hdhp ehb - colorado health insurance brokers · hdhp ehb listed below in ... alprazolam 1 mg odt...

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HDHP EHB

Listed below in alphabetical order are the 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 call the Customer Service phone number on the back of the member ID card to see if it’s covered.

Specialty - plan specific copayments or cost share for high cost/high-technology drugs often requiring special dispensing conditions. Specialty drug coverage varies by plan. Visit Humana.com and log in to MyHumana to view specific prescription drug benefits, including copayments or cost share, limitations and exclusions.

Note: Generic drugs are CAPITALIZED. All others are Brand name drugs.

IR = immediate release, SR = sustained release, ER = extended release, QL = quantity limited, PA = prior authorization, ST = Step Therapy

Effective January 1, 2014

Drug Name SpecialtyMaintenance Medications

Utilization Management Requirements

ABACAVIR 300 MG TABLET Y QLAbilify 10 mg tablet Y QL, PA Abilify 15 mg tablet Y QL, PA Abilify 2 mg tablet Y QL, PA Abilify 20 mg tablet Y QL, PA Abilify 30 mg tablet Y QL, PA Abilify 5 mg tablet Y QL, PA Abilify Discmelt 10 mg disintegrating tablet Y QL, PA Abilify Discmelt 15 mg disintegrating tablet Y QL, PA ACARBOSE 100 MG TABLET YACARBOSE 50 MG TABLET YACEBUTOLOL 200 MG CAPSULE YACEBUTOLOL 400 MG CAPSULE YACETAMINOPHEN-COD #2 TABLET QLACETAZOLAMIDE 250 MG TABLET YActonel 150 mg tablet Y QLActonel 30 mg tablet QLActonel 35 mg tablet Y QLActonel 5 mg tablet Y QLActos 15 mg tablet Y QL, STActos 30 mg tablet Y QL, ST

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Actos 45 mg tablet Y QL, STAcuvail (PF) 0.45 % Eye Dropperette ACYCLOVIR 200 MG CAPSULE YACYCLOVIR 400 MG TABLET YADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL Advair Diskus 100 mcg-50 mcg/dose for Inhalation Y QLAdvair Diskus 250 mcg-50 mcg/dose for Inhalation Y QLAdvair Diskus 500 mcg-50 mcg/dose for Inhalation Y QLAdvair HFA 115 mcg-21 mcg/actuation Aerosol Inhaler Y QL

Advair HFA 230 mcg-21 mcg/actuation Aerosol Inhaler Y QL

Advair HFA 45 mcg-21 mcg/actuation Aerosol Inhaler Y QLAggrenox 200 mg-25 mg capsule, extended release Y STALBUTEROL 5 MG/ML SOLUTION YALBUTEROL SUL 1.25 MG/3 ML SOL YALBUTEROL SULF 2 MG/5 ML SYRUP YALBUTEROL SULFATE 2 MG TAB YALENDRONATE SODIUM 10 MG TAB Y QLALENDRONATE SODIUM 35 MG TAB Y QLALENDRONATE SODIUM 40 MG TAB Y QLALENDRONATE SODIUM 5 MG TABLET Y QLALENDRONATE SODIUM 70 MG TAB Y QLALLOPURINOL 300 MG TABLET YALPRAZOLAM 0.25 MG ODT ALPRAZOLAM 0.25 MG TABLET QLALPRAZOLAM 0.5 MG ODT ALPRAZOLAM 0.5 MG TABLET QLALPRAZOLAM 1 MG ODT ALPRAZOLAM 1 MG TABLET QLALPRAZOLAM 2 MG ODT ALPRAZOLAM 2 MG TABLET QLALPRAZOLAM ER 0.5 MG TABLET QLALPRAZOLAM ER 1 MG TABLET QLALPRAZOLAM ER 2 MG TABLET QLALPRAZOLAM ER 3 MG TABLET QLALPRAZOLAM ODT 0.25 MG TAB ALPRAZOLAM ODT 0.5 MG TAB ALPRAZOLAM ODT 1 MG TAB ALPRAZOLAM ODT 2 MG TAB ALPRAZOLAM XR 0.5 MG TABLET QLALPRAZOLAM XR 1 MG TABLET QL

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ALPRAZOLAM XR 2 MG TABLET QLALPRAZOLAM XR 3 MG TABLET QLAMANTADINE 100 MG TABLET YAMIKACIN SULFATE 100 MG/2 ML AMIODARONE HCL 200 MG TABLET YAMIODARONE HCL 400 MG TABLET YAMITRIPTYLINE HCL 10 MG TAB YAMITRIPTYLINE HCL 100 MG TAB YAMITRIPTYLINE HCL 25 MG TAB YAMITRIPTYLINE HCL 50 MG TAB YAMLODIPINE BESYLATE 10 MG TAB Y QLAMLODIPINE BESYLATE 2.5 MG TAB Y QLAMLODIPINE BESYLATE 5 MG TAB Y QLAMLODIPINE-BENAZEPRIL 10-20 MG Y QLAMLODIPINE-BENAZEPRIL 10-40 MG Y QLAMLODIPINE-BENAZEPRIL 2.5-10 Y QLAMLODIPINE-BENAZEPRIL 5-10 MG Y QLAMLODIPINE-BENAZEPRIL 5-20 MG Y QLAMLODIPINE-BENAZEPRIL 5-40 MG Y QLAMOXAPINE 100 MG TABLET YAMOXAPINE 150 MG TABLET YAMOXAPINE 25 MG TABLET YAMOXAPINE 50 MG TABLET YAmpyra 10 mg tablet, extended release Y QL, PA Amturnide 150 mg-5 mg-12.5 mg tablet Y QLAmturnide 300 mg-10 mg-12.5 mg tablet Y QLAmturnide 300 mg-10 mg-25 mg tablet Y QLAmturnide 300 mg-5 mg-12.5 mg tablet Y QLAmturnide 300 mg-5 mg-25 mg tablet Y QLANASTROZOLE 1 MG TABLET Y QLAndroGel 1 % (50 mg/5 gram) Transdermal Packet Y QLASACOL EC 400 MG TABLET Y QL, STAsacol HD 800 mg tablet, delayed release Y QL, STAsmanex Twisthaler 110 mcg (30 doses) Breath Activated Y QL

