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2015 Coventry Prescription Drug List
www.CoventryHealth.com
©2015 Aetna Inc.
80.05.341.1 G (7/15)
Do you have questions?
Call the toll-free number on your member ID card. Or visit
www.CoventryHealth.com for the most up-to-date information.
Dear Member:
What can I expect to pay?
To help you know how drugs are covered by your plan, we
are pleased to provide you with a copy of our 2015 Coventry
Prescription Drug List.
The amount you pay depends on the drug your doctor
prescribes. It’s either a flat fee or a percent of the
prescription’s price.
This guide provides helpful information about your pharmacy
benefits plan. You may want to take this guide with you when
you see your doctor to talk about what is covered under your
plan and what you can expect to pay for your medicine.
What you pay falls into one of these tiers or levels:
Many commonly prescribed drugs are listed in this guide. Please
remember this is not a complete list of drugs covered under your
plan. Because thousands of drugs are included in your pharmacy
benefits plan, we only list the most commonly prescribed ones.
Tier One: Preferred Generics – You pay the lowest cost
for drugs in this level. Your plan may include an additional
benefit where some Tier 1 drugs would be provided at an
even lower cost to you. These are considered Value Drugs/
Tier 1a and include generics and some over-the-counter
brand and generic products. These would be available at
the lowest cost share indicated in your plan materials.
Tier Two: Preferred Brand – You pay a slightly higher cost
for drugs in this level.
Tier Three: Non-Preferred Brand and Generic – You pay
the highest cost for drugs in this level.
Preferred Specialty – You pay a higher cost for specialty
drugs in this level. Specialty drugs may be injected, infused
or taken by mouth.
Non-Preferred Specialty – You pay a highest cost for
non-Preferred Specialty drugs in this level.
To find your exact costs
Check your Plan Design and Benefits summary. This should be
in your enrollment kit.
Your pharmacy benefits plan may include a program that
encourages you to choose a generic drug over a brand-name
drug, in order to help reduce what you pay. This means that
if you fill a brand-name drug when a generic is available, that
in addition to your standard copay or coinsurance, you must
also pay the difference in cost between the brand-name and
generic drug.
For a summary of your pharmacy benefits plan, including
out-of-pocket costs, visit www.CoventryHealth.com. Or call
the toll-free number on your member ID card.
www.CoventryHealth.com
Where can I find more formulary information?
Why is the formulary subject to change?
You and your doctor can search for a drug, find out if it’s covered
and see what tier it falls under. You can also see if there are
alternatives that cost less. Make sure your doctor knows
that you pay more for two, three, four and five tier drugs.
He or she can consider this before writing a prescription.
We may add or remove drugs for certain reasons. We might
also move a drug from one coverage tier to another.
Take these steps:
1. Visit www.CoventryHealth.com.
2. This is where you can learn more about the types of
drug coverage reviews your drug requires; things like
precertification, step therapy or quantity limits. You will
arrive at a menu page where you can view various drug lists,
including your 2015 Coventry Prescription Drug List and more.
How is the formulary developed?
Our Pharmacy and Therapeutics (P&T) Committee meets
regularly to review new drugs and new information about
drugs that are already on the market. It reviews available
information concerning safety, effectiveness and current use
in therapy. The P&T Committee reviews scientific evidence,
including relevant findings of federal government agencies,
pharmaceutical manufacturers, medical professional
associations, national commissions and peer-reviewed journals.
Our P&T Committee includes licensed pharmacists and doctors,
including those who are currently in practice and others who are
employees. All committee members must tell us if they are in a
situation that can create a conflict of interest or if they have a
financial stake that might affect their decisions.
Once the P&T Committee completes its clinical review, we
also consider overall value (including cost and manufacturer
rebate arrangements) and other factors before adding or
removing a drug from the formulary. The 2015 Coventry
Prescription Drug List shows you recent changes to the guide.
For example, it could show what drugs started requiring
coverage reviews like precertification, step therapy or quantity
limits. Or which drugs no longer do. The P&T Committee can
make recommendations to change the tier level of a drug or
to place it on our Formulary Exclusions List, designating it as
a drug that is no longer covered.
Here are some reasons why:
• As brand-name drugs lose their patents and generic versions
become available, the brand-name may be covered at a higher
out-of-pocket cost while the generic may be covered at a lower
out-of-pocket cost.
• The Food and Drug Administration (FDA) approves many
new drugs throughout the year.
• Drugs can be withdrawn from the market or may become
available without a prescription.
Our website, www.CoventryHealth.com, reflects the most
up-to-date formulary information – so please visit it often.
Why do some drugs require prior authorization
or precertification?
This drug coverage review encourages appropriate and costeffective use of prescription drugs by allowing coverage only
when certain conditions are met.
Reasons for precertification include:
• Compliance with dosing guidelines
• Avoiding duplicate therapies
• Helping health care providers check that a drug is being
used based on generally accepted medical criteria
The precertification program is based upon current medical
findings, FDA-approved manufacturer labeling information,
and cost and manufacturer rebate arrangements.
If your plan requires precertification, you will find a list of drugs
that are subject to precertification with this guide. Please keep
the following in mind:
• Your doctor must contact Coventry Health Care to request
approval of coverage for these drugs.
• If we approve the request, we will notify your doctor. The
drug will then be covered at the applicable out-of-pocket
cost under your plan. You will also be notified of approvals
where the state requires notification to members.
If the request is denied, you and your doctor will be notified.
You can still purchase the drug, but for the full price.
www.CoventryHealth.com
Why do some drugs have quantity limits?
You may be able to save with generic drugs
This drug coverage review limits coverage of quantities for
certain drugs. These limits help your doctor and pharmacist
check that your prescribed drug is used correctly and safely.
Generic drugs are approved by the U.S. Food and Drug
Administration (FDA) and proven to be just as safe and effective
as brand-name drugs. They contain the same active ingredients
in the same amounts as the brand-name products. The
difference is that generics may be a different color, shape or size.
We use medical guidelines and FDA-approved recommendations
from drug makers to set these coverage limits. The quantity limit
program includes:
• Dose Efficiency Edits – Limit coverage of prescriptions to one
dose per day for drugs that are approved for once-daily dosing.
• Maximum Daily Dose – A message is sent to the pharmacy
if a prescription is less than the minimum or higher than the
maximum allowed dose.
• Quantity Limits Over Time – Limit coverage of prescriptions
to a specific number of units in a defined amount of time.
What is step therapy?
This drug coverage review promotes the appropriate use
of equally effective but lower-cost drugs first. Prerequisite
drugs are FDA-approved and treat the same condition as
the corresponding step therapy drugs.
What is therapeutic duplication?
Therapeutic duplication means that two or more drugs of
the same type are prescribed at the same time. This can occur
when two doctors prescribe similar drugs or when your doctor
switches from one drug to another drug in the same class
without cancelling the first prescription.
It is rare that you should ever need two drugs from the same
class to treat a medical condition. Since serious side effects
may occur, we help bring such duplications to your pharmacist’s
and doctor’s attention.
Learn more about drug coverage reviews
If you have a medical need for a drug that requires precertification,
quantity limits or step therapy, your doctor can ask for a medical
exception. The list of drugs requiring precertification, quantity
limits or step therapy is subject to change. Find the most
up-to-date information at www.CoventryHealth.com.
When appropriate, your doctor may decide to prescribe, or allow
substitution with, a generic drug. Please talk to your doctor to
find out if a generic is right for you.
Saving on prescriptions
Here are some other tips to pay less out of pocket for your
prescription drugs:
• Ask your doctor to consider prescribing generic drugs
instead of brand-name drugs.
• Ask your doctor to consider prescribing drugs that are
on the 2015 Coventry Prescription Drug List.
• Check to see if your plan includes our mail-order pharmacy
service. Depending upon your plan, mail order may save
you money.
• Remind your doctor to check your plan to make sure you
get maximum coverage.
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.
• 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.
www.CoventryHealth.com
Need more information?
Visit www.CoventryHealth.com or call the appropriate
toll-free number on your member ID card.
Please note that if your prescription drug benefits plan changes, the information herein may no longer apply.
A copayment is a flat fee. Coinsurance is a percentage of the rate that Coventry negotiates with the plan sponsor for covered prescriptions except as required
by law to be otherwise. Some drugs on the Coventry formulary are subject to manufacturer rebates. Coinsurance is calculated before any rebates are
subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug.
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features
and availability may vary by location and are subject to change.
Coventry receives rebates from drug manufacturers that may be taken into account in determining the Coventry formulary. Rebates do not reduce the
amount a member pays the pharmacy for covered prescriptions. Information is subject to change. For more information about Coventry plans, refer to
www.CoventryHealth.com.
The drugs on the Coventry formulary, Formulary Exclusions, Prior Authorization, 4uantity Limit and Step Therapy Lists are subject to change.{
In accordance with state law, commercial fully-insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are
receiving coverage for medications that are added or removed from the Coventry formulary, Prior Authorization, Quantity Limits or Step-Therapy Lists during
the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, prior authorization approval is
known as “pre-service utilization review.” It is not “verification” as defined by Texas law.
This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan
documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and
are subject to change. Providers are independent contractors and are not agents of Coventry. Provider participation may change without notice. Coventry
does not provide care or guarantee access to health services. Information is subject to change. For more information about Coventry plans, refer to
www.CoventryHealth.com.
www.CoventryHealth.com
©2015 Aetna Inc.
80.05.341.1 G (7/15)
2015 Coventry Prescription Drug List
Table of Contents
Analgesics .......................................................................................................................................................................................................................................................................................................................................... 3
Anesthetics ........................................................................................................................................................................................................................................................................................................................................ 7
Antiarthritics ................................................................................................................................................................................................................................................................................................................................... 8
Antiasthmatics ............................................................................................................................................................................................................................................................................................................................ 10
Antibiotics ...................................................................................................................................................................................................................................................................................................................................... 11
Anticoagulants ........................................................................................................................................................................................................................................................................................................................... 18
Antidotes .......................................................................................................................................................................................................................................................................................................................................... 18
Antifungals .................................................................................................................................................................................................................................................................................................................................... 18
Antihistamine And Decongestant Combination ...................................................................................................................................................................................................................................... 20
Antihistamines ........................................................................................................................................................................................................................................................................................................................... 20
Antihyperglycemics ............................................................................................................................................................................................................................................................................................................. 21
Antiinfectives .............................................................................................................................................................................................................................................................................................................................. 24
Antiinfectives/Miscellaneous ..................................................................................................................................................................................................................................................................................... 24
Antineoplastics .......................................................................................................................................................................................................................................................................................................................... 25
Anti-Obesity Drugs ............................................................................................................................................................................................................................................................................................................... 27
Antiparkinson Drugs ........................................................................................................................................................................................................................................................................................................... 27
Antiplatelet Drugs .................................................................................................................................................................................................................................................................................................................. 28
Antivirals ......................................................................................................................................................................................................................................................................................................................................... 29
Autonomic Drugs .................................................................................................................................................................................................................................................................................................................... 31
Biologicals ..................................................................................................................................................................................................................................................................................................................................... 33
Blood ................................................................................................................................................................................................................................................................................................................................................... 34
Cardiac Drugs ............................................................................................................................................................................................................................................................................................................................. 35
Cardiovascular ........................................................................................................................................................................................................................................................................................................................... 37
Cns Drugs ....................................................................................................................................................................................................................................................................................................................................... 42
Colony Stimulating Factors .......................................................................................................................................................................................................................................................................................... 46
Contraceptives ............................................................................................................................................................................................................................................................................................................................ 46
Cough/Cold Preparations ................................................................................................................................................................................................................................................................................................ 51
Diagnostic ....................................................................................................................................................................................................................................................................................................................................... 51
Diuretics ........................................................................................................................................................................................................................................................................................................................................... 51
Eent Preps ....................................................................................................................................................................................................................................................................................................................................... 52
Elect/Caloric/H2o ................................................................................................................................................................................................................................................................................................................... 55
Gastrointestinal ......................................................................................................................................................................................................................................................................................................................... 57
Herbals ............................................................................................................................................................................................................................................................................................................................................... 61
Hormones ........................................................................................................................................................................................................................................................................................................................................ 61
Immunosuppresant ................................................................................................................................................................................................................................................................................................................ 65
Miscellaneous Medical Supplies, Devices, Non-Drug ..................................................................................................................................................................................................................... 66
Muscle Relaxants .................................................................................................................................................................................................................................................................................................................... 66
Pre-Natal Vitamins ................................................................................................................................................................................................................................................................................................................ 67
Psychotherapeutic Drugs ................................................................................................................................................................................................................................................................................................. 68
Sedative/Hypnotics ............................................................................................................................................................................................................................................................................................................... 73
Skin Preps ....................................................................................................................................................................................................................................................................................................................................... 74
Smoking Deterrents .............................................................................................................................................................................................................................................................................................................. 79
Thyroid Preps .............................................................................................................................................................................................................................................................................................................................. 79
Unclassified Drug Products .......................................................................................................................................................................................................................................................................................... 80
Vitamins ........................................................................................................................................................................................................................................................................................................................................... 83
1
2
2015 Coventry Prescription Drug List
lowercase italics = Generic drugs
UPPERCASE = Brand name drugs
Drug Name
Drug Status
CE = Copay Exception
LA = Limited Access Coverage varies by benefit
NC = Not Covered
NF = Non-formulary
Tier 1 = Preferred Generics
Tier 2 = Preferred Brands
Tier 3 = Non-Preferred
Brands and Generics
Tier 4 = Preferred Specialty
Tier 5 = Non-Preferred
Specialty
Tier 6 = Not Covered
Drug Status
Additional Information
AL = Age Limit
CE = Available to some members at no
cost with a prescription from your
provider when obtained at an in-network
pharmacy. Certain limitations may apply.
LGC = Lowest Generic Copay
Note 3 = Not available as a 90 day supply
Note 4 = Prior authorization applies to
Standard and/or Select
Note 5 = Step therapy applies to Standard
and/or Select
Note 6 = Requires a doctors prescription
PA = Prior Authorization Applies
QL = QL Limit
ST = Step Therapy Applies
Additional Information
Analgesics
ABSTRAL
Tier 3
acetaminophen-codeine oral solution
Tier 1
acetaminophen-codeine oral tablet 300-15 mg
Tier 1
acetaminophen-codeine oral tablet 300-30 mg, 300-60 mg
Tier 1
ACTIQ
Tier 3
ADULT LOW DOSE ASPIRIN
PA; Note 3; Note 4 (Standard,Select)
Note 3
PA; Note 3; Note 4 (Standard,Select); QL
CE
CE
ALSUMA
Tier 6
QL
AMERGE
Tier 3
Note 3; QL
ASPIR-81
CE
CE
ASPIRIN CHILDRENS
CE
CE
ASPIRIN LOW DOSE
CE
CE
ASPIRIN LOW-STRENGTH
CE
CE
aspirin oral tablet
CE
CE
aspirin oral tablet,chewable
CE
CE
aspirin oral tablet,delayed release (dr/ec) 325 mg, 500 mg,
81 mg
CE
CE
ASPIR-LOW
CE
CE
ASPIR-TRIN
CE
CE
AVINZA
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
3
Drug Name
AXERT
Drug Status
Tier 3
Additional Information
ST; Note 3; Note 5 (Standard,Select); QL
BAYER ADVANCED
CE
CE
BAYER ASPIRIN
CE
CE
BAYER CHEWABLE ASPIRIN
CE
CE
butalbital-acetaminop-caf-cod
Tier 1
Note 3
butalbital-acetaminophen
Tier 1
butalbital-acetaminophen-caff oral capsule 50-300-40 mg
Tier 1
Note 3
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
Tier 1
Note 3
butalbital-aspirin-caffeine
Tier 1
Note 3
butorphanol tartrate nasal
Tier 3
QL
BUTRANS TRANSDERMAL PATCH WEEKLY 10
MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5
MCG/HOUR
Tier 2
Note 3; QL
BUTRANS TRANSDERMAL PATCH WEEKLY 7.5
MCG/HOUR
Tier 2
QL
CAFERGOT
Tier 2
Note 3
CAMBIA
Tier 6
CATAFLAM
Tier 3
CHILD ASPIRIN
CE
CE
CHILDREN'S ASPIRIN
CE
CE
choline,magnesium salicylate
Tier 1
codeine sulfate oral solution 30 mg/5 ml
Tier 1
codeine sulfate oral tablet
Tier 1
Note 3
CONZIP
Tier 6
Note 3; QL
D.H.E.45
Tier 3
QL
DEMEROL ORAL
Tier 3
Note 3
diclofenac potassium
Tier 1
diflunisal
Tier 1
dihydroergotamine injection
Tier 3
QL
dihydroergotamine nasal
Tier 3
Note 3
DILAUDID ORAL TABLET
Tier 3
Note 3
DOLOPHINE ORAL
Tier 3
Note 3
DURAGESIC
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
E.C. PRIN
CE
CE
ECOTRIN
CE
CE
ECOTRIN LOW STRENGTH
CE
CE
ELMIRON
Tier 2
EMBEDA
Tier 3
ENTERIC COATED ASPIRIN
CE
PA; QL
CE
ergotamine-caffeine
Tier 1
Note 3
EXALGO ER
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
EXTRA STRENGTH BAYER
fentanyl citrate
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
4
CE
Tier 3
CE
PA; Note 3; Note 4 (Standard,Select); QL
Drug Name
Drug Status
Additional Information
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr,
25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5
mcg/hour, 87.5 mcg/hour
Tier 3
PA; QL
FENTORA
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
FIORICET ORAL TABLET
Tier 3
Note 3
FIORINAL
Tier 3
Note 3
FIORINAL-CODEINE #3
Tier 3
Note 3
FROVA
Tier 3
ST; Note 5 (Standard); QL
HALFPRIN
CE
CE
hydrocodone-acetaminophen oral solution 10-325 mg/15
ml(15 ml), 5-163 mg/7.5ml(7.5ml), 7.5-325 mg/15 ml
Tier 3
hydrocodone-acetaminophen oral tablet 10-325 mg, 10-500
mg, 10-650 mg, 10-660 mg, 10-750 mg, 2.5-325 mg,
2.5-500 mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,
7.5-650 mg, 7.5-750 mg
Tier 1
Note 3
hydrocodone-acetaminophen oral tablet 5-300 mg, 7.5-300
mg
Tier 3
Note 3
hydrocodone-ibuprofen oral tablet 7.5-200 mg
Tier 1
hydromorphone oral liquid
Tier 3
Note 3
hydromorphone oral tablet
Tier 1
Note 3
HYSINGLA ER
Tier 3
PA; QL
IMITREX NASAL SPRAY,NON-AEROSOL 20
MG/ACTUATION, 5 MG/ACTUATION
Tier 3
Note 3; QL
IMITREX ORAL
Tier 3
Note 3; QL
IMITREX STATDOSE KIT REFILL
Tier 3
Note 3; QL
IMITREX SUBCUTANEOUS
Tier 3
Note 3; QL
isometh-dichloral-acetaminophn
Tier 1
Note 3
KADIAN
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
ketorolac oral
Tier 1
Note 3; QL
LAZANDA
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
LITE COAT ASPIRIN
CE
CE
LO-DOSE ASPIRIN
CE
CE
LORTAB
Tier 3
MAXALT
Tier 3
Note 3; QL
MAXALT-MLT
Tier 3
Note 3; QL
mefenamic acid
Tier 3
meperidine oral tablet
Tier 1
Note 3
methadone oral tablet
Tier 1
Note 3
methadone oral tablet,soluble
Tier 1
Note 3
MIGRANAL
Tier 3
QL
CE
CE
MINIPRIN
morphine oral capsule, er multiphase 24 hr
Tier 1
PA; Note 4 (Standard); QL
morphine oral capsule,extend.release pellets
Tier 3
PA; Note 3; Note 4 (Standard); QL
morphine oral solution 10 mg/5 ml
Tier 1
Note 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
5
Drug Name
Drug Status
Additional Information
morphine oral tablet 15 mg
Tier 1
Note 3
morphine oral tablet extended release
Tier 1
Note 3
MS CONTIN
Tier 3
Note 3
naratriptan
Tier 1
Note 3; QL
NUCYNTA
Tier 3
ST; Note 3; Note 5 (Standard,Select); QL
NUCYNTA ER
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
ONSOLIS
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
OPANA ER ORAL TABLET EXTENDED RELEASE 12
HR 10 MG, 20 MG, 30 MG, 40 MG, 5 MG
Tier 2
Note 3; QL
OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12
HR
Tier 2
QL
OPANA ORAL
Tier 3
ST; Note 3; Note 5 (Standard,Select)
OXECTA
Tier 6
Note 3
oxycodone oral capsule
Tier 1
Note 3
oxycodone oral tablet
Tier 1
Note 3
oxycodone oral tablet,oral only,ext.rel.12 hr
Tier 3
QL
oxycodone-acetaminophen oral capsule
Tier 1
Note 3
OXYCONTIN ORAL TABLET EXTENDED RELEASE
12 HR
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR
Tier 3
PA; QL
oxymorphone oral tablet
Tier 3
ST; Note 5 (Standard)
oxymorphone oral tablet extended release 12 hr
Tier 1
QL
PERCOCET
Tier 3
PERCODAN
Tier 3
PONSTEL
Tier 3
PRIMLEV
Tier 3
RELPAX
Tier 3
ST; Note 3; Note 5 (Standard,Select); QL
rizatriptan
Tier 1
Note 3; QL
RYBIX ODT
Tier 6
Note 3
RYZOLT
Tier 6
SPRIX
Tier 3
ST. JOSEPH ASPIRIN
CE
Note 3; QL
CE
SUBSYS
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5
mg/actuation
Tier 1
Note 3; QL
sumatriptan succinate oral
Tier 1
Note 3; QL
sumatriptan succinate subcutaneous cartridge
Tier 1
Note 3; QL
sumatriptan succinate subcutaneous pen injector
Tier 1
Note 3; QL
sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml
Tier 1
Note 3; QL
SUMAVEL DOSEPRO
Tier 6
SYNALGOS-DC
Tier 3
tramadol oral capsule,er biphase 24 hr 25-75 150 mg
Tier 1
Note 3
tramadol oral tablet
Tier 1
Note 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
6
Drug Name
Drug Status
Additional Information
tramadol oral tablet extended release 24 hr
Tier 1
Note 3
tramadol oral tablet, er multiphase 24 hr
Tier 6
tramadol-acetaminophen
Tier 1
TREXIMET
Tier 6
TREZIX
Tier 3
TYLENOL
Tier 3
TYLENOL-CODEINE #3
Tier 3
Note 3
TYLENOL-CODEINE #4
Tier 3
Note 3
TYLOX
Tier 3
ULTRACET
Tier 3
QL
ULTRAM
Tier 3
Note 3
ULTRAM ER
Tier 3
Note 3; QL
VICODIN ES ORAL TABLET 7.5-750 MG
Tier 3
VICODIN HP ORAL TABLET 10-660 MG
Tier 3
VICODIN ORAL TABLET 5-500 MG
Tier 3
VICOPROFEN
Tier 3
XARTEMIS XR
Tier 3
XODOL 10/300
Tier 3
XODOL 5/300
Tier 3
XODOL 7.5/300
Tier 3
ZAMICET
Tier 3
ZIPSOR
Tier 3
ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER
12HR
Tier 3
PA; QL
ZOHYDRO ER ORAL CAPSULE,EXTENDED
RELEASE 12 HR
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
zolmitriptan oral tablet 2.5 mg, 5 mg
Tier 1
QL
zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg
Tier 1
QL
ZOMIG NASAL
Tier 3
ST; Note 5 (Standard,Select); QL
ZOMIG ORAL TABLET 2.5 MG, 5 MG
Tier 3
QL
ZOMIG ZMT ORAL TABLET,DISINTEGRATING 2.5
MG, 5 MG
Tier 3
Note 5 (Standard,Select); QL
QL
QL
ST; Note 5 (Standard,Select); QL
Anesthetics
CETACAINE
Tier 3
CETACAINE ANESTHETIC
Tier 3
EMLA
Tier 3
Note 3
lidocaine topical adhesive patch,medicated
Tier 1
PA; Note 4 (Standard)
LIDOCAINE VISCOUS
Tier 1
lidocaine-prilocaine topical cream
Tier 1
Note 3
LIDODERM
Tier 3
PA; Note 4 (Standard)
LIDORX
Tier 3
QL
phenazopyridine oral tablet 100 mg
Tier 1
LGC
phenazopyridine oral tablet 200 mg
Tier 1
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
7
Drug Name
SYNERA
Drug Status
Additional Information
Tier 3
Antiarthritics
allopurinol
Tier 1
ANAPROX
Tier 3
ANAPROX DS
Tier 3
ANSAID
Tier 3
ARAVA
Tier 3
ARTHROTEC 50
Tier 3
ARTHROTEC 75
Tier 3
CELEBREX
Tier 3
ST; Note 5 (Standard); QL
celecoxib
Tier 3
ST; QL
CLINORIL
Tier 3
colchicine-probenecid
Tier 1
COLCRYS
Tier 3
COMFORT PAC-IBUPROFEN
Tier 6
COMFORT PAC-MELOXICAM
Tier 6
COMFORT PAC-NAPROXEN
Tier 6
CUPRIMINE
Tier 2
DAYPRO
Tier 3
DEPEN TITRATABS
Tier 2
diclofenac sodium oral tablet extended release 24 hr
Tier 1
diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg,
50 mg
Tier 1
diclofenac sodium oral tablet,delayed release (dr/ec) 75 mg
Tier 1
diclofenac-misoprostol
Tier 1
DUEXIS
Tier 6
EC-NAPROSYN
Tier 3
ENBREL SUBCUTANEOUS RECON SOLN
Tier 4
PA; Note 4 (Standard,Select); QL
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML
(0.51), 50 MG/ML (0.98 ML)
Tier 4
PA; Note 4 (Standard,Select); QL
ENBREL SURECLICK
Tier 4
PA; Note 4 (Standard,Select); QL
etodolac
Tier 1
FELDENE
Tier 3
fenoprofen oral capsule
Tier 3
fenoprofen oral tablet
Tier 1
flurbiprofen
Tier 1
HUMIRA CROHN'S DIS START PCK
Tier 4
PA; QL
HUMIRA PED CROHN'S STARTER PK
Tier 4
PA; QL
HUMIRA PEN
Tier 4
PA; Note 4 (Standard,Select); QL
HUMIRA PSORIASIS STARTER PACK
Tier 4
PA; QL
HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2
ML
Tier 4
PA; QL
Tier 4
PA; Note 4 (Standard,Select); QL
HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4
ML, 40 MG/0.8 ML
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
8
LGC
QL
ST; Note 3; Note 5 (Standard); QL
LGC
Drug Name
Drug Status
Additional Information
ibuprofen oral suspension
Tier 1
ibuprofen oral tablet 100 mg, 200 mg
Tier 1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
ibuprofen oral tablet,chewable
Tier 1
INDOCIN ORAL
Tier 2
INDOCIN RECTAL
Tier 3
indomethacin oral
Tier 1
ketoprofen oral capsule
Tier 1
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
Tier 1
KINERET
Tier 5
PA; Note 4 (Standard,Select); QL
leflunomide
Tier 1
Note 3; QL
meclofenamate oral
Tier 1
meloxicam oral suspension
Tier 1
meloxicam oral tablet
Tier 1
LGC
MITIGARE
Tier 3
QL
MOBIC
Tier 3
nabumetone
Tier 1
NALFON
Tier 3
NAPRELAN CR
Tier 3
NAPROSYN
Tier 3
naproxen oral suspension
Tier 1
naproxen oral tablet
Tier 1
LGC
naproxen oral tablet,delayed release (dr/ec) 375 mg
Tier 1
LGC
naproxen oral tablet,delayed release (dr/ec) 500 mg
Tier 1
naproxen sodium oral tablet 275 mg
Tier 1
naproxen sodium oral tablet 550 mg
Tier 1
naproxen sodium oral tablet extended release
Tier 1
naproxen sodium oral tablet, er multiphase 24 hr
Tier 1
ORENCIA
Tier 5
PA; Note 4 (Standard,Select); QL
OTEZLA
Tier 5
PA; Note 4 (Standard,Select); QL
OTEZLA STARTER ORAL TABLETS,DOSE PACK 10
MG (4)-20 MG (4)-30 MG (47)
Tier 5
QL
OTEZLA STARTER ORAL TABLETS,DOSE PACK 10
MG (4)-20 MG (4)-30 MG(19)
Tier 5
PA; Note 4 (Standard,Select); QL
OTREXUP (PF)
Tier 5
PA
oxaprozin
Tier 1
piroxicam
Tier 1
probenecid
Tier 1
RASUVO (PF)
Tier 5
RIDAURA
Tier 2
salsalate
Tier 1
SIMPONI SUBCUTANEOUS PEN INJECTOR
Tier 5
PA; Note 4 (Standard,Select)
SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML
Tier 5
PA; Note 4 (Standard,Select)
LGC
LGC
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
9
Drug Name
Drug Status
SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML
Tier 5
sulindac oral
Tier 1
TIVORBEX
Tier 3
tolmetin
Tier 1
TREPADONE (WITH BROMELAIN)
Additional Information
PA; Note 4 (Standard,Select); QL
QL
LA
ULORIC
Tier 3
ST; Note 5 (Standard); QL
VIMOVO
Tier 6
VOLTAREN-XR
Tier 3
XELJANZ
Tier 5
PA; Note 4 (Standard,Select); QL
ZORVOLEX
Tier 3
ST; Note 5 (Standard); QL
ZYLOPRIM
Tier 3
Antiasthmatics
ACCOLATE
Tier 3
ACCUNEB
Tier 3
acetylcysteine solution
Tier 1
ADVAIR DISKUS
Tier 3
PA; Note 4 (Standard,Select); QL
ADVAIR HFA
Tier 3
PA; Note 4 (Standard,Select); QL
AEROSPAN
Tier 3
QL
albuterol sulfate inhalation solution for nebulization
Tier 1
albuterol sulfate oral
Tier 1
ALVESCO
Tier 3
QL
ANORO ELLIPTA
Tier 3
PA; Note 4 (Standard,Select); QL
ARCAPTA NEOHALER
Tier 3
PA; Note 4 (Standard,Select); QL
ARNUITY ELLIPTA
Tier 5
PA; QL
ASMANEX HFA
Tier 2
ASMANEX TWISTHALER
Tier 2
ATROVENT HFA
Tier 2
QL
BREO ELLIPTA INHALATION BLISTER WITH
DEVICE 100-25 MCG/DOSE
Tier 3
PA; Note 4 (Standard,Select); QL
BROVANA
Tier 3
PA; Note 4 (Standard); QL
budesonide inhalation
Tier 1
PA; QL; AL
COMBIVENT
Tier 2
COMBIVENT RESPIMAT
Tier 2
cromolyn inhalation
Tier 1
DALIRESP
Tier 3
QL
DULERA
Tier 2
QL
DUONEB
Tier 3
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML
Tier 3
FLOVENT DISKUS
Tier 3
PA; Note 4 (Standard,Select); QL
FLOVENT HFA
Tier 3
PA; QL
FORADIL AEROLIZER
Tier 2
QL
INCRUSE ELLIPTA
Tier 5
PA; QL
ipratropium bromide inhalation
Tier 1
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
10
QL
Drug Name
Drug Status
Additional Information
ipratropium-albuterol
Tier 1
levalbuterol hcl
Tier 1
LUFYLLIN
Tier 3
MAXAIR AUTOHALER
Tier 3
metaproterenol oral
Tier 1
montelukast
Tier 1
QL
PERFOROMIST
Tier 3
PA; Note 4 (Standard,Select); QL
PROAIR HFA
Tier 2
QL
PROAIR RESPICLICK
Tier 2
QL
PROVENTIL HFA
Tier 3
PA; Note 4 (Standard,Select); QL
PULMICORT
Tier 3
PA; Note 4 (Standard,Select); QL; AL
PULMICORT FLEXHALER
Tier 3
PA; Note 4 (Standard,Select); QL
QVAR
Tier 2
SEREVENT DISKUS
Tier 2
QL
SINGULAIR
Tier 3
QL
SPIRIVA RESPIMAT
Tier 2
QL
SPIRIVA WITH HANDIHALER
Tier 2
QL
STRIVERDI RESPIMAT
Tier 3
PA; Note 4 (Standard); QL
SYMBICORT
Tier 2
QL
THEO-24 ORAL CAPSULE,EXTENDED RELEASE
24HR 100 MG, 200 MG
Tier 2
QL
THEO-24 ORAL CAPSULE,EXTENDED RELEASE
24HR 300 MG, 400 MG
Tier 2
THEOCHRON
Tier 1
theophylline oral solution
Tier 3
theophylline oral tablet extended release
Tier 1
theophylline oral tablet extended release 12 hr
Tier 1
TUDORZA PRESSAIR
Tier 3
PA; Note 4 (Standard,Select); QL
VENTOLIN HFA
Tier 2
QL
VOSPIRE ER
Tier 3
XOPENEX
Tier 3
XOPENEX CONCENTRATE
Tier 3
XOPENEX HFA
Tier 3
zafirlukast
Tier 1
ZYFLO
Tier 3
ZYFLO CR
Tier 3
QL
PA; Note 4 (Standard,Select); QL
Antibiotics
ACTICLATE
Tier 6
ADOXA ORAL CAPSULE
Tier 6
QL
amoxicillin oral capsule
Tier 1
LGC; Note 3
amoxicillin oral suspension for reconstitution
Tier 1
LGC; Note 3
amoxicillin oral tablet
Tier 1
Note 3
amoxicillin oral tablet,chewable 125 mg, 250 mg, 400 mg
Tier 1
Note 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
11
Drug Name
Drug Status
Additional Information
amoxicillin-pot clavulanate oral suspension for
reconstitution
Tier 1
Note 3
amoxicillin-pot clavulanate oral tablet
Tier 1
Note 3
amoxicillin-pot clavulanate oral tablet,chewable
Tier 1
Note 3
ampicillin
Tier 1
Note 3
AUGMENTIN ORAL SUSPENSION FOR
RECONSTITUTION 125-31.25 MG/5 ML
Tier 2
AUGMENTIN ORAL SUSPENSION FOR
RECONSTITUTION 250-62.5 MG/5 ML
Tier 3
AUGMENTIN ORAL TABLET 500-125 MG, 875-125
MG
Tier 3
AUGMENTIN XR
Tier 3
AVAR TOPICAL CLEANSER
Tier 1
AVAR-E
Tier 3
AVAR-E GREEN
Tier 3
AVELOX
Tier 3
AVIDOXY
Tier 6
AVIDOXY DK
Tier 6
AZASITE
Tier 3
azithromycin oral packet
Tier 1
azithromycin oral suspension for reconstitution
Tier 1
Note 3
azithromycin oral tablet 250 mg, 500 mg
Tier 1
Note 3
azithromycin oral tablet 600 mg
Tier 1
bacitracin ophthalmic
Tier 1
bacitracin-polymyxin b ophthalmic
Tier 1
BACTRIM
Tier 3
Note 3
BACTRIM DS
Tier 3
Note 3
BACTROBAN
Tier 3
BACTROBAN NASAL
Tier 3
BENZAMYCIN
Tier 3
BENZAMYCINPAK
Tier 3
BESIVANCE
Tier 3
BETHKIS
Tier 5
BIAXIN ORAL SUSPENSION FOR RECONSTITUTION
250 MG/5 ML
Tier 3
Note 3; QL
BIAXIN ORAL TABLET
Tier 3
Note 3; QL
BIAXIN XL
Tier 3
Note 3; QL
BLEPH-10
Tier 3
BLEPHAMIDE
Tier 2
BLEPHAMIDE S.O.P.
