Guide
Enrollment
›
Large Provider Network
Coventry Health Care (“Coventry”) has an extensive network of physicians, hospitals and health care
providers. Coventry’s high-quality, cost-effective provider network has thousands of physicians and hundreds of hospitals available. Go online to www.chckansas.com and use our Provider Search tool to find out more.
Premier Customer Service
Coventry’s customer service and claims paying is among the strongest in the nation. Our team of extensively trained customer service representatives delivers courteous service, accurate claims payment, as well as efficient claims turnaround for physicians, hospitals and members. Members can also use secure, password-protected tools on our website, www.chckansas.com, to order ID cards, change personal information, view the status of claims and much more.
Proactive Health Management
The Coventry medical management and case management teams work to improve the health and well-being of those with chronic conditions and severe health issues through education and partnership with physicians. Special programs exist to address the needs of members with congestive heart failure, diabetes and end-stage renal disease.
Value-Added Programs
Coventry partners with vendors to offer special programs to our members. For example:
• Coventry WellBeingSM offers a full suite of interactive web-based resources for self-care and wellness. From
personalized exercise programs and online coaching to educational libraries for children, members are sure to find valuable information to enhance their lives.
• GlobalFit™ Fitness offers substantial discounts on memberships to a broad range of fitness clubs, making
it easier than ever to stay on your exercise program — or start a new one.
• EyeMed Vision Care® provides discounts on glasses, contact lenses and eye examinations obtained
through participating optometrists.
• QualSight® offers discounts on LASIK vision correction procedures.
Make the Most of Your Health and Benefits
Use Online Tools ...3
Find a Provider Online ...4
Make the Most of Your Health
Take Advantage of Health Management Programs Coventry WellBeingSM Program ...5Make the Most of Your Prescription Benefits
Understanding the Program Brand-name and Generic Drugs ...9About Your Formulary ...9
Prescription Benefit Plan Example ...9
Member/Physician Drug Formulary List ...11
Important Member Notices
...20Table of Contents
How to Contact Us
Once you have registered for My Online ServicesSM, you can send us a secure e-mail by going
to our website, www.chckansas.com.
Customer Service —
800-969-3343
Pharmacy Help Desk —
800-378-7040
Behavioral Health and Substance Abuse Services
—
866-607-5970
My Online ServicesSM is the password-protected member section of the Coventry Health Care website. This
section of the website puts you in control of your health benefits and makes it easier for you to find, use and control personal health and benefits information.
Access everything you need from a single screen. Take a look at these features:
Personal Health Record (PHR)
• View, store, track and maintain personal health information
• Print and share with your health care provider, family member or caregiver
Member Transactions
• View medical/prescription claims • View Explanation of Benefits (EOBs) • View/order member ID card
• Secure messaging
Member Health Care
• Health Risk Assessment • Calendars and reminders • Coventry WellBeing — online
wellness programs
• Disease management information
Cost-saving Tools
• Provider search • Provider cost • Procedure cost • Pharmacy tools
Please note: Your personal health
information is private. That is why you, personally, should register for My Online Services. A supervisor, colleague or human resources contact should not register on your behalf and have access to your personal health information.
Make the Most of Your Health and Benefits
Use Online Tools
To register for My Online Services visit
www.chckansas.com
. Select "Log In
or Register Now" under "My Online Services"
and follow the steps given to register.
Use Online Tools Make the Most of Your Health and Benefits
Find a Provider Online
Need to find a provider? Our online provider search gives you flexibility in a simple format. We update the online search weekly. No login is necessary. Just click on the “Locate a Provider” link on the opening page of our website at www.chckansas.com. Make sure you choose the search tool that applies to the
plan your employer offers: HMO or POS, PPO or an out-of-area plan using the Coventry Health Care National Network.
• User-friendly design — makes it easier for you to input search criteria and view results.
• Interactive map and driving directions — based on search criteria, this feature populates a map and
allows you to enter a starting address to obtain directions.
• Condition-based search — allows you to search based on a condition such as diabetes or asthma and find
a provider that specializes in treating the condition.
• Additional search criteria — allows you to search for languages spoken, gender or hospital affiliation. • Save search criteria — allows you to rename, view or delete previous searches.
Personalize Your Results
• Create a personal provider directory based on search criteria you enter. Click on the “Create a Directory” icon that displays at the top of the screen when your provider search is complete.
• Search by county and receive a report by e-mail of all providers in that county. • Search for doctors by location, name or specialty.
• Create a short list of physicians and perform side-by-side comparisons.
Our Net Support Team is available weekdays from 7:00 a.m. until 5:00 p.m., CST if
you need helpful guidance or have forgotten or misplaced your login or password.
Call 866-213-0807.
Helping you maintain and improve your health is a key goal of Coventry Health Care. We know that no two members will have the same health care needs so we offer a wide range of services.
If you are generally healthy, our focus is on preventive care and maintaining your health. We encourage you to visit a PCP for routine and preventive care. This care can help identify medical problems before they become serious or life-threatening. Also, it may prevent future problems.
Coventry WellBeing
SMProgram
Our self-care and wellness program, Coventry WellBeing*, can help you make meaningful lifestyle changes to your diet, fitness level and emotional well-being. Coventry WellBeing makes wellness fun by providing rewards for participation.
Take a Health Risk Assessment
Many diseases can be minimized by taking steps toward a healthier lifestyle. The first step is to know how healthy you truly are. That is the starting point for long-lasting healthy behaviors.
To help you, we offer a Health Risk Assessment (HRA) through our Coventry WellBeing program. The HRA is available to each enrolled family member age 18 or older.
When you take the HRA, you will be asked questions about your personal and family medical history. You will also be asked questions about your lifestyle choices. After you complete the HRA, you will receive an immediate confidential report. The report defines your potential risk factors and offers preventive steps that can be taken to improve your quality of life. You can take the HRA every six months.
Online Health Management
Once you have identified your top risks and discussed your health status with your doctor, you may be ready for any of a variety of personal health improvement initiatives we provide. Our online health and wellness program promotes physical fitness, healthy eating habits and life balance for people of all ages. You can create highly personalized plans to help achieve goals in the areas of fitness, nutrition and life skills. Online program tracking and coaching services provide you with ongoing support and motivation to reach your wellness goals. With Online Health Management, Coventry Health Care members enjoy personalized access to:
• Customized cardiovascular, strength and flexibility plans built for each member.
• Personalized nutrition plans and meal planner providing menus and shopping lists, and calorie and food servings tracker.
• Personal self-improvement programs focusing on community and core values, life-skills management and life challenges assessments.
Because the Health Risk Assessment and Online Health Management are offered exclusively for our members, you must log in to My Online Services and click on “Wellness Tools” to take advantage of these features.
Make the Most of Your Health
Take Advantage of Health Management Programs
*From time to time, Coventry Health Care may offer to provide members access to discounts on health care-related goods or services such as those offered through WellBeing. These services are being offered by a third-party vendor and Coventry Health Care is not liable for the provision of these services, the failure to provide services, or the negligent provision of these services. These services are subject to modification or discontinuance without notice.
Take Advantage of Health Management Programs Make the Most of Your Health
KidsHealth®
Keeping kids healthy and happy can be challenging, and that is why we teamed with KidsHealth. KidsHealth educates families and helps them make informed decisions about their children’s health. KidsHealth is a fun and engaging way to:
• Encourage preventive behaviors
• Encourage kids and teens to become involved in their health
KidsHealth consists of three sites in one: parents, kids, and teens. For parents, KidsHealth offers hot topics and news, recipes, a Q&A section and other information aimed at helping parents understand the health issues that may affect their children. Condition Centers provide information, tools and practical advice to help both newly diagnosed individuals and families with ongoing disease management issues. For children, KidsHealth provides engaging, interactive content such as peer stories and articles on staying healthy in a fun format for kids. Teens can choose from a wide array of emotional and developmental content.
Wellness Reminders
Coventry sends members reminders about important preventive services. Examples include flu shots, immunizations and mammography screening reminders.
First Help
TMCoventry offers a round-the-clock nurse call line that provides information to members seeking guidance on wellness or health-related issues. If FirstHelp is offered as part of your benefits, the telephone number appears on the member ID card.
First Help Audio Library
Members can call and listen to pre-recorded health and wellness information 24 hours a day.
GlobalFit™ Fitness
GlobalFit offers substantial discounts on memberships to a broad range of fitness clubs, making it easier than ever to stay on your exercise program — or start a new one.
EyeMed Vision Care®
EyeMed Vision Care provides discounts on glasses, contact lenses and eye examinations obtained through participating optometrists. Coventry Health Care members now have new options to save on eyewear through a materials discount program offered by EyeMed Vision Care.
