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
, Minocycline
Amerge*
, 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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