Tier 2
BP 10-1
Tier 1
CAYSTON
Tier 5
CEDAX
Tier 3
cefaclor oral capsule
Tier 1
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
12
QL
Note 3; QL
QL
Note 3
Drug Name
Drug Status
Additional Information
cefaclor oral suspension for reconstitution 125 mg/5 ml,
250 mg/5 ml, 375 mg/5 ml
Tier 1
Note 3
cefaclor oral tablet extended release 12 hr
Tier 1
Note 3; QL
cefadroxil oral capsule
Tier 1
Note 3
cefadroxil oral suspension for reconstitution 250 mg/5 ml,
500 mg/5 ml
Tier 1
Note 3
cefadroxil oral tablet
Tier 1
Note 3
cefdinir
Tier 1
Note 3
cefixime
Tier 3
cefprozil
Tier 1
CEFTIN ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
CEFTIN ORAL TABLET 250 MG, 500 MG
Tier 3
cefuroxime axetil oral tablet
Tier 1
Note 3
cephalexin oral capsule 250 mg, 500 mg
Tier 1
LGC; Note 3
cephalexin oral capsule 750 mg
Tier 1
Note 3
cephalexin oral tablet
Tier 1
Note 3
CERISA
Tier 3
CETRAXAL
Tier 3
CILOXAN OPHTHALMIC DROPS
Tier 3
CILOXAN OPHTHALMIC OINTMENT
Tier 2
CIPRO
Tier 3
CIPRO HC
Tier 3
CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR
1,000 MG, 500 MG
Tier 3
CIPRODEX
Tier 2
ciprofloxacin hcl oral tablet 100 mg, 750 mg
Tier 1
Note 3
ciprofloxacin hcl oral tablet 250 mg, 500 mg
Tier 1
LGC; Note 3
ciprofloxacin oral suspension,microcapsule recon 250 mg/5
ml
Tier 1
Note 3
CLARIFOAM EF
Tier 2
clarithromycin oral suspension for reconstitution 125 mg/5
ml
Tier 1
Note 3
clarithromycin oral suspension for reconstitution 250 mg/5
ml
Tier 1
Note 3; QL
clarithromycin oral tablet
Tier 1
Note 3
clarithromycin oral tablet extended release 24 hr
Tier 1
Note 3
CLEOCIN ORAL
Tier 3
CLEOCIN T
Tier 3
CLEOCIN VAGINAL CREAM
Tier 3
CLEOCIN VAGINAL SUPPOSITORY
Tier 2
CLINDACIN PAC
Tier 6
CLINDAGEL
Tier 3
clindamycin hcl
Tier 1
Note 3
clindamycin phosphate topical lotion
Tier 1
Note 3
Note 3
Note 3
QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
13
Drug Name
Drug Status
Additional Information
clindamycin phosphate topical solution
Tier 1
Note 3
clindamycin phosphate topical swab
Tier 3
Note 3
clindamycin phosphate vaginal
Tier 1
Note 3
CLINDAREACH
Tier 6
CLINDESSE
Tier 3
COLY-MYCIN S
Tier 3
CORTISPORIN OTIC SOLUTION
Tier 3
CORTISPORIN-TC
Tier 3
dapsone
Tier 2
dicloxacillin
Tier 1
Note 3
DIFICID
Tier 3
Note 3; QL
DORYX ORAL TABLET,DELAYED RELEASE (DR/EC)
150 MG, 200 MG
Tier 6
doxycycline hyclate oral capsule
Tier 1
doxycycline hyclate oral tablet 100 mg
Tier 1
doxycycline hyclate oral tablet,delayed release (dr/ec)
Tier 6
doxycycline monohydrate oral capsule 100 mg, 50 mg
Tier 1
doxycycline monohydrate oral capsule 150 mg, 75 mg
Tier 6
doxycycline monohydrate oral suspension for reconstitution
Tier 1
doxycycline monohydrate oral tablet
Tier 6
DYNACIN ORAL TABLET
Tier 6
E.E.S. 200
Tier 2
E.E.S. 400 ORAL TABLET
Tier 1
Note 3
E.E.S. GRANULES
Tier 2
Note 3
ERY-TAB
Tier 1
Note 3
ERYTHROCIN (AS STEARATE) ORAL TABLET 250
MG
Tier 1
Note 3
erythromycin ethylsuccinate oral suspension for
reconstitution
Tier 1
LGC
erythromycin ethylsuccinate oral tablet
Tier 1
Note 3
erythromycin oral tablet
Tier 1
Note 3
erythromycin stearate oral tablet 250 mg
Tier 1
LGC
erythromycin with ethanol topical solution
Tier 1
erythromycin-benzoyl peroxide
Tier 1
ethambutol
Tier 1
EVOCLIN
Tier 3
FACTIVE
Tier 3
FLAGYL
Tier 3
FLAGYL ER
Tier 3
FURADANTIN
Tier 3
GARAMYCIN
Tier 3
gatifloxacin
Tier 3
gentamicin ophthalmic
Tier 1
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
14
Note 3
Note 3; QL
Note 3
Drug Name
Drug Status
Additional Information
gentamicin topical
Tier 1
LGC
HIPREX
Tier 3
ILOTYCIN
Tier 3
isoniazid oral solution
Tier 1
Note 3
isoniazid oral tablet 100 mg
Tier 1
Note 3
isoniazid oral tablet 300 mg
Tier 1
LGC; Note 3
KEFLEX ORAL CAPSULE
Tier 3
Note 3
KETEK
Tier 3
QL
LEVAQUIN ORAL SOLUTION
Tier 3
Note 3; QL
LEVAQUIN ORAL TABLET
Tier 3
Note 3; QL
levofloxacin ophthalmic
Tier 1
Note 3
levofloxacin oral
Tier 1
Note 3
MACROBID
Tier 3
MACRODANTIN
Tier 3
MAXITROL
Tier 3
methenamine hippurate
Tier 1
methenamine mandelate
Tier 1
METROGEL VAGINAL
Tier 3
metronidazole oral capsule
Tier 1
Note 3
metronidazole oral tablet
Tier 1
LGC; Note 3
metronidazole vaginal
Tier 1
MINOCIN KIT WITH WIPES
Tier 6
MINOCIN ORAL CAPSULE 100 MG, 50 MG
Tier 3
minocycline oral capsule
Tier 1
minocycline oral tablet
Tier 6
minocycline oral tablet extended release 24 hr
Tier 6
MONODOX ORAL CAPSULE 100 MG, 50 MG
Tier 3
MONODOX ORAL CAPSULE 75 MG
Tier 6
MORGIDOX
Tier 3
MORGIDOX 1X100
Tier 6
MORGIDOX 2X100
Tier 6
MOXATAG
Tier 3
MOXEZA
Tier 3
moxifloxacin
Tier 1
mupirocin
Tier 1
mupirocin calcium
Tier 1
MYAMBUTOL
Tier 3
Note 3
MYCOBUTIN
Tier 3
Note 3
neomycin
Tier 1
Note 3
neomycin-polymyxin b-dexameth
Tier 1
NEOSPORIN (NEO-POLYM-GRAMICID)
Tier 3
NEO-SYNALAR
Tier 3
Note 3
QL
Note 3; QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
15
Drug Name
Drug Status
Additional Information
NEO-SYNALAR KIT
Tier 3
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
Tier 1
nitrofurantoin monohyd/m-cryst
Tier 1
nitrofurantoin oral
Tier 1
Note 3
NOROXIN
Tier 3
Note 3; QL
NUVESSA
Tier 3
OCUFLOX
Tier 3
ofloxacin
Tier 1
Note 3
ORACEA
Tier 6
QL
PASER
Tier 3
PCE
Tier 3
penicillin v potassium oral recon soln
Tier 1
LGC; Note 3
penicillin v potassium oral tablet 250 mg
Tier 1
LGC; Note 3
penicillin v potassium oral tablet 500 mg
Tier 1
Note 3
PLEXION
Tier 3
ST; Note 5 (Standard)
PLEXION CLEANSING CLOTHS
Tier 3
ST; Note 5 (Standard)
polymyxin b sulf-trimethoprim
Tier 1
POLYTRIM
Tier 3
PRED-G
Tier 3
PRED-G S.O.P.
Tier 3
PRIFTIN
Tier 3
pyrazinamide
Tier 1
QUIXIN
Tier 3
rifabutin
Tier 1
RIFADIN
Tier 3
RIFAMATE
Tier 3
rifampin oral
Tier 1
RIFATER
Tier 3
ROSANIL
Tier 3
SEPTRA DS
Tier 3
SEROMYCIN
Tier 3
SILVADENE
Tier 3
silver sulfadiazine
Tier 1
Note 3
SIRTURO
Tier 5
PA; Note 4 (Standard,Select); QL
SIVEXTRO ORAL
Tier 3
PA; Note 4 (Standard); QL
SOLODYN
Tier 6
SPECTRACEF ORAL TABLET 200 MG
Tier 3
sulfacetamide sodium ophthalmic
Tier 1
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w),
9-4.5 %
Tier 1
sulfacetamide sodium-sulfur topical cleanser 9.8-4.8 %
Tier 3
ST
sulfacetamide sodium-sulfur topical cream 9.8-4.8 %
Tier 3
ST
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v)
Tier 1
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
16
Note 3
Note 3
Note 3
Drug Name
Drug Status
Additional Information
sulfacetamide sodium-sulfur topical lotion 9.8-4.8 %
Tier 3
ST
sulfacetamide sodium-sulfur topical suspension 10-5 %
Tier 1
sulfacetamide sod-sulfur-urea
Tier 1
sulfacetamide-prednisolone
Tier 1
sulfacetamide-sulfur-cleansr23
Tier 6
sulfadiazine oral
Tier 3
sulfamethoxazole-trimethoprim oral suspension
Tier 1
LGC; Note 3
sulfamethoxazole-trimethoprim oral tablet
Tier 1
Note 3
SULFAMYLON
Tier 3
SUMADAN
Tier 6
SUMADAN XLT
Tier 6
SUMAXIN CP
Tier 6
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML
Tier 3
QL
SUPRAX ORAL TABLET
Tier 3
QL
SUPRAX ORAL TABLET,CHEWABLE
Tier 3
QL
tetracycline
Tier 1
LGC
THALOMID
Tier 4
PA; Note 4 (Standard,Select)
TOBI
Tier 4
QL
TOBI PODHALER INHALATION CAPSULE
Tier 5
PA; Note 4 (Standard,Select); QL
TOBI PODHALER INHALATION CAPSULE,
W/INHALATION DEVICE
Tier 5
PA; Note 4 (Standard,Select)
TOBRADEX
Tier 3
TOBRADEX ST
Tier 3
tobramycin in 0.225 % nacl
Tier 4
TOBREX
Tier 3
TRECATOR
Tier 3
trimethoprim
Tier 1
TRIOXIN
Tier 3
VANCOCIN ORAL CAPSULE 125 MG, 250 MG
Tier 3
vancomycin intravenous
Tier 1
VANDAZOLE
Tier 1
VIBRAMYCIN ORAL CAPSULE 100 MG
Tier 3
VIBRAMYCIN ORAL SUSPENSION FOR
RECONSTITUTION
Tier 3
VIBRAMYCIN ORAL SYRUP
Tier 3
VIGAMOX
Tier 3
Note 3
XIFAXAN ORAL TABLET 200 MG
Tier 3
Note 3; QL
XIFAXAN ORAL TABLET 550 MG
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
ZITHROMAX ORAL PACKET
Tier 3
ZITHROMAX ORAL SUSPENSION FOR
RECONSTITUTION
Tier 3
ZITHROMAX ORAL TABLET 250 MG
Tier 3
ZITHROMAX ORAL TABLET 500 MG, 600 MG
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
Tier 3
QL
QL
Note 3
Note 3
17
Drug Name
Drug Status
Additional Information
ZITHROMAX TRI-PAK
Tier 3
Note 3
ZITHROMAX Z-PAK
Tier 3
ZMAX
Tier 3
ZYLET
Tier 3
ZYMAXID
Tier 3
QL
ZYVOX ORAL SUSPENSION FOR RECONSTITUTION
Tier 2
Note 3; QL
ZYVOX ORAL TABLET
Tier 2
Note 3; QL
ARIXTRA
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
COUMADIN ORAL
Tier 2
ELIQUIS
Tier 2
QL
enoxaparin
Tier 1
PA; Note 3; Note 4 (Standard); QL
fondaparinux
Tier 3
PA; Note 3; Note 4 (Standard); QL
FRAGMIN SUBCUTANEOUS INJECTABLE
Tier 3
PA; QL
FRAGMIN SUBCUTANEOUS SOLUTION
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
FRAGMIN SUBCUTANEOUS SYRINGE
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
heparin (porcine) injection cartridge
Tier 1
Note 3
heparin (porcine) injection solution
Tier 1
Note 3
IPRIVASK
Tier 3
PA; Note 4 (Standard)
LOVENOX
Tier 3
PA; Note 3; Note 4 (Standard); QL
PRADAXA
Tier 3
ST; Note 5 (Standard,Select); QL
warfarin
Tier 1
LGC
XARELTO ORAL TABLET 10 MG, 20 MG
Tier 2
QL
XARELTO ORAL TABLET 15 MG
Tier 2
LGC; QL
XARELTO ORAL TABLETS,DOSE PACK
Tier 2
QL
EVZIO
Tier 2
PA; Note 4 (Standard)
MOVANTIK
Tier 3
PA; QL
naltrexone oral
Tier 1
Note 3
RELISTOR
Tier 3
REVIA
Tier 3
QL
Anticoagulants
Antidotes
Antifungals
ANCOBON
Tier 3
CICLODAN KIT
Tier 6
ciclopirox topical cream
Tier 1
Note 3
ciclopirox topical gel
Tier 3
Note 3
ciclopirox topical shampoo
Tier 3
clotrimazole mucous membrane
Tier 1
clotrimazole topical cream
Tier 1
clotrimazole vaginal cream
Tier 1
CNL 8 NAIL
Tier 6
CRESEMBA ORAL
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
18
Drug Name
Drug Status
Additional Information
DIFLUCAN ORAL SUSPENSION FOR
RECONSTITUTION
Tier 3
DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG
Tier 3
DIFLUCAN ORAL TABLET 150 MG
Tier 3
econazole topical
Tier 1
ECOZA
Tier 6
ERTACZO
Tier 3
EXELDERM
Tier 2
EXTINA
Tier 3
fluconazole oral suspension for reconstitution
Tier 1
fluconazole oral tablet 100 mg, 200 mg, 50 mg
Tier 1
fluconazole oral tablet 150 mg
Tier 1
LGC
GRIFULVIN V ORAL TABLET
Tier 2
Note 3
griseofulvin microsize
Tier 1
Note 3
griseofulvin ultramicrosize
Tier 1
Note 3
GRIS-PEG (ULTRAMICROSIZE)
Tier 2
Note 3
GYNAZOLE-1 VAGINAL CREAM
Tier 3
QL
itraconazole
Tier 1
QL
JUBLIA
Tier 3
PA; Note 4 (Standard)
KERYDIN
Tier 3
PA
ketoconazole oral
Tier 1
Note 3; QL
ketoconazole topical cream
Tier 1
KETODAN KIT
Tier 6
LAMISIL ORAL GRANULES IN PACKET 125 MG,
187.5 MG
Tier 3
Note 3; QL
LAMISIL ORAL TABLET
Tier 3
Note 3
LOPROX
Tier 3
LOTRISONE
Tier 3
LUZU
Tier 3
MENTAX
Tier 3
MICONAZOLE-3 VAGINAL SUPPOSITORY
Tier 3
NAFTIN
Tier 3
NATACYN
Tier 3
NOXAFIL ORAL SUSPENSION
Tier 3
Note 3; QL
NOXAFIL ORAL TABLET,DELAYED RELEASE
(DR/EC)
Tier 3
Note 3; QL
nystatin oral suspension
Tier 1
nystatin oral tablet
Tier 1
Note 3
nystatin topical cream
Tier 1
Note 3
nystatin topical ointment
Tier 1
Note 3
nystatin vaginal
Tier 1
nystatin-triamcinolone
Tier 1
Note 3
ONMEL
Tier 6
QL
QL
AL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
19
Drug Name
Drug Status
Additional Information
ORAVIG
Tier 3
Note 3; QL
OXISTAT
Tier 3
PEDIPIROX-4
Tier 6
PENLAC
Tier 3
SPORANOX ORAL CAPSULE
Tier 3
QL
SPORANOX ORAL SOLUTION
Tier 2
Note 3
SPORANOX PULSEPAK
Tier 3
QL
TERAZOL 3
Tier 3
TERAZOL 7
Tier 3
terbinafine hcl oral
Tier 1
TERBINEX
Tier 6
terconazole
Tier 1
VFEND
Tier 3
Note 3
voriconazole oral tablet
Tier 1
Note 3
XOLEGEL
Tier 3
Note 3
Antihistamine And Decongestant Combination
ALAVERT D-12 ALLERGY-SINUS
Tier 1
Note 6
ALLEGRA-D 12 HOUR
Tier 6
QL
ALLEGRA-D 24 HOUR
Tier 6
QL
CLARINEX-D 12 HOUR
Tier 3
QL
CLARINEX-D 24 HOUR
Tier 3
QL
CLARITIN-D 12 HOUR
Tier 1
Note 3
CLARITIN-D 24 HOUR
Tier 1
Note 3
PROMETHAZINE VC
Tier 1
SEMPREX-D
Tier 3
ZYRTEC-D
Tier 1
Note 6
ALAVERT ORAL TABLET
Tier 1
Note 6
ALAVERT ORAL TABLET,DISINTEGRATING
Tier 1
LGC; Note 6
ALAWAY
Tier 1
LGC; Note 6
ALLEGRA
Tier 6
ALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MG
Tier 1
ALLEGRA ODT
Tier 6
ALLERGY RELIEF (LORATADINE) ORAL TABLET
Tier 1
Note 6
ALLERGY RELIEF (LORATADINE) ORAL
TABLET,DISINTEGRATING
Tier 1
Note 6
azelastine ophthalmic
Tier 3
BEPREVE
Tier 3
cetirizine oral solution 5 mg/5 ml
Tier 1
cetirizine oral tablet
Tier 1
LGC; Note 6
cetirizine oral tablet,chewable
Tier 1
Note 6
CHILDREN'S ALLEGRA ALLERGY
Tier 1
Note 6
Antihistamines
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
20
Note 6; QL
QL
Drug Name
Drug Status
Additional Information
CHILDREN'S CETIRIZINE ORAL
TABLET,CHEWABLE
Tier 1
CHILDREN'S ZYRTEC ALLERGY ORAL SOLUTION
Tier 1
CLARINEX ORAL SYRUP
Tier 3
CLARINEX ORAL TABLET
Tier 3
QL
CLARINEX ORAL TABLET,DISINTEGRATING
Tier 3
QL
CLARITIN ORAL SOLUTION
Tier 1
CLARITIN REDITABS
Tier 1
clemastine oral tablet 2.68 mg
Tier 1
cyproheptadine
Tier 1
desloratadine
Tier 3
dexchlorpheniramine maleate
Tier 1
ELESTAT
Tier 3
hydroxyzine hcl oral solution 10 mg/5 ml
Tier 1
hydroxyzine hcl oral tablet
Tier 1
hydroxyzine pamoate oral capsule 25 mg, 50 mg
Tier 1
KARBINAL ER
Tier 3
ST; Note 5 (Standard)
LASTACAFT
Tier 3
QL
levocetirizine oral solution
Tier 3
levocetirizine oral tablet
Tier 3
QL
loratadine oral solution
Tier 1
Note 6
loratadine oral tablet
Tier 1
LGC; Note 6
loratadine oral tablet,disintegrating
Tier 1
LGC; Note 6
OPTIVAR
Tier 3
PATADAY
Tier 3
PATANOL
Tier 3
PAZEO
Tier 3
promethazine oral
Tier 1
VISTARIL
Tier 3
XYZAL
Tier 3
QL
ZADITOR
Tier 1
Note 6
ZYRTEC ORAL CAPSULE
Tier 1
ZYRTEC ORAL TABLET
Tier 1
ZYRTEC ORAL TABLET,CHEWABLE
Tier 1
Note 6
QL
LGC
Note 6
Antihyperglycemics
acarbose
Tier 1
ACTOPLUS MET
Tier 3
QL
ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 15-1,000 MG, 30-1,000 MG
Tier 2
QL
ACTOS
Tier 3
QL
AFREZZA
Tier 3
PA
AMARYL
Tier 3
APIDRA
Tier 3
ST; Note 5 (Standard,Select)
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
21
Drug Name
Drug Status
Additional Information
APIDRA SOLOSTAR
Tier 3
ST; Note 5 (Standard,Select)
AVANDAMET
Tier 3
PA; Note 4 (Standard,Select); QL
AVANDARYL
Tier 3
PA; Note 4 (Standard,Select); QL
AVANDIA
Tier 3
PA; Note 4 (Standard,Select); QL
BYDUREON
Tier 2
ST; Note 5 (Standard,Select); QL
BYETTA
Tier 3
ST; Note 5 (Standard,Select); QL
chlorpropamide oral tablet 100 mg
Tier 1
LGC
chlorpropamide oral tablet 250 mg
Tier 1
CYCLOSET
Tier 3
DIABETA
Tier 3
DUETACT
Tier 3
QL
FARXIGA
Tier 3
ST; Note 5 (Standard,Select); QL
FORTAMET
Tier 3
glimepiride
Tier 1
LGC
glipizide oral tablet
Tier 1
LGC
glipizide oral tablet extended release 24hr 10 mg, 5 mg
Tier 1
LGC
glipizide oral tablet extended release 24hr 2.5 mg
Tier 1
glipizide-metformin
Tier 1
GLUCOPHAGE
Tier 3
GLUCOPHAGE XR
Tier 3
GLUCOTROL
Tier 3
GLUCOTROL XL
Tier 3
GLUCOVANCE
Tier 3
GLUMETZA
Tier 3
glyburide micronized oral tablet 1.5 mg
Tier 1
glyburide micronized oral tablet 3 mg, 6 mg
Tier 1
glyburide oral tablet 1.25 mg
Tier 1
glyburide oral tablet 2.5 mg, 5 mg
Tier 1
glyburide-metformin
Tier 1
GLYNASE
Tier 3
GLYSET
Tier 3
GLYXAMBI
Tier 3
HUMALOG
Tier 2
HUMALOG KWIKPEN
Tier 2
HUMALOG MIX 50-50
Tier 2
HUMALOG MIX 50-50 KWIKPEN
Tier 2
HUMALOG MIX 75-25
Tier 2
HUMALOG MIX 75-25 KWIKPEN
Tier 2
HUMULIN 70/30
Tier 2
HUMULIN 70/30 KWIKPEN
Tier 2
HUMULIN 70/30 PEN
Tier 2
HUMULIN N
Tier 2
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
22
QL
LGC
LGC
ST; QL
Drug Name
Drug Status
Additional Information
HUMULIN N KWIKPEN
Tier 2
HUMULIN N PEN
Tier 2
HUMULIN R
Tier 2
HUMULIN R U-500 "CONCENTRATED"
Tier 2
INVOKAMET
Tier 2
ST; Note 5 (Standard,Select); QL
INVOKANA
Tier 2
ST; Note 5 (Standard,Select); QL
JANUMET
Tier 2
ST; Note 5 (Standard); QL
JANUMET XR ORAL TABLET, ER MULTIPHASE 24
HR 100-1,000 MG, 50-1,000 MG, 50-500 MG
Tier 2
ST; Note 5 (Standard); QL
JANUVIA
Tier 2
ST; Note 5 (Standard); QL
JARDIANCE
Tier 3
ST; Note 5 (Standard); QL
JENTADUETO
Tier 3
PA; Note 4 (Standard); QL
JUVISYNC
Tier 2
ST; Note 5 (Standard); QL
KAZANO
Tier 3
PA; Note 4 (Standard); QL
KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE
24 HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG
Tier 2
ST; Note 5 (Standard); QL
KORLYM
Tier 5
PA; Note 4 (Standard,Select); QL
LANTUS
Tier 3
ST; Note 5 (Standard,Select)
LANTUS SOLOSTAR
Tier 3
ST; Note 5 (Standard,Select)
LEVEMIR
Tier 2
LEVEMIR FLEXPEN
Tier 2
LEVEMIR FLEXTOUCH
Tier 2
metformin oral tablet
Tier 1
LGC
metformin oral tablet extended release 24 hr 500 mg
Tier 1
LGC
metformin oral tablet extended release 24 hr 750 mg
Tier 1
metformin oral tablet extended release 24hr
Tier 3
nateglinide
Tier 3
NESINA
Tier 3
PA; Note 4 (Standard); QL
NOVOLIN 70/30
Tier 3
ST; Note 5 (Standard,Select)
NOVOLIN R
Tier 3
ST; Note 5 (Standard,Select)
NOVOLOG
Tier 3
ST; Note 5 (Standard,Select)
NOVOLOG FLEXPEN
Tier 3
ST; Note 5 (Standard,Select)
NOVOLOG MIX 70-30
Tier 3
ST; Note 5 (Standard,Select)
NOVOLOG MIX 70-30 FLEXPEN
Tier 3
ST; Note 5 (Standard,Select)
ONGLYZA
Tier 2
ST; Note 5 (Standard); QL
OSENI
Tier 3
PA; Note 4 (Standard,Select); QL
pioglitazone
Tier 1
pioglitazone-glimepiride
Tier 1
pioglitazone-metformin
Tier 1
QL
PRANDIMET
Tier 3
QL
PRANDIN
Tier 3
PRECOSE
Tier 3
repaglinide
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
23
Drug Name
Drug Status
Additional Information
STARLIX
Tier 3
SYMLIN
Tier 3
PA; Note 4 (Standard,Select)
SYMLINPEN 120
Tier 3
PA; Note 4 (Standard,Select); QL
SYMLINPEN 60
Tier 3
PA; Note 4 (Standard,Select); QL
TANZEUM SUBCUTANEOUS PEN INJECTOR 30
MG/0.5 ML, 50 MG/0.5 ML
Tier 3
PA; Note 4 (Standard); QL
tolazamide
Tier 1
tolbutamide
Tier 1
TOUJEO SOLOSTAR
Tier 3
PA
TRADJENTA
Tier 3
PA; Note 4 (Standard); QL
TRULICITY
Tier 3
PA; QL
VICTOZA 2-PAK
Tier 3
PA; Note 4 (Standard,Select); QL
VICTOZA 3-PAK
Tier 3
PA; Note 4 (Standard,Select); QL
XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC
24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG
Tier 3
ST; QL
Antiinfectives
AVC VAGINAL
Tier 3
Antiinfectives/Miscellaneous
ALBENZA
Tier 3
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
QL
ALINIA ORAL TABLET
Tier 3
QL
ARALEN
Tier 3
Note 3
atovaquone
Tier 1
QL
atovaquone-proguanil
Tier 3
PA; Note 3; Note 4 (Standard); QL
BILTRICIDE
Tier 2
Note 3
chloroquine phosphate oral
Tier 1
Note 3
COARTEM
Tier 2
PA; Note 3; Note 4 (Standard,Select); QL
DARAPRIM
Tier 2
Note 3
FEM PH
Tier 3
hydroxychloroquine oral
Tier 1
ivermectin oral
Tier 3
MALARONE
Tier 3
PA; Note 4 (Standard,Select); QL
MALARONE PEDIATRIC
Tier 3
PA; Note 4 (Standard,Select); QL
MEPRON
Tier 3
Note 3; QL
NEBUPENT
Tier 2
Note 3
paromomycin
Tier 1
Note 3
PLAQUENIL
Tier 3
primaquine
Tier 3
QUALAQUIN
Tier 3
RELAGARD
Tier 3
STROMECTOL
Tier 3
TINDAMAX ORAL TABLET 250 MG, 500 MG
Tier 3
QL
YODOXIN
Tier 2
Note 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
24
PA; Note 3; Note 4 (Standard,Select); QL
Drug Name
Drug Status
Additional Information
ACTIMMUNE
Tier 4
PA; Note 4 (Standard,Select)
AFINITOR
Tier 5
PA; Note 4 (Standard,Select); QL
AFINITOR DISPERZ
Tier 5
PA; Note 4 (Standard,Select); QL
ALKERAN ORAL
Tier 4
anastrozole
Tier 1
PA; Note 3; Note 4 (Standard)
ARIMIDEX
Tier 3
PA; Note 3
AROMASIN
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
bicalutamide
Tier 1
QL
BOSULIF ORAL TABLET 100 MG
Tier 5
PA; Note 4 (Standard,Select); QL
BOSULIF ORAL TABLET 500 MG
Tier 5
PA; Note 4 (Standard,Select)
capecitabine
Tier 4
PA; Note 4 (Standard,Select)
CAPRELSA ORAL TABLET 100 MG, 300 MG
Tier 5
PA; Note 4 (Standard,Select); QL
CASODEX
Tier 3
QL
CEENU ORAL CAPSULE 10 MG, 100 MG, 40 MG
Tier 4
COMETRIQ
Tier 5
cyclophosphamide oral capsule
Tier 5
cyclophosphamide oral tablet
Tier 4
diclofenac sodium topical gel
Tier 1
EFUDEX TOPICAL CREAM
Tier 3
EMCYT
Tier 2
Note 3
ERIVEDGE
Tier 5
PA; Note 4 (Standard,Select); QL
etoposide oral
Tier 4
exemestane
Tier 1
FARESTON
Tier 2
FARYDAK
Tier 5
PA; QL
FEMARA
Tier 3
PA; Note 4 (Standard,Select)
FLUOROPLEX
Tier 3
fluorouracil topical cream 0.5 %
Tier 3
fluorouracil topical cream 5 %
Tier 1
fluorouracil topical solution
Tier 1
flutamide
Tier 1
GILOTRIF
Tier 5
PA; Note 4 (Standard,Select)
GLEEVEC
Tier 4
PA; Note 4 (Standard,Select)
GLEOSTINE
Tier 5
HEXALEN
Tier 4
HYCAMTIN ORAL
Tier 5
PA; Note 3; Note 4 (Standard,Select)
HYDREA
Tier 1
Note 3
hydroxyurea
Tier 1
Note 3
IBRANCE
Tier 5
PA; QL
ICLUSIG ORAL TABLET 15 MG, 45 MG
Tier 5
PA; Note 4 (Standard,Select); QL
IMBRUVICA
Tier 5
PA; Note 4 (Standard,Select)
Antineoplastics
PA; Note 4 (Standard,Select); QL
PA; Note 3; Note 4 (Standard,Select); QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
25
Drug Name
Drug Status
Additional Information
INLYTA
Tier 5
PA; Note 4 (Standard,Select); QL
INTRON A INJECTION RECON SOLN 10 MILLION
UNIT (1 ML), 18 MILLION UNIT (1 ML)
Tier 4
PA
INTRON A INJECTION RECON SOLN 50 MILLION
UNIT (1 ML)
Tier 4
PA; Note 4 (Standard,Select)
INTRON A INJECTION SOLUTION 10 MILLION
UNIT/ML
Tier 4
PA
INTRON A INJECTION SOLUTION 6 MILLION
UNIT/ML
Tier 4
PA; Note 4 (Standard,Select)
JAKAFI
Tier 5
PA; Note 4 (Standard,Select); QL
LENVIMA
Tier 5
PA
letrozole
Tier 1
PA; Note 4 (Standard,Select)
LEUKERAN
Tier 2
leuprolide
Tier 5
LEVULAN
Tier 3
lomustine
Tier 4
LYNPARZA
Tier 5
LYSODREN
Tier 2
MATULANE
Tier 4
megestrol oral tablet
Tier 1
MEKINIST ORAL TABLET 0.5 MG, 2 MG
Tier 5
PA; Note 4 (Standard,Select); QL
mercaptopurine
Tier 1
Note 3
methotrexate sodium
Tier 1
Note 3
methotrexate sodium (pf) injection solution
Tier 1
MYLERAN
Tier 4
NEXAVAR
Tier 5
NILANDRON
Tier 2
PANRETIN
Tier 3
PICATO
Tier 2
Note 3; QL
POMALYST
Tier 5
PA; Note 4 (Standard,Select); QL
PURINETHOL
Tier 3
PURIXAN
Tier 5
PA; Note 4 (Standard,Select); QL
REVLIMID
Tier 5
PA; Note 4 (Standard,Select); QL
SOLARAZE
Tier 3
SOLTAMOX
Tier 3
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50
MG, 70 MG, 80 MG
Tier 5
PA; Note 4 (Standard,Select); QL
STIVARGA
Tier 5
PA; Note 4 (Standard,Select); QL
SUTENT
Tier 4
PA; Note 4 (Standard,Select); QL
SYLATRON
Tier 5
PA; Note 4 (Standard,Select)
SYLATRON 4-PACK
Tier 5
PA; Note 4 (Standard,Select)
TABLOID
Tier 2
TAFINLAR
Tier 5
tamoxifen
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
26
CE
PA; Note 4 (Standard,Select)
PA
PA; Note 4 (Standard,Select); QL
PA; Note 4 (Standard,Select); QL
CE
Drug Name
Drug Status
Additional Information
TARCEVA
Tier 4
PA; Note 4 (Standard,Select); QL
TARGRETIN
Tier 4
TASIGNA
Tier 5
PA; Note 4 (Standard,Select); QL
TEMODAR ORAL
Tier 4
PA; Note 4 (Standard,Select)
temozolomide
Tier 4
PA; Note 4 (Standard,Select)
tretinoin (chemotherapy)
Tier 4
TYKERB
Tier 5
PA; Note 4 (Standard,Select)
VALCHLOR
Tier 5
PA; Note 4 (Standard,Select)
VOTRIENT
Tier 5
PA; Note 4 (Standard,Select); QL
XALKORI ORAL CAPSULE 200 MG
Tier 5
PA; Note 4 (Standard,Select)
XALKORI ORAL CAPSULE 250 MG
Tier 5
PA; Note 4 (Standard,Select); QL
XELODA
Tier 5
PA; Note 4 (Standard,Select)
XTANDI
Tier 5
PA; Note 4 (Standard,Select); QL
ZELBORAF
Tier 5
PA; Note 4 (Standard,Select); QL
ZOLINZA
Tier 5
PA; Note 4 (Standard,Select); QL
ZYDELIG
Tier 5
PA; Note 3; Note 4 (Standard,Select); QL
ZYKADIA
Tier 5
PA; Note 4 (Standard,Select)
ZYTIGA
Tier 4
PA; Note 4 (Standard,Select); QL
Anti-Obesity Drugs
ADIPEX-P ORAL TABLET
Tier 3
ALLI
Tier 3
BELVIQ
LA
benzphetamine
LA
CONTRAVE
Tier 3
DIDREX
Tier 3
diethylpropion
LA
phendimetrazine tartrate
LA
phentermine
LA
QSYMIA
LA
REGIMEX
LA
SAXENDA
LA
SUPRENZA
LA
XENICAL
LA
QL
QL
PA; ST; Note 4 (Standard,Select); Note 5
(Standard,Select); QL
Antiparkinson Drugs
amantadine hcl oral
Tier 1
APOKYN
Tier 5
AZILECT
Tier 2
QL
benztropine oral
Tier 1
LGC
bromocriptine
Tier 1
carbidopa
Tier 3
carbidopa-levodopa
Tier 1
carbidopa-levodopa-entacapone
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
27
Drug Name
Drug Status
Additional Information
COMTAN
Tier 3
DUOPA
Tier 5
ELDEPRYL
Tier 3
entacapone
Tier 1
LODOSYN
Tier 3
MIRAPEX
Tier 3
MIRAPEX ER
Tier 3
QL
NEUPRO
Tier 3
QL
PARCOPA
Tier 3
PARLODEL
Tier 3
pramipexole oral tablet
Tier 1
pramipexole oral tablet extended release 24 hr
Tier 3
REQUIP
Tier 3
REQUIP XL ORAL TABLET EXTENDED RELEASE 24
HR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG
Tier 3
ropinirole oral tablet
Tier 1
ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4
mg, 6 mg, 8 mg
Tier 3
RYTARY
Tier 3
selegiline hcl
Tier 1
SINEMET
Tier 3
SINEMET CR
Tier 3
STALEVO 100
Tier 3
STALEVO 125
Tier 3
STALEVO 150
Tier 3
STALEVO 200
Tier 3
STALEVO 50
Tier 3
STALEVO 75
Tier 3
TASMAR
Tier 3
tolcapone
Tier 3
trihexyphenidyl oral elixir
Tier 1
trihexyphenidyl oral tablet 2 mg
Tier 1
trihexyphenidyl oral tablet 5 mg
Tier 1
ZELAPAR
Tier 3
PA; QL
QL
QL
QL
LGC
QL
Antiplatelet Drugs
AGGRENOX
Tier 2
AGRYLIN
Tier 3
anagrelide
Tier 1
BRILINTA
Tier 2
cilostazol
