2018 rx4 annual changes - inside.nku.edu · airshield effervescent tablet -cvg consult your...

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Humana.com

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)

2018 Rx4 Annual Changes

Effective January 1, 2018

Para visualizarlo en español, haga clic aquí. To view your full Drug List, click here.

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Drug Name Formulary Status AlternativesAbstral sublingual tablet -CVG morphine immediate release tablet;

oxycodone tablet; hydromorphone tablet; fentanyl lozenge on a handle;

acetylcysteine capsule -CVG Consult Your Physician

Afluria 2016-2017 (PF) intramuscular syringe -CVG Consult Your PhysicianAfluria 2016-2017 intramuscular suspension -CVG Consult Your PhysicianAfluria Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your PhysicianAfluria Quad 2016-2017 intramuscular suspension -CVG Consult Your PhysicianAirshield effervescent tablet -CVG Consult Your PhysicianAK-Poly-Bac eye ointment CVG, -Tier (1/2) polymyxin B sulfate-trimethoprim eye

dropsAkten (PF) eye gel -CVG proparacaine eye dropsalendronate oral solution CVG, +Tier (3/2),

QLConsult Your Physician

Alkeran tablet CVG, -Tier (2/3), QL

Consult Your Physician

Alocril eye drops -CVG cromolyn eye drops; azelastine eye drops; Pazeo eye drops; olopatadine eye drops; epinastine eye drops

alogliptin tablet -CVG Januvia tablet; Tradjenta tablet; Onglyza tablet; Nesina tablet;

alogliptin-metformin tablet -CVG Janumet tablet; Janumet XR tablet,extended release; Jentadueto tablet; Jentadueto XR tablet, extended release; Kazano tablet

alogliptin-pioglitazone tablet -CVG Januvia tablet; Tradjenta tablet; Onglyza tablet; Nesina tablet; pioglitazone tablet

Alomide eye drops -CVG cromolyn eye drops; azelastine eye drops; Pazeo eye drops; olopatadine eye drops; epinastine eye drops

Alora transdermal patch -CVG estradiol tablet; estropipate tablet; estradiol weekly transdermal patch; Menest tablet; Enjuvia tablet

Alprazolam Intensol oral concentrate CVG, -Tier (1/2) buspirone tabletalprazolam tablet CVG, -Tier (1/2),

QLbuspirone tablet

ALZ tablet,extended release -CVG Consult Your Physicianamlodipine-valsartan tablet +CVG, QL Consult Your PhysicianAmnesteem capsule -CVG doxycycline hyclate capsule;

minocycline capsule; tretinoin topical gel

amoxicillin ER tablet,extended release 24hr mphase CVG, -Tier (2/3) amoxicillin tablet; ampicillin capsule; dicloxacillin capsule

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

Anti-Allergy Formula tablet -CVG Consult Your Physician


Drug Name Formulary Status AlternativesApatate oral liquid -CVG Consult Your Physicianaprepitant capsule CVG, +PA, QL Consult Your Physicianaprepitant capsules in a dose pack CVG, +PA, QL Consult Your PhysicianAranesp (in polysorbate) injection solution -CVG Procrit injection solutionAranesp (in polysorbate) injection syringe -CVG Procrit injection solutionArginaid Extra oral liquid -CVG Consult Your PhysicianArginaid oral powder packet -CVG Consult Your Physicianaspirin-caffeine-dihydrocodeine capsule -CVG hydrocodone-acetaminophen tablet;

oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet; acetaminophen-codeine tablet; oxycodone-aspirin tablet

astaxanthin capsule -CVG Consult Your PhysicianAtabex EC tablet,delayed release CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA

oral pack; Prenatal 19 chewable tabletatropine eye drops CVG, -Tier (1/2) cyclopentolate eye dropsAtrovent HFA aerosol inhaler -CVG ipratropium bromide solution for

inhalation; ipratropium-albuterol solution for nebulization

Azilect tablet -CVG rasagiline tablet; carbidopa-levodopa tablet; carbidopa-levodopa-entacapone tablet; carbidopa-levodopa ER tablet,extended release; selegiline capsule

B-12 Compliance injection kit CVG, -Tier (1/2) Consult Your PhysicianBaby's Only Dairy oral powder -CVG Consult Your PhysicianBaby's Only Org LactoRelief oral powder -CVG Consult Your PhysicianBaby's Only Organic Dairy oral powder -CVG Consult Your PhysicianBaby's Only Organic Dairy Whey oral powder -CVG Consult Your PhysicianBaby's Only Organic Soy oral powder -CVG Consult Your PhysicianBalanced Nutritional oral liquid -CVG Consult Your PhysicianBalanced Nutritional Plus oral liquid -CVG Consult Your PhysicianBeef-Potatoes-Peas oral liquid -CVG Consult Your PhysicianBenecalorie oral liquid -CVG Consult Your Physicianbetamethasone 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;

Betimol eye drops -CVG latanoprost eye drops; timolol maleate eye drops; dorzolamide-timolol eye drops; dorzolamide eye drops; levobunolol eye drops

Beyaz tablet -CVG Safyral tabletBioflex tablet -CVG Consult Your Physician


Drug Name Formulary Status AlternativesBiotalan Clear oral liquid -CVG Consult Your PhysicianBiotin 100+10 tablet -CVG Consult Your PhysicianBiotin Plus Keratin tablet -CVG Consult Your PhysicianBoost Breeze Nutritional oral liquid -CVG Consult Your PhysicianBoost Calorie Smart oral liquid -CVG Consult Your PhysicianBoost Compact oral liquid -CVG Consult Your PhysicianBoost High Protein oral liquid -CVG Consult Your PhysicianBoost Kid Essentials oral liquid -CVG Consult Your PhysicianBoost Kid Essentials with Fiber oral liquid -CVG Consult Your PhysicianBoost oral liquid -CVG Consult Your PhysicianBoost Plus oral liquid -CVG Consult Your PhysicianBoost Pudding -CVG Consult Your PhysicianBoost VHC oral liquid -CVG Consult Your PhysicianBrain Might-DHA-Co Q10 tablet -CVG Consult Your PhysicianBreakfast Essentials oral liquid -CVG Consult Your PhysicianBright Beginnings Soy oral liquid -CVG Consult Your Physicianbuprenorphine HCl sublingual tablet CVG, +Tier (3/2),

PA, QLConsult Your Physician

butalbital-acetaminophen tablet -CVG tramadol tablet; tramadol-acetaminophen tablet

butalbital-acetaminophen-caffeine capsule CVG, -Tier (2/3), QL

butalbital-acetaminophen-caffeine tablet; tramadol tablet; tramadol-acetaminophen tablet

butalbital-acetaminophen-caffeine-codeine capsule CVG, +Tier (3/2), QL


calcitriol oral solution CVG, -Tier (2/3) ergocalciferol (vitamin D2) capsule; Vitamin D2 capsule; calcitriol capsule

calcium acetate capsule CVG, +Tier (3/2) Consult Your Physiciancalcium acetate tablet CVG, +Tier (3/2) Consult Your PhysicianCapacet capsule CVG, -Tier (2/3),

