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Usd497.org

Altius Health Plans, Inc.
Coventry Health Care plans
2014 Prescription Drug List
Coventry Health and Life Insurance Company
HealthAmerica Pennsylvania, Inc.
HealthAssurance Pennsylvania, Inc.
With our prescription drug plan, most drugs are covered on one of three different copay (or coinsurance) levels. For some benefit plans, specialty copays (or coinsurance) may vary. Please refer to your health plan documents regarding your specialty medication benefit.
Tier-One – Includes preferred generic and select over-the-counter (OTC) drugs.
Tier-Two – Includes preferred brand-name drugs.
Tier-Three – Includes non-preferred generic and brand-name drugs. These drugs may have a lower cost alternative on Tier-
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, preferred drugs may be excluded from your plan (for example, growth hormone, erectile dysfunction drugs). We periodically review our Prescription Drug List. 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.
Tier-One
Benzoyl peroxide/erythromycin Cetirizine OTC (Requires * A generic equivalent is available. Brand-name medications may be covered at a higher member cost or may not be ◆ Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
covered for certain plans. If you need more information, read your prescription drug rider, or call Member Services at the number on the back of your member ID card.
Erythromycin/Benzoyl Peroxide Hydrocodone/homatropine  Mirtazapine (Sol Tab Tier-Three) Pioglitazone/Metformin * A generic equivalent is available. Brand-name medications may be covered at a higher member cost or may not be ◆ Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
covered for certain plans. If you need more information, read your prescription drug rider, or call Member Services at the number on the back of your member ID card.
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 and some brand names may no longer be available. Under some circumstances, preferred drugs may be excluded from your plan (for example, growth hormone, erectile dysfunction drugs). We periodically review our Preferred Drug List. 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.
Zaditor OTC (Requires Doctor’s Estrace Cream Brand with
Equivalent
Tier-Two
* A generic equivalent is available. Brand-name medications may be covered at a higher member cost or may not be ◆ Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
covered for certain plans. If you need more information, read your prescription drug rider, or call Member Services at the number on the back of your member ID card.
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 and some brand names may no longer be available. Under some circumstances, preferred drugs may be excluded from your plan (for example, growth hormone, erectile dysfunction drugs). We periodically review our Preferred Drug List. 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.
* A generic equivalent is available. Brand-name medications may be covered at a higher member cost or may not be ◆ Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
covered for certain plans. If you need more information, read your prescription drug rider, or call Member Services at the number on the back of your member ID card.
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 and some brand names may no longer be available. Under some circumstances, preferred drugs may be excluded from your plan (for example, growth hormone, erectile dysfunction drugs). We periodically review our Preferred Drug List. 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.
Tier-Three
Alternative Tier-One
MS Contin* , Opana ER* , or Tier-Two Drugs
Non-Preferred Drugs
Preferred Alternative
Amerge* , Imitrex* , Maxalt* , Maxalt MLT*  Ambien CR (ST, STS) Ambien* (PA ≤ 17yrs) , Abilify ODT, Soln (ST) Abilify tabs Halcion* (PA ≤ 17yrs) , Oxazepam* (PA ≤ 5yrs) , Accu-chek Brand Test One Touch Test Strips Restoril* (PA ≤ 17yrs) , Benicar HCT (PA, PAS)Avalide*, Diovan HCT*, Oxy IR* , MSIR* , Amturnide (PA, PAS) Cozaar*, Benicar, Micardis PAS)  (not covered) AndroGel (PA, PAS) Breo Ellipta (PA, PAS) Symbicort, Dulera Arixtraπ◆ (PA, PAS)  Fragmin (PA, PAS) , MS Contin* , Opana ER* , Caduet (not covered) Norvasc* plus Lipitor*, Avandamet (PA, PAS) Actos* Glucophage* * A generic equivalent is available. Brand-name medications may be covered at a higher member cost or may not be π Brand name medications and the generic equivalent are covered at a higher member cost.
covered for certain plans. If you need more information, read your prescription drug rider, or call Member Services ■ Initial therapy of 10 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
at the number on the back of your member ID card.
◆ Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
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 and some brand names may no longer be available. Under some circumstances, preferred drugs may be excluded from your plan (for example, growth hormone, erectile dysfunction drugs). We periodically review our Preferred Drug List. 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.
