HDHP Drug List
Listed below in alphabetical order are commonly prescribed drugs that are covered under the High Deductible Health Plans. This is not a complete list. If there is a prescription drug that is not on this list, go to Humana.com or cal the Customer Service phone number on the back of the member ID card to see if it’s covered. Note: The drugs in BOLD TYPE are generic drugs. The drugs in regular type are brand-name drugs.
IR = immediate release, SR = sustained release, ER = extended release, QL = quantity limit, PA = prior authorization, ST = Step Therapy
DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS
ACCU-CHEK SOFTCLIX LANCET DEV ACETAMINOPHEN-CODEINE #3 TABLET ACETAMINOPHEN-CODEINE #4 TABLET
ACUVAIL ACYCLOVIR ALBUTEROL SULFATE DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS ALENDRONATE SODIUM ALLOPURINOL ALPRAZOLAM AMIODARONE HCL AMITRIPTYLINE HCL AMLODIPINE BESYLATE AMLODIPINE BESYLATE-BENAZEPRIL AMMONIUM LACTATE AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN AMPHETAMINE SALT COMBO ANUCORT-HC ANZEMET ATENOLOL ATENOLOL-CHLORTHALIDONE DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS
AVELOX AVIANE
AZASITE AZATHIOPRINE AZITHROMYCIN AZOPT BACLOFEN BENAZEPRIL HCL BENAZEPRIL-HYDROCHLOROTHIAZIDE
BENZACLIN BENZONATATE BENZTROPINE MESYLATE BETAMETHASONE DIPROPIONATE BETASERON BISOPROLOL FUMARATE BISOPROLOL-HYDROCHLOROTHIAZIDE BRIMONIDINE TARTRATE BUDEPRION SR BUDEPRION XL
BUDESONIDE BUMETANIDE BUPROPION HCL SR BUPROPION XL BUSPIRONE HCL BUTALBITAL-ACETAMINOPHEN-CAFFE CALCITONIN-SALMON CALCITRIOL DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS CALCIUM ACETATE CAPTOPRIL CARBAMAZEPINE CARBIDOPA-LEVODOPA CARISOPRODOL CARVEDILOL CEFDINIR CEFUROXIME CELEBREX CEPHALEXIN CEREFOLIN NAC CERON-DM CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE-CLIDINIUM CHLORHEXIDINE GLUCONATE CHLORTHALIDONE CILOSTAZOL CIMETIDINE
CIPRODEX CIPROFLOXACIN HCL CITALOPRAM HBR CLARAVIS CLARITHROMYCIN CLIMARA PRO CLINDAMYCIN HCL CLOBETASOL PROPIONATE CLOBEX CLONAZEPAM CLONIDINE CLONIDINE HCL CLOTRIMAZOLE-BETAMETHASONE COLCHICINE DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS C-PHEN DM CRESTOR
CYANOCOBALAMINCYCLOBENZAPRINE HCLCYMBALTA
DEMECLOCYCLINE HCL DENAVIR DEPAKENE CAP
DERMA-SMOOTHE-FS DESONIDE DETROL LA DEXAMETHASONE DEXTROAMPHETAMINE-AMPHETAMINE DIAZEPAM DICLOFENAC SODIUM DICYCLOMINE HCL DIFFERIN DIGOXIN DIHYDROERGOTAMINE MESYLATE DILANTIN DILTIAZEM 24HR ER DILTIAZEM ER DILTIAZEM HCL DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS DIPHENOXYLATE-ATROPINE DIVALPROEX SODIUM DIVALPROEX SODIUM ER DORZOLAMIDE-TIMOLOL DOXAZOSIN MESYLATE DOXEPIN HCL DOXYCYCLINE HYCLATE DRONABINOL ENALAPRIL MALEATE ENALAPRIL-HYDROCHLOROTHIAZIDE
ENTOCORT EC ENULOSE
ERY-TAB ERYTHROMYCIN ESTRACE ESTRADIOL ESTRADIOL-NORETHINDRONE ACETAT ETODOLAC DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS FAMCICLOVIR FAMOTIDINE FELODIPINE ER FENOFIBRATE FENTANYL CITRATE VIAL FENTANYL PATCH FEXOFENADINE HCL FEXOFENADINE-PSE ER