QLbutalbital-acetaminophen-caffeine tablet; tramadol tablet; tramadol-acetaminophen tablet

Capex shampoo -CVG triamcinolone acetonide lotion; mometasone topical solution; fluticasone lotion; betamethasone valerate lotion; hydrocortisone lotion

captopril-hydrochlorothiazide tablet CVG, +Tier (3/2) Consult Your Physiciancarbamazepine ER tablet,extended release,12 hr +CVG, QL Consult Your Physiciancetirizine oral solution -CVG desloratadine tablet; levocetirizine

oral solution; levocetirizine tabletChewables Multivitamins-A,B,D,E,K,Zn tablet -CVG Consult Your PhysicianChildren's Omega-3 with dha-epa chewable tablet -CVG Consult Your Physiciancholine dihydrogen citrate tablet -CVG Consult Your PhysicianCiclodan topical cream -CVG clotrimazole topical solution;

ketoconazole topical cream; nystatin topical cream

ciclopirox topical cream -CVG clotrimazole topical solution; ketoconazole topical cream; nystatin topical cream


Drug Name Formulary Status Alternativesciclopirox topical suspension CVG, -Tier (2/3) clotrimazole topical solution;

ketoconazole topical cream; nystatin topical cream

CLA capsule -CVG Consult Your PhysicianClarinex-D 12 HOUR tablet,extended release -CVG Consult Your Physicianclindamycin-tretinoin topical gel -CVG Onexton topical gel; Acanya topical

gel with pump; sulfacetamide sodium (acne) lotion (suspension); clindamycin-benzoyl peroxide topical gel;

clobetasol lotion -CVG triamcinolone acetonide lotion; mometasone topical solution; fluocinolone topical solution; betamethasone valerate lotion; hydrocortisone lotion

clobetasol topical foam -CVG triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream

clobetasol topical spray -CVG triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream

clobetasol-emollient topical foam -CVG triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream

clozapine tablet CVG, +Tier (3/2) Consult Your PhysicianC-Nate DHA capsule CVG, -Tier (2/3) Trinatal GT tablet; Prenatal Plus DHA

oral pack; Prenatal 19 chewable tabletcoconut oil capsule -CVG Consult Your PhysicianCollagen Plus Vitamin C capsule -CVG Consult Your PhysicianCompleat oral liquid -CVG Consult Your PhysicianCompleat Pediatric oral liquid -CVG Consult Your PhysicianCompleat Pediatric Reduced Calorie oral liquid -CVG Consult Your PhysicianComplete Nutrition oral liquid -CVG Consult Your PhysicianComplete Nutrition Plus oral liquid -CVG Consult Your PhysicianComplete Nutritional Drink oral liquid -CVG Consult Your PhysicianCondylox topical gel -CVG podofilox topical solution; imiquimod

topical cream packetCore Essentials oral liquid -CVG Consult Your PhysicianCore Essentials Peptide oral liquid -CVG Consult Your PhysicianCoromega oral packet -CVG Consult Your PhysicianCurosurf intratracheal suspension -CVG Consult Your Physiciancyclobenzaprine tablet -CVG cyclobenzaprine tablet; tizanidine

tablet; methocarbamol tablet; baclofen tablet; carisoprodol tablet

Cyclomydril eye drops -CVG cyclopentolate eye drops; atropine eye drops; tropicamide eye drops

cyclopentolate eye drops +CVG Consult Your Physician


Drug Name Formulary Status AlternativesCystagon capsule CVG, -Tier (3/4) Consult Your PhysicianCystex Cranberry oral liquid -CVG Consult Your PhysicianCytotine oral liquid -CVG Consult Your PhysicianDaflonex-XL tablet -CVG Consult Your PhysicianDaklinza tablet -CVG Harvoni tablet; Epclusa tabletdapsone tablet CVG, -Tier (2/3) Consult Your Physiciandesmopressin injection solution -CVG desmopressin tablet; desmopressin

nasal solution; desmopressin nasal spray; desmopressin nasal spray (non-refrigerated); Stimate nasal spray

Desonate topical gel -CVG triamcinolone acetonide topical ointment; mometasone topical ointment; fluticasone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment

desonide lotion -CVG triamcinolone acetonide lotion; mometasone topical solution; fluocinolone topical solution; betamethasone valerate lotion; hydrocortisone lotion

desonide topical cream -CVG triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream

desonide topical ointment -CVG triamcinolone acetonide topical ointment; mometasone topical ointment; fluticasone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment

Dexamethasone Intensol Drops (concentrate) CVG, -Tier (2/4) methylprednisolone tablet; prednisone tablet; dexamethasone tablet; hydrocortisone tablet;

Diabetic Support Formula tablet -CVG Consult Your Physiciandiclofenac eye drops CVG, +Tier (2/1),

+QLConsult Your Physician

Dilatrate-SR capsule,extended release -CVG isosorbide mononitrate tablet; isosorbide mononitrate ER tablet,extended release 24 hr; isosorbide dinitrate tablet; isosorbide dinitrate ER tablet,extended release;

dofetilide capsule -CVG amiodarone tablet; Pacerone tabletdoxycycline hyclate capsule CVG, +Tier (3/2) Consult Your Physiciandoxycycline hyclate capsule CVG, +Tier (3/2),


doxycycline hyclate tablet CVG, +Tier (3/2) Consult Your Physiciandrospirenone-ethinyl estradiol-levomefolate tablet CVG, +Tier (2/1) Consult Your PhysicianDry Eye Formula capsule -CVG Consult Your PhysicianDry Eye Omega Benefits capsule -CVG Consult Your PhysicianDry Eye Omega Benefits oral liquid -CVG Consult Your PhysicianDuocal oral powder -CVG Consult Your Physician


Drug Name Formulary Status Alternativesdutasteride capsule CVG, +Tier (3/2),


Dutoprol tablet,extended release -CVG bisoprolol-hydrochlorothiazide tablet; atenolol-chlorthalidone tablet; metoprolol tartrate-hydrochlorothiazide tablet; propranolol-hydrochlorothiazide tablet; nadolol-bendroflumethiazide tablet

