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Sydist.com

Altius Health Plans, Inc.
Coventry Health Care plans
Coventry Health and Life Insurance Company
2013 Prescription Drug List
HealthAmerica Pennsylvania, Inc.
HealthAssurance Pennsylvania, Inc.
Alphabetical Listing
The Prescription Drug List is an alphabetical list of approved medicines covered by your benefit plan. In the Prescription Drug List, generic drugs are listed by their generic name and begin with lower case letters. You will pay the lowest copay (Tier-One) when you buy preferred generic drugs. For example: Generic name - quinapril.
Preferred 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 (Tier-Two) for preferred brand drugs. For example: Brand name with no generic available: Advair.
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 specific benefit design. Some benefit plans allow you to get non-preferred drugs at the highest copay level (Tier-Three). Some benefit plans do not cover non-preferred drugs.
We have included a list of common non-preferred drugs with their preferred alternatives. Preferred drugs generally will cost you less than non-preferred drugs. This list follows the prescription drug list. We strongly recommend that you take the prescription drug list with you to every doctor visit. Sharing the prescription drug list with your doctor will help ensure that your doctor considers a preferred drug when prescribing a medicine for you.
# Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.) 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
* A generic equivalent is available. Brand-name medications may be 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 covered at a higher member cost or may not be covered for certain plans.
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.
# Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.) 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
* A generic equivalent is available. Brand-name medications may be 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 covered at a higher member cost or may not be covered for certain plans.
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.
metipranolol (ODT non-form) naratriptan  # Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.) 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
* A generic equivalent is available. Brand-name medications may be 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 covered at a higher member cost or may not be covered for certain plans.
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.
paroxetine (CR non-form, ST) Prezista (SP) # Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.) 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
* A generic equivalent is available. Brand-name medications may be 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 covered at a higher member cost or may not be covered for certain plans.
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.
# Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.)
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
* A generic equivalent is available. Brand-name medications may be 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 covered at a higher member cost or may not be covered for certain plans.
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.
Common Non-Preferred Drugs and their Preferred Alternatives
Listed below are some common non-preferred drugs and their preferred alternatives. Some benefit plans allow you to get non-preferred 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-Preferred Drugs
Preferred Alternative
with a prescription for a Tier-One Accu-chek brand test One Touch Test Strips Ambien CR (ST, STS) Ambien* (PA 17yrs) , 5yrs) , Restoril* (PA 17yrs) MS Contin*, Opana ER*, # Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.) π Brand name medications with a generic equivalent are covered at the highest copay plus the difference between the cost of the brand and generic; the generic equivalent is covered at the highest copay.
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.
Detrol*/Detrol LA (ST) Ditropan*, Sanctura* MS Contin*, Opana ER*, Lamictal*, Trileptal*, Tegretol*, Diovan HCT (PA, PAS) Hyzaar*, Benicar HCT, Caduet (not covered) Norvasc* plus Lipitor* Inlyta (PA, PAS) (SP)  no alternative available Insulins Novo Brand Lilly Brand Insulins MS Contin*, Opana ER*, Jakafi (PA, PAS) (SP)  no alternative available Erivedge (PA, PAS) (SP) no alternative available MS Contin*, Opana ER*, MS Contin*, Opana ER*, Celexa*, Prozac*, Zoloft*, Paxil*, Daytrana (PA ≥ 19yrs) Adderall* , Ritalin* , Neurontin*, XR (PA, Depakene*, Depakote*, PAS), Starter Pack  Depakote ER* # Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.) π Brand name medications with a generic equivalent are covered at the highest copay plus the difference between the cost of the brand and generic; the generic equivalent is covered at the highest copay.
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.
Lamictal*, Trileptal*, Tegretol*, Premarin Vag Cream Estrace Vag Crm, Vagifem Novo Brand Insulins Lilly Brand Insulins Nucynta (PA, PAS)  MS Contin* , Opana ER* , Celexa*, Prozac*, Paxil*, Zoloft*, Protonix Packets (PA) Protonix* tablets Onsolis (PA, PAS)  Oxy IR* , MSIR*  Opana IRπ (PA, PAS) MSIR* , Oxycodone IR*  Provigil (PA, PAS)  Ritalin* , Dexedrine* , Oravig (PA, PAS)  Diflucan* , Mycelex* , Malarone (PA, PAS)  Coartem (PA), Aralen*, Pulmicort Flexhaler/ Flovent, QVAR, Asmanex Marinolπ (PA, PAS)  Requires Prior Auth Ortho Tri Cyclen Lo Multiple preferred oral , Concerta* (PA 19yrs)  Oxycontin (PA, PAS)  MS Contin* , Opana ER  Restoril 7.5mg, 22mg Restoril* 15mg & 30mg (PA 17yrs) , Ambien* (PA # Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.) π Brand name medications with a generic equivalent are covered at the highest copay plus the difference between the cost of the brand and generic; the generic equivalent is covered at the highest copay.
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) Protonix*, Nexium, Zegerid Ritalin LA (PA ≥ 19yrs) Adderall* , Ritalin* , Ritalin Valturna (not covered) Cozaar*, Benicar, Micardis Seroquel XR (PA, PAS) Risperdal*, Seroquel*, Sprycel (PA, PAS, PAF) Requires Prior Auth Lamictal*, Trileptal*, Tegretol*, IR* , Concerta* (PA 19yrs)  # Available at a Tier-One copay for select benefit plans. Generic versions are not available. (To determine if your benefit plan is included consult medco.com or Customer Service.) π Brand name medications with a generic equivalent are covered at the highest copay plus the difference between the cost of the brand and generic; the generic equivalent is covered at the highest copay.
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.
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 our organization 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, (PAS) for members with the RxSelect Prior Authorization Program and (PAF) for members with the Freedom 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), (PAF), (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.
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 the customer service number which is listed on your member ID card.
Specialty Medications
SP indicates specialty medications. Some plans direct distribution of specialty medications through a participating specialty pharmacy. Please call the Customer Service number on the back of your ID card for a referral to a participating specialty pharmacy or with questions regarding your pharmacy benefit.
Self-Administered Injectable Drug List
The following medications require prior authorization unless otherwise indicated 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.
Preferred Agents
Non-Preferred Preferred Alternatives
Lupron* 1mg/0.2ml (refer to medical benefits for Depot) Non-Preferred Preferred Alternatives
Stelara is intended for subcutaneous administration under the supervision of a physician.
* 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.
✻ 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, self-administered injectables may be included under a member’s medical benefit, not the pharmacy benefit plan. Please refer to your health plan documents regarding coverage of and any limitations or exclusions that may apply to your self-administered injectable benefit. All self administered injectables require prior authorization unless otherwise indicated.
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