Asmanex Twisthaler 220 mcg (120 doses) Breath Activated Y QL



ATENOLOL 100 MG TABLET YATENOLOL 25 MG TABLET Y

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ATENOLOL 50 MG TABLET YATORVASTATIN 10 MG TABLET Y QLATORVASTATIN 20 MG TABLET Y QLATORVASTATIN 40 MG TABLET Y QLATORVASTATIN 80 MG TABLET Y QLAvandia 2 mg tablet Y QLAvandia 4 mg tablet Y QLAvandia 8 mg tablet Y QLAvinza 120 mg capsule, extended release QL, STAvinza 30 mg capsule, extended release QL, STAvinza 45 mg capsule, extended release QL, STAvinza 60 mg capsule, extended release QL, STAvinza 75 mg capsule, extended release QL, STAvinza 90 mg capsule, extended release QL, STAvodart 0.5 mg capsule Y QLAvonex 30 mcg IM Kit Y QL, PA Avonex Administration Pack 30 mcg/0.5 mL IM Kit Y QL, PA AZATHIOPRINE 50 MG TABLET YAzopt 1 % Eye Drops Y STAzor 10 mg-20 mg tablet Y QL, STAzor 10 mg-40 mg tablet Y QL, STAzor 5 mg-20 mg tablet Y QL, STAzor 5 mg-40 mg tablet Y QL, STBENAZEPRIL HCL 10 MG TABLET YBENAZEPRIL HCL 40 MG TABLET YBENAZEPRIL HCL 5 MG TABLET YBENAZEPRIL-HCTZ 10-12.5 MG TAB YBENAZEPRIL-HCTZ 20-12.5 MG TAB YBENAZEPRIL-HCTZ 20-25 MG TAB YBENAZEPRIL-HCTZ 5-6.25 MG TAB YBenicar 20 mg tablet Y QL, STBenicar 40 mg tablet Y QL, STBenicar 5 mg tablet Y QL, STBenicar HCT 20 mg-12.5 mg tablet Y QL, STBenicar HCT 40 mg-12.5 mg tablet Y QL, STBenicar HCT 40 mg-25 mg tablet Y QL, STBETAMETHASONE DP AUG 0.05% GELBETAMETHASONE VALER 0.12% FOAMBetaseron 0.3 mg Sub-Q Kit Y QL, PA BETAXOLOL 10 MG TABLET YBICALUTAMIDE 50 MG TABLET Y QLBudeprion SR 100 mg tablet, extended release Y QL

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Budeprion SR 150 mg tablet, extended release Y QLBUDESONIDE 0.25 MG/2 ML SUSP YBUDESONIDE 0.5 MG/2 ML SUSP YBUPROPION HCL SR 200 MG TAB Y QLBUPROPION HCL XL 150 MG TABLET Y QLBUPROPION HCL XL 300 MG TABLET Y QLBUPROPION SR 150 MG TABLET Y QLBUPROPION SR 150 MG TABLET Y QLBUSPIRONE HCL 15 MG TABLET YBUSPIRONE HCL 7.5 MG TABLET YButisol 30 mg tablet Butisol 50 mg tablet Bydureon 2 mg SubQ suspension, extended release Y QL, PA Byetta 10 mcg/0.04 mL per dose Sub-Q Pen Injector Y QL, PA Byetta 5 mcg/0.02 mL per dose Sub-Q Pen Injector Y QL, PA Bystolic 10 mg tablet Y QL, STBystolic 2.5 mg tablet Y QL, STBystolic 20 mg tablet Y QL, STBystolic 5 mg tablet Y QL, STCALCIPOTRIENE 0.005% CREAM QLCALCITONIN-SALMON 200 UNITS SP Y QLCALCITRIOL 0.5 MCG CAPSULE YCANDESARTAN-HCTZ 16-12.5 MG TB Y QLCANDESARTAN-HCTZ 32-12.5 MG TB Y QLCANDESARTAN-HCTZ 32-25 MG TAB Y QLCAPTOPRIL 100 MG TABLET YCAPTOPRIL 12.5 MG TABLET YCAPTOPRIL 25 MG TABLET YCAPTOPRIL 50 MG TABLET YCAPTOPRIL-HCTZ 25-15 MG TABLET YCAPTOPRIL-HCTZ 25-25 MG TABLET YCAPTOPRIL-HCTZ 50-15 MG TABLET YCAPTOPRIL-HCTZ 50-25 MG TABLET YCARBAMAZEPINE 100 MG TAB CHEW YCARBAMAZEPINE 200 MG TABLET YCARBAMAZEPINE ER 200 MG TABLET Y QLCARBAMAZEPINE ER 400 MG TABLET Y QLCARBAMAZEPINE XR 200 MG TABLET Y QLCARBAMAZEPINE XR 400 MG TABLET Y QLCARBIDOPA-LEVO 10-100 MG ODT YCARBIDOPA-LEVO 25-100 MG ODT YCARBIDOPA-LEVO 25-250 MG ODT Y

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CARBIDOPA-LEVO ER 25-100 TAB YCARBIDOPA-LEVO ER 50-200 TAB YCARBIDOPA-LEVODOPA 10-100 TAB YCARBIDOPA-LEVODOPA 25-100 TAB YCARBIDOPA-LEVODOPA 25-250 TAB YCartia XT 120 mg capsule, extended release Y QLCartia XT 240 mg capsule, extended release Y QLCartia XT 300 mg capsule, extended release Y QLCARVEDILOL 12.5 MG TABLET YCARVEDILOL 25 MG TABLET YCARVEDILOL 3.125 MG TABLET YCARVEDILOL 6.25 MG TABLET YCelebrex 100 mg capsule Y QLCelebrex 200 mg capsule Y QLCelebrex 400 mg capsule Y QLCelebrex 50 mg capsule Y QLCHLORDIAZEPO-AMITRIPTYL 5-12.5 YCHLORDIAZEPOX-AMITRIPTYL 10-25 YCHLORDIAZEPOXIDE 10 MG CAPSULE QLCHLORDIAZEPOXIDE 25 MG CAPSULE QLCHLORDIAZEPOXIDE 5 MG CAPSULE QLCHLOROTHIAZIDE 250 MG TABLET YCHLOROTHIAZIDE 500 MG TABLET YCILOSTAZOL 100 MG TABLET YCILOSTAZOL 50 MG TABLET YCIMETIDINE 300 MG TABLET YCIMETIDINE 400 MG TABLET YCIMETIDINE 800 MG TABLET YCimzia 400 mg/2 mL (200 mg/mL x 2) SubQ Syringe Kit Y QL, PA

Cimzia Powder for Reconstitution 400 mg (200 mg x 2 vials) Sub-Q Kit QL

CIPROFLOXACIN HCL 250 MG TAB CIPROFLOXACIN HCL 500 MG TAB CIPROFLOXACIN HCL 750 MG TAB CITALOPRAM HBR 10 MG TABLET Y QLCITALOPRAM HBR 20 MG TABLET Y QLCITALOPRAM HBR 40 MG TABLET Y QLCLARITHROMYCIN 250 MG TABLET CLARITHROMYCIN 500 MG TABLET CLINDAMYCIN HCL 75 MG CAPSULE CLONAZEPAM 0.125 MG DIS TAB YCLONAZEPAM 0.25 MG ODT Y

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CLONAZEPAM 0.5 MG DIS TABLET YCLONAZEPAM 0.5 MG TABLET YCLONAZEPAM 1 MG DIS TABLET YCLONAZEPAM 1 MG TABLET YCLONAZEPAM 2 MG ODT YCLONAZEPAM 2 MG TABLET YCLOPIDOGREL 300 MG TABLET QLCLOPIDOGREL 75 MG TABLET Y QLCLORAZEPATE 15 MG TABLET CLORAZEPATE 3.75 MG TABLET CLORAZEPATE 7.5 MG TABLET CLOZAPINE 100 MG TABLET YCLOZAPINE 200 MG TABLET YCLOZAPINE 25 MG TABLET YCLOZAPINE 50 MG TABLET YCombivent 18 mcg-103 mcg/actuation Aerosol Inhaler Y QL

Comtan 200 mg tablet Y QLCoreg CR 10 mg capsule, extended release Y QLCoreg CR 20 mg capsule, extended release Y QLCoreg CR 40 mg capsule, extended release Y QLCoreg CR 80 mg capsule, extended release Y QLCreon 3,000-9,500-15,000 unit capsule, delayed release Y