Accessing Your Vision Care Discount
EyeMed makes it as easy as 1-2-3 to protect your vision.
1. Locate a provider by visiting www.eyemedvisioncare.com. On the homepage, you can select the
Locate a Provider feature and choose the SELECT network to view your providers. You can also locate providers and review your discount by clicking on the Members tab, Log-In/Register, then click on the letter "C". Once there you can choose your Coventry plan and then select the option to locate a provider.
2. Schedule an appointment with a simple phone call. Or stop by one of the many providers who offer
walk-in appointments. Inform the office that you are a Coventry Health Care member with an EyeMed discount plan when you wish to use your discount.
3. Present your Coventry Health Care ID Card when you arrive so the EyeMed provider knows you have a
Make the Most of Your Health Take Advantage of Health Management Programs
Vision Discounts
— Coventry also gives you access to discounts on vision services as shown below:Vision Care Services Member Cost
Exam with Dilation as Necessary $50
Complete pair of glasses purchase*: frame, lenses and lens options must be purchased in the same transaction to receive full discount.
Standard Plastic Lenses:
Single Vision $50
Bifocal $70
Trifocal $105
Frames:
Any frame available at provider location 40% off retail price
Lens Options:
UV Coating $15
Tint (Solid and Gradient) $15
Standard Scratch-Resistance $15
Standard Polycarbonate $40
Standard Progressive (Add-on to Bifocal) $65 Standard Anti-Reflective Coating $45
Other Add-ons and Services 20% discount
Contact Lens Materials:
(Discount applied to materials only)
Disposable 0% off retail price
Conventional (Non-disposable) 15% off retail price
Laser Vision Correction**:
LASIK or PRK 15% off retail price OR 5% off promotional price
Frequency:
Examination Unlimited
Frame Unlimited
Lenses Unlimited
Contact Lenses Unlimited
THIS IS NOT INSURANCE.
*Items purchased separately will be discounted 20% off of the retail price.
**Members also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US Laser Network, owned and operated by LCA vision. Since LASIK or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your location. For a location near you and the discount authorization, please call 1-877-5LASER6.
Member will receive a 20% discount on those items purchased at participating providers that are not specifically covered by this discount design. The 20% discount may not be combined with any other discounts or promotional offers, and the discount does not apply to EyeMed provider’s professional services or contact lenses. Retail prices may vary by location.
This Discount design is offered with the EyeMed Select panel of providers and is based on a 24-month contract term. Limitations/Exclusions:
• Orthoptic or vision training, subnormal vision aids and any associated supplemental testing • Medical and/or surgical treatment of the eye, eyes or supporting structures
• Corrective eyeware required by an employer as a condition of employment and safety eyeware unless specifically covered under plan • Services provided as a result of any Workers’ Compensation law
Take Advantage of Health Management Programs Make the Most of Your Health
Choice and Convenience
The EyeMed SELECT network offers you the choice of leading optical retailers including LensCrafters, Pearle Vision, Sears Optical, Target Optical, JCPenney Optical, as well as thousands of private practitioners, all near where you work and shop.
Preferred LASIK Pricing from QualSight®
QualSight offers a laser vision correction program that is easily accessible and affordable for the millions of Americans who could benefit from the LASIK procedure. QualSight’s mission is to provide affordable access to laser vision correction through a national network of credentialed, board-certified ophthalmologists. Savings are substantial — 40 to 50 percent off the overall national average price for LASIK.
To obtain preferred pricing, call 877-213-3937. A QualSight Care Manager will explain the benefit and answer any questions.
The QualSight program is not an insured benefit. The QualSight program is available to members to provide access to QualSight preferred pricing for LASIK surgery. Members are responsible for all costs associated with LASIK services.
Behavioral Health and Substance Abuse Benefits
Coventry provides mental health and substance abuse services through MHNet Behavioral Health. Coventry and MHNet work with you to address behavioral health issues and to improve your well-being.
MHNet provides confidential support and treatment through a network of licensed and certified professionals, covering a variety of specialties to address your emotional wellness needs.
Your behavioral health benefit provides you support for a wide range of concerns, such as: • Managing stress
• Depression • Eating disorders
• Coping with grief and loss • Alcohol or drug dependency • Anger management
If you have questions about your behavioral health and/or you would like to request services, please call 866-607-5970. This number is also on your member ID card. Experienced MHNet personnel are
available around the clock, and calls are kept confidential. You can also learn more about MHNet by visiting
www.MHNet.com.
You will be connected with an experienced Behavioral Health Specialist who will help you determine the type(s) of service you need. Based on your needs, the MHNet Specialist will refer you to a behavioral health provider. MHNet will provide all the information you need to schedule an appointment and ensure you receive the services you need to address your behavioral health concerns.
• Anxiety • Mental disorders • Physical abuse • Schizophrenia • Mood disorders • Compulsive gambling
Formulary, brand-name drug, generic drug. These can be confusing terms. The following information will help you get the maximum value from your prescription drug benefit.
Brand-name and Generic Drugs
The greatest difference between brand-name and generic drugs is the name. When a drug company develops a new drug, that drug must be approved by the U.S. Food and Drug Administration (FDA). Once approved, the company has the exclusive right to sell the drug and profit from the investment it made in research, testing and advertising. The exclusive selling time can last several years.
When that right runs out, other companies can make and sell the medicine. They can sell it under the generic name but not under the brand name. Since these companies don’t have to cover the same research and advertising costs, they can sell the medicine at a lower price.
To get the most value from your prescription drug benefit when your doctor is prescribing a medication for you, be sure to ask if a generic is available and appropriate.
About Your Formulary
A formulary is a list of preferred medications available through your pharmacy benefit. Medical Directors and pharmacists develop the list of preferred medications based on effectiveness, safety, cost and
recommendations from community doctors.
If you or your prescribing physician selects a medication that is not on the formulary, you may still purchase that prescription. However, you will share in a greater portion of the cost.
If you would like to know if a drug you are taking is on the formulary, you can find this information in this guide and online at www.chckansas.com. You can also contact your benefits office or call Customer Service at 800-969-3343.
Shown on the next page is an example of a prescription benefit plan. The example is for illustrative purposes only. Please consult your Pharmacy Rider for your exact copayments and benefits. Generic drugs are not available for every prescription, but when they are, you’re sure to save.
Make the Most of Your Prescription Benefits
Understanding the Program
Category of drug dispensed: Definition: Copayment as shown on the Pharmacy Rider you received with this packet:
Generic prescription If a formulary generic prescription isdispensed. You pay the lowest-tier copayment shown on the Pharmacy Rider. Formulary Brand-Name
prescription — no Generic available
If a formulary brand-name drug is dispensed and there is no generic
equivalent available.
You pay the middle-tier copayment shown on your Pharmacy Rider.
Any Nonformulary prescription Any nonformulary prescription drug is dispensed. You pay the nonformulary copayment shown on your Pharmacy Rider.
Brand-Name prescription— Generic available
If a formulary brand-name drug or a nonformulary brand-name drug is dispensed at the request of the member
or physician, and there is a generic
available.
You pay the brand-name copayment or the nonformulary copayment (whichever is applicable) shown on your Pharmacy Rider
plus the difference between the average wholesale price of the brand-name prescription drug and the allowed cost of the generic drug.
Understanding the Program Make the Most of Your Prescription Benefits
Mail Order
The prescription drug benefit may include a mail order drug program that allows you to obtain up to a ninety-three (93) day supply of certain drugs. It’s a convenient way to get the medications you need
delivered right to you. Check your benefit documents for copayment information and limitations. You can fill your mail order prescription by following these easy steps.
1. Ask your doctor to specifically write your prescription for a three-month supply (versus a one-month supply with refills). Be sure your doctor actually signs the prescription (versus using a signature stamp). 2. Complete a mail-order pharmacy form. You can get one online at www.chckansas.com or by calling
Customer Service.
3. Send the completed form, along with your written prescription for a three-month supply of the medication, to the address found on the form.
4. Please note that you will need to allow approximately two (2) weeks for delivery. If you need your prescription filled before that time, please consider using a retail pharmacy in the meantime.
5. Once you have your initial prescription filled through the mail-order service, refills may be ordered online, through the mail or by phone.
Please note: Not all drugs can be obtained through a mail order program. Contact our Customer Service
department for more information.
Important points to remember when accessing your pharmacy benefits
• You must use your ID card or have your membership information available to fill a prescription. You may only file a claim for reimbursement for a prescription after it was purchased if it is a true emergency. We may make an exception if you have not yet received your ID card but need to fill a prescription.