Tier 1
clopidogrel
Tier 1
dipyridamole oral
Tier 1
EFFIENT
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
28
QL
QL
PA; QL
Drug Name
Drug Status
PERSANTINE
Tier 3
PLAVIX
Tier 3
PLETAL
Tier 3
ticlopidine
Tier 1
ZONTIVITY
Tier 3
Additional Information
QL
PA; Note 4 (Standard)
Antivirals
abacavir
Tier 4
abacavir-lamivudine-zidovudine
Tier 5
Note 3
ABREVA
Tier 1
Note 6
acyclovir oral capsule
Tier 1
LGC
acyclovir oral suspension 200 mg/5 ml
Tier 1
acyclovir oral tablet 400 mg
Tier 1
acyclovir oral tablet 800 mg
Tier 1
acyclovir topical
Tier 3
adefovir
Tier 4
APTIVUS ORAL CAPSULE
Tier 4
Note 3; QL
APTIVUS ORAL SOLUTION
Tier 4
Note 3
ATRIPLA
Tier 5
QL
BARACLUDE ORAL SOLUTION
Tier 5
BARACLUDE ORAL TABLET
Tier 5
COMBIVIR
Tier 5
COMPLERA
Tier 5
QL
COPEGUS
Tier 4
PA; Note 4 (Standard,Select)
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 5
DENAVIR
Tier 3
didanosine
Tier 4
EDURANT
Tier 5
QL
EMTRIVA
Tier 4
QL
entecavir
Tier 4
PA
EPIVIR
Tier 4
EPIVIR HBV
Tier 4
EPZICOM
Tier 5
EVOTAZ
Tier 5
famciclovir
Tier 1
Note 3; QL
FAMVIR
Tier 3
QL
FLUMADINE ORAL TABLET
Tier 3
FUZEON
Tier 5
HARVONI
Tier 4
PA; QL
HEPSERA
Tier 4
QL
INCIVEK
Tier 5
PA; Note 4 (Standard,Select); QL
INFERGEN
Tier 5
PA; Note 4 (Standard,Select)
INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG
Tier 5
QL
LGC
QL
Note 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
29
Drug Name
Drug Status
Additional Information
INVIRASE
Tier 5
ISENTRESS ORAL POWDER IN PACKET
Tier 5
ISENTRESS ORAL TABLET
Tier 5
ISENTRESS ORAL TABLET,CHEWABLE
Tier 5
KALETRA
Tier 5
lamivudine oral solution
Tier 4
lamivudine oral tablet
Tier 4
lamivudine-zidovudine
Tier 5
LEXIVA
Tier 4
MODERIBA DOSE PACK
Tier 6
nevirapine oral suspension
Tier 4
Note 3
nevirapine oral tablet
Tier 4
Note 3
nevirapine oral tablet extended release 24 hr
Tier 5
Note 3; QL
NORVIR
Tier 4
OLYSIO
Tier 4
PA; ST; Note 4 (Standard,Select); Note 5
(Standard,Select); QL
PEGASYS
Tier 4
PA; Note 4 (Standard,Select)
PEGASYS CONVENIENCE PACK
Tier 4
PA; Note 4 (Standard,Select)
PEGASYS PROCLICK
Tier 4
PA; Note 4 (Standard,Select)
PEGINTRON
Tier 5
PA; Note 4 (Standard,Select)
PEGINTRON REDIPEN
Tier 5
PA; Note 4 (Standard,Select)
PREZCOBIX
Tier 5
PREZISTA ORAL SUSPENSION
Tier 5
Note 3; QL
PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG,
75 MG, 800 MG
Tier 5
Note 3; QL
REBETOL ORAL CAPSULE
Tier 4
PA; Note 4 (Standard,Select)
REBETOL ORAL SOLUTION
Tier 4
PA; Note 4 (Standard,Select); QL
RELENZA DISKHALER
Tier 3
QL
RESCRIPTOR
Tier 5
RETROVIR ORAL
Tier 4
REYATAZ ORAL CAPSULE 100 MG, 150 MG, 200 MG,
300 MG
Tier 4
REYATAZ ORAL POWDER IN PACKET
Tier 4
RIBASPHERE
Tier 4
RIBASPHERE RIBAPAK
Tier 6
ribavirin oral capsule
Tier 4
ribavirin oral tablet 200 mg
Tier 4
rimantadine
Tier 1
Note 3
SELZENTRY
Tier 5
PA; Note 4 (Standard,Select); QL
SOVALDI
Tier 4
PA; Note 4 (Standard,Select); QL
stavudine
Tier 4
STRIBILD
Tier 5
SUSTIVA
Tier 4
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
30
QL
PA
Note 3
QL
PA; Note 4 (Standard,Select)
PA; Note 4 (Standard,Select); QL
Drug Name
Drug Status
Additional Information
SYNAGIS
Tier 6
PA; Note 4 (Standard,Select)
TAMIFLU ORAL CAPSULE
Tier 3
Note 3; QL
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION
Tier 3
Note 3; QL
TIVICAY
Tier 5
trifluridine
Tier 1
TRIUMEQ
Tier 5
PA; QL
TRIZIVIR
Tier 4
Note 3
TRUVADA
Tier 4
PA; Note 4 (Standard,Select)
TYZEKA
Tier 5
QL
valacyclovir oral tablet 1 gram, 500 mg
Tier 1
Note 3; QL
VALCYTE ORAL RECON SOLN
Tier 4
PA; Note 3; Note 4 (Standard,Select);
Note 5 (Standard,Select)
VALCYTE ORAL TABLET
Tier 5
PA; Note 3; Note 4 (Standard,Select);
Note 5 (Standard,Select)
valganciclovir
Tier 4
PA; Note 3; Note 4 (Standard,Select);
Note 5 (Standard,Select)
VALTREX ORAL TABLET 1 GRAM, 500 MG
Tier 3
Note 3; QL
VEREGEN
Tier 3
VICTRELIS
Tier 5
VIDEX 2 GRAM PEDIATRIC
Tier 4
VIDEX 4 GRAM PEDIATRIC
Tier 4
VIDEX EC
Tier 4
VIEKIRA PAK
Tier 5
VIRACEPT ORAL TABLET
Tier 5
VIRAMUNE
Tier 4
VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG
Tier 5
VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR 400 MG
Tier 5
VIREAD ORAL POWDER
Tier 4
VIREAD ORAL TABLET
Tier 4
VIROPTIC
Tier 3
VITEKTA
Tier 5
ZERIT
Tier 4
ZIAGEN
Tier 4
zidovudine
Tier 4
ZIRGAN
Tier 3
ZOVIRAX ORAL
Tier 3
ZOVIRAX TOPICAL CREAM
Tier 3
ZOVIRAX TOPICAL OINTMENT
Tier 3
Note 3
Tier 3
Note 3; QL
PA; QL
PA; QL
QL
QL
QL
Autonomic Drugs
ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG,
20 MG, 30 MG, 5 MG, 7.5 MG
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
31
Drug Name
Drug Status
Additional Information
ADDERALL XR
Tier 3
PA; Note 3; Note 4 (Standard); QL; AL
ADRENACLICK
Tier 3
PA; Note 4 (Standard); QL
ADRENALIN INJECTION
Tier 3
AMPHETAMINE SALT COMBO ORAL TABLET 10
MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG
Tier 1
QL
ARICEPT ODT
Tier 3
AL
ARICEPT ORAL TABLET 10 MG
Tier 3
AL
ARICEPT ORAL TABLET 23 MG, 5 MG
Tier 3
QL; AL
AUVI-Q
Tier 2
QL
bethanechol chloride
Tier 1
DESOXYN ORAL TABLET 5 MG
Tier 3
QL
DEXEDRINE SPANSULE
Tier 3
PA; QL
dextroamphetamine oral capsule, extended release
Tier 1
QL
dextroamphetamine oral solution
Tier 1
PA; Note 4 (Standard); QL
dextroamphetamine oral tablet 10 mg, 5 mg
Tier 1
QL
dextroamphetamine-amphetamine oral capsule,extended
release 24hr
Tier 1
PA; Note 3; Note 4 (Standard); QL
DIBENZYLINE
Tier 2
donepezil oral tablet 10 mg
Tier 1
AL
donepezil oral tablet 23 mg
Tier 3
QL; AL
donepezil oral tablet 5 mg
Tier 1
QL; AL
donepezil oral tablet,disintegrating
Tier 1
AL
epinephrine hcl (pf) injection
Tier 1
epinephrine injection auto-injector 0.15 mg/0.15 ml
(1:1,000), 0.3 mg/0.3 ml (1:1,000)
Tier 1
epinephrine injection solution 1 mg/ml (1:1,000)
Tier 1
epinephrine injection syringe 0.1 mg/ml (1:10,000)
Tier 1
EPIPEN
Tier 2
Note 3; QL
EPIPEN 2-PAK
Tier 2
QL
EPIPEN JR
Tier 2
Note 3; QL
EPIPEN JR 2-PAK
Tier 2
QL
EVEKEO
Tier 3
PA; QL
EVOXAC
Tier 2
QL
EXELON ORAL CAPSULE
Tier 3
QL
EXELON ORAL SOLUTION
Tier 3
QL
EXELON TRANSDERMAL
Tier 3
QL
galantamine
Tier 3
MESTINON ORAL
Tier 3
methamphetamine
Tier 1
midodrine
Tier 3
NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300
MG
Tier 5
PA; Note 4 (Standard,Select); QL
PROCENTRA
Tier 3
PA; Note 4 (Standard,Select); QL
PROSTIGMIN
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
Tier 2
32
QL
QL
Drug Name
Drug Status
Additional Information
pyridostigmine bromide
Tier 1
RAZADYNE ER
Tier 3
QL; AL
RAZADYNE ORAL TABLET
Tier 3
AL
SALAGEN
Tier 3
URECHOLINE
Tier 3
ZENZEDI ORAL TABLET 10 MG, 5 MG
Tier 1
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30
MG, 7.5 MG
Tier 6
QL
Biologicals
AFLURIA 2013-2014
LA
AFLURIA 2013-2014 (PF)
LA
AFLURIA 2014-2015
LA
AFLURIA 2014-2015 (PF)
LA
FLUARIX 2013-2014 (PF)
LA
FLUARIX QUAD 2013-2014 (PF)
LA
FLUBLOK 2013-2014 (PF)
LA
FLULAVAL 2013-2014
LA
FLULAVAL 2014-2015
LA
FLULAVAL QUAD 2013-2014
LA
FLULAVAL QUAD 2014-2015
LA
FLUVIRIN 2013-2014
LA
FLUVIRIN 2013-2014 (PF)
LA
FLUVIRIN 2014-2015
LA
FLUVIRIN 2014-2015 (PF)
LA
FLUZONE 2013-2014
LA
FLUZONE 2013-2014 (PF)
LA
FLUZONE 2014-2015
LA
FLUZONE 2014-2015 (PF)
LA
FLUZONE HIGH-DOSE 2014-15 (PF)
LA
FLUZONE INTRADERM 2013-14 (PF)
LA
FLUZONE INTRADERM 2014-15 (PF)
LA
FLUZONE PEDI 2013-2014 (PF)
LA
FLUZONE QUAD 2013-2014 (PF)
LA
FLUZONE QUAD 2014-2015
LA
FLUZONE QUAD 2014-2015 (PF)
LA
FLUZONE QUAD PEDI 2013-14 (PF)
LA
FLUZONE QUAD PEDI 2014-15 (PF)
LA
GAMMAGARD LIQUID
Tier 5
PA
GAMMAKED
Tier 5
PA; Note 4 (Standard,Select)
GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML
(10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10
%), 5 GRAM/50 ML (10 %)
Tier 5
PA; Note 4 (Standard,Select)
Tier 5
PA
GAMUNEX-C INJECTION SOLUTION 10 GRAM/100
ML (10 %)
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
33
Drug Name
Drug Status
Additional Information
HIZENTRA
Tier 4
PA; Note 4 (Standard,Select)
HYPERRHO S/D
Tier 3
Note 3; QL
HYQVIA
Tier 5
PA
PNEUMOVAX 23 INJECTION SYRINGE
LA
RHOGAM ULTRA-FILTERED PLUS
Tier 3
QL
TRUMENBA
Tier 2
PA; QL
WINRHO SDF
Tier 3
Note 3; QL
ADVATE
Tier 4
PA
ALPHANATE
Tier 5
PA
ALPHANINE SD
Tier 5
PA
ALPROLIX
Tier 5
PA
aminocaproic acid oral
Tier 1
BENEFIX
Tier 4
PA
CORIFACT
Tier 5
PA
ELOCTATE
Tier 5
PA
FEIBA NF
Tier 4
PA
HELIXATE FS
Tier 5
PA
HEMOFIL M HIGH
Tier 5
PA
HEMOFIL M LOW
Tier 5
PA
HEMOFIL M MID
Tier 5
PA
HEMOFIL M SUPER HIGH
Tier 5
PA
HUMATE-P
Tier 5
PA
KCENTRA
Tier 5
PA
KOATE-DVI
Tier 5
PA
KOGENATE FS
Tier 5
PA
LYSTEDA
Tier 3
QL
MONOCLATE-P
Tier 4
PA
MONONINE
Tier 4
PA
NOVOEIGHT
Tier 5
PA
NOVOSEVEN RT
Tier 4
PA
OBIZUR
Tier 5
PA
pentoxifylline
Tier 1
PROFILNINE
Tier 5
PA
RECOMBINATE
Tier 5
PA
RIASTAP
Tier 5
PA
RIXUBIS
Tier 4
PA
TRENTAL
Tier 3
TRETTEN
Tier 5
PA
WILATE
Tier 5
PA
XYNTHA
Tier 5
PA
XYNTHA SOLOFUSE
Tier 5
PA
Blood
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
34
Drug Name
Drug Status
Additional Information
Cardiac Drugs
ADALAT CC ORAL TABLET EXTENDED RELEASE
30 MG, 60 MG, 90 MG
Tier 3
QL
AFEDITAB CR ORAL TABLET EXTENDED RELEASE
30 MG, 60 MG
Tier 1
QL
amiodarone oral
Tier 1
amlodipine
Tier 1
CALAN
Tier 3
CALAN SR
Tier 3
CARDENE SR
Tier 3
CARDIZEM
Tier 3
CARDIZEM CD ORAL CAPSULE,EXTENDED
RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG,
360 MG
Tier 3
QL
CARDIZEM LA ORAL TABLET EXTENDED RELEASE
24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420
MG
Tier 3
QL
CARTIA XT ORAL CAPSULE,EXTENDED RELEASE
24HR 120 MG, 180 MG, 240 MG, 300 MG
Tier 1
QL
CORDARONE
Tier 3
CORLANOR
Tier 3
DIGITEK
Tier 1
DIGOX
Tier 1
digoxin oral solution 50 mcg/ml
Tier 1
digoxin oral tablet
Tier 1
DILACOR XR ORAL CAPSULE,EXT RELEASE
DEGRADABLE 240 MG
Tier 3
DILATRATE-SR
Tier 3
DILT-CD ORAL CAPSULE,EXTENDED RELEASE
24HR 120 MG, 180 MG, 240 MG, 300 MG
Tier 1
DILTIA XT
Tier 1
diltiazem hcl oral capsule, extended release 120 mg, 180
mg, 240 mg, 300 mg, 360 mg
Tier 1
diltiazem hcl oral capsule,extended release 12 hr
Tier 1
diltiazem hcl oral capsule,extended release 24hr 120 mg,
180 mg, 240 mg, 300 mg, 360 mg
Tier 1
QL
diltiazem hcl oral tablet
Tier 1
LGC
diltiazem hcl oral tablet extended release 24 hr 180 mg, 240
mg, 300 mg, 360 mg, 420 mg
Tier 3
QL
DILTZAC ER ORAL CAPSULE, EXTENDED RELEASE
120 MG, 180 MG, 240 MG, 300 MG, 360 MG
Tier 1
QL
disopyramide phosphate oral capsule
Tier 1
felodipine
Tier 1
flecainide
Tier 1
IMDUR
Tier 3
LGC
PA; ST; Note 4 (Standard,Select); Note 5
(Standard,Select); QL
LGC
QL
QL
QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
35
Drug Name
Drug Status
Additional Information
ISOCHRON
Tier 3
ISODITRATE
Tier 1
ISOPTIN SR ORAL TABLET EXTENDED RELEASE
240 MG
Tier 3
ISORDIL
Tier 3
ISORDIL TITRADOSE ORAL TABLET 5 MG
Tier 3
isosorbide dinitrate
Tier 1
isosorbide mononitrate
Tier 1
LANOXIN ORAL TABLET 125 MCG, 250 MCG
Tier 2
LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG
Tier 3
LANOXIN PEDIATRIC
Tier 3
mexiletine
Tier 1
MINITRAN
Tier 2
MONOKET
Tier 3
MULTAQ
Tier 3
nicardipine oral
Tier 1
NIFEDIAC CC ORAL TABLET EXTENDED RELEASE
30 MG, 60 MG, 90 MG
Tier 1
QL
NIFEDICAL XL ORAL TABLET EXTENDED RELEASE
24HR 30 MG, 60 MG
Tier 1
QL
nifedipine oral capsule
Tier 1
nifedipine oral tablet extended release 24hr 30 mg, 60 mg,
90 mg
Tier 1
QL
nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg
Tier 1
QL
nimodipine
Tier 1
nisoldipine oral tablet extended release 24 hr 17 mg, 25.5
mg, 34 mg, 8.5 mg
Tier 1
nisoldipine oral tablet extended release 24 hr 20 mg, 30 mg,
40 mg
Tier 1
NITRO-BID
Tier 3
NITRO-DUR
Tier 3
nitroglycerin oral
Tier 1
nitroglycerin transdermal patch 24 hour
Tier 1
nitroglycerin translingual spray,non-aerosol
Tier 3
NITROLINGUAL
Tier 3
NITROMIST
Tier 3
NITROSTAT
Tier 2
NITRO-TIME
Tier 1
NORPACE
Tier 3
NORPACE CR
Tier 2
NORVASC
Tier 3
NYMALIZE
Tier 3
PROCARDIA
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
36
QL
QL
PA; Note 4 (Standard,Select)
Drug Name
Drug Status
Additional Information
PROCARDIA XL ORAL TABLET EXTENDED
RELEASE 24HR 30 MG, 60 MG, 90 MG
Tier 3
propafenone oral capsule,extended release 12 hr
Tier 3
propafenone oral tablet
Tier 1
quinidine gluconate oral
Tier 1
quinidine sulfate
Tier 1
RANEXA
Tier 2
RYTHMOL ORAL TABLET 150 MG, 225 MG
Tier 3
RYTHMOL SR
Tier 3
QL
SAVAYSA
Tier 3
ST; QL
SULAR
Tier 3
QL
TAMBOCOR
Tier 3
TAZTIA XT ORAL CAPSULE, EXTENDED RELEASE
120 MG, 180 MG, 240 MG, 300 MG, 360 MG
Tier 1
QL
TIAZAC ORAL CAPSULE, EXTENDED RELEASE 120
MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
Tier 3
QL
TIKOSYN
Tier 2
verapamil oral capsule, 24 hr er pellet ct
Tier 1
verapamil oral capsule,ext rel. pellets 24 hr
Tier 1
verapamil oral tablet
Tier 1
LGC
verapamil oral tablet extended release 120 mg
Tier 1
LGC
verapamil oral tablet extended release 180 mg, 240 mg
Tier 1
VERELAN
Tier 3
VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT
100 MG, 200 MG, 300 MG
Tier 3
QL
QL
QL
Cardiovascular
ACCUPRIL
Tier 3
ACCURETIC
Tier 3
acebutolol oral
Tier 1
ACEON ORAL TABLET 2 MG, 4 MG, 8 MG
Tier 3
QL
ADCIRCA
Tier 4
PA; Note 4 (Standard,Select); QL
ADEMPAS
Tier 5
PA; Note 4 (Standard,Select)
ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR
1,000-20 MG, 1,000-40 MG, 500-20 MG, 750-20 MG
Tier 3
QL
ALTACE
Tier 3
ALTOPREV ORAL TABLET EXTENDED RELEASE 24
HR 20 MG, 40 MG, 60 MG
Tier 3
ST; Note 5 (Standard,Select); QL
amlodipine-benazepril
Tier 3
QL
amlodipine-valsartan
Tier 3
ST; QL
amlodipine-valsartan-hcthiazid
Tier 3
ST; QL
AMTURNIDE
Tier 3
PA; Note 4 (Standard,Select); QL
ANTARA
Tier 3
QL
ATACAND
Tier 3
QL
ATACAND HCT
Tier 3
QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
37
Drug Name
Drug Status
Additional Information
atenolol
Tier 1
LGC
atenolol-chlorthalidone
Tier 1
LGC
atorvastatin
Tier 1
QL
AVALIDE
Tier 3
QL
AVAPRO
Tier 3
QL
AZOR
Tier 3
ST; Note 5 (Standard,Select); QL
benazepril
Tier 1
LGC
benazepril-hydrochlorothiazide
Tier 1
LGC
BENICAR
Tier 3
ST; Note 5 (Standard,Select); QL
BENICAR HCT
Tier 3
ST; Note 5 (Standard,Select); QL
BETAPACE
Tier 3
BETAPACE AF
Tier 3
BIDIL
Tier 3
bisoprolol fumarate
Tier 1
LGC
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg,
5-6.25 mg
Tier 1
LGC
bisoprolol-hydrochlorothiazide oral tablet 2.5-6.25 mg
Tier 1
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5
MG
Tier 3
QL
CADUET
Tier 6
QL
candesartan
Tier 1
QL
candesartan-hydrochlorothiazid
Tier 1
QL
captopril
Tier 1
LGC
captopril-hydrochlorothiazide
Tier 1
CARDURA
Tier 3
CARDURA XL
Tier 3
QL
carvedilol
Tier 1
LGC
CATAPRES
Tier 3
CATAPRES-TTS-1
Tier 3
QL
CATAPRES-TTS-2
Tier 3
QL
CATAPRES-TTS-3
Tier 3
QL
cholestyramine (with sugar)
Tier 1
CHOLESTYRAMINE LIGHT
Tier 1
clonidine
Tier 3
clonidine hcl oral tablet
Tier 1
CLORPRES
Tier 3
COLESTID
Tier 3
COLESTID FLAVORED
Tier 3
colestipol
Tier 1
COREG
Tier 3
COREG CR
Tier 3
CORGARD
Tier 3
CORZIDE
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
38
LGC
QL
Drug Name
Drug Status
Additional Information
COZAAR
Tier 3
CRESTOR
Tier 2
DEMSER
Tier 3
DIOVAN
Tier 3
QL
DIOVAN HCT
Tier 3
QL
doxazosin
Tier 1
LGC
DUTOPROL
Tier 3
EDARBI
Tier 3
ST; Note 5 (Standard,Select); QL
EDARBYCLOR
Tier 3
ST; Note 5 (Standard,Select); QL
enalapril maleate
Tier 1
LGC
enalapril-hydrochlorothiazide
Tier 1
LGC
EPANED
Tier 3
PA; Note 4 (Standard); QL; AL
eprosartan
Tier 3
ergoloid
Tier 3
EXFORGE
Tier 3
ST; Note 5 (Standard,Select); QL
EXFORGE HCT
Tier 3
ST; Note 5 (Standard,Select); QL
fenofibrate micronized oral capsule 130 mg, 43 mg
Tier 3
QL
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1
QL
fenofibrate nanocrystallized
Tier 3
QL
fenofibrate oral tablet
Tier 1
QL
fenofibric acid
Tier 1
QL
fenofibric acid (choline)
Tier 1
QL
FENOGLIDE
Tier 3
QL
FIBRICOR
Tier 3
QL
fluvastatin
Tier 1
QL
fosinopril
Tier 1
fosinopril-hydrochlorothiazide
Tier 1
gemfibrozil oral
Tier 1
guanfacine oral tablet
Tier 1
HEMANGEOL
Tier 3
hydralazine oral tablet 10 mg, 100 mg, 50 mg
Tier 1
hydralazine oral tablet 25 mg
Tier 1
HYZAAR
Tier 3
INDERAL LA
Tier 3
INNOPRAN XL ORAL CAPSULE,EXTENDED
RELEASE 24HR 120 MG, 80 MG
Tier 3
QL
irbesartan
Tier 1
QL
irbesartan-hydrochlorothiazide
Tier 1
QL
isoxsuprine
Tier 3
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG
Tier 5
PA; Note 4 (Standard,Select); QL
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG
Tier 5
QL
KERLONE
Tier 3
KYNAMRO
Tier 5
QL
LGC
PA; Note 4 (Standard)
LGC
PA; Note 4 (Standard,Select); QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
39
Drug Name
Drug Status
labetalol oral
Tier 1
LESCOL
Tier 3
QL
LESCOL XL
Tier 3
QL
LETAIRIS
Tier 4
PA; Note 4 (Standard,Select)
LIPITOR
Tier 3
QL
LIPOFEN
Tier 3
QL
LIPTRUZET
Tier 3
ST; Note 5 (Standard); QL
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
LGC
lisinopril oral tablet 30 mg, 40 mg
Tier 1
lisinopril-hydrochlorothiazide
Tier 1
LGC
LIVALO
Tier 3
ST; Note 5 (Standard); QL
LOFIBRA
Tier 3
QL
LOPID
Tier 3
LOPRESSOR HCT
Tier 3
LOPRESSOR ORAL
Tier 3
losartan
Tier 1
losartan-hydrochlorothiazide
Tier 1
LOTENSIN HCT
Tier 3
LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG
Tier 3
LOTREL
Tier 3
QL
lovastatin
Tier 1
LGC; QL
MAVIK
Tier 3
methyldopa
Tier 1
methyldopa-hydrochlorothiazide
Tier 1
metoprolol succinate oral tablet extended release 24 hr 100
mg, 200 mg, 25 mg, 50 mg
Tier 1
metoprolol ta-hydrochlorothiaz
Tier 1
metoprolol tartrate oral
Tier 1
LGC
MEVACOR
Tier 3
QL
MICARDIS
Tier 3
QL
MICARDIS HCT
Tier 3
QL
MINIPRESS
Tier 3
minoxidil oral
Tier 1
moexipril
Tier 1
moexipril-hydrochlorothiazide
Tier 1
nadolol
Tier 1
niacin oral tablet extended release 24 hr
Tier 1
NIASPAN EXTENDED-RELEASE
Tier 3
OPSUMIT
Tier 4
PA; Note 4 (Standard,Select)
ORENITRAM
Tier 5
PA; Note 3; Note 4 (Standard,Select)
papaverine oral
Tier 3
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg
Tier 3
pindolol
Tier 1
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
40
Additional Information
LGC
QL
Note 3
QL
Drug Name
Drug Status
Additional Information
PRAVACHOL
Tier 3
QL
pravastatin
Tier 1
LGC; QL
prazosin oral
Tier 1
LGC
PREVALITE
Tier 1
PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG
Tier 3
PRINZIDE
Tier 3
propranolol oral capsule,extended release 24 hr
Tier 1
propranolol oral solution
Tier 1
propranolol oral tablet 10 mg, 20 mg, 40 mg, 80 mg
Tier 1
propranolol oral tablet 60 mg
Tier 1
propranolol-hydrochlorothiazid
Tier 1
QUESTRAN
Tier 3
QUESTRAN LIGHT
Tier 3
quinapril
Tier 1
quinapril-hydrochlorothiazide
Tier 1
ramipril
Tier 1
reserpine
Tier 3
REVATIO ORAL SUSPENSION FOR
RECONSTITUTION
Tier 5
PA
REVATIO ORAL TABLET
Tier 5
PA; Note 4 (Standard,Select); QL
SECTRAL
Tier 3
sildenafil oral
Tier 5
PA; Note 3; Note 4 (Standard,Select); QL
SIMCOR
Tier 3
QL
simvastatin
Tier 1
LGC; QL
SOTALOL AF
Tier 1
sotalol oral tablet 120 mg, 80 mg
Tier 1
sotalol oral tablet 160 mg, 240 mg
Tier 1
SOTYLIZE
Tier 3
TARKA
Tier 3
TEKAMLO
Tier 3
PA; Note 4 (Standard,Select); QL
TEKTURNA
Tier 3
PA; Note 4 (Standard,Select); QL
TEKTURNA HCT
Tier 3
PA; Note 4 (Standard,Select); QL
telmisartan
Tier 1
QL
telmisartan-amlodipine
Tier 3
ST; Note 5 (Standard); QL
telmisartan-hydrochlorothiazid
Tier 1
QL
TENEX
Tier 3
TENORETIC 100
Tier 3
TENORETIC 50
Tier 3
TENORMIN
Tier 3
terazosin
Tier 1
LGC
TEVETEN HCT
Tier 3
ST; Note 5 (Standard,Select); QL
TEVETEN ORAL TABLET 400 MG, 600 MG
Tier 3
QL
timolol maleate oral
Tier 1
LGC
LGC
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
41
Drug Name
Drug Status
Additional Information
TOPROL XL ORAL TABLET EXTENDED RELEASE 24
HR 100 MG, 200 MG, 25 MG, 50 MG
Tier 3
QL
TRACLEER
Tier 4
PA; Note 4 (Standard,Select)
TRANDATE ORAL
Tier 3
trandolapril
Tier 1
TRIBENZOR
Tier 3
ST; Note 5 (Standard,Select); QL
TRICOR
Tier 3
QL
TRIGLIDE
Tier 3
QL
TRILIPIX
Tier 3
QL
TWYNSTA
Tier 3
ST; Note 5 (Standard,Select); QL
TYVASO
Tier 5
PA; Note 4 (Standard,Select); QL
TYVASO REFILL KIT
Tier 5
PA; Note 4 (Standard,Select); QL
TYVASO STARTER KIT
Tier 5
PA; Note 4 (Standard,Select); QL
UNIRETIC
Tier 3
UNIVASC
Tier 3
valsartan
Tier 1
QL
valsartan-hydrochlorothiazide
Tier 1
QL
VASERETIC
Tier 3
VASOTEC
Tier 3
VAYAROL
LA
VECAMYL
Tier 5
PA; Note 4 (Standard,Select); QL
VENTAVIS
Tier 5
PA; Note 4 (Standard,Select)
VYTORIN 10-10
Tier 3
ST; Note 5 (Standard,Select); QL
VYTORIN 10-20
Tier 3
ST; Note 5 (Standard,Select); QL
VYTORIN 10-40
Tier 3
ST; Note 5 (Standard,Select); QL
VYTORIN 10-80
Tier 3
ST; Note 5 (Standard,Select); QL
WELCHOL ORAL POWDER IN PACKET
Tier 2
WELCHOL ORAL TABLET
Tier 3
ZEBETA
Tier 3
ZESTORETIC
Tier 3
ZESTRIL
Tier 3
ZETIA
Tier 2
ZIAC
Tier 3
ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG,
80 MG
Tier 3
QL
AMPYRA
Tier 5
PA; Note 4 (Standard,Select); QL
APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG,
800 MG
Tier 3
PA; Note 4 (Standard); QL
AUBAGIO
Tier 5
PA; Note 4 (Standard,Select); QL
AVONEX
Tier 5
PA; Note 4 (Standard,Select)
AVONEX (WITH ALBUMIN)
Tier 5
PA; Note 4 (Standard,Select); QL
BANZEL ORAL TABLET
Tier 3
PA; Note 4 (Standard); QL
QL
Cns Drugs
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
42
Drug Name
Drug Status
Additional Information
BETASERON
Tier 5
CAFCIT ORAL
Tier 3
carbamazepine oral capsule, er multiphase 12 hr 100 mg,
200 mg
Tier 1
carbamazepine oral suspension 100 mg/5 ml
Tier 1
carbamazepine oral tablet
Tier 1
carbamazepine oral tablet extended release 12 hr
Tier 1
carbamazepine oral tablet,chewable
Tier 1
CARBATROL
Tier 2
CELONTIN
Tier 2
clonazepam
Tier 1
Note 3
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML
Tier 4
PA
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML
Tier 4
PA; Note 4 (Standard,Select)
COPAXONE SUBCUTANEOUS SYRINGE KIT
Tier 4
PA
DEPAKENE
Tier 3
DEPAKOTE
Tier 3
DEPAKOTE ER
Tier 3
DEPAKOTE SPRINKLES
Tier 3
DIASTAT
Tier 2
QL
DIASTAT ACUDIAL
Tier 3
QL
diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 mg
Tier 1
QL
diazepam rectal kit 2.5 mg
Tier 1
DILANTIN
Tier 2
DILANTIN EXTENDED
Tier 2
DILANTIN INFATABS
Tier 2
DILANTIN-125
Tier 2
divalproex
Tier 1
EPITOL
Tier 1
ethosuximide
Tier 1
EXTAVIA SUBCUTANEOUS KIT
Tier 5
PA; Note 4 (Standard,Select); QL
EXTAVIA SUBCUTANEOUS RECON SOLN
Tier 5
PA; Note 4 (Standard,Select)
felbamate oral tablet
Tier 1
FELBATOL
Tier 3
FYCOMPA
Tier 3
PA; Note 4 (Standard); QL
gabapentin oral capsule
Tier 1
QL
gabapentin oral solution
Tier 1
gabapentin oral tablet
Tier 1
QL
GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG
Tier 3
QL
GILENYA
Tier 5
PA; Note 4 (Standard,Select); QL
GRALISE 30-DAY STARTER PACK
Tier 3
PA; Note 4 (Standard); QL
GRALISE ORAL TABLET EXTENDED RELEASE 24
HR 300 MG, 600 MG
Tier 3
PA; Note 4 (Standard); QL
PA; Note 4 (Standard,Select); QL
LGC
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
43
Drug Name
Drug Status
Additional Information
HORIZANT ORAL TABLET EXTENDED RELEASE 300
MG, 600 MG
Tier 3
KEPPRA ORAL
Tier 3
KEPPRA XR ORAL TABLET EXTENDED RELEASE 24
HR 500 MG, 750 MG
Tier 3
QL
KLONOPIN
Tier 3
Note 3
LAMICTAL
Tier 3
LAMICTAL ODT ORAL TABLET,DISINTEGRATING
100 MG, 200 MG, 25 MG, 50 MG
Tier 3
ST; Note 5 (Standard); QL
LAMICTAL ODT STARTER (BLUE)
Tier 3
ST; Note 5 (Standard)
LAMICTAL ODT STARTER (GREEN)
Tier 3
ST; Note 5 (Standard)
LAMICTAL ODT STARTER (ORANGE)
Tier 3
ST; Note 5 (Standard)
LAMICTAL XR ORAL TABLET EXTENDED RELEASE
24HR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50
MG
Tier 3
ST; Note 5 (Standard); QL
LAMICTAL XR STARTER (BLUE)
Tier 3
ST; Note 5 (Standard)
LAMICTAL XR STARTER (GREEN)
Tier 3
ST; Note 5 (Standard)
LAMICTAL XR STARTER (ORANGE)
Tier 3
ST; Note 5 (Standard)
lamotrigine oral tablet
Tier 1
lamotrigine oral tablet extended release 24hr 100 mg, 200
mg, 25 mg, 250 mg, 300 mg, 50 mg
Tier 1
ST; Note 5 (Standard); QL
lamotrigine oral tablet, chewable dispersible
Tier 3
ST; Note 5 (Standard)
lamotrigine oral tablet,disintegrating
Tier 3
QL
lamotrigine oral tablets,dose pack 25 mg (35)
Tier 3
levetiracetam oral solution 100 mg/ml
Tier 1
levetiracetam oral tablet
Tier 1
levetiracetam oral tablet extended release 24 hr 500 mg
Tier 1
levetiracetam oral tablet extended release 24 hr 750 mg
Tier 1
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG,
225 MG, 25 MG, 300 MG, 50 MG, 75 MG
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
LYRICA ORAL SOLUTION
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
MYSOLINE
Tier 3
NAMENDA ORAL SOLUTION
Tier 2
AL
NAMENDA ORAL TABLET
Tier 2
QL; AL
NAMENDA TITRATION PAK
Tier 2
QL; AL
NAMENDA XR
Tier 2
QL; AL
NAMZARIC
Tier 2
PA; Note 4 (Standard,Select); QL; AL
NEURONTIN ORAL CAPSULE
Tier 3
QL
NEURONTIN ORAL SOLUTION
Tier 3
NEURONTIN ORAL TABLET
