Rx3 Drug List Level One – Lowest copayment for low-cost generic drugs. Level Two – Higher copayment for higher cost brand-name drugs. Level Three – Highest copayment for higher cost drugs. These drugs may have generic or brand-name alternatives in Levels One or Two.
Listed below in alphabetical order are commonly prescribed drugs for each level. This is not a complete list. If there is a prescription drug that is not on this list, go to Humana.com or cal the Customer Service phone number on the back of the Humana member ID card to see if it’s covered and into what level it fal s.
* Specialty - plan specific (copayments or) cost shares for high cost/high-technology drugs often requiring special dispensing
conditions. Specialty drug coverage varies by plan. Visit Humana.com and log in to MyHumana to view specific prescription drug benefits, including copayments, limitations and exclusions. Note: The drugs in BOLD TYPE are generic drugs. The drugs in regular type are brand-name drugs.
IR = immediate release, SR = sustained release, ER = extended release, QL = quantity limit, PA = prior authorization
DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS ACETAMINOPHEN-CODEINE ACYCLOVIR DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS ALBUTEROL SULFATE 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 ATENOLOL ATENOLOL-CHLORTHALIDONE DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS AZATHIOPRINE AZITHROMYCIN BACLOFEN BENAZEPRIL HCL BENAZEPRIL-HYDROCHLOROTHIAZIDE BENZONATATE BENZTROPINE MESYLATE BETAMETHASONE DIPROPIONATE BISOPROLOL FUMARATE BISOPROLOL-HYDROCHLOROTHIAZIDE BRIMONIDINE TARTRATE BUDEPRION SR BUDEPRION XL BUMETANIDE BUPROPION HCL SR BUPROPION XL BUSPIRONE HCL BUTALBITAL-APAP-CAFFEINE DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS CALCITONIN-SALMON CALCITRIOL CALCIUM ACETATE CAPTOPRIL CARBAMAZEPINE CARBIDOPA-LEVODOPA CARISOPRODOL CARVEDILOL CEFDINIR CEFUROXIME CEPHALEXIN CERON-DM CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE-CLIDINIUM CHLORTHALIDONE CILOSTAZOL CIMETIDINE CIPROFLOXACIN HCL CITALOPRAM HBR CLARAVIS CLARITHROMYCIN CLINDAMYCIN HCL CLOBETASOL PROPIONATE DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS CLONAZEPAM CLONIDINE CLONIDINE HCL CLORAZEPATE DIPOTASSIUM CLOTRIMAZOLE-BETAMETHASONE COLCHICINE C-PHEN DM DEMECLOCYCLINE HCL DESONIDE DEXAMETHASONE DEXTROAMPHETAMINE-AMPHETAMINE DIAZEPAM DICLOFENAC SODIUM DICYCLOMINE HCL DIHYDROERGOTAMINE MESYLATE DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS DILTIAZEM 24HR ER DILTIAZEM ER DILTIAZEM HCL DIPHENOXYLATE-ATROPINE DIVALPROEX SODIUM DIVALPROEX SODIUM ER DORZOLAMIDE-TIMOLOL DOXAZOSIN MESYLATE DOXEPIN HCL DOXYCYCLINE HYCLATE DRONABINOL ENALAPRIL MALEATE ENALAPRIL-HYDROCHLOROTHIAZIDE ERYTHROMYCIN ESTRADIOL-NORETHINDRONE ACETAT ETODOLAC DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS ETOPOSIDE FAMCICLOVIR FAMOTIDINE FELODIPINE ER FENOFIBRATE FENTANYL FENTANYL CITRATE FEXOFENADINE HCL FEXOFENADINE-PSE ER FINASTERIDE FLUCONAZOLE FLUOCINONIDE FLUOXETINE HCL FLUTICASONE PROPIONATE FOLIC ACID FOSINOPRIL SODIUM FUROSEMIDE DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS GABAPENTIN GALANTAMINE HBR GEMFIBROZIL GENTAMICIN SULFATE GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER GLIPIZIDE XL GLYBURIDE GLYBURIDE-METFORMIN HCL GRANISETRON HCL GUAIFENESIN-CODEINE HALOPERIDOL HYDRALAZINE HCL HYDROCHLOROTHIAZIDE HYDROCODONE-ACETAMINOPHEN HYDROCODONE-HOMATROPINE HYDROCORTISONE HYDROMET HYDROMORPHONE HCL HYDROXYZINE HCL HYDROXYZINE PAMOATE HYOSCYAMINE SULFATE DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS IBUPROFEN IMIPRAMINE HCL INDAPAMIDE INDOMETHACIN IOPHEN-C NR IPRATROPIUM BROMIDE IPRATROPIUM-ALBUTEROL ISOMETH-D-CHLORALPHENAZ-APAP ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE JANTOVEN KETOCONAZOLE KLOR-CON M10 KLOR-CON M20 LABETALOL HCL LACTULOSE LAMOTRIGINE LANSOPRAZOLE DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS LEVETIRACETAM LEVORA-28 LEVOTHYROXINE SODIUM LIDOCAINE HCL LIDOCAINE-PRILOCAINE LISINOPRIL LISINOPRIL-HYDROCHLOROTHIAZIDE LITHIUM CARBONATE LORAZEPAM LOSARTAN POTASSIUM LOVASTATIN LOW-OGESTREL DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS MELOXICAM METFORMIN HCL METFORMIN HCL ER METHADONE HCL METHIMAZOLE METHOCARBAMOL METHOTREXATE METHYLPREDNISOLONE METOCLOPRAMIDE HCL METOLAZONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METRONIDAZOLE MICROGESTIN FE MIDODRINE HCL MINOCYCLINE HCL MINOXIDIL MIRTAZAPINE MONONESSA NABUMETONE DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS NEOMYCIN-POLYMYXIN-DEXAMETH NEOMYCIN-POLYMYXIN-HC NIFEDIAC CC NIFEDICAL XL NIFEDIPINE ER NIMODIPINE NITROFURANTOIN NITROFURANTOIN MONO-MACRO NITROGLYCERIN NITROGLYCERIN PATCH NORTRIPTYLINE HCL NYSTATIN NYSTATIN-TRIAMCINOLONE ONDANSETRON HCL ONDANSETRON ODT DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS ORPHENADRINE CITRATE OXCARBAZEPINE OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE ER OXYCODONE HCL OXYCODONE HCL-ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN PANTOPRAZOLE SODIUM PAROXETINE HCL PEG 3350-ELECTROLYTE PEG-3350 WITH FLAVOR PACKS PENICILLIN V POTASSIUM PENTOXIFYLLINE PERPHENAZINE PERPHENAZINE-AMITRIPTYLINE PHENOBARBITAL PHENYTOIN SODIUM EXTENDED DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS POTASSIUM CHLORIDE PRAMIPEXOLE DIHYDROCHLORIDE PRAVASTATIN SODIUM PREDNISOLONE SODIUM PHOSPHATE PREDNISONE PRIMIDONE PROCHLORPERAZINE MALEATE PROCTOSOL-HC PROCTOZONE-HC PROMETHAZINE HCL PROMETHAZINE VC PROMETHAZINE VC-CODEINE PROMETHAZINE-CODEINE PROMETHAZINE-DM PROMETHEGAN PROPAFENONE HCL PROPOXYPHENE NAP-ACETAMINOPHEN PROPRANOLOL HCL QUINAPRIL HCL DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS RAMIPRIL RANITIDINE HCL RECLIPSEN RIBASPHERE RIBAVIRIN RISPERIDONE ROPINIROLE HCL DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS SERTRALINE HCL SILVER SULFADIAZINE SIMVASTATIN SPIRONOLACTONE SPIRONOLACTONE-HCTZ SPRINTEC SUCRALFATE SULFAMETHOXAZOLE-TRIMETHOPRIM SULINDAC SUMATRIPTAN SUCCINATE TAMOXIFEN CITRATE TAMSULOSIN HCL DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS TAZTIA XT TEMAZEPAM TERAZOSIN HCL TETRACYCLINE HCL THEOPHYLLINE ANHYDROUS TIMOLOL MALEATE TIZANIDINE HCL TOBRAMYCIN-DEXAMETHASONE TOPIRAMATE TORSEMIDE TRAMADOL HCL TRAMADOL HCL-ACETAMINOPHEN TRAZODONE HCL TRIAMCINOLONE ACETONIDE TRIAMTERENE-HCTZ TRIAZOLAM TRINESSA TRI-SPRINTEC TRIVORA-28 DRUG NAME SPECIALTY MAINTENANCE UTILIZATION MEDICATION MANAGEMENT REQUIREMENTS VALACYCLOVIR VENLAFAXINE HCL VERAPAMIL HCL VITAMIN D VITAMIN K WARFARIN SODIUM DRUG NAME SPECIALTY MAINTENANCE 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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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.
CURRICULUM VITAE Dr. M. Ravishankar 47, 3rd Cross Thiru Nagar. Moolakulam Pondicherry 605 010 INDIA Professor and Head, Dept. of Anaesthesiology Mahatma Gandhi Medical College and Research Institute Pondicherry 607402, INDIA Qualifications: Experience in Faculty Position: 1. Junior Anaesthetist (Specialist), Dept. of Anaesthesiology, JIPMER from 5.2.79 to 2. Assistant Professor,
ALISON SAAR BIOGRAPHY 1956 Born in Los Angeles, CA. 1978 BA, Scripps College, Claremont, CA. 1981 MFA, Otis Art Institute, Los Angeles, CA. ONE-PERSON EXHIBITIONS 2012 “STILL…,” Ben Maltz Gallery, Otis College, Los Angeles, CA, August 18 – October 27 2011 “Alison Saar: Feallen and Fallow” Madison Square Park, New York, NY, September 22 – December 31 “Alison