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Care Management Resources
Carelink Health Plans, Inc.
Coventry Health Care plans
Coventry Health and Life Insurance Company
Group Health Plan, Inc.
Member Drug Formulary
HealthAmerica Pennsylvania, Inc.
HealthAssurance Pennsylvania, Inc.
PersonalCare Insurance of Illinois, Inc.
Alphabetical Listing 2006
WellPath Select, Inc.
The Member Drug Formulary is an alphabetical list of approved medicines covered by your benefi t plan. In the Member Drug Formulary, generic drugs are listed by their generic name and begin with lower case letters. You will pay the lowest copay when you buy formulary generic drugs. For example: Generic name - quinapril.
Formulary brand drugs are listed alphabetically by brand name. The names of brand name drugs begin with upper case letters. You will pay a higher copay for formulary brand drugs. For example: Brand name with no generic available: Lipitor.
Brand name drugs followed by an asterisk have a generic available. Ask your doctor if you can substitute a generic on your prescription. If so, you will receive the generic and pay the lowest copay. For example: Brand name with generic available- Accupril*.
Please consult your Plan coverage documents for more information on your specifi c benefi t design. Some benefi t plans allow you to get nonformulary drugs at the highest copay level. Some benefi t plans do not cover nonformulary drugs.
We have included a list of common nonformulary drugs with their formulary alternatives. This list follows the formulary drug list. We strongly recommend that you take the formulary with you to every doctor visit. Sharing the formulary with your doctor will help ensure that your doctor considers a drug from our formulary when prescribing a medicine for you.
amoxicillin-pot clavulanate (XR non-form) Please Note: 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
* A generic equivalent is available at the lowest copay. You will pay for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone). We periodically more for brand name medications. If you need more information, 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 ask your employer, read your prescription drug rider, or call Member limits (see back page). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
Services at the number on the back of your member ID card.
Claritin* (Requires Doctor’s Prescription) Claritin-D 24 Hour* (Requires Doctor’s Please Note: 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
* A generic equivalent is available at the lowest copay. You will pay for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone). We periodically more for brand name medications. If you need more information, 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 ask your employer, read your prescription drug rider, or call Member limits (see back page). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
Services at the number on the back of your member ID card.
loratadine (Requires Doctor’s Prescription) Please Note: 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
* A generic equivalent is available at the lowest copay. You will pay for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone). We periodically more for brand name medications. If you need more information, 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 ask your employer, read your prescription drug rider, or call Member limits (see back page). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
Services at the number on the back of your member ID card.
ranitidine (Gel & efferdose non-form) Restoril* (7.5 mg & 22.5 mg non-form) Prozac* (20mg tablet & weekly non-form) Please Note: 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
* A generic equivalent is available at the lowest copay. You will pay for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone). We periodically more for brand name medications. If you need more information, 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 ask your employer, read your prescription drug rider, or call Member limits (see back page). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
Services at the number on the back of your member ID card.
Zantac* (Gel caps & efferdose non-form) Please Note: 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
* A generic equivalent is available at the lowest copay. You will pay for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives, growth hormone). We periodically more for brand name medications. If you need more information, 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 ask your employer, read your prescription drug rider, or call Member limits (see back page). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
Services at the number on the back of your member ID card.
Common Non Formulary Drugs and their Formulary Alternatives
Listed below are some common nonformulary drugs and their formulary alternatives. Some benefi t plans allow you to get nonformulary drugs at the highest copay level. If you do not know which plan you have or need more information, ask your employer or read your prescription drug rider.
Non Formulary Drugs
Formulary Alternative
Hydrocortisone*, Synalar*, Desowen* Flovent, QVAR, Asmanex,Vasotec*, Accupril* Prinivil*, Lotensin*, Accupril*, Vasotec* Ativan*, Halcion*, Serax*, Restoril* Valisone*, Kenalog*, Diprosone*, Topicort*, Synalar*, Compazine*, Phenergan*, Tigan*, Zofran, Kytril OTC Benzoyl Peroxide plus Topical Clindamycin* OTC Benzoyl Peroxide plus Topical Erythromycin Diabeta*, Diabinese*, Dymelor, Glucotrol*, Glynase*, Micronase*, Orinase, Tolinase*, Glucophage* Motrin*, Naprosyn*, Voltaren*, Orudis*, Clinoril*, Motrin*, Naprosyn*, Voltaren*, Orudis*, Clinoril*, Motrin*, Naprosyn*, Voltaren*, Orudis*, Clinoril*, Generic over-the-counter Loratadine is covered with a physician’s prescription. Valisone*, Kenalog*, Diprosone*, Topicort*, Synalar*, Vibramycin*, Vibra-Tabs, Sumycin capsules Motrin*, Naprosyn*, Voltaren*, Orudis*, Clinoril*, Prinivil*, Lotensin *, Accupril*, Vasotec* Prinzide*, Lotensin HCT*, Vaseretic*, Accuretic* * A generic equivalent is available at the lowest copay. You will pay more for brand name medications. If you need more information, ask your employer, read your prescription drug rider, or call Member Services at the number on the back of your member ID The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your Doctor.