Dyzbac tablet -CVG Consult Your PhysicianEC Matrixx tablet -CVG Consult Your PhysicianEffient tablet -CVG clopidogrel tablet; Brilinta tabletEgg-Pro oral powder -CVG Consult Your PhysicianElimite topical cream -CVG permethrin topical cream; lindane

lotion; malathion lotion; Eurax lotion; Eliphos tablet CVG, +Tier (3/2) Consult Your PhysicianElon Matrix Complete tablet -CVG Consult Your PhysicianEmbeda capsule, extend release, oral only -CVG morphine ER tablet,extended release;

fentanyl transdermal patch; Xtampza ER capsule sprinkle

Enfagrow Next Step oral liquid -CVG Consult Your PhysicianEnfagrow Toddler Next Step Non-GMO oral powder -CVG Consult Your PhysicianEnfagrow Toddler Next Step oral powder -CVG Consult Your PhysicianEnsure Active Clear oral liquid -CVG Consult Your PhysicianEnsure Active Heart Health oral liquid -CVG Consult Your PhysicianEnsure Active High Protein oral liquid -CVG Consult Your PhysicianEnsure Active Light oral liquid -CVG Consult Your PhysicianEnsure Active Muscle Health oral liquid -CVG Consult Your PhysicianEnsure Active Protein-Muscle oral liquid -CVG Consult Your PhysicianEnsure Compact oral liquid -CVG Consult Your PhysicianEnsure Complete oral liquid -CVG Consult Your PhysicianEnsure Enlive oral liquid -CVG Consult Your PhysicianEnsure High Protein oral liquid -CVG Consult Your PhysicianEnsure High Protein-Muscle oral liquid -CVG Consult Your PhysicianEnsure Muscle Health oral liquid -CVG Consult Your PhysicianEnsure oral liquid -CVG Consult Your PhysicianEnsure oral powder -CVG Consult Your PhysicianEnsure Original oral liquid -CVG Consult Your PhysicianEnsure Plus oral liquid -CVG Consult Your PhysicianEnsure Pudding -CVG Consult Your PhysicianEO28 Splash oral liquid -CVG Consult Your Physicianepinephrine injection,auto-injector +CVG, +QL Consult Your PhysicianEpiPen 2-Pak injection,auto-injector -CVG epinephrine injection,auto-injectorEpiPen injection,auto-injector -CVG epinephrine injection,auto-injectorEpivir HBV oral solution -CVG Baraclude oral solution; lamivudine

tablet; entecavir tablet; adefovir tablet; Vemlidy tablet

Epogen injection solution -CVG Procrit injection solution


Drug Name Formulary Status AlternativesEpzicom tablet -CVG abacavir-lamivudine-zidovudine

tablet; lamivudine-zidovudine tabletErygel topical -CVG clindamycin phosphate topical swab;

erythromycin with ethanol topical solution; erythromycin-benzoyl peroxide topical gel; mupirocin topical ointment;

erythromycin with ethanol topical gel -CVG clindamycin phosphate topical swab; erythromycin with ethanol topical solution; erythromycin-benzoyl peroxide topical gel; mupirocin topical ointment;

esomeprazole strontium capsule,delayed release -CVG omeprazole capsule,delayed release; pantoprazole tablet,delayed release; lansoprazole capsule,delayed release; rabeprazole tablet,delayed release;

Estro Vital Nutrients X-Str tablet -CVG Consult Your PhysicianEstroblend tablet -CVG Consult Your PhysicianEstroGel transdermal gel pump -CVG estradiol tablet; estropipate tablet;

estradiol weekly transdermal patch; Menest tablet; Enjuvia tablet

EstroNatural tablet -CVG Consult Your PhysicianEstroplus tablet -CVG Consult Your PhysicianEye Omega Advantage capsule -CVG Consult Your PhysicianEZ Flu 16-17(Fluzon Quad Ped)(PF) intramuscular syringe kit

-CVG Consult Your Physician

EZ Flu 2016-17 (Afluria) (PF) intramuscular syringe kit -CVG Consult Your PhysicianEZ Flu 2016-17 (Fluvirin) (PF) intramuscular syringe kit -CVG Consult Your Physicianezetimibe tablet +CVG, +ST, QL simvastatin tablet; lovastatin tablet;

atorvastatin tabletFaBB tablet -CVG Virt-Vite Plus tabletfamotidine oral suspension CVG, -Tier (2/3) ranitidine tablet; famotidine tabletfentanyl transdermal patch CVG, +Tier (3/2),


Fibersource HN oral liquid -CVG Consult Your PhysicianFlax, Fish and Borage Oil capsule -CVG Consult Your PhysicianFlexgen tablet -CVG Consult Your PhysicianFlo-Pred oral suspension -CVG prednisolone sodium phosphate oral

solution; prednisone oral solution; prednisolone oral solution

Fluad 2016-2017 (65 yr and up) (PF) intramuscular syringe


Fluarix Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your PhysicianFlublok 2016-2017 (PF) intramuscular solution -CVG Consult Your PhysicianFlucelvax Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physicianfludrocortisone tablet CVG, -Tier (1/2) Consult Your PhysicianFlulaval Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your PhysicianFlulaval Quad 2016-2017 intramuscular suspension -CVG Consult Your PhysicianFlumist Quad 2016-2017 nasal spray syringe -CVG Consult Your Physicianfluorometholone eye drops,suspension CVG, +Tier (3/2) Consult Your Physician


Drug Name Formulary Status AlternativesFluoroplex topical cream -CVG imiquimod topical cream packet;

fluorouracil topical creamfluphenazine oral concentrate CVG, -Tier (1/2) Consult Your Physicianfluphenazine oral elixir CVG, -Tier (1/2) Consult Your Physicianfluphenazine tablet CVG, -Tier (1/3) thioridazine tablet; trifluoperazine

tablet; fluphenazine oral elixirfluticasone lotion -CVG triamcinolone acetonide lotion;

mometasone topical solution; fluocinolone topical solution; betamethasone valerate lotion; hydrocortisone lotion

fluticasone topical cream -CVG triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream

fluticasone topical ointment -CVG triamcinolone acetonide topical ointment; mometasone topical ointment; fluocinolone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment

Fluvirin 2016-2017 (PF) intramuscular syringe -CVG Consult Your PhysicianFluvirin 2016-2017 intramuscular suspension -CVG Consult Your PhysicianFluzone High-Dose 2016-2017 (PF) intramuscular syringe


Fluzone Intraderm Quad 2016-17 (PF) intradermal syringe


Fluzone Quad 2016-2017 (PF) intramuscular suspension -CVG Consult Your PhysicianFluzone Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your PhysicianFluzone Quad 2016-2017 intramuscular suspension -CVG Consult Your PhysicianFluzone Quad Pedi 2016-17 (PF) intramuscular syringe -CVG Consult Your PhysicianFolbee Plus tablet CVG, +Tier (3/2) Consult Your PhysicianFolbee tablet -CVG Virt-Vite Plus tabletfolic acid-vit B6-vit B12 tablet -CVG Virt-Vite Plus tabletFolplex 2.2 tablet -CVG Virt-Vite Plus tabletForfivo XL tablet,extended release -CVG bupropion HCl tablet; bupropion HCl