Tier 3
QL
NUEDEXTA
Tier 3
QL
ONFI ORAL SUSPENSION
Tier 3
PA; Note 4 (Standard)
ONFI ORAL TABLET
Tier 3
PA; Note 4 (Standard); QL
oxcarbazepine
Tier 1
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
44
PA; Note 4 (Standard); QL
QL
Drug Name
Drug Status
Additional Information
OXTELLAR XR ORAL TABLET EXTENDED RELEASE
24 HR 150 MG, 300 MG, 600 MG
Tier 3
PEGANONE
Tier 3
PHENYTEK
Tier 2
phenytoin oral suspension 125 mg/5 ml
Tier 1
phenytoin oral tablet,chewable
Tier 1
phenytoin sodium extended
Tier 1
PLEGRIDY
Tier 5
PA; QL
POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50
MG
Tier 3
PA; Note 4 (Standard); QL
primidone
Tier 1
QUDEXY XR
Tier 3
ST; Note 5 (Standard); QL
REBIF (WITH ALBUMIN)
Tier 4
PA; Note 4 (Standard,Select); QL
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
22 MCG/0.5 ML, 44 MCG/0.5 ML
Tier 4
PA; Note 4 (Standard,Select); QL
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
8.8MCG/0.2ML-22 MCG/0.5ML (6)
Tier 4
PA; Note 4 (Standard,Select)
REBIF TITRATION PACK
Tier 4
PA; Note 4 (Standard,Select); QL
RILUTEK
Tier 3
PA; Note 4 (Standard,Select)
riluzole
Tier 1
PA; Note 4 (Standard,Select)
SABRIL
Tier 5
PA; Note 4 (Standard,Select); QL
STAVZOR
Tier 6
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46),
240 MG
Tier 5
TEGRETOL
Tier 2
TEGRETOL XR
Tier 2
tiagabine oral tablet 2 mg, 4 mg
Tier 1
QL
TOPAMAX ORAL CAPSULE, SPRINKLE
Tier 3
QL
TOPAMAX ORAL TABLET
Tier 3
TOPIRAGEN
Tier 1
topiramate oral capsule, sprinkle
Tier 1
topiramate oral tablet
Tier 1
TRILEPTAL
Tier 3
TROKENDI XR ORAL CAPSULE,EXTENDED
RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG
Tier 3
valproic acid
Tier 1
valproic acid (as sodium salt) oral solution 250 mg/5 ml
Tier 1
VIMPAT ORAL SOLUTION
Tier 3
PA; Note 4 (Standard); QL
VIMPAT ORAL TABLET
Tier 3
PA; Note 4 (Standard); QL
VIMPAT ORAL TABLETS,DOSE PACK
Tier 3
PA; Note 4 (Standard)
XENAZINE ORAL TABLET 12.5 MG, 25 MG
Tier 4
PA; Note 4 (Standard,Select); QL
ZARONTIN
Tier 3
ZONEGRAN
Tier 3
ST; Note 5 (Standard); QL
PA; Note 4 (Standard,Select); QL
QL
ST; Note 5 (Standard); QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
45
Drug Name
zonisamide
Drug Status
Additional Information
Tier 1
Colony Stimulating Factors
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION
Tier 4
PA; Note 4 (Standard,Select)
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
10 MCG/0.4 ML
Tier 4
PA; AL
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML,
25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML,
500 MCG/ML, 60 MCG/0.3 ML
Tier 4
PA; Note 4 (Standard,Select)
EPOGEN INJECTION SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML
Tier 5
PA; Note 4 (Standard,Select)
GRANIX
Tier 5
PA; Note 4 (Standard,Select)
LEUKINE
Tier 4
PA; Note 4 (Standard,Select)
MIRCERA
Tier 5
PA
NEULASTA SUBCUTANEOUS SYRINGE
Tier 5
PA; Note 4 (Standard,Select)
NEULASTA SUBCUTANEOUS SYRINGE, W/
WEARABLE INJECTOR
Tier 5
PA
NEUPOGEN
Tier 4
PA; Note 4 (Standard,Select)
PROCRIT
Tier 4
PA; Note 3; Note 4 (Standard,Select)
PROMACTA
Tier 5
PA; Note 4 (Standard,Select); QL
Contraceptives
ALTAVERA (28)
CE
CE; QL
ALYACEN 1/35 (28)
CE
CE; QL
ALYACEN 7/7/7 (28)
Tier 1
QL
AMETHIA
CE
QL
AMETHIA LO
CE
QL
AMETHYST
CE
QL
APRI
CE
CE; QL
ARANELLE (28)
CE
CE; QL
AVIANE
CE
CE; QL
AZURETTE (28)
CE
CE; QL
BALZIVA (28)
CE
CE; QL
BEYAZ
Tier 3
QL
BREVICON (28)
Tier 3
QL
BRIELLYN
CE
CE; QL
CAMRESE
CE
QL
CAMRESE LO
CE
QL
CAZIANT (28)
CE
CE; QL
CESIA (28)
CE
CE
CHATEAL
CE
CE; QL
CRYSELLE (28)
CE
CE; QL
CYCLAFEM 1/35 (28)
CE
CE; QL
CYCLESSA (28)
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
46
Tier 3
QL
Drug Name
Drug Status
Additional Information
DASETTA 1/35 (28)
CE
DASETTA 7/7/7 (28)
Tier 1
QL
CE
QL
DEPO-PROVERA INTRAMUSCULAR SUSPENSION
Tier 3
QL
DEPO-PROVERA INTRAMUSCULAR SYRINGE
Tier 3
QL
DEPO-SUBQ PROVERA 104
Tier 3
QL
DESOGEN
Tier 3
QL
desogestrel-ethinyl estradiol
Tier 1
drospirenone-ethinyl estradiol
Tier 1
DAYSEE
CE; QL
QL
ELINEST
CE
CE; QL
ELLA
CE
QL
EMOQUETTE
CE
CE; QL
ENPRESSE
CE
CE; QL
ENSKYCE
Tier 1
QL
ERRIN
Tier 1
QL
ESTARYLLA
Tier 1
QL
ESTROSTEP FE-28
Tier 3
QL
FALMINA (28)
CE
CE; QL
FC FEMALE CONDOM
CE
CE
FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM
CE
CE; QL
FEMCON FE
Tier 3
QL
GENERESS FE
Tier 3
QL
GIANVI (28)
Tier 1
QL
GILDAGIA
CE
CE; QL
GILDESS
CE
CE
GILDESS 24 FE
CE
GILDESS FE
CE
CE; QL
IMPLANON
CE
CE; QL
INTROVALE
CE
QL
Tier 1
QL
CE
QL
Tier 1
QL
JENCYCLA
JOLESSA
JOLIVETTE
JUNEL 1.5/30 (21)
CE
CE; QL
JUNEL 1/20 (21)
CE
CE; QL
JUNEL FE 1.5/30 (28)
CE
CE; QL
JUNEL FE 1/20 (28)
CE
CE; QL
KARIVA (28)
CE
CE; QL
KELNOR 1/35 (28)
CE
CE; QL
KURVELO
CE
CE; QL
l norgest&e estradiol-e estrad oral tablets,dose pack,3
month 0.10 mg-20 mcg (84)/10 mcg (7)
Tier 1
QL
LEENA 28
CE
CE; QL
LESSINA
CE
CE; QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
47
Drug Name
Drug Status
Additional Information
LEVONEST (28)
CE
CE; QL
levonorgestrel oral tablet 0.75 mg
CE
CE; QL
levonorgestrel oral tablet 1.5 mg
CE
QL
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg,
90-20 mcg
CE
QL
levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg
CE
CE; QL
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
CE
QL
LEVORA 0.15/30 (28)
CE
CE; QL
LEVORA-28
CE
CE; QL
LILETTA
CE
LO LOESTRIN FE
Tier 3
QL
LO MINASTRIN FE
Tier 3
QL
LOESTRIN 1.5/30 (21)
Tier 3
QL
LOESTRIN 1/20 (21)
Tier 3
QL
LOESTRIN 24 FE
Tier 3
QL
LOESTRIN FE 1.5/30 (28-DAY)
Tier 3
QL
LOESTRIN FE 1/20 (28-DAY)
Tier 3
QL
LOMEDIA 24 FE
Tier 3
QL
LO-OVRAL (28)
Tier 3
QL
LORYNA (28)
Tier 1
QL
LOSEASONIQUE
Tier 3
QL
LOW-OGESTREL (28)
CE
CE; QL
LUTERA (28)
CE
CE; QL
LYZA
Tier 1
QL
MARLISSA
CE
CE; QL
medroxyprogesterone intramuscular
CE
CE; QL
MICROGESTIN 1.5/30 (21)
CE
CE; QL
MICROGESTIN 1/20 (21)
CE
CE; QL
MICROGESTIN FE 1.5/30 (28)
CE
CE; QL
MICROGESTIN FE 1/20 (28)
CE
CE; QL
MINASTRIN 24 FE
Tier 3
QL
MIRCETTE (28)
Tier 3
QL
MIRENA
CE
CE; QL
MODICON (28)
Tier 3
QL
MONO-LINYAH
Tier 1
QL
MONONESSA (28)
Tier 1
QL
MYZILRA
CE
CE
NATAZIA
Tier 3
QL
NECON 0.5/35 (28)
CE
CE; QL
NECON 1/35 (28)
CE
CE; QL
NECON 1/50 (28)
Tier 1
NECON 10/11 (28)
CE
CE; QL
NEXPLANON
CE
CE; QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
48
QL
Drug Name
Drug Status
Additional Information
NEXT CHOICE
CE
CE; QL
NEXT CHOICE ONE DOSE
CE
CE; QL
NORA-BE
Tier 1
QL
NORDETTE (28)
Tier 3
QL
noreth-ethinyl estradiol-iron oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
CE
CE
noreth-ethinyl estradiol-iron oral tablet,chewable
0.8mg-25mcg(24) and 75 mg (4)
CE
QL
norethindrone (contraceptive)
Tier 1
QL
norgestimate-ethinyl estradiol
Tier 1
QL
norgestrel-ethinyl estradiol oral tablet 0.3-30 mg-mcg
CE
CE; QL
NORINYL 1+35 (28)
Tier 3
QL
NORINYL 1+50 (28)
Tier 3
QL
NOR-QD
Tier 3
QL
NORTREL 0.5/35 (28)
CE
CE; QL
NORTREL 1/35 (21)
CE
CE; QL
NORTREL 1/35 (28)
CE
CE; QL
NORTREL 7/7/7 (28)
Tier 1
QL
NUVARING
Tier 2
QL
OCELLA
Tier 1
QL
OGESTREL (28)
Tier 3
QL
ORSYTHIA
CE
CE; QL
ORTHO ALL-FLEX FITTING SET
CE
CE
ORTHO DIAPHRAGM ALL-FLEX 65
CE
CE
ORTHO DIAPHRAGM ALL-FLEX 70
CE
CE
ORTHO DIAPHRAGM ALL-FLEX 75
CE
CE
ORTHO DIAPHRAGM ALL-FLEX 80
CE
CE
ORTHO EVRA
Tier 3
QL
ORTHO MICRONOR
Tier 3
QL
ORTHO TRI-CYCLEN (28)
Tier 3
QL
ORTHO TRI-CYCLEN LO (28)
Tier 3
QL
ORTHO-CEPT (28)
Tier 3
QL
ORTHO-CYCLEN (28)
Tier 3
QL
ORTHO-NOVUM 1/35 (28)
Tier 3
QL
ORTHO-NOVUM 7/7/7 (28)
Tier 3
QL
OVCON-35 (28)
Tier 3
QL
OVCON-50 (28)
Tier 3
QL
PARAGARD T 380A
CE
CE; QL
PHILITH
CE
CE; QL
PIRMELLA ORAL TABLET 1-35 MG-MCG
Tier 1
QL
PLAN B
CE
QL
PLAN B ONE-STEP
CE
QL
PORTIA
CE
CE; QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
49
Drug Name
Drug Status
Additional Information
PREVIFEM
Tier 1
QL
QUARTETTE
Tier 3
QL
QUASENSE
CE
QL
RECLIPSEN (28)
CE
CE; QL
SAFYRAL
Tier 3
QL
SEASONALE CONTRACEPTIVE
Tier 3
QL
SEASONIQUE
Tier 3
QL
SKYLA
Tier 3
QL
SPRINTEC (28)
Tier 1
QL
SRONYX
SYEDA
CE
CE; QL
Tier 1
QL
TAKE ACTION
CE
QL
TILIA FE
CE
CE; QL
TODAY CONTRACEPTIVE SPONGE
CE
CE
Tier 1
QL
TRI-ESTARYLLA
TRI-LEGEST FE
CE
CE; QL
TRI-LINYAH
Tier 1
QL
TRINESSA (28)
Tier 1
QL
TRI-NORINYL (28)
Tier 3
QL
TRI-PREVIFEM (28)
Tier 1
QL
TRI-SPRINTEC (28)
Tier 1
QL
TRIVORA (28)
CE
CE; QL
VAGINAL CONTRACEPTIVE FILM
CE
CE
VAGINAL CONTRACEPTIVE FOAM
CE
CE
VCF CONTRACEPTIVE FILM
CE
CE
VELIVET TRIPHASIC REGIMEN (28)
CE
CE; QL
VESTURA (28)
Tier 1
QL
VIORELE (28)
CE
CE
WERA (28)
CE
CE; QL
WIDE-SEAL DIAPHRAGM 60
CE
CE
WIDE-SEAL DIAPHRAGM 65
CE
CE
WIDE-SEAL DIAPHRAGM 70
CE
CE
WIDE-SEAL DIAPHRAGM 75
CE
CE
WIDE-SEAL DIAPHRAGM 80
CE
CE
WIDE-SEAL DIAPHRAGM 85
CE
CE
WIDE-SEAL DIAPHRAGM 90
CE
CE
WIDE-SEAL DIAPHRAGM 95
CE
CE
WYMZYA FE
CE
CE; QL
XULANE
CE
CE; QL
YASMIN (28)
Tier 3
QL
YAZ (28)
Tier 3
QL
ZARAH
Tier 1
QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
50
Drug Name
Drug Status
Additional Information
ZENCHENT (28)
CE
CE; QL
ZENCHENT FE
CE
CE; QL
ZEOSA
CE
CE; QL
ZOVIA 1/35E (28)
CE
CE; QL
ZOVIA 1/50E (28)
CE
CE; QL
Cough/Cold Preparations
benzonatate oral capsule 100 mg, 200 mg
Tier 1
BROMFED DM
Tier 3
codeine-guaifenesin
Tier 1
cpm-pseudoephed-hydrocodone
Tier 3
hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml
Tier 1
Note 3
hydrocodone-homatropine oral tablet
Tier 1
Note 3
OBREDON
Tier 3
PROMETHAZINE VC-CODEINE
Tier 1
promethazine-codeine
Tier 1
promethazine-dm
Tier 1
promethazine-phenyleph-codeine
Tier 1
REZIRA
Tier 3
TESSALON PERLES
Tier 3
TUSSICAPS
Tier 3
QL
TUSSIONEX PENNKINETIC ER
Tier 3
Note 3; QL
VITUZ
Tier 3
QL
ZONATUSS
Tier 6
ZUTRIPRO
Tier 3
Diagnostic
ACCU-CHEK AVIVA
Tier 6
ACCU-CHEK COMFORT CURVE TEST
Tier 6
ACCU-CHEK SMARTVIEW TEST STRIP
Tier 6
CONTOUR TEST STRIPS
Tier 3
PA
FREESTYLE INSULINX TEST STRIPS
Tier 3
PA; Note 4 (Standard,Select)
FREESTYLE LITE STRIPS
Tier 3
PA; Note 4 (Standard,Select)
FREESTYLE TEST
Tier 3
PA
KETONE URINE TEST
Tier 3
NOVA MAX GLUCOSE TEST
Tier 3
ONETOUCH ULTRA TEST
Tier 2
ONETOUCH VERIO
Tier 2
PRECISION XTRA TEST
Tier 3
PA; Note 4 (Standard,Select)
TRUETEST TEST STRIPS
Tier 3
PA; Note 4 (Standard,Select)
TRUETRACK TEST
Tier 3
PA; Note 4 (Standard,Select)
PA; Note 4 (Standard)
Diuretics
acetazolamide oral
Tier 1
ALDACTAZIDE
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
51
Drug Name
Drug Status
ALDACTONE
Tier 3
amiloride oral
Tier 1
amiloride-hydrochlorothiazide
Tier 1
LGC
bumetanide oral tablet 0.5 mg, 1 mg
Tier 1
LGC
bumetanide oral tablet 2 mg
Tier 1
chlorothiazide
Tier 1
Note 3
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1
LGC
DEMADEX
Tier 3
DIAMOX SEQUELS
Tier 3
DIURIL
Tier 3
DYAZIDE
Tier 3
DYRENIUM
Tier 3
EDECRIN
Tier 3
furosemide oral tablet
Tier 1
LGC
hydrochlorothiazide oral capsule
Tier 1
LGC
hydrochlorothiazide oral tablet 12.5 mg
Tier 1
hydrochlorothiazide oral tablet 25 mg, 50 mg
Tier 1
indapamide
Tier 1
INSPRA ORAL TABLET 25 MG, 50 MG
Tier 3
LASIX
Tier 3
MAXZIDE
Tier 3
MAXZIDE-25MG
Tier 3
methazolamide oral
Tier 1
metolazone
Tier 1
MICROZIDE
Tier 3
MIDAMOR
Tier 3
NEPTAZANE
Tier 3
SAMSCA ORAL TABLET 15 MG, 30 MG
Tier 5
spironolactone oral tablet 100 mg, 50 mg
Tier 1
spironolactone oral tablet 25 mg
Tier 1
spironolacton-hydrochlorothiaz
Tier 1
torsemide oral
Tier 1
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg
Tier 1
triamterene-hydrochlorothiazid oral capsule 50-25 mg
Tier 1
triamterene-hydrochlorothiazid oral tablet
Tier 1
ZAROXOLYN ORAL TABLET 2.5 MG, 5 MG
Tier 3
Eent Preps
ACETASOL HC
Tier 1
acetic acid otic
Tier 1
acetic acid-aluminum acetate
Tier 1
ACULAR
Tier 3
ACULAR LS
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
52
Additional Information
LGC
QL
PA; Note 4 (Standard,Select); QL
LGC
LGC
LGC
Drug Name
Drug Status
ACUVAIL (PF)
Tier 3
ADRENALIN NASAL
Tier 2
ALAMAST
Tier 3
ALOCRIL
Tier 3
ALOMIDE
Tier 3
ALPHAGAN P
Tier 3
ALREX
Tier 2
antipyrine-benzocaine
Tier 1
apraclonidine
Tier 1
ASTELIN
Tier 3
ASTEPRO NASAL SPRAY,NON-AEROSOL
Tier 3
atropine ophthalmic
Tier 1
ATROVENT
Tier 3
azelastine nasal aerosol,spray
Tier 1
azelastine nasal spray,non-aerosol
Tier 3
AZOPT
Tier 2
BECONASE AQ
Tier 3
BETAGAN OPHTHALMIC DROPS 0.5 %
Tier 3
betaxolol ophthalmic
Tier 1
BETIMOL
Tier 2
BETOPTIC S
Tier 2
bimatoprost
Tier 3
brimonidine ophthalmic drops 0.2 %
Tier 1
budesonide nasal
Tier 3
carteolol
Tier 1
COMBIGAN
Tier 3
COSOPT
Tier 3
COSOPT (PF)
Tier 3
cromolyn ophthalmic
Tier 1
CYCLOGYL
Tier 3
CYCLOMYDRIL
Tier 3
cyclopentolate
Tier 1
CYSTARAN
Tier 5
dexamethasone sodium phosphate ophthalmic
Tier 1
diclofenac sodium ophthalmic
Tier 1
dorzolamide
Tier 1
dorzolamide-timolol
Tier 1
DUREZOL
Tier 2
DYMISTA
Tier 6
FLAREX
Tier 3
FLONASE
Tier 3
FLONASE ALLERGY RELIEF
Tier 1
Additional Information
QL
QL
ST; Note 5 (Standard,Select)
QL
ST
PA; Note 4 (Standard,Select)
QL
Note 6
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
53
Drug Name
Drug Status
flunisolide
Tier 1
fluorometholone
Tier 1
flurbiprofen sodium
Tier 1
fluticasone nasal
Tier 1
FML FORTE
Tier 3
FML LIQUIFILM
Tier 3
FML S.O.P.
Tier 2
hydrocortisone-acetic acid
Tier 1
ILEVRO
Tier 3
IOPIDINE
Tier 3
ipratropium bromide nasal
Tier 1
ISOPTO ATROPINE
Tier 3
ISOPTO CARBACHOL
Tier 3
ISOPTO CARPINE
Tier 3
ISOPTO HYOSCINE
Tier 3
ketorolac ophthalmic
Tier 3
LACRISERT
Tier 3
latanoprost
Tier 1
levobunolol
Tier 1
LOTEMAX OPHTHALMIC DROPS,GEL
Tier 2
LOTEMAX OPHTHALMIC DROPS,SUSPENSION
Tier 2
LOTEMAX OPHTHALMIC OINTMENT
Tier 3
LUMIGAN
Tier 3
MAXIDEX
Tier 3
metipranolol
Tier 1
NASACORT
Tier 1
NASACORT AQ
Tier 6
NASONEX
Tier 2
NEVANAC
Tier 3
OCUDOX
Tier 6
OCUFEN
Tier 3
olopatadine
Tier 3
OMNARIS
Tier 3
OMNIPRED
Tier 3
OPTIPRANOLOL
Tier 3
PATANASE
Tier 3
PHOSPHOLINE IODIDE
Tier 2
pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %
Tier 1
PRED FORTE
Tier 3
PRED MILD
Tier 3
prednisolone acetate
Tier 1
prednisolone sodium phosphate ophthalmic
Tier 1
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
54
Additional Information
QL
QL
QL
PA; Note 4 (Standard,Select); QL
Note 6
ST
Drug Name
Drug Status
Additional Information
PROLENSA
Tier 3
QL
QNASL
Tier 3
ST
RESCULA
Tier 3
PA; Note 4 (Standard,Select); QL
RESTASIS
Tier 3
QL
RHINOCORT AQUA
Tier 3
ST; Note 5 (Standard)
SIMBRINZA
Tier 3
QL
timolol maleate ophthalmic
Tier 1
TIMOPTIC
Tier 3
TIMOPTIC-XE
Tier 3
TRAVATAN Z
Tier 2
QL
travoprost (benzalkonium)
Tier 3
PA; Note 4 (Standard,Select); QL
triamcinolone acetonide nasal
Tier 6
TRUSOPT
Tier 3
VERAMYST
Tier 3
VEXOL
Tier 3
VOLTAREN OPHTHALMIC
Tier 3
VOSOL-HC
Tier 3
XALATAN
Tier 3
ST; Note 5 (Standard); QL
ZETONNA
Tier 3
ST; Note 5 (Standard,Select); QL
ZIOPTAN (PF)
Tier 3
PA; Note 4 (Standard,Select); QL
ST; Note 5 (Standard,Select); QL
Elect/Caloric/H2o
calcium acetate oral
Tier 1
CHILDREN'S IRON
CE
CYTRA-3
Tier 1
CYTRA-K
Tier 1
ELIPHOS
Tier 1
CE
FER-IN-SOL
CE
CE
FER-IRON
CE
CE
ferrous sulfate oral drops
CE
CE
FLORIVA (FLUORIDE-VITAMIN D3)
Tier 2
FLUORABON
CE
CE
FLUOR-A-DAY (WITH XYLITOL) ORAL
TABLET,CHEWABLE 0.25 MG F (0.55 MG)-236.79MG,
0.5 MG F (1.1 MG)-236.79 MG
CE
CE
FLUORITAB ORAL TABLET,CHEWABLE
CE
CE
FLURA-DROPS
CE
CE
FOSRENOL
Tier 3
FOSTEUM
LA
GLUCAGEN
Tier 3
QL
GLUCAGEN HYPOKIT
Tier 2
QL
GLUCAGON EMERGENCY KIT (HUMAN)
Tier 2
QL
ICAR-C PLUS
Tier 3
KAOCHLOR EFFERVESCENT
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
55
Drug Name
Drug Status
KAYEXALATE
Tier 3
KIONEX
Tier 1
K-PHOS-NEUTRAL
Tier 3
LUDENT FLUORIDE
CE
MARLEXATE
CE
Tier 1
NEOPHE
LA
PHENYLENE
LA
PHENYLENE 75
LA
PHOSLO
Tier 3
potassium chloride oral capsule, extended release 10 meq
Tier 1
potassium chloride oral capsule, extended release 8 meq
Tier 1
potassium chloride oral liquid 20 meq/15 ml
Tier 1
potassium chloride oral tablet extended release 10 meq, 8
meq
Tier 1
potassium chloride oral tablet extended release 20 meq
Tier 1
potassium chloride oral tablet,er particles/crystals 10 meq
Tier 1
potassium citrate
Tier 1
PROGLYCEM
Tier 3
RENAGEL
Tier 3
RENVELA
Tier 3
sevelamer carbonate
Tier 1
SHOHL'S MODIFIED
Tier 3
SLOESTEROL
Additional Information
LGC
LGC
LA
sodium citrate-citric acid
Tier 1
sodium fluoride oral drops
CE
CE
sodium fluoride oral tablet
CE
CE
sodium fluoride oral tablet,chewable 0.25 mg fluorid (0.55
mg)
CE
LGC; CE
sodium fluoride oral tablet,chewable 0.5 mg fluoride (1.1
mg), 1 mg fluoride (2.2 mg)
CE
CE
SODIUM POLYSTYRENE (SORB FREE)
Tier 1
sodium polystyrene sulfonate oral powder
Tier 1
sodium polystyrene sulfonate oral suspension
Tier 1
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
Tier 1
sodium polystyrene sulfonate rectal enema 50 gram/200 ml
Tier 2
SPS
Tier 1
SSKI
Tier 2
TRICITRATES
Tier 1
UROCIT-K 10
Tier 3
UROCIT-K 15
Tier 3
UROCIT-K 5
Tier 3
VELPHORO
Tier 3
VP-GSTN
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
56
LA
Note 3
Drug Name
Drug Status
Additional Information
Gastrointestinal
ACIPHEX
Tier 3
PA; Note 4 (Standard,Select); QL
ACIPHEX SPRINKLE
Tier 3
PA; Note 4 (Standard); QL
ACTIGALL
Tier 3
AKYNZEO
Tier 3
ALOPHEN
CE
AMITIZA
Tier 2
amoxicil-clarithromy-lansopraz
Tier 1
ANALPRAM ADVANCED
Tier 2
ANALPRAM-HC
Tier 2
ANALPRAM-HC SINGLES
Tier 2
ANASPAZ
Tier 3
ANTIVERT ORAL TABLET 12.5 MG, 25 MG
Tier 3
ANUSOL-HC RECTAL CREAM
Tier 3
ANZEMET ORAL
Tier 3
Note 3; QL
APRISO
Tier 3
ST; Note 5 (Standard,Select); QL
ASACOL
Tier 2
ASACOL HD
Tier 2
AXID ORAL SOLUTION
Tier 3
AZULFIDINE EN-TABS ORAL TABLET,DELAYED
RELEASE (DR/EC) 500 MG
Tier 3
ST; Note 5 (Standard); QL
AZULFIDINE ORAL TABLET 500 MG
Tier 3
ST; Note 5 (Standard); QL
balsalazide
Tier 1
ST; Note 5 (Standard,Select); QL
BENTYL ORAL CAPSULE
Tier 3
BENTYL ORAL TABLET
Tier 3
BUPHENYL
Tier 5
PA
CANASA
Tier 2
QL
CARAFATE
Tier 3
CESAMET
Tier 3
CESINEX
LA
PA; QL
CE
ST; Note 3; Note 5 (Standard,Select); QL
QL
QL
CHENODAL
Tier 5
PA; Note 4 (Standard,Select)
chlordiazepoxide-clidinium
Tier 1
Note 3
CHOLBAM
Tier 5
PA; Note 4 (Standard,Select)
cimetidine hcl oral
Tier 1
cimetidine oral tablet 200 mg, 300 mg, 400 mg
Tier 1
cimetidine oral tablet 800 mg
Tier 1
LGC
CIMZIA
Tier 5
PA; Note 4 (Standard,Select); QL
CIMZIA POWDER FOR RECONST
Tier 5
PA; Note 4 (Standard,Select); QL
CIMZIA STARTER KIT
Tier 5
PA; Note 4 (Standard,Select); QL
COLAZAL
Tier 3
ST; Note 5 (Standard,Select); QL
COLYTE WITH FLAVOR PACKS
Tier 3
COMPAZINE RECTAL
Tier 3
CREON
Tier 2
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
57
Drug Name
Drug Status
Additional Information
CUVPOSA
Tier 3
CYTOTEC
Tier 3
DELZICOL
Tier 2
QL
DEXILANT
Tier 3
PA; Note 4 (Standard,Select); QL
DICLEGIS
Tier 3
QL
dicyclomine oral capsule
Tier 1
LGC
dicyclomine oral tablet
Tier 1
LGC
DIPENTUM
Tier 3
ST; Note 5 (Standard,Select); QL
diphenoxylate-atropine
Tier 1
Note 3
dronabinol
Tier 3
PA; Note 4 (Standard); QL
EMEND ORAL
Tier 3
QL
esomeprazole magnesium
Tier 1
QL
esomeprazole strontium
Tier 6
famotidine oral tablet 10 mg
Tier 1
famotidine oral tablet 20 mg, 40 mg
Tier 1
LGC
FULYZAQ
Tier 3
PA; Note 4 (Standard,Select); QL
GATTEX 30-VIAL
Tier 5
PA; Note 4 (Standard,Select); QL
GATTEX ONE-VIAL
Tier 5
PA; Note 4 (Standard,Select); QL
GAVILAX ORAL POWDER IN PACKET 8.5 GRAM
CE
PA; Note 4 (Standard)
CE
GAVILYTE-H AND BISACODYL
Tier 1
GIAZO
Tier 3
PA; Note 4 (Standard,Select); QL
GOLYTELY ORAL RECON SOLN
Tier 3
Note 3
granisetron hcl oral
Tier 3
QL
HALFLYTELY-BISACODYL W-FLAV PK
Tier 3
Note 3; QL
HELIDAC
Tier 3
hydrocortisone rectal cream
Tier 1
hyoscyamine sulfate oral tablet
Tier 1
hyoscyamine sulfate oral tablet,disintegrating
Tier 1
KRISTALOSE
Tier 2
KYTRIL ORAL
Tier 3
QL
lactulose oral solution 10 gram/15 ml
Tier 1
LGC
lactulose oral solution 10 gram/15 ml (15 ml), 20 gram/30
ml
Tier 1
lansoprazole oral capsule,delayed release(dr/ec)
Tier 6
LEVSIN ORAL
Tier 3
LIALDA
Tier 2
LIBRAX (WITH CLIDINIUM)
Tier 3
lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %
Tier 1
lidocaine hcl-hydrocortison ac rectal kit
Tier 1
LINZESS
Tier 3
LIPICHOL 540
QL
ST; QL
LA
LOMOTIL
Tier 3
Note 3
LOTRONEX
Tier 2
Note 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
58
Drug Name
Drug Status
Additional Information
LOVAZA
Tier 3
QL
MARINOL
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
mesalamine rectal
Tier 1
metoclopramide hcl injection solution
Tier 1
LGC
metoclopramide hcl oral solution
Tier 1
LGC
metoclopramide hcl oral tablet 10 mg
Tier 1
LGC
metoclopramide hcl oral tablet 5 mg
Tier 1
metoclopramide hcl oral tablet,disintegrating
Tier 6
METOZOLV ODT
Tier 6
MIRALAX
Tier 1
misoprostol
Tier 1
MOTOFEN
Tier 3
MOVIPREP
Tier 3
NEXIUM
Tier 1
QL
NEXIUM 24HR
Tier 1
Note 6
NEXIUM PACKET
Tier 2
nizatidine
Tier 1
NULYTELY WITH FLAVOR PACKS
Tier 3
OMECLAMOX-PAK
Tier 3
omega-3 acid ethyl esters
Tier 1
omeprazole oral capsule,delayed release(dr/ec) 10 mg, 40
mg
Tier 1
omeprazole oral capsule,delayed release(dr/ec) 20 mg
Tier 1
omeprazole oral tablet,delayed release (dr/ec)
Tier 1
ondansetron
Tier 1
Note 3; QL
ondansetron hcl oral solution
Tier 1
Note 3; QL
ondansetron hcl oral tablet 24 mg
Tier 3
Note 3; QL
ondansetron hcl oral tablet 4 mg, 8 mg
Tier 1
Note 3; QL
opium tincture oral tincture
Tier 3
OSMOPREP
Tier 3
PAMINE
Tier 3
PAMINE FORTE
Tier 3
PANCREAZE
Tier 3
pantoprazole oral
Tier 1
paregoric
Tier 3
peg 3350-electrolytes
Tier 1
peg-electrolyte soln
Tier 1
PENTASA ORAL CAPSULE, EXTENDED RELEASE
250 MG, 500 MG
Tier 2
PEPCID
Tier 3
PERTZYE
Tier 3
polyethylene glycol 3350 oral
Tier 1
PREPARATION CLEANSING
CE
Note 6
Note 5 (Standard); QL
LGC
ST; Note 5 (Standard)
Note 3
QL
ST; Note 5 (Standard)
CE
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
59
Drug Name
Drug Status
Additional Information
PREVACID
Tier 6
PREVACID 24HR
Tier 1
Note 6; QL
PREVACID SOLUTAB
Tier 3
PA; Note 4 (Standard,Select); QL; AL
PREVPAC
Tier 3
PRILOSEC ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
Tier 3
PRILOSEC ORAL SUSP,DELAYED RELEASE FOR
RECON
Tier 6
PRILOSEC OTC
Tier 1
prochlorperazine
Tier 1
prochlorperazine edisylate injection solution 10 mg/2 ml (5
mg/ml)
Tier 1
prochlorperazine maleate oral
Tier 1
PROCTOCORT RECTAL CREAM
Tier 3
PROCTOCREAM-HC
Tier 3
PROCTOFOAM HC
Tier 3
PROCTOZONE-HC
Tier 1
propantheline
Tier 1
PROTONIX ORAL
Tier 3
PYLERA
Tier 3
rabeprazole
Tier 3
ranitidine hcl oral capsule
Tier 1
ranitidine hcl oral tablet 150 mg, 300 mg
Tier 1
LGC
RAVICTI
Tier 5
PA; Note 4 (Standard,Select); QL
RECTIV
Tier 3
QL
REGLAN ORAL
Tier 3
ROBINUL FORTE
Tier 3
ROBINUL ORAL
Tier 3
SANCUSO
Tier 3
Note 3; QL
SMOOTHLAX ORAL POWDER
Tier 1
LGC
sodium phenylbutyrate
Tier 5
PA; Note 4 (Standard,Select)
SUCLEAR
Tier 3
SUCRAID
Tier 5
sucralfate oral
Tier 1
sulfasalazine
Tier 1
QL
SULFAZINE
Tier 1
QL
SULFAZINE EC
Tier 1
QL
SUPREP BOWEL PREP KIT
Tier 3
TIGAN ORAL CAPSULE 300 MG
Tier 3
TRANSDERM-SCOP
Tier 3
TRILYTE WITH FLAVOR PACKETS
Tier 1
trimethobenzamide oral
Tier 1
ULTRESA
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
60
Note 6
PA; Note 4 (Standard); QL
ST; Note 5 (Standard)
Drug Name
Drug Status
URSO 250
Tier 3
URSO FORTE
Tier 3
ursodiol oral capsule
Tier 1
ursodiol oral tablet
Tier 3
VASCAZEN
Additional Information
LA
VASCEPA
Tier 2
ST; Note 5 (Standard); QL
VIOKACE
Tier 3
ST; Note 5 (Standard)
VSL#3
LA
VSL#3 DS
LA
VSL#3 JUNIOR
LA
ZANTAC 25 EFFERDOSE
Tier 6
ZANTAC ORAL TABLET
Tier 3
ZEGERID
Tier 6
PA; Note 4 (Standard,Select); QL
ZEGERID OTC
Tier 1
Note 6; QL
ZENPEP
Tier 2
ZOFRAN (AS HYDROCHLORIDE) ORAL SOLUTION
Tier 3
Note 3; QL
ZOFRAN (AS HYDROCHLORIDE) ORAL TABLET
Tier 3
Note 3; QL
ZOFRAN ODT
Tier 3
Note 3; QL
Z-PRAM
Tier 3
ZUPLENZ
Tier 6
ZYPRAM
Tier 6
Note 3; QL
Herbals
TEARS AGAIN HYDRATE
LA
VP-PRECIP
LA
Hormones
ACTIVELLA ORAL TABLET 0.5-0.1 MG
Tier 3
QL
ACTIVELLA ORAL TABLET 1-0.5 MG
Tier 2
QL
ALORA
Tier 3
QL
ANADROL-50
Tier 3
ANDRODERM
Tier 6
Note 3
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1
%), 20.25 MG/1.25 GRAM (1.62 %)
Tier 2
PA; Note 3; Note 4 (Standard,Select); QL
ANDROGEL TRANSDERMAL GEL IN PACKET
Tier 2
PA; Note 3; Note 4 (Standard,Select); QL
ANDROID
Tier 2
Note 3
ANDROXY
Tier 1
ANGELIQ
Tier 3
AXIRON
Tier 6
AYGESTIN
Tier 3
BRAVELLE
LA
budesonide oral
Tier 1
cabergoline
Tier 1
calcitonin (salmon)
Tier 1
Note 3; QL
PA; Note 4 (Standard,Select)
Note 3; QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
61
Drug Name
Drug Status
CENESTIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625
MG, 0.9 MG, 1.25 MG
Tier 3
CERVIDIL
Tier 3
Additional Information
QL
CETROTIDE
LA
PA; Note 4 (Standard,Select)
chorionic gonadotropin, human
LA
PA; Note 3; Note 4 (Standard,Select)
CLIMARA
Tier 3
QL
CLIMARA PRO
Tier 3
QL
clomiphene citrate
LA
COMBIPATCH
Tier 3
CORTEF
Tier 3
CORTIFOAM
Tier 2
cortisone
Tier 1
COVARYX
Tier 1
COVARYX H.S.