Amerge* , Imitrex* , Maxalt* , Maxalt MLT*  Iprivask■ (PA, PAS)  Fragmin (PA, PAS) , Doxycycline , Minocycline  Epaned (PA ≥13 years) Vasotec tabs MS Contin* , Opana ER* , Doxycycline , Minocycline MS Contin* , Opana ER* , Ritalin* , Adderall* , Lamictal*, Trileptal*, Tegretol*, Adderall* , Adderall XR* (PA ≥ 19yrs) , Ritalin* , Ritalin ≥ 19yrs) , Ritalin* , Ritalin SR* , Metadate ER* , SR* , Metadate ER* , XR (ST), Starter Pack Keppra*, Trileptal*, Tegretol*, Focalin IR , Concerta* (PA ≥ Focalin IR* , Concerta* (PA Detrol*/Detrol LA (ST) Ditropan*, Sanctura* Amerge* , Imitrex* , Maxalt* , Maxalt MLT*  Lazanda (PA, PAS)  Oxy IR* , MSIR* Lamictal*, Trileptal*, Tegretol*, Amerge* , Imitrex* , Maxalt* , Maxalt MLT* Nizoral* , Nystatin* MS Contin* , Opana ER , Insulins Novo Brand Lilly Brand Insulins Edarbyclor (PA, PAS) Avalide*, Diovan HCT*, Ambien* (PA ≤ 17yrs) , Halcion* (PA ≤ 17yrs) , Oxazepam* (PA ≤ 5yrs) , Ritalin* , Adderall* , Restoril* (PA ≤ 17yrs) , * A generic equivalent is available. Brand-name medications may be covered at a higher member cost or may not be π Brand name medications and the generic equivalent are covered at a higher member cost.
covered for certain plans. If you need more information, read your prescription drug rider, or call Member Services ■ Initial therapy of 10 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
at the number on the back of your member ID card.
◆ Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
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 and some brand names may no longer be available. Under some circumstances, preferred drugs may be excluded from your plan (for example, growth hormone, erectile dysfunction drugs). We periodically review our Preferred Drug List. 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.
Ortho Tri Cyclen Lo Multiple preferred oral Lamictal*, Trileptal*, Tegretol*, Nizoral* , Nystatin* Amerge* , Imitrex* , Maxalt* , Maxalt MLT*   MS Contin* , Opana ER  Malaroneπ (PA, PAS) Coartem (PA) , Aralen* , Daraprim , Plaquenil*, ≥ 19yrs) , Ritalin* , Ritalin Restoril 7.5mg, 22mg Restoril* 15mg & 30mg (PA ≤ 17yrs) , Ambien* (PA ≤ Focalin IR* , Concerta* (PA 17yrs) , Halcion* (PA ≤ Adderall* , Adderall XR* (PA Amerge* , Imitrex* , ≥ 19yrs) , Ritalin* , Maxalt* , Maxalt MLT* Ritalin SR* , Metadate ER* , Focalin IR* , Lamictal*, Trileptal*, Tegretol*, Ambien* (PA ≤ 17yrs) , Doxycycline , Minocycline  Premarin Vag Cream Estrace Vag Crm, Vagifem Seroquel XR (PA, PAS) Geodon*, Risperdal*, Cipro* , Avelox , Protopic (PA, PAS)  Hydorcortisone*, Doxycycline , Minocycline  Novo Brand Insulins Lilly Brand Insulins Tylenol with Codeine* , MSIR* , Oxycodone IR*  Provigilπ (PA, PAS)  Ritalin* , Dexedrine* , MS Contin* , Opana ER* , Ritalin* , Dexedrine* , Pulmicort Flexhaler/ QVAR, Asmanex Adderall* , Ritalin* , Ritalin SR* , Metadate ER* , Focalin IR* , Suboxoneπ (PA, PAS) Requires Prior Auth Qualaquin (PA, PAS) Aralen* , Plaquenil*, Oxy IR* , MSIR* , MSIR* , Oxycodone IR*  Quillivant XR (PA)  Ritalin SR Diflucan* , Mycelex* , * A generic equivalent is available. Brand-name medications may be covered at a higher member cost or may not be π Brand name medications and the generic equivalent are covered at a higher member cost.
covered for certain plans. If you need more information, read your prescription drug rider, or call Member Services ■ Initial therapy of 10 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
at the number on the back of your member ID card.