SR tablet,12 hr sustained-release; bupropion HCl XL 24 hr tablet, extended release

Fosrenol chewable tablet -CVG calcium acetate capsule; Renvela tablet; Auryxia tablet; Renvela oral powder packet;

Fosrenol oral powder packet -CVG calcium acetate capsule; Renvela tablet; Auryxia tablet; Renvela oral powder packet;

Galzin capsule -CVG Consult Your PhysicianGerber Good Start Grow Non-GMO oral powder -CVG Consult Your PhysicianGiazo tablet -CVG sulfasalazine tablet,delayed release;

Lialda tablet,delayed release; Apriso capsule,extended release; balsalazide capsule;


Drug Name Formulary Status AlternativesGleostine capsule CVG, -Tier (3/4),


GlucaGen Diagnostic Kit Injection -CVG Consult Your PhysicianGlucaGen HypoKit Injection CVG, +Tier (3/2) Consult Your PhysicianGlucagon Emergency Kit (human-recomb) injection -CVG Consult Your PhysicianGlycoTrol capsule -CVG Consult Your PhysicianGlydo mucous membrane jelly in applicator CVG, -Tier (2/3) Consult Your PhysicianGlyset tablet -CVG acarbose tabletGmate Lancing Device CVG, +Tier (3/1) Consult Your Physiciangriseofulvin microsize oral suspension CVG, +Tier (3/2) Consult Your PhysicianHair, Skin and Nails Advanced tablet -CVG Consult Your PhysicianHair, Skin, and Nails with Biotin chewable tablet -CVG Consult Your PhysicianHair-Skin-Nails (vit C-biotin) chewable tablet -CVG Consult Your Physicianhalobetasol propionate topical cream -CVG triamcinolone acetonide topical

cream; mometasone topical cream; fluticasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream

halobetasol propionate topical ointment -CVG triamcinolone acetonide topical ointment; mometasone topical ointment; fluocinolone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment

Hematogen Forte capsule CVG, +Tier (2/1) Consult Your PhysicianHi-Cal oral liquid -CVG Consult Your PhysicianHigh-Protein Nutritional Shake oral liquid -CVG Consult Your Physicianhydrocortisone butyrate topical cream -CVG triamcinolone acetonide topical


hydrocortisone butyrate topical ointment -CVG triamcinolone acetonide topical ointment; mometasone topical ointment; fluocinolone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment

hydrocortisone butyrate topical solution -CVG triamcinolone acetonide lotion; mometasone topical solution; fluocinolone topical solution; betamethasone valerate lotion; hydrocortisone lotion

hydrocortisone butyrate-emollient topical cream -CVG triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream

hydrocortisone valerate topical cream -CVG triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream


Drug Name Formulary Status Alternativeshydrocortisone valerate topical ointment -CVG triamcinolone acetonide topical

ointment; mometasone topical ointment; fluocinolone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment

HyProst capsule -CVG Consult Your Physicianimiquimod topical cream packet CVG, +Tier (3/2),


Indocin oral suspension -CVG meloxicam tablet; naproxen tablet; ibuprofen tablet; diclofenac potassium tablet; nabumetone tablet

Infasurf intratracheal suspension -CVG Consult Your PhysicianIngrezza capsule CVG, PA, +QL Consult Your PhysicianIntermezzo sublingual tablet -CVG zaleplon capsule; zolpidem tablet;

eszopiclone tablet; temazepam capsule; triazolam tablet

Intrinsi B12-Folate tablet -CVG Consult Your Physicianipratropium bromide nasal spray CVG, -Tier (1/2),


ISOCHRON tablet,extended release CVG, -Tier (2/3) isosorbide mononitrate tablet; isosorbide mononitrate ER tablet,extended release 24 hr; isosorbide dinitrate tablet

Isosource 1.5 Cal liquid for tube feed -CVG Consult Your PhysicianIsosource HN liquid for tube feed -CVG Consult Your PhysicianJevity 1 Cal oral liquid -CVG Consult Your PhysicianJevity 1.2 Cal oral liquid -CVG Consult Your PhysicianJevity 1.5 Cal oral liquid -CVG Consult Your PhysicianKaletra oral solution -CVG lopinavir-ritonavir oral solutionK-Effervescent tablet CVG, -Tier (2/3) potassium chloride ER

tablet,extended release(part/cryst); Klor-Con M20 tablet,extended release; Klor-Con Sprinkle capsule,extended release

ketoprofen ER 24 hr capsule,extended release -CVG meloxicam tablet; naproxen tablet; ibuprofen tablet; diclofenac potassium tablet; nabumetone tablet

Kids Omega-3 with DHA chewable tablet -CVG Consult Your PhysicianKlor-Con 10 tablet,extended release -CVG potassium chloride ER

tablet,extended releaseKlor-Con 8 tablet,extended release -CVG potassium chloride ER

tablet,extended releaseKlor-Con M15 tablet,extended release CVG, +Tier (2/1) Consult Your PhysicianKlor-Con/EF effervescent tablet CVG, -Tier (2/3) potassium chloride ER


K-Pax Immune Booster oral powder -CVG Consult Your PhysicianK-PAX oral powder -CVG Consult Your Physician


Drug Name Formulary Status AlternativesLamisil oral granules in packet -CVG terbinafine HCl tablet; fluconazole

tablet; ketoconazole tablet; clotrimazole troche; flucytosine capsule

lamotrigine tablets in a dose pack CVG, +Tier (3/1) Consult Your PhysicianLanoxin tablet -CVG Consult Your PhysicianLazanda nasal spray -CVG morphine immediate release tablet;

oxycodone tablet; hydromorphone tablet; fentanyl lozenge on a handle;

Leukeran tablet CVG, -Tier (3/4), QL


leuprolide subcutaneous kit CVG, -Tier (3/4), PA, QL

leuprolide subcutaneous solution

levalbuterol HFA aerosol inhaler -CVG Ventolin HFA aerosol inhalerLevatol tablet -CVG metoprolol tartrate tablet; atenolol

tablet; carvedilol tablet; bisoprolol fumarate tablet; metoprolol succinate ER tablet,extended release 24 hr

Levemir FlexTouch subcutaneous insulin pen CVG, -Tier (2/3) Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen

Levemir subcutaneous solution CVG, -Tier (2/3) Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen

levorphanol tartrate tablet -CVG morphine immediate release tablet; oxycodone tablet; hydromorphone tablet; fentanyl lozenge on a handle;

levothyroxine tablet CVG, -Tier (1/2) Consult Your PhysicianLevoxyl tablet CVG, -Tier (1/2) Consult Your Physicianlidocaine mucosal jelly CVG, -Tier (2/3) Consult Your Physicianlidocaine mucous membrane jelly in applicator CVG, -Tier (2/3) Consult Your Physicianlidocaine-prilocaine topical cream CVG, -Tier (2/3) Consult Your Physicianlidocaine-prilocaine topical kit -CVG lidocaine mucosal jellylinezolid oral suspension CVG, +Tier (4/3),


linezolid tablet CVG, +Tier (4/3), QL


Lipotriad Dry Eye capsule,delayed release -CVG Consult Your PhysicianLiquid Hope oral -CVG Consult Your PhysicianLiquid Nutrition oral -CVG Consult Your PhysicianLiquid Nutrition Plus oral -CVG Consult Your PhysicianLister-V capsule -CVG Consult Your Physicianlomustine capsule CVG, -Tier (3/4),


Lorazepam Intensol oral concentrate CVG, -Tier (1/2), QL

buspirone tablet

Lukaid GLA for Asthma oral emulsion -CVG Consult Your PhysicianMAXIMUM DAILY GREEN tablet -CVG Consult Your PhysicianMebolex tablet -CVG Consult Your Physician


Drug Name Formulary Status AlternativesMegavite Golden Years 55+ tablet -CVG Consult Your PhysicianMegavite tablet -CVG Consult Your Physicianmelphalan tablet CVG, -Tier (2/3),


memantine tablets in a dose pack CVG, +Tier (3/2), QL


metaproterenol tablet CVG, -Tier (1/3) Consult Your Physicianmetoclopramide disintegrating tablet -CVG metoclopramide tablet;

metoclopramide oral solutionMetopirone capsule -CVG Consult Your Physicianmetoprolol succ-hydrochlorothiazide tablet ext.release 24 hr

-CVG bisoprolol-hydrochlorothiazide tablet; atenolol-chlorthalidone tablet; metoprolol tartrate-hydrochlorothiazide tablet; propranolol-hydrochlorothiazide tablet; nadolol-bendroflumethiazide tablet

metoprolol tartrate tablet CVG, +Tier (2/1) Consult Your Physicianmiglitol tablet -CVG acarbose tabletMinitran transdermal 24 hour patch CVG, +Tier (3/2),


minocycline ER tablet,extended release 24 hr CVG, +ST, -PA, QL doxycycline hyclate capsule; minocycline capsule; Solodyn tablet,extended release

Minus Weight Plus Energy capsule -CVG Consult Your PhysicianMirapex ER tablet,extended release -CVG pramipexole tablet; ropinirole tabletMirvaso topical gel -CVG metronidazole topical gel; Rosadan

topical gel; Finacea topical gel; metronidazole topical cream; Finacea topical foam

Mirvaso topical gel with pump -CVG metronidazole topical gel; Rosadan topical gel; Finacea topical gel; metronidazole topical cream; Finacea topical foam

Monogen oral powder -CVG Consult Your PhysicianMotofen tablet -CVG diphenoxylate-atropine tablet;

diphenoxylate-atropine oral liquid; loperamide capsuleparegoric oral liquid

Multi-Vit with Fluoride and Iron oral drops -CVG Consult Your PhysicianMvc-Fluoride chewable tablet -CVG Consult Your PhysicianMyKidz Iron Fluoride oral suspension -CVG Consult Your PhysicianMyleran tablet CVG, -Tier (2/4),


Mynatal capsule CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet

Mynephrocaps capsule -CVG Virt-Vite Plus tabletMyoCalm tablet -CVG Consult Your Physiciannaloxone injection syringe CVG, +Tier (4/2) Consult Your Physiciannaproxen oral suspension CVG, -Tier (2/3) meloxicam tablet; naproxen tablet;

ibuprofen tablet


Drug Name Formulary Status AlternativesNatrol Omega-3 chewable tablet -CVG Consult Your PhysicianNeulasta subcutaneous syringe CVG, PA, +QL Consult Your PhysicianNeurepa capsule -CVG Consult Your PhysicianNicadan ZX tablet -CVG Consult Your PhysicianNicaprin tablet -CVG Consult Your Physiciannifedipine capsule CVG, +Tier (3/2) Consult Your PhysicianNilandron tablet -CVG bicalutamide tablet; flutamide

capsule; nilutamide tabletnitroglycerin sublingual tablet CVG, -Tier (1/3) Consult Your PhysicianNitrostat sublingual tablet CVG, -Tier (1/3) Consult Your PhysicianNorinyl 1+50 (28) tablet -CVG Necon 0.5/35 (28) tablet; Alyacen

1/35 (28) tablet; Gildagia tablet; Balziva (28) tablet; Philith tablet

Nourish oral liquid -CVG Consult Your PhysicianNP Thyroid tablet CVG, -Tier (1/3) Consult Your PhysicianNutra Pro High Protein oral powder -CVG Consult Your PhysicianNutrafit oral liquid -CVG Consult Your PhysicianNutrafit Plus oral liquid -CVG Consult Your PhysicianNutrament oral liquid -CVG Consult Your PhysicianNutri-Drink oral liquid -CVG Consult Your PhysicianNutrition Plus oral liquid -CVG Consult Your PhysicianNutritional Drink oral liquid -CVG Consult Your PhysicianNutritional Drink Plus oral liquid -CVG Consult Your PhysicianNutritional Shake oral liquid -CVG Consult Your PhysicianNutritional Shake Plus oral liquid -CVG Consult Your PhysicianNutritional Supplement (lactose-free) oral liquid -CVG Consult Your PhysicianNutritional Supplement oral liquid -CVG Consult Your PhysicianNutritional Supplement Plus oral liquid -CVG Consult Your PhysicianO-Cal FA tablet CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA

oral pack; Prenatal 19 chewable tabletO-Cal Prenatal tablet CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA

oral pack; Prenatal 19 chewable tabletOcean Blue Prenatal DHA capsule -CVG Consult Your Physicianofloxacin eye drops CVG, +Tier (3/2) Consult Your Physicianolopatadine eye drops +CVG Consult Your PhysicianOmeclamox-Pak oral pack -CVG omeprazole capsule,delayed releaseOmega-3 + Vitamin D3 chewable tablet -CVG Consult Your Physicianomega-3 acid ethyl esters capsule CVG, +PA, QL gemfibrozil tablet; fenofibrate tablet;

fenofibrate micronized capsuleOmega-3 Fish Oil capsule -CVG Consult Your Physicianomega3-dha-epa-other omega3s-fish oil chewable tablet


