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2018 Rx Traditional Annual Drug List Changes

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2018 Rx Traditional Annual Drug List Changes 2018 Rx4 Traditional Annual Changes Effective January 1, 2018 Para visualizarlo en español, haga clic aquí. To view your full Drug List, click here. Welcome to Humana The enclosed formulary, or Drug List, changes are effective January 1, 2018. Please visit Humana.com and log in to MyHumana– your personal, secure online account – on or after your renewal date to view specific prescription medicine benefits, including copayments or cost-share, limitations and exclusions. You also can refer to your Certificate of Coverage/Insurance or Summary Plan Description/Policy of Insurance. If you have questions: • Prospective members: Call the Customer Care number listed in your enrollment materials • Current members: Call the number on the back of your Humana member ID card How to read your annual Drug List changes Some covered medicines may have additional requirements or limits on coverage. Talk to your doctor or healthcare provider if your medicine has an additional requirement. These requirements and limits may include: Coverage status (CVG): Certain medicines that were previously not covered under your plan benefits will be added to your Drug List for 2018, while other medicines that may have been covered in the past will be removed. Please note that if you fill or refill any medicine that is not covered under your plan benefits, you may have to pay the full cost of your prescription. + CVG (addition); CVG (no change); - CVG (removal) Prior authorization (PA): Some medicines need to be approved in advance to be covered under your pharmacy plan. For these medicines to be covered, your doctor must get approval or prior authorization from Humana. Your plan benefits won’t cover this medicine without prior authorization. Should you get the medicine first without the prior authorization, it would cost the full price. + PA (addition); +PA* (addition applies only to new prescriptions); PA (no change); - PA (removal) Quantity limits (QL): You may have a limit on how much you can get of some medicines at one time. These limits can be placed on some medicines because of safety or healthcare concerns and help prevent misuse of these medicines. + QL (addition); QL (no change); - QL (removal) Step therapy (ST): Sometimes more than one medicine works to treat a health condition. Some medicines may cost less but still work for you. Before a prescription is filled for a medicine that costs more, you may be asked to try at least one other medicine first. + ST (addition); +ST* (addition applies only to new prescriptions); ST (no change); - ST (removal) Humana.com GCHJBLZEN 1017 Page 1 of 23 Drug Name Formulary Status Alternatives acetaminophen-caffeine-dihydrocodeine capsule CVG, -Tier (3/4), acetaminophen-caffeine- QL dihydrocodeine tablet; hydrocodone- acetaminophen tablet; oxycodone- acetaminophen tablet acetylcysteine capsule -CVG Consult Your Physician Afluria 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physician Afluria 2016-2017 intramuscular suspension -CVG Consult Your Physician Afluria Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physician Afluria Quad 2016-2017 intramuscular suspension -CVG Consult Your Physician Airshield effervescent tablet -CVG Consult Your Physician AK-Poly-Bac eye ointment CVG, -Tier (1/2) polymyxin B sulfate-trimethoprim eye drops Aldara topical cream packet CVG, +Tier (4/2), Consult Your Physician QL alendronate oral solution CVG, +Tier (3/2), Consult Your Physician QL Alkeran tablet CVG, -Tier (2/3), Consult Your Physician QL alogliptin tablet CVG, +ST, QL Januvia tablet; Tradjenta tablet alogliptin-metformin tablet CVG, +ST, QL Janumet tablet; Janumet XR tablet,extended release; Jentadueto tablet; Jentadueto XR tablet, extended release; alogliptin-pioglitazone tablet CVG, +ST, QL Januvia tablet; Tradjenta tablet; Onglyza tablet; Nesina tablet; pioglitazone tablet Alomide eye drops CVG, +ST cromolyn eye drops; azelastine eye drops; Pazeo eye drops; olopatadine eye drops; epinastine eye drops Alprazolam Intensol oral concentrate CVG, -Tier (1/2) buspirone tablet alprazolam tablet CVG, -Tier (1/2), buspirone tablet QL Alprolix intravenous solution CVG, +PA Consult Your Physician ALZ tablet,extended release -CVG Consult Your Physician Ambien CR tablet,extended release CVG, +Tier (3/2), Consult Your Physician ST, QL amlodipine-valsartan tablet CVG, +Tier (3/2), Consult Your Physician -ST, QL amoxicillin ER tablet,extended release 24hr mphase