Tier 1
CRINONE
Tier 3
danazol oral
Tier 3
DDAVP NASAL
Tier 3
DDAVP ORAL
Tier 3
DELATESTRYL
Tier 3
Note 3
DEPO-TESTOSTERONE
Tier 3
Note 3; QL
desmopressin nasal
Tier 1
desmopressin oral
Tier 1
dexamethasone
Tier 1
DIVIGEL
Tier 3
DUAVEE
Tier 2
EEMT
Tier 1
EEMT HS
Tier 1
EGRIFTA
Tier 5
PA; Note 4 (Standard,Select)
ELESTRIN
Tier 3
QL
ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG
Tier 3
QL
ENTOCORT EC
Tier 3
ESTRACE
Tier 3
estradiol oral
Tier 1
LGC
estradiol transdermal patch semiweekly
Tier 3
QL
estradiol transdermal patch weekly
Tier 1
QL
estradiol-norethindrone acet
Tier 1
ESTRASORB
Tier 3
ESTRING
Tier 3
ESTROGEL
Tier 3
estrogens-methyltestosterone
Tier 1
estropipate
Tier 1
EVAMIST
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
62
QL
QL
QL
QL
QL
Drug Name
Drug Status
FEMHRT 1/5
Tier 3
QL
FEMHRT LOW DOSE
Tier 3
QL
FEMRING
Tier 3
QL
fludrocortisone
Tier 1
FOLLISTIM AQ
LA
Additional Information
PA; Note 4 (Standard,Select)
FORTESTA
Tier 6
Note 3; QL
FORTICAL
Tier 1
QL
ganirelix
LA
GENOTROPIN
Tier 6
GENOTROPIN MINIQUICK
Tier 6
PA; Note 4 (Standard,Select)
GONAL-F
LA
PA; Note 4 (Standard,Select)
GONAL-F RFF
LA
PA; Note 4 (Standard,Select)
GONAL-F RFF PEN
LA
GONAL-F RFF REDI-JECT
LA
HUMATROPE
Tier 6
hydrocortisone oral
Tier 1
INCRELEX
Tier 5
JINTELI
Tier 1
LUVERIS
LA
MEDROL
Tier 3
MEDROL (PAK)
Tier 3
medroxyprogesterone oral
Tier 1
MENEST
Tier 3
MENOPUR
LA
PA; Note 4 (Standard,Select)
LGC
PA; Note 4 (Standard,Select)
MENOSTAR
Tier 3
methylergonovine oral
Tier 1
methylprednisolone
Tier 1
MIACALCIN INJECTION
Tier 3
MIACALCIN NASAL
Tier 3
QL
MIMVEY
Tier 1
QL
MYALEPT
Tier 5
PA; Note 4 (Standard,Select); Note 5
(Standard,Select); QL
NATESTO
Tier 6
NATPARA
Tier 5
NORDITROPIN FLEXPRO SUBCUTANEOUS PEN
INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML
(10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
Tier 6
NORDITROPIN NORDIFLEX
Tier 6
norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg
Tier 3
NOVAREL
LA
NUTROPIN
Tier 6
NUTROPIN AQ
Tier 6
NUTROPIN AQ NUSPIN
Tier 6
QL
PA; Note 4 (Standard,Select); QL
QL
PA; Note 3; Note 4 (Standard,Select)
PA; Note 4 (Standard,Select)
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
63
Drug Name
Drug Status
Additional Information
octreotide acetate
Tier 4
PA; Note 4 (Standard,Select)
OGEN 2.5
Tier 3
OMNITROPE
Tier 4
ORAPRED
Tier 3
ORAPRED ODT
Tier 3
OVIDREL
LA
PA; Note 4 (Standard,Select)
PA; Note 4 (Standard,Select)
OXANDRIN
Tier 3
prednisolone oral solution 5 mg/5 ml
Tier 1
prednisolone sodium phosphate oral tablet,disintegrating
Tier 3
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
prednisone oral tablet 50 mg
Tier 1
prednisone oral tablets,dose pack
Tier 1
LGC
PREFEST
Tier 3
QL
PREGNYL
LA
PRELONE
Tier 3
PREMARIN ORAL
Tier 2
PREMARIN VAGINAL
Tier 2
PREMPHASE
Tier 2
PREMPRO
Tier 2
PREPIDIL
Tier 3
PROMETRIUM
Tier 2
PROVERA
Tier 3
RAYOS
Tier 3
ST; Note 5 (Standard,Select)
LA
PA; Note 4 (Standard,Select)
REPRONEX
LGC
PA; Note 4 (Standard,Select)
QL
SAIZEN
Tier 6
SAIZEN CLICK.EASY
Tier 6
SANDOSTATIN INJECTION SOLUTION 1,000
MCG/ML, 200 MCG/ML, 50 MCG/ML, 500 MCG/ML
Tier 4
PA; Note 4 (Standard,Select)
SANDOSTATIN INJECTION SOLUTION 100 MCG/ML
Tier 5
PA; Note 4 (Standard,Select)
SEROPHENE
LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5
MG, 6 MG
Tier 6
SIGNIFOR
Tier 5
PA; Note 4 (Standard,Select); QL
SOMATULINE DEPOT
Tier 5
PA; Note 4 (Standard,Select)
STIMATE
Tier 4
PA; Note 4 (Standard,Select)
STRIANT
Tier 6
Note 3; QL
SUPPRELIN LA
Tier 5
PA
SYNAREL
Tier 2
TESTIM
Tier 2
PA; Note 3; Note 4 (Standard,Select); QL
testosterone cypionate
Tier 3
Note 3; QL
testosterone enanthate
Tier 3
testosterone transdermal gel
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
64
PA; Note 4 (Standard,Select); QL
Drug Name
Drug Status
Additional Information
testosterone transdermal gel in metered-dose pump 1.25
gram/ actuation (1 %)
Tier 3
PA; Note 4 (Standard,Select); QL
testosterone transdermal gel in packet 1 % (50 mg/5 gram)
Tier 3
PA; Note 4 (Standard,Select); QL
TEV-TROPIN
Tier 6
UCERIS ORAL
Tier 3
ST; Note 5 (Standard,Select); QL
UCERIS RECTAL
Tier 3
ST; QL
VAGIFEM
Tier 3
VIVELLE
Tier 2
QL
VIVELLE-DOT
Tier 3
QL
VOGELXO
Tier 6
ZOMACTON
Tier 5
PA; Note 4 (Standard,Select)
ZORBTIVE
Tier 5
PA; Note 4 (Standard,Select)
ACTEMRA SUBCUTANEOUS
Tier 5
PA; Note 4 (Standard,Select); QL
ASTAGRAF XL
Tier 5
azathioprine
Tier 1
CELLCEPT ORAL CAPSULE
Tier 5
CELLCEPT ORAL SUSPENSION FOR
RECONSTITUTION
Tier 4
CELLCEPT ORAL TABLET
Tier 5
cyclosporine modified
Tier 4
cyclosporine oral capsule
Tier 4
ELIDEL
Tier 3
GENGRAF
Tier 4
HECORIA
Tier 5
IMURAN
Tier 3
mycophenolate mofetil
Tier 4
mycophenolate sodium
Tier 5
Note 3
MYFORTIC
Tier 5
Note 3
NEORAL
Tier 4
PROGRAF INTRAVENOUS
Tier 4
PROGRAF ORAL
Tier 5
PROTOPIC
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
RAPAMUNE ORAL SOLUTION
Tier 4
Note 3
RAPAMUNE ORAL TABLET 0.5 MG
Tier 5
Note 3
RAPAMUNE ORAL TABLET 1 MG, 2 MG
Tier 4
Note 3
SANDIMMUNE ORAL
Tier 4
sirolimus oral tablet 0.5 mg
Tier 4
sirolimus oral tablet 1 mg, 2 mg
Tier 4
STELARA SUBCUTANEOUS SOLUTION
Tier 4
STELARA SUBCUTANEOUS SYRINGE
Tier 4
tacrolimus oral
Tier 4
tacrolimus topical ointment 0.1 %
Tier 3
Immunosuppresant
PA; Note 3; Note 4 (Standard,Select); QL
Note 3
Note 3
PA; Note 4 (Standard,Select); QL
PA; QL
2015 Coventry Health Prescription Drug List
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65
Drug Name
ZORTRESS
Drug Status
Additional Information
Tier 5
Miscellaneous Medical Supplies, Devices, Non-Drug
2TEK GLUCOSE/BLOOD PRESSURE
Tier 3
PA; QL
ACCU-CHEK COMPACT PLUS CARE
Tier 6
ADVOCATE BLOOD GLUCOSE MONITOR
Tier 6
AEROCHAMBER MV
Tier 2
BD AUTOSHIELD PEN NEEDLE
Tier 2
BD INSULIN PEN NEEDLE UF MINI
Tier 2
BD INSULIN PEN NEEDLE UF ORIG
Tier 2
BD INSULIN PEN NEEDLE UF SHORT
Tier 2
BD INSULIN SYRINGE
Tier 2
BD INSULIN SYRINGE HALF UNIT
Tier 2
BD INSULIN SYRINGE MICRO-FINE
Tier 2
BD INSULIN SYRINGE SAFETY-LOK
Tier 2
BD INSULIN SYRINGE SLIP TIP
Tier 2
BD INSULIN SYRINGE ULT-FINE II
Tier 2
BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML
30 X 1/2", 1 ML 29 X 1/2"
Tier 2
BD INTEGRA INSULIN SYRINGE
Tier 2
BD LUER-LOK SYRINGE SYRINGE 5 ML 23 X 1 1/4 "
Tier 2
BD SAFETYGLIDE INSULIN SYRINGE
Tier 2
BD SAFETYGLIDE SHIELDING REG
Tier 2
BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 X
5/8", 10 ML 22 X 1 1/2", 3 ML 22 X 1 1/2"
Tier 2
FREESTYLE FREEDOM LITE
Tier 3
MICROCHAMBER
Tier 2
NOVOFINE 30
Tier 2
NOVOFINE 32
Tier 2
NOVOFINE AUTOCOVER
Tier 2
NOVOFINE PLUS
Tier 2
NOVOPEN 3
Tier 3
NOVOPEN JR
Tier 3
NOVOTWIST
Tier 2
ONETOUCH VERIO IQ METER KIT
Tier 2
OPTICHAMBER ADVANTAGE
Tier 3
PRODIGY AUTOCODE METER
Tier 3
PA; Note 4 (Standard); QL
PRODIGY AUTOCODE PRO
Tier 3
PA; QL
PRODIGY POCKET METER
Tier 3
PA; Note 4 (Standard); QL
PRODIGY POCKET PRO
Tier 3
PA; Note 4 (Standard); QL
PRODIGY VOICE GLUCOSE METER
Tier 3
PA; Note 4 (Standard); QL
PRODIGY VOICE PRO
Tier 3
PA; Note 4 (Standard); QL
Tier 6
QL
QL
PA; Note 4 (Standard,Select)
QL
Muscle Relaxants
AMRIX
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
66
Drug Name
Drug Status
Additional Information
baclofen oral tablet 10 mg
Tier 1
LGC
baclofen oral tablet 20 mg
Tier 1
carisoprodol oral tablet 350 mg
Tier 1
Note 3
carisoprodol-aspirin
Tier 1
Note 3
chlorzoxazone
Tier 1
COMFORT PAC-CYCLOBENZAPRINE
Tier 6
COMFORT PAC-TIZANIDINE
Tier 6
cyclobenzaprine oral tablet 10 mg, 5 mg
Tier 1
LGC; Note 3
cyclobenzaprine oral tablet 7.5 mg
Tier 1
Note 3
DANTRIUM ORAL
Tier 3
dantrolene
Tier 1
FLEXERIL
Tier 3
LIORESAL
Tier 3
LORZONE
Tier 6
metaxalone oral tablet 400 mg
Tier 3
QL
metaxalone oral tablet 800 mg
Tier 3
Note 3; QL
methocarbamol oral
Tier 1
orphenadrine citrate oral
Tier 1
ORPHENADRINE COMPOUND
Tier 3
ORPHENADRINE COMPOUND-DS
Tier 3
PARAFON FORTE DSC
Tier 3
ROBAXIN ORAL
Tier 3
SKELAXIN
Tier 3
SOMA
Tier 6
tizanidine oral tablet
Tier 1
ZANAFLEX ORAL CAPSULE
Tier 6
ZANAFLEX ORAL TABLET
Tier 3
Note 3; QL
Pre-Natal Vitamins
CITRANATAL 90 DHA (ALGAL OIL)
Tier 3
CITRANATAL 90 DHA (NEW FORMULA
Tier 3
CITRANATAL ASSURE ORAL COMBO PACK
35-1-50-300 MG
Tier 3
CITRANATAL B-CALM (FE GLUC)
Tier 3
CITRANATAL DHA (NEW FORMULA)
Tier 3
CITRANATAL HARMONY (IRON FUM)
Tier 3
CITRANATAL HARMONY ORAL CAPSULE 30 MG
IRON-1 MG -50 MG-260 MG
Tier 3
CITRANATAL RX (NEW FORMULA)
Tier 3
DUET DHA BALANCED ORAL COMBO
PACK,TABLET & CAP,DR
Tier 3
LEVOMEFOLATE DHA
Tier 3
MYNATAL
Tier 1
NATAFORT (NEW FORMULA 2011)
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
67
Drug Name
Drug Status
NEEVO
Tier 3
NEEVO DHA
Tier 3
NEEVODHA (WITH ALGAL OIL)
Tier 3
NESTABS
Tier 3
OBTREX
Tier 3
O-CAL PRENATAL
Tier 3
PREFERA-OB ONE
Tier 3
PREFERA-OB PLUS DHA
Tier 3
PRENA1 CHEW
Tier 3
PRENATABS FA
Tier 3
PRENATABS RX
Tier 3
PRENATAL VITAMIN ORAL TABLET
Tier 1
PRENATE DHA
Tier 3
PRENATE ELITE
Tier 3
PRENATE ESSENTIAL
Tier 3
PREQUE 10
Tier 3
SELECT-OB + DHA
Tier 3
TRICARE PRENATAL DHA ONE
Tier 3
TRINATE
Tier 1
ULTIMATE OB DHA
Tier 1
VINATE DHA
Tier 3
VINATE DHA RF
Tier 3
VINATE PN CARE
Tier 1
VITAMEDMD REDICHEW RX
Tier 3
VITAPEARL
Tier 3
VIVA DHA
Tier 3
Additional Information
Psychotherapeutic Drugs
ABILIFY DISCMELT
Tier 3
PA; ST; Note 5 (Standard); QL
ABILIFY ORAL SOLUTION
Tier 3
PA; Note 4 (Standard,Select); QL
ABILIFY ORAL TABLET
Tier 3
PA; Note 4 (Standard,Select); QL
ALPRAZOLAM INTENSOL
Tier 3
alprazolam oral tablet
Tier 1
Note 3; AL
alprazolam oral tablet extended release 24 hr
Tier 1
Note 3; QL; AL
alprazolam oral tablet,disintegrating
Tier 1
Note 3; AL
amitriptyline oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75
mg
Tier 1
LGC
amitriptyline oral tablet 150 mg
Tier 1
amitriptyline-chlordiazepoxide
Tier 3
amoxapine
Tier 1
ANAFRANIL
Tier 3
APLENZIN
Tier 6
Note 3; QL
APTENSIO XR
Tier 3
PA; ST; Note 4 (Standard,Select); Note 5
(Standard,Select); QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
68
Drug Name
Drug Status
Additional Information
aripiprazole
Tier 1
QL
ATIVAN ORAL
Tier 3
Note 3
BRINTELLIX
Tier 3
PA; Note 4 (Standard,Select); QL
BRISDELLE
Tier 6
BUDEPRION SR
Tier 1
QL
BUDEPRION XL
Tier 1
QL
bupropion hcl oral tablet
Tier 1
QL
bupropion hcl oral tablet extended release 100 mg, 200 mg
Tier 1
QL
bupropion hcl oral tablet extended release 150 mg
CE
CE; QL
bupropion hcl oral tablet extended release 24 hr
Tier 1
QL
buspirone oral tablet 10 mg, 5 mg
Tier 1
LGC
buspirone oral tablet 15 mg, 30 mg, 7.5 mg
Tier 1
CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG
Tier 3
QL
chlordiazepoxide hcl
Tier 1
Note 3; AL
chlorpromazine oral
Tier 1
citalopram oral solution
Tier 1
citalopram oral tablet 10 mg, 20 mg, 40 mg
Tier 1
clomipramine
Tier 1
clonidine hcl oral tablet extended release 12 hr
Tier 1
PA; Note 4 (Standard,Select); QL
clorazepate dipotassium
Tier 1
Note 3; AL
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
Tier 1
Note 3; QL
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
Tier 1
QL
clozapine oral tablet,disintegrating 150 mg, 200 mg
Tier 3
QL
CLOZARIL ORAL TABLET 100 MG, 25 MG
Tier 3
QL
CONCERTA ORAL TABLET EXTENDED RELEASE
24HR 18 MG, 27 MG, 36 MG, 54 MG
Tier 3
PA; Note 3; Note 4 (Standard); QL; AL
CYMBALTA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 20 MG, 60 MG
Tier 3
PA; Note 4 (Standard,Select); QL
CYMBALTA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 30 MG
Tier 3
PA; Note 4 (Standard,Select)
DAYTRANA
Tier 3
PA; Note 3; Note 4 (Standard); QL; AL
desipramine oral
Tier 1
desvenlafaxine
Tier 3
PA; Note 4 (Standard,Select); QL
desvenlafaxine fumarate
Tier 3
PA; Note 4 (Standard,Select); QL
dexmethylphenidate oral capsule,er biphasic 50-50 10 mg,
5 mg
Tier 1
PA; QL
dexmethylphenidate oral capsule,er biphasic 50-50 15 mg,
30 mg, 40 mg
Tier 1
PA; Note 3; QL; AL
dexmethylphenidate oral tablet
Tier 1
Note 3; QL
DIAZEPAM INTENSOL
Tier 3
diazepam oral solution 5 mg/5 ml
Tier 1
diazepam oral tablet
Tier 1
doxepin oral
Tier 1
LGC; QL
Note 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
69
Drug Name
Drug Status
Additional Information
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30
mg, 60 mg
Tier 3
EFFEXOR XR
Tier 3
EMSAM
Tier 3
EQUETRO
Tier 3
escitalopram oxalate oral solution
Tier 1
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg
Tier 1
QL
FANAPT ORAL TABLET
Tier 3
ST; Note 5 (Standard); QL
FANAPT ORAL TABLETS,DOSE PACK
Tier 3
ST; Note 5 (Standard); QL
FAZACLO ORAL TABLET,DISINTEGRATING 100 MG,
12.5 MG, 150 MG, 200 MG, 25 MG
Tier 3
QL
FETZIMA
Tier 3
PA; Note 4 (Standard,Select); QL
fluoxetine oral capsule 10 mg, 20 mg, 40 mg
Tier 1
LGC; QL
fluoxetine oral capsule,delayed release(dr/ec)
Tier 1
QL
fluoxetine oral tablet 10 mg
Tier 1
LGC; QL
fluoxetine oral tablet 20 mg
Tier 1
QL
fluoxetine oral tablet 60 mg
Tier 3
QL
fluphenazine hcl oral concentrate
Tier 1
fluphenazine hcl oral tablet
Tier 1
fluvoxamine oral capsule,extended release 24hr
Tier 1
QL
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg
Tier 1
QL
FOCALIN
Tier 3
Note 3; QL
FOCALIN XR
Tier 3
PA; Note 3; Note 4 (Standard); QL; AL
FORFIVO XL
Tier 6
QL
GEODON ORAL
Tier 3
QL
guanfacine oral tablet extended release 24 hr
Tier 3
PA; QL
haloperidol
Tier 1
haloperidol lactate oral
Tier 1
imipramine hcl
Tier 1
imipramine pamoate
Tier 3
INTUNIV ER
Tier 3
PA; Note 4 (Standard,Select); QL
INVEGA ORAL TABLET EXTENDED RELEASE 24HR
1.5 MG, 3 MG, 6 MG, 9 MG
Tier 3
ST; Note 5 (Standard); QL
KAPVAY
Tier 3
PA; Note 4 (Standard,Select); QL
KHEDEZLA
Tier 3
PA; Note 4 (Standard,Select); QL
LATUDA
Tier 2
ST; Note 5 (Standard); QL
LEXAPRO ORAL SOLUTION
Tier 3
LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG
Tier 3
lithium carbonate oral capsule
Tier 1
lithium carbonate oral tablet
Tier 1
lithium carbonate oral tablet extended release 450 mg
Tier 1
lithium citrate oral solution 8 meq/5 ml
Tier 1
LITHOBID
Tier 3
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
70
PA; Note 4 (Standard); QL
QL
QL
Drug Name
Drug Status
Additional Information
LORAZEPAM INTENSOL
Tier 3
lorazepam oral tablet
Tier 1
loxapine succinate
Tier 1
LOXITANE
Tier 3
LUVOX CR
Tier 3
maprotiline
Tier 1
meprobamate
Tier 1
METADATE CD
Tier 3
PA; Note 3; Note 4 (Standard); QL
METADATE ER
Tier 1
Note 3; QL
METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5
ML
Tier 3
QL
METHYLIN ORAL TABLET,CHEWABLE 10 MG, 2.5
MG, 5 MG
Tier 2
PA; Note 4 (Standard,Select)
METHYLIN ORAL TABLET,CHEWABLE 10 MG, 2.5
MG, 5 MG
Tier 3
PA; Note 4 (Standard,Select); QL
methylphenidate oral capsule, er biphasic 30-70
Tier 1
Note 3; QL; AL
methylphenidate oral capsule,er biphasic 50-50 20 mg, 30
mg, 40 mg
Tier 1
PA; Note 4 (Standard,Select); QL; AL
methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml
Tier 1
QL
methylphenidate oral tablet
Tier 1
Note 3; QL
methylphenidate oral tablet extended release 20 mg
Tier 1
QL
methylphenidate oral tablet extended release 24hr 18 mg,
27 mg, 54 mg
Tier 1
PA; Note 3; QL; AL
methylphenidate oral tablet extended release 24hr 36 mg
Tier 1
PA; Note 3; Note 4 (Standard,Select);
QL; AL
methylphenidate oral tablet,chewable
Tier 3
PA; QL
mirtazapine oral tablet
Tier 1
mirtazapine oral tablet,disintegrating
Tier 3
QL
modafinil
Tier 1
PA; Note 4 (Standard,Select); QL
NARDIL
Tier 2
NAVANE ORAL CAPSULE 2 MG
Tier 3
nefazodone
Tier 3
NIRAVAM
Tier 3
NORPRAMIN
Tier 3
nortriptyline oral capsule 10 mg, 25 mg
Tier 1
nortriptyline oral capsule 50 mg, 75 mg
Tier 1
NUVIGIL
Tier 3
PA; QL
olanzapine oral tablet
Tier 1
QL
olanzapine oral tablet,disintegrating 15 mg, 20 mg, 5 mg
Tier 1
QL
OLEPTRO ER
Tier 3
QL
ORAP
Tier 3
oxazepam
Tier 1
PAMELOR
Tier 3
PARNATE
Tier 3
Note 3
QL
Note 3; AL
LGC
Note 3; AL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
71
Drug Name
Drug Status
Additional Information
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
Tier 1
LGC; QL
paroxetine hcl oral tablet extended release 24 hr
Tier 1
Note 3; QL
PAXIL CR
Tier 3
QL
PAXIL ORAL SUSPENSION
Tier 3
QL
PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG
Tier 3
QL
perphenazine
Tier 1
perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg,
4-25 mg
Tier 1
PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG
Tier 6
QL
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR
100 MG, 50 MG
Tier 3
PA; Note 4 (Standard); QL
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR
25 MG
Tier 3
PA; QL
protriptyline
Tier 1
PROVIGIL
Tier 3
PA; QL
PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG
Tier 3
QL
PROZAC WEEKLY
Tier 3
QL
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400
mg, 50 mg
Tier 1
QL
QUILLIVANT XR
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
REMERON
Tier 3
REMERON SOLTAB
Tier 3
QL
RISPERDAL M-TAB ORAL
TABLET,DISINTEGRATING 0.5 MG, 1 MG, 2 MG, 3
MG, 4 MG
Tier 3
ST; Note 5 (Standard); QL
RISPERDAL ORAL SOLUTION
Tier 3
ST
RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2
MG, 3 MG, 4 MG
Tier 3
ST; Note 5 (Standard); QL
risperidone oral solution
Tier 1
ST; Note 5 (Standard)
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4
mg
Tier 1
ST; Note 5 (Standard); QL
risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
Tier 1
ST; Note 5 (Standard); QL
RITALIN
Tier 3
Note 3; QL
RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10
MG, 20 MG, 30 MG, 40 MG
Tier 3
PA; Note 3; Note 4 (Standard,Select);
QL; AL
RITALIN SR
Tier 3
Note 3; QL
SAPHRIS
Tier 3
ST; Note 5 (Standard); QL
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET
2.5 MG
Tier 3
ST; Note 5 (Standard,Select); QL
SARAFEM ORAL TABLET 10 MG, 20 MG
Tier 3
QL
SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG,
300 MG, 400 MG, 50 MG
Tier 3
QL
SEROQUEL XR ORAL TABLET EXTENDED RELEASE
24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG
Tier 3
PA; Note 4 (Standard,Select); QL
sertraline oral concentrate
Tier 1
QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
72
Drug Name
Drug Status
Additional Information
sertraline oral tablet 100 mg, 25 mg, 50 mg
Tier 1
LGC; QL
STRATTERA
Tier 2
QL
SURMONTIL
Tier 3
SYMBYAX
Tier 3
thioridazine
Tier 1
thiothixene
Tier 1
TOFRANIL
Tier 3
TOFRANIL-PM
Tier 3
TRANXENE T-TAB
Tier 3
tranylcypromine
Tier 1
trazodone
Tier 1
trifluoperazine
Tier 1
trimipramine
Tier 3
VALIUM
Tier 3
Note 3
venlafaxine oral capsule,extended release 24hr
Tier 1
QL
venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75
mg
Tier 1
QL
venlafaxine oral tablet extended release 24hr
Tier 3
QL
VERSACLOZ
Tier 3
ST; Note 5 (Standard)
VIIBRYD ORAL TABLET
Tier 3
PA; Note 4 (Standard); QL
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20
MG (7)-40 MG (16)
Tier 3
PA; Note 4 (Standard); QL
VIVACTIL
Tier 3
VYVANSE ORAL CAPSULE 10 MG
Tier 2
QL
VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50
MG, 60 MG, 70 MG
Tier 2
Note 3; QL
WELLBUTRIN
Tier 3
QL
WELLBUTRIN SR
Tier 3
QL
WELLBUTRIN XL
Tier 3
QL
XANAX
Tier 3
Note 3; AL
XANAX XR
Tier 3
Note 3; QL; AL
ziprasidone hcl
Tier 1
QL
ZOLOFT ORAL CONCENTRATE
Tier 3
QL
ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG
Tier 3
QL
ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20
MG, 5 MG, 7.5 MG
Tier 3
QL
ZYPREXA ZYDIS
Tier 3
QL
AMBIEN
Tier 3
Note 3; QL; AL
AMBIEN CR
Tier 3
ST; Note 3; Note 5 (Standard,Select); QL;
AL
BELSOMRA
Tier 3
ST; QL
BUTISOL
Tier 3
DORAL
Tier 3
QL
Note 3; AL
Sedative/Hypnotics
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
73
Drug Name
Drug Status
Additional Information
EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG
Tier 6
QL; AL
estazolam
Tier 1
AL
eszopiclone oral tablet 1 mg, 2 mg
Tier 3
ST; Note 5 (Standard); QL; AL
eszopiclone oral tablet 3 mg
Tier 3
ST; Note 5 (Standard); AL
flurazepam
Tier 1
AL
HALCION ORAL TABLET 0.25 MG
Tier 3
Note 3; AL
HETLIOZ
Tier 5
PA; Note 4 (Standard,Select)
INTERMEZZO
Tier 6
QL; AL
LUNESTA
Tier 3
ST; Note 3; Note 5 (Standard,Select); QL;
AL
phenobarbital
Tier 1
Note 3
RESTORIL ORAL CAPSULE 15 MG, 30 MG
Tier 3
AL
RESTORIL ORAL CAPSULE 22.5 MG, 7.5 MG
Tier 3
QL; AL
ROZEREM
Tier 3
ST; Note 5 (Standard); QL; AL
SILENOR
Tier 6
QL; AL
SONATA
Tier 3
QL
temazepam oral capsule 15 mg, 30 mg
Tier 1
AL
temazepam oral capsule 22.5 mg, 7.5 mg
Tier 3
QL; AL
triazolam
Tier 1
Note 3; AL
XYREM
Tier 5
PA; Note 4 (Standard,Select)
zolpidem oral tablet
Tier 1
Note 3; QL; AL
zolpidem oral tablet,ext release multiphase
Tier 3
ST; Note 3; Note 5 (Standard); QL; AL
ZOLPIMIST
Tier 6
Skin Preps
ABSORICA
Tier 6
ACANYA
Tier 6
acetic acid irrigation
Tier 1
acitretin oral capsule 10 mg, 25 mg
Tier 1
acitretin oral capsule 17.5 mg
Tier 1
ACLOVATE
Tier 3
ACZONE
Tier 3
adapalene topical cream
Tier 3
adapalene topical gel 0.1 %
Tier 3
adapalene topical gel 0.3 %
Tier 3
ST
adapalene topical gel with pump
Tier 3
ST
adapalene topical lotion
Tier 3
ST; Note 5 (Standard,Select)
alclometasone
Tier 1
ALDARA
Tier 3
ALTABAX
Tier 3
aluminum acetate topical
Tier 1
aluminum chloride topical
Tier 1
AMNESTEEM
Tier 3
PA; Note 3; Note 4 (Standard,Select); QL
ATRALIN
Tier 3
ST; Note 5 (Standard); QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
74
QL
QL
Drug Name
Drug Status
Additional Information
AVITA TOPICAL CREAM
Tier 3
QL
AVITA TOPICAL GEL
Tier 3
ST; Note 5 (Standard); QL
AZELEX
Tier 2
BENZACLIN
Tier 3
QL
BENZACLIN PUMP
Tier 6
QL
betamethasone valerate topical cream
Tier 1
betamethasone valerate topical lotion
Tier 1
betamethasone valerate topical ointment
Tier 1
betamethasone, augmented topical cream
Tier 1
betamethasone, augmented topical lotion
Tier 1
betamethasone, augmented topical ointment
Tier 1
BIONECT
Tier 3
calcipotriene
Tier 3
ST; Note 5 (Standard)
CALCITRENE
Tier 3
ST; Note 5 (Standard)
CAPEX
Tier 2
CLARAVIS
Tier 1
PA; Note 4 (Standard,Select); QL
clindamycin-benzoyl peroxide topical gel 1-5 %
Tier 3
QL
clobetasol topical cream
Tier 1
clobetasol topical ointment
Tier 1
clobetasol topical shampoo
Tier 3
clobetasol topical spray,non-aerosol
Tier 3
clobetasol-emollient topical cream
Tier 1
CLOBEX
Tier 3
CLODERM
Tier 3
CONDYLOX
Tier 3
COSENTYX
Tier 5
PA
COSENTYX (2 SYRINGES)
Tier 5
PA
COSENTYX PEN
Tier 5
PA
COSENTYX PEN (2 PENS)
Tier 5
PA
CUTIVATE
Tier 3
DERMA-SMOOTHE/FS BODY OIL
Tier 2
DERMA-SMOOTHE/FS SCALP OIL
Tier 2
DERMATOP
Tier 3
DERMAZENE
Tier 3
DESONATE
Tier 3
desonide topical cream
Tier 1
desonide topical ointment
Tier 1
DESOWEN TOPICAL CREAM
Tier 3
diclofenac sodium topical drops
Tier 3
DIFFERIN TOPICAL CREAM
Tier 3
DIFFERIN TOPICAL GEL
Tier 3
ST; Note 5 (Standard)
DIFFERIN TOPICAL LOTION
Tier 3
ST; Note 5 (Standard)
ST
QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
75
Drug Name
Drug Status
DIPROLENE
Tier 3
DIPROLENE AF
Tier 3
DOVONEX
Tier 3
DRYSOL DAB-O-MATIC
Tier 3
DUAC
Tier 3
ELIMITE
Tier 3
ELOCON
Tier 3
EPIDUO
Tier 3
EURAX
Tier 2
FABIOR
Tier 3
FINACEA
Tier 3
FLECTOR
Tier 6
fluocinolone topical oil
Tier 1
fluocinolone-shower cap
Tier 1
fluocinonide topical cream 0.05 %
Tier 1
fluocinonide topical gel
Tier 1
fluocinonide topical ointment
Tier 1
FLUOCINONIDE-E
Tier 1
fluticasone topical cream
Tier 1
fluticasone topical lotion
Tier 3
fluticasone topical ointment
Tier 1
GRANULEX
Tier 3
halobetasol propionate
Tier 1
HALOG
Tier 3
HALONATE
Tier 6
HALONATE PAC
Tier 6
hydrocortisone butyrate
Tier 1
hydrocortisone butyr-emollient
Tier 1
hydrocortisone topical cream 2.5 %
Tier 1
hydrocortisone topical lotion 2.5 %
Tier 1
hydrocortisone topical ointment 2.5 %
Tier 1
hydrocortisone valerate
Tier 1
hydrocortisone-pramoxine topical
Tier 1
HYLATOPIC
Tier 3
imiquimod
Tier 1
iodoquinol-hc
Tier 3
KENALOG TOPICAL
Tier 3
KLARON
Tier 3
LAC-HYDRIN
Tier 3
LATISSE
Tier 6
lindane topical lotion
Tier 1
Note 3; QL
lindane topical shampoo
Tier 2
Note 3; QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
76
Additional Information
ST; Note 5 (Standard)
ST; Note 5 (Standard); QL
ST
QL
LGC
LGC
QL
Drug Name
Drug Status
Additional Information
LOCOID LIPOCREAM
Tier 3
LOCOID TOPICAL CREAM
Tier 3
LOCOID TOPICAL LOTION
Tier 3
LOCOID TOPICAL OINTMENT
Tier 3
LUXIQ
Tier 3
methoxsalen rapid
Tier 1
METROCREAM
Tier 3
METROGEL TOPICAL GEL 1 %
Tier 3
ST; Note 5 (Standard)
METROGEL TOPICAL GEL WITH PUMP
Tier 3
ST; Note 5 (Standard)
METROLOTION
Tier 3
metronidazole topical cream
Tier 1
Note 3
metronidazole topical gel 0.75 %
Tier 1
Note 3
metronidazole topical gel 1 %
Tier 3
ST; Note 3
metronidazole topical lotion
Tier 1
Note 3
MIRVASO
Tier 3
ST; Note 5 (Standard)
mometasone
Tier 1
MOMEXIN
Tier 6
QL
MYORISAN
Tier 3
PA; Note 4 (Standard,Select); QL
NATROBA
Tier 3
NEUAC
Tier 3
NEUAC KIT
Tier 3
NORITATE
Tier 3
OLUX
Tier 3
OLUX-E
Tier 3
OVACE
Tier 3
OVACE PLUS TOPICAL LOTION
Tier 3
OVIDE
Tier 3
OXSORALEN
Tier 2
OXSORALEN ULTRA
Tier 3
PANDEL
Tier 3
PEDIADERM HC
Tier 6
PENNSAID TOPICAL DROPS
Tier 3
QL
PENNSAID TOPICAL SOLUTION IN METERED-DOSE
PUMP
Tier 3
ST; QL
permethrin
Tier 1
Note 3
PODOCON
Tier 3
podofilox
Tier 1
PRAMOSONE
Tier 3
REGRANEX
Tier 3
RETIN-A
Tier 3
QL
RETIN-A MICRO
Tier 3
ST; Note 5 (Standard); QL
RETIN-A MICRO PUMP
Tier 3
ST; Note 5 (Standard); QL
ROSADAN TOPICAL CREAM
Tier 1
QL
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
77
Drug Name
Drug Status
Additional Information
ROSADAN TOPICAL GEL
Tier 3
ROSADAN TOPICAL KIT, CLEANSER & GEL
Tier 6
ROSADAN TOPICAL KIT,CLEANSER AND CREAM
Tier 6
SALEX TOPICAL SHAMPOO
Tier 3
SANTYL
Tier 3
selenium sulfide
Tier 1
SELRX
Tier 6
SOOLANTRA
Tier 3
ST
SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG
Tier 2
QL
SYNALAR
Tier 3
SYNALAR CREAM KIT
Tier 3
SYNALAR OINTMENT KIT
Tier 3
SYNALAR TS
Tier 6
TAZORAC
Tier 3
TEMOVATE TOPICAL CREAM
Tier 3
TEMOVATE TOPICAL OINTMENT
Tier 3
TEMOVATE TOPICAL SOLUTION
Tier 3
TOPICORT TOPICAL CREAM
Tier 3
TOPICORT TOPICAL GEL
Tier 3
TOPICORT TOPICAL OINTMENT
Tier 3
TOPICORT TOPICAL SPRAY,NON-AEROSOL
Tier 6
tretinoin microspheres topical gel 0.04 %
Tier 1
ST; Note 5 (Standard); QL
tretinoin microspheres topical gel 0.1 %
Tier 1
ST; Note 5 (Standard)
tretinoin topical cream 0.025 %
Tier 1
QL
tretinoin topical cream 0.05 %, 0.1 %
Tier 1
tretinoin topical gel 0.01 %
Tier 1
tretinoin topical gel 0.025 %
Tier 1
TRETIN-X (GEL)
Tier 6
TRETIN-X CREAM KIT
Tier 6
TRETIN-X TOPICAL CREAM 0.0375 %
Tier 3
triamcinolone acetonide topical aerosol
Tier 1
triamcinolone acetonide topical cream
Tier 1
LGC
triamcinolone acetonide topical ointment 0.025 %, 0.1 %
Tier 1
LGC
triamcinolone acetonide topical ointment 0.5 %
Tier 1
ULESFIA
Tier 3
ULTRAVATE
Tier 3
ULTRAVATE PAC
Tier 6
ULTRAVATE X
Tier 6
VANOS
Tier 3
VANOXIDE-HC
Tier 3
VECTICAL
Tier 3
ST; Note 5 (Standard)
VELTIN
Tier 3
ST; Note 5 (Standard)
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
78
ST; Note 5 (Standard)
QL
ST; Note 5 (Standard); QL
QL
ST; Note 5 (Standard)
Drug Name
Drug Status
Additional Information
VERDESO
Tier 3
VOLTAREN TOPICAL
Tier 2
WESTCORT TOPICAL OINTMENT
Tier 3
XERAC AC
Tier 2
ZENATANE
Tier 3
PA; Note 4 (Standard); QL
ZIANA
Tier 3
ST; Note 5 (Standard)
ZITHRANOL
Tier 3
ZYCLARA
Tier 6
QL
Smoking Deterrents
BUPROBAN
CE
CE
CHANTIX
CE
CE; QL
CHANTIX CONTINUING MONTH BOX
CE
CE; QL
CHANTIX CONTINUING MONTH PAK
CE
CE; QL
CHANTIX STARTING MONTH BOX
CE
CE; QL
CHANTIX STARTING MONTH PAK
CE
CE; QL
NICODERM CQ
CE
CE; QL
NICORELIEF BUCCAL GUM
LA
NICORETTE BUCCAL GUM
LA
QL
NICORETTE BUCCAL LOZENGE
LA
QL
nicotine (polacrilex) buccal gum
CE
CE; QL
nicotine (polacrilex) buccal lozenge
CE
CE; QL
nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24
hr, 7 mg/24 hr
CE
CE; QL
nicotine transdermal patch, td daily, sequential
CE
CE; QL
NICOTROL
CE
CE; QL
NICOTROL NS
CE
CE; QL
NTS STEP 1
CE
CE
ZYBAN
LA
QL
Thyroid Preps
ARMOUR THYROID
Tier 3
CYTOMEL
Tier 3
LEVOTHROID
Tier 2
levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137
mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg,
88 mcg
Tier 1
levothyroxine oral tablet 300 mcg
Tier 1
LEVOXYL
Tier 1
liothyronine oral
Tier 1
methimazole
Tier 1
NATURE-THROID ORAL TABLET 113.75 MG, 130 MG,
146.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325
MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG
Tier 3
NATURE-THROID ORAL TABLET 16.25 MG
Tier 3
NP THYROID ORAL TABLET 30 MG
Tier 3
LGC
LGC
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
79
Drug Name
Drug Status
Additional Information
propylthiouracil
Tier 1
SYNTHROID
Tier 2
TAPAZOLE
Tier 3
thyroid
Tier 1
THYROLAR-1
Tier 3
THYROLAR-1/2
Tier 3
THYROLAR-1/4
Tier 3
THYROLAR-2
Tier 3
THYROLAR-3
Tier 3
TIROSINT
Tier 3
UNITHROID
Tier 1
WESTHROID ORAL TABLET 113.75 MG, 130 MG,
146.25 MG, 16.25 MG, 162.5 MG, 260 MG, 32.5 MG, 325
MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG
Tier 3
WESTHROID ORAL TABLET 195 MG
Tier 3
LGC
acamprosate
Tier 3
QL
ACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5
MG
Tier 3
ST; Note 5 (Standard); QL
alendronate oral solution
Tier 1
QL
alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg
Tier 1
QL
alendronate oral tablet 70 mg
Tier 1
LGC; QL
alfuzosin
Tier 1
QL
ANTABUSE
Tier 3
anthralin
Tier 1
Unclassified Drug Products
APPTRIM
LA
ARCALYST
Tier 5
PA; Note 4 (Standard,Select)
ATELVIA
Tier 3
ST; Note 5 (Standard); QL
AVODART
Tier 3
ST; Note 5 (Standard); QL
BERINERT
Tier 5
PA; Note 4 (Standard,Select)
BINOSTO
Tier 6
QL
BONIVA ORAL
Tier 3
PA; Note 4 (Standard); QL
BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG,
6.3-1 MG
Tier 3
PA; QL
buprenorphine hcl sublingual
Tier 1
PA; Note 4 (Standard,Select); QL
buprenorphine-naloxone
Tier 1
PA; Note 4 (Standard,Select); QL
calcipotriene-betamethasone
Tier 3
ST; Note 5 (Standard)
CAMPRAL
Tier 3
QL
CAPHOSOL
Tier 3
CARBAGLU
Tier 5
PA; Note 4 (Standard,Select)
CAVERJECT
Tier 3
Note 3; QL
CAVERJECT IMPULSE
Tier 3
QL
CERDELGA
Tier 4
PA; QL
chloral hydrate
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
Tier 1
80
Drug Name
Drug Status
Additional Information
CIALIS
Tier 2
Note 3; QL
CINRYZE
Tier 5
PA; Note 4 (Standard,Select)
cyclopentolate (bulk)
Tier 1
CYSTADANE
Tier 5
CYSTAGON
Tier 4
PA; Note 4 (Standard,Select)
DETROL
Tier 3
ST; Note 5 (Standard)
DETROL LA
Tier 3
ST; Note 5 (Standard); QL
DIDRONEL
Tier 3
disulfiram
Tier 1
DITROPAN XL ORAL TABLET EXTENDED RELEASE
24HR 10 MG, 15 MG, 5 MG
Tier 3
ST; Note 5 (Standard,Select); QL
doxercalciferol oral
Tier 3
ST; Note 5 (Standard)
doxycycline hyclate oral tablet 20 mg
LA
EDEX
Tier 3
Note 3; QL
ENABLEX
Tier 3
ST; Note 5 (Standard); QL
ENTERAGAM
LA
ESBRIET
Tier 5
etidronate disodium
Tier 3
EVISTA
Tier 3
EXJADE
Tier 4
PA; Note 3; Note 4 (Standard,Select)
FERRIPROX
Tier 5
PA; Note 4 (Standard,Select)
finasteride oral tablet 5 mg
Tier 1
FIRAZYR
Tier 5
flavoxate
Tier 1
FLOMAX
Tier 3
FORTEO
Tier 5
PA; Note 4 (Standard,Select)
FOSAMAX ORAL TABLET
Tier 3
QL
FOSAMAX PLUS D
Tier 3
ST; Note 5 (Standard); QL
FOSTEUM PLUS
LA
FOVEX
LA
GABADONE
LA
PA; QL
PA; Note 4 (Standard,Select); QL
GELCLAIR
Tier 3
GELNIQUE
Tier 3
ST; Note 5 (Standard,Select); QL
HECTOROL ORAL
Tier 3
ST; Note 5 (Standard,Select)
HYPERTENSA
LA
ibandronate oral
Tier 3
PA; Note 4 (Standard); QL
ILARIS (PF)
Tier 4
PA; Note 4 (Standard,Select); Note 5
(Standard,Select); QL
JADENU
Tier 5
PA; Note 4 (Standard,Select)
JALYN
Tier 3
ST; Note 5 (Standard); QL
KALYDECO ORAL GRANULES IN PACKET
Tier 3
QL
KALYDECO ORAL TABLET
Tier 3
PA; Note 4 (Standard,Select); QL
KUVAN ORAL POWDER IN PACKET 100 MG
Tier 5
PA; Note 4 (Standard,Select)
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
81
Drug Name
Drug Status
Additional Information
KUVAN ORAL TABLET,SOLUBLE
Tier 5
PA; Note 4 (Standard,Select)
leucovorin calcium oral
Tier 1
LEVITRA
Tier 3
LIMBREL
LA
LIMBREL250
LA
LIMBREL500
LA
LISTER-V
LA
LUKAID GLA FOR ASTHMA
LA
LUNGLAID FOR ASTHMA
LA
PA; Note 3; Note 5 (Standard,Select); QL
MEGACE
Tier 3
MEGACE ES
Tier 3
MUSE
Tier 3
QL
MYRBETRIQ
Tier 2
ST; Note 5 (Standard); QL
OFEV
Tier 5
PA; QL
ORALONE
LA
ORFADIN
Tier 5
OSPHENA
Tier 3
oxybutynin chloride oral syrup
Tier 1
oxybutynin chloride oral tablet
Tier 1
LGC; Note 3
oxybutynin chloride oral tablet extended release 24hr
Tier 1
Note 3
OXYTROL
Tier 6
OXYTROL FOR WOMEN
Tier 1
Note 6; QL
paricalcitol oral
Tier 1
ST; Note 5 (Standard)
PERCURA
LA
PERIOGARD
LA
PERIOSTAT
LA
polyethylene glycol 3350
PREFLIN
ST; Note 5 (Standard); QL
Tier 1
LA
PROCYSBI ORAL CAPSULE, DELAYED REL
SPRINKLE 25 MG, 75 MG
Tier 5
PROSCAR
Tier 3
PROTEOLIN
LA
PROTEOLIN DS
LA
PULMOZYME
Tier 4
RADIOGARDASE
Tier 3
PA; Note 4 (Standard,Select); QL
PA; Note 4 (Standard,Select); QL
raloxifene
CE
CE
RAPAFLO
Tier 3
QL
risedronate oral tablet 150 mg
Tier 3
ST; Note 5 (Standard); QL
risedronate oral tablet 30 mg, 35 mg, 5 mg
Tier 3
QL
SANCTURA
Tier 3
QL
SANCTURA XR
Tier 3
QL
SAVELLA
Tier 3
PA; Note 4 (Standard); QL
SENSIPAR
Tier 3
ST; Note 5 (Standard,Select)
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
82
Drug Name
Drug Status
SENTRA AM
LA
SENTRA PM
LA
Additional Information
SKELID
Tier 3
sodium chloride inhalation solution for nebulization 0.9 %,
10 %, 3 %
Tier 1
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG,
15 MG, 20 MG
Tier 5
PA; Note 4 (Standard,Select)
SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG,
30 MG
Tier 5
PA
STAXYN
Tier 3
PA; Note 3; Note 5 (Standard,Select); QL
STENDRA
Tier 3
PA; Note 3; Note 5 (Standard,Select); QL
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG,
4-1 MG, 8-2 MG
Tier 3
PA; Note 4 (Standard,Select); QL
SUBOXONE SUBLINGUAL TABLET
Tier 3
PA; Note 4 (Standard,Select); QL
sulfisoxazole
Tier 1
SYPRINE
Tier 3
TACLONEX SCALP
Tier 3
TACLONEX TOPICAL OINTMENT
Tier 3
TACLONEX TOPICAL SUSPENSION
Tier 3
tamsulosin
Tier 1
THERAMINE
QL
ST; Note 5 (Standard)
LGC
LA
tolterodine oral capsule,extended release 24hr
Tier 3
ST; Note 5 (Standard); QL
tolterodine oral tablet
Tier 1
ST; Note 5 (Standard)
TOVIAZ
Tier 3
ST; Note 5 (Standard); QL
TOZAL
LA
trospium oral capsule,extended release 24hr
Tier 1
QL
trospium oral tablet
Tier 1
QL
TYBOST
Tier 3
QL
UROXATRAL
Tier 3
QL
VAYACOG
LA
VAYARIN
LA
VESICARE
Tier 2
ST; QL
VIAGRA
Tier 3
PA; Note 3; Note 5 (Standard,Select); QL
ZAVESCA
Tier 5
PA; Note 4 (Standard,Select); QL
ZEMPLAR ORAL
Tier 3
ST; Note 5 (Standard,Select); QL
ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 5.7-1.4
MG
Tier 3
PA; Note 4 (Standard,Select); QL
ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG
Tier 3
PA; QL
ZYTAZE
LA
Vitamins
ALZ-NAC
LA
BP VIT 3 PLUS
Tier 3
CALAFOL RX
LA
CALCIFEROL
Tier 1
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83
Drug Name
calcitriol oral capsule
Drug Status
Additional Information
Tier 1
CARDIOTEK-RX (BIOPERINE)
LA
CEREFOLIN
LA
CEREFOLIN NAC
LA
CEREFOLIN NAC (ALGAL OIL)
LA
CHILDREN'S VITAMIN D
CE
CE
cholecalciferol (vitamin d3) oral capsule 1,000 unit, 400
unit
CE
CE
cholecalciferol (vitamin d3) oral drops 400 unit/ml
CE
CE
cholecalciferol (vitamin d3) oral tablet 1,000 unit, 400 unit
CE
CE
cholecalciferol (vitamin d3) oral tablet,chewable 400 unit
CE
CE
cyanocobalamin (vitamin b-12) injection
Tier 3
DELTA D3
CE
DEPLIN
LA
DEPLIN (ALGAL OIL)
LA
D-VI-SOL
CE
CE
D-VITA
CE
CE
ergocalciferol (vitamin d2) oral tablet 400 unit
CE
CE
FALESSA
Tier 3
FOLASTIN
LA
FOLBEE AR
LA
FOLBIC
LA
FOLBIC RF
LA
folic acid oral capsule
CE
Tier 1
folic acid oral tablet 1 mg
CE
LGC; CE
folic acid oral tablet 400 mcg, 800 mcg
CE
CE
folic acid-vit b6-vit b12 oral tablet 2.5-25-2 mg
LA
FOLTANX
LA
FOLTANX RF
LA
FOLTX ORAL TABLET 2.5-25-2 MG
LA
levomefolate calcium oral tablet 7.5 mg
LA
L-METHYL-B6-B12
LA
L-METHYLFOLATE
LA
L-METHYLFOLATE CA P-5-P ME-CBL
LA
L-METHYLFOLATE FORMULA
LA
L-METHYLFOLATE FORTE
LA
L-METHYL-MC
LA
L-METHYL-MC NAC
LA
LMTHF-PYRIDOXINE-CYANOCOBALAMN
LA
MACUTEK
LA
MEPHYTON
Tier 2
METAFOLBIC
LA
METAFOLBIC PLUS
LA
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Drug Name
Drug Status
METAFOLBIC PLUS RF
LA
METANX
LA
METANX (ALGAL OIL)
LA
NASCOBAL
Tier 3
niacin oral capsule, extended release
Tier 1
niacin oral tablet
Tier 1
niacin oral tablet extended release
Tier 1
NICOMIDE
Tier 3
PODIAPN
POLY-VI-FLOR ORAL TABLET,CHEWABLE
PROBARIMIN QT
Note 3
Tier 2
LA
Tier 3
REVESTA
Tier 3
ROCALTROL
Tier 3
TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC
0.25 MG/ML FLUORIDE
Tier 2
TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC
0.5 MG/ML FLUORIDE
Tier 3
VIRT-CAPS
Note 3
LA
QUFLORA PEDIATRIC
VASCULERA
Additional Information
LA
Tier 3
VIRT-VITE FORTE
LA
VITACIRC-B
LA
VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 400 UNIT
CE
CE
VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT
CE
CE
VITAMIN D3 ORAL TABLET,CHEWABLE 400 UNIT
CE
CE
VITA-RESPA
LA
2015 Coventry Health Prescription Drug List
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2015 Coventry Health Prescription Drug List
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86
Index
2TEK GLUCOSE/BLOOD PRESSURE
......................................................................................................... 66
abacavir ................................................................................ 29
abacavir-lamivudine-zidovudine ................. 29
ABILIFY .............................................................................. 68
ABILIFY DISCMELT ........................................... 68
ABREVA ............................................................................. 29
ABSORICA ...................................................................... 74
ABSTRAL ............................................................................. 3
acamprosate ...................................................................... 80
ACANYA ........................................................................... 74
acarbose ................................................................................ 21
ACCOLATE .................................................................... 10
ACCU-CHEK AVIVA .......................................... 51
ACCU-CHEK COMFORT CURVE
TEST ........................................................................................ 51
ACCU-CHEK COMPACT PLUS CARE
......................................................................................................... 66
ACCU-CHEK SMARTVIEW TEST
STRIP ...................................................................................... 51
ACCUNEB ........................................................................ 10
ACCUPRIL ....................................................................... 37
ACCURETIC .................................................................. 37
acebutolol ............................................................................ 37
ACEON ................................................................................. 37
acetaminophen-codeine ............................................ 3
ACETASOL HC .......................................................... 52
acetazolamide ................................................................. 51
acetic acid ................................................................. 52, 74
acetic acid-aluminum acetate ......................... 52
acetylcysteine ................................................................... 10
ACIPHEX ........................................................................... 57
ACIPHEX SPRINKLE .......................................... 57
acitretin ................................................................................. 74
ACLOVATE .................................................................... 74
ACTEMRA ....................................................................... 65
ACTICLATE ................................................................... 11
ACTIGALL ....................................................................... 57
ACTIMMUNE ............................................................... 25
ACTIQ ....................................................................................... 3
ACTIVELLA ................................................................... 61
ACTONEL ......................................................................... 80
ACTOPLUS MET ...................................................... 21
ACTOPLUS MET XR ........................................... 21
ACTOS .................................................................................. 21
ACULAR ............................................................................. 52
ACULAR LS ................................................................... 52
ACUVAIL (PF) ............................................................ 53
acyclovir ............................................................................... 29
ACZONE ............................................................................. 74
ADALAT CC .................................................................. 35
adapalene ............................................................................ 74
ADCIRCA .......................................................................... 37
ADDERALL .................................................................... 31
ADDERALL XR ......................................................... 32
adefovir .................................................................................. 29
ADEMPAS ........................................................................ 37
ADIPEX-P .......................................................................... 27
ADOXA ................................................................................ 11
ADRENACLICK ........................................................ 32
ADRENALIN ....................................................... 32, 53
ADULT LOW DOSE ASPIRIN ..................... 3
ADVAIR DISKUS .................................................... 10
ADVAIR HFA ............................................................... 10
ADVATE ............................................................................. 34
ADVICOR .......................................................................... 37
ADVOCATE BLOOD GLUCOSE
MONITOR ......................................................................... 66
AEROCHAMBER MV ........................................ 66
AEROSPAN ..................................................................... 10
AFEDITAB CR ............................................................ 35
AFINITOR ......................................................................... 25
AFINITOR DISPERZ ............................................ 25
AFLURIA 2013-2014 ............................................. 33
AFLURIA 2013-2014 (PF) ............................... 33
AFLURIA 2014-2015 ............................................. 33
AFLURIA 2014-2015 (PF) ............................... 33
AFREZZA .......................................................................... 21
AGGRENOX ................................................................... 28
AGRYLIN .......................................................................... 28
AKYNZEO ........................................................................ 57
ALAMAST ........................................................................ 53
ALAVERT ......................................................................... 20
ALAVERT D-12 ALLERGY-SINUS ... 20
ALAWAY .......................................................................... 20
ALBENZA ......................................................................... 24
albuterol sulfate ............................................................ 10
alclometasone ................................................................. 74
ALDACTAZIDE ......................................................... 51
ALDACTONE ............................................................... 52
ALDARA ............................................................................ 74
alendronate ........................................................................ 80
alfuzosin ................................................................................ 80
ALINIA ................................................................................. 24
ALKERAN ........................................................................ 25
ALLEGRA ......................................................................... 20
ALLEGRA ALLERGY ........................................ 20
ALLEGRA ODT ......................................................... 20
ALLEGRA-D 12 HOUR ..................................... 20
ALLEGRA-D 24 HOUR ..................................... 20
ALLERGY RELIEF (LORATADINE)
......................................................................................................... 20
ALLI ......................................................................................... 27
allopurinol ............................................................................. 8
ALOCRIL ........................................................................... 53
ALOMIDE ......................................................................... 53
ALOPHEN ......................................................................... 57
ALORA ................................................................................. 61
ALPHAGAN P .............................................................. 53
ALPHANATE ................................................................ 34
ALPHANINE SD ........................................................ 34
alprazolam .......................................................................... 68
ALPRAZOLAM INTENSOL ........................ 68
ALPROLIX ....................................................................... 34
ALREX .................................................................................. 53
ALSUMA ............................................................................... 3
ALTABAX ........................................................................ 74
ALTACE .............................................................................. 37
ALTAVERA (28) ....................................................... 46
ALTOPREV ..................................................................... 37
aluminum acetate ........................................................ 74
aluminum chloride ..................................................... 74
ALVESCO ......................................................................... 10
ALYACEN 1/35 (28) .............................................. 46
ALYACEN 7/7/7 (28) ............................................ 46
ALZ-NAC ........................................................................... 83
amantadine hcl ............................................................... 27
AMARYL ........................................................................... 21
AMBIEN .............................................................................. 73
AMBIEN CR ................................................................... 73
AMERGE ............................................................................... 3
AMETHIA ......................................................................... 46
AMETHIA LO ............................................................... 46
AMETHYST .................................................................... 46
amiloride .............................................................................. 52
amiloride-hydrochlorothiazide ...................... 52
aminocaproic acid ...................................................... 34
amiodarone ........................................................................ 35
AMITIZA ............................................................................ 57
amitriptyline ..................................................................... 68
amitriptyline-chlordiazepoxide ..................... 68
amlodipine .......................................................................... 35
amlodipine-benazepril ............................................ 37
amlodipine-valsartan ............................................... 37
amlodipine-valsartan-hcthiazid .................... 37
AMNESTEEM .............................................................. 74
amoxapine ........................................................................... 68
amoxicil-clarithromy-lansopraz ................... 57
amoxicillin .......................................................................... 11
amoxicillin-pot clavulanate .............................. 12
AMPHETAMINE SALT COMBO .......... 32
ampicillin ............................................................................. 12
AMPYRA ........................................................................... 42
AMRIX .................................................................................. 66
AMTURNIDE ................................................................ 37
ANADROL-50 .............................................................. 61
ANAFRANIL ................................................................. 68
anagrelide ........................................................................... 28
ANALPRAM ADVANCED ........................... 57
ANALPRAM-HC ....................................................... 57
ANALPRAM-HC SINGLES .......................... 57
ANAPROX ........................................................................... 8
ANAPROX DS ................................................................. 8
ANASPAZ ......................................................................... 57
anastrozole ......................................................................... 25
ANCOBON ....................................................................... 18
ANDRODERM ............................................................. 61
ANDROGEL ................................................................... 61
ANDROID ......................................................................... 61
ANDROXY ....................................................................... 61
ANGELIQ .......................................................................... 61
ANORO ELLIPTA .................................................... 10
ANSAID .................................................................................. 8
ANTABUSE .................................................................... 80
ANTARA ............................................................................ 37
anthralin ............................................................................... 80
antipyrine-benzocaine ............................................ 53
ANTIVERT ....................................................................... 57
ANUSOL-HC ................................................................. 57
