXTENDED RELEASE MO SEROQUEL XR 50 MG TABLET,EXTENDED RELEASE MO sertraline 20 mg/ml oral conc MO sertraline hcl 100 mg tablet MO sertraline hcl 25 mg tablet MO sertraline hcl 50 mg tablet MO STAFLEX CAPLET MO stagesic 5 mg-500 mg capsule MO STAVZOR 125 MG CAPSULE,DELAYED RELEASE MO STAVZOR 250 MG CAPSULE,DELAYED RELEASE MO STAVZOR 500 MG CAPSULE,DELAYED RELEASE MO STRATTERA 10 MG CAPSULE MO STRATTERA 100 MG CAPSULE MO STRATTERA 18 MG CAPSULE MO STRATTERA 25 MG CAPSULE MO STRATTERA 40 MG CAPSULE MO STRATTERA 60 MG CAPSULE MO STRATTERA 80 MG CAPSULE MO SUBOXONE 2 MG-0.5 MG SUBLINGUAL FILM MO SUBOXONE 8 MG-2 MG SUBLINGUAL FILM MO

TIER
5 5 3 3 4 4 3 3 3 3 3 4 4 3 3 3 3 3 1 1 1 1 4 3 4 4 4 4 4 4 4 4 4 4 4 4

PA,QL (180 per 30 days) PA,QL (180 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA,QL (60 per 30 days) PA,QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (240 per 30 days) QL (240 per 30 days)

QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) PA,QL (90 per 30 days) PA,QL (90 per 30 days)

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DRUG NAME
sufentanil 250 mcg/5 ml ampul MO sulindac 150 mg tablet MO sulindac 200 mg tablet MO sumatriptan 20 mg nasal spray MO sumatriptan 4 mg/0.5 ml cart MO sumatriptan 4 mg/0.5 ml inject MO sumatriptan 4 mg/0.5 ml syrng MO sumatriptan 5 mg nasal spray MO sumatriptan 6 mg/0.5 ml inject MO sumatriptan 6 mg/0.5 ml refill MO sumatriptan 6 mg/0.5 ml syrng MO sumatriptan 6 mg/0.5 ml vial MO sumatriptan succ 100 mg tablet MO sumatriptan succ 25 mg tablet MO sumatriptan succ 50 mg tablet MO SURMONTIL 100 MG CAPSULE MO SURMONTIL 25 MG CAPSULE MO SURMONTIL 50 MG CAPSULE MO TASMAR 100 MG TABLET MO TEGRETOL XR 100 MG TABLET,EXTENDED RELEASE MO TEGRETOL XR 200 MG TABLET,EXTENDED RELEASE MO TEGRETOL XR 400 MG TABLET,EXTENDED RELEASE MO temazepam 15 mg capsule MO temazepam 22.5 mg capsule MO temazepam 30 mg capsule MO temazepam 7.5 mg capsule MO thioridazine 10 mg tablet MO thioridazine 100 mg tablet MO thioridazine 25 mg tablet MO thioridazine 50 mg tablet MO thiothixene 1 mg capsule MO thiothixene 10 mg capsule MO thiothixene 2 mg capsule MO thiothixene 5 mg capsule MO tolmetin sodium 200 mg tab MO tolmetin sodium 400 mg cap MO

TIER
3 2 2 4 4 4 3 4 4 4 3 4 2 2 2 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2 2 2 2 2 3 4

QL (1440 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (12 per 30 days) QL (6 per 30 days) QL (6 per 30 days) QL (6 per 30 days) QL (12 per 30 days) QL (6 per 30 days) QL (6 per 30 days) QL (6 per 30 days) QL (6 per 30 days) QL (9 per 30 days) QL (9 per 30 days) QL (9 per 30 days) PA PA PA PA

QL (30 per 30 days) QL (30 per 30 days) PA PA PA PA

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DRUG NAME
tolmetin sodium 600 mg tab MO TOPAMAX 100 MG TABLET MO TOPAMAX 15 MG SPRINKLE CAPSULE MO TOPAMAX 200 MG TABLET MO TOPAMAX 25 MG SPRINKLE CAPSULE MO TOPAMAX 25 MG TABLET MO TOPAMAX 50 MG TABLET MO topiragen 100 mg tablet MO topiragen 200 mg tablet MO topiragen 25 mg tablet MO topiragen 50 mg tablet MO topiramate 100 mg tablet MO topiramate 15 mg sprinkle cap MO topiramate 200 mg tablet MO topiramate 25 mg sprinkle cap MO topiramate 25 mg tablet MO topiramate 50 mg tablet MO tramadol hcl 50 mg tablet MO tramadol-acetaminophn 37.5-325 MO tranylcypromine sulf 10 mg tab MO trazodone 100 mg tablet MO trazodone 150 mg tablet MO trazodone 300 mg tablet MO trazodone 50 mg tablet MO TREXIMET 85 MG-500 MG TABLET MO trifluoperazine 1 mg tablet MO trifluoperazine 10 mg tablet MO trifluoperazine 2 mg tablet MO trifluoperazine 5 mg tablet MO trihexyphenidyl 2 mg tablet MO trihexyphenidyl 2 mg/5 ml elx MO trihexyphenidyl 5 mg tablet MO TRILEPTAL 300 MG/5 ML ORAL SUSP MO trimipramine maleate 100 mg cp MO trimipramine maleate 25 mg cap MO trimipramine maleate 50 mg cap MO

TIER
3 4 4 4 4 4 4 2 2 2 2 2 2 2 2 2 2 2 2 4 2 2 2 2 4 2 2 2 2 2 2 2 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


QL (120 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (240 per 30 days) QL (240 per 30 days)

QL (12 per 30 days)

PA PA PA PA PA PA

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DRUG NAME
ULTIVA 1 MG SOLUTION MO ULTIVA 2 MG SOLUTION MO ULTIVA 5 MG SOLUTION MO ULTRACET 37.5 MG-325 MG TABLET MO valproate sod 500 mg/5 ml vl MO valproic acid 250 mg capsule MO valproic acid 250 mg/5 ml soln MO valproic acid 250 mg/5 ml syr MO valproic acid 500 mg/10 ml sol MO venlafaxine hcl 100 mg tablet MO venlafaxine hcl 25 mg tablet MO venlafaxine hcl 37.5 mg tablet MO venlafaxine hcl 50 mg tablet MO venlafaxine hcl 75 mg tablet MO venlafaxine hcl er 150 mg cap MO VENLAFAXINE HCL ER 150 MG TAB MO VENLAFAXINE HCL ER 225 MG TAB MO venlafaxine hcl er 37.5 mg cap MO venlafaxine hcl er 37.5 mg tab MO venlafaxine hcl er 75 mg cap MO venlafaxine hcl er 75 mg tab MO VIIBRYD 10 MG (7)-20 MG (7)-40 MG(16) TABLETS IN A DOSE PACK MO VIIBRYD 10 MG TABLET MO VIIBRYD 20 MG TABLET MO VIIBRYD 40 MG TABLET MO VIMOVO 375 MG-20 MG TABLETS,IMMEDIATE & DELAYED RELEASE MO VIMOVO 500 MG-20 MG TABLETS,IMMEDIATE & DELAYED RELEASE MO VIMPAT 10 MG/ML ORAL SOLN MO VIMPAT 100 MG TABLET MO VIMPAT 150 MG TABLET MO VIMPAT 200 MG TABLET MO VIMPAT 200 MG/20 ML IV MO VIMPAT 50 MG TABLET MO vistra 650 tablet MO VIVITROL 380 MG IM SUSPENSION,EXTENDED RELEASE MO VOLTAREN 1 % TOPICAL GEL MO

TIER
4 4 4 4 2 2 2 2 2 3 3 3 3 3 2 4 4 2 4 2 4 4 4 4 4 3 3 4 4 4 4 4 4 1 5 4

QL (450 per 30 days) QL (240 per 30 days) QL (90 per 30 days) QL (240 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) ST,QL (60 per 30 days) ST,QL (60 per 30 days) QL (1395 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (90 per 30 days) PA

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DRUG NAME
XENAZINE 12.5 MG TABLET SP XENAZINE 25 MG TABLET SP XYREM 500 MG/ML ORAL SOLN SP zaleplon 10 mg capsule MO zaleplon 5 mg capsule MO ZARONTIN 250 MG CAPSULE MO ZARONTIN 250 MG/5 ML ORAL SOLN MO zerlor tablet MO zgesic 66 mg-600 mg tablet,extended release MO ziprasidone hcl 20 mg capsule MO ziprasidone hcl 40 mg capsule MO ziprasidone hcl 60 mg capsule MO ziprasidone hcl 80 mg capsule MO zolpidem tartrate 10 mg tablet MO zolpidem tartrate 5 mg tablet MO zonisamide 100 mg capsule MO zonisamide 25 mg capsule MO zonisamide 50 mg capsule MO ZYBAN 150 MG TABLET,EXTENDED RELEASE MO ZYPREXA 10 MG IM MO ZYPREXA RELPREVV 210 MG IM SUSP MO ZYPREXA RELPREVV 300 MG IM SUSP MO ZYPREXA RELPREVV 405 MG IM SUSP MO DEVICES 1ST TIER UNIFINE PENTIPS 29 X 1/2" NEEDLE MO 1ST TIER UNIFINE PENTIPS 31 X 1/4" NEEDLE MO 1ST TIER UNIFINE PENTIPS 31 X 3/16" NEEDLE MO 1ST TIER UNIFINE PENTIPS 31 X 5/16" NEEDLE MO ACCU-CHEK ACTIVE CARE KIT MO ACCU-CHEK ACTIVE GLUCOSE CONT COMBO PACK MO ACCU-CHEK ADVANTAGE DIABETES KIT MO ACCU-CHEK AVIVA PLUS METER MO ACCU-CHEK COMFORT CURVE COMBO PACK MO ACCU-CHEK COMFORT CURVE LINEAR COMBO PACK MO ACCU-CHEK COMPACT GLUCOSE CONT COMBO PACK MO ACCU-CHEK COMPACT PLUS CARE KIT MO

TIER
5 5 5 2 2 4 4 2 2 3 3 3 3 1 1 3 3 3 3 4 4 5 5 1 1 1 1 1 1 1 1 1 1 1 1

PA,QL (240 per 30 days) PA,QL (120 per 30 days) PA,QL (90 per 365 days) PA,QL (90 per 365 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (180 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (90 per 365 days) QL (90 per 365 days)

QL (90 per 30 days) QL (60 per 30 days) PA,QL (2 per 28 days) PA,QL (2 per 28 days) PA,QL (1 per 28 days)

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DRUG NAME
ACCU-CHEK CONTROL SOLUTION MO ACCU-CHEK MULTICLIX LANCET MO ACCU-CHEK MULTICLIX LANCET KIT MO ACCU-CHEK SOFTCLIX LANCET DEV MO ACCU-CHEK SOFTCLIX LANCETS MO ACCU-CHEK VOICEMATE KIT MO ACTI-LANCE LANCETS MO ACURA METER KIT MO ACURA STARTER KIT MO ADJUSTABLE LANCING DEVICE MO ADVANCE INTUITION GLUCOSE KIT MO ADVANCED LANCING DEVICE KIT MO ADVOCATE LANCET MO ADVOCATE PEN NEEDLES 31 X 3/16" MO ADVOCATE PEN NEEDLES 31 X 5/16" MO ADVOCATE SYRINGES 0.3 ML 29 X 1/2" MO ADVOCATE SYRINGES 0.3 ML 30 X 5/16" MO ADVOCATE SYRINGES 0.3 ML 31 X 5/16" MO ADVOCATE SYRINGES 1 ML 29 X 1/2" MO ADVOCATE SYRINGES 1 ML 30 X 5/16" MO ADVOCATE SYRINGES 1 ML 31 X 5/16" MO ADVOCATE SYRINGES 1/2 ML 29 X 1/2" MO ADVOCATE SYRINGES 1/2 ML 30 X 5/16" MO ADVOCATE SYRINGES 1/2 ML 31 X 5/16" MO AIMSCO INS PEN NDL 29GX1/2" MO AIMSCO INS PEN NDL 31GX5/16" MO AIMSCO INS SYR 0.5 ML 28GX1/2" MO AIMSCO INS SYR 1 ML 28GX1/2" MO ALTERNATE SITE LANCET MO ALTERNATE SITE LANCING DEVICE MO ASSURA EASICLOSE MINI POUCH 10 1/4" 470 ML MO ASSURE 4 CONTROL SOLUTION COMBO PACK MO ASSURE 4 METER MO ASSURE ID INSULIN SAFETY 0.5 ML 29 X 1/2" SYRINGE MO ASSURE ID INSULIN SAFETY 1 ML 29 X 1/2" SYRINGE MO ASSURE LANCE MISC MO

TIER
1 1 1 1 1 1 4 4 4 2 4 4 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 4 4 4 4 1 1 4

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
ASSURE PLATINUM MO ASSURE PRO BLOOD GLUCOSE METER KIT MO AURORA HEALTHCARE LANCETS MO AUTOJECT 2 INJECTION DEVICE MO AUTOJECT 2 INJECTION DEVICE SUB-Q INSULIN PEN MO AUTOLET IMPRESSION LANCING DEVICE KIT MO AUTOLET LITE CLINISAFE DEV MO AUTOLET LITE CLINISAFE DEVICE MO AUTOLET MINI KIT MO AUTOLET MKII CLINISAFE DEVICE MO AUTOLET PLATFORMS MO AUTOPEN 1 TO 16 UNITS SUB-Q INSULIN PEN MO AUTOPEN 1 TO 21 UNITS SUB-Q INSULIN PEN MO AUTOPEN 2 TO 32 UNITS SUB-Q INSULIN PEN MO AUTOPEN 2 TO 42 UNITS SUB-Q INSULIN PEN MO BD AUTOSHIELD PEN NEEDLE 29 X 1/2" MO BD AUTOSHIELD PEN NEEDLE 29 X 3/16" MO BD AUTOSHIELD PEN NEEDLE 29 X 5/16" MO BD ECLIPSE LUER-LOK 1 ML 30 X 1/2" SYRINGE MO BD INSULIN PEN NEEDLE UF MINI 31 X 3/16" MO BD INSULIN PEN NEEDLE UF ORIG 29 X 1/2" MO BD INSULIN PEN NEEDLE UF SHORT 31 X 5/16" MO BD INSULIN SYR 1 ML 25GX5/8" MO BD INSULIN SYR 1 ML 27GX5/8" MO BD INSULIN SYRINGE 1 ML 25 X 1" MO BD INSULIN SYRINGE 1 ML 25 X 5/8" MO BD INSULIN SYRINGE 1 ML 26 X 1/2" MO BD INSULIN SYRINGE 1 ML 28 X 1/2" MO BD INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 15/64" MO BD INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO BD INSULIN SYRINGE MICRO-FINE 0.3 ML 28 MO BD INSULIN SYRINGE MICRO-FINE 0.3 ML 28 X 1/2" MO BD INSULIN SYRINGE MICRO-FINE 1 ML 28 X 1/2" MO BD INSULIN SYRINGE MICRO-FINE 1/2 ML 28 X 1/2" MO BD INSULIN SYRINGE SAFETY-LOK 1 ML 29 X 1/2" MO BD INSULIN SYRINGE SLIP TIP 1 ML MO

TIER
1 4 4 1 1 4 4 4 4 4 4 1 1 1 1 1 1 1 2 1 1 1 1 1 2 2 2 1 1 1 1 1 1 1 1 2

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
BD INSULIN SYRINGE ULT-FINE II 0.3 ML 31 X 5/16" MO BD INSULIN SYRINGE ULT-FINE II 1 ML 31 X 5/16" MO BD INSULIN SYRINGE ULT-FINE II 1/2 ML 31 X 5/16" MO BD INSULIN SYRINGE ULTRA-FINE 0.3 ML 30 X 1/2" MO BD INSULIN SYRINGE ULTRA-FINE 1 ML 29 X 1/2" MO BD INSULIN SYRINGE ULTRA-FINE 1 ML 30 X 1/2" MO BD INSULIN SYRINGE ULTRA-FINE 1/2 ML 30 X 1/2" MO BD INTEGRA INSULIN SYRINGE 1 ML 29 X 1/2" MO BD LANCET DEVICE MO BD LO-DOSE MICRO-FINE IV 0.3 ML 28 X 1/2" SYRINGE MO BD LO-DOSE MICRO-FINE IV 1/2 ML 28 X 1/2" SYRINGE MO BD LO-DOSE ULTRA-FINE 0.3 ML 29 X 1/2" SYRINGE MO BD LO-DOSE ULTRA-FINE 1/2 ML 29 X 1/2" SYRINGE MO BD LUER-LOK SYRINGE 1 ML MO BD MICROTAINER LANCET MO BD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 29 X 1/2" MO BD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 31 X 5/16" MO BD SAFETYGLIDE INSULIN SYRINGE 1/2 ML 29 X 1/2" MO BD SAFETYGLIDE INSULIN SYRINGE 1/2 ML 30 X 5/16" MO BD SAFETYGLIDE SYRINGE 1 ML 27 X 5/8" MO BD ULTRA FINE 33G LANCETS MO BD ULTRA FINE LANCETS MO BD ULTRA-FINE NANO PEN NEEDLES 32 X 5/32" MO BLOOD GLUCOSE MONITORING KIT MO BLOOD GLUCOSE MONITORING SYST MO BREATHERITE MDI SPACER MO BREATHERITE RIGID SPACER & MASK MO BREATHERITE RIGID SPACER & MASK, ADULT MO BREATHERITE RIGID SPACER & MASK, CHILD MO BREATHERITE RIGID SPACER & MASK, INFANT MO BREATHERITE RIGID SPACER & MASK, SMALL CHILD MO BREATHERITE VALVED MDI CHAMBER SPACER MO BREATHERITE VALVED MDI SPACER MO BREATHERITE WITH MASK, LARGE MO BREATHERITE WITH MASK, MEDIUM MO BREATHERITE WITH MASK, SMALL MO

TIER
1 1 1 1 1 1 1 2 4 1 1 1 1 2 4 1 1 1 1 2 4 4 1 4 4 4 4 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
BREEZE 2 KIT MO CAREONE LANCING DEVICE MO CAREONE THIN LANCET MO CAREONE ULTIGUARD 0.3 ML 29 X 1/2" SYRINGE MO CAREONE ULTIGUARD 0.3 ML 30 X 5/16" SYRINGE MO CAREONE ULTIGUARD 1 ML 29 X 1/2" SYRINGE MO CAREONE ULTIGUARD 1 ML 30 X 5/16" SYRINGE MO CAREONE ULTIGUARD 1/2 ML 29 X 1/2" SYRINGE MO CAREONE ULTIGUARD 1/2 ML 30 X 5/16" SYRINGE MO CAREONE ULTRA THIN LANCET MO CLEVER CHEK LANCETS MO CLICKFINE 31 X 1/4" NEEDLE MO CLICKFINE 31 X 5/16" NEEDLE MO COAGUCHEK LANCETS MO COMFORT EZ 0.3 ML 29 X 1/2" SYRINGE MO COMFORT EZ 0.3 ML 30 X 1/2" SYRINGE MO COMFORT EZ 0.3 ML 30 X 5/16" SYRINGE MO COMFORT EZ 0.3 ML 31 X 5/16" SYRINGE MO COMFORT EZ 1 ML 28 X 1/2" SYRINGE MO COMFORT EZ 1 ML 29 X 1/2" SYRINGE MO COMFORT EZ 1 ML 30 X 1/2" SYRINGE MO COMFORT EZ 1 ML 30 X 5/16" SYRINGE MO COMFORT EZ 1 ML 31 X 5/16" SYRINGE MO COMFORT EZ 1/2 ML 28 X 1/2" SYRINGE MO COMFORT EZ 1/2 ML 29 X 1/2" SYRINGE MO COMFORT EZ 1/2 ML 30 X 1/2" SYRINGE MO COMFORT EZ 1/2 ML 30 X 5/16" SYRINGE MO COMFORT EZ 1/2 ML 31 X 5/16" SYRINGE MO COMFORT EZ 31 X 1/4" NEEDLE MO COMFORT EZ 31 X 3/16" NEEDLE MO COMFORT EZ 31 X 5/16" NEEDLE MO COMFORT LANCETS MO CONTOUR METER KIT MO CONTOUR USB KIT MO CONTROL MONITORING SYSTEM KIT MO CVS LANCING DEVICE MO

TIER
4 4 4 1 1 1 1 1 1 4 4 1 1 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
CVS SYRINGE 3/10 ML MO DIABETIC.COM STARTER KIT MO DIDGET METER MO DISCOVISC 40 MG-17 MG/ML INTRAOCULAR SYRINGE MO DUOVISC VISCO ELASTIC 3 %-4 % (0.35 ML) 1 %(0.4 ML) INTRAOCULAR KIT MO E-Z JECT LANCETS MO E-Z JECT SUPER THIN LANCET 30G MO E-Z JECT THIN LANCETS MO EASY COMFORT INSULIN SYRINGE 0.3 ML 30 X 5/16" MO EASY COMFORT INSULIN SYRINGE 1 ML 30 X 5/16" MO EASY COMFORT INSULIN SYRINGE 1/2 ML 30 X 5/16" MO EASY COMFORT LANCETS MO EASY COMFORT LANCETS MO EASY COMFORT LANCETS MO EASY COMFORT LANCETS MO EASY COMFORT LANCETS MO EASY COMFORT LANCETS MO EASY COMFORT LANCETS MO EASY COMFORT LANCETS MO EASY PRO PLUS KIT MO EASY TALK HIGH CONTROL SOLN MO EASY TALK LOW CONTROL SOLN MO EASY TOUCH 29 X 1/2" NEEDLE MO EASY TOUCH 31 X 1/4" NEEDLE MO EASY TOUCH 31 X 3/16" NEEDLE MO EASY TOUCH 31 X 5/16" NEEDLE MO EASY TOUCH 32 X 1/4" NEEDLE MO EASY TOUCH 32 X 3/16" NEEDLE MO EASY TOUCH INSULIN SYRINGE 0.3 ML 30 X 1/2" MO EASY TOUCH INSULIN SYRINGE 0.3 ML 30 X 5/16" MO EASY TOUCH INSULIN SYRINGE 0.3 ML 31 X 5/16" MO EASY TOUCH INSULIN SYRINGE 1 ML 27 X 1/2" MO EASY TOUCH INSULIN SYRINGE 1 ML 28 X 1/2" MO EASY TOUCH INSULIN SYRINGE 1 ML 29 X 1/2" MO EASY TOUCH INSULIN SYRINGE 1 ML 30 X 1/2" MO

TIER
1 4 4 4 4 4 4 4 1 1 1 4 4 4 4 4 4 4 4 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
EASY TOUCH INSULIN SYRINGE 1 ML 30 X 5/16" MO EASY TOUCH INSULIN SYRINGE 1 ML 31 X 5/16" MO EASY TOUCH INSULIN SYRINGE 1/2 ML 27 X 1/2" MO EASY TOUCH INSULIN SYRINGE 1/2 ML 28 X 1/2" MO EASY TOUCH INSULIN SYRINGE 1/2 ML 29 X 1/2" MO EASY TOUCH INSULIN SYRINGE 1/2 ML 30 X 1/2" MO EASY TOUCH INSULIN SYRINGE 1/2 ML 30 X 5/16" MO EASY TOUCH INSULIN SYRINGE 1/2 ML 31 X 5/16" MO EASY TRAK HIGH CONTROL SOLN MO EASY TRAK LOW CONTROL SOLN MO EASY TRAK NORMAL CONTROL SOLN MO EASYGLUCO METER KIT MO EASYGLUCO MONITORING SYSTEM KIT MO euflexxa 10 mg/ml intra-articular syringe MO EVENCARE KIT MO EXEL INSULIN 0.3 ML 29 X 1/2" SYRINGE MO EXEL INSULIN 1 ML 27 X 1/2" SYRINGE MO EXEL INSULIN 1 ML 30 X 5/16" SYRINGE MO EXEL INSULIN 1/2 ML 28 X 1/2" SYRINGE MO EXEL INSULIN 1/2 ML 30 X 5/16" SYRINGE MO EZ SMART LANCETS MO EZ SMART PLUS SYSTEM KIT MO EZ SMART SYSTEM KIT MO FIFTY50 2.0 GLUCOSE METER MO FIFTY50 RESERVOIR 1.8 ML MISC MO FIFTY50 RESERVOIR 3 ML MISC MO FINGERSTIX LANCETS MO FIRST CHOICE LANCETS THIN MO FREESTYLE FLASH SYSTEM KIT MO FREESTYLE FREEDOM KIT MO FREESTYLE FREEDOM LITE KIT MO FREESTYLE LANCETS MO FREESTYLE LITE METER KIT MO FREESTYLE SIDEKICK II KIT MO FREESTYLE SYSTEM KIT MO G-4 KIT MO

TIER
1 1 1 1 1 1 1 1 1 1 1 4 4 4 4 2 1 2 2 2 4 4 4 4 2 2 4 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
GENTLE DRAW LANCING DEVICE MO GLUCOCARD 01 METER MO GLUCOCARD 01 METER KIT MO GLUCOCARD 01-MINI KIT MO GLUCOCARD VITAL KIT MO GLUCOCARD X-METER KIT MO GLUCOCOM LANCETS MO GLUCOLET 2 AUTOMATIC LANCING KIT MO GLUCOLET 2 AUTOMATIC LANCING MISC MO GLUCOPRO 0.3 ML 29 X 1/2" SYRINGE MO GLUCOPRO 0.3 ML 30 X 1/2" SYRINGE MO GLUCOPRO 0.3 ML 30 X 5/16" SYRINGE MO GLUCOPRO 0.3 ML 31 X 5/16" SYRINGE MO GLUCOPRO 1 ML 29 X 1/2" SYRINGE MO GLUCOPRO 1 ML 30 X 1/2" SYRINGE MO GLUCOPRO 1 ML 30 X 5/16" SYRINGE MO GLUCOPRO 1 ML 31 X 5/16" SYRINGE MO GLUCOPRO 1/2 ML 29 X 1/2" SYRINGE MO GLUCOPRO 1/2 ML 30 X 1/2" SYRINGE MO GLUCOPRO 1/2 ML 30 X 5/16" SYRINGE MO GLUCOPRO 1/2 ML 31 X 5/16" SYRINGE MO GLUCOPRO SYRINGE MO GLUCOSOURCE MISC MO HAEMOLANCE LOW FLOW LANCETS MO HAEMOLANCE PLUS LANCETS MO HAEMOLANCE PLUS MISC MO HAEMOLANCE, RETRACTABLE LANCET MO HEALTHY ACCENTS UNIFINE PENTIP 29 X 1/2" NEEDLE MO HEALTHY ACCENTS UNIFINE PENTIP 31 X 1/4" NEEDLE MO HEALTHY ACCENTS UNIFINE PENTIP 31 X 3/16" NEEDLE MO HEALTHY ACCENTS UNIFINE PENTIP 31 X 5/16" NEEDLE MO HUMAPEN LUXURA HD SUB-Q INSULIN PEN MO HUMAPEN MEMOIR SUB-Q INSULIN PEN MO HYALGAN 10 MG/ML INTRA-ARTICULAR MO HYALGAN 10 MG/ML INTRA-ARTICULAR SYRINGE MO HYPOLANCE AST LANCING KIT MO

TIER
1 4 4 1 4 4 4 4 4 1 1 1 1 1 1 1 1 1 1 1 1 1 4 4 4 4 4 1 1 1 1 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
IN CONTROL PEN NEEDLE 29 X 1/2" MO IN CONTROL PEN NEEDLE 31 X 1/4" MO IN CONTROL PEN NEEDLE 31 X 5/16" MO INFINITY METER KIT MO INFINITY STARTER KIT MO INJECT-EASE AUTOMATIC INJECTOR MISC MO INNOVO SUB-Q INSULIN PEN MO INSULIN 1 ML SYRINGE MO INSULIN 1/2 ML SYRINGE MO INSULIN 3/10 ML SYRINGE MO INSULIN PEN NEEDLE 29 X 1/2" MO INSULIN PEN NEEDLE 31 MO INSULIN PEN NEEDLE 31 X 1/4" MO INSULIN SYR 1/2 ML BULK PACK MO INSULIN SYRIN 0.3 ML 31GX5/16" MO INSULIN SYRIN 0.5 ML 31GX5/16" MO INSULIN SYRINGE 1 ML MO INSULIN SYRINGE 1 ML 28 X 1/2" MO INSULIN SYRINGE 1 ML 29 X 1/2" MO INSULIN SYRINGE 1 ML 30 X 5/16" MO INSULIN SYRINGE 1 ML 31GX5/16" MO INSULIN SYRINGE 1/2 ML 28 X 1/2" MO INSULIN SYRINGE 1/2 ML 29 X 1/2" MO INSULIN SYRINGE 1/2 ML 30 X 5/16" MO INSULIN SYRINGE MICROFINE 0.3 ML 28 X 1/2" MO INSULIN SYRINGE MICROFINE 1 ML 27 X 5/8" MO INSULIN SYRINGE MICROFINE 1/2 ML 28 X 1/2" MO INSULIN SYRINGE U100 0.5 ML MO INSULIN SYRINGE U100 1 ML MO INSULIN SYRINGE ULTRA-FINE 0.3 ML 31 X 15/64" MO INSULIN SYRINGE ULTRA-FINE 1 ML 31 X 15/64" MO INSULIN SYRINGE ULTRA-FINE 1/2 ML 31 X 15/64" MO INSULIN SYRINGE ULTRAFINE 1/2 ML 29 X 1/2" MO INSULIN SYRINGE/NEEDLE 0.5CC/27G 1/2 ML 27 X 1/2" MO INSUMED SYR 0.3 ML 31GX5/16" MO INSUPEN 29 X 1/2" NEEDLE MO

TIER
2 1 1 4 4 4 1 1 1 1 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
INSUPEN 30 X 5/16" NEEDLE MO INSUPEN 31 X 1/4" NEEDLE MO INSUPEN 31 X 5/16" NEEDLE MO INSUPEN 32 X 1/4" NEEDLE MO INSUPEN 32 X 5/16" NEEDLE MO INSUPEN 32 X 5/32" NEEDLE MO KINRAY VALUE PACK MO KMART VALU PLUS SYR 1/2 ML MO LANCETS, SUPER THIN MO LANCETS,THIN MO LANCETS,ULTRA THIN MO LANCING DEVICE WITH LANCETS MO LANCING SYSTEM MO LEADER PEN NEEDLES 12MM 29G MO LIBERTY BLOOD GLUCOSE MONITOR MO LIFE MEDICAL STARTER KIT MO LIFESCAN FINEPOINT LANCETS MO LITE TOUCH INSULIN PEN NEEDLES 29 X 1/2" MO LITE TOUCH INSULIN PEN NEEDLES 31 X 3/16" MO LITE TOUCH INSULIN PEN NEEDLES 31 X 5/16" MO LITE TOUCH INSULIN SYRINGE 0.3 ML 29 X 1/2" MO LITE TOUCH INSULIN SYRINGE 0.3 ML 30 X 5/16" MO LITE TOUCH INSULIN SYRINGE 0.3 ML 31 X 5/16" MO LITE TOUCH INSULIN SYRINGE 1 ML 28 MO LITE TOUCH INSULIN SYRINGE 1 ML 29 MO LITE TOUCH INSULIN SYRINGE 1 ML 30 X 7/16" MO LITE TOUCH INSULIN SYRINGE 1 ML 31 X 5/16" MO LITE TOUCH INSULIN SYRINGE 1/2 ML 28 MO LITE TOUCH INSULIN SYRINGE 1/2 ML 29 MO LITE TOUCH INSULIN SYRINGE 1/2 ML 30 MO LITE TOUCH INSULIN SYRINGE 1/2 ML 31 X 5/16" MO LITE TOUCH LANCETS MO LITE TOUCH LANCING DEVICE MO MAGELLAN INSULIN SAFETY SYRINGE 0.3 ML 29 X 1/2" MO MAGELLAN INSULIN SAFETY SYRINGE 0.5 ML 29 X 1/2" MO MAGELLAN INSULIN SAFETY SYRINGE 1 ML 29 X 1/2" MO

TIER
2 2 2 1 1 2 4 1 4 4 2 2 4 2 4 4 1 1 2 1 2 2 2 2 2 2 2 2 2 2 2 4 4 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
MAGELLAN INSULIN SAFETY SYRINGE 1 ML 30 X 5/16" MO MAGELLAN SYRINGE 0.3 ML 30 X 5/16" MO MAGELLAN SYRINGE 0.5 ML 30 X 5/16" MO MAGELLAN SYRINGE 1 ML 27 X 1/2" MO MAJOR COMFORT MISC MO MAXI-COMFORT INSULIN SYRINGE 1 ML 28 X 1/2" MO MAXI-COMFORT INSULIN SYRINGE 1/2 ML 28 X 1/2" MO MEDI-JECTOR NEEDLE-FREE SYR A MISC MO MEDI-JECTOR NEEDLE-FREE SYR B MISC MO MEDI-JECTOR NEEDLE-FREE SYR C MISC MO MEDI-JECTOR VISION SUB-Q INSULIN PEN MO MEDI-LANCE LANCETS MO MEDISENSE COMBO PACK MO MEDISENSE CONTROLS 1-HI 1-LO COMBO PACK MO MEDISENSE GLUCOSE KETONE COMBO PACK MO MEDLANCE PLUS LANCETS MO MICRO BLOOD GLUCOSE KIT MO MICROLET 2 LANCING DEVICE KIT MO MICROLET LANCET MO MINI ULTRA-THIN II 31 X 3/16" NEEDLE MO MINI WRIGHT PEAK FLOW METER MO MINI-WRIGHT PEAK FLOW METER MO MINIMED SYRINGE RESERVOIR 3 ML MO MONOJECT INSULIN SAFETY SYRINGE 0.3 ML 29 X 1/2" MO MONOJECT INSULIN SAFETY SYRINGE 0.3 ML 30 X 5/16" MO MONOJECT INSULIN SAFETY SYRINGE 1/2 ML 29 X 1/2" MO MONOJECT INSULIN SAFETY SYRINGE 1/2 ML 30 X 5/16" MO MONOJECT INSULIN SAFETY SYRINGE 29 X 1/2" MO MONOJECT INSULIN SYRINGE 0.3 ML 29 X 1/2" MO MONOJECT INSULIN SYRINGE 0.3 ML 30 X 5/16" MO MONOJECT INSULIN SYRINGE 0.3 ML 31 X 5/16" MO MONOJECT INSULIN SYRINGE 1 ML MO MONOJECT INSULIN SYRINGE 1 ML 25 X 5/8" MO MONOJECT INSULIN SYRINGE 1 ML 27 X 1/2" MO MONOJECT INSULIN SYRINGE 1 ML 28 X 1/2" MO MONOJECT INSULIN SYRINGE 1 ML 29 X 1/2" MO

TIER
1 1 1 1 4 1 1 1 1 1 1 4 4 4 4 4 4 4 4 2 4 4 4 1 1 1 1 1 1 1 1 1 1 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
MONOJECT INSULIN SYRINGE 1 ML 30 X 5/16" MO MONOJECT INSULIN SYRINGE 1 ML 31 X 5/16" MO MONOJECT INSULIN SYRINGE 1/2 ML 28 X 1/2" MO MONOJECT INSULIN SYRINGE 1/2 ML 29 X 1/2" MO MONOJECT INSULIN SYRINGE 1/2 ML 30 X 5/16" MO MONOJECT INSULIN SYRINGE 1/2 ML 31 X 5/16" MO MONOJECT SYRINGE 1/2 ML 28 MO MONOJECT ULTRA COMFORT INSULIN 1/2 ML 28 SYRINGE MO MONOJECTOR LANCET DEVICE MO MONOLET LANCETS MO MONOLET THIN LANCETS MO MS INS SYRINGE 1 ML 30GX1/2" MO MULTI-LANCET DEVICE MO NEEDLE-PRO EDGE 0.3 ML 29GX1/2 MO NEEDLE-PRO EDGE 0.3 ML 30GX1/2 MO NEEDLE-PRO EDGE 0.5 ML 28GX1/2 MO NEEDLE-PRO EDGE 0.5 ML 29GX1/2 MO NEEDLE-PRO EDGE 0.5 ML 30GX1/2 MO NEEDLE-PRO EDGE 1 ML 26GX1/2" MO NEEDLE-PRO EDGE 1 ML 27GX1/2" MO NEEDLE-PRO EDGE 1 ML 28GX1/2" MO NEEDLE-PRO EDGE 1 ML 29GX1/2" MO NEEDLE-PRO EDGE 1 ML 30GX1/2" MO NOVA SUREFLEX LANCETS MO NOVOFINE 30 30 X 1/3" NEEDLE MO NOVOFINE 32 32 X 1/4" NEEDLE MO NOVOFINE AUTOCOVER 30 X 1/3" NEEDLE MO NOVOPEN 3 PENMATE SUB-Q INSULIN PEN MO NOVOPEN 3 SUB-Q INSULIN PEN MO NOVOPEN JR SUB-Q INSULIN PEN MO NOVOTWIST 30 X 1/3" NEEDLE MO NOVOTWIST 32 X 1/5" NEEDLE MO NUTRIPORT BALLOON KIT MO ONE TOUCH BASIC SYSTEM KIT MO ONE TOUCH DELICA LANCETS MO ONE TOUCH DELICA LANCING DEVICE KIT MO

TIER
1 1 1 1 1 1 1 1 4 4 4 1 4 1 1 1 1 1 1 1 1 1 1 4 1 1 1 1 1 1 1 1 4 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
ONE TOUCH SURESOFT LANCING DEVICES MO ONE TOUCH ULTRA 2 KIT MO ONE TOUCH ULTRA SMART KIT MO ONE TOUCH ULTRA SYSTEM KIT MO ONE TOUCH ULTRALINK KIT MO ONE TOUCH ULTRAMINI KIT MO ONE TOUCH ULTRASOFT LANCETS MO ORSINI INSULIN SYRINGE 1 ML 30 X 5/16" MO ORSINI INSULIN SYRINGE 1/2 ML 29 X 1/2" MO ORSINI INSULIN SYRINGE 1/2 ML 30 X 5/16" MO PEN NEEDLE 29 GAUGE MO PEN NEEDLE 29 X 1/2" MO PEN NEEDLE 30 X 3/16" MO PEN NEEDLE 30 X 5/16" MO PEN NEEDLE 31 X 1/4" MO PEN NEEDLE 31 X 3/16" MO PEN NEEDLE 31 X 5/16" MO PEN NEEDLES 6MM 31G MO PENLET PLUS BLOOD SAMPLER KIT MO POCKETCHEM EZ KIT MO PRECISION GLUCOSE CONTROL SOLN COMBO PACK MO PRECISION GLUCOSE/KETONE CONTR COMBO PACK MO PRECISION MISC MO PRECISION SURE DOSE SYRINGE MO PRECISION XTRA MONITOR MO PREFERRED PLUS SYRINGE 0.5 ML MO PREFERRED PLUS SYRINGE 1 ML MO PRESTIGE BLOOD GLUCOSE METR MO PRESTIGE METER MO PRESTIGE SMART SYS IQ KIT MO PRESTIGE SMART SYS TEST STP MO PRESTIGE SMART SYS VALUE PK MO PRESTIGE SMART SYSTEM METER MO PRESTIGE STARTER KIT MO PRESTIGE VALUE PACK MO PRODIGY CONTROL SOLUTION,HIGH MO

TIER
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 4 4 4 4 4 2 4 1 1 4 4 4 4 4 4 4 4 2

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
PRODIGY INSULIN SYRINGE 0.3 ML 31 X 5/16" MO PRODIGY INSULIN SYRINGE 1 ML 28 X 1/2" MO PRODIGY INSULIN SYRINGE 1 ML 29 X 1/2" MO PRODIGY INSULIN SYRINGE 1/2 ML 31 X 5/16" MO PRODIGY LANCETS MO PRODIGY PEN NEEDLE 29 X 1/2" MO PRODIGY PEN NEEDLE 31 X 3/16" MO PRODIGY PEN NEEDLE 31 X 5/16" MO PRODIGY TWIST TOP LANCET MO provisc 10 mg/ml intraocular syringe MO PUB INS SYRIN 0.3 ML 30GX1/2" MO PUB INSUL SYR 0.5 ML 30GX1/2" MO PUBLIX 28G LANCET MO QUICKTEK KIT MO RELION CONFIRM KIT MO RELION INS SYR 0.3 ML 29GX1/2" MO RELION INS SYR 0.3 ML 30GX5/16 MO RELION INS SYR 1 ML 29GX1/2" MO RELION INS SYR 1 ML 30GX5/16" MO RELION NEEDLES 31 X 1/4" MO RELION PEN 31G X 5/16" NEEDLE MO RELION SYR 0.5 ML 30GX5/16" MO RELION ULTRA THIN PLUS LANCETS MO RENEW ADVANCED MICRO-LANCETS MO SAFESNAP INSULIN SYRINGE 0.3 ML 30 X 5/16" MO SAFESNAP INSULIN SYRINGE 0.5 ML 29 X 1/2" MO SAFESNAP INSULIN SYRINGE 0.5 ML 30 X 5/16" MO SAFESNAP INSULIN SYRINGE 1 ML 28 X 1/2" MO SAFESNAP INSULIN SYRINGE 1 ML 29 X 1/2" MO SAFETY-LET LANCETS MO SELECT-LITE LANCING DEVICE MO SELECT-LITE MISC MO SENSURA CLICK OSTOMY POUCH MO SENSURA FLEX OSTOMY BASE PLATE MO SENSURA FLEX OSTOMY POUCH MO SENSURA OSTOMY BASE PLATE MO