◆ Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
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 and some brand names may no longer be available. Under some circumstances, preferred drugs may be excluded from your plan (for example, growth hormone, erectile dysfunction drugs). We periodically review our Preferred Drug List. 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.
Zegerid (not covered) Zegerid OTC, Prilosec OTC, Doxycycline, MinocyclineAmerge* , Imitrex* , Maxalt* , Maxalt MLT* Tobrex* , Gentamicin* , Ciloxan* , Ocuflox*  Valturna (not covered) Avapro*, Cozaar*, Diovan* Tobrex* , Gentamicin* , Ciloxan* , Ocuflox* Lamictal*, Trileptal*, Tegretol*, Adderall* , Adderall XR* (PA ≥ 19yrs) , Ritalin* , Ritalin SR* , Metadate ER* , Focalin IR* , * A generic equivalent is available. Brand-name medications may be covered at a higher member cost or may not be π Brand name medications and the generic equivalent are covered at a higher member cost.
covered for certain plans. If you need more information, read your prescription drug rider, or call Member Services ■ Initial therapy of 10 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
at the number on the back of your member ID card.
◆ Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
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 and some brand names may no longer be available. Under some circumstances, preferred drugs may be excluded from your plan (for example, growth hormone, erectile dysfunction drugs). We periodically review our Preferred Drug List. 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.
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.
Preferred
Non-Preferred
Preferred Alternatives
Non-Preferred
Preferred Alternatives
Genotropin ✻ (PA, PAS, PAF) Omnitrope ✻ (PA, PAS, PAF) ✻ Some plans cover only one growth hormone product -- Omnitrope. 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.
■ Initial therapy of 10 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
For some benefit plans, specialty medications may be included under a member’s medical benefit, not the pharmacy benefit plan. The preferred alternatives are listed only as a suggestion. Please discuss appropriateness with your doctor. Please refer to your health plan documents regarding coverage of and any limitations or exclusions that may apply to your specialty Non-Preferred
Preferred Alternatives
Non-Preferred
Preferred Alternatives
Norditropin ✻ (PA, PAS, PAF) Omnitrope ✻ (PA, PAS, PAF) Nutropin AQ ✻ (PA, PAS, PAF) Omnitrope ✻ (PA, PAS, PAF) TOBI Podhaler (PA, PAS, PAF) Tobi nebs (PA, PAS, PAF) Vitamins, Smoking Cessation, Dental Preparations
Your prescription drug benefit may provide coverage for Vitamins, Smoking Cessation and Dental Preparations. Examples of these drugs are listed below. This is not meant to be a complete list of the drugs covered under your plan. Coverage for these drugs may have limitations. Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
Vitamins
Smoking Cessation
Dental Preparations
Drug Name
Drug Name
Drug Name
✻ Some plans cover only one growth hormone product -- Omnitrope. 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.
■ Initial therapy of 10 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.
For some benefit plans, specialty medications may be included under a member’s medical benefit, not the pharmacy benefit plan. The preferred alternatives are listed only as a suggestion. Please discuss appropriateness with your doctor. Please refer to your health plan documents regarding coverage of and any limitations or exclusions that may apply to your specialty Quantity Limits
Some of the drugs listed in this Prescription Drug List 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 to the customer service number which is listed on your member ID card.
Prior Authorization
Coventry Health Care has two broad goals for the prescription drug benefit we offer. One is to never compromise the quality or effectiveness of treatment. The second is to provide a comprehensive, affordable pharmacy benefit. One of the tools we use to help control prescription drug costs is to require prior approval, or authorization, before we will cover the cost of certain medications. These medications include those that (1) are not suggested for first-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 identified by (PA) for members with the Standard Prior Authorization Program and (PAS) for members with the RxSelect Prior Authorization Program.
Step Therapy is an automated form of Prior Authorization based on previous pharmaceutical treatment. Drugs designated as stepped therapy will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Drugs that could require Step Therapy are identified by (ST) for members with the Standard Step Therapy Program and (STS) for members with the RxSelect Step Therapy Program.
Only your physician can provide the information necessary to complete the prior authorization process. If you have been prescribed one of the drugs identified by (PA), (PAS), (ST) or (STS), make sure your doctor knows that this medication requires prior authorization. Your doctor should contact Coventry’s Pharmacy Call Center at 877-215-4100.
For more updated
information, visit
our web site at:

Source: http://www.usd497.org/employment/benefits/documents/2014TieredFormulary.pdf

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