ANZEMET ........................................................................ 57
APIDRA ............................................................................... 21
APIDRA SOLOSTAR ........................................... 22
APLENZIN ....................................................................... 68
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APOKYN ............................................................................ 27
APPTRIM ........................................................................... 80
apraclonidine ................................................................... 53
APRI ......................................................................................... 46
APRISO ................................................................................ 57
APTENSIO XR ............................................................. 68
APTIOM .............................................................................. 42
APTIVUS ............................................................................ 29
ARALEN ............................................................................. 24
ARANELLE (28) ........................................................ 46
ARANESP (IN POLYSORBATE) ........... 46
ARAVA .................................................................................... 8
ARCALYST ..................................................................... 80
ARCAPTA NEOHALER ................................... 10
ARICEPT ............................................................................ 32
ARICEPT ODT ............................................................. 32
ARIMIDEX ....................................................................... 25
aripiprazole ....................................................................... 69
ARIXTRA .......................................................................... 18
ARMOUR THYROID ........................................... 79
ARNUITY ELLIPTA ............................................. 10
AROMASIN .................................................................... 25
ARTHROTEC 50 ........................................................... 8
ARTHROTEC 75 ........................................................... 8
ASACOL ............................................................................. 57
ASACOL HD .................................................................. 57
ASMANEX HFA ........................................................ 10
ASMANEX TWISTHALER ........................... 10
ASPIR-81 ............................................................................... 3
aspirin ........................................................................................ 3
ASPIRIN CHILDRENS .......................................... 3
ASPIRIN LOW DOSE ............................................. 3
ASPIRIN LOW-STRENGTH ........................... 3
ASPIR-LOW ....................................................................... 3
ASPIR-TRIN ....................................................................... 3
ASTAGRAF XL .......................................................... 65
ASTELIN ............................................................................ 53
ASTEPRO .......................................................................... 53
ATACAND ....................................................................... 37
ATACAND HCT ........................................................ 37
ATELVIA ........................................................................... 80
atenolol .................................................................................. 38
atenolol-chlorthalidone ......................................... 38
ATIVAN .............................................................................. 69
atorvastatin ........................................................................ 38
atovaquone ......................................................................... 24
atovaquone-proguanil ............................................ 24
ATRALIN ........................................................................... 74
ATRIPLA ............................................................................ 29
atropine ................................................................................. 53
ATROVENT .................................................................... 53
ATROVENT HFA ..................................................... 10
AUBAGIO ......................................................................... 42
AUGMENTIN ................................................................ 12
AUGMENTIN XR ..................................................... 12
AUVI-Q ................................................................................ 32
AVALIDE .......................................................................... 38
AVANDAMET ............................................................. 22
AVANDARYL .............................................................. 22
AVANDIA ......................................................................... 22
AVAPRO ............................................................................. 38
AVAR ..................................................................................... 12
AVAR-E ............................................................................... 12
AVAR-E GREEN ....................................................... 12
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AVC VAGINAL .......................................................... 24
AVELOX ............................................................................. 12
AVIANE .............................................................................. 46
AVIDOXY ......................................................................... 12
AVIDOXY DK .............................................................. 12
AVINZA .................................................................................. 3
AVITA ................................................................................... 75
AVODART ....................................................................... 80
AVONEX ............................................................................ 42
AVONEX (WITH ALBUMIN) .................... 42
AXERT ..................................................................................... 4
AXID ....................................................................................... 57
AXIRON .............................................................................. 61
AYGESTIN ....................................................................... 61
AZASITE ............................................................................ 12
azathioprine ...................................................................... 65
azelastine ................................................................... 20, 53
AZELEX .............................................................................. 75
AZILECT ............................................................................ 27
azithromycin ..................................................................... 12
AZOPT .................................................................................. 53
AZOR ...................................................................................... 38
AZULFIDINE ................................................................ 57
AZULFIDINE EN-TABS ................................... 57
AZURETTE (28) ......................................................... 46
bacitracin ............................................................................. 12
bacitracin-polymyxin b .......................................... 12
baclofen ................................................................................. 67
BACTRIM .......................................................................... 12
BACTRIM DS ............................................................... 12
BACTROBAN ............................................................... 12
BACTROBAN NASAL ....................................... 12
balsalazide .......................................................................... 57
BALZIVA (28) .............................................................. 46
BANZEL .............................................................................. 42
BARACLUDE ............................................................... 29
BAYER ADVANCED .............................................. 4
BAYER ASPIRIN ......................................................... 4
BAYER CHEWABLE ASPIRIN .................. 4
BD AUTOSHIELD PEN NEEDLE ......... 66
BD INSULIN PEN NEEDLE UF MINI
......................................................................................................... 66
BD INSULIN PEN NEEDLE UF ORIG
......................................................................................................... 66
BD INSULIN PEN NEEDLE UF SHORT
......................................................................................................... 66
BD INSULIN SYRINGE .................................... 66
BD INSULIN SYRINGE HALF UNIT
......................................................................................................... 66
BD INSULIN SYRINGE MICRO-FINE
......................................................................................................... 66
BD INSULIN SYRINGE SAFETY-LOK
......................................................................................................... 66
BD INSULIN SYRINGE SLIP TIP ......... 66
BD INSULIN SYRINGE ULT-FINE II
......................................................................................................... 66
BD INSULIN SYRINGE ULTRA-FINE
......................................................................................................... 66
BD INTEGRA INSULIN SYRINGE ..... 66
BD LUER-LOK SYRINGE ............................. 66
BD SAFETYGLIDE INSULIN
SYRINGE ........................................................................... 66
BD SAFETYGLIDE SHIELDING REG
......................................................................................................... 66
BD SAFETYGLIDE SYRINGE ................. 66
BECONASE AQ ......................................................... 53
BELSOMRA .................................................................... 73
BELVIQ ................................................................................ 27
benazepril ............................................................................ 38
benazepril-hydrochlorothiazide .................... 38
BENEFIX ............................................................................ 34
BENICAR ........................................................................... 38
BENICAR HCT ............................................................ 38
BENTYL .............................................................................. 57
BENZACLIN .................................................................. 75
BENZACLIN PUMP .............................................. 75
BENZAMYCIN ............................................................ 12
BENZAMYCINPAK .............................................. 12
benzonatate ........................................................................ 51
benzphetamine ................................................................ 27
benztropine ........................................................................ 27
BEPREVE .......................................................................... 20
BERINERT ....................................................................... 80
BESIVANCE ................................................................... 12
BETAGAN ........................................................................ 53
betamethasone valerate ........................................ 75
betamethasone, augmented ............................... 75
BETAPACE ..................................................................... 38
BETAPACE AF ........................................................... 38
BETASERON ................................................................. 43
betaxolol ............................................................................... 53
bethanechol chloride ............................................... 32
BETHKIS ............................................................................ 12
BETIMOL .......................................................................... 53
BETOPTIC S ................................................................... 53
BEYAZ .................................................................................. 46
BIAXIN ................................................................................. 12
BIAXIN XL ...................................................................... 12
bicalutamide ..................................................................... 25
BIDIL ...................................................................................... 38
BILTRICIDE ................................................................... 24
bimatoprost ........................................................................ 53
BINOSTO ........................................................................... 80
BIONECT ........................................................................... 75
bisoprolol fumarate ................................................... 38
bisoprolol-hydrochlorothiazide .................... 38
BLEPH-10 .......................................................................... 12
BLEPHAMIDE ............................................................. 12
BLEPHAMIDE S.O.P. .......................................... 12
BONIVA .............................................................................. 80
BOSULIF ............................................................................ 25
BP 10-1 .................................................................................. 12
BP VIT 3 PLUS ............................................................ 83
BRAVELLE ..................................................................... 61
BREO ELLIPTA ......................................................... 10
BREVICON (28) ......................................................... 46
BRIELLYN ....................................................................... 46
BRILINTA ......................................................................... 28
brimonidine ....................................................................... 53
BRINTELLIX ................................................................. 69
BRISDELLE .................................................................... 69
BROMFED DM ........................................................... 51
bromocriptine .................................................................. 27
BROVANA ....................................................................... 10
BUDEPRION SR ........................................................ 69
BUDEPRION XL ....................................................... 69
budesonide ...................................................... 10, 53, 61
bumetanide ......................................................................... 52
BUNAVAIL ..................................................................... 80
BUPHENYL .................................................................... 57
buprenorphine hcl ....................................................... 80
buprenorphine-naloxone ...................................... 80
BUPROBAN .................................................................... 79
bupropion hcl .................................................................. 69
buspirone ............................................................................. 69
butalbital-acetaminop-caf-cod .......................... 4
butalbital-acetaminophen ...................................... 4
butalbital-acetaminophen-caff .......................... 4
butalbital-aspirin-caffeine ..................................... 4
BUTISOL ............................................................................ 73
butorphanol tartrate .................................................... 4
BUTRANS ............................................................................ 4
BYDUREON ................................................................... 22
BYETTA .............................................................................. 22
BYSTOLIC ....................................................................... 38
cabergoline ........................................................................ 61
CADUET ............................................................................. 38
CAFCIT ................................................................................ 43
CAFERGOT ........................................................................ 4
CALAFOL RX .............................................................. 83
CALAN ................................................................................. 35
CALAN SR ....................................................................... 35
CALCIFEROL ............................................................... 83
calcipotriene ..................................................................... 75
calcipotriene-betamethasone ........................... 80
calcitonin (salmon) .................................................... 61
CALCITRENE .............................................................. 75
calcitriol ............................................................................... 84
calcium acetate .............................................................. 55
CAMBIA ................................................................................. 4
CAMPRAL ........................................................................ 80
CAMRESE ........................................................................ 46
CAMRESE LO .............................................................. 46
CANASA ............................................................................. 57
candesartan ....................................................................... 38
candesartan-hydrochlorothiazid .................. 38
capecitabine ...................................................................... 25
CAPEX .................................................................................. 75
CAPHOSOL ..................................................................... 80
CAPRELSA ...................................................................... 25
captopril ............................................................................... 38
captopril-hydrochlorothiazide ....................... 38
CARAFATE ..................................................................... 57
CARBAGLU ................................................................... 80
carbamazepine ............................................................... 43
CARBATROL ................................................................ 43
carbidopa ............................................................................. 27
carbidopa-levodopa .................................................. 27
carbidopa-levodopa-entacapone ................. 27
CARDENE SR ............................................................... 35
CARDIOTEK-RX (BIOPERINE) ............. 84
CARDIZEM ..................................................................... 35
CARDIZEM CD .......................................................... 35
CARDIZEM LA ........................................................... 35
CARDURA ....................................................................... 38
CARDURA XL ............................................................. 38
carisoprodol ..................................................................... 67
carisoprodol-aspirin ................................................ 67
carteolol ................................................................................ 53
CARTIA XT ..................................................................... 35
carvedilol ............................................................................. 38
CASODEX ........................................................................ 25
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
CATAFLAM ....................................................................... 4
CATAPRES ...................................................................... 38
CATAPRES-TTS-1 .................................................. 38
CATAPRES-TTS-2 .................................................. 38
CATAPRES-TTS-3 .................................................. 38
CAVERJECT .................................................................. 80
CAVERJECT IMPULSE .................................... 80
CAYSTON ........................................................................ 12
CAZIANT (28) .............................................................. 46
CEDAX ................................................................................. 12
CEENU .................................................................................. 25
cefaclor ........................................................................ 12, 13
cefadroxil ............................................................................. 13
cefdinir ................................................................................... 13
cefixime .................................................................................. 13
cefprozil ................................................................................. 13
CEFTIN ................................................................................. 13
cefuroxime axetil .......................................................... 13
CELEBREX ......................................................................... 8
celecoxib .................................................................................. 8
CELEXA .............................................................................. 69
CELLCEPT ....................................................................... 65
CELONTIN ....................................................................... 43
CENESTIN ........................................................................ 62
cephalexin ........................................................................... 13
CERDELGA .................................................................... 80
CEREFOLIN ................................................................... 84
CEREFOLIN NAC .................................................... 84
CEREFOLIN NAC (ALGAL OIL) .......... 84
CERISA ................................................................................ 13
CERVIDIL ......................................................................... 62
CESAMET ......................................................................... 57
CESIA (28) ........................................................................ 46
CESINEX ............................................................................ 57
CETACAINE ...................................................................... 7
CETACAINE ANESTHETIC ........................... 7
cetirizine ............................................................................... 20
CETRAXAL .................................................................... 13
CETROTIDE ................................................................... 62
CHANTIX .......................................................................... 79
CHANTIX CONTINUING MONTH
BOX .......................................................................................... 79
CHANTIX CONTINUING MONTH
PAK ........................................................................................... 79
CHANTIX STARTING MONTH BOX
......................................................................................................... 79
CHANTIX STARTING MONTH PAK
......................................................................................................... 79
CHATEAL ......................................................................... 46
CHENODAL ................................................................... 57
CHILD ASPIRIN ........................................................... 4
CHILDREN'S ALLEGRA ALLERGY
......................................................................................................... 20
CHILDREN'S ASPIRIN ......................................... 4
CHILDREN'S CETIRIZINE ........................... 21
CHILDREN'S IRON ............................................... 55
CHILDREN'S VITAMIN D ............................ 84
CHILDREN'S ZYRTEC ALLERGY ..... 21
chloral hydrate ............................................................... 80
chlordiazepoxide hcl ................................................ 69
chlordiazepoxide-clidinium ............................... 57
chloroquine phosphate ........................................... 24
chlorothiazide ................................................................. 52
chlorpromazine .............................................................. 69
chlorpropamide ............................................................. 22
chlorthalidone ................................................................. 52
chlorzoxazone ................................................................. 67
CHOLBAM ....................................................................... 57
cholecalciferol (vitamin d3) .............................. 84
cholestyramine (with sugar) ............................. 38
CHOLESTYRAMINE LIGHT ..................... 38
choline,magnesium salicylate ............................ 4
chorionic gonadotropin, human ................... 62
CIALIS .................................................................................. 81
CICLODAN KIT ......................................................... 18
ciclopirox ............................................................................. 18
cilostazol .............................................................................. 28
CILOXAN .......................................................................... 13
cimetidine ............................................................................ 57
cimetidine hcl .................................................................. 57
CIMZIA ................................................................................ 57
CIMZIA POWDER FOR RECONST .... 57
CIMZIA STARTER KIT .................................... 57
CINRYZE ........................................................................... 81
CIPRO .................................................................................... 13
CIPRO HC ......................................................................... 13
CIPRO XR ......................................................................... 13
CIPRODEX ....................................................................... 13
ciprofloxacin .................................................................... 13
ciprofloxacin hcl ........................................................... 13
citalopram ........................................................................... 69
CITRANATAL 90 DHA (ALGAL OIL)
......................................................................................................... 67
CITRANATAL 90 DHA (NEW
FORMULA ....................................................................... 67
CITRANATAL ASSURE .................................. 67
CITRANATAL B-CALM (FE GLUC)
......................................................................................................... 67
CITRANATAL DHA (NEW
FORMULA) ..................................................................... 67
CITRANATAL HARMONY ......................... 67
CITRANATAL HARMONY (IRON
FUM) ....................................................................................... 67
CITRANATAL RX (NEW FORMULA)
......................................................................................................... 67
CLARAVIS ....................................................................... 75
CLARIFOAM EF ....................................................... 13
CLARINEX ...................................................................... 21
CLARINEX-D 12 HOUR .................................. 20
CLARINEX-D 24 HOUR .................................. 20
clarithromycin ................................................................ 13
CLARITIN ......................................................................... 21
CLARITIN REDITABS ....................................... 21
CLARITIN-D 12 HOUR ..................................... 20
CLARITIN-D 24 HOUR ..................................... 20
clemastine ........................................................................... 21
CLEOCIN ........................................................................... 13
CLEOCIN T ..................................................................... 13
CLIMARA ......................................................................... 62
CLIMARA PRO ........................................................... 62
CLINDACIN PAC ..................................................... 13
CLINDAGEL .................................................................. 13
clindamycin hcl .............................................................. 13
clindamycin phosphate ................................ 13, 14
clindamycin-benzoyl peroxide ........................ 75
CLINDAREACH ........................................................ 14
CLINDESSE .................................................................... 14
CLINORIL ............................................................................ 8
89
clobetasol ............................................................................. 75
clobetasol-emollient .................................................. 75
CLOBEX ............................................................................. 75
CLODERM ....................................................................... 75
clomiphene citrate ...................................................... 62
clomipramine ................................................................... 69
clonazepam ........................................................................ 43
clonidine ............................................................................... 38
clonidine hcl ........................................................... 38, 69
clopidogrel ......................................................................... 28
clorazepate dipotassium ....................................... 69
CLORPRES ...................................................................... 38
clotrimazole ....................................................................... 18
clozapine .............................................................................. 69
CLOZARIL ....................................................................... 69
CNL 8 NAIL .................................................................... 18
COARTEM ....................................................................... 24
codeine sulfate ................................................................... 4
codeine-guaifenesin .................................................. 51
COLAZAL ......................................................................... 57
colchicine-probenecid ................................................ 8
COLCRYS ............................................................................. 8
COLESTID ........................................................................ 38
COLESTID FLAVORED ................................... 38
colestipol .............................................................................. 38
COLY-MYCIN S ........................................................ 14
COLYTE WITH FLAVOR PACKS ....... 57
COMBIGAN .................................................................... 53
COMBIPATCH ............................................................ 62
COMBIVENT ................................................................ 10
COMBIVENT RESPIMAT .............................. 10
COMBIVIR ....................................................................... 29
COMETRIQ ..................................................................... 25
COMFORT PAC-CYCLOBENZAPRINE
......................................................................................................... 67
COMFORT PAC-IBUPROFEN ..................... 8
COMFORT PAC-MELOXICAM ................. 8
COMFORT PAC-NAPROXEN ...................... 8
COMFORT PAC-TIZANIDINE ................. 67
COMPAZINE ................................................................. 57
COMPLERA .................................................................... 29
COMTAN ........................................................................... 28
CONCERTA .................................................................... 69
CONDYLOX ................................................................... 75
CONTOUR TEST STRIPS ............................... 51
CONTRAVE .................................................................... 27
CONZIP ................................................................................... 4
COPAXONE .................................................................... 43
COPEGUS .......................................................................... 29
CORDARONE .............................................................. 35
COREG ................................................................................. 38
COREG CR ....................................................................... 38
CORGARD ....................................................................... 38
CORIFACT ....................................................................... 34
CORLANOR ................................................................... 35
CORTEF .............................................................................. 62
CORTIFOAM ................................................................. 62
cortisone ............................................................................... 62
CORTISPORIN ............................................................ 14
CORTISPORIN-TC ................................................. 14
CORZIDE ........................................................................... 38
COSENTYX .................................................................... 75
COSENTYX (2 SYRINGES) ......................... 75
COSENTYX PEN ...................................................... 75
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
90
COSENTYX PEN (2 PENS) ........................... 75
COSOPT .............................................................................. 53
COSOPT (PF) ................................................................. 53
COUMADIN ................................................................... 18
COVARYX ....................................................................... 62
COVARYX H.S. ......................................................... 62
COZAAR ............................................................................. 39
cpm-pseudoephed-hydrocodone ................... 51
CREON ................................................................................. 57
CRESEMBA .................................................................... 18
CRESTOR .......................................................................... 39
CRINONE .......................................................................... 62
CRIXIVAN ....................................................................... 29
cromolyn ..................................................................... 10, 53
CRYSELLE (28) ......................................................... 46
CUPRIMINE ....................................................................... 8
CUTIVATE ....................................................................... 75
CUVPOSA ......................................................................... 58
cyanocobalamin (vitamin b-12) .................... 84
CYCLAFEM 1/35 (28) ......................................... 46
CYCLESSA (28) ......................................................... 46
cyclobenzaprine ............................................................ 67
CYCLOGYL .................................................................... 53
CYCLOMYDRIL ....................................................... 53
cyclopentolate ................................................................. 53
cyclopentolate (bulk) ............................................... 81
cyclophosphamide ...................................................... 25
CYCLOSET ..................................................................... 22
cyclosporine ...................................................................... 65
cyclosporine modified ............................................. 65
CYMBALTA ................................................................... 69
cyproheptadine .............................................................. 21
CYSTADANE ................................................................ 81
CYSTAGON .................................................................... 81
CYSTARAN .................................................................... 53
CYTOMEL ........................................................................ 79
CYTOTEC ......................................................................... 58
CYTRA-3 ............................................................................ 55
CYTRA-K .......................................................................... 55
D.H.E.45 .................................................................................. 4
DALIRESP ........................................................................ 10
danazol ................................................................................... 62
DANTRIUM .................................................................... 67
dantrolene ........................................................................... 67
dapsone .................................................................................. 14
DARAPRIM ..................................................................... 24
DASETTA 1/35 (28) ............................................... 47
DASETTA 7/7/7 (28) ............................................. 47
DAYPRO ................................................................................ 8
DAYSEE .............................................................................. 47
DAYTRANA ................................................................... 69
DDAVP ................................................................................. 62
DELATESTRYL ......................................................... 62
DELTA D3 ........................................................................ 84
DELZICOL ....................................................................... 58
DEMADEX ....................................................................... 52
DEMEROL ........................................................................... 4
DEMSER ............................................................................. 39
DENAVIR .......................................................................... 29
DEPAKENE ..................................................................... 43
DEPAKOTE ..................................................................... 43
DEPAKOTE ER ........................................................... 43
DEPAKOTE SPRINKLES ................................ 43
DEPEN TITRATABS ............................................... 8
DEPLIN ................................................................................ 84
DEPLIN (ALGAL OIL) ....................................... 84
DEPO-PROVERA ..................................................... 47
DEPO-SUBQ PROVERA 104 ...................... 47
DEPO-TESTOSTERONE .................................. 62
DERMA-SMOOTHE/FS BODY OIL ... 75
DERMA-SMOOTHE/FS SCALP OIL
......................................................................................................... 75
DERMATOP ................................................................... 75
DERMAZENE ............................................................... 75
desipramine ....................................................................... 69
desloratadine ................................................................... 21
desmopressin .................................................................... 62
DESOGEN ......................................................................... 47
desogestrel-ethinyl estradiol ............................ 47
DESONATE ..................................................................... 75
desonide ................................................................................ 75
DESOWEN ....................................................................... 75
DESOXYN ........................................................................ 32
desvenlafaxine ................................................................ 69
desvenlafaxine fumarate ....................................... 69
DETROL .............................................................................. 81
DETROL LA ................................................................... 81
dexamethasone ............................................................... 62
dexamethasone sodium phosphate ............. 53
dexchlorpheniramine maleate ........................ 21
DEXEDRINE SPANSULE .............................. 32
DEXILANT ...................................................................... 58
dexmethylphenidate ................................................... 69
dextroamphetamine ................................................... 32
dextroamphetamine-amphetamine ............. 32
DIABETA ........................................................................... 22
DIAMOX SEQUELS .............................................. 52
DIASTAT ........................................................................... 43
DIASTAT ACUDIAL ............................................ 43
diazepam .................................................................... 43, 69
DIAZEPAM INTENSOL ................................... 69
DIBENZYLINE ............................................................ 32
DICLEGIS .......................................................................... 58
diclofenac potassium ................................................... 4
diclofenac sodium ............................. 8, 25, 53, 75
diclofenac-misoprostol .............................................. 8
dicloxacillin ....................................................................... 14
dicyclomine ........................................................................ 58
didanosine ........................................................................... 29
DIDREX ............................................................................... 27
DIDRONEL ...................................................................... 81
diethylpropion ................................................................. 27
DIFFERIN .......................................................................... 75
DIFICID ................................................................................ 14
DIFLUCAN ...................................................................... 19
diflunisal .................................................................................. 4
DIGITEK ............................................................................. 35
DIGOX .................................................................................. 35
digoxin .................................................................................... 35
dihydroergotamine ........................................................ 4
DILACOR XR ............................................................... 35
DILANTIN ........................................................................ 43
DILANTIN EXTENDED ................................... 43
DILANTIN INFATABS ...................................... 43
DILANTIN-125 ............................................................ 43
DILATRATE-SR ........................................................ 35
DILAUDID ........................................................................... 4
DILT-CD ............................................................................. 35
DILTIA XT ....................................................................... 35
diltiazem hcl ...................................................................... 35
DILTZAC ER ................................................................. 35
DIOVAN .............................................................................. 39
DIOVAN HCT ............................................................... 39
DIPENTUM ...................................................................... 58
diphenoxylate-atropine .......................................... 58
DIPROLENE ................................................................... 76
DIPROLENE AF ......................................................... 76
dipyridamole .................................................................... 28
disopyramide phosphate ....................................... 35
disulfiram ............................................................................. 81
DITROPAN XL ............................................................ 81
DIURIL ................................................................................. 52
divalproex ........................................................................... 43
DIVIGEL ............................................................................. 62
DOLOPHINE ..................................................................... 4
donepezil .............................................................................. 32
DORAL ................................................................................. 73
DORYX ................................................................................ 14
dorzolamide ....................................................................... 53
dorzolamide-timolol ................................................. 53
DOVONEX ....................................................................... 76
doxazosin ............................................................................. 39
doxepin ................................................................................... 69
doxercalciferol ............................................................... 81
doxycycline hyclate .......................................... 14, 81
doxycycline monohydrate .................................... 14
dronabinol .......................................................................... 58
drospirenone-ethinyl estradiol ....................... 47
DRYSOL DAB-O-MATIC ............................... 76
DUAC ..................................................................................... 76
DUAVEE ............................................................................. 62
DUET DHA BALANCED ................................ 67
DUETACT ......................................................................... 22
DUEXIS ................................................................................... 8
DULERA ............................................................................. 10
duloxetine ............................................................................ 70
DUONEB ............................................................................ 10
DUOPA ................................................................................. 28
DURAGESIC ..................................................................... 4
DUREZOL ......................................................................... 53
DUTOPROL .................................................................... 39
D-VI-SOL ........................................................................... 84
D-VITA ................................................................................. 84
DYAZIDE .......................................................................... 52
DYMISTA .......................................................................... 53
DYNACIN ......................................................................... 14
DYRENIUM .................................................................... 52
E.C. PRIN ............................................................................... 4
E.E.S. 200 ........................................................................... 14
E.E.S. 400 ........................................................................... 14
E.E.S. GRANULES .................................................. 14
EC-NAPROSYN ............................................................. 8
econazole ............................................................................. 19
ECOTRIN .............................................................................. 4
ECOTRIN LOW STRENGTH ......................... 4
ECOZA .................................................................................. 19
EDARBI ............................................................................... 39