• If “PA” is listed on the formulary next to a drug, preauthorization is required. If preauthorization is not received, your prescription may not be covered.
• Retail prescriptions must be filled at a participating pharmacy or a non-participating pharmacy that has agreed to accept Medco’s reimbursement rate as payment in full. You pay the appropriate copayment or the cost of the medication if it is less than the copayment. You also have a retail maintenance benefit. Contact the Pharmacy Help Desk at 800-378-7040 for information regarding the retail maintenance benefit.
• If you take specific maintenance medications on a regular basis, you may be eligible to get your prescriptions filled through the mail-order program. The mail-order benefit allows up to a 90-day supply to be delivered directly to your home. Coventry Health Care does not cover certain controlled substances through the mail-order program. To find out about mail-order coverage, please call the Pharmacy Help Desk at 800-378-7040.
Member/Physician Reference
2011 Prescription Drug List
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed below are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
With our prescription drug plan, you have three options when a doctor gives you a prescription.
Generic (Tier One)- includes most generic and a few selected OTC (over-the-counter) drugs.
Formulary brand (Tier Two) - formulary brand-name drugs.
Nonformulary (Tier Three) - nonformulary brand-name, and a few nonformulary generic drugs.
These drugs may have a lower cost alternative on Tier One or Tier Two.
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
Tier One
A
Acarbose Acebutolol Acetazolamide Acetic acid ear drops Acetic acid-aluminum acetate
Acetohexamide Acetylcysteine
Acyclovir (not ointment) Alavert (Requires Doctor’s Prescription)
Alaway (Requires Doctor’s Prescription) Albuterol Albuterol/ipratropium Alclometasone Dipropionate Alendronate AIlopurinol AIprazolam, XR Altoprev Aluminum chloride Amantadine Amiloride Amiloride/HCTZ Aminocaproic acid Amiodarone Amitriptyline
Amlodipine (ODT not covered) Amlodipine/benazepril Amoxapine AmoxiciIIin Amoxicillin-potassium clavulanate Amphetamine/Dextroamphet (XR Tier Three, PA)
Ampicillin
Anagrelide
Anastrazole (PA, PAS) Anthralin APAP/Butalbital/Caffeine Apraclonidine Apri Aranelle Aspirin/butalbital/caffeine Aspirin/caff/butalbital/ codeine Atenolol Atenolol/chlorthalidone Atropine Aviane Azathioprine Azithromycin, XL B Baclofen Balsalazide Balziva Benazepril Benazepril HCTZ Benzonatate Benzoyl peroxide/ erythromycin Benztropine Betamethasone (cream/oint) Betaxolol (ophth) Bethanechol Bicalutamide Bisoprolol Fumarate Bisoprolol HCTZ Bromocriptine Brompheniramine- Pseudoephedrine Bumetanide Bupropion, SR, XL Buspirone C
Calcitonin nasal spray Calcitriol Camila Captopril Captopril/HCTZ Carbamazepine, XR Carbidopa/levodopa Carboptic Carisoprodol Carisoprodol/aspirin Carteolol soln. Carvedilol (CR non-form, ST) Cefaclor, CD Cefadroxil Cefdinir Cefprozil Cefuroxime Cephalexin Cesia
Cetirizine OTC (Requires Doctor’s Prescription) Cetirizine D OTC (Requires Doctor’s Prescription) Chloral hydrate Chlordiazepoxide (tab Tier Three) Chlordiazepoxide/clidinium Chloroquine Chlorothiazide Chlorphen/phenyleph/ methscop Chlorpromazine (spansule Tier Three) Chlorpropamide Chlorthalidone Cholestyramine Choline & magnesium Ciclopirox Cilostazol Cimetidine Ciprofloxacin soln. Ciprofloxacin (XR Tier Three) Citalopram Citrate/citric acid Clarithromycin, ER
Claritin OTC (Requires Doctor’s Prescription) Claritin D-24 OTC (Requires Doctor’s Prescription) Clemastine 2.68mg Clindamycin
Clobetasol (cream, oint) Clomipramine
Clonazepam
Clonidine (TTS Tier Three) Clorazepate (SD Tier Three)
Clotrimazole Troche Clozapine
Codeine
Colchicine Colestipol
Cromolyn sodium ophth Cryselle Cyclobenzaprine (Amrix not covered) Cyclopentolate Cyproheptadine D Dantrolene Desipramine Desmopressin acetate Desogestrel-Ethinyl Estradiol Desonide Desoximetasone Dexamethasone Dexchlorpheniramine Dextroamphetamine Diazepam
Diclofenac ophth soln Diclofenac potassium Diclofenac sodium, XR Dicloxacillin Dicyclomine Diethylstilbestrol Diflorasone diacetate Diflunisal Digoxin Diltiazem Diphenoxylate-atropine Dipivefrin Dipyridamole Disopyramide DisuIfiram
Divalproex Sodium (DR, ER) Dorzolamide Doxazosin mesylate (XL Tier Three) Doxepin Doxycycline (20mg, Adoxa, Doryx not covered) (Oracea -
Tier Three)
Doxycycline susp (syrup Tier Three) E Econazole cream/oint EnaIapriI Enalapril HCTZ Enoxaparin (PA,PAS) Enpresse Epinephrine HCI ErgocaIciferol Errin Erythromycin Erythromycin/Benzoyl Peroxide Estradiol Estropipate Ethosuximide Etodolac, XR F Famciclovir Famotidine Felodipine Fenofibrate Fenoprofen Fentanyl patch Finasteride Flavoxate Flecainide
Fluconazole (Susp PA)
Fludrocortisone acetate Flunisolide
Fluocinonide (topical) Fluoride/polyvitamins for children
Fluoride/vitamins A,D,C for children Fluorometholone FIuorouraciI Fluoxetine (20mg tablet Tier Three) Fluphenazine Flurazepam Flurbiprofen
Flurbiprofen sodium (ophth)
Flutamide
Fluticasone Propionate (nasal, cream, oint) (lotion Tier 3) Fluvoxamine Folic acid 1 mg Fosinopril Fosinopril/HCTZ Furosemide G Gabapentin Ganciclovir GemfibroziI Gentamicin (not IV) Glimepiride Glipizide, XL Glipizide/metformin Glyburide Griseofulvin Guaifenesin/codeine Guanabenz acetate Guanfacine H Halobetasol cream/oint Haloperidol HydraIazine Hydrochlorothiazide Hydrocodone/APAP Hydrocodone/homatropine Hydrocodone/ibuprofen Hydrocortisone Ace-Pramoxine Hydrocortisone tablets Hydromorphone HCI Hydroxychloroquine Hydroxyurea Hydroxyzine, pamoate Hyoscyamine I Ibuprofen
Imipramine (PM Tier Three) Indapamide
Indomethacin, SR (not suppos.)