Crestor 10 mg tablet Y QLCrestor 20 mg tablet Y QLCrestor 40 mg tablet Y QLCrestor 5 mg tablet Y QLCrixivan 200 mg capsule Y QLCrixivan 400 mg capsule Y QLCROMOLYN 20 MG/2 ML NEB SOLN YCYCLOSPORINE MODIFIED 25 MG YCymbalta 20 mg capsule, delayed release Y QL, PA Cymbalta 30 mg capsule, delayed release Y QL, PA Cymbalta 60 mg capsule, delayed release Y QL, PA DANAZOL 100 MG CAPSULE DANAZOL 50 MG CAPSULE DESIPRAMINE 10 MG TABLET YDESIPRAMINE 100 MG TABLET YDESIPRAMINE 25 MG TABLET YDESIPRAMINE 50 MG TABLET YDESIPRAMINE 75 MG TABLET YDESLORATADINE 2.5 MG ODT Y QL, ST

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DESLORATADINE 5 MG ODT Y QL, STDESLORATADINE 5 MG TABLET Y QL, STDESOXIMETASONE 0.05% OINTMENT Detrol 1 mg tablet Y QL, STDetrol 2 mg tablet Y QL, STDetrol LA 2 mg capsule, extended release Y QLDetrol LA 4 mg capsule, extended release Y QLDEXAMETHASONE 1 MG TABLET DEXAMETHASONE 1.5 MG TABLET DEXAMETHASONE 2 MG TABLET DEXAMETHASONE 4 MG TABLET DEXAMETHASONE 6 MG TABLET Dexilant 30 mg capsule, delayed release Y QL, STDexilant 60 mg capsule, delayed release Y QL, STDEXTROAMP-AMPHET ER 10 MG CAP QLDEXTROAMP-AMPHET ER 15 MG CAP QLDEXTROAMP-AMPHET ER 20 MG CAP QLDEXTROAMP-AMPHET ER 25 MG CAP QLDEXTROAMP-AMPHET ER 30 MG CAP QLDEXTROAMP-AMPHET ER 5 MG CAP QLDIAZEPAM 10 MG TABLET QLDIAZEPAM 2 MG TABLET QLDIAZEPAM 5 MG TABLET QLDICLOFENAC-MISOPROST 50-0.2 TB Y STDICLOFENAC-MISOPROST 50-200 TB Y STDICLOFENAC-MISOPROST 75-0.2 TB Y STDICLOFENAC-MISOPROST 75-200 TB Y STDIGOXIN 125 MCG TABLET Y QLDIGOXIN 250 MCG TABLET YDILTIAZEM 120 MG TABLET YDILT-XR 180 mg capsule, extended release Y QLDiovan 160 mg tablet Y QL, STDiovan 320 mg tablet Y QL, STDiovan 40 mg tablet Y QL, STDiovan 80 mg tablet Y QL, STDiovan HCT 160 mg-12.5 mg tablet Y QL, STDiovan HCT 160 mg-25 mg tablet Y QL, STDiovan HCT 320 mg-12.5 mg tablet Y QL, STDiovan HCT 320 mg-25 mg tablet Y QL, STDiovan HCT 80 mg-12.5 mg tablet Y QL, STDIPYRIDAMOLE 25 MG TABLET YDIPYRIDAMOLE 50 MG TABLET Y

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DIPYRIDAMOLE 75 MG TABLET YDONEPEZIL HCL 10 MG TABLET Y QLDONEPEZIL HCL 5 MG TABLET Y QLDONEPEZIL HCL ODT 10 MG TABLET Y QLDONEPEZIL HCL ODT 5 MG TABLET Y QLDORZOLAMIDE HCL 2% EYE DROPS Y QLDORZOLAMIDE-TIMOLOL EYE DROPS Y QLDOXAZOSIN MESYLATE 1 MG TAB YDOXAZOSIN MESYLATE 2 MG TAB YDOXAZOSIN MESYLATE 4 MG TAB YDOXAZOSIN MESYLATE 8 MG TAB YDOXYCYCLINE HYC DR 100 MG TAB QLDOXYCYCLINE HYC DR 75 MG TAB QLDUETACT 30 mg-2 mg tablet Y QL, STDUETACT 30 mg-4 mg tablet Y QL, STDulera 100 mcg-5 mcg/actuation HFA Aerosol Inhaler Y QLDulera 200 mcg-5 mcg/actuation HFA Aerosol Inhaler Y QLEffient 10 mg tablet Y QLEffient 5 mg tablet Y QLEliquis 2.5 mg tablet Y QLEliquis 5 mg tablet Y QLEnablex 15 mg tablet, extended release Y QLEnablex 7.5 mg tablet, extended release Y QLENALAPRIL MALEATE 10 MG TAB YENALAPRIL-HCTZ 10-25 MG TABLET YEnbrel 25 mg (1 mL) Sub-Q Kit Y QL, PA Enbrel 25 mg/0.5 mL (0.51 mL) Sub-Q Syringe Y QL, PA Enbrel 50 mg/mL (0.98 mL) Sub-Q Syringe Y QL, PA Endocet 10 mg-325 mg tablet QLEndocet 10 mg-650 mg tablet QLEndocet 5 mg-325 mg tablet QLEndocet 7.5 mg-325 mg tablet QLEndocet 7.5 mg-500 mg tablet QLENOXAPARIN 100 MG/ML SYR QLENOXAPARIN 100 MG/ML SYRINGE QLENOXAPARIN 120 MG/0.8 ML SYR QLENOXAPARIN 150 MG/ML SYR QLENOXAPARIN 150 MG/ML SYRINGE QLENOXAPARIN 30 MG/0.3 ML SYR QLENOXAPARIN 300 MG/3 ML VIAL QLENOXAPARIN 40 MG/0.4 ML SYR QLENOXAPARIN 60 MG/0.6 ML SYR QL

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ENOXAPARIN 80 MG/0.8 ML SYR QLENTACAPONE 200 MG TABLET Y QLEpivir 300 mg tablet Y QLEpivir HBV 100 mg tablet Y QLESCITALOPRAM 10 MG TABLET Y QLESCITALOPRAM 20 MG TABLET Y QLESCITALOPRAM 5 MG TABLET Y QLESCITALOPRAM OXALATE 5 MG/5 ML Y QLESTAZOLAM 1 MG TABLET QLESTAZOLAM 2 MG TABLET QLESTROPIPATE 0.625(0.75 MG) TAB YESTROPIPATE 1.25(1.5 MG) TAB YESTROPIPATE 2.5(3 MG) TAB YEvista 60 mg tablet Y QLExelon 4.6 mg/24 hour Transderm 24 hr Patch Y QLExelon 9.5 mg/24 hour Transderm 24 hr Patch Y QLExforge 10 mg-160 mg tablet Y QL, STExforge 10 mg-320 mg tablet Y QL, STExforge 5 mg-160 mg tablet Y QL, STExforge 5 mg-320 mg tablet Y QL, STExforge HCT 10 mg-160 mg-12.5 mg tablet Y QL, STExforge HCT 10 mg-160 mg-25 mg tablet Y QL, STExforge HCT 10 mg-320 mg-25 mg tablet Y QL, STExforge HCT 5 mg-160 mg-12.5 mg tablet Y QL, STExforge HCT 5 mg-160 mg-25 mg tablet Y QL, STFAMCICLOVIR 125 MG TABLET QLFAMCICLOVIR 250 MG TABLET QLFAMCICLOVIR 500 MG TABLET QLFAMOTIDINE 20 MG TABLET YFAMOTIDINE 40 MG TABLET YFELODIPINE ER 10 MG TABLET Y QLFELODIPINE ER 2.5 MG TABLET Y QLFELODIPINE ER 5 MG TABLET Y QLFENOFIBRATE 134 MG CAPSULE Y QLFENOFIBRATE 145 MG TABLET Y QLFENOFIBRATE 200 MG CAPSULE Y QLFENOFIBRATE 48 MG TABLET Y QLFENOFIBRATE 54 MG TABLET Y QLFENOFIBRATE 67 MG CAPSULE Y QLFENTANYL 100 MCG/HR PATCH QLFINASTERIDE 5 MG TABLET Y QLFlovent Diskus 100 mcg/actuation for Inhalation Y QL