TIER
2 2 1 2 4 2 2 2 4 4 1 1 4 4 4 1 1 1 1 2 2 1 4 4 1 1 1 1 1 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
SINGLE-LET MISC MO SMARTEST LANCET MO SOFT TOUCH LANCET DEVICE MO SOLO V2 LANCETS MO supartz 10 mg/ml intra-articular syringe MO SURE COMFORT INSULIN SYRINGE 0.3 ML 29 X 1/2" MO SURE COMFORT INSULIN SYRINGE 0.3 ML 30 X 1/2" MO SURE COMFORT INSULIN SYRINGE 0.3 ML 30 X 5/16" MO SURE COMFORT INSULIN SYRINGE 0.3 ML 31 X 5/16" MO SURE COMFORT INSULIN SYRINGE 1 ML 28 X 1/2" MO SURE COMFORT INSULIN SYRINGE 1 ML 29 X 1/2" MO SURE COMFORT INSULIN SYRINGE 1 ML 30 X 1/2" MO SURE COMFORT INSULIN SYRINGE 1 ML 30 X 5/16" MO SURE COMFORT INSULIN SYRINGE 1 ML 31 X 5/16" MO SURE COMFORT INSULIN SYRINGE 1/2 ML 28 X 1/2" MO SURE COMFORT INSULIN SYRINGE 1/2 ML 30 X 1/2" MO SURE COMFORT INSULIN SYRINGE 1/2 ML 30 X 5/16" MO SURE COMFORT INSULIN SYRINGE 1/2 ML 31 X 5/16" MO SURE COMFORT INSULIN SYRINGE U-100 1/2 ML 29 X 1/2" MO SURE COMFORT LANCETS MO SURE COMFORT PEN NEEDLE 29 X 1/2" MO SURE COMFORT PEN NEEDLE 30 X 5/16" MO SURE COMFORT PEN NEEDLE 31 X 3/16" MO SURE COMFORT PEN NEEDLE 31 X 5/16" MO SURE EDGE BLOOD GLUCOSE METER MO SURE-FINE PEN NEEDLES 29 X 1/2" MO SURE-FINE PEN NEEDLES 31 X 3/16" MO SURE-FINE PEN NEEDLES 31 X 5/16" MO SURE-JECT INSULIN SYRINGE 0.3 ML 29 X 1/2" MO SURE-JECT INSULIN SYRINGE 0.3 ML 30 X 5/16" MO SURE-JECT INSULIN SYRINGE 0.3 ML 31 X 5/16" MO SURE-JECT INSULIN SYRINGE 1 ML 28 X 1/2" MO SURE-JECT INSULIN SYRINGE 1 ML 29 X 1/2" MO SURE-JECT INSULIN SYRINGE 1 ML 30 X 5/16" MO SURE-JECT INSULIN SYRINGE 1 ML 31 X 5/16" MO SURE-JECT INSULIN SYRINGE 1/2 ML 28 X 1/2" MO

TIER
4 4 4 4 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 1 1 1 1 4 2 1 1 1 1 1 1 1 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
SURE-JECT INSULIN SYRINGE 1/2 ML 29 X 1/2" MO SURE-JECT INSULIN SYRINGE 1/2 ML 30 X 5/16" MO SURE-JECT INSULIN SYRINGE 1/2 ML 31 X 5/16" MO SURE-LANCE MISC MO SURESTEP GLUC CONTROL SOLN MO SURESTEP PRO LINEARITY KIT MO SURESTEP SYSTEM MO SYNVISC 16MG/2 ML INTRA-ARTICULAR SYRINGE MO SYNVISC-ONE 48 MG/6 ML INTRA-ARTICULAR SYRINGE MO TECHLITE AST LANCETS MO TECHLITE LANCETS MO TERUMO INS SYRINGE U100-1 ML MO TERUMO INSULIN SYRINGE 0.3 ML 30 X 3/8" MO TERUMO INSULIN SYRINGE 0.5CC/27G 1/2 ML 27 X 1/2" MO TERUMO INSULIN SYRINGE 1 ML 27 X 1/2" MO TERUMO INSULIN SYRINGE 1 ML 28 X 1/2" MO TERUMO INSULIN SYRINGE 1 ML 29 X 1/2" MO TERUMO INSULIN SYRINGE 1/2 ML 28 X 1/2" MO TERUMO INSULIN SYRINGE 1/2 ML 29 X 1/2" MO TERUMO INSULIN SYRINGE 1/2 ML 30 X 3/8" MO TERUMO SURGUARD SYR 28G-1 ML MO TERUMO SURGUARD SYR 28G-1/2 ML MO TERUMO SURGUARD SYR 29G-0.3 ML MO TERUMO SURGUARD SYR 29G-1/2 ML MO TERUMO SURGUARD SYRN 29G-1 ML MO THINPRO INSULIN SYRINGE 0.3 ML 29 X 1/2" MO THINPRO INSULIN SYRINGE 0.3 ML 30 X 3/8" MO THINPRO INSULIN SYRINGE 0.3 ML 31 X 3/8" MO THINPRO INSULIN SYRINGE 0.5 ML 31 X 3/8" MO THINPRO INSULIN SYRINGE 1 ML 28 X 1/2" MO THINPRO INSULIN SYRINGE 1 ML 29 X 1/2" MO THINPRO INSULIN SYRINGE 1 ML 30 X 3/8" MO THINPRO INSULIN SYRINGE 1 ML 31 X 3/8" MO THINPRO INSULIN SYRINGE 1/2 ML 28 X 1/2" MO THINPRO INSULIN SYRINGE 1/2 ML 29 X 1/2" MO THINPRO INSULIN SYRINGE 1/2 ML 30 X 3/8" MO

TIER
1 1 1 2 4 4 4 4 4 4 4 1 2 2 1 2 1 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
THINSET RESERVOIR 1.8 ML MO THINSET RESERVOIR 3 ML MO TOPCARE CLICKFINE 31 X 1/4" NEEDLE MO TOPCARE CLICKFINE 31 X 5/16" NEEDLE MO TOPCARE ULTRA COMFORT 0.3 ML 29 X 1/2" SYRINGE MO TOPCARE ULTRA COMFORT 0.3 ML 30 X 5/16" SYRINGE MO TOPCARE ULTRA COMFORT 0.3 ML 31 X 5/16" SYRINGE MO TOPCARE ULTRA COMFORT 1 ML 29 X 1/2" SYRINGE MO TOPCARE ULTRA COMFORT 1 ML 30 X 5/16" SYRINGE MO TOPCARE ULTRA COMFORT 1 ML 31 X 5/16" SYRINGE MO TOPCARE ULTRA COMFORT 1/2 ML 29 X 1/2" SYRINGE MO TOPCARE ULTRA COMFORT 1/2 ML 30 X 5/16" SYRINGE MO TOPCARE ULTRA COMFORT 1/2 ML 31 X 5/16" SYRINGE MO TOPCARE UNIVERSAL1 THIN LANCET MO TRUERESULT BLOOD GLUCOSE SYSTM KIT MO TRUETEST HIGH GLUCOSE CONTROL SOLN MO TRUETEST NORMAL GLUCOSE CONTROL SOLN MO TRUETRACK BLOOD GLUCOSE SYSTEM KIT MO TRUETRACK SMART SYSTEM KIT MO TRUZONE PEAK FLOW METER MO ULTI-LANCE KIT MO ULTICARE 0.3 ML 30 X 1/2" SYRINGE MO ULTICARE 1 ML 30 X 1/2" SYRINGE MO ULTICARE 1.5 ML 22 X 1 1/2" SYRINGE MO ULTICARE 1/2 ML 30 X 1/2" SYRINGE MO ULTICARE 29 X 1/2" NEEDLE MO ULTICARE 31 X 1/4" NEEDLE MO ULTICARE 31 X 5/16" NEEDLE MO ULTICARE 32 X 5/32" NEEDLE MO ULTICARE INS SYR 1 ML 28GX1/2" MO ULTICARE MISC MO ULTICARE SYRIN 0.5 ML 28GX1/2" MO ULTICARE U100 0.5 ML 29GX1/2" MO ULTIGUARD 0.3 ML 29 X 1/2" SYRINGE MO ULTIGUARD 0.3 ML 30 X 1/2" SYRINGE MO ULTIGUARD 0.3 ML 30 X 5/16" SYRINGE MO

TIER
4 4 2 2 1 1 1 1 1 1 1 1 1 4 2 2 2 4 4 4 4 1 1 1 1 1 1 1 1 1 4 1 1 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
ULTIGUARD 0.3 ML 31 X 5/16" SYRINGE MO ULTIGUARD 1 ML 29 X 1/2" SYRINGE MO ULTIGUARD 1 ML 30 X 1/2" SYRINGE MO ULTIGUARD 1 ML 30 X 5/16" SYRINGE MO ULTIGUARD 1 ML 31 X 5/16" SYRINGE MO ULTIGUARD 1/2 ML 29 X 1/2" SYRINGE MO ULTIGUARD 1/2 ML 30 X 1/2" SYRINGE MO ULTIGUARD 1/2 ML 30 X 5/16" SYRINGE MO ULTIGUARD 1/2 ML 31 X 5/16" SYRINGE MO ULTILET CLASSIC LANCETS MO ULTILET INSULIN SYRINGE 0.3 ML 29 MO ULTILET INSULIN SYRINGE 0.3 ML 29 X 1/2" MO ULTILET INSULIN SYRINGE 0.3 ML 30 X 5/16" MO ULTILET INSULIN SYRINGE 0.3 ML 31 X 5/16" MO ULTILET INSULIN SYRINGE 1 ML 29 MO ULTILET INSULIN SYRINGE 1 ML 29 X 1/2" MO ULTILET INSULIN SYRINGE 1 ML 30 X 5/16" MO ULTILET INSULIN SYRINGE 1 ML 31 X 5/16" MO ULTILET INSULIN SYRINGE 1/2 ML 29 MO ULTILET INSULIN SYRINGE 1/2 ML 29 X 1/2" MO ULTILET INSULIN SYRINGE 1/2 ML 30 X 5/16" MO ULTILET INSULIN SYRINGE 1/2 ML 31 X 5/16" MO ULTILET LANCETS MO ULTILET PEN NEEDLE 29 GAUGE MO ULTIMA MONITOR MO ULTRA COMFORT INSULIN SYRINGE MO ULTRA COMFORT INSULIN SYRINGE 0.3 ML 29 MO ULTRA COMFORT INSULIN SYRINGE 0.3 ML 30 MO ULTRA COMFORT INSULIN SYRINGE 0.3 ML 30 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE 1 ML 28 MO ULTRA COMFORT INSULIN SYRINGE 1 ML 28 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE 1 ML 29 MO ULTRA COMFORT INSULIN SYRINGE 1 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE 1 ML 30 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE 1 ML 30 X 7/16" MO ULTRA COMFORT INSULIN SYRINGE 1 ML 31 X 5/16" MO

TIER
1 1 1 1 1 1 1 1 1 4 1 1 2 2 1 2 2 1 1 1 2 2 4 1 4 1 1 2 2 2 2 2 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
ULTRA COMFORT INSULIN SYRINGE 1/2 ML 28 MO ULTRA COMFORT INSULIN SYRINGE 1/2 ML 28 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE 1/2 ML 29 MO ULTRA COMFORT INSULIN SYRINGE 1/2 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE 1/2 ML 30 MO ULTRA COMFORT INSULIN SYRINGE 1/2 ML 30 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE 1/2 ML 31 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 30 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MO ULTRA THIN II LANCETS MO ULTRA THIN LANCETS MO ULTRA THIN PLUS LANCETS MO ULTRA TLC LANCETS MO ULTRA-THIN II (SHORT) INS SYR 0.3 ML 30 X 5/16" SYRINGE MO ULTRA-THIN II (SHORT) INS SYR 0.3 ML 31 X 5/16" SYRINGE MO ULTRA-THIN II (SHORT) INS SYR 1 ML 30 X 5/16" SYRINGE MO ULTRA-THIN II (SHORT) INS SYR 1/2 ML 30 X 5/16" SYRINGE MO ULTRA-THIN II (SHORT) INS SYR 1/2 ML 31 X 5/16" SYRINGE MO ULTRA-THIN II (SHORT) PEN NDL 31 X 5/16" NEEDLE MO ULTRA-THIN II INS PEN NEEDLES 29 X 1/2" MO ULTRA-THIN II INSULIN SYRINGE 0.3 ML 29 X 1/2" MO

TIER
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 2 5 4 1 1 1 1 1 1 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
ULTRA-THIN II INSULIN SYRINGE 1 ML 29 X 1/2" MO ULTRA-THIN II INSULIN SYRINGE 1/2 ML 29 X 1/2" MO ULTRACOMFORT 1 ML 29 X 1/2" SYRINGE MO ULTRACOMFORT 1 ML 30 X 1/2" SYRINGE MO ULTRACOMFORT 1 ML 31 X 5/16" SYRINGE MO ULTRACOMFORT 1/2 ML 29 X 1/2" SYRINGE MO ULTRACOMFORT 1/2 ML 30 X 1/2" SYRINGE MO ULTRACOMFORT 1/2 ML 31 X 5/16" SYRINGE MO ULTRACOMFORT 31 X 1/4" NEEDLE MO ULTRACOMFORT 31 X 5/16" NEEDLE MO ULTRACOMFORT W/ CONTAINER 1 ML 29 X 1/2" SYRINGE MO ULTRACOMFORT W/ CONTAINER 1 ML 30 X 1/2" SYRINGE MO ULTRACOMFORT W/ CONTAINER 1 ML 31 X 5/16" SYRINGE MO ULTRACOMFORT W/ CONTAINER 1/2 ML 29 X 1/2" SYRINGE MO ULTRACOMFORT W/ CONTAINER 1/2 ML 30 X 1/2" SYRINGE MO ULTRACOMFORT W/ CONTAINER 1/2 ML 31 X 5/16" SYRINGE MO UNIFINE PENTIPS 29 GAUGE NEEDLE MO UNIFINE PENTIPS 29 X 1/2" NEEDLE MO UNIFINE PENTIPS 29 X 5/16" NEEDLE MO UNIFINE PENTIPS 30 X 5/16" NEEDLE MO UNIFINE PENTIPS 31 NEEDLE MO UNIFINE PENTIPS 31 X 1/4" NEEDLE MO UNIFINE PENTIPS 31 X 3/16" NEEDLE MO UNIFINE PENTIPS 31 X 5/16" NEEDLE MO UNIFINE PENTIPS 6MM NEEDLES MO UNILET COMFORTOUCH LANCET MO UNILET EXCELITE II LANCET MO UNILET EXCELITE LANCET MO UNILET GP LANCET MO UNILET GP LANCET MO UNILET GP LANCET SUPERLITE MO UNILET LANCET MO UNILET SUPERLITE LANCET MO UNISTIK 2 DEVICE KIT MO UNISTIK 2 EXTRA KIT MO UNISTIK 2 NORMAL LANCET&DEVICE KIT MO

TIER
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 4 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
UNISTIK 3 COMFORT DEVICE KIT MO UNISTIK 3 COMFORT LANCET MO UNISTIK 3 EXTRA LANCET MO UNISTIK 3 KIT MO UNISTIK 3 MM DEVICE MO UNISTIK 3 NEONATAL DEVICE KIT MO UNISTIK 3 NEONATAL KIT MO UNISTIK 3 NORMAL LANCET MO UNISTIK CZT LANCET MO UNISTIK KIT MO UNISTIK-2 3 MM DEVICE MO VANISHPOINT SYRINGE 1 ML 29 X 1/2" MO VANISHPOINT SYRINGE 1/2 ML 30 X 1/2" MO VICTORY HIGH, LOW CONTROL SOLN MO VISCOAT 4 %-3 % (40 MG-30 MG/ML) INTRAOCULAR SYRINGE MO WAVESENSE LANCETS MO DIAGNOSTIC AGENTS ACCU-CHEK ACTIVE TEST STRIPS MO ACCU-CHEK AVIVA STRIPS MO ACCU-CHEK COMFORT CURVE TEST STRIPS MO ACCUTREND GLUCOSE STRIPS MO ACTHAR H.P. 80 UNIT/ML INJECTION GEL SP ACURA TEST STRIPS MO ADVANCE TEST STRIPS MO ADVOCATE REDI-CODE STRIPS MO ADVOCATE TEST STRIPS MO ASCENSIA AUTODISC TEST STRIPS MO ASSURE 3 TEST STRIPS MO ASSURE 4 STRIPS MO ASSURE PLATINUM STRIPS MO ASSURE PRO TEST STRIPS MO BIONIME RIGHTEST TEST STRIPS MO BLOOD GLUCOSE TEST STRIPS MO BREEZE 2 TEST STRIPS MO CARESENS N TEST STRIPS MO CHEMSTRIP UGK MO

TIER
4 4 4 4 4 4 4 4 4 4 4 1 1 1 4 4 1 1 1 4 5 4 4 4 4 4 4 4 1 4 4 4 4 3 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) PA QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days)

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DRUG NAME
CLEVER CHEK TEST STRIPS MO CLEVER CHOICE PRO BLOOD GLUCOSE MONITOR STRIPS MO CLEVER CHOICE TEST STRIPS MO CLINISTIX REAGENT STRIPS MO CLINITEST REAGENT TABLET,NON-ORAL MO CONTOUR TEST STRIPS MO CONTROL G3 STRIPS MO CONTROL TEST STRIPS MO CVS TEST STRIP MO DIASCREEN 10 STRIPS MO DIASCREEN 1G REAGENT STRIPS MO DIASCREEN 2GK REAGENT STRIPS MO DIASCREEN 3 REAGENT STRIPS MO DIASCREEN 4OBL REAGENT STRIPS MO DIASCREEN 5 REAGENT STRIPS MO DIASCREEN 6 REAGENT STRIPS MO DIASCREEN 7 REAGENT STRIPS MO DIASCREEN 8 REAGENT STRIPS MO DIASCREEN 9 REAGENT STRIPS MO DIASTIX STRIPS MO EASY CHECK TEST STRIPS MO EASY GLUCO G2 STRIPS MO EASY PRO PLUS TEST STRIPS MO EASY TALK GLUCOSE TEST STRIPS MO EASY TRAK GLUCOSE TEST STRIPS MO EASYGLUCO TEST STRIPS MO EASYMAX STRIPS MO ECLIPSE TEST STRIPS MO ELEMENT TEST STRIPS MO EMBRACE BLOOD GLUCOSE SYSTEM STRIPS MO enlon 10 mg/ml injection MO ENVISION TEST STRIPS MO EVENCARE TEST STRIPS MO EVOLUTION TEST STRIPS MO EZ SMART PLUS TEST STRIPS MO EZ SMART TEST STRIPS MO

TIER
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 1 1 4 4 4 4 4 1 4 4 4 4 4

QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days)

QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days)

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DRUG NAME
FAST TAKE TEST STRIPS MO FIFTY50 TEST STRIP MO FORA D10 STRIPS MO FORA D15C STRIPS MO FORA D15G STRIPS MO FORA D15Z STRIPS MO FORA D20 STRIPS MO FORA G20 STRIPS MO FORA G71A STRIPS MO FORA V10 STRIPS MO FORA V12 GLUCOSE STRIPS MO FORA V20 STRIPS MO FREESTYLE LITE STRIPS MO FREESTYLE TEST STRIPS MO G-4 TEST STRIPS MO GLUCOCARD 01 SENSOR STRIPS MO GLUCOCARD VITAL SENSOR STRIPS MO GLUCOCARD X-SENSOR STRIPS MO GLUCOCOM GLUCOSE STRIPS MO GLUCOLAB STRIPS MO GM100 STRIPS MO INFINITY TEST STRIPS MO KETO-DIASTIX STRIPS MO KEYNOTE STRIPS MO LIBERTY TEST STRIPS MO MAXIMA STRIPS MO MICRO BLOOD GLUCOSE STRIPS MO MICRODOT BLOOD GLUCOSE MONITORING SYSTEM STRIPS MO MYGLUCOHEALTH STRIPS MO NOVA MAX GLUCOSE TEST STRIPS MO ONE TOUCH TEST STRIPS MO ONE TOUCH ULTRA TEST STRIPS MO OPTIUM EZ STRIPS MO OPTIUM TEST STRIPS MO PHARMACIST CHOICE GLUCOSE TEST STRIPS MO POCKETCHEM EZ STRIPS MO

TIER
4 4 4 4 4 4 4 4 1 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 1 1 5 4 4 4

QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
PRECISION PCX PLUS TEST STRIPS MO PRECISION PCX TEST STRIPS MO PRECISION POINT OF CARE TEST STRIPS MO PRECISION Q-I-D TEST STRIPS MO PRECISION XTRA TEST STRIPS MO PRESTIGE SMART SYSTEM TEST STRIPS MO PRODIGY AUTOCODE TEST STRIPS MO PRODIGY EJECT TEST STRIPS MO PRODIGY GLUCOSE TEST STRIP MO PRODIGY NO CODING STRIPS MO PSS TEST STRIP MO QUICKTEK TEST STRIPS MO REFUAH PLUS STRIPS MO RELION ULTIMA STRIPS MO RIGHTEST GS550 TEST STRIPS MO SMART CARESENS N TEST STRIPS MO SMARTEST TEST STRIPS MO SOLO V2 TEST STRIPS MO SURE EDGE STRIPS MO SURE-TEST EASYPLUS MINI STRIPS MO SURECHEK TEST STRIPS MO SURESTEP PRO TEST STRIPS MO SURESTEP TEST STRIPS MO TRUETEST TEST STRIPS MO TRUETRACK SMART SYSTEM STRIPS MO TRUETRACK TEST STRIPS MO ULTIMA TEST STRIPS MO ULTRATRAK STRIPS MO VICTORY GLUCOSE TEST STRIPS MO WAVESENSE AMP STRIPS MO WAVESENSE JAZZ STRIPS MO WAVESENSE PRESTO STRIPS MO DISINFECTANTS (FOR NON-DERMATOLOGIC USE) glutaraldehyde 25% aq solution MO ELECTROLYTIC, CALORIC, AND WATER BALANCE acetic acid 0.25% irrig soln MO

TIER
4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 4 4 4 4 4 4 4 4 4 4 4 4 1 4 4 4 1 2

QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days) QL (150 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
amiloride hcl 5 mg tablet MO amiloride hcl-hctz 5-50 mg tab MO amino acids 15 % iv MO AMINOACETIC ACID 1.5 % IRRIGATION SOLN MO AMINOSYN 10 % IV MO AMINOSYN 3.5 % IV MO AMINOSYN 7 % IV MO AMINOSYN 7 % WITH ELECTROLYTES IV MO AMINOSYN 8.5 % IV MO AMINOSYN 8.5 % WITH ELECTROLYTES IV MO AMINOSYN II 10 % IV MO AMINOSYN II 15% IV MO AMINOSYN II 7 % IV MO AMINOSYN II 8.5 % IV MO AMINOSYN II 8.5 % WITH ELECTROLYTES IV MO AMINOSYN M 3.5 % IV MO AMINOSYN-HBC 7% IV MO AMINOSYN-PF 10 % IV MO AMINOSYN-PF 7 % (SULFITE-FREE) IV MO AMINOSYN-RF 5.2 % IV MO ammonium chloride 5 meq/ml MO AMMONUL 10 %-10 % IV MO AXONA 20 GRAM/40 GRAM ORAL POWDER PACKET MO bumetanide 0.25 mg/ml vial MO bumetanide 0.5 mg tablet MO bumetanide 1 mg tablet MO bumetanide 2 mg tablet MO BUPHENYL 500 MG TABLET MO BUPHENYL ORAL POWDER MO calcium acetate 667 mg capsule MO calcium acetate 667 mg tablet MO calcium chloride 10% abbjct MO calcium chloride 10% vial MO calcium gluconate 10% vial MO CARBAGLU 200 MG DISPERSIBLE TABLET SP chlorothiazide 250 mg tablet MO

TIER
4 2 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 1 5 4 2 2 2 2 5 5 4 2 1 1 1 5 2

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D

B vs D PA

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DRUG NAME
chlorothiazide 500 mg tablet MO chlorothiazide sod 500 mg vial MO chlorthalidone 25 mg tablet MO chlorthalidone 50 mg tablet MO CLINIMIX 2.75%/D5 SULFITE FREE IV MO CLINIMIX 4.25%/D10 SULFITE FREE IV MO CLINIMIX 4.25%/D20 SULFITE FREE IV MO CLINIMIX 4.25%/D25 SULFITE FREE IV MO CLINIMIX 4.25%/D5 SULFITE FREE IV MO CLINIMIX 5%/D15 SULFITE FREE IV MO CLINIMIX 5%/D20 SULFITE FREE IV MO CLINIMIX 5%/D25 SULFITE FREE IV MO CLINIMIX E 2.75%/D10 SULFITE FREE IV MO CLINIMIX E 2.75%/D5 SULFITE FREE IV MO CLINIMIX E 4.25%/D10 SULFITE FREE IV MO CLINIMIX E 4.25%/D25 SULFITE FREE IV MO CLINIMIX E 4.25%/D5 SULFITE FREE IV MO CLINIMIX E 5%/D15 SULFITE FREE IV MO CLINIMIX E 5%/D20 SULFITE FREE IV MO CLINIMIX E 5%/D25 SULFITE FREE IV MO clinisol sf 15 % iv MO constulose 10 gram/15 ml oral soln MO cytra k crystals 3,300 mg-1,002 mg oral packet MO cytra-3 550 mg-500 mg-334 mg/5 ml oral soln MO cytra-k 1,100 mg-334 mg/5 ml oral soln MO d10%-1/2ns soln/excel cont MO d5%-1/2ns-kcl 10 meq/l iv sol MO d5%-1/2ns-kcl 30 meq/l iv sol MO d5%-1/2ns-kcl 40 meq/l iv sol MO d5%-1/4ns-kcl 10 meq/l iv sol MO d5%-1/4ns-kcl 30 meq/l iv sol MO d5%-1/4ns-kcl 40 meq/l iv sol MO d5w-kcl 30 meq/l iv solution MO DEMADEX 10 MG TABLET MO DEMADEX 100 MG TABLET MO DEMADEX 20 MG TABLET MO

TIER
2 2 2 2 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 4 2 2 1 2 2 2 2 2 2 2 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D

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DRUG NAME
DEMADEX 5 MG TABLET MO dextrose 10% ampul MO dextrose 10%-1/4ns iv soln MO dextrose 10%-ns iv solution MO dextrose 10%-water iv solution MO dextrose 2.5%-1/2ns iv soln MO dextrose 2.5%-water iv soln MO dextrose 20%-water iv soln MO dextrose 25%-water syringe MO dextrose 30%-water iv soln MO dextrose 40%-water iv soln MO dextrose 5%-1/2ns iv solution MO dextrose 5%-1/3ns iv solution MO dextrose 5%-electrolyte 48 MO dextrose 5%-lr iv solution MO dextrose 5%-ns iv solution MO dextrose 5%-ringers iv soln MO dextrose 5%-sod chloride 0.2% MO dextrose 5%-water iv soln MO dextrose 5%-water vial MO dextrose 50%-water syringe MO dextrose 50%-water vial MO dextrose 70%-water iv soln MO DIURIL 250 MG/5 ML ORAL SUSP MO DIURIL IV 500 MG SOLUTION MO DYAZIDE 37.5 MG-25 MG CAPSULE MO DYRENIUM 100 MG CAPSULE MO DYRENIUM 50 MG CAPSULE MO effer-k 25 meq effervescent tablet MO eliphos 667 mg tablet MO enulose 10 gram/15 ml oral soln MO epiklor 20 meq packet MO epiklor 25 meq packet MO FREAMINE HBC 6.9 % IV MO FREAMINE III 10 % IV MO FREAMINE III 3 % WITH ELECTROLYTES IV MO

TIER
4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 4 4 2 4 2 2 2 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D

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DRUG NAME
FREAMINE III 8.5 % IV MO furosemide 10 mg/ml solution MO furosemide 10 mg/ml syringe MO furosemide 10 mg/ml vial MO furosemide 20 mg tablet MO furosemide 40 mg tablet MO furosemide 40 mg/5 ml soln MO furosemide 80 mg tablet MO generlac 10 gram/15 ml oral soln MO glycine 1.5% irrigation MO GLYCINE UROLOGIC 1.5 % IRRIGATION SOLN MO HEPATAMINE 8% IV MO HEPATASOL 8 % IV MO hydrochlorothiazide 12.5 mg cp MO hydrochlorothiazide 12.5 mg tb MO hydrochlorothiazide 25 mg tab MO hydrochlorothiazide 50 mg tab MO HYPERLYTE-CR 25 MEQ-20 MEQ-5 MEQ/20 ML IV MO indapamide 1.25 mg tablet MO indapamide 2.5 mg tablet MO INPERSOL WITH 1.5% DEXTROSE MO inpersol with 4.25% dextrose MO INTRALIPID 20 % IV MO INTRALIPID 30 % IV MO IONOSOL-B IN D5W IV MO IONOSOL-MB IN D5W IV MO ISOLYTE-H IN D5W IV MO ISOLYTE-M IN D5W IV MO ISOLYTE-P IN D5W IV MO ISOLYTE-S IN D5W IV MO ISOLYTE-S IV MO ISOLYTE-S PH 7.4 IV MO k-effervescent 25 meq tablet MO K-PHOS M.F. TABLET MO K-PHOS NO 2 305 MG-700 MG TABLET MO K-PHOS ORIGINAL 500 MG SOLUBLE TABLET MO

TIER
4 1 1 1 1 1 1 1 2 1 4 4 4 1 1 1 1 4 1 1 4 4 4 4 4 4 4 4 4 4 4 4 2 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D

B vs D B vs D

B vs D B vs D

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DRUG NAME
K-PHOS-NEUTRAL 250 MG TABLET MO K-TAB 10 MEQ TABLET,EXTENDED RELEASE MO kalexate oral powder MO KAON-CL ER 10 MEQ TABLET MO KAYEXALATE ORAL POWDER MO kcl 10 meq in d5w-1/3 ns MO kcl 20 meq in d5w solution MO kcl 20 meq in d5w-1/2 ns MO kcl 20 meq in d5w-1/4 ns MO kcl 20 meq in d5w-lact ringer MO kcl 20 meq in d5w-ns MO kcl 20 meq-ns 1,000 ml iv soln MO kcl 40 meq in d5w solution MO kcl 40 meq in d5w-lact ringer MO kcl 40 meq in d5w-nacl 0.9% MO kcl 40 meq-ns 1,000 ml iv soln MO kionex 15 gram/60 ml oral susp MO kionex oral powder MO KLOR-CON 10 10 MEQ TABLET,EXTENDED RELEASE MO klor-con 20 meq oral packet MO KLOR-CON 25 MEQ ORAL PACKET MO KLOR-CON 8 MEQ TABLET,EXTENDED RELEASE MO klor-con m10 10 meq tablet,extended release MO klor-con m15 15 meq tablet,extended release MO klor-con m20 20 meq tablet,extended release MO klor-con/ef 25 meq effervescent tablet MO KRISTALOSE 10 GRAM ORAL PACKET MO KRISTALOSE 20 GRAM ORAL PACKET MO l-cysteine 50 mg/ml vial MO lactated ringers injection MO lactated ringers irrigation MO lactulose 10 gm/15 ml solution MO lactulose 20 gm/30 ml solution MO LASIX 20 MG TABLET MO LASIX 40 MG TABLET MO LASIX 80 MG TABLET MO

TIER
4 4 4 1 4 2 2 2 2 2 2 2 2 2 2 2 3 3 2 3 2 2 2 2 2 2 4 4 1 2 2 2 2 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

PA

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DRUG NAME
LIPOSYN II 10 % IV MO LIPOSYN II 20 % IV MO LIPOSYN III 10 % IV MO LIPOSYN III 20 % IV MO LIPOSYN III 30 % IV MO MAGNEBIND 400 400 MG-200 MG-1 MG TABLET MO mannitol 10% iv solution MO mannitol 20% iv solution MO mannitol 25% vial MO mannitol 5% iv solution MO MAXZIDE 75 MG-50 MG TABLET MO MAXZIDE-25MG 37.5 MG-25 MG TABLET MO methyclothiazide 5 mg tablet MO metolazone 10 mg tablet MO metolazone 2.5 mg tablet MO metolazone 5 mg tablet MO MICRO-K 10 MEQ EXTENCAPS MO MICRO-K 8 MEQ EXTENCAPS MO MICROZIDE 12.5 MG CAPSULE MO MIDAMOR 5 MG TABLET MO NEPHRAMINE 5.4 % IV MO NEUT 4 % IV MO NORMOSOL-M IN D5W IV MO NORMOSOL-R IN D5W IV MO NORMOSOL-R IV MO NORMOSOL-R PH 7.4 IV MO NUTRILYTE 25 MEQ-40.6 MEQ-5 MEQ/20 ML IV MO nutrilyte ii 35 meq-20 meq-5 meq/20 ml iv MO ORACIT 490 MG-640 MG/5 ML ORAL SOLN MO OSMITROL 10 % IV MO OSMITROL 15 % IV MO OSMITROL 20 % IV MO OSMITROL 5 % IV MO PHOSLO 667 MG CAPSULE MO PHOSLYRA 667 MG (169 MG CALCIUM)/5 ML ORAL SOLN MO phospha 250 neutral 250 mg tablet MO

TIER
4 4 4 4 4 4 2 2 2 2 4 4 2 2 2 2 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 2

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D B vs D B vs D B vs D B vs D

PA PA

B vs D

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DRUG NAME
PHYSIOLYTE 140 MEQ-5 MEQ-3 MEQ-98 MEQ/L IRRIGATION SOLN MO PHYSIOSOL IRRIGATION 140 MEQ-5 MEQ-3 MEQ-98 MEQ/L SOLN MO PLASMA-LYTE 148 IV MO PLASMA-LYTE A IV MO PLASMA-LYTE-56 IN D5W IV MO potassium 25 meq tablet eff MO potassium acet 2 meq/ml vial MO potassium acet 4 meq/ml vial MO potassium cit-citric acid sln MO potassium citrate er 10 meq tb MO potassium citrate er 5 meq tab MO potassium cl 10 meq/100 ml sol MO potassium cl 10 meq/50 ml sol MO potassium cl 10% (20 meq/15 ml MO potassium cl 2 meq/ml syrng MO potassium cl 2 meq/ml vial MO potassium cl 20 meq-0.45% nacl MO potassium cl 20 meq/100 ml sol MO potassium cl 20 meq/50 ml sol MO potassium cl 20% (40 meq/15 ml MO potassium cl 25 meq tab eff MO potassium cl 30 meq/100 ml sol MO potassium cl 40 meq/100 ml sol MO potassium cl er 10 meq capsule MO potassium cl er 10 meq tablet MO potassium cl er 20 meq tablet MO potassium cl er 8 meq capsule MO potassium cl er 8 meq tablet MO potassium ph 3mm/ml vial MO PREMASOL 10 % IV MO PREMASOL 6 % IV MO probenecid 500 mg tablet MO probenecid-colchicine tabs MO PROCALAMINE 3% IV MO PROSOL 20% IV MO RENACIDIN 6.602 G-0.198 G/100 ML IRRIGATION SOLN MO

TIER
1 1 4 4 4 2 1 1 2 3 3 1 1 1 1 1 2 1 1 1 2 1 1 2 2 2 2 2 1 1 1 2 3 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D

B vs D B vs D

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DRUG NAME
RENVELA 0.8 GRAM ORAL POWDER PACKET MO RENVELA 2.4 GRAM ORAL POWDER PACKET MO RENVELA 800 MG TABLET MO RESECTISOL 5 % URETHRAL MO ringer's iv solution MO ringers irrigation solution MO saline 0.45% soln-excel con MO SAMSCA 15 MG TABLET SP SAMSCA 30 MG TABLET SP sodium acetate 2 meq/ml vial MO sodium acetate 4 meq/ml vial MO sodium bicarb 4.2% abbjct MO sodium bicarb 4.2% vial MO sodium bicarb 7.5% abboject MO sodium bicarb 7.5% vial MO sodium bicarb 8.4% abboject MO sodium bicarb 8.4% abboject MO sodium bicarb 8.4% vial MO sodium chloride 0.45% soln MO sodium chloride 0.9% irrig. MO sodium chloride 0.9% soln. MO sodium chloride 0.9% solution MO sodium chloride 10% vial MO sodium chloride 3% iv soln MO sodium chloride 3% vial MO sodium chloride 4 meq/ml vl MO sodium chloride 5% iv soln MO sodium cl 2.5 meq/ml vial MO SODIUM EDECRIN 50 MG IV SOLUTION MO sodium lactate 1/6molar inj MO sodium lactate 5 meq/ml vial MO sodium phosphate 3mm/ml vial MO sodium polystyrene sulf pwd MO sodium polystyrene sulfonate (sorbitol free) 15 gram/60 ml oral susp MO sorbitol-mannitol irrig MO

TIER
3 3 3 4 1 1 2 5 5 1 1 2 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 1 1 1 3 3 1

QL (540 per 30 days) QL (180 per 30 days) QL (540 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (60 per 30 days)

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DRUG NAME
SPS 15 GRAM/60 ML ORAL SUSP MO SPS 30 GRAM/120 ML ENEMA MO sterile water for irrigation MO taron-crystals 3,300 mg-1,002 mg oral packet MO THALITONE 15 MG TABLET MO THAM 36 MG/ML (0.3 M) IV SOLUTION MO torsemide 10 mg tablet MO torsemide 100 mg tablet MO torsemide 20 mg tablet MO torsemide 20 mg/2 ml vial MO torsemide 5 mg tablet MO torsemide 50 mg/5 ml vial MO TPN ELECTROLYTES 35 MEQ-20 MEQ-5 MEQ/20 ML IV MO TPN ELECTROLYTES II 18 MEQ-18 MEQ-5 MEQ/20 ML IV MO TRAVASOL 10 % IV MO triamterene-hctz 37.5-25 mg cp MO triamterene-hctz 37.5-25 mg tb MO triamterene-hctz 50-25 mg cap MO triamterene-hctz 75-50 mg tab MO tricitrates 550 mg-500 mg-334 mg/5 ml oral soln MO tricitrates oral solution MO TROPHAMINE 10 % IV MO TROPHAMINE 6% IV MO vis-phos n 250 mg tablet MO VOLUVEN 6 % IV MO ZAROXOLYN 2.5 MG TABLET MO ZAROXOLYN 5 MG TABLET MO ENZYMES ADAGEN 250 UNIT/ML IM MO ALDURAZYME 2.9 MG/5 ML IV MO CEREDASE 80 UNITS/ML VIAL MO CEREZYME 200 UNIT IV SOLUTION MO CEREZYME 400 UNIT IV SOLUTION MO ELAPRASE 6 MG/3 ML IV MO ELELYSO 200 UNIT IV SOLUTION MO ELITEK 1.5 MG IV SOLUTION MO

TIER
4 4 2 4 4 4 2 2 2 2 2 2 4 4 4 2 2 1 2 2 2 4 4 1 4 4 4 5 5 5 5 5 5 5 5

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D

B vs D B vs D

PA,QL (480 per 28 days) PA PA PA PA PA,QL (60 per 30 days) PA

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DRUG NAME
ELITEK 7.5 MG IV SOLUTION MO FABRAZYME 35 MG IV SOLUTION MO FABRAZYME 5 MG IV SOLUTION MO HYLENEX 150 UNIT/ML INJECTION MO LUMIZYME 50 MG IV SOLUTION MO MYOZYME 50 MG IV SOLUTION MO NAGLAZYME 5 MG/5 ML IV MO PULMOZYME 1 MG/ML SOLN FOR INHALATION SP VITRASE 200 UNIT/ML INJECTION MO VPRIV 400 UNIT SOLUTION MO EYE, EAR, NOSE AND THROAT (EENT) PREPS. acetasol hc 1 %-2 % ear drops MO acetazolamide 125 mg tablet MO acetazolamide 250 mg tablet MO acetazolamide er 500 mg cap MO acetazolamide sod 500 mg vial MO acetic acid 2% ear solution MO acetic acid-aluminum drops MO ACULAR 0.5 % EYE DROPS MO ACULAR LS 0.4 % EYE DROPS MO ACUVAIL (PF) 0.45 % EYE DROPPERETTE MO ak-con 0.1 % eye drops MO AK-PENTOLATE 1 % EYE DROPS MO ak-poly-bac 500 unit-10,000 unit/g eye ointment MO akorn balanced salt intraocular MO AKTEN (PF) 3.5 % EYE GEL MO ALCAINE 0.5 % EYE DROPS MO allersol 0.1% eye drops MO ALOMIDE 0.1 % EYE DROPS MO ALPHAGAN P 0.1 % EYE DROPS MO ALPHAGAN P 0.15 % EYE DROPS MO ALREX 0.2 % EYE DROPS MO altafrin 10 % eye drops MO altafrin 2.5 % eye drops MO antipyrine-benzocaine ear drop MO APHTHASOL 5% PASTE MO