FINACEA FINASTERIDE
FLUARIX FLUCONAZOLE
FLULAVAL FLUOCINONIDE FLUOXETINE HCL FLUTICASONE PROPIONATE FLUVIRIN FLUZONE FOCALIN XR FOLBIC FOLIC ACID FOSINOPRIL SODIUM FUROSEMIDE GABAPENTIN GALANTAMINE HBR GEMFIBROZIL GENTAK GENTAMICIN SULFATE GEODON GLIMEPIRIDE DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS GLIPIZIDE GLIPIZIDE ER GLIPIZIDE XL
GLUCAGON EMERGENCY KIT GLYBURIDE GLYBURIDE-METFORMIN HCL
GOLYTELY HALFLYTELY-BISACODYL HALOPERIDOL HYDRALAZINE HCL HYDROCHLOROTHIAZIDE HYDROCODONE-ACETAMINOPHEN HYDROCODONE-HOMATROPINE HYDROCORTISONE HYDROMET HYDROMORPHONE HCL HYDROXYCHLOROQUINE SULFATE HYDROXYZINE HCL HYDROXYZINE PAMOATE HYOSCYAMINE SULFATE IBUPROFEN IMIPRAMINE HCL IMIPRAMINE PAMOATE INDAPAMIDE INDOMETHACIN INFERGEN IPRATROPIUM BROMIDE DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS IPRATROPIUM-ALBUTEROL ISOMETHEPT-DICHLORALP-ACETAMIN ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE JANTOVEN KETOCONAZOLE KINERET KLOR-CON M10 KLOR-CON M20 LABETALOL HCL LACTULOSE LAMOTRIGINE LANSOPRAZOLE LEVETIRACETAM LEVORA-28 LEVOTHYROXINE SODIUM DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS LISINOPRIL LISINOPRIL-HYDROCHLOROTHIAZIDE LITHIUM CARBONATE LITHIUM CARBONATE ER
LOCOIDLOCOID LIPOCREAMLODRANE 24LODRANE 24DLOESTRIN 24 FE
LORAZEPAM LOSARTAN POTASSIUM LOVASTATIN LOW-OGESTREL
MEDROXYPROGESTERONE ACETATE POWDER MEDROXYPROGESTERONE ACETATE TAB MEDROXYPROGESTERONE ACETATE VIAL MELOXICAM
METANX METFORMIN HCL METFORMIN HCL ER METHADONE HCL METHIMAZOLE POWDER METHIMAZOLE TAB METHYLPREDNISOLONE DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS METOCLOPRAMIDE HCL METOLAZONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METRONIDAZOLE MIACALCIN MICROGESTIN FE MIDODRINE HCL MINOCYCLINE HCL MINOXIDIL MINOXIDIL MIRTAZAPINE MONONESSA NABUMETONE NAPROXEN NECON 0.5/35 NECON 1/50 NECON 1/35 NECON 10/11 NECON 7/7/7 NEOMYCIN-POLYMYXIN-DEXAMETH NEOMYCIN-POLYMYXIN-HC NEULASTA DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS NIFEDIAC CC NIFEDICAL XL NIFEDIPINE NIFEDIPINE ER NIMODIPINE NITROFURANTOIN NITROFURANTOIN MONO-MACRO NITROGLYCERIN NITROGLYCERIN PATCH NORTREL 0.5/35 NORTREL 1/35 NORTREL 7/7/7 NORTRIPTYLINE HCL NYSTATIN NYSTATIN-TRIAMCINOLONE OCELLA ONDANSETRON HCL ONDANSETRON ODT ORPHENADRINE CITRATE DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS
OSMOPREP OXCARBAZEPINE
OXSORALEN OXSORALEN-ULTRA OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE ER OXYCODONE HCL OXYCODONE HCL-ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN PANTOPRAZOLE SODIUM PAROXETINE HCL
PATANOL PEG 3350-ELECTROLYTE PEG-3350 WITH FLAVOR PACKS PEGASYS PENICILLIN V POTASSIUM PENTASA PENTOXIFYLLINE ER TAB
PENTOXIFYLLINE POWDER PERPHENAZINE PERPHENAZINE-AMITRIPTYLINE PHENOBARBITAL PHENYTOIN SODIUM EXTENDED PIROXICAM CAP
PNEUMOVAX 23 POTASSIUM CHLORIDE PRAMIPEXOLE DIHYDROCHLORIDE DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS PRAVASTATIN SODIUM