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Flovent Diskus 250 mcg/actuation for Inhalation Y QLFlovent Diskus 50 mcg/actuation for Inhalation Y QLFlovent HFA 110 mcg/actuation Aerosol Inhaler Y QLFlovent HFA 220 mcg/actuation Aerosol Inhaler Y QLFlovent HFA 44 mcg/actuation Aerosol Inhaler Y QLFLUOROURACIL 2% TOPICAL SOLN FLUOROURACIL 5% TOP SOLUTION FLUOXETINE HCL 10 MG CAPSULE Y QLFLUOXETINE HCL 20 MG CAPSULE Y QLFLUOXETINE HCL 40 MG CAPSULE Y QLFLUOXETINE HCL 60 MG TABLET Y QLFLURAZEPAM 15 MG CAPSULE QLFLURAZEPAM 30 MG CAPSULE QLFLUVASTATIN SODIUM 20 MG CAP Y QLFLUVASTATIN SODIUM 40 MG CAP Y QLFONDAPARINUX 2.5 MG/0.5 ML SYR QLFONDAPARINUX 5 MG/0.4 ML SYR QLFONDAPARINUX 7.5 MG/0.6 ML SYR QLForteo 20 mcg/dose (600 mcg/2.4 mL) Sub-Q Pen Injector Y QL, PA

FORTICAL 200 unit/actuation Nasal Spray Y QLFOSINOPRIL SODIUM 10 MG TAB YFUROSEMIDE 20 MG TABLET YFUROSEMIDE 80 MG TABLET YGABAPENTIN 300 MG CAPSULE Y QLGABAPENTIN 400 MG CAPSULE Y QLGABAPENTIN 600 MG TABLET Y QLGABAPENTIN 800 MG TABLET Y QLGALANTAMINE ER 16 MG CAPSULE Y QLGALANTAMINE ER 24 MG CAPSULE Y QLGALANTAMINE ER 8 MG CAPSULE Y QLGALANTAMINE HBR 12 MG TABLET Y QLGALANTAMINE HBR 4 MG TABLET Y QLGALANTAMINE HBR 8 MG TABLET Y QLGilenya 0.5 mg capsule Y QL, PA GLIMEPIRIDE 1 MG TABLET YGLIMEPIRIDE 2 MG TABLET YGLIMEPIRIDE 4 MG TABLET YGLIPIZIDE 10 MG TABLET YGLIPIZIDE ER 2.5 MG TABLET YGLIPIZIDE XL 2.5 MG TABLET YGLIPIZIDE-METFORMIN 2.5-250 MG YGLIPIZIDE-METFORMIN 2.5-500 MG Y

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GLIPIZIDE-METFORMIN 5-500 MG YGlumetza 500 mg tablet, extended release Y QL, STGLYBURIDE 2.5 MG TABLET YGLYBURIDE MICRO 1.5 MG TAB YGLYBURIDE MICRO 3 MG TABLET YGLYBURIDE MICRO 6 MG TABLET YGLYBURIDE-METFORMIN 2.5-500 MG YGLYBURIDE-METFORMIN 5-500 MG YGLYBURID-METFORMIN 1.25-250 MG YGolytely 227.1 g-21.5 g-6.36 g-5.53 g Packet Golytely 236 g-22.74 g-6.74 g-5.86 g Oral Solution HALOPERIDOL 1 MG TABLET YHALOPERIDOL 2 MG TABLET YHectorol 0.5 mcg capsule YHectorol 1 mcg capsule YHectorol 2.5 mcg capsule YHumalog Mix 50-50 100 unit/mL (50-50) Susp, Sub-Q Inj Y

Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj Y

Humira 20 mg/0.4 mL Sub-Q Kit Y QL, PA Humira 40 mg/0.8 mL Sub-Q Kit Y QL, PA Humira Crohn’s Disease Starter Pack 40 mg/0.8 mL SubQ Pen Kit Y QL, PA

Humulin 70/30 100 unit/mL (70-30) Susp, Sub-Q Inj Y

Humulin 70/30 Pen 100 unit/mL (70-30) SubQ YHumulin N 100 unit/mL Susp, Sub-Q Inj YHumulin N Pen 100 unit/mL (3 mL) SubQ YHumulin R 100 unit/mL Injection YHumulin R U-500 “Concentrated” Insulin 500 unit/mL Sub-Q Y

HYDRALAZINE 10 MG TABLET YHYDRALAZINE 100 MG TABLET YHYDRALAZINE 25 MG TABLET YHYDRALAZINE 50 MG TABLET YHYDROCHLOROTHIAZIDE 25 MG TAB YHYDROCORTISONE 0.1% SOLN HYDROCORTISONE BUTY 0.1% CREAMHYDROCORTISONE BUTYR 0.1% OINTHYDROXYZINE HCL 10 MG TABLET HYDROXYZINE HCL 25 MG TABLET IBANDRONATE SODIUM 150 MG TAB Y QLIBUPROFEN 600 MG TABLET Y

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IBUPROFEN 800 MG TABLET YIlevro 0.3 % Eye Drops Invega Sustenna 117 mg/0.75 mL IM Syringe Y QL, PA Invega Sustenna 156 mg/mL (1 mL) IM Syringe Y QL, PA Invega Sustenna 234 mg/1.5 mL IM Syringe Y QL, PA Invega Sustenna 39 mg/0.25 mL IM Syringe Y QL, PA Invega Sustenna 78 mg/0.5 mL IM Syringe Y QL, PA IRBESARTAN 150 MG TABLET Y QLIRBESARTAN 300 MG TABLET Y QLIRBESARTAN 75 MG TABLET Y QLIRBESARTAN-HCTZ 150-12.5 MG TB Y QLIRBESARTAN-HCTZ 300-12.5 MG TB Y QLJalyn 0.5 mg-0.4 mg capsule, extended release Y QLJanumet 50 mg-1,000 mg tablet Y QL, STJanumet 50 mg-500 mg tablet Y QL, STJanumet XR 100 mg-1,000 mg tablet, extended release Y QL, ST

Janumet XR 50 mg-1,000 mg tablet, extended release Y QL, ST

Janumet XR 50 mg-500 mg tablet, extended release Y QL, STJanuvia 100 mg tablet Y QL, STJanuvia 25 mg tablet Y QL, STJanuvia 50 mg tablet Y QL, STJuvisync 100 mg-10 mg tablet Y QL, STJuvisync 100 mg-20 mg tablet Y QL, STJuvisync 100 mg-40 mg tablet Y QL, STKombiglyze XR 2.5 mg-1,000 mg tablet, extended release Y QL, ST