TIER
5 5 5 4 5 5 5 5 4 5 4 2 2 4 2 2 2 4 4 4 1 4 2 1 4 2 1 4 3 3 4 1 1 2 4

UTILIZATION MANAGEMENT REQUIREMENTS


PA PA PA

PA PA PA,QL (480 per 28 days) B vs D,QL (150 per 30 days) PA

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DRUG NAME
apraclonidine hcl 0.5% drops MO ASTELIN 137 MCG NASAL SPRAY AEROSOL MO ASTEPRO 0.15 % (205.5 MCG) NASAL SPRAY MO atropine 1% eye drops MO atropine 1% eye ointment MO ATROPINE-CARE 1 % EYE DROPS MO ATROVENT 0.03 % NASAL SPRAY MO ATROVENT 0.06 % NASAL SPRAY MO aurodex 5.4 %-1.4 % ear drops MO auroguard 5.4 %-1.4 % ear drops MO AZASITE 1 % EYE DROPS MO azelastine 137 mcg nasal spray MO azelastine hcl 0.05% drops MO AZOPT 1 % EYE DROPS MO bacitracin 500 unit/gm ointmnt MO bacitracin-polymyxin eye oint MO BACTROBAN NASAL 2 % OINTMENT MO balanced salt intraocular MO BESIVANCE 0.6 % EYE DROPS MO BETADINE OPHTHALMIC PREP 5 % SOLN MO BETAGAN 0.5 % EYE DROPS MO betaxolol hcl 0.5% eye drop MO BETIMOL 0.25 % EYE DROPS MO BETIMOL 0.5 % EYE DROPS MO BLEPH-10 10 % EYE DROPS MO BLEPHAMIDE 10 %-0.2 % EYE DROPS MO BLEPHAMIDE S.O.P. 10 %-0.2 % EYE OINTMENT MO brimonidine 0.2% eye drop MO brimonidine tartrate 0.15% drp MO BSS INTRAOCULAR MO BSS PLUS INTRAOCULAR MO carteolol hcl 1% eye drops MO chlorhexidine 0.12% rinse MO chloroxylenol-pramoxine hcl MO CILOXAN 0.3 % EYE DROPS MO CILOXAN 0.3 % EYE OINTMENT MO

TIER
4 4 3 2 2 2 4 4 2 2 3 4 3 3 3 2 4 1 3 4 4 4 4 4 4 4 2 3 3 4 4 2 1 2 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


PA,QL (30 per 25 days) QL (30 per 25 days)

QL (30 per 30 days) QL (45 per 30 days)

QL (30 per 25 days)

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DRUG NAME
CIPRODEX 0.3 %-0.1 % EAR DROPS, SUSP MO ciprofloxacin 0.3% eye drop MO cocaine 10% solution MO cocaine 4% solution MO COLY-MYCIN S 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS, SUSP MO COMBIGAN 0.2 %-0.5 % EYE DROPS MO CORTISPORIN 3.5 MG-10,000 UNIT/ML-1 % EAR SOLN MO CORTISPORIN-TC 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS, SUSP MO cortomycin ear solution MO cortomycin ear suspension MO cortomycin eye ointment MO CRESYLATE 25 % EAR DROPS MO CYCLOGYL 0.5 % EYE DROPS MO CYCLOGYL 1 % EYE DROPS MO CYCLOGYL 2 % EYE DROPS MO cyclopentolate 1% eye drops MO cyclopentolate hcl 2% drops MO cylate 1% eye drops MO dexamethasone 0.1% eye drop MO dexasol 0.1 % eye drops MO diclofenac 0.1% eye drops MO dorzolamide hcl 2% eye drops MO dorzolamide-timolol eye drops MO doxycycline hyclate 20 mg tab MO DUREZOL 0.05 % EYE DROPS MO ELESTAT 0.05 % EYE DROPS MO EMADINE 0.05 % EYE DROPS MO epinastine hcl 0.05% eye drops MO erythromycin eye ointment MO FLAREX 0.1 % EYE DROPS MO FLONASE 50 MCG/ACTUATION NASAL SPRAY MO FLUCAINE 0.25 %-0.5 % EYE DROPS MO flunisolide 0.025% spray MO flunisolide 29 mcg-0.025% spr MO fluorometholone 0.1% drops MO flurbiprofen 0.03% eye drop MO

TIER
4 1 1 1 4 3 4 4 2 2 2 4 4 4 4 2 4 2 2 3 2 3 3 2 3 4 4 3 2 4 4 1 4 4 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (10 per 30 days) QL (10 per 30 days)

PA,QL (16 per 30 days) QL (50 per 30 days) QL (50 per 30 days)

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DRUG NAME
fluticasone prop 50 mcg spray MO FML FORTE 0.25 % EYE DROPS MO FML LIQUIFILM 0.1 % EYE DROPS MO FML S.O.P. 0.1 % EYE OINTMENT MO GARAMYCIN 0.3 % (3 MG/G) EYE OINTMENT MO GARAMYCIN 0.3 % EYE DROPS MO gentak 0.3 % (3 mg/g) eye ointment MO gentak 0.3 % eye drops MO gentamicin 3 mg/gm eye oint MO gentamicin 3 mg/ml eye drops MO gentasol 3 mg/ml eye drops MO homatropaire 5 % eye drops MO hydrocortison-acetic acid soln MO ILOTYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT MO INTROL 75% SOLUTION MO IOPIDINE 0.5 % EYE DROPS MO IOPIDINE 1 % EYE DROPPERETTE MO ipratropium 0.03% spray MO ipratropium 0.06% spray MO IQUIX 1.5% EYE DROPS MO ISOPTO ATROPINE 1 % EYE DROPS MO isopto carpine 1 % eye drops MO ISOPTO CARPINE 2 % EYE DROPS MO ISOPTO CARPINE 4 % EYE DROPS MO ISOPTO HOMATROPINE 2 % EYE DROPS MO ISOPTO HOMATROPINE 5 % EYE DROPS MO ISOPTO HYOSCINE 0.25 % EYE DROPS MO ketorolac 0.4% ophth solution MO ketorolac 0.5% ophth solution MO LACRISERT 5 MG EYE INSERTS MO latanoprost 0.005% eye drops MO levobunolol 0.25% eye drops MO levobunolol 0.5% eye drops MO levofloxacin 0.5% eye drops MO lidocaine 2% viscous soln MO lidocaine hcl 2% jelly MO

TIER
2 4 4 4 3 3 4 4 2 2 4 2 4 3 4 4 4 2 2 4 4 4 4 4 4 4 4 2 2 4 2 2 2 2 2 2

QL (16 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

PA QL (30 per 30 days) QL (45 per 30 days)

QL (3 per 25 days)

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DRUG NAME
lidocaine hcl 4% solution MO lidocaine viscous 2 % mucosal soln MO LOTEMAX 0.5 % EYE DROPS MO LOTEMAX 0.5 % EYE OINTMENT MO LUMIGAN 0.01 % EYE DROPS MO LUMIGAN 0.03 % EYE DROPS MO MAXIDEX 0.1 % EYE DROPS MO MAXITROL 3.5 MG-10,000 UNIT/G-0.1 % EYE OINTMENT MO MAXITROL 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS MO methazolamide 25 mg tablet MO methazolamide 50 mg tablet MO metipranolol 0.3% eye drops MO MIOCHOL-E 1:100 (20 MG/2 ML) INTRAOCULAR KIT MO MIOSTAT 0.01 % INTRAOCULAR MO MOXEZA 0.5 % EYE DROPS MO MYDFRIN 2.5 % EYE DROPS MO mydral 0.5% eye drops MO mydral 1% eye drops MO MYDRIACYL 1 % EYE DROPS MO NASONEX 50 MCG/ACTUATION SPRAY MO NATACYN 5 % EYE DROPS MO neo-bacit-poly-hc eye ointment MO neo-polycin 3.5 mg-400 unit-10,000 unit/g eye ointment MO neofrin 10 % eye drops MO neofrin 2.5 % eye drops MO neomyc-bacit-polymix eye oint MO neomyc-polym-dexamet eye ointm MO neomyc-polym-dexameth eye drop MO neomyc-polym-gramicid eye drop MO neomycin-poly-hc eye drops MO neomycin-polymyxin-hc ear soln MO neomycin-polymyxin-hc ear susp MO neosporin (neo-polym-gramicid) 1.75 mg-10k unit-0.025 mg/ml eye drops MO NEVANAC 0.1 % EYE DROPS MO OCUFEN 0.03 % EYE DROPS MO

TIER
2 2 4 4 3 3 4 4 4 4 4 4 4 4 4 4 1 1 2 3 4 3 2 1 1 2 2 2 2 2 2 2 2 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (3 per 25 days) QL (3 per 25 days)

QL (34 per 30 days)

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DRUG NAME
OCUFLOX 0.3 % EYE DROPS MO ofloxacin 0.3% ear drops MO ofloxacin 0.3% eye drops MO OMNARIS 50 MCG NASAL SPRAY MO OPTIPRANOLOL 0.3 % EYE DROPS MO otic edge otic solution MO oticin 0.1 %-1 % ear drops MO otogesic ear drops MO parcaine 0.5 % eye drops MO PAREMYD 1 %-0.25 % EYE DROPS MO PATADAY 0.2 % EYE DROPS MO PATANASE 0.6 % NASAL SPRAY MO periogard 0.12 % mouthwash MO PERIOSTAT 20 MG TABLET MO phenylephrine 2.5% eye drop MO phenylephrine hcl 10% drops MO PHOSPHOLINE IODIDE 0.125 % EYE DROPS MO pilocarpine 1% eye drops MO pilocarpine 2% eye drops MO pilocarpine 4% eye drops MO PILOPINE HS 4 % EYE GEL MO poly-dex eye drops MO poly-dex eye ointment MO POLY-PRED EYE DROPS MO polymyxin b-tmp eye drops MO POLYTRIM 0.1 %-10,000 UNIT/ML EYE DROPS MO PR OTIC SOLUTION 5.4 %-1.4 % EAR DROPS MO PRAMOTIC EAR DROPS MO PRED FORTE 1 % EYE DROPS MO PRED MILD 0.12 % EYE DROPS MO PRED-G 0.3 %-1 % EYE DROPS MO PRED-G S.O.P. 0.3 %-0.6 % EYE OINTMENT MO prednisol 1% eye drops MO prednisolone ac 1% eye drop MO prednisolone sod 1% eye drop MO proparacaine 0.5% eye drops MO

TIER
4 2 2 3 4 2 1 1 1 4 3 4 1 4 1 1 4 4 4 4 4 1 1 4 2 2 4 4 4 4 4 4 1 2 2 1

UTILIZATION MANAGEMENT REQUIREMENTS

QL (13 per 30 days)

QL (31 per 30 days)

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DRUG NAME
QUIXIN 0.5% EYE DROPS MO RESTASIS 0.05 % EYE DROPPERETTE MO romycin eye ointment MO sulf-pred 10-0.23% eye drops MO sulfac 10% eye drops MO sulfacetamide 10% eye drops MO sulfacetamide 10% eye ointment MO sulfamide 10 % eye drops MO TERRAMYCIN WITH POLYMYXIN B 5 MG-10,000 UNIT/GRAM EYE OINTMENT MO tetcaine 0.5 % eye drops MO tetracaine 0.5% eye drops MO TETRAVISC 0.5 % VISCOUS EYE DROPPERETTE MO TETRAVISC 0.5 % VISCOUS EYE DROPS MO TETRAVISC FORTE 0.5 % DROPPERETTE, HYPERVISCOUS MO TETRAVISC FORTE 0.5 % DROPS, HYPERVISCOUS MO timolol 0.25% eye drops MO timolol 0.25% gfs gel-solution MO timolol 0.5% eye drops MO timolol 0.5% gfs gel-solution MO TIMOPTIC 0.25 % EYE DROPS MO TIMOPTIC 0.5 % EYE DROPS MO TIMOPTIC OCUDOSE (PF) 0.25 % EYE DROPPERETTE MO TIMOPTIC OCUDOSE (PF) 0.5 % EYE DROPPERETTE MO TIMOPTIC-XE 0.25 % EYE GEL MO TIMOPTIC-XE 0.5 % EYE GEL MO TOBRADEX 0.3 %-0.1 % EYE DROPS MO TOBRADEX 0.3 %-0.1 % EYE OINTMENT MO TOBRADEX ST 0.3 %-0.05 % EYE DROPS MO tobramycin 0.3% eye drops MO tobramycin-dexameth ophth susp MO tobrasol 0.3% eye drops MO TOBREX 0.3 % EYE DROPS MO TOBREX 0.3 % EYE OINTMENT MO TRAVATAN Z 0.004 % EYE DROPS MO treagan otic 5.4 %-1.4 % ear drops MO

TIER
4 3 1 2 2 2 2 2 4 1 4 4 4 4 4 2 3 2 3 4 4 4 4 4 4 4 4 4 2 3 2 4 4 3 4

UTILIZATION MANAGEMENT REQUIREMENTS


QL (60 per 30 days)

PA

PA

QL (3 per 25 days)

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DRUG NAME
trifluridine 1% eye drops MO tropicamide 0.5% eye drops MO tropicamide 1% eye drops MO TYZINE 0.05 % NASAL DROPS MO TYZINE 0.1 % NASAL DROPS MO TYZINE 0.1 % NASAL SPRAY MO VERAMYST 27.5 MCG/ACTUATION NASAL SPRAY MO VEXOL 1 % EYE DROPS MO VIGAMOX 0.5 % EYE DROPS MO VIROPTIC 1 % EYE DROPS MO XYLOCAINE 2% JELLY MO XYLOCAINE 4 % MUCOSAL SOLN MO ZINOTIC ES EAR DROPS MO ZIRGAN 0.15 % EYE GEL MO ZYLET 0.3 %-0.5 % EYE DROPS MO ZYMAR 0.3% EYE DROPS MO ZYMAXID 0.5 % EYE DROPS MO GASTROINTESTINAL DRUGS AMITIZA 24 MCG CAPSULE MO AMITIZA 8 MCG CAPSULE MO ANTIVERT 12.5 MG TABLET MO ANTIVERT 25 MG TABLET MO ANTIVERT 50 MG TABLET MO APRISO 0.375 GRAM CAPSULE,EXTENDED RELEASE MO ASACOL 400 MG TABLET,DELAYED RELEASE MO ASACOL HD 800 MG TABLET,DELAYED RELEASE MO balsalazide disodium 750 mg cp MO CANASA 1,000 MG RECTAL SUPPOSITORY MO CARAFATE 1 GRAM TABLET MO CARAFATE 100 MG/ML ORAL SUSP MO CHENODAL 250 MG TABLET SP cimetidine 150 mg/ml vial MO cimetidine 200 mg tablet MO cimetidine 300 mg tablet MO cimetidine 300 mg/5 ml soln MO cimetidine 400 mg tablet MO

TIER
4 1 1 4 3 3 4 4 4 4 4 4 4 4 4 4 4 3 3 4 4 4 3 4 4 4 3 4 4 4 2 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (10 per 30 days)

QL (5 per 30 days)

QL (3 per 25 days)

QL (120 per 30 days) QL (360 per 30 days) QL (180 per 30 days) QL (30 per 30 days)

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DRUG NAME
cimetidine 800 mg tablet MO CIMZIA 400 MG/2 ML (200 MG/ML X 2) SUBQ SYRINGE KIT SP CIMZIA POWDER FOR RECONSTITUTION 400 MG (200 MG X 2) SUB-Q KIT MO CIMZIA STARTER KIT 400 MG/2 ML (200 MG/ML X 2) SUBQ SYRINGE KIT SP COLYTE WITH FLAVOR PACKS 227.1 GRAM-21.5 GRAM-6.36GRAM ORAL SOLUTION MO COLYTE WITH FLAVOR PACKS 240 G-22.72 G-6.72 G-5.84 G ORAL SOLUTION MO compro 25 mg rectal suppository MO CREON 12,000-38,000-60,000 UNIT CAPSULE,DELAYED RELEASE MO CREON 24,000-76,000-120,000 UNIT CAPSULE,DELAYED RELEASE MO CREON 3,000-9,500-15,000 UNIT CAPSULE,DELAYED RELEASE MO CREON 6,000-19,000-30,000 UNIT CAPSULE,DELAYED RELEASE MO CYTOTEC 100 MCG TABLET MO CYTOTEC 200 MCG TABLET MO DEXILANT 30 MG CAPSULE, DELAYED RELEASE MO DEXILANT 60 MG CAPSULE, DELAYED RELEASE MO dimenhydrinate 50 mg/ml vial MO diphenoxylate-atropine liq MO diphenoxylate-atropine tablet MO dronabinol 10 mg capsule MO dronabinol 2.5 mg capsule MO dronabinol 5 mg capsule MO EMEND 115 MG IV SOLUTION MO EMEND 125 MG (1)-80 MG (1)-80 MG(1) CAPSULES IN A DOSE PACK MO EMEND 125 MG CAPSULE MO EMEND 150 MG IV SOLUTION MO EMEND 40 MG CAPSULE MO EMEND 80 MG CAPSULE MO famotidine 10 mg/ml vial MO famotidine 20 mg piggyback MO famotidine 20 mg tablet MO famotidine 20 mg/2 ml vial MO famotidine 40 mg tablet MO famotidine 40 mg/5 ml susp MO

TIER
2 5 5 5 4 4 2 3 3 3 3 4 4 4 4 1 2 2 5 4 4 4 4 4 4 4 4 2 2 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS


PA,QL (6 per 30 days) PA,QL (6 per 30 days) PA,QL (6 per 30 days)

PA QL (30 per 30 days) QL (30 per 30 days) PA PA B vs D,QL (120 per 30 days) B vs D,QL (120 per 30 days) B vs D,QL (120 per 30 days) PA,QL (2 per 28 days) B vs D,QL (6 per 28 days) B vs D,QL (2 per 28 days) PA,QL (2 per 28 days) B vs D,QL (2 per 28 days) B vs D,QL (4 per 28 days)

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DRUG NAME
gavilyte-c 240 g-22.72 g-6.72 g-5.84 g oral solution MO gavilyte-g 236 g-22.74 g-6.74 g-5.86 g oral solution MO gavilyte-n 420 g oral solution MO GOLYTELY 227.1 G-21.5 G-6.36 G-5.53 G PACKET MO GOLYTELY 236 G-22.74 G-6.74 G-5.86 G ORAL SOLUTION MO granisetron hcl 0.1 mg/ml vial MO granisetron hcl 1 mg tablet MO granisetron hcl 1 mg/ml vial MO granisetron hcl 4 mg/4 ml vial MO granisol 1 mg/5 ml oral soln MO HALFLYTELY-BISACODYL W-FLAVOR PACK 5 MG-210 GRAM ORAL KIT MO lansoprazole dr 15 mg capsule MO lansoprazole dr 30 mg capsule MO LIALDA 1.2 G TABLET,DELAYED RELEASE MO loperamide 2 mg capsule MO LOTRONEX 0.5 MG TABLET MO LOTRONEX 1 MG TABLET MO meclizine 12.5 mg tablet MO meclizine 25 mg tablet MO mesalamine 4 gm/60 ml enema MO mesalamine 4 gm/60 ml kit MO metoclopramide 10 mg tablet MO metoclopramide 5 mg tablet MO metoclopramide 5 mg/5 ml soln MO metoclopramide 5 mg/ml syr MO metoclopramide 5 mg/ml vial MO misoprostol 100 mcg tablet MO misoprostol 200 mcg tablet MO MOVIPREP 100 G-7.5 G-2.691 G-4.7 G ORAL POWDER PACKET MO NEXIUM 20 MG CAPSULE,DELAYED RELEASE MO NEXIUM 40 MG CAPSULE,DELAYED RELEASE MO NEXIUM PACKET 10 MG ORAL SUSPENSION,DELA YED RELEASE MO NEXIUM PACKET 20 MG ORAL SUSPENSION,DELA YED RELEASE MO NEXIUM PACKET 40 MG ORAL SUSPENSION,DELA YED RELEASE MO nizatidine 15 mg/ml solution MO nizatidine 150 mg capsule MO

TIER
2 2 2 3 3 4 4 4 4 2 3 3 3 3 2 5 5 2 2 4 4 2 2 2 2 2 3 3 4 3 3 3 3 3 2 3

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D,QL (28 per 28 days) QL (4 per 28 days) B vs D,QL (150 per 28 days) QL (30 per 30 days) QL (30 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

QL (1800 per 30 days) QL (1800 per 30 days)

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
nizatidine 300 mg capsule MO NULYTELY WITH FLAVOR PACKS 420 G ORAL SOLUTION MO NUTRESTORE 5 GRAM ORAL POWDER PACKET MO omeprazole dr 10 mg capsule MO omeprazole dr 20 mg capsule MO omeprazole dr 40 mg capsule MO ondansetron 32 mg/50 ml bag MO ondansetron 4 mg/5 ml solution MO ondansetron 40 mg/20 ml vial MO ondansetron hcl 24 mg tablet MO ondansetron hcl 32 mg/50 ml bg MO ondansetron hcl 4 mg tablet MO ondansetron hcl 4 mg/2 ml syr MO ondansetron hcl 4 mg/2 ml vial MO ondansetron hcl 8 mg tablet MO ondansetron odt 4 mg tablet MO ondansetron odt 8 mg tablet MO OSMOPREP 1.5 GRAM (1.102-0.398) TABLET MO PANCREAZE 10,500-25,000-43,750 UNIT CAPSULE,DELAYED RELEASE MO PANCREAZE 16,800-40,000-70,000 UNIT CAPSULE,DELAYED RELEASE MO PANCREAZE 21,000-37,000-61,000 UNIT CAPSULE,DELAYED RELEASE MO PANCREAZE 4,200-10,000-17,500 UNIT CAPSULE,DELAYED RELEASE MO pancrelipase 5000 5,000-17,000-27,000 unit capsule,delayed release
MO

TIER
3 3 4 2 2 2 2 4 2 2 2 2 2 2 2 2 2 4 4 4 4 4 4 1 1 2 2 2 2 2 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) B vs D,QL (450 per 30 days) B vs D,QL (30 per 30 days) B vs D,QL (90 per 30 days)

B vs D,QL (90 per 30 days) B vs D,QL (90 per 30 days) B vs D,QL (90 per 30 days)

pantoprazole sod dr 20 mg tab MO pantoprazole sod dr 40 mg tab MO paregoric liquid MO peg 3350 electrolyte soln MO peg-3350 and electrolytes soln MO peg-3350 with flavor packs 420 g oral solution MO peg-3350 with flavor packs sol MO PENTASA 250 MG CAPSULE,EXTENDED RELEASE MO PENTASA 500 MG CAPSULE,EXTENDED RELEASE MO

QL (30 per 30 days) QL (30 per 30 days)

QL (150 per 30 days) QL (300 per 30 days)

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DRUG NAME
polyethylene glycol 3350 powd MO prochlorperazine 10 mg tab MO prochlorperazine 25 mg supp MO prochlorperazine 5 mg tablet MO prochlorperazine 5 mg/ml vial MO PROTONIX 20 MG TABLET,DELAYED RELEASE MO PROTONIX 40 MG IV SOLUTION MO PROTONIX 40 MG TABLET,DELAYED RELEASE MO ranitidine 1,000 mg/40 ml vial MO ranitidine 15 mg/ml syrup MO ranitidine 150 mg capsule MO ranitidine 150 mg tablet MO ranitidine 300 mg capsule MO ranitidine 300 mg tablet MO ranitidine hcl 25 mg/ml vial MO RELISTOR 12 MG/0.6 ML SUB-Q MO RELISTOR 12 MG/0.6 ML SUB-Q KIT MO RELISTOR 12 MG/0.6 ML SUB-Q SYRINGE MO RELISTOR 8 MG/0.4 ML SUB-Q SYRINGE MO SANCUSO 3.1 MG/24 HOUR TRANSDERM PATCH MO sucralfate 1 gm tablet MO sucralfate 1 gm/10 ml susp MO SUPREP 17.5 GRAM-3.13 GRAM-1.6 GRAM ORAL SOLUTION MO TIGAN 300 MG CAPSULE MO trilyte with flavor packets 420 g oral solution MO trimethobenzamide 300 mg cap MO ULTRASE EC 250 MG (4,500-25K-20K UNIT) CAPSULE,DELAYED RELEASE MO ULTRASE MT 12 223 MG (12,000-39K-39K UNIT) CAPSULE,DELAYED RELEASE MO ULTRASE MT 18 333 MG(18K-58.5K-58.5K UNIT) CAPSULE,DELAYED RELEASE MO ULTRASE MT 20 371 MG (20,000-65K-65K UNIT) CAPSULE,DELAYED RELEASE MO ursodiol 250 mg tablet MO ursodiol 300 mg capsule MO ursodiol 500 mg tablet MO

TIER
2 1 2 1 2 4 4 4 1 2 2 2 2 2 1 4 5 4 4 4 2 2 3 4 2 3 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D B vs D PA,QL (30 per 30 days) PA,QL (30 per 30 days)

PA,QL (18 per 30 days) PA,QL (28 per 28 days) PA,QL (18 per 30 days) PA,QL (12 per 30 days) QL (4 per 30 days)

PA PA

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DRUG NAME
VIOKASE 16 TABLET MO VIOKASE 8 TABLET MO ZENPEP 10,000-34,000-55,000 UNIT CAPSULE,DELAYED RELEASE MO ZENPEP 15,000-51,000-82,000 UNIT CAPSULE,DELAYED RELEASE MO ZENPEP 20,000-68,000-109,000 UNIT CAPSULE,DELAYED RELEASE MO ZENPEP 25,000-85,000-136,000 UNIT CAPSULE,DELAYED RELEASE MO ZENPEP 3,000-10,000-16,000 UNIT CAPSULE,DELAYED RELEASE MO ZENPEP 5,000-17,000-27,000 UNIT CAPSULE,DELAYED RELEASE MO GOLD COMPOUNDS MYOCHRYSINE 50 MG/ML VIAL MO RIDAURA 3 MG CAPSULE MO HEAVY METAL ANTAGONISTS BAL IN OIL 100 MG/ML IM MO CAL DISOD VERSENAT 200 MG/ML MO CHEMET 100 MG CAPSULE MO CUPRIMINE 250 MG CAPSULE MO deferoxamine 2 gram vial MO deferoxamine 500 mg vial MO DEPEN TITRATABS 250 MG TABLET MO EXJADE 125 MG DISPERSIBLE TABLET SP EXJADE 250 MG DISPERSIBLE TABLET SP EXJADE 500 MG DISPERSIBLE TABLET SP SYPRINE 250 MG CAPSULE MO HORMONES AND SYNTHETIC SUBSTITUTES a-hydrocort 100 mg solution for injection HI,MO a-methapred 125 mg/2 ml solution for injection MO a-methapred 40 mg solution for injection MO a-methapred 40 mg/ml solution for injection MO acarbose 100 mg tablet MO acarbose 25 mg tablet MO acarbose 50 mg tablet MO ACTOPLUS MET 15 MG-500 MG TABLET MO ACTOPLUS MET 15 MG-850 MG TABLET MO ACTOS 15 MG TABLET MO ACTOS 30 MG TABLET MO ACTOS 45 MG TABLET MO

TIER
4 4 3 3 3 3 3 3 4 4 4 1 4 4 3 3 4 4 5 5 4 1 2 2 2 3 3 3 3 3 3 3 3

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D PA PA PA

ST,QL (90 per 30 days) ST,QL (90 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days)

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DRUG NAME
ALORA 0.025 MG/24 HR TRANSDERM PATCH MO ALORA 0.05 MG/24 HR TRANSDERM PATCH MO ALORA 0.075 MG/24 HR TRANSDERM PATCH MO ALORA 0.1 MG/24 HR TRANSDERM PATCH MO altavera (28) 0.15 mg-30 mcg tablet MO alyacen 0.5/0.75/1 mg-35 mcg tablet MO alyacen 1 mg-35 mcg tablet MO amethia 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack
MO

TIER
4 4 4 4 4 4 4 4 4 4 5 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 1 2 4 4 5 4 4 3

PA,QL (8 per 28 days) PA,QL (8 per 28 days) PA,QL (8 per 28 days) PA,QL (8 per 28 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (91 per 90 days) QL (91 per 90 days)

amethia lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose pack MO amethyst 90 mcg-20 mcg tablet MO ANADROL-50 50 MG TABLET MO ANDROGEL 1 % (25 MG/2.5 GRAM) TRANSDERMAL PACKET MO ANDROGEL 1 % (50 MG/5 GRAM) TRANSDERMAL PACKET MO ANDROGEL 1.25 GRAM/ACTUATION (1%) TRANSDERMAL GEL PUMP MO ANDROGEL 20.25 MG/1.25 GRAM (1.62 %) TRANSDERMAL GEL PUMP MO androxy 10 mg tablet MO APIDRA 100 UNIT/ML SUB-Q MO APIDRA SOLOSTAR 100 UNIT/ML SUB-Q INSULIN PEN MO apri 0.15 mg-30 mcg tablet MO aranelle (28) 0.5/1/0.5 mg-35 mcg tablet MO ARISTOSPAN INTRA-ARTICULAR 20 MG/ML SUSP FOR INJECTION MO ARISTOSPAN INTRALESIONAL 5 MG/ML SUSP FOR INJECTION MO aviane 0.1 mg-20 mcg tablet MO AYGESTIN 5 MG TABLET MO azurette 0.15 mg-0.02 mg x21/0.01 mgx5 tablet MO balziva (28) 0.4 mg-35 mcg tablet MO baycadron 0.5 mg/5 ml elixir MO betamethasone ac-sp 6 mg/ml vl MO BREVICON (28) 0.5 MG-35 MCG TABLET MO briellyn 0.4 mg-35 mcg tablet MO budesonide ec 3 mg capsule MO BYETTA 10 MCG/0.04 ML PER DOSE SUB-Q PEN INJECTOR MO BYETTA 5 MCG/0.02 ML PER DOSE SUB-Q PEN INJECTOR MO calcitonin-salmon 200 units sp MO

QL (300 per 30 days) QL (300 per 30 days) QL (300 per 30 days) QL (176 per 30 days)

PA,QL (3 per 30 days) PA,QL (3 per 30 days) B vs D,QL (4 per 28 days)

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DRUG NAME
camila 0.35 mg tablet MO camrese 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack
MO

TIER
4 4 4 4 4 4 4 4 4 4 4 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


QL (91 per 90 days) QL (91 per 90 days)

camrese lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose pack MO caziant 0.1/0.125/0.15 mg-25 mcg tablet MO CELESTONE 0.6 MG/5 ML ORAL SOLN MO CELESTONE SOLUSPAN 6 MG/ML SUSP FOR INJECTION MO CESIA 28 DAY TABLET MO chorionic gonad 10,000 unit vl MO CORTEF 10 MG TABLET MO CORTEF 20 MG TABLET MO CORTEF 5 MG TABLET MO cortisone 25 mg tablet MO CRINONE 4 % VAGINAL GEL MO CRINONE 8 % VAGINAL GEL MO cryselle (28) 0.3 mg-30 mcg tablet MO cyclafem 1/35 (28) 1 mg-35 mcg tablet MO cyclafem 7/7/7 (28) 0.5/0.75/1 mg-35 mcg tablet MO CYCLESSA 0.1/0.125/0.15 MG-25 MCG TABLET MO CYTOMEL 25 MCG TABLET MO CYTOMEL 5 MCG TABLET MO CYTOMEL 50 MCG TABLET MO danazol 100 mg capsule MO danazol 200 mg capsule MO danazol 50 mg capsule MO DELESTROGEN 10 MG/ML IM OIL MO DELESTROGEN 20 MG/ML IM OIL MO DELESTROGEN 40 MG/ML IM OIL MO DEPO-ESTRADIOL 5 MG/ML IM OIL MO DEPO-MEDROL 20 MG/ML SUSP FOR INJECTION HI,MO DEPO-MEDROL 40 MG/ML SUSP FOR INJECTION HI,MO DEPO-MEDROL 80 MG/ML SUSP FOR INJECTION HI,MO DEPO-PROVERA 150 MG/ML IM SUSP MO DEPO-PROVERA 150 MG/ML IM SYRINGE MO DEPO-PROVERA 400 MG/ML IM MO

PA PA PA PA

QL (1 per 90 days) QL (1 per 90 days)

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DRUG NAME
DEPO-SUBQ PROVERA 104 104 MG/0.65 ML SYRINGE MO DEPO-TESTOSTERONE 100 MG/ML IM OIL MO DEPO-TESTOSTERONE 200 MG/ML IM OIL MO desmopressin 0.1 mg/ml sol MO desmopressin 0.1 mg/ml spray MO desmopressin ac 4 mcg/ml vl MO desmopressin acetate 0.1 mg tb MO desmopressin acetate 0.2 mg tb MO DESOGEN 0.15 MG-30 MCG TABLET MO dexamethasone 0.5 mg tablet MO dexamethasone 0.5 mg/5 ml elx MO dexamethasone 0.5 mg/5 ml liq MO dexamethasone 0.75 mg tablet MO dexamethasone 1 mg tablet MO dexamethasone 1.5 mg tablet MO dexamethasone 10 mg/ml vial MO dexamethasone 2 mg tablet MO dexamethasone 4 mg tablet MO dexamethasone 4 mg/ml vial MO dexamethasone 6 mg tablet MO dexamethasone intensol 1 mg/ml drops (concentrate) MO DEXPAK 10 DAY 1.5 MG (35 TABS) TABLETS IN A DOSE PACK MO DEXPAK 13 DAY 1.5 MG (51 TABS) TABLETS IN A DOSE PACK MO DEXPAK 6 DAY 1.5 MG (21 TABS) TABLETS IN A DOSE PACK MO DUETACT 30 MG-2 MG TABLET MO DUETACT 30 MG-4 MG TABLET MO EGRIFTA 1 MG SUB-Q SOLN SP emoquette 0.15 mg-30 mcg tablet MO ENDOMETRIN 100 MG VAGINAL INSERTS MO enpresse 50-30 (6)/75-40(5)/125-30(10) tablet MO errin 0.35 mg tablet MO ESTRACE 0.01% (0.1 MG/G) VAGINAL CREAM MO estradiol 0.5 mg tablet MO estradiol 1 mg tablet MO estradiol 10 mg/ml vial MO estradiol 2 mg tablet MO

TIER
4 3 3 3 4 3 4 4 4 2 2 2 2 2 2 2 2 2 2 1 3 4 4 4 4 4 5 4 4 4 4 4 2 2 4 2

UTILIZATION MANAGEMENT REQUIREMENTS


QL (1 per 90 days)

QL (30 per 30 days) QL (30 per 30 days) PA,QL (60 per 30 days)

PA PA PA PA

Need more information about the indicators displayed by the drug names? Please go to page 9. ST - Step Therapy QL - Quantity Limit PA - Prior Authorization B vs D - Part B versus Part D 140 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

DRUG NAME
estradiol tds 0.025 mg/day MO estradiol tds 0.0375 mg/day MO estradiol tds 0.05 mg/day MO estradiol tds 0.06 mg/day MO estradiol tds 0.075 mg/day MO estradiol tds 0.1 mg/day MO estradiol valerate 20 mg/ml vl MO estradiol valerate 40 mg/ml vl MO ESTRING 2 MG VAGINAL MO ESTROSTEP FE-28 1-20 (5)/1-30(7)/1MG-35MCG(9) TABLET MO EVISTA 60 MG TABLET MO FEMCON FE 0.4 MG-35 MCG (21)/75 MG (7) CHEWABLE TABLET MO FEMRING 0.05 MG/24 HR VAGINAL MO FEMRING 0.1 MG/24 HR VAGINAL MO fludrocortisone 0.1 mg tablet MO FORTEO 20 MCG/DOSE (600 MCG/2.4 ML) SUB-Q PEN INJECTOR MO FORTICAL 200 UNIT/ACTUATION NASAL SPRAY MO gianvi 3 mg-20 mcg (24) tablet MO gildess fe 1 mg-20 mcg tablet MO gildess fe 1.5 mg-30 mcg tablet MO glimepiride 1 mg tablet MO glimepiride 2 mg tablet MO glimepiride 4 mg tablet MO glipizide 10 mg tablet MO glipizide 5 mg tablet MO glipizide er 10 mg tablet MO glipizide er 2.5 mg tablet MO glipizide er 5 mg tablet MO glipizide-metformin 2.5-250 mg MO glipizide-metformin 2.5-500 mg MO glipizide-metformin 5-500 mg MO GLUCAGEN 1 MG SOLUTION FOR INJECTION MO GLUCAGEN HYPOKIT 1 MG INJECTION MO GLUCAGON EMERGENCY 1 MG INJECTION KIT MO GLUCOTROL 10 MG TABLET MO GLUCOTROL 5 MG TABLET MO

TIER
2 2 2 2 2 2 4 4 4 4 3 4 4 4 2 4 4 3 4 4 1 1 1 1 1 2 2 2 2 2 2 4 4 3 4 4

PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA PA QL (1 per 90 days) QL (30 per 30 days) QL (1 per 90 days) QL (1 per 90 days) ST,QL (2 per 28 days) B vs D,QL (4 per 28 days)

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
GLUCOTROL XL 10 MG TABLET,EXTENDED RELEASE MO GLUCOTROL XL 2.5 MG TABLET,EXTENDED RELEASE MO GLUCOTROL XL 5 MG TABLET,EXTENDED RELEASE MO GLUMETZA 1,000 MG TABLET,EXTENDED RELEASE MO GLUMETZA 500 MG TABLET,EXTENDED RELEASE MO glyburid-metformin 1.25-250 mg MO glyburide 1.25 mg tablet MO glyburide 2.5 mg tablet MO glyburide 5 mg tablet MO glyburide micro 1.5 mg tab MO glyburide micro 3 mg tablet MO glyburide micro 6 mg tablet MO glyburide-metformin 2.5-500 mg MO glyburide-metformin 5-500 mg MO GLYSET 100 MG TABLET MO GLYSET 25 MG TABLET MO GLYSET 50 MG TABLET MO heather 0.35 mg tablet MO HUMALOG 100 UNIT/ML SUB-Q MO HUMALOG 100 UNIT/ML SUBQ CARTRIDGE MO HUMALOG 100 UNITS/ML PEN MO HUMALOG KWIKPEN 100 UNIT/ML SUB-Q PEN MO HUMALOG MIX 50-50 100 UNIT/ML (50-50) SUSP, SUB-Q INJ MO HUMALOG MIX 50-50 KWIKPEN 100 UNIT/ML (50-50) SUB-Q PEN MO HUMALOG MIX 50-50 PEN MO HUMALOG MIX 75-25 100 UNIT/ML (75-25) SUSP, SUB-Q INJ MO HUMALOG MIX 75-25 KWIKPEN 100 UNIT/ML (75-25) SUB-Q PEN MO HUMALOG MIX 75-25 PEN MO HUMULIN 70/30 100 UNIT/ML (70-30) SUSP, SUB-Q INJ MO HUMULIN 70/30 PEN 100 UNIT/ML (70-30) SUBQ MO HUMULIN N 100 UNIT/ML SUSP, SUB-Q INJ MO HUMULIN N PEN 100 UNIT/ML (3 ML) SUBQ MO HUMULIN R 100 UNIT/ML INJECTION MO HUMULIN R U-500 "CONCENTRATED" INSULIN 500 UNIT/ML INJECTION MO hydrocortisone 10 mg tablet MO

TIER
4 4 4 4 4 2 2 2 2 2 2 2 2 2 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days) QL (120 per 30 days) PA PA PA PA PA PA PA PA PA

QL (240 per 30 days) QL (240 per 30 days)