PREDNISOLONE ACETATE PREDNISOLONE SODIUM PHOSPHATE PREDNISONE PREMARIN TAB PRIMIDONE PROCHLORPERAZINE MALEATE PROCRIT PROCTOSOL-HC PROCTOZONE-HC PROGRAF PROMETHEGAN PROMETRIUM PROPAFENONE HCL PROPRANOLOL HCL PROPRANOLOL HCL ER QUINAPRIL HCL RAMIPRIL RANITIDINE HCL RECLIPSEN
REMICADE (covered via medical benefits on most stan-
DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS RIBASPHERE RIBAVIRIN RISPERIDONE ROPINIROLE HCL R-TANNA RYTHMOL SERTRALINE HCL SILVER SULFADIAZINE SILVER SULFADIAZINE SIMCOR SIMVASTATIN DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS
SORIATANE SORIATANE CK SOTALOL SPIRONOLACTONE SPIRONOLACTONE-HCTZ SPRINTEC SUCRALFATE SULFAMETHOXAZOLE-TRIMETHOPRIM SULINDAC SUMATRIPTAN SUCCINATE TAMOXIFEN CITRATE TAMSULOSIN HCL TAZTIA XT TEMAZEPAM TERAZOSIN HCL TETRACYCLINE HCL TEV-TROPIN DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS THEOPHYLLINE ANHYDROUS TIMOLOL MALEATE TIZANIDINE HCL
TOBRADEX TOBRAMYCIN SULFATE TOBRAMYCIN-DEXAMETHASONE TOPAMAX TOPIRAMATE TORSEMIDE TRAMADOL HCL TRAMADOL HCL-ACETAMINOPHEN TRAZODONE HCL TRIAMCINOLONE ACETONIDE TRIAMTERENE-HCTZ TRIAZOLAM TRINESSA TRI-SPRINTEC TRIVORA-28 DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS VALACYCLOVIR
VANOS VENLAFAXINE HCL VERAPAMIL HCL
VIGAMOX VITAMIN D2 VITAMIN K VIVELLE-DOT WARFARIN SODIUM DRUG NAME SPECIALTY MAINTENTANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS ZOLPIDEM TARTRATE Please Note: This is a partial list.
Al lists are subject to change. Benefits vary by plan. This Drug List may not apply to al plans. Please check the Summary of Benefits or Humana.com for the specific prescription drug benefit, including copayments, limitations and exclusions. You may also cal a Humana Customer Service representative at the phone number on the back of the Humana member ID card. Go to Humana.com for a current Drug List Visit Humana’s Website for the most up-to-date Drug List. The online list is updated regularly. You can also learn more about the prescription drug benefit and copayments. It is suggested that before members go to the pharmacy, they go to Humana.com, and log in to MyHumana or click on “Register Now” for access to this information and more.
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of Texas, Inc. – A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana
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Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company
Our health benefit plans have limitations and exclusions.
DIMENHYDRINATE INJECTION USP THERAPEUTIC CATEGORY : ANTIEMETIC Children are very susceptible to the convulsant action of antihistamines anddoses of 150 to 800 mg of diphenhydramine in children aged 11 2 PHARMACOLOGY: While the precise mode of action of dimenhydrinate is not been reported to produce convulsions. A suspected dose of 700 mg ofknown, it has a depressant action on hyperstimul