Kombiglyze XR 5 mg-1,000 mg tablet, extended release Y QL, ST

Kombiglyze XR 5 mg-500 mg tablet, extended release Y QL, ST

LABETALOL HCL 100 MG TABLET YLABETALOL HCL 200 MG TABLET YLABETALOL HCL 300 MG TABLET YLamictal XR 250 mg tablet, extended release YLAMOTRIGINE 100 MG TABLET YLAMOTRIGINE 150 MG TABLET YLAMOTRIGINE 200 MG TABLET YLAMOTRIGINE 25 MG DISPER TAB Y QLLAMOTRIGINE 25 MG TABLET YLAMOTRIGINE 5 MG DISPER TABLET Y QLLAMOTRIGINE ER 100 MG TABLET YLAMOTRIGINE ER 200 MG TABLET Y

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LAMOTRIGINE ER 25 MG TABLET YLAMOTRIGINE ER 250 MG TABLET YLAMOTRIGINE ER 300 MG TABLET YLAMOTRIGINE ER 50 MG TABLET YLANSOPRAZOLE DR 30 MG CAPSULE Y QLLantus 100 unit/mL Sub-Q YLatuda 20 mg tablet Y QL, PA Latuda 40 mg tablet Y QL, PA Latuda 80 mg tablet Y QL, PA LEFLUNOMIDE 10 MG TABLET Y QLLescol XL 80 mg tablet, extended release Y QL, STLetairis 10 mg tablet Y QL, PA Letairis 5 mg tablet Y QL, PA LETROZOLE 2.5 MG TABLET Y QLLevemir 100 unit/mL Sub-Q YLevemir Flexpen 100 unit/mL (3 mL) Sub-Q Insulin Pen Y

LEVETIRACETAM 1,000 MG TABLET YLEVETIRACETAM 250 MG TABLET YLEVETIRACETAM 500 MG TABLET YLEVETIRACETAM 750 MG TABLET YLEVOCETIRIZINE 5 MG TABLET Y QLLEVOFLOXACIN 250 MG TABLET LEVOFLOXACIN 500 MG TABLET LEVOTHYROXINE 112 MCG TABLET YLEVOTHYROXINE 88 MCG TABLET YLevoxyl 100 mcg tablet YLevoxyl 112 mcg tablet YLevoxyl 125 mcg tablet YLevoxyl 137 mcg tablet YLevoxyl 150 mcg tablet YLevoxyl 175 mcg tablet YLevoxyl 200 mcg tablet YLevoxyl 25 mcg tablet YLevoxyl 50 mcg tablet YLevoxyl 75 mcg tablet YLevoxyl 88 mcg tablet YLinzess 145 mcg capsule Y QLLinzess 290 mcg capsule Y QLLISINOPRIL 10 MG TABLET YLISINOPRIL 20 MG TABLET YLISINOPRIL 30 MG TABLET YLISINOPRIL 40 MG TABLET Y

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LISINOPRIL-HCTZ 10-12.5 MG TAB YLISINOPRIL-HCTZ 20-12.5 MG TAB YLISINOPRIL-HCTZ 20-25 MG TAB YLITHIUM CARBONATE 150 MG CAP YLITHIUM CARBONATE ER 300 MG TB YLivalo 1 mg tablet Y QL, STLivalo 2 mg tablet Y QL, STLivalo 4 mg tablet Y QL, STLORAZEPAM 0.5 MG TABLET QLLORAZEPAM 1 MG TABLET QLLORAZEPAM 2 MG TABLET QLLOSARTAN POTASSIUM 100 MG TAB Y QLLOSARTAN POTASSIUM 25 MG TAB Y QLLOSARTAN POTASSIUM 50 MG TAB Y QLLOSARTAN-HCTZ 100-12.5 MG TAB Y QLLOSARTAN-HCTZ 100-25 MG TAB Y QLLOSARTAN-HCTZ 50-12.5 MG TAB Y QLLOVASTATIN 10 MG TABLET Y QLLOVASTATIN 20 MG TABLET Y QLLOVASTATIN 40 MG TABLET Y QLLovaza 1 gram capsule Y QLLumigan 0.01 % Eye Drops Y QLLyrica 100 mg capsule Y QL, PA Lyrica 150 mg capsule Y QL, PA Lyrica 20 mg/mL Oral Soln Y QL, PA Lyrica 200 mg capsule Y QL, PA Lyrica 225 mg capsule Y QL, PA Lyrica 25 mg capsule Y QL, PA Lyrica 300 mg capsule Y QL, PA Lyrica 50 mg capsule Y QL, PA Lyrica 75 mg capsule Y QL, PA MELOXICAM 15 MG TABLET Y QLMELOXICAM 7.5 MG TABLET Y QLMepron 750 mg/5 mL Oral Susp QLMETFORMIN HCL 1,000 MG TABLET YMETFORMIN HCL 500 MG TABLET YMETFORMIN HCL 850 MG TABLET YMETFORMIN HCL ER 500 MG TABLET Y QLMETFORMIN HCL ER 750 MG TABLET Y QLMETHOTREXATE 2.5 MG TABLET YMETHYLDOPA 250 MG TABLET YMETHYLDOPA 500 MG TABLET Y

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METHYLPHENIDATE CD 10 MG CAP QLMETHYLPHENIDATE CD 50 MG CAP QLMETHYLPHENIDATE CD 60 MG CAP QLMETHYLPHENIDATE ER 27 MG TAB QLMETOCLOPRAMIDE 10 MG TABLET METOCLOPRAMIDE 5 MG TABLET METOPROLOL SUCC ER 200 MG TAB Y QLMETOPROLOL SUCC ER 25 MG TAB Y QLMETOPROLOL TARTRATE 100 MG TAB YMETOPROLOL TARTRATE 25 MG TAB YMETOPROLOL TARTRATE 50 MG TAB YMETOPROLOL-HCTZ 100-25 MG TAB YMETOPROLOL-HCTZ 100-50 MG TAB YMETOPROLOL-HCTZ 50-25 MG TAB YMINOXIDIL 10 MG TABLET YMINOXIDIL 2.5 MG TABLET YMIRTAZAPINE 15 MG ODT Y QLMIRTAZAPINE 15 MG TABLET Y QLMIRTAZAPINE 30 MG ODT Y QLMIRTAZAPINE 30 MG TABLET Y QLMIRTAZAPINE 45 MG ODT Y QLMIRTAZAPINE 45 MG TABLET Y QLMIRTAZAPINE 7.5 MG TABLET YMISOPROSTOL 100 MCG TABLET YMODAFINIL 100 MG TABLET Y QL, PA MODAFINIL 200 MG TABLET Y QL, PA MONTELUKAST SOD 10 MG TABLET Y QLMONTELUKAST SOD 4 MG GRANULES Y QLMONTELUKAST SOD 4 MG TAB CHEW Y QLMONTELUKAST SOD 5 MG TAB CHEW Y QLMORPHINE SULF ER 100 MG TABLET QLMORPHINE SULF ER 30 MG TABLET QLMUPIROCIN 2% CREAM MYCOPHENOLATE 250 MG CAPSULE Y QLMYCOPHENOLATE 500 MG TABLET Y QLNamenda 10 mg tablet Y QLNamenda 10 mg/5 mL Oral Soln Y QLNamenda 5 mg tablet Y QLNamenda Titration Pak 5 mg-10 mg tablets in a dose pack QL