EDARBYCLOR ........................................................... 39
EDECRIN ........................................................................... 52
EDEX ...................................................................................... 81
EDLUAR ............................................................................. 74
EDURANT ........................................................................ 29
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
EEMT ...................................................................................... 62
EEMT HS ............................................................................ 62
EFFEXOR XR ............................................................... 70
EFFIENT ............................................................................. 28
EFUDEX .............................................................................. 25
EGRIFTA ............................................................................ 62
ELDEPRYL ...................................................................... 28
ELESTAT ........................................................................... 21
ELESTRIN ........................................................................ 62
ELIDEL ................................................................................. 65
ELIMITE ............................................................................. 76
ELINEST ............................................................................. 47
ELIPHOS ............................................................................. 55
ELIQUIS .............................................................................. 18
ELIXOPHYLLIN ....................................................... 10
ELLA ....................................................................................... 47
ELMIRON ............................................................................. 4
ELOCON ............................................................................. 76
ELOCTATE ...................................................................... 34
EMBEDA ............................................................................... 4
EMCYT ................................................................................. 25
EMEND ................................................................................ 58
EMLA ........................................................................................ 7
EMOQUETTE ............................................................... 47
EMSAM ............................................................................... 70
EMTRIVA .......................................................................... 29
ENABLEX ......................................................................... 81
enalapril maleate ......................................................... 39
enalapril-hydrochlorothiazide ....................... 39
ENBREL ................................................................................. 8
ENBREL SURECLICK ........................................... 8
ENJUVIA ............................................................................ 62
enoxaparin .......................................................................... 18
ENPRESSE ....................................................................... 47
ENSKYCE ......................................................................... 47
entacapone ......................................................................... 28
entecavir ............................................................................... 29
ENTERAGAM .............................................................. 81
ENTERIC COATED ASPIRIN ....................... 4
ENTOCORT EC .......................................................... 62
EPANED .............................................................................. 39
EPIDUO ................................................................................ 76
epinephrine ........................................................................ 32
epinephrine hcl (pf) ................................................... 32
EPIPEN ................................................................................. 32
EPIPEN 2-PAK ............................................................. 32
EPIPEN JR ......................................................................... 32
EPIPEN JR 2-PAK .................................................... 32
EPITOL ................................................................................. 43
EPIVIR .................................................................................. 29
EPIVIR HBV ................................................................... 29
EPOGEN .............................................................................. 46
eprosartan ........................................................................... 39
EPZICOM ........................................................................... 29
EQUETRO ......................................................................... 70
ergocalciferol (vitamin d2) ................................ 84
ergoloid ................................................................................. 39
ergotamine-caffeine ...................................................... 4
ERIVEDGE ....................................................................... 25
ERRIN .................................................................................... 47
ERTACZO ......................................................................... 19
ERY-TAB ........................................................................... 14
ERYTHROCIN (AS STEARATE) ........... 14
erythromycin .................................................................... 14
erythromycin ethylsuccinate ............................. 14
erythromycin stearate ............................................. 14
erythromycin with ethanol .................................. 14
erythromycin-benzoyl peroxide ..................... 14
ESBRIET ............................................................................. 81
escitalopram oxalate ................................................ 70
esomeprazole magnesium ................................... 58
esomeprazole strontium ........................................ 58
ESTARYLLA ................................................................. 47
estazolam ............................................................................. 74
ESTRACE .......................................................................... 62
estradiol ................................................................................ 62
estradiol-norethindrone acet ........................... 62
ESTRASORB ................................................................. 62
ESTRING ............................................................................ 62
ESTROGEL ...................................................................... 62
estrogens-methyltestosterone .......................... 62
estropipate .......................................................................... 62
ESTROSTEP FE-28 ................................................. 47
eszopiclone ......................................................................... 74
ethambutol .......................................................................... 14
ethosuximide ..................................................................... 43
etidronate disodium .................................................. 81
etodolac .................................................................................... 8
etoposide .............................................................................. 25
EURAX ................................................................................. 76
EVAMIST .......................................................................... 62
EVEKEO ............................................................................. 32
EVISTA ................................................................................ 81
EVOCLIN ........................................................................... 14
EVOTAZ ............................................................................. 29
EVOXAC ............................................................................ 32
EVZIO .................................................................................... 18
EXALGO ER ...................................................................... 4
EXELDERM .................................................................... 19
EXELON ............................................................................. 32
exemestane ......................................................................... 25
EXFORGE ......................................................................... 39
EXFORGE HCT .......................................................... 39
EXJADE ............................................................................... 81
EXTAVIA .......................................................................... 43
EXTINA ............................................................................... 19
EXTRA STRENGTH BAYER ........................ 4
FABIOR ............................................................................... 76
FACTIVE ............................................................................ 14
FALESSA ........................................................................... 84
FALMINA (28) ............................................................. 47
famciclovir .......................................................................... 29
famotidine ........................................................................... 58
FAMVIR .............................................................................. 29
FANAPT .............................................................................. 70
FARESTON ..................................................................... 25
FARXIGA .......................................................................... 22
FARYDAK ........................................................................ 25
FAZACLO ......................................................................... 70
FC FEMALE CONDOM .................................... 47
FEIBA NF .......................................................................... 34
felbamate .............................................................................. 43
FELBATOL ...................................................................... 43
FELDENE .............................................................................. 8
felodipine ............................................................................. 35
FEM PH ................................................................................ 24
FEMARA ............................................................................ 25
FEMCAP ............................................................................. 47
91
FEMCON FE ................................................................... 47
FEMHRT 1/5 ................................................................... 63
FEMHRT LOW DOSE ......................................... 63
FEMRING .......................................................................... 63
fenofibrate ........................................................................... 39
fenofibrate micronized ........................................... 39
fenofibrate nanocrystallized ............................. 39
fenofibric acid ................................................................. 39
fenofibric acid (choline) ....................................... 39
FENOGLIDE ................................................................... 39
fenoprofen .............................................................................. 8
fentanyl ...................................................................................... 5
fentanyl citrate ................................................................... 4
FENTORA ............................................................................. 5
FER-IN-SOL .................................................................... 55
FER-IRON ......................................................................... 55
FERRIPROX ................................................................... 81
ferrous sulfate ................................................................. 55
FETZIMA ........................................................................... 70
FIBRICOR ......................................................................... 39
FINACEA ........................................................................... 76
finasteride ........................................................................... 81
FIORICET ............................................................................. 5
FIORINAL ............................................................................ 5
FIORINAL-CODEINE #3 .................................... 5
FIRAZYR ........................................................................... 81
FLAGYL .............................................................................. 14
FLAGYL ER ................................................................... 14
FLAREX .............................................................................. 53
flavoxate ................................................................................ 81
flecainide .............................................................................. 35
FLECTOR .......................................................................... 76
FLEXERIL ........................................................................ 67
FLOMAX ............................................................................ 81
FLONASE .......................................................................... 53
FLONASE ALLERGY RELIEF ................. 53
FLORIVA (FLUORIDE-VITAMIN D3)
......................................................................................................... 55
FLOVENT DISKUS ................................................ 10
FLOVENT HFA ........................................................... 10
FLUARIX 2013-2014 (PF) ............................... 33
FLUARIX QUAD 2013-2014 (PF) .......... 33
FLUBLOK 2013-2014 (PF) ............................. 33
fluconazole ......................................................................... 19
fludrocortisone ............................................................... 63
FLULAVAL 2013-2014 ...................................... 33
FLULAVAL 2014-2015 ...................................... 33
FLULAVAL QUAD 2013-2014 ................. 33
FLULAVAL QUAD 2014-2015 ................. 33
FLUMADINE ................................................................. 29
flunisolide ............................................................................ 54
fluocinolone ....................................................................... 76
fluocinolone-shower cap ...................................... 76
fluocinonide ....................................................................... 76
FLUOCINONIDE-E ................................................ 76
FLUORABON ............................................................... 55
FLUOR-A-DAY (WITH XYLITOL) .... 55
FLUORITAB ................................................................... 55
fluorometholone ............................................................ 54
FLUOROPLEX ............................................................. 25
fluorouracil ........................................................................ 25
fluoxetine .............................................................................. 70
fluphenazine hcl ............................................................ 70
FLURA-DROPS .......................................................... 55
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
92
flurazepam .......................................................................... 74
flurbiprofen ........................................................................... 8
flurbiprofen sodium ................................................... 54
flutamide ............................................................................... 25
fluticasone ................................................................. 54, 76
fluvastatin ............................................................................ 39
FLUVIRIN 2013-2014 .......................................... 33
FLUVIRIN 2013-2014 (PF) ............................. 33
FLUVIRIN 2014-2015 .......................................... 33
FLUVIRIN 2014-2015 (PF) ............................. 33
fluvoxamine ....................................................................... 70
FLUZONE 2013-2014 ........................................... 33
FLUZONE 2013-2014 (PF) .............................. 33
FLUZONE 2014-2015 ........................................... 33
FLUZONE 2014-2015 (PF) .............................. 33
FLUZONE HIGH-DOSE 2014-15 (PF)
......................................................................................................... 33
FLUZONE INTRADERM 2013-14 (PF)
......................................................................................................... 33
FLUZONE INTRADERM 2014-15 (PF)
......................................................................................................... 33
FLUZONE PEDI 2013-2014 (PF) ............. 33
FLUZONE QUAD 2013-2014 (PF) ......... 33
FLUZONE QUAD 2014-2015 ...................... 33
FLUZONE QUAD 2014-2015 (PF) ......... 33
FLUZONE QUAD PEDI 2013-14 (PF)
......................................................................................................... 33
FLUZONE QUAD PEDI 2014-15 (PF)
......................................................................................................... 33
FML FORTE ................................................................... 54
FML LIQUIFILM ....................................................... 54
FML S.O.P. ....................................................................... 54
FOCALIN ........................................................................... 70
FOCALIN XR ................................................................ 70
FOLASTIN ........................................................................ 84
FOLBEE AR .................................................................... 84
FOLBIC ................................................................................ 84
FOLBIC RF ...................................................................... 84
folic acid ............................................................................... 84
folic acid-vit b6-vit b12 ......................................... 84
FOLLISTIM AQ .......................................................... 63
FOLTANX ......................................................................... 84
FOLTANX RF ............................................................... 84
FOLTX .................................................................................. 84
fondaparinux .................................................................... 18
FORADIL AEROLIZER .................................... 10
FORFIVO XL ................................................................. 70
FORTAMET .................................................................... 22
FORTEO .............................................................................. 81
FORTESTA ...................................................................... 63
FORTICAL ....................................................................... 63
FOSAMAX ....................................................................... 81
FOSAMAX PLUS D ............................................... 81
fosinopril .............................................................................. 39
fosinopril-hydrochlorothiazide ...................... 39
FOSRENOL ..................................................................... 55
FOSTEUM ......................................................................... 55
FOSTEUM PLUS ....................................................... 81
FOVEX .................................................................................. 81
FRAGMIN ......................................................................... 18
FREESTYLE FREEDOM LITE ................. 66
FREESTYLE INSULINX TEST STRIPS
......................................................................................................... 51
FREESTYLE LITE STRIPS ........................... 51
FREESTYLE TEST ................................................. 51
FROVA ..................................................................................... 5
FULYZAQ ......................................................................... 58
FURADANTIN ............................................................. 14
furosemide .......................................................................... 52
FUZEON .............................................................................. 29
FYCOMPA ........................................................................ 43
GABADONE ................................................................... 81
gabapentin .......................................................................... 43
GABITRIL ......................................................................... 43
galantamine ....................................................................... 32
GAMMAGARD LIQUID .................................. 33
GAMMAKED ................................................................ 33
GAMUNEX-C ............................................................... 33
ganirelix ................................................................................ 63
GARAMYCIN ............................................................... 14
gatifloxacin ........................................................................ 14
GATTEX 30-VIAL ................................................... 58
GATTEX ONE-VIAL ............................................ 58
GAVILAX .......................................................................... 58
GAVILYTE-H AND BISACODYL ....... 58
GELCLAIR ....................................................................... 81
GELNIQUE ...................................................................... 81
gemfibrozil .......................................................................... 39
GENERESS FE ............................................................. 47
GENGRAF ........................................................................ 65
GENOTROPIN ............................................................. 63
GENOTROPIN MINIQUICK ....................... 63
gentamicin ................................................................ 14, 15
GEODON ............................................................................ 70
GIANVI (28) ................................................................... 47
GIAZO ................................................................................... 58
GILDAGIA ....................................................................... 47
GILDESS ............................................................................. 47
GILDESS 24 FE ........................................................... 47
GILDESS FE ................................................................... 47
GILENYA .......................................................................... 43
GILOTRIF .......................................................................... 25
GLEEVEC .......................................................................... 25
GLEOSTINE ................................................................... 25
glimepiride ......................................................................... 22
glipizide ................................................................................. 22
glipizide-metformin ................................................... 22
GLUCAGEN ................................................................... 55
GLUCAGEN HYPOKIT .................................... 55
GLUCAGON EMERGENCY KIT
(HUMAN) .......................................................................... 55
GLUCOPHAGE ........................................................... 22
GLUCOPHAGE XR ................................................ 22
GLUCOTROL ................................................................ 22
GLUCOTROL XL ..................................................... 22
GLUCOVANCE .......................................................... 22
GLUMETZA ................................................................... 22
glyburide .............................................................................. 22
glyburide micronized ............................................... 22
glyburide-metformin ................................................. 22
GLYNASE ......................................................................... 22
GLYSET .............................................................................. 22
GLYXAMBI .................................................................... 22
GOLYTELY .................................................................... 58
GONAL-F ........................................................................... 63
GONAL-F RFF ............................................................. 63
GONAL-F RFF PEN ............................................... 63
GONAL-F RFF REDI-JECT ........................... 63
GRALISE ............................................................................ 43
GRALISE 30-DAY STARTER PACK
......................................................................................................... 43
granisetron hcl ............................................................... 58
GRANIX .............................................................................. 46
GRANULEX ................................................................... 76
GRIFULVIN V .............................................................. 19
griseofulvin microsize ............................................. 19
griseofulvin ultramicrosize ................................ 19
GRIS-PEG (ULTRAMICROSIZE) .......... 19
guanfacine ................................................................ 39, 70
GYNAZOLE-1 .............................................................. 19
HALCION .......................................................................... 74
HALFLYTELY-BISACODYL W-FLAV
PK ............................................................................................... 58
HALFPRIN ........................................................................... 5
halobetasol propionate .......................................... 76
HALOG ................................................................................. 76
HALONATE .................................................................... 76
HALONATE PAC ..................................................... 76
haloperidol ......................................................................... 70
haloperidol lactate ..................................................... 70
HARVONI ......................................................................... 29
HECORIA .......................................................................... 65
HECTOROL .................................................................... 81
HELIDAC ........................................................................... 58
HELIXATE FS .............................................................. 34
HEMANGEOL .............................................................. 39
HEMOFIL M HIGH ................................................ 34
HEMOFIL M LOW .................................................. 34
HEMOFIL M MID .................................................... 34
HEMOFIL M SUPER HIGH .......................... 34
heparin (porcine) ......................................................... 18
HEPSERA .......................................................................... 29
HETLIOZ ............................................................................ 74
HEXALEN ........................................................................ 25
HIPREX ................................................................................ 15
HIZENTRA ....................................................................... 34
HORIZANT ...................................................................... 44
HUMALOG ...................................................................... 22
HUMALOG KWIKPEN ..................................... 22
HUMALOG MIX 50-50 ...................................... 22
HUMALOG MIX 50-50 KWIKPEN ...... 22
HUMALOG MIX 75-25 ...................................... 22
HUMALOG MIX 75-25 KWIKPEN ...... 22
HUMATE-P ...................................................................... 34
HUMATROPE .............................................................. 63
HUMIRA ................................................................................ 8
HUMIRA CROHN'S DIS START PCK
............................................................................................................ 8
HUMIRA PED CROHN'S STARTER PK
............................................................................................................ 8
HUMIRA PEN .................................................................. 8
HUMIRA PSORIASIS STARTER PACK
............................................................................................................ 8
HUMULIN 70/30 ........................................................ 22
HUMULIN 70/30 KWIKPEN ....................... 22
HUMULIN 70/30 PEN ......................................... 22
HUMULIN N .................................................................. 22
HUMULIN N KWIKPEN .................................. 23
HUMULIN N PEN .................................................... 23
HUMULIN R .................................................................. 23
HUMULIN R U-500
"CONCENTRATED" ............................................. 23
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
HYCAMTIN .................................................................... 25
hydralazine ........................................................................ 39
HYDREA ............................................................................ 25
hydrochlorothiazide .................................................. 52
hydrocodone-acetaminophen .............................. 5
hydrocodone-homatropine ................................. 51
hydrocodone-ibuprofen ............................................ 5
hydrocortisone ............................................ 58, 63, 76
hydrocortisone butyrate ........................................ 76
hydrocortisone butyr-emollient ..................... 76
hydrocortisone valerate ........................................ 76
hydrocortisone-acetic acid ................................ 54
hydrocortisone-pramoxine ................................. 76
hydromorphone ................................................................. 5
hydroxychloroquine .................................................. 24
hydroxyurea ...................................................................... 25
hydroxyzine hcl .............................................................. 21
hydroxyzine pamoate ............................................... 21
HYLATOPIC .................................................................. 76
hyoscyamine sulfate .................................................. 58
HYPERRHO S/D ........................................................ 34
HYPERTENSA ............................................................. 81
HYQVIA .............................................................................. 34
HYSINGLA ER ............................................................... 5
HYZAAR ............................................................................ 39
ibandronate ....................................................................... 81
IBRANCE ........................................................................... 25
ibuprofen ................................................................................. 9
ICAR-C PLUS ............................................................... 55
ICLUSIG .............................................................................. 25
ILARIS (PF) ..................................................................... 81
ILEVRO ................................................................................ 54
ILOTYCIN ........................................................................ 15
IMBRUVICA .................................................................. 25
IMDUR .................................................................................. 35
imipramine hcl ............................................................... 70
imipramine pamoate ................................................. 70
imiquimod ........................................................................... 76
IMITREX ................................................................................ 5
IMITREX STATDOSE KIT REFILL ....... 5
IMPLANON ..................................................................... 47
IMURAN ............................................................................. 65
INCIVEK ............................................................................. 29
INCRELEX ....................................................................... 63
INCRUSE ELLIPTA ............................................... 10
indapamide ........................................................................ 52
INDERAL LA ................................................................ 39
INDOCIN ............................................................................... 9
indomethacin ....................................................................... 9
INFERGEN ....................................................................... 29
INLYTA ............................................................................... 26
INNOPRAN XL ........................................................... 39
INSPRA ................................................................................ 52
INTELENCE ................................................................... 29
INTERMEZZO ............................................................. 74
INTRON A ........................................................................ 26
INTROVALE .................................................................. 47
INTUNIV ER .................................................................. 70
INVEGA .............................................................................. 70
INVIRASE ......................................................................... 30
INVOKAMET ................................................................ 23
INVOKANA .................................................................... 23
iodoquinol-hc ................................................................... 76
IOPIDINE ........................................................................... 54
ipratropium bromide ...................................... 10, 54
ipratropium-albuterol ............................................. 11
IPRIVASK ......................................................................... 18
irbesartan ............................................................................ 39
irbesartan-hydrochlorothiazide .................... 39
ISENTRESS ..................................................................... 30
ISOCHRON ...................................................................... 36
ISODITRATE ................................................................. 36
isometh-dichloral-acetaminophn .................... 5
isoniazid ................................................................................ 15
ISOPTIN SR ..................................................................... 36
ISOPTO ATROPINE .............................................. 54
ISOPTO CARBACHOL ...................................... 54
ISOPTO CARPINE .................................................. 54
ISOPTO HYOSCINE ............................................. 54
ISORDIL .............................................................................. 36
ISORDIL TITRADOSE ....................................... 36
isosorbide dinitrate .................................................... 36
isosorbide mononitrate .......................................... 36
isoxsuprine ......................................................................... 39
itraconazole ....................................................................... 19
ivermectin ............................................................................ 24
JADENU .............................................................................. 81
JAKAFI ................................................................................. 26
JALYN ................................................................................... 81
JANUMET ......................................................................... 23
JANUMET XR .............................................................. 23
JANUVIA ........................................................................... 23
JARDIANCE ................................................................... 23
JENCYCLA ...................................................................... 47
JENTADUETO ............................................................. 23
JINTELI ................................................................................ 63
JOLESSA ............................................................................ 47
JOLIVETTE ..................................................................... 47
JUBLIA ................................................................................. 19
JUNEL 1.5/30 (21) .................................................... 47
JUNEL 1/20 (21) ......................................................... 47
JUNEL FE 1.5/30 (28) ........................................... 47
JUNEL FE 1/20 (28) ................................................ 47
JUVISYNC ........................................................................ 23
JUXTAPID ........................................................................ 39
KADIAN ................................................................................. 5
KALETRA ......................................................................... 30
KALYDECO ................................................................... 81
KAOCHLOR EFFERVESCENT ............... 55
KAPVAY ............................................................................ 70
KARBINAL ER ........................................................... 21
KARIVA (28) ................................................................. 47
KAYEXALATE ........................................................... 56
KAZANO ............................................................................ 23
KCENTRA ........................................................................ 34
KEFLEX .............................................................................. 15
KELNOR 1/35 (28) ................................................... 47
KENALOG ........................................................................ 76
KEPPRA .............................................................................. 44
KEPPRA XR ................................................................... 44
KERLONE ......................................................................... 39
KERYDIN .......................................................................... 19
KETEK .................................................................................. 15
ketoconazole ..................................................................... 19
KETODAN KIT ........................................................... 19
KETONE URINE TEST ...................................... 51
ketoprofen ............................................................................... 9
ketorolac ........................................................................ 5, 54
93
KHEDEZLA .................................................................... 70
KINERET ............................................................................... 9
KIONEX .............................................................................. 56
KLARON ............................................................................ 76
KLONOPIN ...................................................................... 44
KOATE-DVI ................................................................... 34
KOGENATE FS ........................................................... 34
KOMBIGLYZE XR ................................................. 23
KORLYM ........................................................................... 23
K-PHOS-NEUTRAL ............................................... 56
KRISTALOSE ............................................................... 58
KURVELO ........................................................................ 47
KUVAN ...................................................................... 81, 82
KYNAMRO ...................................................................... 39
KYTRIL ................................................................................ 58
l norgest&e estradiol-e estrad ....................... 47
labetalol ................................................................................ 40
LAC-HYDRIN .............................................................. 76
LACRISERT .................................................................... 54
lactulose ................................................................................ 58
LAMICTAL ...................................................................... 44
LAMICTAL ODT ...................................................... 44
LAMICTAL ODT STARTER (BLUE)
......................................................................................................... 44
LAMICTAL ODT STARTER (GREEN)
......................................................................................................... 44
LAMICTAL ODT STARTER
(ORANGE) ........................................................................ 44
LAMICTAL XR ........................................................... 44
LAMICTAL XR STARTER (BLUE) .... 44
LAMICTAL XR STARTER (GREEN)
......................................................................................................... 44
LAMICTAL XR STARTER (ORANGE)
......................................................................................................... 44
LAMISIL ............................................................................. 19
lamivudine .......................................................................... 30
lamivudine-zidovudine ........................................... 30
lamotrigine ......................................................................... 44
LANOXIN .......................................................................... 36
LANOXIN PEDIATRIC ..................................... 36
lansoprazole ..................................................................... 58
LANTUS .............................................................................. 23
LANTUS SOLOSTAR .......................................... 23
LASIX .................................................................................... 52
LASTACAFT ................................................................. 21
latanoprost ......................................................................... 54
LATISSE ............................................................................. 76
LATUDA ............................................................................. 70
LAZANDA ........................................................................... 5
LEENA 28 .......................................................................... 47
leflunomide ............................................................................ 9
LENVIMA ......................................................................... 26
LESCOL ............................................................................... 40
LESCOL XL .................................................................... 40
LESSINA ............................................................................. 47
LETAIRIS .......................................................................... 40
letrozole ................................................................................. 26
leucovorin calcium ..................................................... 82
LEUKERAN .................................................................... 26
LEUKINE ........................................................................... 46
leuprolide ............................................................................. 26
levalbuterol hcl .............................................................. 11
LEVAQUIN ...................................................................... 15
LEVEMIR .......................................................................... 23
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
94
LEVEMIR FLEXPEN ........................................... 23
LEVEMIR FLEXTOUCH ................................. 23
levetiracetam .................................................................... 44
LEVITRA ........................................................................... 82
levobunolol ........................................................................ 54
levocetirizine .................................................................... 21
levofloxacin ....................................................................... 15
levomefolate calcium ............................................... 84
LEVOMEFOLATE DHA ................................... 67
LEVONEST (28) ......................................................... 48
levonorgestrel ................................................................. 48
levonorgestrel-ethinyl estrad ........................... 48
LEVORA 0.15/30 (28) .......................................... 48
LEVORA-28 .................................................................... 48
LEVOTHROID ............................................................. 79
levothyroxine .................................................................... 79
LEVOXYL ........................................................................ 79
LEVSIN ................................................................................ 58
LEVULAN ........................................................................ 26
LEXAPRO ......................................................................... 70
LEXIVA ............................................................................... 30
LIALDA ............................................................................... 58
LIBRAX (WITH CLIDINIUM) .................. 58
lidocaine .................................................................................. 7
lidocaine hcl-hydrocortison ac ...................... 58
LIDOCAINE VISCOUS ......................................... 7
lidocaine-prilocaine ..................................................... 7
LIDODERM ........................................................................ 7
LIDORX .................................................................................. 7
LILETTA ............................................................................. 48
LIMBREL ........................................................................... 82
LIMBREL250 ................................................................. 82
LIMBREL500 ................................................................. 82
lindane .................................................................................... 76
LINZESS ............................................................................. 58
LIORESAL ........................................................................ 67
liothyronine ....................................................................... 79
LIPICHOL 540 .............................................................. 58
LIPITOR .............................................................................. 40
LIPOFEN ............................................................................. 40
LIPTRUZET .................................................................... 40
lisinopril ............................................................................... 40
lisinopril-hydrochlorothiazide ....................... 40
LISTER-V .......................................................................... 82
LITE COAT ASPIRIN ............................................. 5
lithium carbonate ........................................................ 70
lithium citrate .................................................................. 70
LITHOBID ........................................................................ 70
LIVALO ............................................................................... 40
L-METHYL-B6-B12 ............................................... 84
L-METHYLFOLATE ............................................ 84
L-METHYLFOLATE CA P-5-P
ME-CBL ............................................................................... 84