One Daily tablet -CVG Consult Your PhysicianOne Daily Women's Metabolism tablet -CVG Consult Your PhysicianOpana ER tablet, crush resistant, ext. rel. -CVG morphine ER tablet,extended release;

fentanyl transdermal patch; Xtampza ER capsule sprinkle


Drug Name Formulary Status AlternativesOrange Chicken-Carrots-Brown Rice oral liquid -CVG Consult Your PhysicianOrenitram tablet,extended release -CVG sildenafil tablet; Adcirca tablet;

Opsumit tablet; Letairis tablet; Orenitram tablet,extended release -CVG Consult Your PhysicianOrganic PediaSmart oral powder -CVG Consult Your Physicianoseltamivir capsule -CVG rimantadine tablet; amantadine HCl

tabletOstera tablet -CVG Consult Your PhysicianOxaydo tablet,oral ONLY (not feeding tubes) -CVG morphine immediate release tablet;

oxycodone tablet; hydromorphone tablet

Oxecta tablet,oral ONLY (not feeding tubes) -CVG morphine immediate release tablet; oxycodone tablet; hydromorphone tablet

oxycodone-acetaminophen oral solution CVG, -Tier (2/3), QL

hydrocodone-acetaminophen tablet; oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet

oxymorphone ER tablet,extended release,12 hr -CVG morphine ER tablet,extended release; fentanyl transdermal patch; Xtampza ER capsule sprinkle

oxymorphone tablet -CVG morphine immediate release tablet; oxycodone tablet; hydromorphone tablet

Pancrelipase 5000 capsule,delayed release CVG, -Tier (2/4) Creon capsule,delayed release; Zenpep capsule,delayed release

Paremyd eye drops -CVG cyclopentolate eye drops; atropine eye drops; tropicamide eye drops

Pediasure Enteral oral liquid -CVG Consult Your PhysicianPediaSure Enteral with Fiber 1.0 oral liquid -CVG Consult Your PhysicianPediaSure oral liquid -CVG Consult Your PhysicianPediaSure Shake Mix oral powder -CVG Consult Your PhysicianPediasure Sidekicks Clear oral liquid -CVG Consult Your PhysicianPediaSure Sidekicks oral liquid -CVG Consult Your PhysicianPediaSure with Fiber oral liquid -CVG Consult Your PhysicianPediatric Balanced Nutrition oral liquid -CVG Consult Your PhysicianPediatric Drink With Fiber oral liquid -CVG Consult Your PhysicianPentasa capsule,controlled release -CVG sulfasalazine tablet,delayed release;

Lialda tablet,delayed release; Apriso capsule,extended release; balsalazide capsule;

Phlexy-Vits oral packet -CVG Consult Your PhysicianPhoslyra oral solution -CVG calcium acetate capsule; Renvela

tablet; Auryxia tablet; Renvela oral powder packet;

pimozide tablet CVG, +Tier (3/2) Consult Your PhysicianPoDiaPN capsule -CVG Virt-Vite Plus tabletPortagen oral powder -CVG Consult Your Physician


Drug Name Formulary Status Alternativespotassium bicarbonate and chloride effervescent tablet CVG, -Tier (2/3) potassium chloride ER


potassium bicarbonate-citric acid effervescent tablet CVG, -Tier (1/3) potassium chloride ER tablet,extended release(part/cryst); Klor-Con M20 tablet,extended release; Klor-Con Sprinkle capsule,extended release

potassium chloride ER tablet,extended release(part/cryst)

CVG, +Tier (2/1) Consult Your Physician

Prandimet tablet -CVG nateglinide tablet; metformin tabletprednicarbate topical cream -CVG triamcinolone acetonide topical


prednicarbate topical ointment -CVG triamcinolone acetonide topical ointment; mometasone topical ointment; fluocinolone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment

prednisolone acetate eye drops,suspension CVG, +Tier (3/2) Consult Your Physicianprednisolone sodium phosphate oral solution -CVG prednisolone sodium phosphate oral

solution; prednisone oral solution; prednisolone oral solution

Premarin vaginal cream -CVG Estrace vaginal creamPreNata chewable tablet CVG, -Tier (1/3) Trinatal GT tablet; Prenatal Plus DHA

oral pack; Prenatal 19 chewable tabletPreviDent dental solution -CVG Fluoritab chewable tablet; Fluoritab

oral drops; Ludent Fluoride chewable tablet; sodium fluoride chewable tablet; sodium fluoride oral drops

Prilosec oral suspension,delayed release -CVG omeprazole capsule,delayed release; pantoprazole tablet,delayed release; lansoprazole capsule,delayed release; rabeprazole tablet,delayed release;

Primlev tablet -CVG hydrocodone-acetaminophen tablet; oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet; acetaminophen-codeine tablet; oxycodone-aspirin tablet

Procysbi capsule,delayed release sprinkle -CVG Cystagon capsuleProsight with Lutein capsule -CVG Consult Your PhysicianProstate PQ tablet -CVG Consult Your PhysicianProtein Nutritional Shake oral liquid -CVG Consult Your PhysicianProxeed Plus oral powder packet -CVG Consult Your Physicianpyridostigmine bromide tablet CVG, -Tier (2/3) donepezil tablet; donepezil tablet

dissolved on the tongue


Drug Name Formulary Status AlternativesQuartette tablets,3 month dose pack -CVG Amethia tablets,3 month dose pack;

Ashlyna tablets,3 month dose pack; Camrese tablets,3 month dose pack; Daysee tablets,3 month dose pack; levonorgestrel/ethinyl estradiol and e.estradiol oral 3MPk

quetiapine ER tablet,extended release 24 hr CVG, +Tier (4/3), PA, QL


Quflora Pediatric chewable tablet -CVG Consult Your PhysicianQuinoa-Kale-Hemp oral liquid -CVG Consult Your PhysicianRadiogardase capsule -CVG Consult Your PhysicianRajani tablet CVG, +Tier (2/1) Consult Your Physicianrasagiline tablet CVG, -Tier (3/4),

PApramipexole tablet; ropinirole tablet; selegiline tablet

Red Wine Complex capsule -CVG Consult Your PhysicianRed Wine Extract capsule -CVG Consult Your PhysicianRed Wine Extract Plus capsule -CVG Consult Your PhysicianRe-Gen oral liquid -CVG Consult Your PhysicianRegranex topical gel -CVG Consult Your PhysicianRelpax tablet -CVG sumatriptan tablet; rizatriptan tablet;

naratriptan tablet; almotriptan malate tablet; zolmitriptan tablet

Renal Caps capsule -CVG Virt-Vite Plus tabletRena-Vite Rx tablet CVG, +Tier (3/2) Consult Your PhysicianReno Caps capsule -CVG Virt-Vite Plus tabletrepaglinide-metformin tablet -CVG nateglinide tablet; metformin tabletRepHresh Pro-B capsule -CVG Consult Your PhysicianResource 2.0 oral liquid -CVG Consult Your PhysicianResource Thickenup Dairy oral liquid -CVG Consult Your PhysicianRespa-AR tablet,extended release -CVG Respa-AR tablet,extended releaseresveratrol-quercetin tablet -CVG Consult Your Physicianresveratrol-r.wine-bioflav-grape sd-p.cusp.-C-pomg capsule