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DRUG NAME
hydrocortisone 20 mg tablet MO hydrocortisone 5 mg tablet MO INCRELEX 10 MG/ML SUB-Q SP introvale 0.15 mg-30 mcg tablets,3 month dose pack MO JANUMET 50 MG-1,000 MG TABLET MO JANUMET 50 MG-500 MG TABLET MO JANUMET XR 100 MG-1000 MG TABLET,EXTENDED RELEASE MO JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE MO JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE MO JANUVIA 100 MG TABLET MO JANUVIA 25 MG TABLET MO JANUVIA 50 MG TABLET MO jolessa 0.15 mg-30 mcg tablets,3 month dose pack MO jolivette 0.35 mg tablet MO junel 1.5/30 (21) 1.5 mg-30 mcg tablet MO junel 1/20 (21) 1 mg-20 mcg tablet MO junel fe 1.5/30 (28) 1.5 mg-30 mcg tablet MO junel fe 1/20 (28) 1 mg-20 mcg tablet MO JUVISYNC 100 MG-10 MG TABLET MO JUVISYNC 100 MG-20 MG TABLET MO JUVISYNC 100 MG-40 MG TABLET MO kariva 0.15 mg-0.02 mg x21/0.01 mgx5 tablet MO kelnor 1/35 (28) 1 mg-35 mcg tablet MO KENALOG 10 MG/ML SUSP FOR INJECTION MO KENALOG 40 MG/ML SUSP FOR INJECTION MO KOMBIGLYZE XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASE MO KOMBIGLYZE XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE MO KOMBIGLYZE XR 5 MG-500 MG TABLET,EXTENDED RELEASE MO KORLYM 300 MG TABLET MO LANTUS 100 UNIT/ML SUB-Q MO LANTUS 100 UNITS/ML CARTRIDGE MO LANTUS SOLOSTAR 100 UNIT/ML (3 ML) SUB-Q INSULIN PEN MO leena 28 0.5/1/0.5 mg-35 mcg tablet MO lessina 0.1 mg-20 mcg tablet MO LEVEMIR 100 UNIT/ML SUB-Q MO LEVEMIR FLEXPEN 100 UNIT/ML (3 ML) SUB-Q INSULIN PEN MO

TIER
2 2 5 4 3 3 3 3 3 3 3 3 4 4 4 4 4 4 3 3 3 4 4 4 4 3 3 3 5 3 3 3 4 4 3 3

UTILIZATION MANAGEMENT REQUIREMENTS

PA QL (91 per 90 days) ST,QL (60 per 30 days) ST,QL (60 per 30 days) ST,QL (30 per 30 days) ST,QL (60 per 30 days) ST,QL (60 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days) QL (91 per 90 days)

ST,QL (30 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days)

ST,QL (60 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days) PA,QL (120 per 30 days)

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DRUG NAME
LEVLEN (28) 0.15 MG-30 MCG TABLET MO levonorg-eth estrad eth estrad MO levonorgestrel 0.75 mg tablet MO levora-28 0.15 mg-30 mcg tablet MO LEVOTHROID 100 MCG TABLET MO LEVOTHROID 112 MCG TABLET MO LEVOTHROID 125 MCG TABLET MO LEVOTHROID 137 MCG TABLET MO LEVOTHROID 150 MCG TABLET MO LEVOTHROID 175 MCG TABLET MO LEVOTHROID 200 MCG TABLET MO LEVOTHROID 25 MCG TABLET MO LEVOTHROID 300 MCG TABLET MO LEVOTHROID 50 MCG TABLET MO LEVOTHROID 75 MCG TABLET MO LEVOTHROID 88 MCG TABLET MO levothyroxine 100 mcg tablet MO levothyroxine 100 mcg vial MO levothyroxine 112 mcg tablet MO levothyroxine 125 mcg tablet MO levothyroxine 137 mcg tablet MO levothyroxine 150 mcg tablet MO levothyroxine 175 mcg tablet MO levothyroxine 200 mcg tablet MO levothyroxine 200 mcg vial MO levothyroxine 25 mcg tablet MO levothyroxine 300 mcg tablet MO levothyroxine 50 mcg tablet MO levothyroxine 500 mcg vial MO levothyroxine 75 mcg tablet MO levothyroxine 88 mcg tablet MO LEVOXYL 100 MCG TABLET MO LEVOXYL 112 MCG TABLET MO LEVOXYL 125 MCG TABLET MO LEVOXYL 137 MCG TABLET MO LEVOXYL 150 MCG TABLET MO

TIER
4 4 4 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 3 3 3

UTILIZATION MANAGEMENT REQUIREMENTS


QL (91 per 90 days)

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DRUG NAME
LEVOXYL 175 MCG TABLET MO LEVOXYL 200 MCG TABLET MO LEVOXYL 25 MCG TABLET MO LEVOXYL 50 MCG TABLET MO LEVOXYL 75 MCG TABLET MO LEVOXYL 88 MCG TABLET MO liothyronine sod 10 mcg/ml vl MO liothyronine sod 25 mcg tab MO liothyronine sod 5 mcg tab MO liothyronine sod 50 mcg tab MO LO-OVRAL (28) 0.3 MG-30 MCG TABLET MO LOESTRIN 1.5/30 (21) 1.5 MG-30 MCG TABLET MO LOESTRIN 1/20 (21) 1 MG-20 MCG TABLET MO LOESTRIN 24 FE 1 MG-20 MCG (24)/75 MG (4) TABLET MO LOESTRIN FE 1.5/30 (28) 1.5 MG-30 MCG TABLET MO LOESTRIN FE 1/20 (28) 1 MG-20 MCG TABLET MO loryna 3 mg-20 mcg (24) tablet MO LOSEASONIQUE 0.10 MG-20 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE PACK MO low-ogestrel (28) 0.3 mg-30 mcg tablet MO lutera (28) 0.1 mg-20 mcg tablet MO LYBREL 90-20 MCG TABLET MO marlissa 0.15 mg-30 mcg tablet MO MEDROL (PAK) 4 MG TABLETS IN A DOSE PACK MO MEDROL 16 MG TABLET MO MEDROL 2 MG TABLET MO MEDROL 32 MG TABLET MO MEDROL 4 MG TABLET MO MEDROL 8 MG TABLET MO medroxyprogesterone 10 mg tab MO medroxyprogesterone 150 mg/ml MO medroxyprogesterone 2.5 mg tab MO medroxyprogesterone 5 mg tab MO MENEST 0.3 MG TABLET MO MENEST 0.625 MG TABLET MO MENEST 1.25 MG TABLET MO

TIER
3 3 3 3 3 3 2 3 3 2 4 4 4 4 4 4 3 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (91 per 90 days)

B vs D B vs D B vs D B vs D B vs D B vs D QL (1 per 90 days)

PA PA PA

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DRUG NAME
MENEST 2.5 MG TABLET MO MENOSTAR 14 MCG/24 HR TRANSDERM PATCH MO metformin hcl 1,000 mg tablet MO metformin hcl 500 mg tablet MO metformin hcl 850 mg tablet MO metformin hcl er 750 mg tablet MO methimazole 10 mg tablet MO methimazole 5 mg tablet MO methylprednisolone 125 mg vial HI,MO methylprednisolone 16 mg tab MO methylprednisolone 32 mg tab MO methylprednisolone 4 mg dosepk MO methylprednisolone 4 mg tablet MO methylprednisolone 40 mg vial HI,MO methylprednisolone 40 mg/ml vl HI,MO methylprednisolone 500 mg vial MO methylprednisolone 8 mg tab MO methylprednisolone 80 mg/ml vl HI,MO methylprednisolone ss 1 gm vl HI,MO microgestin 1.5/30 (21) 1.5 mg-30 mcg tablet MO microgestin 1/20 (21) 1 mg-20 mcg tablet MO microgestin fe 1.5/30 (28) 1.5 mg-30 mcg tablet MO microgestin fe 1/20 (28) 1 mg-20 mcg tablet MO mimvey 1 mg-0.5 mg tablet MO MIRCETTE 0.15 MG-0.02 MG X21/0.01 MGX5 TABLET MO MODICON (28) 0.5 MG-35 MCG TABLET MO mononessa (28) 0.25 mg-35 mcg tablet MO myzilra 50-30 (6)/75-40(5)/125-30(10) tablet MO NATAZIA 3 MG/2 MG-2 MG/2 MG-3 MG/1 MG TABLET MO nateglinide 120 mg tablet MO nateglinide 60 mg tablet MO necon 0.5/35 (28) 0.5 mg-35 mcg tablet MO necon 1/35 (28) 1 mg-35 mcg tablet MO necon 1/50 (28) 1 mg-50 mcg tablet MO necon 10/11 (28) 0.5mg-35mcg(10)/1mg-35mcg(11) tablet MO necon 7/7/7 (28) 0.5/0.75/1 mg-35 mcg tablet MO

TIER
4 4 1 1 1 1 2 2 2 2 2 2 2 2 1 2 2 1 4 4 4 4 4 4 4 4 4 4 4 3 3 4 4 4 4 4

PA PA,QL (8 per 28 days)

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days)

B vs D B vs D B vs D B vs D

B vs D

PA

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DRUG NAME
NOR-QD 0.35 MG TABLET MO nora-be 0.35 mg tablet MO NORDETTE-28 0.15 MG-30 MCG TABLET MO norethin-ethinyl estrad ch tb MO norethindrone 0.35 mg tablet MO norethindrone 5 mg tablet MO norg-ethin estr 0.3-0.03 mg tb MO norg-ethin estra 0.25-0.035 mg MO norgestimate-eth estradiol tab MO NORINYL 1+35 (28) 1 MG-35 MCG TABLET MO NORINYL 1+50 (28) 1 MG-50 MCG TABLET MO nortrel 0.5/35 (28) 0.5 mg-35 mcg tablet MO nortrel 1/35 (21) 1 mg-35 mcg tablet MO nortrel 1/35 (28) 1 mg-35 mcg tablet MO nortrel 7/7/7 (28) 0.5/0.75/1 mg-35 mcg tablet MO NOVOLIN 70/30 100 UNIT/ML (70-30) SUSP, SUB-Q INJ MO NOVOLIN N 100 UNIT/ML SUSP, SUB-Q INJ MO NOVOLIN R 100 UNIT/ML INJECTION MO NOVOLOG 100 UNIT/ML SUB-Q MO NOVOLOG FLEXPEN 100 UNIT/ML SUB-Q MO NOVOLOG MIX 70-30 100 UNIT/ML (70-30) SUB-Q MO NOVOLOG MIX 70-30 FLEXPEN 100 UNIT/ML (70-30) SUB-Q MO NOVOLOG PENFILL 100 UNIT/ML SUBQ CARTRIDGE MO NUVARING 0.12 MG -0.015 MG/24 HR VAGINAL MO ocella 3 mg-0.03 mg tablet MO ogestrel (28) 0.5 mg-50 mcg tablet MO OMNITROPE 10 MG/1.5 ML SUBQ CARTRIDGE SP OMNITROPE 5 MG/1.5 ML (3.3 MG/ML) SUBQ CARTRIDGE SP OMNITROPE 5.8 MG SUB-Q SOLN SP ONGLYZA 2.5 MG TABLET MO ONGLYZA 5 MG TABLET MO ORAPRED 15 MG/5 ML ORAL SOLN MO ORAPRED ODT 10 MG DISINTEGRATING TABLET MO ORAPRED ODT 15 MG DISINTEGRATING TABLET MO ORAPRED ODT 30 MG DISINTEGRATING TABLET MO orsythia 0.1 mg-20 mcg tablet MO

TIER
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 4 4 4 4 4 5 3 3 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (1 per 28 days)

PA PA PA ST,QL (30 per 30 days) ST,QL (30 per 30 days)

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DRUG NAME
ORTHO EVRA 150 MCG-20 MCG/24 HR TRANSDERM PATCH MO ORTHO MICRONOR 0.35 MG TABLET MO ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 MG-35 MCG(28) TABLET MO ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 MG-25 MCG TABLET MO ORTHO-CEPT (28) 0.15 MG-30 MCG TABLET MO ORTHO-CYCLEN (28) 0.25 MG-35 MCG TABLET MO ORTHO-NOVUM 1/35 (28) 1 MG-35 MCG TABLET MO ORTHO-NOVUM 7/7/7 (28) 0.5/0.75/1 MG-35 MCG TABLET MO OVCON-35 (28) 0.4 MG-35 MCG TABLET MO OVCON-50 28 TABLET MO oxandrolone 10 mg tablet MO oxandrolone 2.5 mg tablet MO PEDIAPRED 6.7 MG/5 ML SOLN MO philith 0.4 mg-35 mcg tablet MO PITRESSIN 20 UNIT/ML INJECTION MO portia 0.15 mg-30 mcg tablet MO PRANDIN 0.5 MG TABLET MO PRANDIN 1 MG TABLET MO PRANDIN 2 MG TABLET MO PRECOSE 100 MG TABLET MO PRECOSE 25 MG TABLET MO PRECOSE 50 MG TABLET MO prednisolone 15 mg/5 ml soln MO prednisolone 15 mg/5 ml syrup MO prednisolone 5 mg/5 ml soln MO prednisolone 5 mg/5 ml syrup MO prednisone 1 mg tablet MO prednisone 10 mg tablet MO prednisone 2.5 mg tablet MO prednisone 20 mg tablet MO prednisone 5 mg tablet MO prednisone 5 mg/5 ml solution MO prednisone 50 mg tablet MO prednisone intensol 5 mg/ml oral concentrate MO PRELONE 15 MG/5 ML ORAL SOLN MO PREMARIN 0.625 MG/GRAM VAGINAL CREAM MO

TIER
4 4 4 4 4 4 4 4 4 4 5 3 4 4 1 4 4 4 4 4 4 4 2 2 2 2 1 1 1 1 1 1 1 3 1 3

UTILIZATION MANAGEMENT REQUIREMENTS


QL (3 per 28 days)

QL (60 per 30 days) QL (120 per 30 days)

B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D

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DRUG NAME
previfem 0.25 mg-35 mcg tablet MO PROCHIEVE 4% GEL MO PROCHIEVE 8% GEL MO progesterone 100 mg capsule MO progesterone 200 mg capsule MO progesterone in oil 50 mg/ml im MO progesterone oil 50 mg/ml vl MO PROMETRIUM 100 MG CAPSULE MO PROMETRIUM 200 MG CAPSULE MO propylthiouracil 50 mg tablet MO PROVERA 10 MG TABLET MO PROVERA 2.5 MG TABLET MO PROVERA 5 MG TABLET MO quasense 0.15 mg-30 mcg tablets,3 month dose pack MO reclipsen (28) 0.15 mg-30 mcg tablet MO RIOMET 500 MG/5 ML ORAL SOLN MO SAIZEN 5 MG SUB-Q SOLN SP SAIZEN 8.8 MG SUB-Q SOLN SP SAIZEN CLICK.EASY 8.8 MG/1.5 ML (FINAL CONC.) SUBQ CARTRIDGE SP SEASONIQUE 0.15 MG-30 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE PACK MO SEROSTIM 4 MG SUB-Q SOLN SP SEROSTIM 5 MG SUB-Q SOLN SP SEROSTIM 6 MG SUB-Q SOLN SP SOLIA 0.15-0.03 MG TABLET MO SOLU-CORTEF (PF) 1,000 MG/8 ML SOLUTION FOR INJECTION MO SOLU-CORTEF (PF) 100 MG/2 ML SOLUTION FOR INJECTION MO SOLU-CORTEF (PF) 250 MG/2 ML SOLUTION FOR INJECTION MO SOLU-CORTEF (PF) 500 MG/4 ML SOLUTION FOR INJECTION MO SOLU-CORTEF 100 MG SOLUTION FOR INJECTION MO SOLU-MEDROL (PF) 1,000 MG/8 ML IV SOLUTION MO SOLU-MEDROL (PF) 125 MG/2 ML SOLUTION FOR INJECTION HI,MO SOLU-MEDROL (PF) 40 MG/ML SOLUTION FOR INJECTION HI,MO SOLU-MEDROL (PF) 500 MG/4 ML IV SOLUTION MO SOLU-MEDROL 1,000 MG IV SOLUTION MO SOLU-MEDROL 125 MG/2 ML SOLUTION FOR INJECTION MO

TIER
4 4 4 4 4 1 1 4 4 2 4 4 4 4 4 4 5 5 5 4 5 5 5 4 4 4 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (91 per 90 days)

PA PA PA QL (91 per 90 days) PA PA PA

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DRUG NAME
SOLU-MEDROL 2 GRAM IV SOLUTION MO SOLU-MEDROL 500 MG IV SOLUTION MO SOMAVERT 10 MG SUB-Q SOLN SP SOMAVERT 15 MG SUB-Q SOLN SP SOMAVERT 20 MG SUB-Q SOLN SP sprintec (28) 0.25 mg-35 mcg tablet MO sronyx 0.1 mg-20 mcg tablet MO STIMATE 150 MCG/SPRAY (0.1 ML) NASAL SPRAY MO STRIANT 30 MG BUCCAL SYSTEM,SUSTAINED RELEASE MO syeda 3 mg-0.03 mg tablet MO SYMLIN 600 MCG/ML SUB-Q MO SYMLINPEN 120 2,700 MCG/2.7 ML SUB-Q PEN INJECTOR MO SYMLINPEN 60 1,500 MCG/1.5 ML SUB-Q PEN INJECTOR MO SYNAREL 2 MG/ML NASAL SPRAY SP SYNTHROID 100 MCG TABLET MO SYNTHROID 112 MCG TABLET MO SYNTHROID 125 MCG TABLET MO SYNTHROID 137 MCG TABLET MO SYNTHROID 150 MCG TABLET MO SYNTHROID 175 MCG TABLET MO SYNTHROID 200 MCG TABLET MO SYNTHROID 25 MCG TABLET MO SYNTHROID 300 MCG TABLET MO SYNTHROID 50 MCG TABLET MO SYNTHROID 75 MCG TABLET MO SYNTHROID 88 MCG TABLET MO TAPAZOLE 10 MG TABLET MO TAPAZOLE 5 MG TABLET MO testosterone cyp 100 mg/ml MO testosterone cyp 200 mg/ml MO testosterone enan 200 mg/ml MO THYROLAR-1 12.5 MCG-50 MCG TABLET MO THYROLAR-1/2 6.25 MCG-25 MCG TABLET MO THYROLAR-1/4 3.1 MCG-12.5 MCG TABLET MO THYROLAR-2 25 MCG-100 MCG TABLET MO THYROLAR-3 37.5 MCG-150 MCG TABLET MO

TIER
4 4 5 5 5 4 4 4 4 4 4 4 4 5 3 3 3 3 3 3 3 3 3 3 3 3 4 4 3 3 4 2 1 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA,QL (60 per 30 days) PA,QL (60 per 30 days) PA,QL (60 per 30 days)

PA,QL (25 per 30 days) PA,QL (11 per 30 days) PA,QL (11 per 30 days)

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DRUG NAME
tilia fe 1-20 (5)/1-30(7)/1mg-35mcg(9) tablet MO tolazamide 250 mg tablet MO tolazamide 500 mg tablet MO tolbutamide 500 mg tablet MO tri-legest fe 1-20 (5)/1-30(7)/1mg-35mcg(9) tablet MO TRI-NORINYL (28) 0.5/1/0.5 MG-35 MCG TABLET MO tri-previfem (28) 0.18/0.215/0.25 mg-35 mcg(28) tablet MO tri-sprintec (28) 0.18/0.215/0.25 mg-35 mcg(28) tablet MO trinessa (28) 0.18/0.215/0.25 mg-35 mcg(28) tablet MO trivora (28) 50-30 (6)/75-40(5)/125-30(10) tablet MO UNITHROID 100 MCG TABLET MO UNITHROID 112 MCG TABLET MO UNITHROID 125 MCG TABLET MO UNITHROID 150 MCG TABLET MO UNITHROID 175 MCG TABLET MO UNITHROID 200 MCG TABLET MO UNITHROID 25 MCG TABLET MO UNITHROID 300 MCG TABLET MO UNITHROID 50 MCG TABLET MO UNITHROID 75 MCG TABLET MO UNITHROID 88 MCG TABLET MO VAGIFEM 10 MCG VAGINAL TABLET MO vasopressin 10 unit/0.5 ml vl MO velivet 0.1/0.125/0.15 mg-25 mcg tablet MO VERIPRED 20 20 MG/5 ML ORAL SOLN MO vestura 3 mg-20 mcg (24) tablet MO VICTOZA 0.6 MG/0.1 ML (18 MG/3 ML) SUB-Q PEN INJECTOR MO viorele 0.15 mg-0.02 mg x21/0.01 mgx5 tablet MO VIVELLE-DOT 0.025 MG/24 HR TRANSDERM PATCH MO VIVELLE-DOT 0.0375 MG/24 HR TRANSDERM PATCH MO VIVELLE-DOT 0.05 MG/24 HR TRANSDERM PATCH MO VIVELLE-DOT 0.075 MG/24 HR TRANSDERM PATCH MO VIVELLE-DOT 0.1 MG/24 HR TRANSDERM PATCH MO YASMIN 28 3 MG-0.03 MG TABLET MO YAZ 28 3 MG-20 MCG (24) TABLET MO zarah 3 mg-0.03 mg tablet MO

TIER
4 4 4 4 4 4 4 4 4 4 2 2 2 2 2 2 2 2 2 2 2 4 1 4 4 2 4 4 4 4 4 4 4 4 4 3

UTILIZATION MANAGEMENT REQUIREMENTS

PA,QL (9 per 30 days) PA,QL (8 per 28 days) PA,QL (8 per 28 days) PA,QL (8 per 28 days) PA,QL (8 per 28 days) PA,QL (8 per 28 days)

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DRUG NAME
zema-pak 10 day 1.5 mg tablet MO zema-pak 13 day 1.5 mg tablet MO zema-pak 6 day 1.5 mg tablet MO zenchent (28) 0.4 mg-35 mcg tablet MO zenchent fe 0.4 mg-35 mcg (21)/75 mg (7) chewable tablet MO zeosa 0.4 mg-35 mcg (21)/75 mg (7) chewable tablet MO ZORBTIVE 8.8 MG SUB-Q SOLN SP zovia 1/35e (28) 1 mg-35 mcg tablet MO zovia 1/50e (28) 1 mg-50 mcg tablet MO LOCAL ANESTHETICS (PARENTERAL) bupivacaine 0.25% ampul MO bupivacaine 0.25% vial MO bupivacaine 0.5% ampul MO bupivacaine 0.75% vial MO bupivacaine-dextr 0.75% amp MO bupivacaine-epi 0.25%-0.0005 MO bupivacaine-epi 0.5%-0.0005 MO bupivacaine-epi 0.75%-0.0005 MO CARBOCAINE (PF) 10 MG/ML (1 %) INJECTION MO CARBOCAINE (PF) 15 MG/ML (1.5 %) INJECTION MO CARBOCAINE (PF) 20 MG/ML (2 %) INJECTION MO CARBOCAINE 1 % INJECTION MO CARBOCAINE 2 % INJECTION MO chloroprocaine 2% vial MO chloroprocaine 3% vial MO lidocaine 0.5%-epi 1:200,000 MO lidocaine 1%-epi 1:100,000 MO lidocaine 1.5%-epi 1:200,000 MO lidocaine 2% - epi 1:100,000 MO lidocaine 2% - epi 1:50,000 MO lidocaine 2%-epi 1:100,000 MO lidocaine 2%-epi 1:200,000 MO lidocaine 5% in d7.5w ampul MO lidocaine hcl 0.5% vial MO lidocaine hcl 1% ampul MO lidocaine hcl 1% vial MO

TIER
2 2 2 4 4 4 5 4 4 1 1 1 1 1 1 1 1 4 4 4 4 4 1 1 2 2 2 2 1 2 2 1 1 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA

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DRUG NAME
lidocaine hcl 1.5% ampul MO lidocaine hcl 2% vial MO lidocaine hcl 2% vial MO lidocaine hcl 4% ampul MO MARCAINE (PF) 0.25 % (2.5 MG/ML) INJECTION MO MARCAINE (PF) 0.5 % (5 MG/ML) INJECTION MO MARCAINE (PF) 0.75 % (7.5 MG/ML) INJECTION MO MARCAINE 0.25 % (2.5 MG/ML) INJECTION MO MARCAINE SPINAL (PF) 7.5 MG/ML (0.75 %) INJECTION MO MARCAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION MO MARCAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION MO MARCAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION MO MARCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION MO mepivacaine hcl 3% cartridge MO NAROPIN (PF) 10 MG/ML (1 %) INJECTION MO NAROPIN (PF) 2 MG/ML (0.2 %) INJECTION MO NAROPIN (PF) 5 MG/ML (0.5 %) INJECTION MO NAROPIN (PF) 7.5 MG/ML (0.75 %) INJECTION MO NESACAINE 10 MG/ML (1 %) INJECTION MO NESACAINE 20 MG/ML (2 %) INJECTION MO NESACAINE-MPF 20 MG/ML (2 %) INJECTION MO NESACAINE-MPF 30 MG/ML (3 %) INJECTION MO polocaine (pf) 10 mg/ml (1 %) injection MO polocaine (pf) 15 mg/ml (1.5 %) injection MO polocaine (pf) 20 mg/ml (2 %) injection MO polocaine 1 % injection MO PONTOCAINE (PF) 20 MG SOLUTION FOR INJECTION MO SENSORCAINE 0.25 % (2.5 MG/ML) INJECTION MO SENSORCAINE-MPF 0.25 % (2.5 MG/ML) INJECTION MO sensorcaine-mpf 0.5 % (5 mg/ml) injection MO sensorcaine-mpf 0.75 % (7.5 mg/ml) injection MO sensorcaine-mpf spinal 7.5 mg/ml (0.75 %) injection MO sensorcaine-mpf/epinephrine 0.25 %-1:200,000 injection MO SENSORCAINE-MPF/EPINEPHRINE 0.5 %-1:200,000 INJECTION MO SENSORCAINE-MPF/EPINEPHRINE 0.75 %-1:200,000 INJECTION MO sensorcaine/epinephrine 0.25 %-1:200,000 injection MO

TIER
1 2 1 1 4 4 4 4 4 4 4 4 4 1 4 4 4 4 4 4 4 4 1 1 1 1 4 4 4 4 4 1 1 4 4 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
sensorcaine/epinephrine 0.5 %-1:200,000 injection MO XYLOCAINE 10 MG/ML (1 %) INJECTION MO XYLOCAINE 20 MG/ML (2 %) INJECTION MO XYLOCAINE 5 MG/ML (0.5 %) INJECTION MO XYLOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION MO XYLOCAINE-EPINEPHRINE 1 %-1:100,000 INJECTION MO XYLOCAINE-EPINEPHRINE 2 %-1:100,000 INJECTION MO XYLOCAINE-MPF 10 MG/ML (1 %) INJECTION MO XYLOCAINE-MPF 15 MG/ML (1.5 %) INJECTION MO XYLOCAINE-MPF 20 MG/ML (2 %) INJECTION MO XYLOCAINE-MPF 40 MG/ML (4 %) INJECTION MO XYLOCAINE-MPF 5 MG/ML (0.5 %) INJECTION MO XYLOCAINE-MPF/EPINEPHRINE 1 %-1:200,000 INJECTION MO XYLOCAINE-MPF/EPINEPHRINE 1.5 %-1:200,000 INJECTION MO XYLOCAINE-MPF/EPINEPHRINE 2 %-1:200,000 INJECTION MO MISCELLANEOUS THERAPEUTIC AGENTS ACTIMMUNE 2 MILLION UNIT/0.5 ML SUB-Q SP ACTONEL 150 MG TABLET MO ACTONEL 30 MG TABLET MO ACTONEL 35 MG TABLET MO ACTONEL 5 MG TABLET MO alendronate sodium 10 mg tab MO alendronate sodium 35 mg tab MO alendronate sodium 40 mg tab MO alendronate sodium 5 mg tablet MO alendronate sodium 70 mg tab MO allopurinol 100 mg tablet MO allopurinol 300 mg tablet MO allopurinol sodium 500 mg vial MO ALOPRIM 500 MG IV SOLUTION MO amifostine 500 mg vial MO AMPYRA 10 MG TABLET,EXTENDED RELEASE SP ANTABUSE 250 MG TABLET MO ANTABUSE 500 MG TABLET MO ARCALYST 220 MG SUB-Q SOLN SP AREDIA 30 MG VIAL MO

TIER
1 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 4 4 4 4 1 1 1 1 1 1 1 1 4 5 5 4 4 5 4

UTILIZATION MANAGEMENT REQUIREMENTS

PA QL (2 per 30 days) QL (30 per 30 days) QL (4 per 28 days) QL (30 per 30 days) QL (30 per 30 days) QL (4 per 28 days) QL (30 per 30 days) QL (30 per 30 days) QL (4 per 28 days)

B vs D PA,QL (60 per 30 days)

PA B vs D

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DRUG NAME
AREDIA 90 MG VIAL MO ATELVIA 35 MG TABLET,DELAYED RELEASE MO ATGAM 50 MG/ML IV HI,MO AVODART 0.5 MG CAPSULE MO AVONEX 30 MCG IM KIT SP AVONEX 30 MCG/0.5 ML IM PEN INJECTOR MO AVONEX 30 MCG/0.5 ML IM PEN KIT MO AVONEX ADMINISTRATION PACK 30 MCG/0.5 ML IM KIT SP azathioprine 50 mg tablet MO azathioprine sod 100 mg vial MO BENLYSTA 120 MG IV SOLUTION MO BENLYSTA 400 MG IV SOLUTION MO BETASERON 0.3 MG SUB-Q KIT SP BONIVA 3 MG/3 ML IV SYRINGE MO calcium folinate (leucovorin) 10 mg/ml injection MO CARNITOR 100 MG/ML ORAL SOLN MO CARNITOR 200 MG/ML IV HI,MO CARNITOR 330 MG TABLET MO CARNITOR SUGAR-FREE 100 MG/ML ORAL SOLN MO CARTICEL SUSP FOR IMPLANTATION MO cavirinse oral rinse MO CELLCEPT 200 MG/ML ORAL SUSP MO CELLCEPT 250 MG CAPSULE MO CELLCEPT 500 MG TABLET MO CELLCEPT INTRAVENOUS 500 MG IV SOLUTION MO COLCRYS 0.6 MG TABLET MO control rx cream MO COPAXONE 20 MG SUB-Q KIT SP cyanide antidote 300 mg/10 ml-12.5 gram/50 ml iv kit MO cyclosporine 100 mg capsule MO cyclosporine 100 mg/ml soln MO cyclosporine 25 mg capsule MO cyclosporine 50 mg softgel MO cyclosporine 50 mg/ml vial MO cyclosporine modified 100 mg MO cyclosporine modified 25 mg MO

TIER
5 4 3 3 5 5 5 5 2 1 5 5 5 4 2 4 4 4 4 4 1 5 4 5 4 3 1 5 1 4 4 4 4 4 4 4

B vs D QL (4 per 28 days) PA,QL (1050 per 28 days) QL (30 per 30 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) PA,QL (4 per 28 days) B vs D B vs D PA,QL (30 per 28 days) PA,QL (6 per 28 days) PA,QL (15 per 30 days) PA,QL (3 per 90 days) B vs D B vs D B vs D B vs D

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D QL (120 per 30 days) PA,QL (30 per 30 days) B vs D B vs D B vs D B vs D B vs D B vs D B vs D

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DRUG NAME
CYSTADANE ORAL POWDER MO CYSTAGON 150 MG CAPSULE MO CYSTAGON 50 MG CAPSULE MO DEMSER 250 MG CAPSULE MO denta 5000 plus 1.1 % cream MO dentagel 1.1 % MO dexrazoxane 250 mg vial MO dexrazoxane 500 mg vial MO disulfiram 250 mg tablet MO disulfiram 500 mg tablet MO ELMIRON 100 MG CAPSULE MO ENBREL 25 MG (1 ML) SUB-Q KIT SP ENBREL 25 MG/0.5 ML (0.51 ML) SUB-Q SYRINGE SP ENBREL 50 MG/ML (0.98 ML) SUB-Q SYRINGE SP ENBREL SURECLICK 50 MG/ML (0.98 ML) SUB-Q PEN INJECTOR SP epiflur 0.25 mg tablet chew MO epiflur 0.5 mg tablet chewable MO epiflur 1 mg tablet chewable MO ETHYOL 500 MG VIAL MO etidronate disodium 200 mg tab MO etidronate disodium 400 mg tab MO finasteride 5 mg tablet MO FIRAZYR 30 MG/3 ML SUB-Q SYRINGE SP FLUORABON 0.25 MG FLUORIDE(0.55)/0.6 ML ORAL DROPS MO fluoride 0.25 mg tablet chew MO fluoride 0.5 mg tablet chew MO fluoride 1 mg chew tablet MO fluoridex defense 1.1% gel MO fluoridex whitening 1.1% gel MO fluoritab 0.125 mg fluoride(0.275)/drop oral drops MO FLUORITAB 0.25 MG/DRP DROPS MO fluoritab 0.5 mg fluoride (1.1 mg) chewable tablet MO FLUORITAB 1 MG FLUORIDE (2.2 MG) CHEWABLE TABLET MO FLURA-DROPS 0.25 MG FLUORIDE (0.55)/DROP ORAL MO fomepizole 1.5 gm/1.5 ml vial MO FUSILEV 50 MG IV SOLUTION MO

TIER
4 4 4 4 2 2 4 4 4 4 4 5 5 5 5 1 1 1 5 3 3 2 5 4 1 1 1 2 2 1 4 1 4 4 1 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D

PA,QL (8 per 28 days) PA,QL (8 per 28 days) PA,QL (8 per 28 days) PA,QL (8 per 28 days)

B vs D

QL (30 per 30 days) PA,QL (9 per 30 days)

PA

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DRUG NAME
gel-kam 0.63% dental rinse MO gengraf 100 mg capsule MO gengraf 100 mg/ml oral soln MO gengraf 25 mg capsule MO hecoria 0.5 mg capsule MO hecoria 1 mg capsule MO hecoria 5 mg capsule MO HUMIRA 20 MG/0.4 ML SUB-Q KIT SP HUMIRA 40 MG/0.8 ML SUB-Q KIT SP HUMIRA CROHN'S DISEASE STARTER PACK 40 MG/0.8 ML SUBQ PEN KIT SP HUMIRA PEN 40 MG/0.8 ML SUBQ KIT SP HUMIRA PSORIASIS STARTER PACK 40 MG/0.8 ML SUBQ PEN KIT SP ibandronate sodium 150 mg tab MO JALYN 0.5 MG-0.4 MG CAPSULE, EXTENDED RELEASE MO KUVAN 100 MG SOLUBLE TABLET SP leflunomide 10 mg tablet MO leflunomide 20 mg tablet MO leucovorin cal 500 mg/50 ml vl MO leucovorin calcium 10 mg tab MO leucovorin calcium 100 mg vl MO leucovorin calcium 15 mg tab MO leucovorin calcium 200 mg vl MO leucovorin calcium 25 mg tab MO leucovorin calcium 350 mg vl MO leucovorin calcium 5 mg tab MO leucovorin calcium 50 mg vl MO leucovorin calcium 500 mg vl MO levocarnitine 100 mg/ml soln MO levocarnitine 200 mg/ml vial MO levocarnitine 330 mg tablet MO lozi-flur 1 mg fluoride (2.2 mg) lozenges MO ludent fluoride 0.25 mg fluoride (0.55 mg) chewable tablet MO ludent fluoride 0.5 mg fluoride (1.1 mg) chewable tablet MO ludent fluoride 1 mg fluoride (2.2 mg) chewable tablet MO mesna 1 gram/10 ml vial MO

TIER
2 4 4 4 2 2 2 5 5 5 5 5 4 3 5 3 3 2 2 2 2 2 2 2 2 2 2 3 3 3 1 1 1 1 4

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D B vs D B vs D B vs D B vs D B vs D PA,QL (6 per 28 days) PA,QL (6 per 28 days) PA,QL (6 per 28 days) PA,QL (6 per 28 days) PA,QL (6 per 28 days) QL (1 per 28 days) QL (30 per 30 days) PA QL (30 per 30 days) QL (30 per 30 days) B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D B vs D

B vs D

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DRUG NAME
MESNEX 100 MG/ML IV MO MESNEX 400 MG TABLET MO methylene blue 1% vial MO mycophenolate 250 mg capsule MO mycophenolate 500 mg tablet MO MYFORTIC 180 MG TABLET,DELAYED RELEASE MO MYFORTIC 360 MG TABLET,DELAYED RELEASE MO MYOBLOC 10,000 UNIT/2 ML IM MO MYOBLOC 2,500 UNIT/0.5 ML IM MO MYOBLOC 5,000 UNIT/ML IM MO neutral sodium fluoride MO NEXAVIR 25.5 MG/ML INJECTION MO NULOJIX 250 MG IV SOLUTION MO octreotide 1,000 mcg/ml vial MO octreotide acet 100 mcg/ml syr SP octreotide acet 100 mcg/ml vl MO octreotide acet 200 mcg/ml vl MO octreotide acet 50 mcg/ml amp MO octreotide acet 50 mcg/ml syr SP octreotide acet 500 mcg/ml syr SP octreotide acet 500 mcg/ml vl MO ORFADIN 10 MG CAPSULE MO ORFADIN 2 MG CAPSULE MO ORFADIN 5 MG CAPSULE MO ORTHOCLONE OKT-3 5 MG/5 ML MO pamidronate 30 mg/10 ml vial MO pamidronate 60 mg/10 ml vial MO pamidronate 90 mg/10 ml vial MO pamidronate disod 30 mg vial MO pamidronate disod 90 mg vial MO PANHEMATIN 313 MG IV SOLUTION MO PERIO MED DENTAL RINSE MO PHOS-FLUR 1.1 % DENTAL GEL MO PREVIDENT 0.2 % DENTAL SOLN MO PREVIDENT 1.1 % GEL MO PREVIDENT 5000 BOOSTER 1.1 % DENTAL PASTE MO

TIER
4 4 1 2 2 3 3 4 4 4 2 4 5 5 5 5 5 3 3 3 5 5 5 5 5 3 3 3 3 3 5 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D

B vs D B vs D B vs D B vs D PA PA PA

PA,QL (20 per 30 days) PA PA PA PA PA PA PA PA

B vs D B vs D B vs D B vs D B vs D B vs D

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DRUG NAME
PREVIDENT 5000 DRY MOUTH 1.1 % GEL MO PREVIDENT 5000 ENAMEL PROTECT 1.1 %-5 % DENTAL PASTE MO PREVIDENT 5000 PLUS 1.1 % CREAM MO PREVIDENT 5000 SENSITIVE 1.1 %-5 % DENTAL PASTE MO PROGRAF 0.5 MG CAPSULE MO PROGRAF 1 MG CAPSULE MO PROGRAF 5 MG CAPSULE MO PROGRAF 5 MG/ML IV MO PROLIA 60 MG/ML SUB-Q SYRINGE MO RAPAMUNE 0.5 MG TABLET MO RAPAMUNE 1 MG TABLET MO RAPAMUNE 1 MG/ML ORAL SOLN MO RAPAMUNE 2 MG TABLET MO REBIF 22 MCG/0.5 ML SUB-Q SYRINGE SP REBIF 44 MCG/0.5 ML SUB-Q SYRINGE SP REBIF TITRATION PACK 8.8 MCG/0.2 ML-22 MCG/0.5 ML SUB-Q SYRINGE SP RECLAST 5 MG/100 ML IV MO REMICADE 100 MG IV SOLUTION MO renaf fluoride 0.25 mg tb chew MO renaf fluoride 0.5 mg tab chew MO renaf fluoride 1 mg tab chew MO SANDOSTATIN 1,000 MCG/ML INJECTION MO SANDOSTATIN 100 MCG/ML INJECTION MO SANDOSTATIN 200 MCG/ML INJECTION MO SANDOSTATIN 50 MCG/ML INJECTION MO SANDOSTATIN 500 MCG/ML INJECTION MO SANDOSTATIN LAR DEPOT 10 MG IM KIT MO SANDOSTATIN LAR DEPOT 20 MG IM KIT MO SANDOSTATIN LAR DEPOT 30 MG IM KIT MO SENSIPAR 30 MG TABLET MO SENSIPAR 60 MG TABLET MO SENSIPAR 90 MG TABLET MO sf 1.1 % dental gel MO sf 5000 plus 1.1 % dental cream MO SIMULECT 10 MG IV SOLUTION MO

TIER
4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 4 5 1 1 1 5 5 5 4 5 5 5 5 3 5 5 2 2 5

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D PA,QL (60 per 180 days) B vs D B vs D B vs D B vs D PA,QL (12 per 30 days) PA,QL (12 per 30 days) PA,QL (12 per 30 days) PA,QL (100 per 365 days) PA

PA PA PA PA PA PA PA PA QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days)