Ipratropium (not inhaler) Isonarif Isoniazid Isosorbide dinitrate Isosorbide mononitrate Isotretinion (ST, STS) Itraconazole capsules (PA, PAS) J Jolivette Junel FE K Kariva Ketoconazole Ketoprofen, ER Ketorolac L Labetalol Lactulose
Lamotrigine (Starter Pack Tier 3, ODT (PA) Tier 3, XR (PA) tier 3) Leena Lessina Levetiracetam (XR Tier Three, PA) Levobunolol Levodopa/carbidopa Levora Levothyroxine Lidocaine viscous Lidocaine/HC Lidocaine-prilocaine Lindane lotion Liothyronine LisinopriI LisinopriI/HCTZ Lithium Loratadine D-24 OTC (Requires Doctor’s Prescription) Loratadine OTC (Requires Doctor’s Prescription) Lorazepam Lovastatin Low-Ogestrel Loxapine Lutera M Maprotiline Mebendazole (tablets, cream) (ER Tier Three)
Meclofenamate Medroxyprogesterone (tab, inj.) Megestrol acetate Meloxicam Meperidine Mercaptopurine Mesalamine enema Metaproterenol Metformin/Glyburide Metformin, XR Methadone Methazolamide Methenamine Methimazole Methocarbamol
Methotrexate (oral, inj)
Methyldopa Methyldopa/HCTZ Methylphenidate Methylprednisolone Metipranolol (ophth) Metoclopramide Metolazone Metoprolol, XL Metronidazole tablets, cream, lotion, gel 0.75% (ER Tier Three)
Mexiletine
Minocycline (tabs and Solodyn not covered) Minoxidil (not soln) Miralax* OTC (Requires Doctor’s Prescription) Mirtazapine (Sol Tab Tier Three) Misoprostol Moexipril Moexipril-hydrochlorothiazide MonaNessa Morphine IR MPH-A Mupirocin oint N Nabumetone Nadolol Naltrexone Naproxen Naproxen sodium Naratriptan Necon Neomycin Neomycin/bacitracin Nephazoline ophth Next Choice (Requires Doctor’s Prescription) Nifedipine XL Nimodipine Nisoldipine Nitrofurantoin Nitroglycerin, all forms Nizatidine Nor-BE Norethindrone acetate Norgestrel-ethinyl estradiol Nortrel Nortriptyline Nystatin O Ocella Ofloxacin Ogestrel
Omeprazole (See Prilosec OTC) Ondansetron, ODT
Oxaprozin Oxazepam
Oxcarbazepine
Oxybutynin (XL Tier Three) Oxycodone IR (SR Tier Three, PA, PAS)
P
Paromomycin
Paroxetine (CR Tier Three, ST) Penicillin VK Pentoxifylline Permethrin Perphenazine Phenazopyridine Phenobarbital Phenytoin
Phenytoin Sodium Extended Physostigmine sulfate Pilocarpine Pindolol Piroxicam Podofilox solution Polyethylene glycol 3350 Portia Potassium chloride Potassium citrate (15mEq not covered) Pramoxine/HC Pravastatin Prazosin Prednisolone Prednisolone Acetate Prednisone Prenatal Vitamins (prescription forms only) (Prenate and Neevo brands Tier Three) Prevacid 24HR™ (Requires Doctor’s Prescription) Prilosec* Prilosec OTC 20mg (Requires Doctor’s Prescription) Primidone Probenecid Prochlorperazine Promethazine Propafenone HCI Propantheline Propoxyphene Propoxyphene HCI/APAP Propoxyphene napsylate/ APAP Propranolol, LA Propylthiouracil ProtriptylineT Q Quasense QuinapriI QuinapriI/HCTZ Quinidine R
Ramipril caps (tabs Tier Three) Ranitidine (Gel & efferdose Tier Three)
Rifampin
Riluzole
Rimantadine
Risperidone
Ropinirole (XL Tier Three, ST)
S
Salsalate
Selegiline (patch Tier Three) Selenium sulfide 2.5% Sertraline
Silver sulfadiazine
Simvastatin
Sodium fluoride (drops, tablets) Sodium polystyrene sulfonate Sotalol Spironolactone Spironolactone/HCTZ Sprintec SucraIfate Sulfacetamide Sulfacetamide/phenylephrine Sulfacetamide prednisolone Sulfacetamide/sulfur Sulfamethoxazole/ trimethoprim Sulfasalazine, EC SuIfisoxazole Sulindac Sumatriptan T Tamoxifen citrate Tamsulosin Temazepam (7.5mg, 22.5mg Tier Three) Terazosin
Terbinafine (tabs only) (4rx/yr then PA required) Terbutaline sulfate Terconazole Testosterone inj Tetracycline Theophylline, XR Thioguanine Thioridazine Thiothixene Ticlopidine Timolol Timolol maleate
Tizanidine (caps not covered) Tobramycin
Tobramycin-Dexamethasone (Tobra-Dex ST Susp Tier Three) Tolazamide Tolbutamide Tolmetin Topiramate Torsemide Tramadol Tramadol-acetaminophen Trandolapril Tranylcypromine Trazodone Tretinoin (topical) Triamcinolone topical (cream, lot., oint.) Triamterene/HCTZ Triazolam Trifluoperazine Trifluridine Trihexyphenidyl Trimethobenzamide Trimethoprim Trimethoprim-polymyxinB Trinessa Tri-Previfem Tri-Sprintec Trivora U Ursodiol V Valacyclovir HCl Valproic acid Vancomycin inj. Velivet Venlafaxine IR (ST) Verapamil, SR (caps Tier Three) W Warfarin Z
Zaditor OTC (Requires Doctor’s Prescription) (Prescription Zaditor not covered) Zaleplon
Zolpidem (CR Tier Three, ST, STS)
Zonisamide Zovia
Zyrtec OTC (Requires Doctor’s Prescription) Zyrtec D OTC (Requires Doctor’s Prescription)
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed. A Accolate Actinex Actos (ST) Advair Aggrenox Aldara Alesse Anakit
Androgel (PA, PAS)
Antabuse Apriso
Aricept (23mg Tier Three) Aromasin (PA, PAS)
Asacol, HD Asmanex Astelin
Atrovent Inhaler, HFA Avelox Azathioprine Azelex Azopt B Bactroban Cream Benicar Benicar HCT Betimol Biltricide Blephamide Brevicon C Capex Shampoo Carbatrol Celontin Ciloxan oint. Ciprodex Combivent Comtan Concerta Cortifoam Coumadin Crestor Crestor 5mg (ST) Cuprimine Cyclessa Cytadren D Dapsone Daranide Daraprim Demulen Depen Derma-Smoothe/FS Desogen Diastat Dibenzyline Dilantin Dostinex Dritho-Scalp E Elmiron Emcyt Entocort EC Epipen, Jr Estrace Cream Estraderm Eurax Evista Evoxac Exelderm F Fareston
FastTake Test Strips Femara (PA, PAS) Flovent Diskus, HFA Fluoroplex
FML Forte Fosamax D Fragmin (PA, PAS)
G Grifulvin V tabs Gris-Peg H Hectorol Humalog Humulin (pens/cartridges - PA) I
Insulin, Only Lilly Brands (Humulin pens/cartridges PA, Humalog) Intal Inhaler lopidine 1% J Janumet (ST) Januvia (ST) Jenest K Kadian L Lanoxin Lantus
Lantus SoloStar (PA) Lessina
Leukeran
Levemir (pens/cartridges – PA)
Levlen Levlite Levothroid Lexapro (ST) Lidoderm
LifeScan Test Strips Lindane Shampoo Locoid
Loestrin (24 FE Tier Three) Lo/Ovral Lotronex Lumigan Lysodren M Maxalt, MLT Mephyton Mepron Methergine Micardis Micardis HCT MigranaI Mircette Modicon Mycobutin N Namenda Nardil Nasonex Nebupent Nexium Niaspan Nilandron Nitrolingual Translingual Spray Nitrostat SL Nordette Norinyl NuvaRing O
One Touch Test Strips One Touch Ultra Test Strips Onglyza (ST) Opana ER Ortho Cept Ortho Cyclen Ortho Micronor Ortho Novum Ortho Tri-Cyclen Ortho Tri-Cyclen LO Ovcon-50 Oxsoralen, Ultra P P1E1, P2E1 Phospholine Iodide Plan B (Requires Doctor’s Prescription) Plavix Poly-Pred PreCare Chewables PreCare Conceive PreCare Premier Pred G
Premarin tabs (Cream Tier Three) Premesis RX Premphase Prempro PrimaCare PrimaCare ONE Prometrium Prostigmin Psoriatec
Pulmicort Respules (PA, PAS >4yrs) Q Quixin QVAR R Ranexa Renvela Retin A Micro Ridaura S Sanctura, XR Seasonale Seasonique Sensipar Serevent Seroquel, XR Simcor Singulair (ST) Solia Soriatane Spiriva
Sporanox soln. (PA, PAS)
SSKI
SureStep Test Strips Symbicort Synarel T Tabloid Tazorac Theo-24 Tikosyn Travatan TravatanZ Trilipix Tri-Norinyl Trisoralen Twinject U Uroxatral V Vagifem Valcyte Ventolin HFA Vexol
Vfend (PA, PAS)
Vivelle-Dot Vytorin Vytorin 10/10mg (ST) X Y Yasmin Yaz Yodoxin Z Zemplar Zenpep
Zyvox (PA, PAS)
Not available as 90-day supply
* A generic equivalent is available.
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
Brand with
Generic
Equivalent
*The following brand name drugs have generics available at a Tier One copay. Depending on your plan, either a Tier Three copay or a Tier Two copay plus an ancillary charge will apply if the brand name drug is selected. Please refer to your certificate or evidence of coverage for your specific benefit.