Retaine OM3 capsule -CVG Consult Your PhysicianRevia tablet CVG, +Tier (3/2) Consult Your PhysicianRezira oral solution -CVG Consult Your PhysicianRheumatrex tablets in a dose pack CVG, -Tier (2/3) methotrexate sodium tabletRifater tablet CVG, -Tier (2/3) rifampin capsuleRiomet oral solution -CVG metformin tablet; metformin ER

tablet,extended release 24 hrSalmon-Oats-Squash oral liquid -CVG Consult Your PhysicianScandiCal oral powder -CVG Consult Your PhysicianScandishake (Lactose Free) packet -CVG Consult Your PhysicianScandishake oral powder -CVG Consult Your PhysicianScandishake packet -CVG Consult Your PhysicianSea-Omega capsule -CVG Consult Your PhysicianSemprex-D capsule -CVG Consult Your Physician


Drug Name Formulary Status AlternativesSimbrinza eye drops,suspension -CVG latanoprost eye drops; timolol

maleate eye drops; dorzolamide-timolol eye drops; dorzolamide eye drops; levobunolol eye drops

Similac Go and Grow Non-GMO oral powder -CVG Consult Your PhysicianSimilac Go and Grow oral powder -CVG Consult Your PhysicianSimilac Go and Grow Sensitive oral powder -CVG Consult Your Physiciansodium polystyrene sulfonate enema +CVG Consult Your PhysicianSorilux topical foam -CVG triamcinolone acetonide topical


South African Hoodia Plus Cap capsule -CVG Consult Your PhysicianSovaldi tablet -CVG Harvoni tablet; Epclusa tabletSprix nasal spray -CVG Consult Your PhysicianStages Men's Multi-Vitamin tablet -CVG Consult Your PhysicianSuboxone sublingual film -CVG buprenorphine HCl sublingual tablet;

Zubsolv sublingual tabletSumavel DosePro subcutaneous needle-free injector -CVG sumatriptan tablet; rizatriptan tablet;

naratriptan tablet; almotriptan malate tablet; zolmitriptan tablet

Super Omega-3 capsule -CVG Consult Your PhysicianSuprane inhalation liquid -CVG Consult Your PhysicianSurvanta intratracheal suspension -CVG Consult Your PhysicianTamiflu capsule -CVG rimantadine tablet; amantadine HCl

tabletTamiflu oral suspension -CVG rimantadine tablet; amantadine HCl

tabletTart Cherry capsule -CVG Consult Your PhysicianTencon tablet -CVG tramadol tablet; tramadol-

acetaminophen tabletterbinafine HCl tablet +CVG, QL Consult Your Physicianterbutaline tablet CVG, -Tier (2/3) Consult Your PhysicianTestopel implant pellet -CVG testosterone cypionate intramuscular

oil; testosterone enanthate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet;

Theochron tablet,extended release CVG, -Tier (1/2) Consult Your Physiciantheophylline oral elixir CVG, -Tier (2/3) Consult Your Physiciantheophylline oral solution CVG, -Tier (2/3) Consult Your PhysicianThera Tears Nutrition capsule -CVG Consult Your PhysicianThickenUp Apple Honey oral liquid -CVG Consult Your PhysicianThickenUp Apple Nectar oral liquid -CVG Consult Your PhysicianThickenup Cranberry Honey oral liquid -CVG Consult Your PhysicianThickenup Cranberry Nectar oral liquid -CVG Consult Your PhysicianThickenUp Orange Honey oral liquid -CVG Consult Your PhysicianThickenUp Orange Nectar oral liquid -CVG Consult Your Physicianthiothixene capsule CVG, -Tier (2/3) Consult Your Physician


Drug Name Formulary Status AlternativesTikosyn capsule -CVG amiodarone tablet; Pacerone tablettinidazole tablet CVG, +Tier (3/2) Consult Your PhysicianTirosint capsule -CVG levothyroxine tablet; Synthroid

tablet; Levoxyl tablet; Levo-T tablet; Unithroid tablet

TL Gard Rx tablet -CVG Virt-Vite Plus tabletTL Icon capsule CVG, +Tier (2/1) Consult Your PhysicianTL-ICare capsule -CVG Consult Your PhysicianTonalin CLA capsule -CVG Consult Your Physiciantopiramate XR capsule sprinkle,ext.release 24 hr CVG, -Tier (3/4),

ST, QLlamotrigine tablet; topiramate tablet; divalproex tablet,delayed release

Tozal capsule -CVG Consult Your PhysicianTracleer tablet -CVG Letairis tablet; Opsumit tablettramadol ER capsule 24 hr,extended release -CVG tramadol ER tablet,extended release

24 hr; meloxicam tablet; naproxen tablet,delayed release; diclofenac sodium tablet,delayed release; nabumetone tablet

tramadol ER capsule 24h,extended release(25-75) -CVG tramadol ER tablet,extended release 24 hr; meloxicam tablet; naproxen tablet,delayed release; diclofenac sodium tablet,delayed release; nabumetone tablet

tramadol ER tablet,extended release 24 hr CVG, +Tier (3/2), ST, QL


tramadol ER tablet,extended release 24hr mphase -CVG tramadol ER tablet,extended release 24 hr; meloxicam tablet; naproxen tablet,delayed release; diclofenac sodium tablet,delayed release; nabumetone tablet

Tresiba FlexTouch U-100 subcutaneous insulin pen CVG, -Tier (2/3) Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen

Tresiba FlexTouch U-200 subcutaneous insulin pen CVG, -Tier (2/3) Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen

tretinoin topical cream CVG, +PA tretinoin topical cream; adapalene lotion

tretinoin topical cream CVG, +PA Consult Your Physiciantretinoin topical gel CVG, +PA Consult Your Physiciantretinoin topical gel CVG, +PA tretinoin topical gel; adapalene lotiontretinoin topical gel +CVG, +PA Consult Your PhysicianTrigels-F Forte capsule CVG, +Tier (2/1) Consult Your PhysicianTriphrocaps capsule -CVG Virt-Vite Plus tabletTrombonex capsule -CVG Consult Your PhysicianTrombonex-D capsule -CVG Consult Your PhysicianTwoCal HN oral liquid -CVG Consult Your PhysicianTyzine nasal drops CVG, -Tier (2/3) Consult Your PhysicianTyzine nasal spray CVG, -Tier (2/3) Consult Your Physician