CVG, -Tier (2/3) amoxicillin tablet; ampicillin capsule; dicloxacillin capsule Analpram-HC rectal cream CVG, -Tier (3/4) Consult Your Physician Androderm transdermal 24 hour patch CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet AndroGel transdermal gel packet CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet GCHJBLZEN 1017 Page 2 of 23 Drug Name Formulary Status Alternatives AndroGel transdermal gel packet CVG, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet AndroGel transdermal gel pump CVG, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet AndroGel transdermal gel pump CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Anti-Allergy Formula tablet -CVG Consult Your Physician Apatate oral liquid -CVG Consult Your Physician Arginaid Extra oral liquid -CVG Consult Your Physician Arginaid oral powder packet -CVG Consult Your Physician aspirin-caffeine-dihydrocodeine capsule CVG, -Tier (3/4), hydrocodone-acetaminophen tablet; QL oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet astaxanthin capsule -CVG Consult Your Physician Atabex EC tablet,delayed release CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Atralin topical gel CVG, -ST, +PA tretinoin topical gel; adapalene lotion atropine eye drops CVG, -Tier (1/2) cyclopentolate eye drops Atrovent nasal spray CVG, +Tier (3/2), Consult Your Physician QL Auvi-Q injection,auto-injector CVG, +Tier (4/3), Consult Your Physician PA, +QL Auvi-Q injection,auto-injector CVG, +Tier (4/3), Consult Your Physician PA, QL Avita topical cream CVG, +PA tretinoin topical cream; tretinoin topical gel; adapalene lotion Avita topical gel CVG, +PA tretinoin topical cream; tretinoin topical gel; adapalene lotion Avodart capsule CVG, +Tier (3/2), Consult Your Physician ST, QL Axiron transderm solution in metered pump CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Azilect tablet CVG, -Tier (3/4), pramipexole tablet; ropinirole tablet; PA selegiline tablet B-12 Compliance injection kit CVG, -Tier (1/2) Consult Your Physician BabyBIG intravenous solution CVG, -PA Consult Your Physician Baby's Only Dairy oral powder -CVG Consult Your Physician Baby's Only Org LactoRelief oral powder -CVG Consult Your Physician Baby's Only Organic Dairy oral powder -CVG Consult Your Physician Baby's Only Organic Dairy Whey oral powder -CVG Consult Your Physician Baby's Only Organic Soy oral powder -CVG Consult Your Physician Balanced Nutritional oral liquid -CVG Consult Your Physician Balanced Nutritional Plus oral liquid -CVG Consult Your Physician GCHJBLZEN 1017 Page 3 of 23 Drug Name Formulary Status Alternatives Basaglar KwikPen subcutaneous CVG, +ST, -PA Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen; Levemir FlexTouch subcutaneous insulin pen; Tresiba FlexTouch U-100 subcutaneous insulin pen Beef-Potatoes-Peas oral liquid -CVG Consult Your Physician Benecalorie oral liquid -CVG Consult Your Physician betamethasone dipropionate lotion CVG, -Tier (2/3) triamcinolone acetonide lotion; mometasone topical solution; hydrocortisone lotion betamethasone dipropionate topical cream CVG, -Tier (2/3) triamcinolone acetonide topical cream; mometasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream; betamethasone dipropionate topical ointment CVG, -Tier (2/3) triamcinolone acetonide topical ointment; mometasone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment; Betapace AF tablet CVG, -Tier (3/4) Sotalol AF tablet Betapace tablet CVG, -Tier (3/4) sotalol tablet; Sorine tablet Beyaz tablet CVG, -Tier (2/3) Safyral tablet Bifera Rx tablet CVG, -Tier (2/3) FE C Plus tablet; Poly-Iron 150 Forte capsule; Ferrocite Plus tablet Bioflex tablet -CVG Consult Your Physician Biotalan Clear oral liquid -CVG Consult Your Physician Biotin 100+10 tablet -CVG Consult Your Physician Biotin Plus Keratin tablet -CVG Consult Your Physician Boost Breeze Nutritional oral liquid -CVG Consult Your Physician Boost Calorie Smart oral liquid -CVG Consult Your Physician Boost Compact oral liquid -CVG Consult Your Physician Boost High Protein oral liquid -CVG Consult Your Physician Boost Kid Essentials oral liquid -CVG Consult Your Physician Boost Kid Essentials with Fiber oral liquid -CVG Consult Your Physician Boost oral liquid -CVG Consult Your Physician Boost Plus oral liquid -CVG Consult Your Physician Boost Pudding -CVG Consult Your Physician Boost VHC oral liquid -CVG Consult Your Physician Brain Might-DHA-Co Q10 tablet -CVG Consult Your Physician Breakfast Essentials oral liquid -CVG Consult Your Physician Bright Beginnings Soy oral liquid -CVG Consult Your Physician
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