A/T/S* Accuneb* Accupril* Accuretic* Aclovate* Actigall* Adalat CC*
Adderall* (XR (PA) Tier Three)
Adrenalin* Agrylin* Aldactazide* Aldactone * Aldomet*
Alphagan* (P Tier Three) Altace* capsules (tab Tier- Three)
Amaryl*
Ambien* (CR Tier Three, ST, STS) (ODT not covered)
Amerge* Amicar* Amoxil * Anafranil * Analpram HC* Anaprox*, DS* Anaspaz* Android * Ansaid* Antipyrine/Benzocaine Otic Anusol-HC* Apresoline* Aralen* Arava*
Arimidex* (PA, PAS)
Artane* Atarax* Ativan* Atrovent Soln* Augmentin ES* Augmentin ES*, XR* Axid* Aygestin* Azulfidine*, EN* Bacitracin ophthalmic* Bactrim*, DS* Bactroban Oint.* Bentyl* Benzamycin* Betagan* Betapace*, AF* Betoptic* Biaxin*, XL* Bicitra* BIeph10* Brethine* Bromfed*, PD*, DM* Bumex * Buspar* Cafergot* Calan*, SR* CaIciferol *
Calcitonin Nasal Spray
Capoten * Capozide* Carafate*
Cardizem*, SR*, CD* Cardura* (XL Tier Three) Cartia XT*
Casodex* Cataflam*
Catapres* (TTS Tier Three) Ceclor*, CD* Ceftin* Cefzil* Celexa* Cheracol* Ciloxan Soln*
Cipro* (XR Tier Three)
Cleocin*, T*, Vag* Climara * Clinoril* Clozaril* Cogentin* Colazal* Colestid* Colyte* Compazine* Condylox Gel*, Soln* Cordarone*
Coreg* (CR Tier Three, ST) Corgard *
Cortef* Cortisporin* Crolom *
Cutivate* cream, oint (lotion Tier 3) Cyclogyl* Cycrin* Cylessa* Cystospaz* Cytomel* Cytotec* Cytovene* Dalmane* Danazol* Dantrium* Darvocet N100* Darvocet N50* Darvon * Daypro* DDAVP* Decadron* Demadex* Demerol* Depakene* Depakote*, ER* Desowen* Desyrel* Dexedrine* DextroStat* Diabeta* Diabinese* Diamox* Diflucan* Dilacor XR* Dilaudid* (oral soln Tier Three)
Diprolene*, AF* Diprosone* Disalcid*
Ditropan* (XL* Tier Three) Diuril*
Dolobid* Dolophine*
Domeboro Otic*
Donnatal (caps Tier Three)* Dovonex* Drysol* Duoneb* Duragesic* Duricef* Dyazide* Dynacin* capsules (tabs not covered)
EC-Naprosyn* EES* Effexor*, XR* (ST) Efudex* EIaviI* Eldepryl* Elimite* Elocon* Emla* Eryc* Ery-Tab* Erythrocin* Estrace tabs* Estrostep FE* Famvir* Feldene* Fioricet * Fiorinal w/Codeine* Fiorinal*
Flagyl* (ER Tier Three)
Flexeril* Flomax* Flonase* Flumadine* FML* Fosamax* Furadantin* Garamycin* Genoptic* Glucophage*, XR* Glucotrol*, XL* Glucovance* Glynase* Golytely* Grifulvin V susp* Guiatuss AC* Halcion* Haldol * Heparin* Humatin* Hydrea* Hytrin* Imdur* Imitrex* Imuran* Inderal*, LA* Indocin, SR* (suppositories Tier Three) Intal Neb* Iopidine* ISMO* Isoptin* Isopto Atropine* Isopto Carbachol* Isopto Carpine* Isordil* Karidium * Kayexalate* K-Dur* Keflex* Kenalog*
Keppra* (XR Tier Three, PA) Klaron* Klonopin* K-Lor* Klorvess* K-Lyte* K-Phos Neutral* Kristalose* KweIl*
Lamictal* (Starter Pack Tier 3, ODT (PA) Tier 3, XR (PA) tier 3) Lamisil* (tabs only) (4rx/yr then PA, PAS required)
Lasix* Levoxyl *
Levsin* (SL Tier Three) Levsinex* Librax* Librium* Lidex* Lioresal* Locoid* Lodine*, XL* Lofibra* Lomotil* Loniten* Lopid * Lopressor* Lopressor HCT* Lortab* Lotensin HCT* Lotensin* Lotrel*
Lotrisone Cream*, Lotion* Lovenox* (PA, PAS) Loxitane*
Lozol * Ludiomil* Luride*
Luvox* (CR Tier Three, ST) Macrobid * Macrodantin * Mandelamine* Mavik* Maxitrol * Maxzide* Meclomen* Medrol * Megace* MelIariI * Menest* Mestinon* Metadate ER* Metaglip* Metimyd* MetroCream* MetroLotion* Mevacor* Mexitil*
Miacalcin nasal spray* Microgestin*, FE* Micronase* Microzide* Midodrine* Midamor* Midrin* Minipress*
Minocin* (tabs not covered) MiraIax* Mobic* Monodox* (75mg not covered) Motrin* MS Contin* MSIR* Myambutol * Mycelex Troche* Mycostatin* Mysoline* NaIfon* Naprosyn* (Naprelan Tier Three) Navane* Neosporin ophthalmic* Neurontin* Nimotop* Nitrobid * NitroDur* NizoraI * Nolvadex* Norpace*, CR* Norpramin * Norvasc* (ODT not covered) Nulytely* Ocufen* Ocuflox* Ocupress* Omnicef* Optipranolol* Orasone* Orinase* Ortho Est* Ovcon-35* OxyIR* Pamelor* Parlodel * Parnate*
Paxil* (CR Tier Three, ST)
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor. * A generic equivalent is available.
π Brand-name medications and the generic equivalent are covered at a higher member cost.
Not available as 90-day supply
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
PEG - electrolyte soln*
Penlac*
Pepcid* (RPD Tier Three) Percocet * Percodan* Persantine* Phenergan Codeine, DM, VC, & VC/Codeine* Phenergan* Phenytek* Phoslo* Plan B 0.75mg* Plaquenil* PIetaI* Polyhistine CS, D, DM* Polytrim * PoIy-Vi-FIor* Potassium Citrate/Citric Acid* Pravachol* Precose* Pred Forte* Pred Mild*
Prednisolone, Acetate, Sod Phos* Prelone* Prevalite* Primaquine* Principen* Prinivil* Prinzide* Proamatine* Procardia XL* Proctocort* Proctocream-HC* Proctofoam-HC* Proscar*
Proventil* (Not HFA) Provera*
Prozac (20mg non-form) (weekly Tier Three,ST) Purinethol*
Pyrazinamide*
Pyridium* Questran, Light* RegIan*
Remeron* (sol Tab Tier Three)
Requip*, (XL Tier Three, ST) Restoril* (7.5 & 22.5mg Tier Three) Retin A* Revia* Rifadin* Rifamate* Rilutek*
Risperdal* (M-Tab Tier Three) Ritalin*, SR*
RMS suppositories*
Robaxin*
Robitussin AC*, DAC*
Rocaltrol*
Rondec, DM*
Rowasa Enema* Rynatan*
Rythmol* (SR Tier Three) Salagen* Seasonale* Sectral* Septra*, DS* Silvadene* Sinemet*, CR* Soma Compound*
Soma* (250mg not covered) Sonata*
Spectazole*
Sporanox capsules* (PA, PAS)
Sulamyd* Sular* Synthroid* Tagamet* Tambocor* Tapazole* Tegretol*, XR* Temovate* Tenex* Tenoretic* Tenormin* Terazol* TessaIon Perles* Tiazac* Ticlid* Tigan* Timoptic*, XE* Tobradex (Tobra-Dex ST Susp Tier Three) Tobrex*
Tofranil* (PM Tier Three) Topamax*
Topicort* Toprol XL* Trandate*
Tranxene* (SD, T Tier Three)
Trental* Trileptal* Trimethobenazmide Trimethoprim Trusopt* Tylenol 2, 3, 4* Tylox* Ultracet*
Ultram* (ER, ST Tier Three) Ultravate* cream/oint Uniphyl*
Uniretic* Univasc* Urecholine*
Urocit K* (15 mEq not covered) Valium* Valtrex* Vancocin* inj. Vaseretic* Vasotec* Verelan SR* Vibramycin*
Vibramycin Susp* (syrup Tier Three) Vicodin*, ES* Vicoprofen* Viroptic* Vistaril* Vivactil* Voltaren, XR* Voltaren Ophthalmic* Vosol*, HC* Wellbutrin*, SR*, XL* Westcort* Wigraine* Xanax*, XR* Xylocaine* Zaditor*
Zanaflex (caps not covered) Zantac* (efferdose not covered) Zarontin* Zaroxolyn* Zebeta* Ziac* Zithromax* Zocor* Zofran* Zoloft* Zonegran*