NAPROXEN 250 MG TABLET YNAPROXEN 375 MG TABLET YNAPROXEN 500 MG TABLET Y

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NARATRIPTAN 1 MG TABLET QLNARATRIPTAN 2.5 MG TABLET QLNARATRIPTAN HCL 1 MG TABLET QLNARATRIPTAN HCL 2.5 MG TABLET QLNasonex 50 mcg/actuation Spray Y QLNATEGLINIDE 120 MG TABLET YNATEGLINIDE 60 MG TABLET YNevanac 0.1 % Eye Drops STNexium 20 mg capsule, delayed release Y QLNexium 40 mg capsule, delayed release Y QLNiaspan Extended-Release 1,000 mg tablet, extended release Y PA

Niaspan Extended-Release 500 mg tablet, extended release Y PA

Niaspan Extended-Release 750 mg tablet, extended release Y PA

NIFEDIPINE ER 30 MG TABLET Y QLNIFEDIPINE ER 60 MG TABLET Y QLNIFEDIPINE ER 90 MG TABLET Y QLNISOLDIPINE ER 17 MG TABLET Y QLNISOLDIPINE ER 20 MG TABLET Y QLNISOLDIPINE ER 25.5 MG TABLET Y QLNISOLDIPINE ER 30 MG TABLET Y QLNISOLDIPINE ER 34 MG TABLET Y QLNISOLDIPINE ER 40 MG TABLET Y QLNISOLDIPINE ER 8.5 MG TABLET Y QLNITROGLYCERIN 0.2 MG/HR PATCH Y QLNITROGLYCERIN 0.4 MG/HR PATCH Y QLNITROGLYCERIN 0.6 MG/HR PATCH Y QLNORTRIPTYLINE HCL 75 MG CAP YNorvir 100 mg tablet Y QLNovolin 70/30 100 unit/mL (70-30) Susp, Sub-Q Inj YNovolin N 100 unit/mL Susp, Sub-Q Inj YNovolin R 100 unit/mL Injection YNovolog 100 unit/mL Sub-Q YNovolog Flexpen 100 unit/mL Sub-Q YNovolog Mix 70-30 100 unit/mL (70-30) Sub-Q YNovolog Mix 70-30 FlexPen 100 unit/mL (70-30) Sub-Q Y

NuLYTELY with Flavor Packs 420 gram Oral Solution OLANZAPINE 10 MG TABLET Y QLOLANZAPINE 15 MG TABLET Y QLOLANZAPINE 2.5 MG TABLET Y QL

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OLANZAPINE 20 MG TABLET Y QLOLANZAPINE 5 MG TABLET Y QLOLANZAPINE 7.5 MG TABLET Y QLOLANZAPINE ODT 10 MG TABLET Y QLOLANZAPINE ODT 15 MG TABLET Y QLOLANZAPINE ODT 20 MG TABLET Y QLOLANZAPINE ODT 5 MG TABLET Y QLOMEPRAZOLE DR 20 MG CAPSULE Y QLOMEPRAZOLE DR 40 MG CAPSULE Y QLOnfi 10 mg tablet Y QL, PA Onfi 20 mg tablet Y QL, PA Onfi 5 mg tablet Y QL, PA Onglyza 2.5 mg tablet Y QL, STOnglyza 5 mg tablet Y QL, STOXAZEPAM 10 MG CAPSULE OXAZEPAM 15 MG CAPSULE OXAZEPAM 30 MG CAPSULE OXYBUTYNIN 5 MG TABLET YOXYBUTYNIN CL ER 10 MG TABLET Y QLOXYBUTYNIN CL ER 15 MG TABLET Y QLOXYBUTYNIN CL ER 5 MG TABLET Y QLOXYCODONE HCL 10 MG TABLET QLOXYCODONE HCL 20 MG TABLET QLOXYMORPHONE HCL ER 10 MG TAB QLOXYMORPHONE HCL ER 20 MG TAB QLOXYMORPHONE HCL ER 30 MG TAB QLOXYMORPHONE HCL ER 40 MG TAB QLOXYMORPHONE HCL ER 5 MG TABLET QLPancreaze 10,500-25,000-43,750 unit capsule, delayed release Y

Pancreaze 16,800-40,000-70,000 unit capsule, delayed release Y



PANTOPRAZOLE SOD DR 20 MG TAB Y QLPANTOPRAZOLE SOD DR 40 MG TAB Y QLPataday 0.2 % Eye Drops Patanase 0.6 % Nasal Spray QL, STPegasys 180 mcg/mL Sub-Q Y QL, PA PegIntron 50 mcg/0.5 mL Sub-Q Kit Y QL, PA PegIntron Redipen 120 mcg/0.5 mL SubQ Kit Y QL, PA

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PegIntron Redipen 150 mcg/0.5 mL SubQ Kit Y QL, PA PegIntron Redipen 50 mcg/0.5 mL SubQ Kit Y QL, PA PegIntron Redipen 80 mcg/0.5 mL SubQ Kit Y QL, PA Pennsaid 1.5 % Topical Drops YPHENOBARBITAL 100 MG TABLET Y QLPHENOBARBITAL 15 MG TABLET Y QLPHENOBARBITAL 16.2 MG TABLET Y QLPHENOBARBITAL 20 MG/5 ML ELIX Y QLPHENOBARBITAL 20 MG/5 ML SOLN Y QLPHENOBARBITAL 30 MG TABLET Y QLPHENOBARBITAL 32.4 MG TABLET Y QLPHENOBARBITAL 60 MG TABLET Y QLPHENOBARBITAL 64.8 MG TABLET Y QLPHENOBARBITAL 97.2 MG TABLET Y QLPhenytek 200 mg capsule YPhenytek 300 mg capsule YPHENYTOIN 50 MG INFATAB YPHENYTOIN 50 MG TABLET CHEW YPhosLo 667 mg capsule YPIOGLITAZ-GLIMEPIR 30-2 MG TAB Y QL, STPIOGLITAZ-GLIMEPIR 30-4 MG TAB Y QL, STPIOGLITAZONE HCL 15 MG TABLET Y QLPIOGLITAZONE HCL 30 MG TABLET Y QLPIOGLITAZONE HCL 45 MG TABLET Y QLPIOGLITAZONE-METFORMIN 15-500 Y QLPIOGLITAZONE-METFORMIN 15-850 Y QLPOTASSIUM CITRATE ER 10 MEQ TB YPOTASSIUM CITRATE ER 5 MEQ TAB YPotiga 200 mg tablet Y PAPotiga 300 mg tablet Y PAPotiga 400 mg tablet Y PAPotiga 50 mg tablet Y PAPradaxa 150 mg capsule Y QLPradaxa 75 mg capsule Y QLPRAMIPEXOLE 0.125 MG TABLET YPRAMIPEXOLE 0.25 MG TABLET YPRAMIPEXOLE 0.5 MG TABLET YPRAMIPEXOLE 0.75 MG TABLET YPRAMIPEXOLE 1 MG TABLET YPRAMIPEXOLE 1.5 MG TABLET YPRAVASTATIN SODIUM 10 MG TAB Y QLPRAVASTATIN SODIUM 20 MG TAB Y QL