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). 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 back page). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information. Motrin*, Naprosyn*, Voltaren*, Orudis*, Clinoril*, Calan SR*, Cardizen CD*, Adalat CC, Procardia XL*, Flexeril*, Lioresal*, Robaxin*, Soma* Motrin*, Naprosyn*, Voltaren*, Orudis*, Clinoril*, Prinzide*, Lotensin HCT*, Vaseretic*, Accuretic* Premarin Cream, Estrace Cream, Ogen Cream Calan*, SR*, Cardizem CD*, Adalat CC*, Flexeril*, Lioresal*, Robaxin*, Soma* Zaditor, Alocril, Alomide, Livostin Motrin*, Naprosyn*, Voltaren*, Orudis*, Clinoril*, Calan SR*, Cardizem CD*, Adalat CC*, Procardia XL* Hydorcortisone*, Betamethasone*, Triamcinolone* Elocon*, Temovate*, Sinalar*, Topicort* Albuterol Inhaler*, Maxair Inhaler, Albuterol Ativan*, Halcion*, Serax*, Restoril* Generic over-the-counter Loratadine is covered with a physician’s prescription. Generic over-the-counter Loratadine is covered with a physician’s prescription. Flexeril*, Lioresal*, Robaxin*, Soma* Ativan*, Halcion*, Serax*, Restoril* Tylenol with Codeine*, Darvocet-N 100*, Ultram* * A generic equivalent is available at the lowest copay. You will pay more for brand name medications. If you need more information, ask your employer, read your prescription drug rider, or call Member Services at the number on the back of your member ID The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your Doctor.
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). 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 back page). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information. Prior Authorization
Coventry Health Care has two broad goals for the prescription drug benefi t we offer. One is to never compromise the quality or effectiveness of treatment. The second is to provide a comprehensive, affordable pharmacy benefi t. One of the tools we use to help control prescription drug costs is to require prior approval, or authorization, before our organization will cover their cost. These medications include those that (1) are not suggested for fi rst-line therapy, (2) may require special tests before starting them or (3) have very limited approval for use. Drugs that could require Prior Authorization are identifi ed by (PA).
Only your physician can provide the information necessary to complete the prior authorization process. If you have been prescribed one of the drugs identifi ed by (PA), make sure your doctor knows that this medication requires prior authorization. Your doctor should contact Coventry’s Pharmacy Call Center at 877-215-4100.
Self-Administered Injectable Formulary
The following medications require prior authorization and are covered through our contracted Specialty Pharmacy. Your doctor should contact Coventry’s Pharmacy Call Center at 877-215-4100 to request prior authorization. We limit these drugs to a one month supply at a time or the quantity prescribed in the prescription order, whichever is less.
Formulary Agents
Non-Formulary Formulary Alternatives
Erectile Dysfunction Medications on 3rd tier Erectile Dysfunction Medications on 3rd tier * Generic is on the Formulary✦ Initial therapy of 5 doses will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
★ Initial therapy of 10 doses will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
❉ Some plans cover only one growth hormone product -- Norditropin. Under these plans, Nutropin, Nutropin AQ, Humatrope, Genotropin, Saizen, Tev-Tropin, and comparable agents are not covered. Please contact Member Services with questions if your doctor prescribes a growth hormone agent that is not covered.
Please refer to your health plan documents regarding any limitations or exclusions that may apply to your pharmacy benefi t.
All self administered injectables require prior authorization.
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Source: http://www.rsionline.com/ResourceCenter/ontheindustry/PDF/Coventry/pres_drug_form_2006.pdf