Zovirax* (oint. Tier Three) Zyloprim*
A
Abilify (ST) Clozaril* , Risperdal*,
Seroquel, Seroquel XR
Accu-chek brand
test strips (PA, PAS) One Touch Test Strips
Accutane* (ST, STS) Doxycycline, Minocycline
Aceonπ Zestril*, Prinivil*, Lotensin*,
Accupril*
Aciphex (PA) Prilosec OTC™ (requires doctor’s prescription), omeprazole*, Prevacid 24HR™ (requires doctor’s prescription), Nexium
Actiq (PA, PAS) Oxy IR* , MSIR* , Dilaudid* (oral soln tier 3)
Activellaπ Prempro, Premphase
Actonel Fosamax* ACTOplusmet (ST) Actos (ST) Amaryl*
Acular Ocufen*, Voltaren Ophthalmic*
Adderall XR Adderall* , Ritalin* , (PA > 17yrs) Ritalin SR* , Metadate (generic not covered) ER* , Concerta
Advicor Zocor*, Simcor
Aerobid Flovent, QVAR, Asmanex
Alamast Zaditor OTC (covered with a prescription for tier 1 copay), Alaway*
Allegraπ , ODT(ST) Claritin OTC* or Zyrtec OTC*
(covered with a prescription for a tier 1 copay)
Allegra Dπ Claritin D OTC* or Zyrtec D
OTC* (covered with a prescription for a tier 1 copay)
Alocril Zaditor OTC (covered with a prescription for tier 1 copay), Alaway*, Crolom*
Alomide Zaditor OTC (covered with a prescription for tier 1 copay), Alaway*, Crolom*
Aloxi Zofran*
Alphagan-P Alphagan*
Ambien CR (PA, PAS) Ambien* , Ativan* , Halcion* , oxazepam* , Restoril* , Sonata*
Amitiza (ST, STS) Miralax OTC*, Chronulac*, Colyte*
Androderm (PA, PAS) Androgel (PA, PAS)
(not covered)
Anzemet Compazine*, Phenergan*, Tigan*, Zofran*
Apidra Humalog
Arixtra (PA, PAS) Lovenox* (PA, PAS)
Fragmin (PA, PAS), Arthrotec Voltaren* plus Cytotec*
Ascensia Brand
Test Strips (PA, PAS) One Touch Test Strips Atacand (PA, PAS) Benicar, Micardis
Atacand HCT (PA, PAS) Benicar HCT, Micardis HCT Auralgan A/B Otic Soln
Avalide (PA, PAS) Benicar HCT, Micardis HCT
Avandamet (PA) Actos (ST) plus Glucophage*
Avandaryl (PA) Actos (ST)
Avandia (PA) Actos (ST)
Avapro (PA, PAS) Benicar, Micardis
Avita Gel Retin A*, Retin A Micro
Avodart Proscar*, Uroxatral
Axert Imitrex*, Maxalt, Amerge*
Azmacort QVAR, Asmanex, Flovent Azor (PA, PAS) Norvasc* plus Benicar,
Norvasc* plus Micardis
B
Beclovent Flovent, QVAR, Asmanex
Beconase (ST,STS) Flonase*, Nasalide*,
Nasonex
Benzaclinπ OTC Benzoyl Peroxide plus
Topical Clindamycin*
Betoptic S Betoptic*, Timoptic*,
Timoptic XE*, Betagan*
Boniva Fosamax*
Brovana (PA) Spiriva, Advair, Symbicort,
Serevent
Byetta (PA, PAS) Amaryl*, Glucophage*,
Actos (ST)
Bystolic Inderal LA*, Toprol XL*, Lopressor*, Coreg*
C
Caduet (not covered) Norvasc* plus Zocor* Cardizem LAπ Cardizem CD*
Catapres TTSπ Catapres*, Aldomet*,
Hytrin*, Minipress*,
Tier Three
Alternative Tier One
or Tier Two Drugs
Caverject (ST) no alternative available Celebrex (ST) Motrin*, Naprosyn*,
Mobic*, Voltaren*, Clinoril*, Disalcid*, Relafen*
Cenestin Premarin, Ogen*
Cialis (2.5mg not covered) no alternative available
Clarinex (ST) Claritin* OTC or Zyrtec*
OTC are covered with a Doctor’s prescription
Clarinex D (ST) Claritin D* OTC or Zyrtec
D* OTC are covered with a Doctor’s prescription
Colcrys (PA, PAS) colchicine*
Coreg CR (ST) Coreg*
Cosoptπ Timoptic* plus Azopt
Cozaarπ Benicar, Micardis
Creon Zenpep, Ultrase
Cymbalta (PA, PAS) Celexa*, Prozac*, Zoloft*,
Paxil*, Effexor* (ST), Effexor XR* (ST)
D
Daytrana Adderall*, Ritalin*, (PA, PAS > 17yrs) Ritalin SR* , Metadate ER*
, Concerta
Detrol/Detrol LA (ST) Ditropan*, Sanctura,
Sanctura XR
Dexilant (PA) Prilosec OTC™ (requires
doctor’s prescription), omeprazole*, Prevacid 24HR™ (requires doctor’s prescription), Nexium
D.H.E. 45 Amerge* , Migranal, Imitrex*, Maxalt
Differin Retin-A*
Diovan (PA, PAS) Benicar, Micardis
Diovan HCT (PA, PAS) Benicar HCT, Micardis HCT Dipentum Azulfidine*, Asacol
Ditropan XLπ Ditropan*, Sanctura,
Sanctura XR
Duac OTC Benzoyl Peroxide plus Topical Clindamycin*
Duetact (ST) Actos (ST) plus Amaryl*
Dynacirc CR Norvasc*
E
Edex (ST) no alternative available Effient Plavix
Elidel (PA) Kenalog*, Diprosone*, Topicort*, Locoid*,
Wescort*, Elocon*
Embeda (PA, PAS) Dolophine* , MS Contin*, Kadian*, Duragesic*, Opana ER*
Emsam (PA) Celexa*, Prozac*, Zoloft*,
Paxil*
Enablex (ST) Ditropan*, Sanctura,
Sanctura XR
Exelon Aricept, Namenda
Exforge (PA, PAS) Norvasc* plus Benicar,
Norvasc* plus Micardis
F
Fanapt (PA) Risperdal*, Seroquel, Seroquel XR
Femcon Desogen*, Necon*, Nordette*, Norinyl*, Ortho Cept*, Ortho Cyclen*, Ortho Novum*, Yasmin*, Yaz
FemHRT Prempro, Premphase
FemPatch Estraderm*, Vivelle
Fenoglide Lofibra*, Trilipix
Fentora (PA, PAS) Morphine oral sol, OxylR*
Focalin Adderall*, Ritalin*, Concerta
Focalin XR (PA > 17yrs) Adderall* , Ritalin*, Ritalin SR*, Metadate ER*
, Concerta
Foradil Serevent
Frova Amerge* , Imitrex*, Maxalt
G
Gabitril Nuerontin*, Keppra*,
Lamictal*, Trileptal*, Tegretol*, Tegretol XR*, Topamax*, Depakene*, Depakote*, Depakote ER*
Geodon (PA) Risperdal*, Seroquel,
Seroquel XR
H
HalfLyte CoLyte*
HyperRho no alternative available
Hyzaarπ Benicar HCT, Micardis HCT
I
Innohep (PA, PAS) Lovenox* (PA, PAS),
Fragmin (PA, PAS) Innopran XL Inderal LA*, Toprol XL*,
Lopressor*, Coreg*
Insulins Lilly Brand Insulins
Novo Brand
Intuniv Ritalin*, Adderall*, Concerta
Invega (PA) Risperdal*, Seroquel, Seroquel XR
Iprivask (PA required Lovenox* (PA, PAS), for > than 20 doses) Fragmin (PA, PAS)
J K
Keppra XR (PA) Keppra*, Neurontin*, Lamictal*, Trileptal*, Tegretol*, Tegretol XR*, Topamax*, Depakene*, Depakote*, Depakote ER*
Ketek First Line Generic Antibiotics
Kytril Zofran* L
Lamictal ODT (PA), XR Lamictal*, Neurontin*, (PA), Starter Pack Keppra*, Trileptal*,
Tegretol*, Tegretol XR*, Topamax*, Depakene*, Depakote*, Depakote ER*
Lamisil Granules (PA) Lamisil* tab Lescol, XL (ST) Zocor*, Pravachol*,
Mevacor*
Levaquin Cipro*, Avelox
Levitra no alternative available
Lialda (ST) Colazal*, Apriso, Asacol, Asacol HD
Lipitor 10mg, 20mg (ST) Zocor*, Pravachol* Lipitor 40mg, 80mg (ST) Crestor (5mg ST), Vytorin
(10/10mg ST)
Loestrin 24 FE Yaz, Several other oral
contraceptives are available on the Formulary
Loproxπ Nizoral* or Nystatin*
Lotemax Pred Forte*, Decadron*, FML Liquifilm*
Lovaza (PA) Lofibra*, Tilipix, Niaspan
Lunesta (ST, STS) Halcion* , oxazepam , Restoril* , Sonata*