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PRAVASTATIN SODIUM 40 MG TAB Y QLPRAVASTATIN SODIUM 80 MG TAB Y QLPREDNISONE 1 MG TABLET PREDNISONE 10 MG TABLET PREDNISONE 2.5 MG TABLET Premarin 0.625 mg/gram Vaginal Cream YPRIMAQUINE 26.3 MG TABLET YPristiq 100 mg tablet, extended release Y QLPristiq 50 mg tablet, extended release Y QLProAir HFA 90 mcg/actuation Aerosol Inhaler Y QLPROCHLORPERAZINE 25 MG SUPP Procrit 10,000 unit/mL Injection Y QL, PA Procrit 2,000 unit/mL Injection Y QL, PA Procrit 20,000 unit/mL Injection Y QL, PA Procrit 3,000 unit/mL Injection Y QL, PA Procrit 4,000 unit/mL Injection Y QL, PA Procrit 40,000 unit/mL Injection Y QL, PA Prolia 60 mg/mL Sub-Q Syringe QL, PA PROMETHAZINE 12.5 MG SUPPOS PROMETHAZINE 25 MG SUPPOSITORYPROPAFENONE HCL ER 225 MG CAP YPROPAFENONE HCL SR 325 MG CAP YPROPAFENONE HCL SR 425 MG CAP YPROPRANOLOL 40 MG TABLET YPROPRANOLOL 60 MG TABLET YPROPRANOLOL 80 MG TABLET YProventil HFA 90 mcg/actuation Aerosol Inhaler Y QLQUETIAPINE FUMARATE 100 MG TAB Y QLQUETIAPINE FUMARATE 200 MG TAB Y QLQUETIAPINE FUMARATE 25 MG TAB Y QLQUETIAPINE FUMARATE 300 MG TAB Y QLQUETIAPINE FUMARATE 400 MG TAB Y QLQUETIAPINE FUMARATE 50 MG TAB Y QLQUININE SULFATE 324 MG CAPSULE QL, PA Qvar 40 mcg/actuation Metered Aerosol Oral Inhaler Y QLQvar 80 mcg/actuation Metered Aerosol Oral Inhaler Y QLRAMIPRIL 1.25 MG CAPSULE YRAMIPRIL 10 MG CAPSULE YRAMIPRIL 2.5 MG CAPSULE YRAMIPRIL 5 MG CAPSULE YRANITIDINE 150 MG CAPSULE YRANITIDINE 150 MG TABLET Y

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RANITIDINE 300 MG CAPSULE YRANITIDINE 300 MG TABLET YRebif 22 mcg/0.5 mL Sub-Q Syringe Y QL, PA Rebif 44 mcg/0.5 mL Sub-Q Syringe Y QL, PA Rebif Titration Pack 8.8 mcg/0.2 mL-22 mcg/0.5 mL Sub-Q Syringe Y QL, PA

Remicade 100 mg IV Solution PARenvela 0.8 gram Oral Powder Packet Y QLRenvela 2.4 gram Oral Powder Packet Y QLRenvela 800 mg tablet Y QLRestasis 0.05 % Eye Dropperette Y QLRISPERIDONE 0.25 MG ODT Y QLRISPERIDONE 0.25 MG TABLET Y QLRISPERIDONE 0.5 MG ODT Y QLRISPERIDONE 0.5 MG TABLET Y QLRISPERIDONE 1 MG TABLET Y QLRISPERIDONE 2 MG ODT Y QLRISPERIDONE 2 MG TABLET Y QLRISPERIDONE 3 MG ODT Y QLRISPERIDONE 3 MG TABLET Y QLRISPERIDONE 4 MG ODT Y QLRISPERIDONE 4 MG TABLET Y QLRIVASTIGMINE 1.5 MG CAPSULE Y QLRIVASTIGMINE 3 MG CAPSULE Y QLRIVASTIGMINE 4.5 MG CAPSULE Y QLRIVASTIGMINE 6 MG CAPSULE Y QLRIZATRIPTAN 10 MG ODT QLRIZATRIPTAN 10 MG TABLET QLRIZATRIPTAN 5 MG ODT QLRIZATRIPTAN 5 MG TABLET QLROPINIROLE HCL 0.25 MG TABLET Y QLROPINIROLE HCL 0.5 MG TABLET Y QLROPINIROLE HCL 1 MG TABLET Y QLROPINIROLE HCL 2 MG TABLET Y QLROPINIROLE HCL 3 MG TABLET Y QLROPINIROLE HCL 4 MG TABLET Y QLROPINIROLE HCL 5 MG TABLET Y QLSensipar 30 mg tablet Y QLSensipar 60 mg tablet Y QLSensipar 90 mg tablet Y QLSerevent Diskus 50 mcg/dose for Inhalation Y QLSeroquel XR 150 mg tablet, extended release Y QLSeroquel XR 200 mg tablet, extended release Y QL

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Seroquel XR 300 mg tablet, extended release Y QLSeroquel XR 400 mg tablet, extended release Y QLSeroquel XR 50 mg tablet, extended release Y QLSERTRALINE HCL 100 MG TABLET Y QLSERTRALINE HCL 25 MG TABLET Y QLSERTRALINE HCL 50 MG TABLET Y QLSILDENAFIL 20 MG TABLET Y QL, PA Simcor 1,000 mg-40 mg tablet, extended release Y QL, STSimcor 500 mg-20 mg tablet, extended release Y QL, STSimcor 500 mg-40 mg tablet, extended release Y QL, STSimcor 750 mg-20 mg tablet, extended release Y QL, STSIMVASTATIN 10 MG TABLET Y QLSIMVASTATIN 20 MG TABLET Y QLSIMVASTATIN 40 MG TABLET Y QLSIMVASTATIN 5 MG TABLET Y QLSIMVASTATIN 80 MG TABLET Y QLSODIUM LACTATE 1/6MOLAR INJ Soriatane 17.5 mg capsule PASOTALOL 160 MG TABLET YSOTALOL 240 MG TABLET YSOTALOL 80 MG TABLET YSpiriva with HandiHaler 18 mcg & inhalation capsules Y QLSPIRONOLACTONE 100 MG TABLET YSPIRONOLACTONE 25 MG TABLET YSPIRONOLACTONE 50 MG TABLET YStelara 45 mg/0.5 mL Sub-Q Syringe QL, PA Stelara 90 mg/mL Sub-Q Syringe QL, PA Suboxone 2 mg-0.5 mg sublingual film Y QL, PA Suboxone 8 mg-2 mg sublingual film Y QL, PA SULFAMETHOXAZOLE-TMP DS TABLETSULFAMETHOXAZOLE-TMP SS TABLETSUMATRIPTAN 6 MG/0.5 ML VIAL QLSUMATRIPTAN SUCC 100 MG TABLET QLSUMATRIPTAN SUCC 25 MG TABLET QLSUMATRIPTAN SUCC 50 MG TABLET QLSuprep 17.5 gram-3.13 gram-1.6 gram Oral Solution Sustiva 200 mg capsule Y QLSustiva 50 mg capsule Y QLSustiva 600 mg tablet Y QLSymbicort 160 mcg-4.5 mcg/actuation HFA Aerosol Inhaler Y QL