B vs D

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DRUG NAME
SIMULECT 20 MG IV SOLUTION MO SKELID 240 MG TABLET MO sodiphluor 0.5 mg/ml drops MO sodium fluoride 0.5 mg/ml drop MO sodium fluoride 1 mg (2.2 mg) MO sodium nitrite 300 mg/10 ml vl MO sodium thiosulfat 12.5 g/50 ml MO sodium thiosulfate 1 g/10 ml MO SOMATULINE DEPOT 120 MG/0.5 ML SUB-Q SYRINGE SP SOMATULINE DEPOT 60 MG/0.2 ML SUB-Q SYRINGE SP SOMATULINE DEPOT 90 MG/0.3 ML SUB-Q SYRINGE SP stannous fluor 0.63% rinse MO tacrolimus 0.5 mg capsule MO tacrolimus 1 mg capsule MO tacrolimus 5 mg capsule MO THALOMID 100 MG CAPSULE SP THALOMID 150 MG CAPSULE SP THALOMID 200 MG CAPSULE SP THALOMID 50 MG CAPSULE SP THYMOGLOBULIN 25 MG IV SOLUTION MO TYSABRI 300 MG/15 ML IV MO ULORIC 40 MG TABLET MO ULORIC 80 MG TABLET MO XGEVA 120 MG/1.7 ML (70 MG/ML) SUB-Q MO XIGRIS 20 MG VIAL MO XIGRIS 5 MG VIAL MO ZAVESCA 100 MG CAPSULE SP ZINECARD 250 MG IV SOLUTION MO ZINECARD 500 MG IV SOLUTION MO ZOMETA 4 MG/100 ML IV MO ZOMETA 4 MG/5 ML IV MO ZORTRESS 0.25 MG TABLET MO ZORTRESS 0.5 MG TABLET MO ZORTRESS 0.75 MG TABLET MO ZYLOPRIM 100 MG TABLET MO ZYLOPRIM 300 MG TABLET MO

TIER
5 4 1 1 1 1 1 1 5 5 5 2 2 2 2 5 5 5 5 3 5 3 3 5 5 4 5 5 5 5 5 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D

PA,QL (1 per 28 days) PA,QL (1 per 28 days) PA,QL (1 per 28 days) B vs D B vs D B vs D PA,QL (30 per 30 days) PA,QL (60 per 30 days) PA,QL (30 per 30 days) PA,QL (30 per 30 days) B vs D PA ST,QL (30 per 30 days) ST,QL (30 per 30 days) PA,QL (2 per 28 days)

QL (90 per 30 days) B vs D B vs D PA,QL (300 per 21 days) PA,QL (15 per 21 days) B vs D,QL (60 per 30 days) B vs D,QL (60 per 30 days) B vs D,QL (60 per 30 days)

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DRUG NAME
OXYTOCICS CERVIDIL 10 MG VAGINAL INSERT,CONTROLLED RELEASE MO HEMABATE 250 MCG/ML IM MO METHERGINE 0.2 MG TABLET MO METHERGINE 0.2 MG/ML AMPUL MO methylergonovine 0.2 mg tablet MO methylergonovine 0.2 mg/ml amp MO oxytocin 10 units/ml vial MO PITOCIN 10 UNIT/ML INJECTION MO PREPIDIL 0.5 MG/3 G VAGINAL GEL MO PROSTIN E2 20 MG VAGINAL SUPPOSITORY MO PHARMACEUTICAL AIDS FORMA-RAY 20 % SOLN MO GAUZE PAD 3" X 3" BANDAGE MO STERILE BANDAGE ROLL 2.25"X3YD MO STERILE GAUZE PAD 2" X 2" BANDAGE MO STERILE GAUZE PAD 4" X 4" BANDAGE MO STERILE PADS 2" X 2" BANDAGE MO STERILE PADS 3" X 3" BANDAGE MO STERILE PADS 4" X 4" BANDAGE MO STERILE PADS BANDAGE MO STERILE STRETCH GAUZE BANDAGE 2" X 2 YARD MO STERILE STRETCH GAUZE BANDAGE 3" X 147" MO VEHICLE/N MILD TOPICAL SOLN MO VEHICLE/N TOPICAL SOLN MO RESPIRATORY TRACT AGENTS acetylcysteine 10% vial MO acetylcysteine 20% vial MO ADVAIR DISKUS 100 MCG-50 MCG/DOSE FOR INHALATION MO ADVAIR DISKUS 250 MCG-50 MCG/DOSE FOR INHALATION MO ADVAIR DISKUS 500 MCG-50 MCG/DOSE FOR INHALATION MO ADVAIR HFA 115 MCG-21 MCG/ACTUATION AEROSOL INHALER MO ADVAIR HFA 230 MCG-21 MCG/ACTUATION AEROSOL INHALER MO ADVAIR HFA 45 MCG-21 MCG/ACTUATION AEROSOL INHALER MO AEROBID AEROSOL WITH ADAPTER MO AEROBID-M AEROSOL WITH ADAPTER MO

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UTILIZATION MANAGEMENT REQUIREMENTS

4 4 4 4 3 3 1 4 4 4 1 1 1 1 1 1 1 2 1 1 1 4 4 2 3 3 3 3 3 3 3 4 4

PA

B vs D B vs D QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (12 per 30 days) QL (12 per 30 days) QL (12 per 30 days) QL (21 per 30 days) QL (21 per 30 days)

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DRUG NAME
ALVESCO 160 MCG/ACTUATION AEROSOL INHALER MO ALVESCO 80 MCG/ACTUATION AEROSOL INHALER MO ARALAST 1,000 MG VIAL MO ARALAST NP 1,000 MG IV SUSP MO ARALAST NP 500 MG IV SUSP MO ASMANEX TWISTHALER 110 MCG (30 DOSES) BREATH ACTIVATED MO ASMANEX TWISTHALER 110 MCG (7 DOSES) BREATH ACTIVATED MO ASMANEX TWISTHALER 220 MCG (120 DOSES) BREATH ACTIVATED MO ASMANEX TWISTHALER 220 MCG (14 DOSES) BREATH ACTIVATED MO ASMANEX TWISTHALER 220 MCG (30 DOSES) BREATH ACTIVATED MO ASMANEX TWISTHALER 220 MCG (60 DOSES) BREATH ACTIVATED MO budesonide 0.25 mg/2 ml susp MO budesonide 0.5 mg/2 ml susp MO cromolyn 20 mg/2 ml neb soln MO cromolyn 4% eye drops MO cromolyn sodium 100 mg/5 ml MO CUROSURF 120 MG/1.5 ML INTRATRACHEAL SUSP MO CUROSURF 240 MG/3 ML INTRATRACHEAL SUSP MO DALIRESP 500 MCG TABLET MO DULERA 100 MCG-5 MCG/ACTUATION HFA AEROSOL INHALER MO DULERA 200 MCG-5 MCG/ACTUATION HFA AEROSOL INHALER MO FLOVENT DISKUS 100 MCG/ACTUATION FOR INHALATION MO FLOVENT DISKUS 250 MCG/ACTUATION FOR INHALATION MO FLOVENT DISKUS 50 MCG/ACTUATION FOR INHALATION MO FLOVENT HFA 110 MCG/ACTUATION AEROSOL INHALER MO FLOVENT HFA 220 MCG/ACTUATION AEROSOL INHALER MO FLOVENT HFA 44 MCG/ACTUATION AEROSOL INHALER MO GASTROCROM 100 MG/5 ML ORAL SOLN MO GLASSIA 1 GRAM/50 ML (2 %) IV MO INFASURF 35 MG/ML INTRATRACHEAL SUSP MO KALYDECO 150 MG TABLET MO montelukast sod 10 mg tablet MO montelukast sod 4 mg tab chew MO montelukast sod 5 mg tab chew MO PROLASTIN 1,000 MG IV SUSP MO PROLASTIN 500 MG IV SUSP MO

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4 4 5 5 5 3 3 3 3 3 3 4 4 2 2 2 4 5 4 3 3 3 3 3 3 3 3 5 5 4 5 2 2 2 5 5

QL (18 per 28 days) QL (18 per 28 days) PA PA PA QL (0 per 28 days) QL (0 per 28 days) QL (0 per 28 days) QL (0 per 28 days) QL (0 per 28 days) QL (0 per 28 days) B vs D B vs D B vs D

UTILIZATION MANAGEMENT REQUIREMENTS

QL (30 per 30 days) QL (13 per 30 days) QL (13 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (24 per 30 days) QL (24 per 30 days) QL (11 per 30 days) PA PA,QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) PA PA

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DRUG NAME
PROLASTIN C 1,000 MG IV SUSP MO QVAR 40 MCG/ACTUATION AEROSOL INHALER MO QVAR 80 MCG/ACTUATION AEROSOL INHALER MO SINGULAIR 10 MG TABLET MO SINGULAIR 4 MG CHEWABLE TABLET MO SINGULAIR 4 MG ORAL GRANULES IN PACKET MO SINGULAIR 5 MG CHEWABLE TABLET MO SURVANTA 25 MG/ML INTRATRACHEAL SUSP MO SYMBICORT 160 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER MO SYMBICORT 80 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER MO XOLAIR 150 MG SUB-Q SOLN MO zafirlukast 10 mg tablet MO zafirlukast 20 mg tablet MO ZEMAIRA 1,000 MG IV SUSP MO ZYFLO CR 600 MG TABLET,EXTENDED RELEASE MO SERUMS, TOXOIDS, AND VACCINES ACTHIB (PF) 10 MCG/0.5 ML IM MO ADACEL (ADOLESCENT & ADULT) (PF) 2 LF-(5-3-5MCG)-5 LF/0.5 ML IM SUSP MO ADACEL (ADOLESCENT & ADULT) (PF) 2 LF-(5-3-5MCG)-5 LF/0.5ML IM SYRINGE MO antivenin micrurus fulvius MO BCG VACCINE (TICE STRAIN) VIAL MO BOOSTRIX (PF) 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP MO BOOSTRIX (PF) 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SYRINGE MO carimune nf nanofiltered 12 g iv solution MO carimune nf nanofiltered 3 gram iv solution MO carimune nf nanofiltered 6 gram iv solution MO CERVARIX VACCINE (PF) 20 MCG-20 MCG/0.5 ML IM SYRINGE MO CERVARIX VACCINE VIAL MO COMVAX (PF) 5 MCG-7.5 MCG-125 MCG/0.5 ML IM MO CYTOGAM 50 MG/ML IV MO DAPTACEL (PEDIATRIC) (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP
MO

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5 3 3 4 4 4 4 4 3 3 5 3 3 5 4 4 4 4 1 4 4 4 5 5 5 4 4 4 5 4 4 5 4

PA QL (37 per 30 days) QL (22 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days) ST,QL (30 per 30 days) QL (11 per 30 days) QL (11 per 30 days) PA,QL (900 per 28 days) QL (60 per 30 days) QL (60 per 30 days) PA QL (120 per 30 days)

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D

PA PA PA

PA,QL (1050 per 30 days)

DECAVAC VIAL MO DIGIBIND 38 MG VIAL MO DIGIFAB 40 MG IV SOLUTION MO

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DRUG NAME
diphtheria-tetanus tox-ped MO diphtheria-tetanus toxoids-ped MO ENGERIX-B (PF) 10 MCG/0.5 ML IM SUSP MO ENGERIX-B (PF) 10 MCG/0.5 ML IM SYRINGE MO ENGERIX-B (PF) 20 MCG/ML IM SUSP MO ENGERIX-B (PF) 20 MCG/ML IM SYRINGE MO flebogamma dif 5 % iv MO GAMASTAN S/D 15 %-18 % RANGE IM MO GAMASTAN S/D SYRINGE MO gammagard liquid 10 % iv MO GAMMAGARD S-D (IGA<1UG/ML) 10 GRAM IV SOLUTION MO GAMMAGARD S-D (IGA<1UG/ML) 5 GRAM IV SOLUTION MO GAMMAGARD S-D 0.5 GM VL W-ST MO GAMMAGARD S/D 10 GRAM IV SOLUTION MO GAMMAGARD S/D 2.5 G IV SOLUTION MO GAMMAGARD S/D 5 GRAM IV SOLUTION MO GAMMAKED 1 GRAM/10 ML (10 %) INJECTION MO GAMMAKED 10 GRAM/100 ML (10 %) INJECTION MO GAMMAKED 2.5 GRAM/25 ML (10 %) INJECTION MO GAMMAKED 20 GRAM/200 ML (10 %) INJECTION MO GAMMAKED 5 GRAM/50 ML (10 %) INJECTION MO gammaplex 5 % iv MO GAMUNEX 10 % IV MO GAMUNEX-C 1 GRAM/10 ML (10 %) INJECTION MO GAMUNEX-C 10 GRAM/100 ML (10 %) INJECTION MO GAMUNEX-C 2.5 GRAM/25 ML (10 %) INJECTION MO GAMUNEX-C 20 GRAM/200 ML (10 %) INJECTION MO GAMUNEX-C 5 GRAM/50 ML (10 %) INJECTION MO GARDASIL (PF) 20MCG-40MCG-40MCG-20MCG/0.5ML IM SUSP MO GARDASIL (PF) 20MCG-40MCG-40MCG-20MCG/0.5ML IM SYRINGE MO HAVRIX (PF) 1,440 ELISA UNIT/ML IM SUSP MO HAVRIX (PF) 1,440 ELISA UNIT/ML IM SYRINGE MO HAVRIX (PF) 720 ELISA UNIT/0.5 ML IM SUSP MO HAVRIX (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE MO HIBERIX VACCINE VIAL MO HIZENTRA 1 GRAM/5 ML (20 %) SUB-Q MO

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4 4 4 4 4 4 5 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA QL (3 per 365 days) QL (3 per 365 days)

PA

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DRUG NAME
HIZENTRA 2 GRAM/10 ML (20 %) SUB-Q MO HIZENTRA 4 GRAM/20 ML (20 %) SUB-Q MO HYPERRAB S/D (PF) 150 UNIT/ML IM MO HYPERRAB S/D SYRINGE MO HYPERRHO S/D 1,500 UNIT (300 MCG) IM SYRINGE MO hyperrho s/d 250 unit (50 mcg) im syringe MO HYPERTET S/D (PF) 250 UNIT IM SYRINGE MO IMOGAM RABIES-HT (PF) 150 UNIT/ML IM MO IMOVAX RABIES VACCINE (PF) 2.5 UNIT IM MO INFANRIX (PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SUSP MO INFANRIX (PF) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE MO INFLUENZA A (H1N1) 2009 SYR MO INFLUENZA A (H1N1) 2009 VIAL MO IPOL 40 UNIT-8 UNIT-32 UNIT/0.5 ML SUSP FOR INJECTION MO IPOL 40 UNIT-8 UNIT-32 UNIT/0.5 ML SYRINGE MO IXIARO (PF) 6 MCG/0.5 ML IM SYRINGE MO JE-VAX SUB-Q SOLN MO KINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SUSP MO KINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE MO M-M-R II (PF) 1,000-12,500 TCID50/0.5 ML SUB-Q SUSP MO MENACTRA (PF) 4 MCG/0.5 ML IM MO MENACTRA 4 MCG/0.5 ML SYRINGE MO MENOMUNE - A/C/Y/W-135 (PF) 50 MCG SUB-Q SOLN MO MENOMUNE - A/C/Y/W-135 50 MCG SUB-Q SOLN MO MENVEO A-C-Y-W-135-DIP (PF) 10 MCG-5 MCG/0.5 ML IM KIT MO MICRHOGAM ULTRA-FILTERED PLUS 250 UNIT (50 MCG) IM SYRINGE MO MICRHOGAM ULTRA-FILTRD SYRN MO NABI-HB >1,560 UNIT/5 ML IM MO NABI-HB >312 UNIT/ML IM MO OCTAGAM 5 % IV MO PEDIARIX (PF) 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRINGE MO PEDVAX HIB (PF) 7.5 MCG/0.5 ML IM MO PENTACEL (PF) 15 LF UNIT-20 MCG-5 LF /0.5ML IM KIT MO PREVNAR 13 (PF) 0.5 ML IM SYRINGE MO privigen 10 % soln MO PROQUAD (PF) 10EXP3-4.3-3-3.99TCID50/0.5ML SUB-Q MO

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5 5 4 4 4 4 4 4 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 4 4 4 4 5 4

UTILIZATION MANAGEMENT REQUIREMENTS


PA PA

B vs D

PA

PA

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DRUG NAME
RABAVERT (PF) 2.5 UNIT IM KIT MO RECOMBIVAX HB (PF) 10 MCG/ML IM SUSP MO RECOMBIVAX HB (PF) 10 MCG/ML IM SYRINGE MO RECOMBIVAX HB (PF) 40 MCG/ML IM SUSP MO RECOMBIVAX HB (PF) 5 MCG/0.5 ML IM SUSP MO RECOMBIVAX HB (PF) 5 MCG/0.5 ML IM SYRINGE MO RHOGAM ULTRA-FILTERED PLUS 1,500 UNIT (300 MCG) IM SYRINGE MO RHOGAM ULTRA-FILTERED SYRINGE MO RHOPHYLAC 1,500 UNIT (300 MCG)/2 ML SYRINGE MO ROTARIX 10EXP6 CCID50/ML ORAL SUSP MO ROTATEQ VACCINE 2 ML ORAL SUSP MO TENIVAC (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP MO TENIVAC (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE MO tetanus diphtheria toxoids MO tetanus toxoid adsorbed vial MO TETANUS-DIPHTERIA-DECAVAC MO THERACYS 81 MG INTRAVESICAL SUSP MO TICE BCG 50 MG INTRAVESICAL SUSP MO TRIHIBIT PRESERVATIVE FREE MO TRIPEDIA (PF) 6.7 LF UNIT-46.8 MCG-5/0.5 ML IM SUSP MO TWINRIX (PF) 720 ELISA UNIT-20 MCG/ML IM SUSP MO TWINRIX (PF) 720 ELISA UNIT-20 MCG/ML IM SYRINGE MO TYPHIM VI 25 MCG/0.5 ML IM MO TYPHIM VI 25 MCG/0.5 ML IM SYRINGE MO VAQTA (PF) 25 UNIT/0.5 ML IM SUSP MO VAQTA (PF) 25 UNIT/0.5 ML IM SYRINGE MO VAQTA (PF) 50 UNIT/ML IM SUSP MO VAQTA (PF) 50 UNIT/ML IM SYRINGE MO VARIVAX (PF) 1,350 UNIT/0.5 ML SUB-Q SOLN MO YF-VAX (PF) 10 EXP4.74 UNIT/0.5 ML SUB-Q SUSP MO ZOSTAVAX (PF) 19,400 UNIT SUB-Q SOLN MO SKIN AND MUCOUS MEMBRANE AGENTS 8-MOP 10 MG CAPSULE MO acid jelly MO acticin 5% cream MO ACZONE 5 % TOPICAL GEL MO

TIER
3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 4 2 3 4

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D B vs D B vs D B vs D B vs D B vs D

B vs D B vs D

QL (1 per 365 days)

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DRUG NAME
adapalene 0.1% cream MO adapalene 0.1% gel MO AKNE-MYCIN 2 % OINTMENT MO ALA-CORT 1 % TOPICAL CREAM MO ALA-SCALP 2 % LOTION MO alclometasone dipr 0.05% oint MO alclometasone dipro 0.05% crm MO ALCOHOL PADS MO ALCOHOL PREP PADS MO ALCOHOL PREP SWABS MO ALCOHOL WIPES MO aliclen 6 % shampoo MO ALTABAX 1 % OINTMENT MO amcinonide 0.1% cream MO amcinonide 0.1% lotion MO amcinonide 0.1% ointment MO AMERICAINE LUBRICANT MO ammonium lactate 12% cream MO ammonium lactate 12% lotion MO amnesteem 10 mg capsule MO amnesteem 20 mg capsule MO amnesteem 40 mg capsule MO ANACAINE 10 % OINTMENT MO ANUSOL-HC 2.5 % RECTAL CREAM MO apexicon 0.05 % ointment MO apexicon e 0.05 % topical cream MO AVC VAGINAL 15 % CREAM MO AZELEX 20 % TOPICAL CREAM MO BACTROBAN 2 % OINTMENT MO BACTROBAN 2 % TOPICAL CREAM MO BD ALCOHOL SWAB TOPICAL PADS MO bencort lotion MO benprox 2.75% gel MO benprox 5.25% wash MO bensal hp 3 %-6 % ointment MO BENZAC AC 10% GEL MO

TIER
4 4 4 2 3 2 2 1 1 1 1 2 4 3 2 2 4 2 2 3 3 3 4 4 3 3 2 4 4 4 1 1 2 2 2 4

UTILIZATION MANAGEMENT REQUIREMENTS

PA

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DRUG NAME
BENZAC AC 5 % TOPICAL GEL MO benzac ac wash 10 % topical cleanser MO BENZAC AC WASH 5% LIQUID MO benzac w wash 10 % topical cleanser MO BENZAC W WASH 5% LIQUID MO BENZACLIN 1 %-5 % TOPICAL GEL MO BENZACLIN CAREKIT MO BENZACLIN PUMP 1 %-5 % TOPICAL GEL MO BENZASHAVE 10% CREAM MO BENZASHAVE 5% CREAM MO BENZIQ LS 2.75% GEL MO benzoin tincture MO benzoyl perox 4% creamy wash MO benzoyl perox 8% creamy wash MO benzoyl peroxide 10% gel MO benzoyl peroxide 10% wash MO benzoyl peroxide 2.5% gel MO benzoyl peroxide 2.5% wash MO benzoyl peroxide 3% cleanser MO benzoyl peroxide 3% pad MO benzoyl peroxide 4% lotion MO benzoyl peroxide 4.5% cleanser MO benzoyl peroxide 5% gel MO benzoyl peroxide 5% wash MO benzoyl peroxide 6% cleanser MO benzoyl peroxide 6% pad MO benzoyl peroxide 6.5% cleanser MO benzoyl peroxide 6.5% pads MO benzoyl peroxide 8% lotion MO benzoyl peroxide 8.5% cleanser MO benzoyl peroxide 8.5% pads MO benzoyl peroxide 9% cleanser MO benzoyl peroxide 9% pad MO BETA-VAL 0.1% CREAM MO beta-val 0.1% lotion MO betamethasone dp 0.05% crm MO

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4 1 4 1 4 4 4 4 4 4 4 1 2 2 2 2 2 2 2 2 2 2 2 2 4 2 2 2 2 2 2 4 2 4 4 3

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
betamethasone dp 0.05% lot MO betamethasone dp 0.05% oint MO betamethasone dp aug 0.05% crm MO betamethasone dp aug 0.05% gel MO betamethasone dp aug 0.05% lot MO betamethasone dp aug 0.05% oin MO betamethasone va 0.1% cream MO betamethasone va 0.1% lotion MO betamethasone valer 0.1% ointm MO bp 10-1 10 %-1 % topical cleanser MO bp 5.25 % topical susp MO bpo 4 % topical gel MO bpo 8 % topical gel MO BREVOXYL-4 GEL MO BREVOXYL-8 GEL MO calcipotriene 0.005% ointment MO calcipotriene 0.005% solution MO calcitrene 0.005 % ointment MO CAPEX 0.01 % SHAMPOO MO CARAC 0.5 % TOPICAL CREAM MO CARMOL 10% SCALP LOTION MO carmol 40 cream MO CARMOL 40 GEL MO CARMOL 40 LOTION MO CARMOL SCALP TREATMENT KIT MO CENTANY 2 % OINTMENT MO CENTANY AT 2 % OINTMENT TOPICAL KIT MO cerisa 10 %-1 % topical cleanser MO CETACAINE MEDICAL KIT E 2 %-2 %-14 % TOPICAL MO ciclodan 0.77 % topical cream MO ciclodan 8 % topical soln MO ciclopirox 0.77% cream MO ciclopirox 0.77% gel MO ciclopirox 0.77% topical susp MO ciclopirox 1% shampoo MO ciclopirox 8 % kit MO

TIER
3 3 3 3 3 3 2 2 2 2 1 2 2 4 4 4 3 3 4 4 4 2 4 4 4 4 3 1 4 3 3 3 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (60 per 30 days)

B vs D

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DRUG NAME
ciclopirox 8% solution MO claravis 10 mg capsule MO claravis 20 mg capsule MO claravis 30 mg capsule MO claravis 40 mg capsule MO CLEOCIN 100 MG VAGINAL SUPPOSITORY MO CLEOCIN 2 % VAGINAL CREAM MO CLEOCIN T 1 % LOTION MO CLEOCIN T 1 % SOLN MO CLEOCIN T 1 % TOPICAL GEL MO CLEOCIN T 1 % TOPICAL SWAB MO CLINAC BPO 7% GEL MO clinda-derm 1 % topical soln MO clindacin p 1 % topical swab MO CLINDAGEL 1 % TOPICAL MO clindamax 1 % lotion MO clindamax 1 % topical gel MO clindamycin 2% vaginal cream MO clindamycin ph 1% gel MO clindamycin ph 1% solution MO clindamycin phos 1% pledget MO clindamycin phosp 1% lotion MO clindamycin phosphate 1% foam MO clindamycin-benzoyl perox gel MO CLINDAREACH 1% KIT MO CLINDESSE 2 % VAGINAL CREAM,EXTENDED RELEASE MO clindets 1% pledgets MO clobetasol 0.05% cream MO clobetasol 0.05% gel MO clobetasol 0.05% ointment MO clobetasol 0.05% solution MO clobetasol emollient 0.05% crm MO clobetasol prop 0.05% foam MO CLODERM 0.1 % TOPICAL CREAM MO clotrimazole 1% cream MO clotrimazole 1% solution MO

TIER
3 3 3 3 3 4 4 4 4 4 4 4 1 2 4 3 3 3 3 3 2 3 4 4 4 4 2 3 3 2 4 2 3 4 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA

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DRUG NAME
clotrimazole 10 mg troche MO clotrimazole-betamethasone crm MO clotrimazole-betamethasone lot MO CNL 8 NAIL 8 % TOPICAL KIT MO colocort 100 mg/60 ml enema MO CONDYLOX 0.5 % TOPICAL GEL MO CONDYLOX 0.5 % TOPICAL SOLN MO CONSTANT CLENS SPRAY MO CORDRAN 0.05 % LOTION MO CORDRAN 4 MCG/CM2 TAPE MO CORDRAN SP 0.05 % TOPICAL CREAM MO cormax 0.05 % topical soln MO cormax 0.05% ointment MO cortalo 2% gel MO CORTENEMA 100 MG/60 ML MO CORTIFOAM 10 % (80 MG) RECTAL MO CORTISPORIN 1 % OINTMENT MO CORTISPORIN 3.5 MG/G-10,000 UNIT/G-0.5 % TOPICAL CREAM MO CURITY ALCOHOL SWABS MO CVS ALCOHOL SWABS MO DEBACTEROL 30 %-50 % MUCOSAL SWAB MO DENAVIR 1 % TOPICAL CREAM MO DERMA-SMOOTHE/FS BODY OIL 0.01 % TOPICAL MO DERMATOP 0.1 % OINTMENT MO DERMATOP 0.1 % TOPICAL CREAM MO DESONATE 0.05 % TOPICAL GEL MO desonide 0.05% cream MO desonide 0.05% lotion MO desonide 0.05% ointment MO desoximetasone 0.05% cream MO desoximetasone 0.05% gel MO desoximetasone 0.25% cream MO desoximetasone 0.25% ointment MO DESQUAM-X 10 % TOPICAL CLEANSER MO desquam-x 5 % topical cleanser MO diflorasone 0.05% cream MO

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2 3 3 4 4 4 4 4 4 4 4 4 2 4 4 4 4 4 1 1 4 4 4 4 4 4 3 3 3 4 4 4 4 4 1 4

UTILIZATION MANAGEMENT REQUIREMENTS

PA

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DRUG NAME
diflorasone 0.05% ointment MO DOAK TAR DISTILLATE LIQUID MO DRITHO-SCALP 0.5% CREAM MO DRITHOCREME HP 1 % TOPICAL MO DRYSOL DAB-O-MATIC 20 % TOPICAL SOLN MO DUAC CS CONVENIENCE KIT MO DURASAL 26% LIQUID MO EASY TOUCH ALCOHOL PREP PADS MO econazole nitrate 1% cream MO ELIDEL 1 % TOPICAL CREAM MO ELOCON 0.1 % LOTION MO ELOCON 0.1 % OINTMENT MO ELOCON 0.1 % TOPICAL CREAM MO emgel 2% topical gel MO EMLA 2.5 %-2.5 % TOPICAL CREAM MO EPIDUO 0.1 %-2.5 % TOPICAL GEL MO ery pads 2 % topical swab MO erythromycin 2% gel MO erythromycin 2% pledgets MO erythromycin 2% solution MO erythromycin-benzoyl gel MO EURAX 10 % LOTION MO EURAX 10 % TOPICAL CREAM MO EXELDERM 1 % TOPICAL CREAM MO EXELDERM 1 % TOPICAL SOLN MO exoderm 25 %-1 % lotion MO EXTINA 2 % TOPICAL FOAM MO FEM PH 0.9 %-0.025 % VAGINAL GEL MO fluocinolone 0.01% body oil MO fluocinolone 0.01% cream MO fluocinolone 0.01% solution MO fluocinolone 0.025% cream MO fluocinolone 0.025% oint MO fluocinonide 0.05% cream MO fluocinonide 0.05% gel MO fluocinonide 0.05% ointment MO

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3 4 4 4 4 4 4 1 2 4 4 4 4 2 4 4 2 2 2 2 3 4 4 4 4 1 4 4 2 2 2 2 2 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D

PA

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DRUG NAME
fluocinonide 0.05% solution MO fluocinonide-e 0.05 % topical cream MO fluocinonide-emol 0.05% cream MO FLUOROPLEX 1 % TOPICAL CREAM MO fluorouracil 2% topical soln MO fluorouracil 5% cream MO fluorouracil 5% top solution MO fluticasone prop 0.005% oint MO fluticasone prop 0.05% cream MO FORMADON 10 % TOPICAL SOLN MO formalaz 10% solution MO gentamicin 0.1% cream MO gentamicin 0.1% ointment MO GLUCOPRO ALCOHOL TOPICAL PADS MO GORDOFILM 16.7 %-16.7 % TOPICAL SOLN MO GORDONS UREA 22 % OINTMENT MO GORDONS UREA 40 % OINTMENT MO GUAIACOL LIQUID PURIFIED MO GYNAZOLE-1 2 % VAGINAL CREAM,EXTENDED RELEASE MO halac 0.05 %-12 % topical pack, ointment & lotion MO halobetasol prop 0.05% cream MO halobetasol prop 0.05% ointmnt MO HALOG 0.1 % OINTMENT MO HALOG 0.1 % TOPICAL CREAM MO halonate 0.05 %-12 % topical pack, ointment & foam MO halonate pac 0.05 %-12 % topical pack, ointment & lotion MO HALOTIN 1% CREAM MO HYDRO 40 40 % TOPICAL FOAM MO hydrocortisone 0.1% soln MO hydrocortisone 1% absorbase MO hydrocortisone 1% cream MO hydrocortisone 1% ointment MO hydrocortisone 100 mg enema MO hydrocortisone 2.5% lotion MO hydrocortisone 2.5% ointment MO hydrocortisone acetate 2% gel MO

TIER
2 2 2 4 4 4 4 2 2 4 2 2 2 1 4 4 4 4 4 3 3 3 4 4 4 3 4 4 2 1 2 2 1 2 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA

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DRUG NAME
hydrocortisone buty 0.1% cream MO hydrocortisone butyr 0.1% oint MO hydrocortisone val 0.2% cream MO hydrocortisone val 0.2% ointmt MO hypercare 20 % topical soln MO imiquimod 5% cream packet MO INOVA 4 %-5 % TOPICAL COMBO PACK MO INOVA 4-1 1 %-4 %-5 % TOPICAL COMBO PACK MO IV PREP WIPES MEDICATED MO KENALOG 0.147 MG/GRAM TOPICAL AEROSOL MO KEPIVANCE 6.25 MG SOLUTION MO KERAFOAM 30 % TOPICAL FOAM MO KERAFOAM 42 % TOPICAL FOAM MO keralac cream MO KERALAC NAILSTIK MO KERALAC OINTMENT MO KERALYT RX 6 % TOPICAL GEL MO KEROL 42% REDI-CLOTHS MO ketoconazole 2% cream MO ketoconazole 2% foam MO ketoconazole 2% shampoo MO ketodan 2 % topical foam MO KLARON 10 % TOPICAL SUSP MO kuric 2% cream MO LAC-HYDRIN 12 % LOTION MO LAC-HYDRIN 12 % TOPICAL CREAM MO laclotion 12 % MO lavoclen-4 (new cleanser) 4 % topical kit MO lavoclen-4 4 % topical cleanser MO lavoclen-8 (new cleanser) 8 % topical kit MO lavoclen-8 8 % topical cleanser MO LEVULAN 20 % TOPICAL SOLN MO LIDAMANTLE HC 3 %-0.5 % TOPICAL CREAM MO LIDAMANTLE HC LOTION MO lidocaine 3% cream MO lidocaine 5% ointment MO

TIER
2 2 2 2 1 4 4 4 1 4 5 4 4 1 4 4 4 4 2 4 2 4 4 2 4 4 3 2 2 2 2 4 4 4 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

QL (12 per 30 days)

PA B vs D B vs D

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DRUG NAME
lidocaine hcl 3% lotion MO lidocaine-hc 3-0.5% cream MO lidocaine-hc 3-0.5% cream kit MO lidocaine-hc 3-0.5% lotion MO lidocaine-hc 3-1% cream kit MO lidocaine-prilocaine cream MO LIDODERM 5 % (700 MG/PATCH) ADHESIVE PATCH MO lindane 1% lotion MO lindane 1% shampoo MO LOCOID 0.1 % LOTION MO LOCOID 0.1 % OINTMENT MO LOCOID 0.1 % TOPICAL CREAM MO LOCOID 0.1 % TOPICAL SOLN MO LOCOID LIPOCREAM 0.1 % TOPICAL MO lokara 0.05 % lotion MO LOTRISONE 1 %-0.05 % TOPICAL CREAM MO LTA PRE-ATTACHED 4 % LARYNGOTRACHEAL SOLN MO malathion 0.5% lotion MO MENTAX 1 % TOPICAL CREAM MO METROCREAM 0.75 % TOPICAL MO metronidazole 0.75% cream MO metronidazole 0.75% lotion MO metronidazole topical 0.75% gl MO metronidazole vaginal 0.75% gl MO METVIXIA 16.8 % (168 MG/GRAM) TOPICAL CREAM MO miconazole-3 200 mg vaginal suppository MO mometasone furoate 0.1% cream MO mometasone furoate 0.1% oint MO mometasone furoate 0.1% soln MO mupirocin 2% ointment MO myorisan 10 mg capsule MO myorisan 20 mg capsule MO myorisan 40 mg capsule MO NAFTIN 1 % TOPICAL GEL MO NAFTIN 2 % TOPICAL CREAM MO NEOBENZ MICRO CREAM PLUS PACK 5.5 % TOPICAL KIT MO

TIER
1 3 4 3 3 3 4 4 4 4 4 4 4 4 3 4 4 2 4 4 1 1 1 3 4 3 3 3 3 2 3 3 3 3 3 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D PA,QL (90 per 30 days)

B vs D

PA

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DRUG NAME
NEOBENZ MICRO SD 5.5% CREAM MO neomy-polymyxin b 40 mg/ml amp MO NEOSPORIN GU IRRIGANT 40 MG-200,000 UNIT/ML MO NIZORAL 2 % SHAMPOO MO NORITATE 1 % TOPICAL CREAM MO nuzole 2 % topical cream MO NUZON GEL MO nyamyc 100,000 unit/g topical powder MO nystatin 100,000 unit/gm cream MO nystatin 100,000 unit/gm powd MO nystatin 100,000 units/gm oint MO nystatin vaginal tablet MO nystatin-triamcinolone cream MO nystatin-triamcinolone ointm MO nystop 100,000 unit/g topical powder MO oralone 0.1 % dental paste MO oscion 3% cleanser MO oscion 3% pad MO oscion 6% cleanser MO oscion 6% pad MO oscion 9% cleanser MO oscion 9% pad MO OVACE PLUS SHAMPOO 10 % MO OVIDE 0.5 % LOTION MO OXALIS OINTMENT MO OXISTAT 1 % LOTION MO OXISTAT 1 % TOPICAL CREAM MO OXSORALEN 1 % LOTION MO OXSORALEN ULTRA 10 MG CAPSULE MO PAIN EASE TOPICAL SPRAY MO PANDEL 0.1 % TOPICAL CREAM MO PANRETIN 0.1 % TOPICAL GEL MO pedi-dri 100,000 unit/g topical powder MO permethrin 5% cream MO phenazopyridine 100 mg tab MO phenazopyridine 200 mg tab MO

TIER
4 3 4 4 4 3 4 2 2 2 2 2 2 2 2 1 2 1 2 1 2 1 4 4 4 4 4 4 5 4 4 5 2 3 2 2

UTILIZATION MANAGEMENT REQUIREMENTS

PA

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DRUG NAME
podocon 25 % topical liquid MO podofilox 0.5% topical soln MO PONTOCAINE 2 % TOPICAL SOLN MO prednicarbate 0.1% cream MO prednicarbate 0.1% ointment MO procto-pak 1 % rectal cream MO PROCTOCORT 1 % RECTAL CREAM MO proctocream-hc 2.5 % rectal MO proctosol hc 2.5 % rectal cream MO proctozone-hc 2.5 % rectal cream MO PYRIDIUM 100 MG TABLET MO PYRIDIUM 200 MG TABLET MO PYROGALLIC ACID 25 %-2 % OINTMENT MO re 40 gel MO re benzoyl peroxide 3.5% cream MO re benzoyl peroxide 5.5% cream MO re benzoyl peroxide 8.5% cream MO re sa 6% cream MO re sa 6% lotion MO re urea 40 lotion MO re-u40 foam MO REGRANEX 0.01 % TOPICAL GEL MO relagard 0.9 %-0.025 % vaginal gel MO remeven 50 % topical cream MO RIMSO-50 50 % INTRAVESICAL MO rosadan 0.75 % topical gel MO ROSULA AQUEOUS GEL MO ROSULA CLEANSER MO ROSULA NS MEDICATED PADS MO salacyn 6 % lotion MO SALEX 6 % SHAMPOO MO salicylic acid 6% gel MO salicylic acid 6% shampoo MO SANTYL 250 UNIT/G OINTMENT MO scalacort 2 % lotion MO scalp treatment kit MO

TIER
3 3 4 3 2 2 4 2 2 2 4 4 4 2 2 2 2 4 2 4 2 5 2 2 2 1 4 4 4 2 4 3 2 4 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

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DRUG NAME
selenium sulfide 2.25% shampoo MO selenium sulfide 2.5% lotion MO SELSEB 2.25% SHAMPOO MO SILVADENE 1 % TOPICAL CREAM MO silver nitrate 0.5% soln MO silver nitrate 10% ointment MO silver nitrate 10% solution MO silver nitrate 25% solution MO silver nitrate 50% solution MO silver sulfadiazine 1% cream MO sod sulfacet-sulfur 10-4% pad MO sod sulfacetamide-sulfur foam MO sod sulfacetamide-sulfur lotn MO sod.sulfacet-sulfur susp MO sodium sulfacetamide med pads MO sodium sulfacetamide-sulfur MO SORIATANE 10 MG CAPSULE MO SORIATANE 17.5 MG CAPSULE MO SORIATANE 22.5 MG CAPSULE MO SORIATANE 25 MG CAPSULE MO sotret 20 mg capsule MO SPRAY AND STRETCH TOPICAL MO SSD 1 % TOPICAL CREAM MO SSD AF 1% CREAM MO STELARA 45 MG/0.5 ML SUB-Q SYRINGE MO STELARA 45 MG/0.5 ML VIAL MO STELARA 90 MG/ML SUB-Q SYRINGE MO sulfacetamide sod 10% top susp MO sulfacetamide sodium 10% lot MO SULFAMYLON 50 GRAM TOPICAL PACKET MO SULFAMYLON 85 MG/G TOPICAL CREAM MO SURE COMFORT ALCOHOL PREP PADS MO SURE-PREP ALCOHOL PREP PADS MO SYNERA 70 MG-70 MG PATCH MO TACLONEX 0.005 %-0.064 % OINTMENT MO TACLONEX SCALP 0.005 %-0.064 % TOPICAL SUSP MO

TIER
2 2 4 4 1 1 1 1 1 2 2 2 2 2 2 2 5 5 5 5 3 4 2 2 5 5 5 2 2 4 4 1 1 4 3 3

UTILIZATION MANAGEMENT REQUIREMENTS

PA

PA,QL (3 per 84 days) PA,QL (3 per 84 days) PA,QL (3 per 84 days)

B vs D QL (120 per 30 days)