Luvox CR (ST) Luvox*, Celexa*, Prozac*,
Paxil*, Zoloft*, Lexapro (ST)
Lyrica (PA, PAS) Neurontin*, Keppra*, Lamictal*, Trileptal*, Tegretol*, Tegretol XR*, Topamax*, Depakene*, Depakote*, Depakote ER*
M
Marinol (PA, PAS) Requires Prior Auth
Maxair Ventolin HFA
Metadate CD Adderall*, Ritalin*,
(PA > 17yrs) Ritalin SR*, Metadate ER*
, Concerta
Metrogel 1% (ST) Metronidazole 0.75% Gel
Miacalcin Injection (PA) Miacalcin Nasal Spray* Mirapex Requip*
Multaq Cordarone*
N
Naprelanπ Motrin*, Naprosyn*,
Voltaren*, Clinoril*, Disalcid*, Relafen*, Mobic*
Nasacort (ST, STS) Flonase*, Nasalide*,
Nasonex
Neevo Multiple prenatal vitamins on formulary Tier 1
Neevo DHA Multiple prenatal vitamins on formulary Tier 1
Niravam (ST) Xanax*
Noroxin Cipro*, Avelox
Norgesic/Norflex Flexeril*, Lioresal*, Robaxin*, Soma* (250mg not covered)
Novo Brand
Insulins Lilly Brand Insulins
Noxafil (PA, PAS) Requires Prior Auth
Nucynta (PA, PAS) MSIR*, Oxycodone IR*
Nuvigil (PA, PAS) Ritalin* , Dexedrine* , Adderall*
O
Omnaris (ST, STS) Flonase*, Nasalide*, Nasonex
Opana IR (PA, PAS) MSIR* , Oxycodone IR*
Ortho Evra Several oral contraceptives
are available on the Formulary
Oxistat Nizoral* or Nystatin*
Oxycontin (PA, PAS) MS Contin*, Duragesic*, Kadian, Opana ER
Oxytrol (ST) Ditropan*, Sanctura,
Sanctura XR
P
Pancreaze Zenpep, Ultrase Parafon Forte Flexeril*, Lioresal*, DSCπ Robaxin*, Soma* (250 mg
not covered)
Pataday Alaway*, Zaditor OTC
(covered with a prescription for tier 1 copay)
Patanol Alaway*, Zaditor OTC (covered with a prescription for tier 1 copay)
Paxil CRπ (ST) Celexa*, Prozac*, Zoloft*,
Paxil*
Pentasa Asacol
Perforomist (PA) Spiriva, Advair, Symbicort,
Serevent
Prandin Diabeta*, Glucotrol*, Amaryl*
Prefest Prempro, Premphase
Not available as 90-day supply
The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor. * A generic equivalent is available.
Premarin Vag Cream Estrace Vag Crm, Vagifem
Prenate DHA Multiple prenatal vitamins on formulary Tier 1
Prenate Elite Multiple prenatal vitamins on formulary Tier 1
Prevacid (Solutab Prilosec OTC™ (covered not covered) with a prescription for tier
1 copay), omeprazole*, Prevacid24HR™ (covered with a prescription for tier 1 copay), Nexium
Prevpac Prilosec OTC™* 20mg plus amoxicillin and clarithromycin
Pristiq (ST) Effexor*(ST), Effexor XR (ST),
Celexa*, Prozac*, Paxil*, Zoloft*, Lexapro (ST), Luvox*
ProAir HFA Ventolin HFA
Procardia Capsulesπ Calan SR*, Cardizem CD*,
Adalat CC*, Procardia XL*
Protonixπ (PA) Prilosec OTC™ (covered
with a prescription for tier 1 copay), omeprazole*, Prevacid24HR™ (covered with a prescription for tier 1 copay), Nexium Protopic Hydorcortisone*, Betamethasone*, Triamcinolone*, Elocon*, Temovate*, Sinalar*, Topicort*
Proventil HFA Ventolin HFA
Provigil (PA, PAS) Ritalin* , Dexedrine*, Adderall*
Prozac Weekly (ST) Prozac Capsules*
Pulmicort Flexhaler/ Flovent, QVAR, Asmanex
Turbuhaler
Q
Qualaquin (PA, PAS) Aralen*, Lariam*, Plaquenil*, Primaquine*
R
Renagel Phoslo*, Renvela
Regranex (PA, PAS) Requires Prior Auth
Relistor (PA, PAS) Lactulose*, Miralax* OTC
(covered with a prescription for tier 1 copay)
Relpax Maxalt, Imitrex*
Remeron Soltabπ Remeron*, Celexa*,
Ludiomil*, Desyrel*
Razadyne Aricept, Namenda
Requip XL (ST) Requip*
Rescula Lumigan, Travatan
Restasis Various OTC artificial tears available
Restoril 7.5mg, 22mg Restoril* 15mg & 30mg, Ambien*, Halcion*
Rhinocort (ST, STS) Flonase*, Nasalide*, Nasonex
Rhogam no alternative available
Ritalin LA (PA > 17yrs) Adderall* , Ritalin*, Ritalin SR*, Metadate ER*
, Concerta
Rogaine Benefit exclusion
Rozerem (ST, STS) Ambien*, Sonata*
Ryzolt (ST) Ultram*
S
Saphris (ST) Clozaril* , Risperdal*, Seroquel, Seroquel XR
Sarafem (tabs not covered) π Prozac Capsules*
Serzoneπ Celexa*, Prozac*, Zoloft*,
Paxil*
Skelaxinπ Flexeril*, Lioresal*,
Robaxin*, Soma* (250 mg not covered)
Stadol NSπ Tylenol with Codeine*, Darvocet-N 100*, Ultram*
Starlixπ Diabeta*, Glucotrol*,
Amaryl*
Striant (PA, PAS) Androgel (PA, PAS)
Strattera Ritalin*, Adderall*, Concerta
Suboxone (PA, PAS) Requires Prior Auth
Subutex (PA, PAS) Requires Prior Auth
Symbyax (ST) Prozac* plus Risperdal*
Symlin (PA, PAS) Humulin, Humalog, Lantus,
Levemir
T
Tamiflu
Tarka Mavik* plus Calan SR*
Tasmar Comtan
Tekturna (PA, PAS) Benicar, Micardis
Tekturna HCT (PA, PAS) Benicar HCT, Micardis HCT Testim (not covered) Androgel (PA, PAS)
Teveten (PA, PAS) Benicar, Micardis
Teveten HCT (PA, PAS) Benicar HCT, Micardis HCT Tofranil PM Tofranil*
Toviaz Ditropan*, Sanctura, Sanctura XR
Tricor Lofibra*, Trilipix
Triglide Lofibra*, Trilipix Tussionex Robitussin AC
Twynsta (PA, PAS) Benicar plus amlodipine, Micardis plus amlodipine
U
Ulesfia Elimite*, Lindane* Uloric (ST) Zyloprim*
Ultram ER (ST) Ultram* V
Valturna (PA, PAS) Benicar, Micardis
Veramyst (ST, STS) Flonase*, Nasalide*, Nasonex
Verelan PM Calan*, SR*, Cardizem CD*,
Adalat CC*, Procardia XL*
Vesicare (ST) Ditropan*, Sanctura,
Sanctura XR
Viagra no alternative available
Victoza (PA, PAS) Amaryl*, Diabeta*,
Glucotrol*, Glynase*, Micronase*, Glucophage*
Vigamox Tobrex*, Gentamicin*, Ciloxan*, Ocuflox*
Vimpat Neurontin*, Keppra*,
Lamictal*, Trileptal*, Tegretol*, Tegretol XR*, Topamax*, Depakene*, Depakote*, Depakote ER*
Vyvanse (ST, STS) Adderall*, Ritalin*, Ritalin SR*, Metadate ER*
, Concerta W
Welchol Questran/Colestid*
WinRho X
Xalatan Lumigan, Travatan
Xifaxan (550mg PA, PAS) Lactulose
Xopenex, HFA Ventolin HFA, albuterol neb Xyzal (ST) Claritin OTC or Zyrtec OTC
(covered with a prescription for a tier 1 copay)
Z
Zantac Efferdose Zantac tab/cap*, Tagamet*, (not covered) Pepcid*
Zegerid (PA) Prilosec OTC™ (covered
with a prescription for a tier 1 copay), omeprazole*, Prevacid 24HR™ (covered with a prescription for a tier 1 copay), Nexium
Zelapar ODT (ST) Eldepryl*
ZMax Zithromax*
Zetia Zocor*, Pravachol*, Vytorin (10/10mg ST), Niaspan
Zomig Imitrex*, Maxalt
Zovirax Ointment Oral Zovirax*
Zybanπ Benefit exclusion
Zylet Tobradex*
Zymar Tobrex*, Gentamicin*, Ciloxan*, Ocuflox*
Zyprexa (ST) Risperdal*, Seroquel,
Seroquel XR
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor. * A generic equivalent is available.