Symbicort 80 mcg-4.5 mcg/actuation HFA Aerosol Inhaler Y QL

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TAMOXIFEN 10 MG TABLET YTAMOXIFEN 20 MG TABLET YTAMSULOSIN HCL 0.4 MG CAPSULE Y QLTekamlo 150 mg-10 mg tablet Y QLTekamlo 150 mg-5 mg tablet Y QLTekamlo 300 mg-10 mg tablet Y QLTekamlo 300 mg-5 mg tablet Y QLTekturna 150 mg tablet Y QLTekturna 300 mg tablet Y QLTekturna HCT 150 mg-12.5 mg tablet Y QLTekturna HCT 150 mg-25 mg tablet Y QLTekturna HCT 300 mg-12.5 mg tablet Y QLTekturna HCT 300 mg-25 mg tablet Y QLTEMAZEPAM 15 MG CAPSULE QLTEMAZEPAM 22.5 MG CAPSULE QLTEMAZEPAM 30 MG CAPSULE QLTEMAZEPAM 7.5 MG CAPSULE QLTIAGABINE HCL 2 MG TABLET YTIAGABINE HCL 4 MG TABLET Y QLTIMOLOL 0.25% EYE DROPS YTIMOLOL 0.25% GEL-SOLUTION YTIMOLOL 0.25% GFS GEL-SOLUTION YTIMOLOL 0.5% EYE DROPS YTIMOLOL 0.5% GEL-SOLUTION YTIMOLOL 0.5% GFS GEL-SOLUTION YTIMOLOL MALEATE 10 MG TABLET YTIMOLOL MALEATE 20 MG TABLET YTIMOLOL MALEATE 5 MG TABLET YTINIDAZOLE 250 MG TABLET TINIDAZOLE 500 MG TABLET TOLTERODINE TARTRATE 1 MG TAB Y QLTOLTERODINE TARTRATE 2 MG TAB Y QLTOPIRAMATE 100 MG TABLET Y QLTOPIRAMATE 15 MG SPRINKLE CAP Y QLTOPIRAMATE 200 MG TABLET Y QLTOPIRAMATE 25 MG SPRINKLE CAP Y QLTOPIRAMATE 25 MG TABLET Y QLTOPIRAMATE 50 MG TABLET Y QLTORSEMIDE 10 MG TABLET YTORSEMIDE 100 MG TABLET YTORSEMIDE 20 MG TABLET YTORSEMIDE 5 MG TABLET Y

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Toviaz 4 mg tablet, extended release Y QLToviaz 8 mg tablet, extended release Y QLTravatan Z 0.004 % Eye Drops Y QLTRAZODONE 150 MG TABLET YTRAZODONE 300 MG TABLET YTrelstar 22.5 mg IM Susp QL, PA Treximet 85 mg-500 mg tablet QLTRIAMTERENE-HCTZ 37.5-25 MG CP YTRIAMTERENE-HCTZ 37.5-25 MG TB YTRIAMTERENE-HCTZ 75-50 MG TAB YTRIAZOLAM 0.125 MG TABLET QLTRIAZOLAM 0.25 MG TABLET QLTribenzor 20 mg-5 mg-12.5 mg tablet Y QL, STTribenzor 40 mg-10 mg-12.5 mg tablet Y QL, STTribenzor 40 mg-10 mg-25 mg tablet Y QL, STTribenzor 40 mg-5 mg-12.5 mg tablet Y QL, STTribenzor 40 mg-5 mg-25 mg tablet Y QL, STTricor 145 mg tablet Y QL, STTricor 48 mg tablet Y QL, STTrizivir 300 mg-150 mg-300 mg tablet Y QLTROSPIUM CHLORIDE 20 MG TABLET Y QLTROSPIUM CHLORIDE ER 60 MG CAP Y QLTudorza Pressair 400 mcg/actuation Breath Activated Y QL, PA VALSARTAN-HCTZ 160-12.5 MG TAB Y QLVALSARTAN-HCTZ 160-25 MG TAB Y QLVALSARTAN-HCTZ 320-12.5 MG TAB Y QLVALSARTAN-HCTZ 320-25 MG TAB Y QLVALSARTAN-HCTZ 80-12.5 MG TAB Y QLVENLAFAXINE HCL 100 MG TABLET YVENLAFAXINE HCL 25 MG TABLET YVENLAFAXINE HCL 37.5 MG TABLET YVENLAFAXINE HCL 50 MG TABLET YVENLAFAXINE HCL 75 MG TABLET YVENLAFAXINE HCL ER 150 MG CAP Y QLVENLAFAXINE HCL ER 150 MG TAB Y QLVENLAFAXINE HCL ER 225 MG TAB Y QLVENLAFAXINE HCL ER 37.5 MG CAP Y QLVENLAFAXINE HCL ER 75 MG CAP Y QLVENLAFAXINE HCL ER 75 MG TAB Y QLVentolin HFA 90 mcg/actuation Aerosol Inhaler Y QLVeramyst 27.5 mcg/actuation Nasal Spray Y QLVERAPAMIL 120 MG TABLET Y

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VERAPAMIL 80 MG TABLET Y QLVesicare 10 mg tablet Y QLVesicare 5 mg tablet Y QLVictoza 3-Pak 0.6 mg/0.1 mL (18 mg/3 mL) Sub-Q Pen Injector Y QL, ST

Viibryd 10 mg (7)-20 mg (7)-40 mg(16) tablets in a dose pack QL, ST

Vimovo 375 mg-20 mg tablet,immediate & delayed release Y QL, ST

Vimovo 500 mg-20 mg tablet,immediate & delayed release Y QL, ST

Vimpat 10 mg/mL Oral Soln Y QLViread 150 mg tablet Y QLViread 200 mg tablet Y QLViread 250 mg tablet Y QLViread 300 mg tablet Y QLViread 40 mg/scoop (40 mg/gram) Oral Powder Y QLVoltaren 1 % Topical Gel YVytorin 10-10 10 mg-10 mg tablet Y QL, STVytorin 10-20 10 mg-20 mg tablet Y QL, STVytorin 10-40 10 mg-40 mg tablet Y QL, STVytorin 10-80 10 mg-80 mg tablet Y QL, STWARFARIN SODIUM 1 MG TABLET YWARFARIN SODIUM 2 MG TABLET YWARFARIN SODIUM 2.5 MG TABLET YWARFARIN SODIUM 3 MG TABLET YWARFARIN SODIUM 4 MG TABLET YWARFARIN SODIUM 5 MG TABLET YWARFARIN SODIUM 6 MG TABLET YWARFARIN SODIUM 7.5 MG TABLET YWelChol 625 mg tablet YXarelto 10 mg tablet QLXarelto 15 mg tablet Y QLXarelto 20 mg tablet Y QLZAFIRLUKAST 10 MG TABLET Y QLZAFIRLUKAST 20 MG TABLET Y QLZemplar 1 mcg capsule Y QLZemplar 2 mcg capsule Y QLZemplar 4 mcg capsule Y QLZenpep 10,000-34,000-55,000 unit capsule, delayed release Y

Zenpep 15,000-51,000-82,000 unit capsule, delayed release Y

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Zetia 10 mg tablet Y QLZIPRASIDONE HCL 20 MG CAPSULE Y QLZIPRASIDONE HCL 40 MG CAPSULE Y QLZIPRASIDONE HCL 60 MG CAPSULE Y QLZIPRASIDONE HCL 80 MG CAPSULE Y QLZOLPIDEM TART ER 12.5 MG TAB QL, STZOLPIDEM TART ER 6.25 MG TAB QL, STZOLPIDEM TARTRATE 10 MG TABLET QLZOLPIDEM TARTRATE 5 MG TABLET QLZONISAMIDE 100 MG CAPSULE YZONISAMIDE 25 MG CAPSULE YZONISAMIDE 50 MG CAPSULE YZOSTAVAX (PF) 19,400 unit Sub-Q Susp QLZyclara 3.75 % Topical Cream Packet STZymaxid 0.5 % Eye Drops QLZytiga 250 mg tablet Y QL, PA

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Humana.com

Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plans of Michigan, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. – A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # 00187-0009 or administered by Humana Insurance Company or Humana Health Plan, Inc.

For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company or Humana Health Plan, Inc.

Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company providing your benefits.

Our health benefit plans have limitations and exclusions.

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