Drug Name Formulary Status AlternativesUltra Men's Pack oral pack -CVG Consult Your PhysicianUltra Omega-3 capsule -CVG Consult Your PhysicianUltramino oral powder -CVG Consult Your PhysicianUrinozinc Prostate Formula capsule -CVG Consult Your PhysicianUTI-Stat oral liquid -CVG Consult Your PhysicianVagifem vaginal tablet -CVG Estrace vaginal creamValcyte oral solution -CVG valganciclovir oral solution;

valganciclovir tabletvalproic acid capsule CVG, +Tier (2/1) Consult Your PhysicianVasoflex capsule -CVG Consult Your PhysicianVasoflex Forte capsule -CVG Consult Your PhysicianVasoflex tablet -CVG Consult Your Physicianverapamil ER (PM) capsule 24hr pellet CT,ext.release CVG, +Tier (3/2),


Verdrocet tablet CVG, +Tier (3/2), QL


Veripred 20 oral solution -CVG prednisolone sodium phosphate oral solution; prednisone oral solution; prednisolone oral solution

Vesicare tablet -CVG oxybutynin chloride ER tablet,extended release 24 hr; Toviaz tablet,extended release; Myrbetriq tablet,extended release; tolterodine ER capsule,extended release 24 hr; trospium ER capsule,extended release 24 hr

Vigraplex tablet -CVG Consult Your PhysicianVirazole solution for inhalation -CVG Consult Your PhysicianVirt-Caps capsule -CVG Virt-Vite Plus tabletVirt-Vite Plus tablet CVG, +Tier (3/2) Consult Your PhysicianVirt-Vite tablet -CVG Virt-Vite Plus tabletVitafol tablet -CVG Se-Tan Plus capsule; FE 90 Plus tablet;

FE C Plus tabletVital High Nitrogen oral packet -CVG Consult Your PhysicianVital-D Rx tablet CVG, +Tier (3/2) Consult Your PhysicianVitamin D3 Complete tablet -CVG Consult Your PhysicianVita-Respa tablet -CVG Virt-Vite Plus tabletVituz oral solution -CVG Consult Your PhysicianVivelle-Dot transdermal patch -CVG estradiol tablet; estropipate tablet;

estradiol weekly transdermal patch; Menest tablet; Enjuvia tablet

Vol-Care Rx tablet CVG, +Tier (3/2) Consult Your PhysicianVoltaren topical gel -CVG lidocaine topical patch; lidocaine-

prilocaine topical creamVP-Vite Rx tablet +CVG Consult Your PhysicianWellbaby DHA-Vitamin D3 oral drops -CVG Consult Your Physician


Drug Name Formulary Status AlternativesXartemis XR tablet extended release, oral only -CVG hydrocodone-acetaminophen tablet;


Xopenex HFA aerosol inhaler -CVG Ventolin HFA aerosol inhalerXtampza ER capsule sprinkle +CVG, QL Consult Your PhysicianXydra EF capsule -CVG Consult Your PhysicianYuvafem vaginal tablet -CVG Estrace vaginal creamZamicet oral solution -CVG hydrocodone-acetaminophen tablet;


Zetia tablet -CVG ezetimibe tabletZiana topical gel -CVG Onexton topical gel; Acanya topical

gel with pump; sulfacetamide sodium (acne) lotion (suspension); clindamycin-benzoyl peroxide topical gel;

zileuton ER tablet,extended release 12hr mphase -CVG Consult Your Physicianzolpidem ER tablet,extended release,multiphase CVG, +Tier (3/2),

ST, QLConsult Your Physician

zolpidem sublingual tablet -CVG zaleplon capsule; zolpidem tablet; eszopiclone tablet; temazepam capsule; triazolam tablet

Zolpimist oral spray -CVG zaleplon capsule; zolpidem tablet; eszopiclone tablet; temazepam capsule; triazolam tablet

Zorvolex capsule -CVG meloxicam tablet; naproxen tablet; ibuprofen tablet; diclofenac potassium tablet; nabumetone tablet

Zubsolv sublingual tablet +CVG, +PA, QL buprenorphine HCl sublingual tabletZubsolv sublingual tablet +CVG, +PA, QL Consult Your PhysicianZyflo CR tablet,extended release -CVG montelukast tablet; zafirlukast tabletZyflo tablet -CVG montelukast tablet; zafirlukast tabletZytaze capsule -CVG Consult Your Physician


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.


Discrimination is Against the Law

Humana Inc. and its subsidiaries (“Humana”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Humana does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Humana provides:• Free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation,

and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate.

• Free language services to people whose primary language is not English when those services are necessary to provide meaningful access, such as translated documents or oral interpretation.

If you need these services, call the number on your ID card or send an email to [email protected], or if you use a TTY, call 711.

If you believe that Humana has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Discrimination GrievancesP.O. Box 14618Lexington, KY 40512 - 4618

If you need help filing a grievance, call the number on your ID card, or if you use a TTY, call 711.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 202011-800–368–1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

http://[email protected]

http://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html


Multi-Language Interpreter ServicesEnglish: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call the number on your ID card (TTY: 711).

Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación (TTY: 711).

繁體中文 (Chinese): 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電會員卡上的電話號碼（TTY： 711）。Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số điện thoại ghi trên thẻ ID của quý vị (TTY: 711).

한국어 (Korean): 주의 : 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 . ID 카드에 적혀 있는 번호로 전화해 주십시오 (TTY: 711).

Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tawagan ang numero na nasa iyong ID card (TTY: 711).

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Наберите номер, указанный на вашей карточке-удостоверении (телетайп: 711).

Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele nimewo ki sou kat idantite manm ou (TTY: 711).

Français (French): ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le numéro figurant sur votre carte de membre (ATS : 711).

Polski (Polish): UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Proszę zadzwonić pod numer podany na karcie identyfikacyjnej (TTY: 711).

Português (Portuguese): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para o número presente em seu cartão de identificação (TTY: 711).

Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero che appare sulla tessera identificativa (TTY: 711).

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Wählen Sie die Nummer, die sich auf Ihrer Versicherungskarte befindet (TTY: 711).

日本語 (Japanese): 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。お手持ちの ID カードに記載されている電話番号までご連絡ください (TTY：711)。

:(Farsi) فارسی توجه: اگر به زبان فارسی گفتگو می کنید، تسهیالت زبانی بصورت رایگان برای شما فراھم می باشد.

.(TTY: 711) با شماره تلفن روی کارت شناسایی تان تماس بگیرید

:(Arabic) العربيةملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم الهاتف

الموجود على بطاقة الهوية الخاصة بك )رقم هاتف الصم والبكم: 711).

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