π Brand-name medications and the generic equivalent are covered at a higher member cost.
Not available as 90-day supply
Specialty Medications
Specialty medications are typically high-cost drugs, including but not limited to the oral, topical, inhaled, inserted or implanted, and injected routes of administration used to treat rare and complex diseases (see list of Specialty medications listed below).
Specialty medications require prior authorization unless otherwise indicated. Your doctor should contact Coventry’s Pharmacy Call Center at 877-215-4100 to request prior authorization.
Except in urgent situations, all specialty medications are distributed through a participating specialty pharmacy. Specialty drugs are limited to a 30-day supply at a time or the quantity prescribed in the prescription order, whichever is less. Please call Customer Service at the number on your member ID card for a referral to a participating specialty pharmacy or with questions regarding your pharmacy benefit. Please refer to your health plan documents regarding coverage of and any limitations or exclusions that may apply to your specialty drug benefit.
* Generic is on the Formulary
i Some plans cover only one growth hormone product — Omnitrope. Under these plans, Nutropin, Nutropin AQ, Humatrope, Genotropin, Saizen, Tev-Tropin and comparable
Actimmune (PA, PAS) Adcirca (PA, PAS) Alkeran Apokyn (PA, PAS) Arcalyst (PA, PAS) Avonex (PA, PAS) Ceenu
Cellcept
Copaxone (PA, PAS) Copegus (PA, PAS) Crixivan
Cyclophosphamide Cyclosporine Emtriva
Enbrel (PA, PAS) Epivir
Epivir Hbv Etoposide Fuzeon (PA, PAS) Gleevec (PA, PAS) Hepsera Hexalen Humira (PA, PAS) Intelence Intron-A (PA, PAS) Invirase
Isentress (PA, PAS) Kaletra
Leukine (PA, PAS) Lexiva
Matulane Myleran Neoral
Neupogen (PA, PAS) Norvir
Octreotide (PA, PAS) Omnitropei (PA, PAS) Pegasys (PA, PAS) Prezista Procrit (PA, PAS) Prograf
Pulmozyme (PA, PAS) Rapamune
Rebetol (PA, PAS) Retrovir Reyataz
Ribavirin (PA, PAS) Sandimmune Sandostatin (PA, PAS) Sustiva
Tarceva (PA, PAS) Targretin (PA, PAS) Temodar (PA, PAS) Thalomid (PA, PAS) Tobi Neb (PA, PAS)
Tracleer (PA, PAS)
Tretinoin - Cancer (PA, PAS) Vesanoid Videx Videx Ec Viracept Viramune Viread Xeloda (PA, PAS) Xenazine (PA, PAS) Zerit
Ziagen
Formulary (Preferred)
Nonformulary
(Nonpreferred) Formulary Alternatives(Preferred) Nonformulary(Nonpreferred) Formulary Alternatives(Preferred) Nonformulary(Nonpreferred) Formulary Alternatives(Preferred)
Afinitor (PA, PAS) Agenerase Ampyra (PA, PAS) Aptivus Aranesp (PA, PAS) Atripla
Baraclude Betaseron (PA, PAS) Bravelle
Buphenyl (PA, PAS) Cayston (PA, PAS) Chenodal (PA, PAS) Chorionic Gonadotropin Cimzia (PA, PAS) Combivir Cystadane Egrifta (PA, PAS) Epogen (PA, PAS) Epzicom Exjade (PA, PAS) Extavia (PA, PAS) Follistim Aq Forteo (PA, PAS) Gammunex-C Ganirelix
Genotropini (PA, PAS) Gilenya (PA, PAS) Gonal-F RFF
no alternative available Lexiva
no alternative available Norvir, Prestiza, Reyataz Procrit (PA, PAS) Sustiva plus Emtriva plus Viread
Epivir HBV, Hepsera Avonex (PA, PAS), Copaxone (PA, PAS) coverage varies by benefit
no alternative available Tobi Neb (PA, PAS) Actigall*
coverage varies by benefit Enbrel (PA, PAS), Humira (PA, PAS) Epivir plus Retrovir no alternative available no alternative available Procrit (PA, PAS) Epivir plus Ziagen no alternative available Avonex (PA, PAS), Copaxone (PA, PAS) coverage varies by benefit
Fosamax*, Fosamax plus D, Miacalcin nasal spray* refer to medical benefit for IVIG
coverage varies by benefit
Omnitropei (PA, PAS) Avonex(PA, PAS), Copaxone (PA, PAS) coverage varies by benefit
Hizentra (PA, PAS) Humatropei (PA, PAS) Hycamtin (PA, PAS) Ilaris (PA, PAS) Increlex (PA, PAS) Infergen (PA, PAS) Iressa (PA, PAS) Kineret (PA, PAS) Kuvan (PA, PAS) Letairis (PA, PAS) Lupron 1 Mg/0.2 Ml (PA, PAS) Menopur Myfortic Neulasta (PA, PAS) Nexavar (PA, PAS) Norditropini (PA, PAS) Novarel
Nutropini (PA, PAS) Nutropin AQi (PA, PAS) Oforta (PA, PAS) Orfadin Ovidrel
Peg-Intron (PA, PAS) Pregnyl
Promacta (PA, PAS) Protropini (PA, PAS) Rebif (PA, PAS) Repronex Rescriptor Revatio (PA, PAS) Revlimid (PA, PAS)
refer to medical benefit for IVIG
Omnitropei (PA, PAS) no alternative available Arcalyst (PA, PAS) no alternative available Pegasys (PA, PAS) Tarceva (PA, PAS) Enbrel (PA, PAS), Humira (PA, PAS) no alternative available Tracleer (PA, PAS) refer to medical benefit coverage varies by benefit Mycophenolate, Cellcept
Neupogen (PA, PAS) no alternative available Omnitropei (PA, PAS) coverage varies by benefit
Omnitropei (PA, PAS) Omnitropei (PA, PAS) no alternative available no alternative available coverage varies by benefit Pegasys (PA, PAS) coverage varies by benefit
no alternative available Omnitropei (PA, PAS) Avonex (PA, PAS), Copaxone (PA, PAS) coverage varies by benefit Sustiva Adcirca (PA, PAS) no alternative available
Sabril Powder For Oral Solution (PA, PAS) Sabril Tablets (PA, PAS) Saizeni (PA, PAS) Samsca (PA, PAS) Selzentry (PA, PAS) Serostimi (PA, PAS) Simponi (PA, PAS) Somavert (PA, PAS) Sprycel (PA, PAS) Stelara (PA, PAS) Sutent (PA, PAS) Tasigna (PA, PAS) Tev-Tropini (PA, PAS) Trizivir
Truvada Tykerb (PA, PAS) Tyvaso (PA, PAS) Tyzeka (PA, PAS) Ventavis (PA, PAS) Vivaglobin (PA, PAS) Votrient (PA, PAS) Xyrem (PA, PAS) Zavesca (PA, PAS) Zolinza (PA, PAS) Zorbtive (PA, PAS) Zortress multiple formulary antiepileptic agents available multiple formulary antiepileptic agents available
Omnitropei (PA, PAS) no alternative available multiple formulary first line HIV agents available
Omnitropei (PA, PAS) Enbrel (PA, PAS) , Humira (PA, PAS) Sandostatin (PA, PAS) Gleevec (PA, PAS) Enbrel (PA, PAS), Humira (PA, PAS) no alternative available Gleevec (PA, PAS) Omnitropei (PA, PAS) Epivir plus Ziagen plus Retrovir
Emtriva plus Viread no alternative available no alternative available Epivir HBV, Hepsera no alternative available refer to medical benefit for IVIG
no alternative available Adderall*, Ritalin* no alternative available Targretin (PA, PAS) no alternative available Rapamune, Prograf
Quantity Limits
Some of the drugs listed in this formulary are subject to Quantity limits. For a complete list of drugs that are subject to quantity limits for your benefit plan, please refer to your health plan website or the customer service number which is listed on your member ID card.
Prior Authorization
Coventry Health Care has two broad goals for the pres
