5010_5.wpc

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.
Alphabetical Listing 2005
PersonalCare Insurance of Illinois, Inc.
Southern Health Services, Inc.
WellPath Select, Inc.
Claritin* (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 for informational reference. Under some
circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to
Not all dosage forms are available generically change. Some medications may require prior authorization or have quantity limits. Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more 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 for informational reference. Under some
circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to
Not all dosage forms are available generically change. Some medications may require prior authorization or have quantity limits. Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more ranitidine* (Gel & 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 for informational reference. Under some
circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to
Not all dosage forms are available generically change. Some medications may require prior authorization or have quantity limits. Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more Zantac* (Gel caps & efferdose non-form) For more updated
information, visit
our web site at:
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 for informational reference. Under some
circumstances, formulary drugs may be excluded from your plan (for example, oral contraceptives). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to
Not all dosage forms are available generically change. Some medications may require prior authorization or have quantity limits. Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more

Source: http://www.onesourcepeo.com/images/PDFs/Coventry2005formulary.pdf?itemID=2805&link=child&Community=Member