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DRUG NAME
TARGRETIN 1 % TOPICAL GEL SP TAZORAC 0.05 % TOPICAL CREAM MO TAZORAC 0.05 % TOPICAL GEL MO TAZORAC 0.1 % TOPICAL CREAM MO TAZORAC 0.1 % TOPICAL GEL MO TERAZOL 3 0.8 % VAGINAL CREAM MO TERAZOL 3 80 MG VAGINAL SUPPOSITORY MO TERAZOL 7 0.4 % VAGINAL CREAM MO terconazole 0.4% cream MO terconazole 0.8% cream MO terconazole 80 mg suppository MO TEXACORT 2.5 % TOPICAL SOLN MO THERMAZENE 1 % TOPICAL CREAM MO tretinoin 0.01% gel MO tretinoin 0.025% cream MO tretinoin 0.025% gel MO tretinoin 0.05% cream MO tretinoin 0.1% cream MO TRI-CHLOR 80 % TOPICAL SOLN MO triamcinolone 0.025% cream MO triamcinolone 0.025% lotion MO triamcinolone 0.025% oint MO triamcinolone 0.05% oint MO triamcinolone 0.1% cream MO triamcinolone 0.1% lotion MO triamcinolone 0.1% ointment MO triamcinolone 0.1% paste MO triamcinolone 0.5% cream MO triamcinolone 0.5% ointment MO TRIAZ 3% CLEANSER MO TRIAZ 3% PAD MO TRIAZ 6% CLEANSER MO TRIAZ 6% PAD MO TRIAZ 9% CLEANSER MO TRIAZ 9% PAD MO trichloroacetic acid 25% MO

TIER
5 4 4 4 4 4 4 4 2 2 2 4 2 3 3 3 3 3 4 2 2 2 2 2 2 2 2 2 2 4 4 4 4 4 4 1

UTILIZATION MANAGEMENT REQUIREMENTS


PA

PA PA PA PA PA

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DRUG NAME
trichloroacetic acid 70% MO trichloroacetic acid 75% MO trichloroacetic acid 80% MO triderm 0.1 % topical cream MO u-cort 1 %-10 % topical cream MO u40 foam MO ULTILET ALCOHOL SWAB MO UMECTA 40 % TOPICAL MO umecta 40 % topical foam MO UMECTA 40 % TOPICAL SUSP MO UMECTA PD 40 % TOPICAL EMULSION MO UMECTA PD 40 % TOPICAL SUSPENSION MO URAMAXIN 20 % TOPICAL FOAM MO urea 35% foam MO urea 40 gel MO urea 40 lotion MO urea 40% cream MO urea 40% gel MO urea 40% nail film susp MO urea 42% cloths MO urea 50% cream MO urea 50% nailstik MO urea 50% ointment MO urea nail stick 50 % topical soln MO UVADEX 20 MCG/ML INJECTION MO VANDAZOLE 0.75 % VAGINAL GEL MO VANOS 0.1 % TOPICAL CREAM MO VANOXIDE-HC 5 %-0.5 % TOPICAL SUSP MO VELTIN 1.2 %-0.025 % TOPICAL GEL MO VERDESO 0.05 % TOPICAL FOAM MO VEREGEN 15 % OINTMENT MO VERSICLEAR LOTION MO vitazol 0.75 % topical cream MO WEBCOL TOPICAL PADS MO WESTCORT 0.2 % OINTMENT MO x-viate 40 % lotion MO

TIER
1 1 1 2 2 2 1 4 4 4 4 4 4 4 1 3 2 2 4 2 2 2 2 4 4 3 4 4 4 4 4 4 4 1 4 2

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D

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DRUG NAME
x-viate 40 % topical cream MO x-viate 40 % topical gel MO XERAC AC 6.25 % TOPICAL SOLN MO zaclir 4% cleansing lotion MO zaclir 8% cleansing lotion MO zazole 0.4 % vaginal cream MO ZAZOLE 0.8 % VAGINAL CREAM MO ZODERM 4.5% CLEANSER MO ZODERM 4.5% CREAM MO ZODERM 4.5% GEL MO ZODERM 4.5% REDI-PADS MO ZODERM 6.5% CLEANSER MO ZODERM 6.5% CREAM MO ZODERM 6.5% GEL MO ZODERM 6.5% REDI-PADS MO ZODERM 8.5% CLEANSER MO ZODERM 8.5% CREAM MO ZODERM 8.5% GEL MO ZODERM 8.5% REDI-PADS MO ZOVIRAX 5 % OINTMENT MO ZOVIRAX 5 % TOPICAL CREAM MO ZYCLARA 2.5 % TOPICAL CREAM PUMP MO ZYCLARA 3.75 % TOPICAL CREAM PACKET MO ZYCLARA 3.75 % TOPICAL CREAM PUMP MO SMOOTH MUSCLE RELAXANTS aminophylline 100 mg tablet MO aminophylline 200 mg tablet MO aminophylline 250 mg/10 ml vl MO aminophylline 500 mg/20 ml vl MO DETROL 1 MG TABLET MO DETROL 2 MG TABLET MO DETROL LA 2 MG CAPSULE,EXTENDED RELEASE MO DETROL LA 4 MG CAPSULE,EXTENDED RELEASE MO ELIXOPHYLLIN 80 MG/15 ML MO ENABLEX 15 MG TABLET,EXTENDED RELEASE MO ENABLEX 7.5 MG TABLET,EXTENDED RELEASE MO

TIER
2 2 4 1 1 2 2 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2 3 3 3 3 2 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

PA ST QL (15 per 30 days) QL (15 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
flavoxate hcl 100 mg tablet MO GELNIQUE 10 % (100 MG/GRAM) TRANSDERMAL GEL PACKET MO GELNIQUE 28 MG/0.92 GRAM (3 %) TRANSDERMAL GEL PUMP MO LUFYLLIN 200 MG TABLET MO oxybutynin 5 mg tablet MO oxybutynin 5 mg/5 ml syrup MO oxybutynin cl er 10 mg tablet MO oxybutynin cl er 15 mg tablet MO oxybutynin cl er 5 mg tablet MO SANCTURA XR 60 MG CAPSULE,EXTENDED RELEASE MO theochron 100 mg tablet,extended release MO theochron 200 mg tablet,extended release MO theochron 300 mg tablet,extended release MO theophylline 200 mg/100 ml d5w MO theophylline 200 mg/50 ml d5w MO theophylline 400 mg/250 ml d5w MO theophylline 400 mg/500 ml d5w MO theophylline 80 mg/15 ml soln MO theophylline 800 mg/1 l d5w MO theophylline 800 mg/250 ml d5w MO theophylline 800 mg/500 ml d5w MO theophylline er 100 mg tablet MO theophylline er 200 mg tablet MO theophylline er 300 mg tab MO theophylline er 400 mg tablet MO theophylline er 450 mg tab MO theophylline er 600 mg tablet MO tolterodine tartrate 1 mg tab MO tolterodine tartrate 2 mg tab MO trospium chloride 20 mg tablet MO VESICARE 10 MG TABLET MO VESICARE 5 MG TABLET MO VITAMINS ATABEX EC 29 MG-1 MG-50 MG TABLET,DELAYED RELEASE MO bal-care dha 27 mg-1 mg-430 mg tablet&capsule,delayed release MO bp multinatal plus chew tablet MO

TIER
3 4 4 4 2 2 3 3 3 4 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 3 3 4 3 3 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


QL (30 per 30 days) QL (92 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days)

QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

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DRUG NAME
bp multinatal plus tablet MO CALCIJEX 1 MCG/ML IV MO calcitriol 0.25 mcg capsule MO calcitriol 0.5 mcg capsule MO calcitriol 1 mcg/ml ampul MO calcitriol 1 mcg/ml solution MO cavan one omega softgel MO cavan-ec sod dha 30 mg-1 mg-440 mg tablet&capsule,delayed release MO cavan-folate dha combo pack MO cavan-folate ob tablet MO cavan-heme ob tablet MO CITRANATAL 90 DHA (NEW FORMULA) 90 MG-1 MG-50 MG-300 MG ORAL PACK MO CITRANATAL ASSURE 35 MG-1 MG-50 MG-300 MG ORAL PACK MO CITRANATAL B-CALM PACK MO CITRANATAL DHA (NEW FORMULA) 27 MG-1 MG-50 MG-250 MG ORAL PACK MO CITRANATAL HARMONY CAPSULE MO CITRANATAL RX (NEW FORMULA) 27 MG-1 MG-50 MG TABLET MO co-natal fa 29 mg-1 mg tablet MO complete natal dha 29 mg-1 mg-250 mg oral pack MO complete-rf prenatal 90 mg-1 mg-50 mg tablet MO completenate 29 mg-1 mg chewable tablet MO CONCEPT DHA 35 MG-1 MG-200 MG CAPSULE MO CONCEPT OB 85 MG-1 MG CAPSULE MO corenate-dha combo pack MO dexpanthenol 250 mg/ml vial MO docosavit softgel MO DUET DHA COMPLETE COMBO PACK MO DUET DHA WITH OMEGA-3 25 MG IRON-1 MG-400 MG ORAL PACK MO DUET DHA WITH OMEGA-3 25 MG IRON-1 MG-430 MG ORAL PACK MO ED CYTE F TABLET MO edge ob caplet MO elite-ob 28 mg-1.25 mg-200 mg capsule MO elite-ob 400 35 mg-5 mg-1.2 mg-400 mg capsule MO elite-ob 50 mg-1.25 mg tablet MO

TIER
4 4 2 2 2 2 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 1 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS


B vs D B vs D B vs D B vs D B vs D

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DRUG NAME
FEMECAL OB TABLET MO folbecal 1 mg-200 mg-75 mg-12 mcg tablet,extended release MO folcaps care one capsule MO folinatal plus b 1 mg-200 mg-75 mg-12 mcg tablet,extended release MO folivane-ec calcium dha combo MO folivane-ob 85 mg-1 mg capsule MO folivane-prx dha nf 30 mg-1.24 mg-55 mg-265 mg capsule MO GESTICARE DHA 27 MG-1 MG-250 MG TABLET,EXTENDED RELEASE & CAPSULE MO GESTICARE TABLET MO HECTOROL 0.5 MCG CAPSULE MO HECTOROL 1 MCG CAPSULE MO HECTOROL 2 MCG/ML (1 ML) IV MO HECTOROL 2.5 MCG CAPSULE MO HECTOROL 4 MCG/2 ML IV MO ICAR-C PLUS SR CAPSULE MO inatal advance 90 mg-1 mg-50 mg tablet MO inatal gt tablet MO inatal ultra 90 mg-1 mg-50 mg tablet MO kolnatal dha dr combo pack MO lactocal-f 65 mg-1 mg tablet MO levomefolatepnv 29 mg-0.5 mg-1.4 mg-200 mg oral pack MO M-VIT 27 MG-1 MG TABLET MO MARNATAL-F 60 MG IRON-1 MG CAPSULE MO maternity 27 mg-1 mg tablet MO MAXINATE 20 MG-0.8 MG TABLET MO MULTI-NATE 30 DHA 430 MG VIT MO MULTI-NATE 30 DHA PRENATAL VIT MO multi-nate 30 tablet MO MULTI-NATE DHA EXTRA PRENATAL MO multi-vitamin with fluoride 0.25 mg chewable tablet MO multi-vitamin with fluoride 0.5 mg chewable tablet MO multi-vitamin with fluoride 1 mg chewable tablet MO multivit-fluor 0.5 mg tab chew MO multivitamin with fluoride 0.5 mg chewable tablet MO

TIER
4 4 4 4 4 4 4 4 4 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 4 4 1 1

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D B vs D

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DRUG NAME
multivitamins with fluoride 0.5 mg chewable tablet MO multivitamins with fluoride 1 mg chewable tablet MO MVC-FLUORIDE 0.25 MG CHEWABLE TABLET MO MVC-FLUORIDE 0.5 MG CHEWABLE TABLET MO MVC-FLUORIDE 1 MG CHEWABLE TABLET MO MYKIDZ IRON FLUORIDE 10 MG-0.25 MG-1,500 UNIT/2 ML ORAL SUSP
MO

TIER
1 1 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

MYNATAL 65 MG-1 MG CAPSULE MO mynatal 90 mg-1 mg-50 mg tablet MO mynatal advance 90 mg-1 mg-50 mg tablet MO mynatal plus 65 mg-1 mg tablet MO mynatal-z 65 mg-1 mg tablet MO mynate 90 plus 90 mg-1 mg tablet,extended release MO NATA KOMPLETE 25 MG IRON-1 MG TABLET MO NATACHEW TABLET CHEW MO NATAFORT TABLET MO NATALVIT 75 MG-1 MG TABLET MO NATELLE-EZ TABLET MO navatab + dha pack MO NEEVO CAPLET MO NEEVO DHA CAPSULE MO O-CAL FA 66 MG-1 MG TABLET MO O-CAL PRENATAL 15 MG-1 MG TABLET MO ob-natal one 27 mg-1 mg-330 mg capsule MO obstetrix dha 29 mg iron-1 mg-50 mg tablet&capsule,delayed release
MO

OBSTETRIX EC 29 MG-1 MG-50 MG TABLET,DELAYED RELEASE MO OBTREX 29 MG-1 MG-50 MG TABLET MO OBTREX DHA 29 MG IRON-1 MG-50 MG TABLET&CAPSULE,DELAYED RELEASE MO paire ob plus dha 22 mg-6 mg-1 mg-200 mg oral pack MO pnv ob+dha 27 mg-1 mg-50 mg-250 mg oral pack MO pnv-dha 27 mg-1 mg-300 mg capsule MO pnv-omega 28 mg-1 mg-300 mg capsule MO pnv-select 27 mg-1 mg tablet MO pnv-total 35 mg-5 mg-1.2 mg-400 mg capsule MO poly iron pn forte tablet MO

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DRUG NAME
poly iron pn tablet MO polyvit-iron-fl 0.5 mg/ml MO pr natal 400 29 mg-1 mg-400 mg oral pack MO pr natal 400 ec 29 mg-1 mg-400 mg tablet&capsule,delayed release MO pr natal 430 29 mg-1 mg-430 mg oral pack MO pr natal 430 ec 29 mg-1 mg-430 mg tablet&capsule,delayed release
MO

TIER
4 1 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

pr natal 440 ec combo pack MO PRECARE CHEWABLE TABLET MO PRECARE CONCEIVE TABLET MO PRECARE PREMIER CAPLETS MO PREMESIS RX TABLET MO prenacare tablet MO prenafirst 17 mg-1 mg tablet MO prenaplus 27 mg-1 mg tablet MO PRENATA 29 MG IRON-1 MG CHEWABLE TABLET MO PRENATABS FA 29 MG-1 MG TABLET MO PRENATABS RX 29 MG-1 MG TABLET MO prenatal 19 29 mg-1 mg chewable tablet MO prenatal 19 29 mg-1 mg tablet MO prenatal ad 90 mg-1 mg-50 mg tablet MO prenatal low iron 27 mg-1 mg tablet MO prenatal plus (calcium carbonate) 27 mg-1 mg tablet MO prenatal plus with iron (calcium carbonate) 27 mg-1 mg tablet MO PRENATAL-U 106.5 MG-1 MG CAPSULE MO PRENATE DHA 28 MG IRON-1 MG-300 MG CAPSULE MO PRENATE ELITE 26 MG IRON-1 MG TABLET MO PRENATE ELITE TABLET MO PRENATE ESSENTIAL 29 MG IRON-1 MG-300 MG CAPSULE MO PRENATE ESSENTIAL SOFTGEL MO prenate plus tablet MO PREQUE 10 15 MG IRON-0.5 MG-25 MG TABLET MO PREQUE 10 TABLET MO previte rx tablet MO PRIMACARE ADVANTAGE COMBO PACK MO

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DRUG NAME
PRIMACARE ONE SOFTGEL MO re dualvit ob capsule MO re multivit-fluor 0.25 mg tab MO re multivit-fluor 0.5 mg tab MO re multivit-fluor 1 mg tab chw MO re ob + dha pack MO RE OB 90 + DHA PACK MO re prenatal multivit w-iron tb MO re previt+dha softgel MO re-nata 29 ob prenatal tablet MO re-nata 29 prenatal tablet MO relnate dha 28 mg-1 mg-200 mg capsule MO ROCALTROL 0.25 MCG CAPSULE MO ROCALTROL 0.5 MCG CAPSULE MO ROCALTROL 1 MCG/ML ORAL SOLN MO se-care chewable tablet MO se-care conceive tablet MO se-care gesture tablet MO se-natal 19 29 mg-1 mg chewable tablet MO se-natal 19 29 mg-1 mg tablet MO se-natal 90 dr tablet MO se-natal one tablet MO se-plete dha softgel MO se-tan dha 30 mg-1 mg-310.1 mg capsule MO SELECT-OB + DHA 29 MG IRON-1 MG-250 MG ORAL PACK MO SELECT-OB 29 MG-1 MG CHEWABLE TABLET MO setonet 29 mg-1 mg-430 mg oral pack MO SETONET-EC 29 MG-1 MG-430 MG TABLET&CAPSULE,DELAYED RELEASE
MO

TIER
4 4 1 1 1 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D

TANDEM DHA CAPSULE MO TANDEM OB CAPSULE MO taron ec calcium dha comb pack MO taron-bc 20 mg iron-1 mg/25 mg tablets MO taron-c dha 35 mg-1 mg-200 mg capsule MO TARON-DUO EC 29 MG-1 MG-400 MG TABLET&CAPSULE,DELAYED RELEASE MO

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DRUG NAME
taron-ec cal tablet MO taron-prex prenatal-dha 30 mg iron-1.2 mg-55 mg-265mg capsule MO tri rx 27 mg-1 mg-50 mg tablet MO tri-vit with fluoride & iron 0.25 mg-10 mg/ml oral drops MO tri-vit-fluor-iron 0.25 mg/ml MO tri-vitamin with fluoride 0.5 mg fluoride (1.1 mg)/ml oral drops MO triadvance 90 mg-1 mg-50 mg tablet MO trimesis rx 1 mg-200 mg-75 mg-12 mcg tablet,extended release MO trinatal gt 90 mg-1 mg-50 mg tablet MO trinatal rx 1 60 mg iron-1 mg tablet MO trinatal ultra 90 mg-1 mg-50 mg tablet MO TRINATE 28 MG-1 MG TABLET MO triveen-duo dha 29 mg-1 mg-400 mg oral pack MO triveen-one 27 mg-1 mg-250 mg capsule MO triveen-prx rnf 26 mg-1.2 mg-55 mg-300 mg capsule MO triveen-ten 15 mg-0.5 mg-50 mg-50 mg tablet MO triveen-u 106.5 mg-1 mg capsule MO trust natal dha 29 mg-1 mg-250 mg oral pack MO ultimate ob dha 22 mg-6 mg-1 mg-200 mg oral pack MO ultimatecare advantage combo MO ultimatecare combo pack MO ultimatecare one 27 mg-1 mg-330 mg capsule MO ultimatecare one nf 27 mg-1 mg-50 mg-500 mg capsule MO vena-bal dha 27 mg-1 mg-430 mg tablet&capsule,delayed release MO venatal complete dha 27 mg-1 mg-430 mg tablet &capsule,delayed release MO vinacal 27 mg-1 mg-50 mg tablet MO vinate az 27 mg-1 mg tablet MO vinate az extra tablets MO vinate c tablet MO vinate calcium 27 mg-1 mg-50 mg tablet MO vinate care 40 mg-1 mg chewable tablet MO vinate gt 90 mg-1 mg-50 mg tablet MO vinate ic 162 mg-115.2 mg (106 mg)-1 mg capsule MO vinate ii 29 mg-1 mg tablet MO vinate m 27 mg-1 mg tablet MO

TIER
4 4 4 1 1 1 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

UTILIZATION MANAGEMENT REQUIREMENTS

QL (50 per 30 days)

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DRUG NAME
vinate one 60 mg iron-1 mg tablet MO vinate pn care 30 mg-1 mg-50 mg tablet MO vinate ultra 90 mg-1 mg-50 mg tablet MO virt-pn 27 mg-1 mg tablet MO virt-pn dha 27 mg-1 mg-300 mg capsule MO VITAFOL-OB 65 MG-1 MG TABLET MO VITAFOL-OB+DHA 65 MG-1 MG-250 MG ORAL PACK MO VITAFOL-PN (UD) 65 MG-1 MG TABLET MO vitaphil + dha pack MO vitaphil caplet MO vitaspire 29 mg-1 mg tablet MO VIVA DHA 28 MG-1 MG-200 MG CAPSULE MO vp-era ob plus 22 mg-6 mg-1 mg tablet MO vynatal fa 65 mg-1 mg tablet MO zatean-ch 27 mg-1 mg-50 mg-250 mg capsule MO zatean-pn 27 mg-1 mg tablet MO zatean-pn dha 27 mg-1 mg-300 mg capsule MO ZEMPLAR 1 MCG CAPSULE MO ZEMPLAR 2 MCG CAPSULE MO ZEMPLAR 2 MCG/ML IV SOLUTION MO ZEMPLAR 4 MCG CAPSULE MO ZEMPLAR 5 MCG/ML IV SOLUTION MO

TIER
4 4 4 3 3 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3

UTILIZATION MANAGEMENT REQUIREMENTS

B vs D B vs D B vs D B vs D B vs D

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Index
A ACCURETIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 a-hydrocort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 ACCUTREND GLUCOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 a-methapred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 acebutolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 abacavir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 ACEON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 acetaminophen-codeine . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 ABILIFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64, 65 acetasol hc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ABILIFY DISCMELT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 acetazolamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 acetazolamide sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 acetic acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115, 125 ACCU-CHEK ACTIVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 acetic acid-aluminum acetate . . . . . . . . . . . . . . . . . . . . . 125 ACCU-CHEK ACTIVE GLUCOSE CONT . . . . . . . . . . . . . . . . . 92 acetylcysteine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 ACCU-CHEK ACTIVE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . 112 acid jelly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 ACCU-CHEK ADVANTAGE DIABETES . . . . . . . . . . . . . . . . . 92 ACTHAR H.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 ACCU-CHEK AVIVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 ACTHIB (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 ACCU-CHEK AVIVA PLUS METER . . . . . . . . . . . . . . . . . . . . . 92 ACTI-LANCE LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 ACCU-CHEK COMFORT CURVE . . . . . . . . . . . . . . . . . . . . . . . 92 acticin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 ACCU-CHEK COMFORT CURVE LINEAR . . . . . . . . . . . . . . . 92 ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 ACCU-CHEK COMFORT CURVE TEST . . . . . . . . . . . . . . . . . 112 ACTIVASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 ACCU-CHEK COMPACT GLUCOSE CONT . . . . . . . . . . . . . . . 92 ACTONEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 ACCU-CHEK COMPACT PLUS CARE . . . . . . . . . . . . . . . . . . . 92 ACTOPLUS MET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 ACCU-CHEK INSTANT CONTROL . . . . . . . . . . . . . . . . . . . . . 93 ACTOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 ACCU-CHEK MULTICLIX LANCET . . . . . . . . . . . . . . . . . . . . . 93 ACUFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 ACCU-CHEK SOFTCLIX LANCET DEV . . . . . . . . . . . . . . . . . . 93 ACULAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ACCU-CHEK SOFTCLIX LANCETS . . . . . . . . . . . . . . . . . . . . . 93 ACULAR LS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ACCU-CHEK VOICEMATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 ACURA METER KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 ACCUPRIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47, 48 ACURA STARTER KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

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ACURA TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 AFINITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ACUVAIL (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 AGGRENOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 acyclovir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 AIMSCO INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 93 acyclovir sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 AIMSCO ULTRA THIN II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 ACZONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 ak-con . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ADACEL (ADOLESCENT &ADULT)(PF) . . . . . . . . . . . . . . . 163 AK-PENTOLATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 ak-poly-bac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ADALAT CC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 AKNE-MYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 adapalene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 akorn balanced salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ADCIRCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 AKTEN (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ADENOCARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ALA-CORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 adenosine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ALA-SCALP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 ADJUSTABLE LANCING DEVICE . . . . . . . . . . . . . . . . . . . . . . 93 ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 adriamycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 albuterol sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 adriamycin pfs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ALCAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 ADVAIR DISKUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 alclometasone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 ALCOHOL PADS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 ADVANCE INTUITION GLUCOSE . . . . . . . . . . . . . . . . . . . . . 93 ALCOHOL PREP PADS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 ADVANCE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 ALCOHOL PREP SWABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 ADVANCED LANCING DEVICE . . . . . . . . . . . . . . . . . . . . . . . 93 ALCOHOL SWABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 ADVOCATE LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 ALCOHOL WIPES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 ADVOCATE PEN NEEDLES . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 ALDACTAZIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ADVOCATE REDI-CODE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 ALDACTONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ADVOCATE SYRINGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 ALDURAZYME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 ADVOCATE TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 alendronate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 AEROBID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 alfentanil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 AEROBID-M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 alfuzosin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 afeditab cr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ali-flex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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aliclen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 AMICAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 amifostine crystalline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 ALINIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 amikacin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 ALKERAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 amikacin (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 allersol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 amiloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 amiloride-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . 116 allopurinol sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 amino acids 15 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ALOMIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 AMINOACETIC ACID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ALOPRIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 aminocaproic acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 aminophylline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 ALPHAGAN P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 AMINOSYN II 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ALPHANINE SD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 AMINOSYN II 15% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 alprazolam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 AMINOSYN II 7 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ALREX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 AMINOSYN II 8.5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ALTABAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 AMINOSYN II 8.5 %-ELECTROLYTES . . . . . . . . . . . . . . . . 116 altafrin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 AMINOSYN M 3.5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 altavera (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 AMINOSYN 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ALTERNATE SITE LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 AMINOSYN 3.5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ALTERNATE SITE LANCING DEVICE . . . . . . . . . . . . . . . . . . 93 AMINOSYN 7 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ALVESCO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 AMINOSYN 7 % WITH ELECTROLYTES . . . . . . . . . . . . . . 116 alyacen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 AMINOSYN 8.5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 amantadine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 AMINOSYN 8.5 %-ELECTROLYTES . . . . . . . . . . . . . . . . . . 116 AMBISOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 AMINOSYN-HBC 7% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 amcinonide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 AMINOSYN-PF 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 AMERICAINE ANESTHETIC . . . . . . . . . . . . . . . . . . . . . . . . . 167 AMINOSYN-PF 7 % (SULFITE-FREE) . . . . . . . . . . . . . . . . . 116 amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 AMINOSYN-RF 5.2 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 amiodarone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 amethyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 192 - 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amitriptyline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 ANTABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 amlodipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ANTARA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 amlodipine-atorvastatin . . . . . . . . . . . . . . . . . . . . . . . . 48, 49 antipyrine-benzocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 amlodipine-benazepril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 antivenin micrurus fulvius . . . . . . . . . . . . . . . . . . . . . . . . . 163 ammonium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 ANTIVERT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ammonium lactate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 ANUSOL-HC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 AMMONUL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 apexicon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 amnesteem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 apexicon e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 amoxapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 APHTHASOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 amoxicillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10, 11 APIDRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 amoxicillin-pot clavulanate . . . . . . . . . . . . . . . . . . . . . . 10, 11 APIDRA SOLOSTAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 AMPHOTEC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 amphotericin b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 apraclonidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 ampicillin sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ampicillin-sulbactam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 ARALAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 AMTURNIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 ARALAST NP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 amyl nitrite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 ARALEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 anabar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 aranelle (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 ANACAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 ARCALYST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 ANADROL-50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 AREDIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154, 155 anagrelide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 argatroban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 ANASPAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 ARISTOSPAN INTRA-ARTICULAR . . . . . . . . . . . . . . . . . . . 138 anastrozole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ARISTOSPAN INTRALESIONAL . . . . . . . . . . . . . . . . . . . . . 138 ANCOBON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 ARRANON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ANDROGEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 ARZERRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 androxy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 ASACOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 193

ASACOL HD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ATROVENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 ASCENSIA AUTODISC TEST . . . . . . . . . . . . . . . . . . . . . . . . . 112 ATROVENT HFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 ASMANEX TWISTHALER . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 aurodex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 ASSURA EASICLOSE MINI POUCH . . . . . . . . . . . . . . . . . . . 93 auroguard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 ASSURE ID INSULIN SAFETY . . . . . . . . . . . . . . . . . . . . . . . . 93 AURORA HEALTHCARE LANCETS . . . . . . . . . . . . . . . . . . . . . 94 ASSURE LANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 AUTOJECT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 ASSURE PLATINUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94, 112 AUTOJECT 2 INJECTION DEVICE . . . . . . . . . . . . . . . . . . . . . 94 ASSURE PRO BLOOD GLUCOSE METER . . . . . . . . . . . . . . . 94 AUTOLET IMPRESSION LANC DEV . . . . . . . . . . . . . . . . . . . 94 ASSURE PRO TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . 112 AUTOLET LITE CLINISAFE . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 ASSURE 3 TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 AUTOLET LITE CLINISAFE DEVICE . . . . . . . . . . . . . . . . . . . 94 ASSURE 4 CONTROL SOLUTION . . . . . . . . . . . . . . . . . . . . . 93 AUTOLET MINI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 ASSURE 4 METER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 AUTOLET MKII CLINISAFE DEVICE . . . . . . . . . . . . . . . . . . . 94 ASSURE 4 STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 AUTOLET PLATFORMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 ASTELIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 AUTOPEN 1 TO 16 UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 ASTEPRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 AUTOPEN 1 TO 21 UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 astramorph-pf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 AUTOPEN 2 TO 32 UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 ATABEX EC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 AUTOPEN 2 TO 42 UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 ATELVIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 AVC VAGINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 atenolol-chlorthalidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 AVELOX IN NACL (ISO-OSMOTIC) . . . . . . . . . . . . . . . . . . . . 11 ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 atorvastatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 AVINZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 atovaquone-proguanil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 AVODART . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 atracurium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 AVONEX ADMINISTRATION PACK . . . . . . . . . . . . . . . . . . 155 atropine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39, 126 AXONA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 atropine sulfate (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 AYGESTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 ATROPINE-CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 194 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

AZACTAM-ISO-OSMOTIC DEXTROSE . . . . . . . . . . . . . . 11, 12 BANZEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 BARACLUDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 azathioprine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 baycadron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 azathioprine sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 BCG VACCINE, LIVE (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 azelastine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 BD ALCOHOL SWAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 AZELEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 BD AUTOSHIELD PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . 94 AZILECT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 BD ECLIPSE LUER-LOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 azithromycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BD INSULIN PEN NEEDLE UF MINI . . . . . . . . . . . . . . . . . . . 94 azithromycin hydrogen citrate . . . . . . . . . . . . . . . . . . . . . . 12 BD INSULIN PEN NEEDLE UF ORIG . . . . . . . . . . . . . . . . . . . 94 AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 BD INSULIN PEN NEEDLE UF SHORT . . . . . . . . . . . . . . . . . 94 aztreonam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BD INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 AZULFIDINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BD INSULIN SYRINGE HALF UNIT . . . . . . . . . . . . . . . . . . . . 94 AZULFIDINE EN-TABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BD INSULIN SYRINGE MICRO-FINE . . . . . . . . . . . . . . . . . . 94 azurette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 BD INSULIN SYRINGE SAFETY-LOK . . . . . . . . . . . . . . . . . . 94 B BD INSULIN SYRINGE SLIP TIP . . . . . . . . . . . . . . . . . . . . . . 94

baciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BD INSULIN SYRINGE ULT-FINE II . . . . . . . . . . . . . . . . . . . 95 bacitracin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12, 126 BD INSULIN SYRINGE ULTRA-FINE . . . . . . . . . . . . . . . . . . 95 bacitracin-polymyxin b . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 BD INTEGRA INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . 95 baclofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 BD LANCET DEVICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 BACTRIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BD LO-DOSE MICRO-FINE IV . . . . . . . . . . . . . . . . . . . . . . . . 95 BACTRIM DS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BD LO-DOSE ULTRA-FINE . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 BACTROBAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 BD MICROTAINER LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . 95 BACTROBAN NASAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 BD SAFETYGLIDE INSULIN SYRINGE . . . . . . . . . . . . . . . . . 95 BAL IN OIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 BD SAFETYGLIDE SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . . 95 bal-care dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 BD ULTRA FINE LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 balanced salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 BD ULTRA FINE 33G LANCETS . . . . . . . . . . . . . . . . . . . . . . . 95 balsalazide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 BD ULTRA-FINE NANO PEN NEEDLES . . . . . . . . . . . . . . . . 95 balziva (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 be-flex plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 195

benazepril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 BETASERON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 benazepril-hydrochlorothiazide . . . . . . . . . . . . . . . . . . 49, 50 betaxolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50, 126 bencort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 bethanechol chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 BENLYSTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 BETIMOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 benprox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 bicalutamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 bensal hp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 BICILLIN C-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BENZAC AC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167, 168 BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 benzac ac wash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 benzac w wash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 BENZACLIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BENZACLIN CAREKIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 BIONIME RIGHTEST TEST STRIPS . . . . . . . . . . . . . . . . . . . 112 BENZACLIN PUMP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 bioregesic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 BENZASHAVE-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 bisoprolol fumarate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 BENZASHAVE-5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 bisoprolol-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . 50 BENZIQ LS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 bleomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 benzoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 BLEPH-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 benzoyl peroxide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 benzoyl peroxide microspheres . . . . . . . . . . . . . . . . . . . . 177 BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 benzoyl peroxide-urea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 BLOOD GLUCOSE MONITOR KIT . . . . . . . . . . . . . . . . . . . . 101 benztropine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 BLOOD GLUCOSE MONITORING . . . . . . . . . . . . . . . . . . . . . 95 BESIVANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 BLOOD GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 BETA-VAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 BLOOD SUGAR DIAGNOSTIC . . . . . . . . . . . . . . . . . . . . . . . 113 BETADINE OPHTHALMIC PREP . . . . . . . . . . . . . . . . . . . . . 126 BLOOD-GLUCOSE METER . . . . . . . . . . . . . . . . . . . . . . . . . 95, 98 BETAGAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 BONIVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 betamethasone acet & sod phos . . . . . . . . . . . . . . . . . . . 138 BOOSTRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 betamethasone dipropionate . . . . . . . . . . . . . . . . . 168, 169 bp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 betamethasone valerate . . . . . . . . . . . . . . . . . . . . . . . . . . 169 bp 10-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 betamethasone, augmented . . . . . . . . . . . . . . . . . . . . . . 169 bpo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 196 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

BREATHERITE MDI SPACER . . . . . . . . . . . . . . . . . . . . . . . . . . 95 BUPHENYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 BREATHERITE RIGID SPACER& MASK . . . . . . . . . . . . . . . . 95 bupivacaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 BREATHERITE SPACER& MASK,ADULT . . . . . . . . . . . . . . . 95 bupivacaine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 BREATHERITE SPACER& MASK,CHILD . . . . . . . . . . . . . . . . 95 bupivacaine-dextrose-water(pf) . . . . . . . . . . . . . . . . . . . 152 BREATHERITE SPACER&MASK,INFANT . . . . . . . . . . . . . . . 95 bupivacaine-epinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . 152 BREATHERITE SPACER&MASK,S.CHLD . . . . . . . . . . . . . . . 95 BUPRENEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 BREATHERITE VALVED MDI CHAMBER . . . . . . . . . . . . . . . 95 buprenorphine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 BREATHERITE VALVED MDI SPACER . . . . . . . . . . . . . . . . . 95 buproban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 BREATHERITE WITH MASK, LARGE . . . . . . . . . . . . . . . . . . . 95 bupropion hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66, 67 BREATHERITE WITH MASK, MEDIUM . . . . . . . . . . . . . . . . 95 buspirone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 BREATHERITE WITH MASK, SMALL . . . . . . . . . . . . . . . . . . 95 BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 BREEZE 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 BUTISOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 BREEZE 2 TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 butorphanol tartrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 BREVIBLOC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 BYETTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 BREVIBLOC IN NACL (ISO-OSM) . . . . . . . . . . . . . . . . . . . . . 50 BYSTOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 BREVICON (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 C

BREVOXYL-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 cabergoline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 BREVOXYL-8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 CAFCIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 CAFERGOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 brimonidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 caffeine citrated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 bromocriptine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 caffeine-sodium benzoate . . . . . . . . . . . . . . . . . . . . . . . . . . 67 BROVANA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 cafgesic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 BSS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 cafgesic forte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 BSS PLUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 CALAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 budeprion sr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 CALAN SR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 budeprion xl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 CALCIJEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 budesonide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138, 162 calcipotriene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 bumetanide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 calcitonin (salmon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 197

calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 carbidopa-levodopa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 calcitriol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 carbidopa-levodopa-entacapone . . . . . . . . . . . . . . . . . . . 68 calcium acetate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 CARBOCAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 calcium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 CARBOCAINE (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 CALCIUM DISODIUM VERSENATE . . . . . . . . . . . . . . . . . . . 137 carboplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 calcium folinate (leucovorin) . . . . . . . . . . . . . . . . . . . . . . 155 CARDENE SR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 calcium gluconate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 CAREONE LANCING DEVICE . . . . . . . . . . . . . . . . . . . . . . . . . 96 camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 CAREONE THIN LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CAMPATH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 CAREONE ULTIGUARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CAMPRAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 CAREONE ULTRA THIN LANCET . . . . . . . . . . . . . . . . . . . . . . 96 CAMPRAL DOSE PAK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 CARESENS N TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . 112 CAMPTOSAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 carimune nf nanofiltered . . . . . . . . . . . . . . . . . . . . . . . . . . 163 camrese . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 carisoprodol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 camrese lo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 carisoprodol-asa-codeine . . . . . . . . . . . . . . . . . . . . . . . . . . 40 CANASA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 carisoprodol-aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 CARMOL SCALP TREATMENT . . . . . . . . . . . . . . . . . . . . . . . 169 CANTIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 carmol 40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 CAPASTAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 CARNITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 CAPEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 CARNITOR SUGAR-FREE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 CAPITAL WITH CODEINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 carteolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 CAPRELSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50, 51 captopril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 CARTICEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 captopril-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . . 50 carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 CARAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 CASODEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 CARAFATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 cavan one omega . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 cavan-ec sod dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 carbamazepine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 cavan-folate dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 CARBATROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 cavan-folate ob . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 198 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

cavan-heme ob . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 CELEBREX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 cavirinse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 CELESTONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 CELESTONE SOLUSPAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 CELLCEPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 CEDAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 CELLCEPT INTRAVENOUS . . . . . . . . . . . . . . . . . . . . . . . . . . 155 CEENU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12, 13 CENTANY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CENTANY AT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 cephalexin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 cefazolin in dextrose (iso-os) . . . . . . . . . . . . . . . . . . . . . . . 13 CEPROTIN (BLUE BAR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CEPROTIN (GREEN BAR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CEREDASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 cefepime in dextrose,iso-osm . . . . . . . . . . . . . . . . . . . . . . 13 CEREZYME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 cefepime in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 cerisa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 cefotaxime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CERUBIDINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CERVARIX VACCINE (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 cefotetan in dextrose, iso-osm . . . . . . . . . . . . . . . . . . . . . . 13 CERVIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 cefoxitin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CESIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 cefoxitin in dextrose, iso-osm . . . . . . . . . . . . . . . . . . . . . . . 13 CETACAINE MEDICAL KIT E . . . . . . . . . . . . . . . . . . . . . . . . 169 cefpodoxime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 cetirizine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHANTIX CONTINUING MONTH BOX . . . . . . . . . . . . . . . . . 40 ceftazidime in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . 40 ceftriaxone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHANTIX STARTING MONTH BOX . . . . . . . . . . . . . . . . . . . . 40 ceftriaxone in dextrose,iso-os . . . . . . . . . . . . . . . . . . . . . . . 14 CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . 40 cefuroxime axetil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 cefuroxime sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHEMSTRIP UGK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 cefuroxime-dextrose (iso-osm) . . . . . . . . . . . . . . . . . . . . . 14 CHENODAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 199

chloramphenicol sod succinate . . . . . . . . . . . . . . . . . . . . . 15 cisatracurium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 chlorhexidine gluconate . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 chloroprocaine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 citalopram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 chloroquine phosphate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 CITRANATAL ASSURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 chlorothiazide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116, 117 CITRANATAL B-CALM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 chlorothiazide sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 CITRANATAL DHA (NEW FORMULA) . . . . . . . . . . . . . . . . 183 chloroxylenol-pramoxine . . . . . . . . . . . . . . . . . . . . . . . . . . 126 CITRANATAL HARMONY . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 chlorpromazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 CITRANATAL RX (NEW FORMULA) . . . . . . . . . . . . . . . . . . 183 chlorthalidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 CITRANATAL 90 DHA (NEW FORMULA . . . . . . . . . . . . . . 183 cholestyramine (with sugar) . . . . . . . . . . . . . . . . . . . . . . . . 51 cladribine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 cholestyramine light . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 CLAFORAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 choline & magnesium salicylate . . . . . . . . . . . . . . . . . . . . 68 claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 choline-mag trisalicylate . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 clarithromycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 chorionic gonadotropin, human . . . . . . . . . . . . . . . . . . . 139 CLEOCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15, 170 ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 CLEOCIN IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 ciclopirox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169, 170 CLEOCIN T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 ciclopirox-vite-nail lacq remo . . . . . . . . . . . . . . . . . . . . . . 169 CLEVER CHEK LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 CLEVER CHEK TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . 113 CILOXAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 CLEVER CHOICE PRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132, 133 CLEVER CHOICE TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . 113 cimetidine hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 CLICKFINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CIMZIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 CLINAC BPO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 CIMZIA POWDER FOR RECONST . . . . . . . . . . . . . . . . . . . . 133 clinda-derm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 CIMZIA STARTER KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 clindacin p . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 CLINDAGEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 ciprofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15, 127 clindamax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 ciprofloxacin (mixture) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 clindamycin hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15, 16 ciprofloxacin in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 clindamycin palmitate hcl . . . . . . . . . . . . . . . . . . . . . . . . . . 15 200 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

clindamycin phosphate .........................

15, 16, CLODERM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 170 CLOLAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 clomipramine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 clonazepam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 clonidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 clonidine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 clopidogrel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 clorazepate dipotassium . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 clorpres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 clotrimazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170, 171 clotrimazole-betamethasone . . . . . . . . . . . . . . . . . . . . . 171 clozapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 CNL 8 NAIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 co-natal fa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 COAGUCHEK LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 COARTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 cocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 codeine phosphate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 codeine sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 COGENTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 colchicine-probenecid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 COLCRYS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 colestipol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 colestipol,micronized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 colistin (colistimethate na) . . . . . . . . . . . . . . . . . . . . . . . . . 16 colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 COLY-MYCIN M PARENTERAL . . . . . . . . . . . . . . . . . . . . . . . . 16 COLY-MYCIN S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

clindamycin-benzoyl peroxide . . . . . . . . . . . . . . . . . . . . . 170 CLINDAREACH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 CLINDESSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 clindets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 CLINIMIX E 2.75/D10 SULFITFREE . . . . . . . . . . . . . . . . . . 117 CLINIMIX E 2.75/D5 SULFITEFREE . . . . . . . . . . . . . . . . . . 117 CLINIMIX E 4.25/D10 SULFITFREE . . . . . . . . . . . . . . . . . . 117 CLINIMIX E 4.25/D25 SULFITFREE . . . . . . . . . . . . . . . . . . 117 CLINIMIX E 4.25/D5 SULFITEFREE . . . . . . . . . . . . . . . . . . 117 CLINIMIX E 5%/D15 SULFITE FREE . . . . . . . . . . . . . . . . . 117 CLINIMIX E 5%/D20 SULFITE FREE . . . . . . . . . . . . . . . . . 117 CLINIMIX E 5%/D25 SULFITE FREE . . . . . . . . . . . . . . . . . 117 CLINIMIX 2.75%/D5 SULFITE FREE . . . . . . . . . . . . . . . . . 117 CLINIMIX 4.25/D10 SULFITE FREE . . . . . . . . . . . . . . . . . . 117 CLINIMIX 4.25/D20 SULFITE FREE . . . . . . . . . . . . . . . . . . 117 CLINIMIX 4.25/D25 SULFITE FREE . . . . . . . . . . . . . . . . . . 117 CLINIMIX 4.25%/D5 SULFITE FREE . . . . . . . . . . . . . . . . . 117 CLINIMIX 5%/D15 SULFITE FREE . . . . . . . . . . . . . . . . . . . 117 CLINIMIX 5%/D20 SULFITE FREE . . . . . . . . . . . . . . . . . . . 117 CLINIMIX 5%/D25 SULFITE FREE . . . . . . . . . . . . . . . . . . . 117 clinisol sf 15 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 CLINISTIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 CLINITEST REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 CLINORIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 clobetasol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 clobetasol-emollient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 201

COLYTE WITH FLAVOR PACKS . . . . . . . . . . . . . . . . . . . . . . 133 CORDRAN SP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 COREG CR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 COMBIVENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 corenate-dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 COMBIVENT RESPIMAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 CORLOPAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 COMFORT EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 cormax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 COMFORT LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 cortalo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 COMPLERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 CORTEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 complete natal dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 CORTENEMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 complete-rf prenatal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 CORTIFOAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 completenate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 cortisone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 compro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 CORTISPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127, 171 COMTAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 CORTISPORIN-TC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 COMVAX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 cortomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 CONCEPT DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 CORVERT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 CONCEPT OB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 CORZIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 CONDYLOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 COSMEGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 CONSTANT CLENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 COUMADIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 constulose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 COVERA-HS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 CONTOUR METER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 CONTOUR TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51, 52 CONTOUR USB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CRESYLATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 CONTROL G3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 CRINONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 CONTROL MONITORING SYSTEM . . . . . . . . . . . . . . . . . . . . 96 CRIXIVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 CONTROL TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 cromolyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 controlrx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 cryselle (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 COPAXONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 COPEGUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 CORDRAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 CURITY ALCOHOL SWABS . . . . . . . . . . . . . . . . . . . . . . . . . . 171 202 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

CUROSURF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 DACOGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 cyanide antidote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 dactinomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 cyclafem 1/35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 cyclafem 7/7/7 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 CYCLESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 dantrolene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 CYCLOGYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 dapsone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 cyclopentolate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 DAPTACEL (PEDIATRIC) (PF) . . . . . . . . . . . . . . . . . . . . . . . . 163 cyclophosphamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 cyclosporine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 daunorubicin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 cyclosporine modified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 DAUNOXOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 CYKLOKAPRON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 DEBACTEROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 cylate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 DECAVAC (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163, 166 CYMBALTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 deferoxamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 CYSTADANE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 DELESTROGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 DEMADEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117, 118 cysteine (l-cysteine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 demeclocycline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 cytarabine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 CYTOGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 denta 5000 plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 CYTOMEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 dentagel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 CYTOTEC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 DEPACON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 CYTOVENE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 depade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 cytra k crystals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 DEPAKENE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 cytra-k . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 DEPEN TITRATABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 cytra-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 DEPO-ESTRADIOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 D DEPO-MEDROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

D.H.E.45 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 DEPO-PROVERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 dacarbazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 DEPO-SUBQ PROVERA 104 . . . . . . . . . . . . . . . . . . . . . . . . . 140 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 203

DEPO-TESTOSTERONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 dextrose 2.5% in water (d2.5w) . . . . . . . . . . . . . . . . . . . . 118 DEPOCYT (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 dextrose 20% in water (d20w) . . . . . . . . . . . . . . . . . . . . . 118 DERMA-SMOOTHE/FS BODY OIL . . . . . . . . . . . . . . . . . . . . 171 dextrose 25% in water (d25w) . . . . . . . . . . . . . . . . . . . . . 118 DERMATOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 dextrose 30% in water (d30w) . . . . . . . . . . . . . . . . . . . . . 118 desipramine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 dextrose 40% in water (d40w) . . . . . . . . . . . . . . . . . . . . . 118 desmopressin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 dextrose 5% in water (d5w) . . . . . . . . . . . . . . . . . . . . . . . . 118 DESOGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 dextrose 5%-lactated ringers . . . . . . . . . . . . . . . . . . . . . . 118 DESONATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 dextrose 5%-0.2 % sod chloride . . . . . . . . . . . . . . . . . . . 118 desonide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 dextrose 5%-0.3 % sod.chloride . . . . . . . . . . . . . . . . . . . 118 desoximetasone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 dextrose 50% in water (d50w) . . . . . . . . . . . . . . . . . . . . . 118 DESQUAM-X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 dextrose 70% in water (d70w) . . . . . . . . . . . . . . . . . . . . . 118 DETROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 DIABETIC.COM STARTER KIT . . . . . . . . . . . . . . . . . . . . . . . . 97 DETROL LA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 DIASCREEN 1G REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . . 113 dexamethasone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 DIASCREEN 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 dexamethasone intensol . . . . . . . . . . . . . . . . . . . . . . . . . . 140 DIASCREEN 2GK REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . 113 dexamethasone sodium phosphate . . . . . . . . . . 127, 140 DIASCREEN 3 REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 dexasol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 DIASCREEN 4OBL REAGENT . . . . . . . . . . . . . . . . . . . . . . . . 113 DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 DIASCREEN 5 REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 dexmethylphenidate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 DIASCREEN 6 REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 DEXPAK 10 DAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 DIASCREEN 7 REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 DEXPAK 13 DAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 DIASCREEN 8 REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 DEXPAK 6 DAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 DIASCREEN 9 REAGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 dexpanthenol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 DIASTIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 dexrazoxane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 diazepam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 dextroamphetamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69, 70 diazepam intensol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 dextrose in ringers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 diclofenac potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 dextrose 10 % & 0.225 % nacl . . . . . . . . . . . . . . . . . . . . . 118 diclofenac sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70, 127 dextrose 10% in water (d10w) . . . . . . . . . . . . . . . . . . . . . 118 dicloxacillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 204 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

didanosine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 DISCOVISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 DIDGET METER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 disopyramide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 diflorasone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171, 172 DIURIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 DIFLUCAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 DIURIL IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 DIFLUCAN IN DEXTROSE (ISO-OSM) . . . . . . . . . . . . . . . . . 16 divalproex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70, 71 DIFLUCAN IN NACL (ISO-OSM) . . . . . . . . . . . . . . . . . . . . . . 16 DOAK TAR DISTILLATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 dobutamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 DIGIBIND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 dobutamine in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 DIGIFAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 DOCEFREZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 digoxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 docetaxel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32, 33 dihydrocode-acetaminophen-caff . . . . . . . . . . . . . . . . . . 65 docosavit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 dihydroergotamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 dologesic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DILACOR XR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 DOLOPHINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DILANTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 DOLOREX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DILANTIN EXTENDED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 donepezil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 dilantin infatabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 dopamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40, 41 DILANTIN-125 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 dopamine in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40, 41 DILATRATE-SR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 DOPRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 dilt-cd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 DORIBAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 dorzolamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 diltia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 dorzolamide-timolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 diltiazem hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52, 53 doxapram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 diltzac er . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 dimenhydrinate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 doxepin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DIOVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 DOXIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 DIOVAN HCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 doxorubicin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 diphenoxylate-atropine . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 205

doxycycline hyclate ............................

16, 17, d2.5 %-0.45 % sodium chloride . . . . . . . . . . . . . . . . . . . . 118 127 d5 % and 0.9 % sodium chloride . . . . . . . . . . . . . . . . . . . 118 d5 %-0.45 % sodium chloride . . . . . . . . . . . . . . . . . . . . . . 118 d5 in 0.45%nacl & potassium cl . . . . . . . . . . . . . . . 117, 120 d5-lr with potassium chloride . . . . . . . . . . . . . . . . . . . . . . 120 d5-0.225 % nacl and kcl . . . . . . . . . . . . . . . . . . . . . . 117, 120 d5-0.3 % nacl & potassium chl . . . . . . . . . . . . . . . . . . . . . 120 d5-0.9%nacl-potassium chloride . . . . . . . . . . . . . . . . . . 120 d5w with potassium chloride . . . . . . . . . . . . . . . . . 117, 120 E E.E.S. GRANULES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 E.E.S. 400 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 E-Z JECT LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 E-Z JECT SUPER THIN LANCET 30G . . . . . . . . . . . . . . . . . . 97 E-Z JECT THIN LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 EASY CHECK TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 EASY COMFORT INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . 97 EASY COMFORT LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 EASY GLUCO G2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 EASY PRO PLUS KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 EASY PRO PLUS TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . 113 EASY TALK GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . 113 EASY TALK HIGH CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . 97 EASY TALK LOW CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . 97 EASY TOUCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 EASY TOUCH ALCOHOL PREP PADS . . . . . . . . . . . . . . . . . 172 EASY TOUCH INSULIN SYRINGE . . . . . . . . . . . . . . . . . . 97, 98 EASY TRAK GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . 113

doxycycline monohydrate . . . . . . . . . . . . . . . . . . . . . . . . . . 17 DRITHO-SCALP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 DRITHOCREME HP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 dronabinol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 droperidol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 DRYSOL DAB-O-MATIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 DUAC CS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 DUET DHA COMPLETE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 DUET DHA WITH OMEGA-3 . . . . . . . . . . . . . . . . . . . . . . . . . 183 DUETACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 DULERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 DUONEB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 DUOVISC VISCO ELASTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 DURABAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DURABAC FORTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DURACLON (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DURAMORPH (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DURASAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 duraxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 DYAZIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 DYNACIRC CR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 DYRENIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 d10 % & 0.45 % sodium chloride . . . . . . . . . . . . . . . . . . . 117 d10 %-0.9 % sodium chloride . . . . . . . . . . . . . . . . . . . . . . 118

206 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

EASY TRAK HIGH CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . 98 ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124, 125 EASY TRAK LOW CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . 98 ELIXOPHYLLIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 EASY TRAK NORMAL CONTROL . . . . . . . . . . . . . . . . . . . . . . 98 ELLENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 EASYGLUCO METER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 EASYGLUCO MONITORING SYSTEM . . . . . . . . . . . . . . . . . . 98 ELOCON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 EASYGLUCO TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 ELOXATIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 EASYMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 ELSPAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 EC-NAPROSYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 EMADINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 ECLIPSE TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 EMBEDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 econazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 EMBRACE BLOOD GLUCOSE SYSTEM . . . . . . . . . . . . . . . . 113 ED CYTE F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ed-flex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 EMEND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 emgel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 edge ob . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 EMLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 EDURANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 emoquette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 effer-k . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 EFFIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 EMTRIVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 EGRIFTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 ENABLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 enalapril maleate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 electrolyte-48 in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 enalapril-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . . 53 ELELYSO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 enalaprilat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 ELEMENT TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 ENBREL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 ELESTAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 ENBREL SURECLICK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 endocet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71, 72 ELIGARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ENDOMETRIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 eliphos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 ENGERIX-B (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 elite-ob . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 enlon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 elite-ob 400 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 enoxaparin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44, 45 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 207

enpresse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 ery pads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ENVISION TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 ERYPED 200 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ephedrine sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 ERYPED 400 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 EPIDUO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 ERYTHROCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 epiflur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 ERYTHROCIN STEARATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 epiklor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 erythromycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18, 127 epinastine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 erythromycin ethylsuccinate . . . . . . . . . . . . . . . . . . . . . . . 18 epinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 erythromycin with ethanol . . . . . . . . . . . . . . . . . . . . . . . . 172 epinephrine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 erythromycin-benzoyl peroxide . . . . . . . . . . . . . . . . . . . . 172 epinephrine hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 erythromycin-sulfisoxazole . . . . . . . . . . . . . . . . . . . . . . . . . 18 EPIPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 escitalopram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 EPIPEN JR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 esmolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 epirubicin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ESTRACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 estradiol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140, 141 EPIVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 estradiol valerate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140, 141 EPIVIR HBV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 eplerenone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 ESTROSTEP FE-28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 EPOGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 ethambutol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 epoprostenol (glycine) . . . . . . . . . . . . . . . . . . . . . . . . . . 53, 54 ethosuximide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 EPZICOM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 EQUETRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 etidronate disodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 ERAXIS(WATER DILUENT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ETOPOPHOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ERGOMAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 etoposide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ergotamine-caffeine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 euflexxa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 EURAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 EVENCARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 208 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

EVENCARE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 FASTTAKE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 EVISTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 FAZACLO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72, 73 EVOLUTION TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . 113 fe c plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 EXALGO ER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 felbamate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 EXEL INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FELBATOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 EXELDERM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 felodipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 EXELON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 FEM PH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 exemestane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 FEMCON FE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 EXFORGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 FEMECAL OB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 EXFORGE HCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 FEMRING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 fenofibrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 exoderm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 fenofibrate micronized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 EXTINA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 fenoldopam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 EZ SMART LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 fenoprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 EZ SMART PLUS SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 EZ SMART PLUS TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 fentanyl citrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 EZ SMART SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 fentanyl citrate (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 EZ SMART TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 fexofenadine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 F fexofenadine-pseudoephedrine . . . . . . . . . . . . . . . . . . . . . 30

FABRAZYME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 FIFTY50 RESERVOIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FACTIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 FIFTY50 TEST STRIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 famciclovir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 finasteride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 famotidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 FINGERSTIX LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 famotidine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 famotidine (pf)-nacl (iso-os) . . . . . . . . . . . . . . . . . . . . . . 133 FIRMAGON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 FANAPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 FIRST CHOICE LANCETS THIN . . . . . . . . . . . . . . . . . . . . . . . 98 FARESTON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 FLAREX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 FASLODEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 flavoxate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 209

flebogamma dif . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 fluoritab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 flecainide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 fluorometholone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 FLECTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 FLUOROPLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 FLEXTRA DS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 fluorouracil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34, 173 FLEXTRA PLUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 fluoxetine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 FLEXTRA-650 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 fluphenazine decanoate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 FLONASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 fluphenazine hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73, 74 FLOVENT DISKUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 FLURA-DROPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 FLOVENT HFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 floxuridine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 flurbiprofen sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 FLUCAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 fluconazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 fluticasone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128, 173 fluconazole in dextrose(iso-o) . . . . . . . . . . . . . . . . . . . . . . 18 fluvastatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 fluconazole in nacl (iso-osm) . . . . . . . . . . . . . . . . . . . . . . . 18 fluvoxamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 flucytosine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 FML FORTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 FLUDARA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 FML LIQUIFILM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 fludarabine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 FML S.O.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 fludrocortisone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 folbecal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 FLUMADINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 folcaps care one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 flumazenil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 folinatal plus b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 folivane-ec calcium dha nf . . . . . . . . . . . . . . . . . . . . . . . . 184 fluocinolone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 folivane-ob . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 fluocinonide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172, 173 folivane-prx dha nf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 fluocinonide-e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 fluocinonide-emollient . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 fomepizole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 FLUORABON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 fondaparinux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 fluoridex daily defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 FORA D10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 fluoridex daily defense whiten . . . . . . . . . . . . . . . . . . . . . 156 FORA D15C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 210 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

FORA D15G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FREESTYLE FREEDOM LITE . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FORA D15Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FREESTYLE LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FORA D20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FREESTYLE LITE METER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FORA G20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FREESTYLE LITE STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FORA G71A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FREESTYLE SIDEKICK II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FORA V10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FREESTYLE SYSTEM KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FORA V12 GLUCOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FREESTYLE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FORA V20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 frenadol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 FORADIL AEROLIZER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 furosemide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 FORMA-RAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 FORMADON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18, 19 formalaz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 G

FORTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 G-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 FORTAZ IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 G-4 TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 gabapentin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 FORTICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GABITRIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 foscarnet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 galantamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 FOSCAVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 GAMASTAN S/D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 fosinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 gammagard liquid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 fosinopril-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . . 54 GAMMAGARD S-D (IGA<1UG/ML) . . . . . . . . . . . . . . . . . . . 164 fosphenytoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 GAMMAGARD S/D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 FRAGMIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 GAMMAKED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 FREAMINE HBC 6.9 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 gammaplex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 FREAMINE III 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 GAMUNEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 FREAMINE III 3 %-ELECTROLYTES . . . . . . . . . . . . . . . . . . 118 GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 FREAMINE III 8.5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 ganciclovir sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 FREESTYLE FLASH SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . 98 GARAMYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 FREESTYLE FREEDOM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 GARDASIL (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 211

GASTROCROM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 glimepiride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GAUZE BANDAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 glipizide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GAUZE PAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 glipizide-metformin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 GLUCAGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 GLUCAGEN HYPOKIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 gavilyte-n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 GLUCAGON EMERGENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 gel-kam oral care rinse . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 GLUCOCARD VITAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 GELNIQUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 GLUCOCARD VITAL SENSOR . . . . . . . . . . . . . . . . . . . . . . . . 114 gemcitabine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 GLUCOCARD X-METER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 GLUCOCARD X-SENSOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 GEMZAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 GLUCOCARD 01 METER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 generlac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 GLUCOCARD 01 SENSOR . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 GLUCOCARD 01-MINI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 GLUCOCOM GLUCOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 gentamicin ................................... 19, 128, GLUCOCOM LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 173 GLUCOLAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 GLUCOLET 2 AUTOMATIC LANCING . . . . . . . . . . . . . . . . . . 99 GLUCOPRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 GLUCOPRO ALCOHOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 GLUCOSOURCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 GLUCOTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GLUCOTROL XL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 GLUMETZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 glutaraldehyde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 glyburide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 glyburide micronized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 glyburide-metformin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 glycine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

gentamicin in nacl (iso-osm) . . . . . . . . . . . . . . . . . . . . . 19, 20 gentamicin sulfate (ped) (pf) . . . . . . . . . . . . . . . . . . . . . . . 19 gentamicin sulfate (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 gentasol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 GENTLE DRAW LANCING DEVICE . . . . . . . . . . . . . . . . . . . . 99 GEODON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 GESTICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 GESTICARE DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 gianvi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 gildess fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 GLASSIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 GLEEVEC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

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GLYCINE UROLOGIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 HALFLYTELY-BISACODYL W-FLAV PK . . . . . . . . . . . . . . . 134 glycopyrrolate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 halobetasol propionate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 GLYSET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HALOG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 GM100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 halonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 GOLYTELY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 halonate pac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 GORDOFILM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 haloperidol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74, 75 GORDONS UREA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 haloperidol decanoate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 GRALISE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 haloperidol lactate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 GRALISE 30-DAY STARTER PACK . . . . . . . . . . . . . . . . . . . . . 74 HALOTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 granisetron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 HAVRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 granisetron (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 HEALTHY ACCENTS UNIFINE PENTIP . . . . . . . . . . . . . . . . 99 granisol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 heather . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 GRIFULVIN V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 hecoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 GRIS-PEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 HECTOROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 griseofulvin microsize . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 HELIDAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 GUAIACOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 HEMABATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 guanfacine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 heparin (porcine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 guanidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 heparin (porcine) in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 GYNAZOLE-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 heparin (porcine) in nacl (pf) . . . . . . . . . . . . . . . . . . . . . . . . 46 H heparin lockflush(porcine)(pf) . . . . . . . . . . . . . . . . . . . . . . 45

HAEMOLANCE LOW FLOW LANCETS . . . . . . . . . . . . . . . . . 99 heparin(porcine) in 0.45% nacl . . . . . . . . . . . . . . . . . . . . . . 46 HAEMOLANCE PLUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 heparin, porcine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 HAEMOLANCE PLUS LANCETS . . . . . . . . . . . . . . . . . . . . . . . 99 HEPATAMINE 8% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 HAEMOLANCE, RETRACTABLE LANCET . . . . . . . . . . . . . . . 99 HEPATASOL 8 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 halac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 HEPSERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 HERCEPTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 HALDOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 HALDOL DECANOATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 HIBERIX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 213

HIPREX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 HIZENTRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164, 165 hydrocodone-acetaminophen . . . . . . . . . . . . . . . . . . . . . . 75 homatropaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 hydrocodone-ibuprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 HORIZANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 hydrocortisone HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMALOG KWIKPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMALOG MIX 50-50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMALOG MIX 50-50 KWIKPEN . . . . . . . . . . . . . . . . . . . . 142 HUMALOG MIX 75-25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMALOG MIX 75-25 KWIKPEN . . . . . . . . . . . . . . . . . . . . 142 HUMALOG PEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMAPEN LUXURA HD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 HUMAPEN MEMOIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 HUMIRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 HUMIRA CROHN'S DIS START PCK . . . . . . . . . . . . . . . . . . 157 HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 HUMIRA PSORIASIS STARTER PACK . . . . . . . . . . . . . . . . . 157 HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMULIN N PEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMULIN R U-500 "CONCENTRATED" . . . . . . . . . . . . . . 142 HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HUMULIN 70/30 PEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 HYALGAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 HYCAMTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 hydralazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54, 55 HYDREA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 HYDRO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 ............................... 142, 143, 173

hydrocortisone acet-aloe vera . . . . . . . . . . . . . . . . . . . . . 173 hydrocortisone butyrate . . . . . . . . . . . . . . . . . . . . . . 173, 174 hydrocortisone valerate . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 hydrocortisone-acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 128 hydrocortisone-min oil-wht pet . . . . . . . . . . . . . . . . . . . . 173 hydromorphone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 hydromorphone (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 hydroxychloroquine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 HYLENEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 hypercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 HYPERLYTE-CR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 HYPERRAB S/D (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 HYPERRHO S/D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 HYPERTET S/D (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 HYPOLANCE AST LANCING . . . . . . . . . . . . . . . . . . . . . . . . . . 99 I ibandronate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 ibuprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 ibuprofen-oxycodone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 ibutilide fumarate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 ICAR-C PLUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 ICAR-C PLUS SR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

214 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

IDAMYCIN PFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 INFINITY STARTER KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 idarubicin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 INFINITY TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 IFEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34, 35 INFLUENZA A (H1N1) VAC 09 (PF) . . . . . . . . . . . . . . . . . . 165 ifosfamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 INFUMORPH P/F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 ifosfamide-mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 INJECT-EASE AUTOMATIC INJECTOR . . . . . . . . . . . . . . . 100 ILOTYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 IMDUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 INNOHEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 imipenem-cilastatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 INNOVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 imipramine hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 INOVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 imipramine pamoate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 INOVA 4-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 INPERSOL/1.5% DEXTROSE . . . . . . . . . . . . . . . . . . . . . . . . 119 IMOGAM RABIES-HT (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 inpersol/4.25% dextrose . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 IMOVAX RABIES VACCINE (PF) . . . . . . . . . . . . . . . . . . . . . 165 INS SYRINGE/NEEDLE 0.5CC/27G . . . . . . . . . . . . . . . . . . . 100 IN CONTROL PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . . . . 100 INSULIN NEEDLES (DISPOSABLE) inamrinone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 inatal advance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 inatal gt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 inatal ultra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 INCIVEK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 indapamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 INDOCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 indomethacin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 indomethacin sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 INFANRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 INFASURF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 INFERGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 INFINITY METER KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 ............. ............. 101, 104, 105

INSULIN PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 INSULIN SYRINGE MICROFINE . . . . . . . . . . . . . . . . . . . . . 100 INSULIN SYRINGE NEEDLELESS . . . . . . . . . . . . . . . . . . . . . 95 INSULIN SYRINGE ULTRA-FINE . . . . . . . . . . . . . . . . . . . . . 100 INSULIN SYRINGE ULTRAFINE . . . . . . . . . . . . . . . . . . . . . 100 INSULIN SYRINGE-NEEDLE U-100 94, 97, 100, 101, 103, 104, 105, 107, 108 INSULIN SYRINGES (DISPOSABLE) . . . . . . . . . . . . . . . . . 100 INSUMED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 INSUPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 101

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 215

INTEGRILIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 ISOLYTE-S PH 7.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 INTELENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 isonarif . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 isoniazid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 INTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 isoproterenol hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 INTRON A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 ISOPTIN SR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 introvale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 ISOPTO ATROPINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 isopto carpine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 INVEGA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 ISOPTO HOMATROPINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 INVEGA SUSTENNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 ISOPTO HYOSCINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 INVIRASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 ISORDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 IONOSOL-B IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 ISORDIL TITRADOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 IONOSOL-MB IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 isosorbide dinitrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 IOPIDINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 isosorbide mononitrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 IPOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 isradipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 ipratropium bromide . . . . . . . . . . . . . . . . . . . . . . . . . . 41, 128 ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 ipratropium-albuterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 ISUPREL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 IQUIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 itraconazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 IV PREP WIPES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 irbesartan-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . 55 IXEMPRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 IXIARO (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 J

ISENTRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 isoditrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 JALYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 ISOLYTE-H IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 ISOLYTE-M IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 JANUMET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 ISOLYTE-P IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 JANUMET XR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 ISOLYTE-S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 ISOLYTE-S IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 JE-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 216 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 keralac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 KERALAC NAILSTIK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 KERALYT RX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 junel fe 1.5/30 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 KEROL REDI-CLOTHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 junel fe 1/20 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 KETEK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 junel 1.5/30 (21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 KETO-DIASTIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 junel 1/20 (21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 ketoconazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20, 174 JUVISYNC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 ketodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 K ketoprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

k-effervescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 ketorolac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 K-PHOS MF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 KEYNOTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 K-PHOS NO 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 KINRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 K-PHOS ORIGINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 K-PHOS-NEUTRAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 KLARON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 K-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 KALETRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 klor-con m10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 kalexate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 klor-con m15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 KALYDECO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 klor-con m20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 kanamycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 KAON CL-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 klor-con/ef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 KAPVAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 kolnatal dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 KOMBIGLYZE XR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 KAYEXALATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 KEFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 KRISTALOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 kelnor 1/35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 kuric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 KENALOG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143, 174 KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 KEPIVANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 L

KERAFOAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 l norgest&e estradiol-e estrad . . . . . . . . . . . . . . . . . . . . . 144 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 217

labetalol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55, 56 LANOXIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 LAC-HYDRIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 LANOXIN PEDIATRIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 laclotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 lansoprazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 LACRISERT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 lactated ringers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 LANTUS SOLOSTAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 lactocal-f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 LASIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 lactulose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 latanoprost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 LAGESIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 LATUDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77, 78 LAMICTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76, 77 lavoclen-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 LAMICTAL ODT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 lavoclen-4 (new cleanser) . . . . . . . . . . . . . . . . . . . . . . . . . 174 LAMICTAL ODT STARTER (BLUE) . . . . . . . . . . . . . . . . . . . . . 77 lavoclen-8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 LAMICTAL ODT STARTER (GREEN) . . . . . . . . . . . . . . . . . . . 77 lavoclen-8 (new cleanser) . . . . . . . . . . . . . . . . . . . . . . . . . 174 LAMICTAL ODT STARTER (ORANGE) . . . . . . . . . . . . . . . . . . 77 leena 28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 LAMICTAL STARTER (BLUE) KIT . . . . . . . . . . . . . . . . . . . . . . 77 leflunomide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 LAMICTAL STARTER (GREEN) KIT . . . . . . . . . . . . . . . . . . . . 77 lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 LAMICTAL STARTER (ORANGE) KIT . . . . . . . . . . . . . . . . . . . 77 LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 LAMICTAL XR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 LAMICTAL XR STARTER (BLUE) . . . . . . . . . . . . . . . . . . . . . . . 77 leucovorin calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 LAMICTAL XR STARTER (GREEN) . . . . . . . . . . . . . . . . . . . . . 77 LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 LAMICTAL XR STARTER (ORANGE) . . . . . . . . . . . . . . . . . . . 77 LEUKINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 lamivudine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 leuprolide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 lamivudine-zidovudine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 LEUSTATIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 LEVACET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 LANCETS, SUPER THIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 levalbuterol hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 LANCETS,THIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 LEVAQUIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 LANCETS,ULTRA THIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 LEVAQUIN IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 LANCING DEVICE WITH LANCETS . . . . . . . . . . . . . . 96, 101 LEVATOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 LANCING SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 218 - 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LEVEMIR FLEXPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 lidocaine hcl levetiracetam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 levetiracetam in nacl (iso-os) . . . . . . . . . . . . . . . . . . . . . . . 78 LEVLEN (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 levobunolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 levocarnitine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 levocarnitine (with sugar) . . . . . . . . . . . . . . . . . . . . . . . . . . 157 levocetirizine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 levofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20, 128 levofloxacin in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20, 21 levomefolatepnv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 levonorgestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 LEVOPHED (BITARTRATE) . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 levora-28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 levorphanol tartrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 LEVOTHROID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 levothyroxine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144, 145 LEVULAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 LEXAPRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 LEXIVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 LIBERTY BLOOD GLUCOSE MONITOR . . . . . . . . . . . . . . . . 101 LIBERTY TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 LIDAMANTLE HC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 lidocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 lidocaine (pf) .................................. 56, 152, 153

128, 129, 152, 153, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174, 175

lidocaine hcl-hydrocortison ac . . . . . . . . . . . . . . . . . . . . . 175 lidocaine in d5w (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 lidocaine in d7.5w (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 lidocaine viscous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 lidocaine-epinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 lidocaine-epinephrine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . 152 lidocaine-epinephrine bit . . . . . . . . . . . . . . . . . . . . . . . . . . 152 lidocaine-prilocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 LIDODERM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 LIFE MED BLOOD GLUCOSE MONITOR . . . . . . . . . . . . . . . 101 LIFESCAN FINEPOINT LANCETS . . . . . . . . . . . . . . . . . . . . 101 LINCOCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 LIORESAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 liothyronine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 lipodox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 lipodox 50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 LIPOSYN II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 lisinopril-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . . . 56 LITE TOUCH INSULIN PEN NEEDLES . . . . . . . . . . . . . . . . 101 LITE TOUCH INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . 101 LITE TOUCH LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 LITE TOUCH LANCING DEVICE . . . . . . . . . . . . . . . . . . . . . . 101

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 219

lithium carbonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 LOXITANE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 lithium citrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 lozi-flur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 LO-OVRAL (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 LTA PRE-ATTACHED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 LOCOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 ludent fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 LOCOID LIPOCREAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 LUFYLLIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 LOESTRIN FE 1.5/30 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 LOESTRIN FE 1/20 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 LOESTRIN 1.5/30 (21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 LUNESTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78, 79 LOESTRIN 1/20 (21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 LUPRON DEPOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 LOESTRIN 24 FE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 LUPRON DEPOT (3 MONTH) . . . . . . . . . . . . . . . . . . . . . . . . . 35 lokara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 LUPRON DEPOT (4 MONTH) . . . . . . . . . . . . . . . . . . . . . . . . . 35 loperamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 LUPRON DEPOT (6 MONTH) . . . . . . . . . . . . . . . . . . . . . . . . . 35 LOPRESSOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 LUPRON DEPOT-PED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35, 36 LOPRESSOR HCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 LUPRON DEPOT-PED (3 MONTH) . . . . . . . . . . . . . . . . . . . . . 35 lorazepam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 lutera (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 loryna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 LUVOX CR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 losartan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 LYBREL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 losartan-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . . . 56 LYRICA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 LOSEASONIQUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 LYSODREN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 M

LOTENSIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 M-M-R II (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 LOTENSIN HCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 M-VIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 LOTRISONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 MAGELLAN INSULIN SAFETY SYRNG . . . . . . . . . . . 101, 102 LOTRONEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 MAGELLAN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 lovastatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 MAGNEBIND 400 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 LOVAZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 magnesium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 low-ogestrel (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 magnesium sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 loxapine succinate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 magnesium sulfate in d5w . . . . . . . . . . . . . . . . . . . . . . . . . 79 220 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

MAJOR COMFORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 MAXIPIME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 MALARONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 MAXITROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 malathion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 MAXZIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 mannitol 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 MAXZIDE-25MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 mannitol 20 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 MEBARAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 mannitol 25 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 mebendazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 mannitol 5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 meclizine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 maprotiline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 meclofenamate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 MARCAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 MEDI-JECTOR NEEDLE-FREE SYR A . . . . . . . . . . . . . . . . . 102 MARCAINE (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 MEDI-JECTOR NEEDLE-FREE SYR B . . . . . . . . . . . . . . . . . . 102 MARCAINE SPINAL (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 MEDI-JECTOR NEEDLE-FREE SYR C . . . . . . . . . . . . . . . . . . 102 MARCAINE-EPINEPHRINE . . . . . . . . . . . . . . . . . . . . . . . . . 153 MEDI-JECTOR VISION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 MARCAINE-EPINEPHRINE (PF) . . . . . . . . . . . . . . . . . . . . . 153 MEDI-LANCE LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 margesic-h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 MEDISENSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 MEDISENSE CONTROLS 1-HI 1-LO . . . . . . . . . . . . . . . . . . 102 MARNATAL-F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 MEDISENSE GLUCOSE KETONE . . . . . . . . . . . . . . . . . . . . . 102 MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 MEDLANCE PLUS LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . 102 maternity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 MEDROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 MATULANE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 MEDROL (PAK) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 MAVIK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 medroxyprogesterone . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 MAXAIR AUTOHALER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 mefloquine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 MAXALT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 MEFOXIN IN DEXTROSE (ISO-OSM) . . . . . . . . . . . . . . . . . . 21 MAXALT-MLT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 megestrol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 MAXI-COMFORT INSULIN SYRINGE . . . . . . . . . . . . . . . . . 102 meloxicam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 MAXIDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 melphalan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 MAXIDONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 MENACTRA (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 MAXIMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145, 146 MAXINATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 MENOMUNE - A/C/Y/W-135 . . . . . . . . . . . . . . . . . . . . . . . . 165 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 221

MENOMUNE - A/C/Y/W-135 (PF) . . . . . . . . . . . . . . . . . . . . 165 methotrexate sodium (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . 36 MENOSTAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 methscopolamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 MENTAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 methyclothiazide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 MENVEO A-C-Y-W-135-DIP (PF) . . . . . . . . . . . . . . . . . . . . 165 methyl salicylate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 mepivacaine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 methylene blue (antidote) . . . . . . . . . . . . . . . . . . . . . . . . . 158 MEPRON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 methylergonovine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 mercaptopurine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 methylphenidate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 meropenem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 methylprednisolone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 MERREM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 methylprednisolone acetate . . . . . . . . . . . . . . . . . . . . . . . 146 mesalamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 methylprednisolone sodium succ . . . . . . . . . . . . . . . . . . 146 mesalamine-cleansing wipes . . . . . . . . . . . . . . . . . . . . . . 134 metipranolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 metoclopramide hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 MESNEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 metolazone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 MESTINON TIMESPAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 metoprolol succinate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 metaproterenol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 metoprolol ta-hydrochlorothiaz . . . . . . . . . . . . . . . . . . . . 57 metaxalone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 metoprolol tartrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 metformin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 METRO I.V. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 methadone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 METROCREAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 methadone intensol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 metronidazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21, 175 methadose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 metronidazole in nacl (iso-os) . . . . . . . . . . . . . . . . . . . . . . 21 methamphetamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 METVIXIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 methazolamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 mexiletine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 methenamine hippurate . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 miconazole-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 methenamine mandelate . . . . . . . . . . . . . . . . . . . . . . . . . . 21 MICRHOGAM ULTRA-FILTERED . . . . . . . . . . . . . . . . . . . . . 165 METHERGINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 MICRHOGAM ULTRA-FILTERED PLUS . . . . . . . . . . . . . . . 165 methimazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 MICRO BLOOD GLUCOSE . . . . . . . . . . . . . . . . . . . . . . 102, 114 methocarbamol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 MICRO-K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 methotrexate sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 MICRODOT BLOOD GLUCOSE SYSTEM . . . . . . . . . . . . . . . 114 222 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

microgestin fe 1.5/30 (28) . . . . . . . . . . . . . . . . . . . . . . . . . 146 MOBAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 microgestin fe 1/20 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 microgestin 1.5/30 (21) . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 MODICON (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 microgestin 1/20 (21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 moexipril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 MICROLET LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 moexipril-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . 57, 58 MICROLET 2 LANCING DEVICE . . . . . . . . . . . . . . . . . . . . . 102 mometasone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 MICROZIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 MONOJECT INSULIN SAFETY SYRING . . . . . . . . . . . . . . . 102 MIDAMOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 MONOJECT INSULIN SYRINGE midodrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 migergot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 MIGRANAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 milrinone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 milrinone in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 mimvey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 MINI ULTRA-THIN II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 MINI WRIGHT PEAK FLOW METER . . . . . . . . . . . . . . . . . . 102 MINI-WRIGHT PEAK FLOW METER . . . . . . . . . . . . . . . . . . 102 MINIMED SYRINGE RESERVOIR . . . . . . . . . . . . . . . . . . . . . 102 MINIPRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 minocycline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21, 22 minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 MIOCHOL-E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 MIOSTAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 MIRCETTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 mirtazapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 misoprostol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 mitomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 mitoxantrone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 ................. 100, 102, 103

monoject prefill (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 MONOJECT SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 MONOJECT ULTRA COMFORT INSULIN . . . . . . . . . . . . . . 103 MONOJECTOR LANCET DEVICE . . . . . . . . . . . . . . . . . . . . . 103 MONOKET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 MONOLET LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 MONOLET THIN LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . 103 mononessa (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 montelukast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 MONUROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 morgidox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 morphine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80, 81 morphine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80, 81 morphine (pf) in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 morphine concentrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 MOXEZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 mst 600 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 223

MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 mynate 90 plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 MULTI-LANCET DEVICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 MYOBLOC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 MULTI-NATE DHA EXTRA . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 MYOCHRYSINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 multi-nate 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 MULTI-NATE 30 DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 MYOZYME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 multi-vitamin with fluoride . . . . . . . . . . . . . . . . . . . . . . . . 184 MYTELASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 multinatal plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182, 183 myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 multivitamin with fluoride . . . . . . . . . . . . . . . . . . . . . . . . . 184 N

multivitamins with fluoride . . . . . . . . . . . . . . . . . . . . . . . . 185 NABI-HB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 multivitamins-fluoride-folic a . . . . . . . . . . . . . . . . . . . . . . 184 nabumetone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 MUSTARGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 nadolol-bendroflumethiazide . . . . . . . . . . . . . . . . . . . . . . . 58 MVC-FLUORIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 nafcillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 MYAMBUTOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 nafcillin in d2.4w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 MYCAMINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 NAFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 MYCOBUTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 NAGLAZYME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 mycophenolate mofetil . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 nalbuphine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 MYDFRIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 NALFON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81, 82 mydral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 naloxone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 MYDRIACYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 naltrexone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 MYFORTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 NAMENDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 MYGLUCOHEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 NAMENDA TITRATION PAK . . . . . . . . . . . . . . . . . . . . . . . . . . 82 MYKIDZ IRON FLUORIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 naproxen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 MYLERAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 naproxen sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 MYNATAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 naratriptan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 mynatal advance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 NARDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 mynatal plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 NAROPIN (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 mynatal-z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 NASONEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 224 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

NATA KOMPLETE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 neomycin-bacitracin-polymyxin . . . . . . . . . . . . . . . . . . . 129 NATACHEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 neomycin-polymyxin b gu . . . . . . . . . . . . . . . . . . . . . . . . . 176 NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 neomycin-polymyxin-dexameth . . . . . . . . . . . . . . . . . . 129 NATAFORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 neomycin-polymyxin-gramicidin . . . . . . . . . . . . . . . . . . 129 NATALVIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 neomycin-polymyxin-hc . . . . . . . . . . . . . . . . . . . . . . . . . . 129 NATAZIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 neosporin (neo-polym-gramicid) . . . . . . . . . . . . . . . . . . 129 nateglinide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 NEOSPORIN GU IRRIGANT . . . . . . . . . . . . . . . . . . . . . . . . . 176 NATELLE-EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 neostigmine methylsulfate . . . . . . . . . . . . . . . . . . . . . . . . . 42 NATRECOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 NEPHRAMINE 5.4 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 NAVANE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 NESACAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 navatab + dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 NESACAINE-MPF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 necon 0.5/35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 NEULASTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 necon 1/35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 NEUMEGA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 necon 1/50 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 NEUPOGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 necon 10/11 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 necon 7/7/7 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 NEURONTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 NEEDLE-PRO EDGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 NEUT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 NEEVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 NEVANAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 NEEVO DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 nevirapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 nefazodone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 neo-fradin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 NEXAVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 neo-polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 NEXIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 NEO-SYNEPHRINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 NEXIUM PACKET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 NEOBENZ MICRO CREAM PLUS PACK . . . . . . . . . . . . . . . . 175 NEXTERONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 NEOBENZ MICRO SD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 neofrin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 NIASPAN EXTENDED-RELEASE . . . . . . . . . . . . . . . . . . . . . . 58 neomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 nicardipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 neomycin-bacitracin-poly-hc . . . . . . . . . . . . . . . . . . . . . . 129 NICOTROL NS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 2013 PRESCRIPTION DRUG 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nifediac cc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 norgestimate-ethinyl estradiol . . . . . . . . . . . . . . . . . . . . . 147 nifedical xl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 norgestrel-ethinyl estradiol . . . . . . . . . . . . . . . . . . . . . . . . 147 nifedipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 NORINYL 1+35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NILANDRON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 NORINYL 1+50 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NIMBEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 NORITATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 nimodipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 NORMOSOL-M IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 NORMOSOL-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 nisoldipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58, 59 NORMOSOL-R IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 NITRO-DUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 NORMOSOL-R PH 7.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 NOROXIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 nitrofurantoin macrocrystal . . . . . . . . . . . . . . . . . . . . . . . . 22 NORPRAMIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 nitrofurantoin monohyd/m-cryst . . . . . . . . . . . . . . . . . . . 22 nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 nitroglycerin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 nortrel 1/35 (21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 nitroglycerin in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 nortrel 1/35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NITROLINGUAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 nortrel 7/7/7 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NITROPRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 nortriptyline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 NITROSTAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 NORVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 nizatidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134, 135 NOVA MAX GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . 114 NIZORAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 NOVA SUREFLEX LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . 103 NOR-QD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NOVANTRONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NOVOFINE AUTOCOVER . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 NORDETTE-28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NOVOFINE 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 NOREL SR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 NOVOFINE 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 norepinephrine bitartrate . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 NOVOLIN N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 noreth-ethinyl estradiol-iron . . . . . . . . . . . . . . . . . . . . . . . 147 NOVOLIN R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 norethindrone (contraceptive) . . . . . . . . . . . . . . . . . . . . . 147 NOVOLIN 70/30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 norethindrone acetate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NOVOLOG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NORFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 NOVOLOG FLEXPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 226 - 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NOVOLOG MIX 70-30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 OBSTETRIX EC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 NOVOLOG MIX 70-30 FLEXPEN . . . . . . . . . . . . . . . . . . . . . 147 OBTREX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 NOVOLOG PENFILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 OBTREX DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 NOVOPEN JR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 ocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 NOVOPEN 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 OCTAGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 NOVOPEN 3 PENMATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 octreotide acetate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 NOVOTWIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 OCUDOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 NOXAFIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 OCUFEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 OCUFLOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 ofloxacin NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 NULYTELY WITH FLAVOR PACKS . . . . . . . . . . . . . . . . . . . . 135 NUTRESTORE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 NUTRILYTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 nutrilyte ii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 NUTRIPORT BALLOON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 NUVARING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 nuzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 NUZON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22, 176 nystatin-triamcinolone . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 O O-CAL FA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 O-CAL PRENATAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 ob-natal one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 obstetrix dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 ...................................... 22, 23, 130

OFORTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 ogestrel (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 olanzapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 omeprazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 OMNARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 OMNITROPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 ONCASPAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 ondansetron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 ondansetron (pf) in dextrose . . . . . . . . . . . . . . . . . . . . . . . 135 ondansetron (pf) in nacl (iso) . . . . . . . . . . . . . . . . . . . . . . 135 ondansetron hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 ondansetron hcl (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 ONE TOUCH BASIC SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . 103 ONE TOUCH DELICA LANC DEVICE . . . . . . . . . . . . . . . . . . 103 ONE TOUCH DELICA LANCETS . . . . . . . . . . . . . . . . . . . . . . 103 ONE TOUCH SURESOFT LANCING DEV . . . . . . . . . . . . . . 104 ONE TOUCH TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 227

ONE TOUCH ULTRA SMART . . . . . . . . . . . . . . . . . . . . . . . . . 104 ORTHO-CEPT (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 ONE TOUCH ULTRA SYSTEM KIT . . . . . . . . . . . . . . . . . . . . 104 ORTHO-CYCLEN (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 ONE TOUCH ULTRA TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 ORTHO-NOVUM 1/35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . 148 ONE TOUCH ULTRA 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 ORTHO-NOVUM 7/7/7 (28) . . . . . . . . . . . . . . . . . . . . . . . . . 148 ONE TOUCH ULTRALINK . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 ORTHOCLONE OKT3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 ONE TOUCH ULTRAMINI . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 oscion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 ONE TOUCH ULTRASOFT LANCETS . . . . . . . . . . . . . . . . . . 104 OSMITROL 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 ONFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 OSMITROL 15 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 ONGLYZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 OSMITROL 20 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 ONTAK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 OSMITROL 5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 onxol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 OSMOPREP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 OPANA ER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 otic edge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 OPTIPRANOLOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 oticin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 OPTIUM EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 otogesic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 OPTIUM TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 OVACE PLUS SHAMPOO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 ORACIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 OVCON-35 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 oralone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 OVCON-50 (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 ORAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 OVIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 ORAPRED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 oxacillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 ORAPRED ODT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 oxacillin in dextrose, iso-osm . . . . . . . . . . . . . . . . . . . . . . . 23 ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 oxaliplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 orphenadrine citrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 OXALIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 ORSINI INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 104 oxandrolone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 ORTHO EVRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83, 84 ORTHO MICRONOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 oxcarbazepine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 ORTHO TRI-CYCLEN (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 OXISTAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 ORTHO TRI-CYCLEN LO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 OXSORALEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 228 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

OXSORALEN ULTRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 PATADAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 oxybutynin chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 PATANASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 oxycodone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 PAXIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 oxycodone hcl-oxycodone-asa . . . . . . . . . . . . . . . . . . . . . 84 PCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 oxycodone-acetaminophen . . . . . . . . . . . . . . . . . . . . . . . . 84 pedi-dri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 oxycodone-aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 PEDIAPRED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 oxymorphone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 PEDIARIX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 oxytocin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 PEDVAX HIB (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 P peg 3350-electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

PACERONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 peg-electrolyte soln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 peg-3350 with flavor packs . . . . . . . . . . . . . . . . . . . . . . . . 135 PAIN EASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 PEGANONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 paire ob plus dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 PEGASYS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 pamidronate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 PEGASYS CONVENIENCE PACK . . . . . . . . . . . . . . . . . . . . . . 23 PANCREAZE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 PEGASYS PROCLICK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 pancrelipase 5000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 PEGINTRON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 pancuronium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 PEGINTRON REDIPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 PANDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 PANHEMATIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 penicillin g pot in dextrose . . . . . . . . . . . . . . . . . . . . . . . . . . 23 PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 penicillin g potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 pantoprazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 penicillin g procaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 papaverine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 penicillin g sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 parcaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 penicillin v potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . 23, 24 paregoric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 PENLET PLUS BLOOD SAMPLER . . . . . . . . . . . . . . . . . . . . . 104 PAREMYD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 PENNSAID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 paromomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 PENTACEL (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 paroxetine hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 PENTAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 229

pentostatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 phospha 250 neutral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 pentoxifylline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 phosphasal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PERFOROMIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 PHOSPHOLINE IODIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 perindopril erbumine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 PHOTOFRIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 PERIO MED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 periogard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 PHYSIOSOL IRRIGATION . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PERIOSTAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 pilocarpine hcl PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 permethrin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 perphenazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 perphenazine-amitriptyline . . . . . . . . . . . . . . . . . . . . . . . . . 85 pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PHARMACIST CHOICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 phenazopyridine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 phenelzine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 PHENERGAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 phenobarbital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 phentolamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 phenylephrine hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42, 130 PHENYTEK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 phenytoin sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 phenytoin sodium extended . . . . . . . . . . . . . . . . . . . . . . . . 85 philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 PHOS-FLUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 PHOSLO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 ................................. 42, 43, 130

PILOPINE HS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 piperacillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 piperacillin-tazobactam . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 PITOCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 PITRESSIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 PLASMA-LYTE A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PLASMA-LYTE 148 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PLASMA-LYTE-56 IN D5W . . . . . . . . . . . . . . . . . . . . . . . . . 122 PLETAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 pnv ob+dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 pnv-dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 pnv-omega . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 pnv-select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 pnv-total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 POCKETCHEM EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104, 114 podocon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 polocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

230 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

polocaine (pf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 pramipexole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85, 86 poly iron pn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRAMOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 poly iron pn forte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 PRANDIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 poly-dex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 pravastatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 POLY-PRED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 prazosin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 poly-vitamin/fluoride/iron . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRECARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 poly-650 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 PRECARE CONCEIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 polyethylene glycol 3350 . . . . . . . . . . . . . . . . . . . . . . . . . . 136 PRECARE PREMIER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 polymyxin b sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PRECEDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 POLYTRIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 PRECISION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 PONTOCAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 PRECISION GLUCOSE CONTROL SOLN . . . . . . . . . . . . . . . 104 PONTOCAINE (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 PRECISION GLUCOSE/KETONE CONTR . . . . . . . . . . . . . . 104 portia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 PRECISION PCX PLUS TEST . . . . . . . . . . . . . . . . . . . . . . . . . 115 potassium acetate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PRECISION PCX TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 potassium bicarb & chloride . . . . . . . . . . . . . . . . . . . . . . . 122 PRECISION POINT OF CARE TEST . . . . . . . . . . . . . . . . . . . 115 potassium bicarb-citric acid . . . . . . . . . . . . . . . . . . . . . . . 122 PRECISION Q-I-D TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 potassium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PRECISION XTRA MONITOR . . . . . . . . . . . . . . . . . . . . . . . . 104 potassium citrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PRECISION XTRA TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 potassium citrate-citric acid . . . . . . . . . . . . . . . . . . . . . . . 122 PRECOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 potassium phosphate dibasic . . . . . . . . . . . . . . . . . . . . . . 122 PRED FORTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 POTIGA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 PRED MILD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 pr natal 400 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 pr natal 400 ec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 pr natal 430 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 prednicarbate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 pr natal 430 ec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 prednisol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 pr natal 440 ec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 prednisolone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 PR OTIC SOLUTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 prednisolone acetate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46, 47 prednisolone sodium phosphate . . . . . . . . . . . . . . 130, 148 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 231

prednisone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 PRESTIGE LX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 prednisone intensol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 PRESTIGE LX BLOOD GLUCOSE KIT . . . . . . . . . . . . . . . . . . 104 PRELONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 PRESTIGE SMART SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . 104 PREMARIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 PRESTIGE SMART SYSTEM IQ KIT . . . . . . . . . . . . . . . . . . . 104 PREMASOL 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PRESTIGE SMART SYSTEM METER . . . . . . . . . . . . . . . . . . . 104 PREMASOL 6 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PRESTIGE SMART SYSTEM TEST . . . . . . . . . . . . . . . . . . . . . 115 PREMESIS RX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRESTIGE SMART SYSTEM VALUE PK . . . . . . . . . . . . . . . . 104 prenacare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRESTIGE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 prenafirst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRESTIGE VALUE PACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 prenaplus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 PRENATA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PREVIDENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 PRENATABS FA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PREVIDENT 5000 BOOSTER . . . . . . . . . . . . . . . . . . . . . . . . 158 PRENATABS RX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PREVIDENT 5000 DRY MOUTH . . . . . . . . . . . . . . . . . . . . . . 159 prenatal ad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PREVIDENT 5000 ENAMEL PROTECT . . . . . . . . . . . . . . . . 159 prenatal low iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PREVIDENT 5000 PLUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 prenatal multivit with iron . . . . . . . . . . . . . . . . . . . . . . . . . 187 PREVIDENT 5000 SENSITIVE . . . . . . . . . . . . . . . . . . . . . . . 159 prenatal plus (calcium carb) . . . . . . . . . . . . . . . . . . . . . . . 186 previfem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 prenatal plus with iron (ca) . . . . . . . . . . . . . . . . . . . . . . . . 186 previt+dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 prenatal 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 previte rx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRENATAL-U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PREVNAR 13 (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 PRENATE DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PREZISTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PRENATE ELITE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRIALT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 PRENATE ELITE (NEW FORM) . . . . . . . . . . . . . . . . . . . . . . . 186 PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PRENATE ESSENTIAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRIMACARE ADVANTAGE . . . . . . . . . . . . . . . . . . . . . . . . . . 186 prenate plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRIMACARE ONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 PREPIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 primaquine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PREQUE 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 PRIMAXIN IM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PRESTIGE BLOOD GLUCOSE MONITOR . . . . . . . . . . . . . . 104 PRIMAXIN IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 232 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

primidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 PRODIGY PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 PRIMSOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 PRODIGY TWIST TOP LANCET . . . . . . . . . . . . . . . . . . . . . . 105 PRINIVIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 progesterone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 PRINZIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 progesterone in oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 progesterone micronized . . . . . . . . . . . . . . . . . . . . . . . . . . 149 privigen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 PROGLYCEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 PROAIR HFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 PROGRAF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 PROAMATINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 PROLASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 probenecid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PROLASTIN C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 procainamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 PROCALAMINE 3% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 PROCHIEVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 PROMACTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 prochlorperazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 promethegan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 prochlorperazine edisylate . . . . . . . . . . . . . . . . . . . . . . . . . 136 PROMETRIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 prochlorperazine maleate . . . . . . . . . . . . . . . . . . . . . . . . . 136 propafenone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 PROCRIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 propantheline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 procto-pak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 proparacaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 PROCTOCORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 propranolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 proctocream-hc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 propranolol-hydrochlorothiazid . . . . . . . . . . . . . . . . . . 60, 61 proctosol hc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 propylthiouracil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 proctozone-hc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 PROQUAD (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 PRODIGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 PROSOL 20% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 PRODIGY AUTOCODE TEST STRIPS . . . . . . . . . . . . . . . . . . 115 PROSTIGMIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 PRODIGY CONTROL SOLUTION,HIGH . . . . . . . . . . . . . . . 104 PROSTIN E2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 PRODIGY EJECT TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . 115 protamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 PRODIGY INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . 105 PROTID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 PRODIGY LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 PROTONIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 PRODIGY NO CODING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 protriptyline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 233

PROVENTIL HFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 PROVERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 provisc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 ranitidine hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 PUBLIX LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 RAPAFLO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 PULMOZYME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 RAPAMUNE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 PURINETHOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 re dualvit ob . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 PYLERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 re multivit-fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 pyrazinamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 re ob + dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 PYRIDIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 RE OB 90 + DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 pyridostigmine bromide . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 re sa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 PYROGALLIC ACID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 re urea 40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Q re-nata 29 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

QUALAQUIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 re-nata 29 ob . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 quasense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 re-u40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 QUESTRAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 REBETOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 QUESTRAN LIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 quetiapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 REBIF TITRATION PACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 QUICKTEK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 RECLAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 QUICKTEK TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 reclipsen (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 quinapril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 RECOMBIVAX HB (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 quinapril-hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . . 61 REFLUDAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 quinidine gluconate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 REFUAH PLUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 quinidine sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 REGONOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 quinine sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 REGRANEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 QUIXIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 relagard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 QVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 RELAGESIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 R RELENZA DISKHALER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

RABAVERT (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 RELION CONFIRM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 234 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

RELION NEEDLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 RHOGAM ULTRA-FILTERED . . . . . . . . . . . . . . . . . . . . . . . . . 166 RELION ULTIMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 RHOGAM ULTRA-FILTERED PLUS . . . . . . . . . . . . . . . . . . . 166 RELION ULTRA THIN PLUS LANCETS . . . . . . . . . . . . . . . . 105 RHOPHYLAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 RELISTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 RIASTAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 relnate dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 RIBAPAK DOSE PACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 remeven . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 ribasphere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 REMICADE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 RIBATAB DOSE PACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 REMODULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 ribavirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 RENACIDIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 renaf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 RIFADIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 RENEW ADVANCED MICRO-LANCETS . . . . . . . . . . . . . . . 105 RIFAMATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 RENVELA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 REOPRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 REQUIP XL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 RIGHTEST GS550 TEST STRIPS . . . . . . . . . . . . . . . . . . . . . 115 RESCRIPTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 RILUTEK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 RESECTISOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 rimantadine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 reserpine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 RIMSO-50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 RESPA-AR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 ringers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 RETROVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24, 25 RISPERDAL CONSTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 REVATIO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 RISPERDAL M-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86, 87 revia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 risperidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 REVLIMID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 risperidone m-tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 revonto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 REYATAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 rivastigmine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 RHEUMATREX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 ROBINUL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 rhinoflex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 ROBINUL FORTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 rhinoflex-650 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 ROCALTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 235

ROCEPHIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 rocuronium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 SAVELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 ROMAZICON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 scalacort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 romycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 scalp treatment kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 ropinirole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 se-care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 se-care conceive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 ROSULA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 se-care gesture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 ROSULA NS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 se-natal one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 se-natal 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 ROTATEQ VACCINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 se-natal 90 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 roxicet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 se-plete dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 ru-tuss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 se-tan dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 S SEASONIQUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

SABRIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 SELECT-LITE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 SAFESNAP INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . 105 SELECT-LITE LANCING DEVICE . . . . . . . . . . . . . . . . . . . . . 105 SAFETY-LET LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 SELECT-OB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 SAIZEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 SELECT-OB + DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 SAIZEN CLICK.EASY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 selegiline hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 salacyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 selenium sulfide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 SALEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 SELSEB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 salicylic acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 SELZENTRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 SEMPREX-D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 SAMSCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SENSIPAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 SANCTURA XR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 SENSORCAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 SENSORCAINE-MPF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 SANDOSTATIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 sensorcaine-mpf spinal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 SANDOSTATIN LAR DEPOT . . . . . . . . . . . . . . . . . . . . . . . . . 159 sensorcaine-mpf/epinephrine . . . . . . . . . . . . . . . . . . . . . 153 SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 sensorcaine/epinephrine . . . . . . . . . . . . . . . . . . . . . 153, 154 236 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

SENSURA CLICK OSTOMY POUCH . . . . . . . . . . . . . . . . . . . 105 sodium acetate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SENSURA FLEX OSTOMY BASE PLATE . . . . . . . . . . . . . . . 105 sodium bicarbonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SENSURA FLEX OSTOMY POUCH . . . . . . . . . . . . . . . . . . . . 105 sodium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SENSURA OSTOMY BASE PLATE . . . . . . . . . . . . . . . . . . . . 105 sodium chloride 0.45 % . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SEPTRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 sodium chloride 0.9 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SEPTRA DS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 sodium chloride 3 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SEREVENT DISKUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 sodium chloride 5 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SEROMYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 SODIUM EDECRIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SEROQUEL XR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 sodium fluoride SEROSTIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 sertraline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 setonet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 SETONET-EC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 sf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 sf 5000 plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 SILVADENE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 silver nitrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 silver sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 SIMCOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159, 160 simvastatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61, 62 SINGLE-LET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 SINGULAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 SKELID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 SMART CARESENS N TEST STRIPS . . . . . . . . . . . . . . . . . . . 115 SMARTEST LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 SMARTEST TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 sodiphluor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 .............................. 156, 158, 160

sodium lactate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 sodium nitrite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 sodium phosphate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 sodium polystyrene (sorb free) . . . . . . . . . . . . . . . . . . . . 123 sodium polystyrene sulfonate . . . . . . . . . . . . . . . . . . . . . 123 sodium thiosulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 SOFT TOUCH LANCET DEVICE . . . . . . . . . . . . . . . . . . . . . . 106 SOLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 SOLO V2 LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 SOLO V2 TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 SOLU-CORTEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 SOLU-CORTEF (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 SOLU-MEDROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149, 150 SOLU-MEDROL (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 SOMATULINE DEPOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 sorbitol-mannitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 SORIATANE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 237

sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 SUBOXONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 sotalol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 sotalol af . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 sufentanil citrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 sotret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 sulfac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 SPIRIVA WITH HANDIHALER . . . . . . . . . . . . . . . . . . . . . . . . 43 sulfacetamide sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 spironolacton-hydrochlorothiaz . . . . . . . . . . . . . . . . . . . . 62 sulfacetamide sodium (acne) . . . . . . . . . . . . . . . . . . . . . . 178 spironolactone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 sulfacetamide sodium-sulfur . . . . . . . . . . . . . . . . . . . . . . 178 SPRAY AND STRETCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 sulfacetamide sodium-urea . . . . . . . . . . . . . . . . . . . . . . . 178 sprintec (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 sulfacetamide-prednisolone . . . . . . . . . . . . . . . . . . . . . . . 131 SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 SPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 sulfamethoxazole-trimethoprim . . . . . . . . . . . . . . . . . . . 26 sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 sulfamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 SULFAMYLON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 SSD AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 sulfasalazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 STAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 sulfazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 stagesic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 sulfazine ec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 stannous fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 stavudine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 sumatriptan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 STAVZOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 sumatriptan succinate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 STELARA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 supartz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 STERILE GAUZE PAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 SUPRAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 STERILE PADS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 SUPREP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 STERILE STRETCH GAUZE BANDAGE . . . . . . . . . . . . . . . . 161 SURE COMFORT ALCOHOL PREP PADS . . . . . . . . . . . . . . . 178 STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 SURE COMFORT INS. SYR. U-100 . . . . . . . . . . . . . . . . . . . . 106 STRATTERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 SURE COMFORT INSULIN SYRINGE . . . . . . . . . . . . . . . . . 106 streptomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 SURE COMFORT LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . 106 STRIANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 SURE COMFORT PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . 106 STROMECTOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 SURE EDGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 238 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

SURE EDGE BLOOD GLUCOSE METER . . . . . . . . . . . . . . . . 106 SYNVISC-ONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 SURE-FINE PEN NEEDLES . . . . . . . . . . . . . . . . . . . . . . . . . . 106 SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 SURE-JECT INSULIN SYRINGE . . . . . . . . . . . . . . . . . 106, 107 T

SURE-LANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 TABLOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 SURE-PREP ALCOHOL PREP PADS . . . . . . . . . . . . . . . . . . . 178 TACLONEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 SURE-TEST EASYPLUS MINI . . . . . . . . . . . . . . . . . . . . . . . . 115 TACLONEX SCALP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 SURECHEK TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 tacrolimus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 SURESTEP COMPLETE SYSTEM . . . . . . . . . . . . . . . . . . . . . . 107 TAMIFLU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 SURESTEP GLUCOSE CONTROL . . . . . . . . . . . . . . . . . . . . . 107 tamoxifen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 SURESTEP PRO LINEARITY . . . . . . . . . . . . . . . . . . . . . . . . . 107 tamsulosin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 SURESTEP PRO TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 TANDEM DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 SURESTEP TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 TANDEM OB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 SURMONTIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 TAPAZOLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 SURVANTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 TARCEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 SUSTIVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 TARGRETIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37, 179 SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 taron ec calcium-dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 syeda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 taron-bc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 SYLATRON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 taron-c dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 SYLATRON 4-PACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 taron-crystals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 SYMBICORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 TARON-DUO EC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 SYMLIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 taron-ec cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 SYMLINPEN 120 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 taron-prex prenatal-dha . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 TASIGNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 TASMAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 SYNERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 TAXOTERE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 SYNERCID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 SYNTHROID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 TAZORAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 SYNVISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 taztia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 239

TECHLITE AST LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 tetanus-diphtheria toxoids-td . . . . . . . . . . . . . . . . . . . . . 166 TECHLITE LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 tetanus,diphtheria tox ped(pf) . . . . . . . . . . . . . . . . . . . . . 164 TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 tetcaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 TEGRETOL XR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 tetracaine hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 TEKAMLO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 tetracycline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 TETRAVISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 TEKTURNA HCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 TETRAVISC FORTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 temazepam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 TEXACORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 TEMODAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 THALITONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 TENIVAC (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 THALOMID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 TENORETIC 100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 THAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 TENORETIC 50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 theochron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 TENORMIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62, 63 theophylline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 TERAZOL 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 theophylline in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 TERAZOL 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 THERACYS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 terazosin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 THERMAZENE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 terbinafine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 THINPRO INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . 107 terbutaline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 THINSET RESERVOIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 terconazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 thioridazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 TERRAMYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 TERRAMYCIN IM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 thiothixene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 TERRAMYCIN WITH POLYMYXIN B . . . . . . . . . . . . . . . . . . 131 THYMOGLOBULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 TERUMO INS SYRINGE 0.5CC/27G . . . . . . . . . . . . . . . . . . 107 THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 TERUMO INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . 107 THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 TERUMO SURGUARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 testosterone cypionate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 testosterone enanthate . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 tetanus toxoid,adsorbed (pf) . . . . . . . . . . . . . . . . . . . . . . 166 TIAZAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 240 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

TICE BCG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 TOPCARE ULTRA COMFORT . . . . . . . . . . . . . . . . . . . . . . . . . 108 ticlopidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 TOPCARE UNIVERSAL1 THIN LANCET . . . . . . . . . . . . . . . 108 TIGAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 topiragen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 TIKOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 topiramate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 TIMENTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 topotecan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 timolol maleate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63, 131 TOPROL XL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 TIMOPTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 TIMOPTIC OCUDOSE (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 torsemide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 TIMOPTIC-XE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 TPN ELECTROLYTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 tinidazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 TPN ELECTROLYTES II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 tizanidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 TRACLEER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 TNKASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 tramadol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 TOBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 tramadol-acetaminophen . . . . . . . . . . . . . . . . . . . . . . . . . . 90 TOBRADEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 TRANDATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 TOBRADEX ST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 trandolapril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 tobramycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 tranexamic acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 tobramycin in ns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 tranylcypromine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 tobramycin sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 TRAVASOL 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 tobramycin-dexamethasone . . . . . . . . . . . . . . . . . . . . . . 131 TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 tobrasol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 trazodone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 TOBREX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 treagan otic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 tolazamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 TREANDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 tolbutamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 TRECATOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 tolmetin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89, 90 TRELSTAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 tolterodine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 TRELSTAR DEPOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 TOPAMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 TRELSTAR LA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 TOPCARE CLICKFINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 TRENTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 241

tretinoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 TRILIPIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 tretinoin (chemotherapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 trilyte with flavor packets . . . . . . . . . . . . . . . . . . . . . . . . . . 136 TREXALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 trimesis rx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TREXIMET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 trimethobenzamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 tri rx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 trimethoprim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 TRI-CHLOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 trimethoprim-polymyxin b . . . . . . . . . . . . . . . . . . . . . . . . 130 tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 trimipramine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 TRI-NORINYL (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 trinatal gt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 tri-previfem (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 trinatal rx 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 tri-sprintec (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 trinatal ultra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 tri-vit with fluoride & iron . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRINATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 tri-vitamin w/fluoride & iron . . . . . . . . . . . . . . . . . . . . . . . 188 trinessa (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 tri-vitamin with fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRIPEDIA (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 triadvance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRISENOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 triamcinolone acetonide . . . . . . . . . . . . . . . . . . . . . . . . . . 179 triveen-duo dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 triamterene-hydrochlorothiazid . . . . . . . . . . . . . . . . . . . 124 triveen-one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRIAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 triveen-prx rnf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRIAZ CLEANSER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 triveen-ten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 trichloroacetic acid . . . . . . . . . . . . . . . . . . . . . . . . . . . 179, 180 triveen-u . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 tricitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 trivora (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 tricitrates (w/ sucrose) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 TRIZIVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 TRICOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 TROPHAMINE 10 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 triderm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 TROPHAMINE 6% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 trifluoperazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 tropicamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 trospium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 trihexyphenidyl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 TRUERESULT BLOOD GLUCOSE SYSTM . . . . . . . . . . . . . . 108 TRIHIBIT PRESERVATIVE FREE . . . . . . . . . . . . . . . . . . . . . . 166 TRUETEST HIGH GLUCOSE CONTROL . . . . . . . . . . . . . . . . 108 TRILEPTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 TRUETEST NORMAL GLUCOSE CNTRL . . . . . . . . . . . . . . . 108 242 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

TRUETEST TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 ULTIMA TEST STRIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 TRUETRACK BLOOD GLUCOSE SYSTEM . . . . . . . . . . . . . . 108 ultimate ob dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRUETRACK SMART SYSTEM . . . . . . . . . . . . . . . . . . . 108, 115 ultimatecare advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRUETRACK TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 ultimatecare combo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 trust natal dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 ultimatecare one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 ultimatecare one nf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 TRUZONE PEAK FLOW METER . . . . . . . . . . . . . . . . . . . . . . 108 ULTIVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 tubocurarine chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 ULTRA CMFT INS SYR HALF UNIT . . . . . . . . . . . . . . . . . . . 110 TWINJECT AUTOINJECTOR . . . . . . . . . . . . . . . . . . . . . . . . . 43 ULTRA COMFORT INSULIN SYRINGE . . . . . . . . . . . 109, 110 TWINRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 ULTRA THIN II LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 ULTRA THIN LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 ULTRA THIN PLUS LANCETS . . . . . . . . . . . . . . . . . . . . . . . . 110 TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 ULTRA TLC LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 ULTRA-THIN II (SHORT) INS SYR . . . . . . . . . . . . . . . . . . . 110 TYZEKA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 ULTRA-THIN II (SHORT) PEN NDL . . . . . . . . . . . . . . . . . . . 110 TYZINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ULTRA-THIN II INS PEN NEEDLES . . . . . . . . . . . . . . . . . . 110 U ULTRA-THIN II INSULIN SYRINGE . . . . . . . . . . . . . 110, 111

u-cort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 ULTRACET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 ULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 ULTRACOMFORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 ULTI-LANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 ULTRACOMFORT W/ CONTAINER . . . . . . . . . . . . . . . . . . . 111 ULTICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 ULTRASE EC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 ULTIGUARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108, 109 ULTRASE MT 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 ULTILET ALCOHOL SWAB . . . . . . . . . . . . . . . . . . . . . . . . . . 180 ULTRASE MT 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 ULTILET CLASSIC LANCETS . . . . . . . . . . . . . . . . . . . . . . . . 109 ULTRASE MT 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 ULTILET INSULIN SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . 109 ULTRATRAK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 ULTILET LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 UMECTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 ULTILET PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 UMECTA PD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 ULTIMA MONITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 UNIFINE PENTIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 243

UNILET COMFORTOUCH LANCET . . . . . . . . . . . . . . . . . . . 111 urea 40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 UNILET EXCELITE II LANCET . . . . . . . . . . . . . . . . . . . . . . . 111 URETRON D-S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 UNILET EXCELITE LANCET . . . . . . . . . . . . . . . . . . . . . . . . . 111 urin ds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 UNILET G.P. LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 UROQID-ACID NO.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 UNILET G.P. SUPERLITE LANCET . . . . . . . . . . . . . . . . . . . . 111 ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 UNILET GP LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 ustell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 UNILET LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 utira-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 UNILET SUPERLITE LANCET . . . . . . . . . . . . . . . . . . . . . . . . 111 UVADEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 UNIRETIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63, 64 u40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 UNISTIK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 V

UNISTIK CZT LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 VAGIFEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 UNISTIK 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 valacyclovir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 UNISTIK 2 DEVICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 VALCYTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 UNISTIK 2 EXTRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 valproate sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 UNISTIK 2 NORMAL LANCET&DEVICE . . . . . . . . . . . . . . . 111 valproic acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 UNISTIK 2 SUPER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 valproic acid (as sodium salt) . . . . . . . . . . . . . . . . . . . . . . . 91 UNISTIK 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 VALSTAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 UNISTIK 3 COMFORT DEVICE . . . . . . . . . . . . . . . . . . . . . . . 112 VALTURNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 UNISTIK 3 COMFORT LANCET . . . . . . . . . . . . . . . . . . . . . . 112 VANCOCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 UNISTIK 3 EXTRA LANCET . . . . . . . . . . . . . . . . . . . . . . . . . . 112 vancomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 UNISTIK 3 NEONATAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 vancomycin in dextrose iso-osm . . . . . . . . . . . . . . . . . . . . 28 UNISTIK 3 NEONATAL DEVICE . . . . . . . . . . . . . . . . . . . . . 112 vancomycin in d5w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 UNISTIK 3 NORMAL LANCET . . . . . . . . . . . . . . . . . . . . . . . 112 VANDAZOLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 UNITHROID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 VANDETANIB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 UNIVASC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 VANISHPOINT SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 URAMAXIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 VANOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 urea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 VANOXIDE-HC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 urea nail stick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 VAQTA (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 244 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

VARIVAX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 VICTORY GLUCOSE TEST . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 vasopressin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 VICTORY HIGH, LOW CONTROL . . . . . . . . . . . . . . . . . . . . . 112 VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 vecuronium bromide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 VICTRELIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 VEHICLE/N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 VIDAZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VEHICLE/N MILD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 VIDEX EC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 VELCADE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VIDEX 2 GRAM PEDIATRIC . . . . . . . . . . . . . . . . . . . . . . . . . . 28 VELETRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 VIDEX 4 GRAM PEDIATRIC . . . . . . . . . . . . . . . . . . . . . . . . . . 28 velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 VELTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 vena-bal dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VIMOVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 venatal complete dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VIMPAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 venlafaxine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 vinacal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 vinate az . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VENTOLIN HFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 vinate c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VERAMYST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 vinate calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 verapamil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 vinate care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VERDESO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 vinate gt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VEREGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 vinate ic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VERIPRED 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 vinate ii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VERSICLEAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 vinate m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 VESICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 vinate one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 vestura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 vinate pn care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 VEXOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 vinate ultra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 VFEND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 vinblastine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VFEND IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VIBATIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 vincristine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VIBRAMYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 vinorelbine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 245

VIOKASE 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 VOLUVEN 6 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 VIOKASE 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 voriconazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VIRACEPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 vp-era ob plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 VIRAMUNE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 VIRAMUNE XR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 VUMON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VIRAZOLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 vynatal fa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 VIREAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 VYTORIN 10-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 VIROPTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 VYTORIN 10-20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 virt-pn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 VYTORIN 10-40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 virt-pn dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 VYTORIN 10-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 vis-phos n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 W

VISCOAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 warfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 visqid a/a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 water for irrigation, sterile . . . . . . . . . . . . . . . . . . . . . . . . . 124 VISTIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 WAVESENSE AMP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 vistra 650 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 WAVESENSE JAZZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 VITAFOL-OB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 WAVESENSE LANCETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 VITAFOL-OB+DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 WAVESENSE PRESTO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 VITAFOL-PN (UD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 WEBCOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 vitaphil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 vitaphil + dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 WESTCORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 vitaspire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 X

vitazol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 x-viate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180, 181 VITRASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 XALKORI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VIVA DHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 XARELTO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 VIVELLE-DOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 XENAZINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 XERAC AC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 VOLTAREN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 246 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

XIFAXAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 zatean-pn dha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 XIGRIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 zazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 XYLOCAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132, 154 ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 XYLOCAINE (CARDIAC) (PF) . . . . . . . . . . . . . . . . . . . . . . . . . 64 zema-pak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 XYLOCAINE JELLY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 XYLOCAINE-EPINEPHRINE . . . . . . . . . . . . . . . . . . . . . . . . . 154 ZEMPLAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 XYLOCAINE-MPF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 ZEMURON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 XYLOCAINE-MPF/EPINEPHRINE . . . . . . . . . . . . . . . . . . . . 154 zenchent (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 zenchent fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 XYZAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Y zeosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

YASMIN 28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 ZERIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 YAZ 28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 zerlor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 YERVOY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 YF-VAX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 zgesic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 YODOXIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 ZIAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Z ZIAGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

zaclir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 zidovudine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 zafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 ZINACEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ZINACEF IN DEXTROSE (ISO-OSM) . . . . . . . . . . . . . . . . . . . 29 ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38, 39 ZINACEF IN STERILE WATER . . . . . . . . . . . . . . . . . . . . . . . . 29 ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 ZINECARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 ZINOTIC ES (WITH GLYCERIN) . . . . . . . . . . . . . . . . . . . . . . 132 ZARONTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ziprasidone hcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ZAROXOLYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 zatean-ch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 ZITHROMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29, 30 zatean-pn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 ZITHROMAX TRI-PAK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY - 247

ZITHROMAX Z-PAK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 0.45 % nacl-potassium chloride . . . . . . . . . . . . . . . . . . . 122 ZODERM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 0.9% nacl & potassium chloride . . . . . . . . . . . . . . . . . . . . 120 ZODERM REDI-PADS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 1ST TIER UNIFINE PENTIPS . . . . . . . . . . . . . . . . . . . . . . . . . 92 ZOLADEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 8-MOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 zolpidem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ZOMETA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 zonisamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ZORBTIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 ZORTRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 ZOSTAVAX (PF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 ZOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 ZOSYN IN DEXTROSE (ISO-OSM) . . . . . . . . . . . . . . . . . . . . . 30 zovia 1/35e (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 zovia 1/50e (28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 ZOVIRAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 ZYBAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 ZYFLO CR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ZYLOPRIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 ZYMAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ZYMAXID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 ZYPREXA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ZYPREXA RELPREVV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ZYTIGA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 ZYVOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 # 248 - 2013 PRESCRIPTION DRUG GUIDE HUMANA FORMULARY

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Humana is a Medicare Advantage organization with a Medicare contract. Medicare beneficiaries may enroll in the plan only during specific times of the year. Contact Humana for more information. You must use network pharmacies, except under non-routine circumstances. Quantity limitations, copayments, and restrictions may apply. If you are a member of a qualified State Pharmaceutical Assistance Program, please contact the Program to verify that the mail-order pharmacy will coordinate with that Program. You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call 1-800-MEDICARE (1-800-633-4227) (TTY or TDD users should call 1-877-486-2048, 24 hours a day/7days a week); the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday (TTY or TDD users should call-1-800-325-0778); or your State Medical Assistance (Medicaid) Office. We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-457-4708. Someone who speaks Spanish can help you. This is a free service. Contamos con servicios de interpretacin gratuitos para responder a cualquier pregunta que pueda tener sobre nuestro plan de salud o de medicamentos. Para tener acceso a un intrprete, llmenos al 1-800-457-4708. Alguien que habla espaol le puede ayudar. Este es un servicio gratuito.

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