L-METHYLFOLATE FORMULA .......... 84
L-METHYLFOLATE FORTE ...................... 84
L-METHYL-MC ......................................................... 84
L-METHYL-MC NAC .......................................... 84
LMTHF-PYRIDOXINE-CYANOCOBA
LAMN .................................................................................... 84
LO LOESTRIN FE .................................................... 48
LO MINASTRIN FE ............................................... 48
LOCOID ............................................................................... 77
LOCOID LIPOCREAM ....................................... 77
LO-DOSE ASPIRIN ................................................... 5
LODOSYN ........................................................................ 28
LOESTRIN 1.5/30 (21) ........................................ 48
LOESTRIN 1/20 (21) ............................................. 48
LOESTRIN 24 FE ...................................................... 48
LOESTRIN FE 1.5/30 (28-DAY) .............. 48
LOESTRIN FE 1/20 (28-DAY) ................... 48
LOFIBRA ........................................................................... 40
LOMEDIA 24 FE ....................................................... 48
LOMOTIL .......................................................................... 58
lomustine .............................................................................. 26
LO-OVRAL (28) ......................................................... 48
LOPID .................................................................................... 40
LOPRESSOR .................................................................. 40
LOPRESSOR HCT ................................................... 40
LOPROX ............................................................................. 19
loratadine ............................................................................ 21
lorazepam ............................................................................ 71
LORAZEPAM INTENSOL ............................. 71
LORTAB ................................................................................. 5
LORYNA (28) ............................................................... 48
LORZONE ......................................................................... 67
losartan .................................................................................. 40
losartan-hydrochlorothiazide ......................... 40
LOSEASONIQUE ..................................................... 48
LOTEMAX ....................................................................... 54
LOTENSIN ....................................................................... 40
LOTENSIN HCT ........................................................ 40
LOTREL .............................................................................. 40
LOTRISONE ................................................................... 19
LOTRONEX .................................................................... 58
lovastatin .............................................................................. 40
LOVAZA ............................................................................. 59
LOVENOX ........................................................................ 18
LOW-OGESTREL (28) ........................................ 48
loxapine succinate ...................................................... 71
LOXITANE ...................................................................... 71
LUDENT FLUORIDE ........................................... 56
LUFYLLIN ....................................................................... 11
LUKAID GLA FOR ASTHMA ................... 82
LUMIGAN ........................................................................ 54
LUNESTA .......................................................................... 74
LUNGLAID FOR ASTHMA ......................... 82
LUTERA (28) ................................................................. 48
LUVERIS ............................................................................ 63
LUVOX CR ...................................................................... 71
LUXIQ ................................................................................... 77
LUZU ...................................................................................... 19
LYNPARZA .................................................................... 26
LYRICA ............................................................................... 44
LYSODREN .................................................................... 26
LYSTEDA .......................................................................... 34
LYZA ...................................................................................... 48
MACROBID .................................................................... 15
MACRODANTIN ...................................................... 15
MACUTEK ....................................................................... 84
MALARONE .................................................................. 24
MALARONE PEDIATRIC .............................. 24
maprotiline ......................................................................... 71
MARINOL ......................................................................... 59
MARLEXATE ............................................................... 56
MARLISSA ...................................................................... 48
MATULANE ................................................................... 26
MAVIK ................................................................................. 40
MAXAIR AUTOHALER ................................... 11
MAXALT ............................................................................... 5
MAXALT-MLT .............................................................. 5
MAXIDEX ........................................................................ 54
MAXITROL ..................................................................... 15
MAXZIDE ......................................................................... 52
MAXZIDE-25MG ...................................................... 52
meclofenamate ................................................................... 9
MEDROL ............................................................................ 63
MEDROL (PAK) ........................................................ 63
medroxyprogesterone .................................... 48, 63
mefenamic acid ................................................................. 5
MEGACE ............................................................................ 82
MEGACE ES .................................................................. 82
megestrol .............................................................................. 26
MEKINIST ........................................................................ 26
meloxicam .............................................................................. 9
MENEST ............................................................................. 63
MENOPUR ....................................................................... 63
MENOSTAR ................................................................... 63
MENTAX ........................................................................... 19
meperidine ............................................................................. 5
MEPHYTON ................................................................... 84
meprobamate ................................................................... 71
MEPRON ............................................................................ 24
mercaptopurine ............................................................. 26
mesalamine ........................................................................ 59
MESTINON ...................................................................... 32
METADATE CD ........................................................ 71
METADATE ER ......................................................... 71
METAFOLBIC ............................................................. 84
METAFOLBIC PLUS ........................................... 84
METAFOLBIC PLUS RF .................................. 85
METANX ........................................................................... 85
METANX (ALGAL OIL) .................................. 85
metaproterenol ............................................................... 11
metaxalone ......................................................................... 67
metformin ............................................................................. 23
methadone .............................................................................. 5
methamphetamine ....................................................... 32
methazolamide ................................................................ 52
methenamine hippurate ......................................... 15
methenamine mandelate ....................................... 15
methimazole ...................................................................... 79
methocarbamol .............................................................. 67
methotrexate sodium ................................................ 26
methotrexate sodium (pf) ..................................... 26
methoxsalen rapid ....................................................... 77
methyldopa ......................................................................... 40
methyldopa-hydrochlorothiazide ................. 40
methylergonovine ........................................................ 63
METHYLIN ..................................................................... 71
methylphenidate ............................................................ 71
methylprednisolone ................................................... 63
metipranolol ..................................................................... 54
metoclopramide hcl ................................................... 59
metolazone .......................................................................... 52
metoprolol succinate ................................................ 40
metoprolol ta-hydrochlorothiaz .................... 40
metoprolol tartrate ..................................................... 40
METOZOLV ODT .................................................... 59
METROCREAM ......................................................... 77
METROGEL .................................................................... 77
METROGEL VAGINAL .................................... 15
METROLOTION ........................................................ 77
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
metronidazole ........................................................ 15, 77
MEVACOR ....................................................................... 40
mexiletine ............................................................................. 36
MIACALCIN .................................................................. 63
MICARDIS ....................................................................... 40
MICARDIS HCT ........................................................ 40
MICONAZOLE-3 ...................................................... 19
MICROCHAMBER ................................................. 66
MICROGESTIN 1.5/30 (21) ........................... 48
MICROGESTIN 1/20 (21) ................................ 48
MICROGESTIN FE 1.5/30 (28) .................. 48
MICROGESTIN FE 1/20 (28) ....................... 48
MICROZIDE ................................................................... 52
MIDAMOR ....................................................................... 52
midodrine ............................................................................. 32
MIGRANAL ....................................................................... 5
MIMVEY ............................................................................ 63
MINASTRIN 24 FE ................................................. 48
MINIPRESS ..................................................................... 40
MINIPRIN ............................................................................. 5
MINITRAN ....................................................................... 36
MINOCIN ........................................................................... 15
MINOCIN KIT WITH WIPES ..................... 15
minocycline ........................................................................ 15
minoxidil ............................................................................... 40
MIRALAX ......................................................................... 59
MIRAPEX .......................................................................... 28
MIRAPEX ER ................................................................ 28
MIRCERA .......................................................................... 46
MIRCETTE (28) .......................................................... 48
MIRENA .............................................................................. 48
mirtazapine ........................................................................ 71
MIRVASO ......................................................................... 77
misoprostol ........................................................................ 59
MITIGARE ........................................................................... 9
MOBIC ..................................................................................... 9
modafinil .............................................................................. 71
MODERIBA DOSE PACK .............................. 30
MODICON (28) ........................................................... 48
moexipril .............................................................................. 40
moexipril-hydrochlorothiazide ...................... 40
mometasone ....................................................................... 77
MOMEXIN ....................................................................... 77
MONOCLATE-P ........................................................ 34
MONODOX ..................................................................... 15
MONOKET ....................................................................... 36
MONO-LINYAH ........................................................ 48
MONONESSA (28) .................................................. 48
MONONINE .................................................................... 34
montelukast ........................................................................ 11
MORGIDOX ................................................................... 15
MORGIDOX 1X100 ............................................... 15
MORGIDOX 2X100 ............................................... 15
morphine ........................................................................... 5, 6
MOTOFEN ........................................................................ 59
MOVANTIK .................................................................... 18
MOVIPREP ...................................................................... 59
MOXATAG ...................................................................... 15
MOXEZA ........................................................................... 15
moxifloxacin ...................................................................... 15
MS CONTIN ....................................................................... 6
MULTAQ ........................................................................... 36
mupirocin ............................................................................. 15
mupirocin calcium ...................................................... 15
MUSE ..................................................................................... 82
MYALEPT ........................................................................ 63
MYAMBUTOL ............................................................ 15
MYCOBUTIN ................................................................ 15
mycophenolate mofetil ........................................... 65
mycophenolate sodium ........................................... 65
MYFORTIC ..................................................................... 65
MYLERAN ....................................................................... 26
MYNATAL ....................................................................... 67
MYORISAN .................................................................... 77
MYRBETRIQ ................................................................. 82
MYSOLINE ...................................................................... 44
MYZILRA .......................................................................... 48
nabumetone ........................................................................... 9
nadolol .................................................................................... 40
NAFTIN ................................................................................ 19
NALFON ................................................................................ 9
naltrexone ........................................................................... 18
NAMENDA ...................................................................... 44
NAMENDA TITRATION PAK .................. 44
NAMENDA XR ........................................................... 44
NAMZARIC .................................................................... 44
NAPRELAN CR ............................................................. 9
NAPROSYN ....................................................................... 9
naproxen .................................................................................. 9
naproxen sodium ............................................................. 9
naratriptan ............................................................................. 6
NARDIL ............................................................................... 71
NASACORT .................................................................... 54
NASACORT AQ ......................................................... 54
NASCOBAL .................................................................... 85
NASONEX ........................................................................ 54
NATACYN ....................................................................... 19
NATAFORT (NEW FORMULA 2011)
......................................................................................................... 67
NATAZIA .......................................................................... 48
nateglinide .......................................................................... 23
NATESTO .......................................................................... 63
NATPARA ........................................................................ 63
NATROBA ........................................................................ 77
NATURE-THROID .................................................. 79
NAVANE ............................................................................ 71
NEBUPENT ..................................................................... 24
NECON 0.5/35 (28) .................................................. 48
NECON 1/35 (28) ....................................................... 48
NECON 1/50 (28) ....................................................... 48
NECON 10/11 (28) ................................................... 48
NEEVO ................................................................................. 68
NEEVO DHA ................................................................. 68
NEEVODHA (WITH ALGAL OIL) ...... 68
nefazodone .......................................................................... 71
neomycin .............................................................................. 15
neomycin-polymyxin b-dexameth ................ 15
NEOPHE .............................................................................. 56
NEORAL ............................................................................. 65
NEOSPORIN
(NEO-POLYM-GRAMICID) ........................ 15
NEO-SYNALAR ......................................................... 15
NEO-SYNALAR KIT ............................................ 16
NEPTAZANE ................................................................. 52
NESINA ................................................................................ 23
NESTABS .......................................................................... 68
NEUAC ................................................................................. 77
NEUAC KIT .................................................................... 77
95
NEULASTA ..................................................................... 46
NEUPOGEN .................................................................... 46
NEUPRO ............................................................................. 28
NEURONTIN ................................................................. 44
NEVANAC ....................................................................... 54
nevirapine ........................................................................... 30
NEXAVAR ....................................................................... 26
NEXIUM ............................................................................. 59
NEXIUM 24HR ............................................................ 59
NEXIUM PACKET .................................................. 59
NEXPLANON ............................................................... 48
NEXT CHOICE ............................................................ 49
NEXT CHOICE ONE DOSE ......................... 49
niacin ............................................................................. 40, 85
NIASPAN EXTENDED-RELEASE ...... 40
nicardipine ......................................................................... 36
NICODERM CQ ......................................................... 79
NICOMIDE ....................................................................... 85
NICORELIEF ................................................................. 79
NICORETTE ................................................................... 79
nicotine .................................................................................. 79
nicotine (polacrilex) ................................................. 79
NICOTROL ...................................................................... 79
NICOTROL NS ............................................................ 79
NIFEDIAC CC .............................................................. 36
NIFEDICAL XL .......................................................... 36
nifedipine ............................................................................. 36
NILANDRON ................................................................ 26
nimodipine .......................................................................... 36
NIRAVAM ........................................................................ 71
nisoldipine .......................................................................... 36
NITRO-BID ...................................................................... 36
NITRO-DUR ................................................................... 36
nitrofurantoin .................................................................. 16
nitrofurantoin macrocrystal ............................. 16
nitrofurantoin monohyd/m-cryst .................. 16
nitroglycerin ..................................................................... 36
NITROLINGUAL ...................................................... 36
NITROMIST .................................................................... 36
NITROSTAT ................................................................... 36
NITRO-TIME ................................................................. 36
nizatidine .............................................................................. 59
NORA-BE .......................................................................... 49
NORDETTE (28) ........................................................ 49
NORDITROPIN FLEXPRO ........................... 63
NORDITROPIN NORDIFLEX ................... 63
noreth-ethinyl estradiol-iron ........................... 49
norethindrone (contraceptive) ....................... 49
norethindrone ac-eth estradiol ...................... 63
norgestimate-ethinyl estradiol ....................... 49
norgestrel-ethinyl estradiol ............................... 49
NORINYL 1+35 (28) .............................................. 49
NORINYL 1+50 (28) .............................................. 49
NORITATE ....................................................................... 77
NOROXIN ......................................................................... 16
NORPACE ......................................................................... 36
NORPACE CR .............................................................. 36
NORPRAMIN ................................................................ 71
NOR-QD .............................................................................. 49
NORTHERA .................................................................... 32
NORTREL 0.5/35 (28) .......................................... 49
NORTREL 1/35 (21) ............................................... 49
NORTREL 1/35 (28) ............................................... 49
NORTREL 7/7/7 (28) ............................................. 49
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
96
nortriptyline ...................................................................... 71
NORVASC ........................................................................ 36
NORVIR .............................................................................. 30
NOVA MAX GLUCOSE TEST ................. 51
NOVAREL ........................................................................ 63
NOVOEIGHT ................................................................. 34
NOVOFINE 30 .............................................................. 66
NOVOFINE 32 .............................................................. 66
NOVOFINE AUTOCOVER ........................... 66
NOVOFINE PLUS .................................................... 66
NOVOLIN 70/30 ......................................................... 23
NOVOLIN R ................................................................... 23
NOVOLOG ....................................................................... 23
NOVOLOG FLEXPEN ........................................ 23
NOVOLOG MIX 70-30 ....................................... 23
NOVOLOG MIX 70-30 FLEXPEN ........ 23
NOVOPEN 3 ................................................................... 66
NOVOPEN JR ............................................................... 66
NOVOSEVEN RT ..................................................... 34
NOVOTWIST ................................................................ 66
NOXAFIL ........................................................................... 19
NP THYROID ................................................................ 79
NTS STEP 1 ..................................................................... 79
NUCYNTA ........................................................................... 6
NUCYNTA ER ................................................................. 6
NUEDEXTA .................................................................... 44
NULYTELY WITH FLAVOR PACKS
......................................................................................................... 59
NUTROPIN ...................................................................... 63
NUTROPIN AQ ........................................................... 63
NUTROPIN AQ NUSPIN ................................. 63
NUVARING .................................................................... 49
NUVESSA ......................................................................... 16
NUVIGIL ............................................................................ 71
NYMALIZE ..................................................................... 36
nystatin ................................................................................... 19
nystatin-triamcinolone ........................................... 19
OBIZUR ............................................................................... 34
OBREDON ........................................................................ 51
OBTREX ............................................................................. 68
O-CAL PRENATAL ............................................... 68
OCELLA .............................................................................. 49
octreotide acetate ........................................................ 64
OCUDOX ........................................................................... 54
OCUFEN ............................................................................. 54
OCUFLOX ........................................................................ 16
OFEV ....................................................................................... 82
ofloxacin ............................................................................... 16
OGEN 2.5 ........................................................................... 64
OGESTREL (28) ......................................................... 49
olanzapine ........................................................................... 71
OLEPTRO ER ................................................................ 71
olopatadine ........................................................................ 54
OLUX ..................................................................................... 77
OLUX-E ............................................................................... 77
OLYSIO ................................................................................ 30
OMECLAMOX-PAK ............................................. 59
omega-3 acid ethyl esters .................................... 59
omeprazole ......................................................................... 59
OMNARIS ......................................................................... 54
OMNIPRED ..................................................................... 54
OMNITROPE ................................................................. 64
ondansetron ....................................................................... 59
ondansetron hcl ............................................................. 59
ONETOUCH ULTRA TEST .......................... 51
ONETOUCH VERIO ............................................. 51
ONETOUCH VERIO IQ METER ............ 66
ONFI ........................................................................................ 44
ONGLYZA ........................................................................ 23
ONMEL ................................................................................ 19
ONSOLIS ............................................................................... 6
OPANA .................................................................................... 6
OPANA ER .......................................................................... 6
opium tincture ................................................................. 59
OPSUMIT ........................................................................... 40
OPTICHAMBER ADVANTAGE ............. 66
OPTIPRANOLOL ...................................................... 54
OPTIVAR ........................................................................... 21
ORACEA ............................................................................. 16
ORALONE ........................................................................ 82
ORAP ...................................................................................... 71
ORAPRED ......................................................................... 64
ORAPRED ODT ......................................................... 64
ORAVIG .............................................................................. 20
ORENCIA .............................................................................. 9
ORENITRAM ................................................................ 40
ORFADIN .......................................................................... 82
orphenadrine citrate ................................................. 67
ORPHENADRINE COMPOUND ............ 67
ORPHENADRINE COMPOUND-DS
......................................................................................................... 67
ORSYTHIA ...................................................................... 49
ORTHO ALL-FLEX FITTING SET ...... 49
ORTHO DIAPHRAGM ALL-FLEX 65
......................................................................................................... 49
ORTHO DIAPHRAGM ALL-FLEX 70
......................................................................................................... 49
ORTHO DIAPHRAGM ALL-FLEX 75
......................................................................................................... 49
ORTHO DIAPHRAGM ALL-FLEX 80
......................................................................................................... 49
ORTHO EVRA ............................................................. 49
ORTHO MICRONOR ........................................... 49
ORTHO TRI-CYCLEN (28) ........................... 49
ORTHO TRI-CYCLEN LO (28) ................ 49
ORTHO-CEPT (28) .................................................. 49
ORTHO-CYCLEN (28) ....................................... 49
ORTHO-NOVUM 1/35 (28) ........................... 49
ORTHO-NOVUM 7/7/7 (28) ......................... 49
OSENI .................................................................................... 23
OSMOPREP ..................................................................... 59
OSPHENA ......................................................................... 82
OTEZLA ................................................................................. 9
OTEZLA STARTER .................................................. 9
OTREXUP (PF) ............................................................... 9
OVACE ................................................................................. 77
OVACE PLUS ............................................................... 77
OVCON-35 (28) ........................................................... 49
OVCON-50 (28) ........................................................... 49
OVIDE ................................................................................... 77
OVIDREL ........................................................................... 64
OXANDRIN .................................................................... 64
oxaprozin ................................................................................. 9
oxazepam ............................................................................. 71
oxcarbazepine ................................................................. 44
OXECTA ................................................................................ 6
OXISTAT ........................................................................... 20
OXSORALEN ................................................................ 77
OXSORALEN ULTRA ........................................ 77
OXTELLAR XR .......................................................... 45
oxybutynin chloride ................................................... 82
oxycodone ............................................................................... 6
oxycodone-acetaminophen .................................... 6
OXYCONTIN .................................................................... 6
oxymorphone ....................................................................... 6
OXYTROL ........................................................................ 82
OXYTROL FOR WOMEN .............................. 82
PAMELOR ........................................................................ 71
PAMINE .............................................................................. 59
PAMINE FORTE ........................................................ 59
PANCREAZE ................................................................. 59
PANDEL .............................................................................. 77
PANRETIN ....................................................................... 26
pantoprazole ..................................................................... 59
papaverine .......................................................................... 40
PARAFON FORTE DSC ................................... 67
PARAGARD T 380A ............................................. 49
PARCOPA ......................................................................... 28
paregoric .............................................................................. 59
paricalcitol ......................................................................... 82
PARLODEL ..................................................................... 28
PARNATE ......................................................................... 71
paromomycin ................................................................... 24
paroxetine hcl .................................................................. 72
PASER ................................................................................... 16
PATADAY ........................................................................ 21
PATANASE ..................................................................... 54
PATANOL ......................................................................... 21
PAXIL .................................................................................... 72
PAXIL CR .......................................................................... 72
PAZEO .................................................................................. 21
PCE ............................................................................................ 16
PEDIADERM HC ...................................................... 77
PEDIPIROX-4 ................................................................ 20
peg 3350-electrolytes .............................................. 59
PEGANONE .................................................................... 45
PEGASYS .......................................................................... 30
PEGASYS CONVENIENCE PACK ...... 30
PEGASYS PROCLICK ........................................ 30
peg-electrolyte soln ................................................... 59
PEGINTRON .................................................................. 30
PEGINTRON REDIPEN .................................... 30
penicillin v potassium ............................................. 16
PENLAC .............................................................................. 20
PENNSAID ....................................................................... 77
PENTASA .......................................................................... 59
pentoxifylline .................................................................... 34
PEPCID ................................................................................. 59
PERCOCET ......................................................................... 6
PERCODAN ....................................................................... 6
PERCURA ......................................................................... 82
PERFOROMIST .......................................................... 11
perindopril erbumine ............................................... 40
PERIOGARD .................................................................. 82
PERIOSTAT .................................................................... 82
permethrin .......................................................................... 77
perphenazine .................................................................... 72
perphenazine-amitriptyline ............................... 72
PERSANTINE ............................................................... 29
PERTZYE ........................................................................... 59
PEXEVA .............................................................................. 72
phenazopyridine ............................................................... 7
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
phendimetrazine tartrate ..................................... 27
phenobarbital .................................................................. 74
phentermine ....................................................................... 27
PHENYLENE ................................................................. 56
PHENYLENE 75 ........................................................ 56
PHENYTEK ..................................................................... 45
phenytoin .............................................................................. 45
phenytoin sodium extended ............................... 45
PHILITH .............................................................................. 49
PHOSLO .............................................................................. 56
PHOSPHOLINE IODIDE .................................. 54
PICATO ................................................................................ 26
pilocarpine hcl ............................................................... 54
pindolol .................................................................................. 40
pioglitazone ....................................................................... 23
pioglitazone-glimepiride ...................................... 23
pioglitazone-metformin ......................................... 23
PIRMELLA ....................................................................... 49
piroxicam ................................................................................ 9
PLAN B ................................................................................ 49
PLAN B ONE-STEP ............................................... 49
PLAQUENIL ................................................................... 24
PLAVIX ................................................................................ 29
PLEGRIDY ....................................................................... 45
PLETAL ............................................................................... 29
PLEXION ........................................................................... 16
PLEXION CLEANSING CLOTHS ........ 16
PNEUMOVAX 23 ..................................................... 34
PODIAPN ........................................................................... 85
PODOCON ........................................................................ 77
podofilox ............................................................................... 77
polyethylene glycol 3350 ........................... 59, 82
polymyxin b sulf-trimethoprim ....................... 16
POLYTRIM ...................................................................... 16
POLY-VI-FLOR .......................................................... 85
POMALYST .................................................................... 26
PONSTEL .............................................................................. 6
PORTIA ................................................................................ 49
potassium chloride ..................................................... 56
potassium citrate .......................................................... 56
POTIGA ................................................................................ 45
PRADAXA ........................................................................ 18
pramipexole ....................................................................... 28
PRAMOSONE ............................................................... 77
PRANDIMET ................................................................. 23
PRANDIN .......................................................................... 23
PRAVACHOL ............................................................... 41
pravastatin .......................................................................... 41
prazosin ................................................................................. 41
PRECISION XTRA TEST ................................ 51
PRECOSE ........................................................................... 23
PRED FORTE ................................................................ 54
PRED MILD .................................................................... 54
PRED-G ................................................................................ 16
PRED-G S.O.P. ............................................................. 16
prednisolone ..................................................................... 64
prednisolone acetate ................................................ 54
prednisolone sodium phosphate ......... 54, 64
prednisone .......................................................................... 64
PREFERA-OB ONE ................................................ 68
PREFERA-OB PLUS DHA ............................. 68
PREFEST ............................................................................ 64
PREFLIN ............................................................................. 82
PREGNYL ......................................................................... 64
PRELONE .......................................................................... 64
PREMARIN ..................................................................... 64
PREMPHASE ................................................................. 64
PREMPRO ......................................................................... 64
PRENA1 CHEW ......................................................... 68
PRENATABS FA ....................................................... 68
PRENATABS RX ...................................................... 68
PRENATAL VITAMIN ....................................... 68
PRENATE DHA .......................................................... 68
PRENATE ELITE ...................................................... 68
PRENATE ESSENTIAL ..................................... 68
PREPARATION CLEANSING ................... 59
PREPIDIL ........................................................................... 64
PREQUE 10 ...................................................................... 68
PREVACID ....................................................................... 60
PREVACID 24HR ..................................................... 60
PREVACID SOLUTAB ...................................... 60
PREVALITE .................................................................... 41
PREVIFEM ....................................................................... 50
PREVPAC .......................................................................... 60
PREZCOBIX ................................................................... 30
PREZISTA ......................................................................... 30
PRIFTIN ............................................................................... 16
PRILOSEC ........................................................................ 60
PRILOSEC OTC ......................................................... 60
primaquine ......................................................................... 24
primidone ............................................................................. 45
PRIMLEV .............................................................................. 6
PRINIVIL ........................................................................... 41
PRINZIDE .......................................................................... 41
PRISTIQ ............................................................................... 72
PROAIR HFA ................................................................ 11
PROAIR RESPICLICK ........................................ 11
PROBARIMIN QT .................................................... 85
probenecid ............................................................................. 9
PROCARDIA ................................................................. 36
PROCARDIA XL ....................................................... 37
PROCENTRA ................................................................ 32
prochlorperazine .......................................................... 60
prochlorperazine edisylate ................................ 60
prochlorperazine maleate ................................... 60
PROCRIT ............................................................................ 46
PROCTOCORT ............................................................ 60
PROCTOCREAM-HC .......................................... 60
PROCTOFOAM HC ............................................... 60
PROCTOZONE-HC ................................................ 60
PROCYSBI ....................................................................... 82
PRODIGY AUTOCODE METER ............ 66
PRODIGY AUTOCODE PRO ..................... 66
PRODIGY POCKET METER ...................... 66
PRODIGY POCKET PRO ................................ 66
PRODIGY VOICE GLUCOSE METER
......................................................................................................... 66
PRODIGY VOICE PRO ...................................... 66
PROFILNINE ................................................................. 34
PROGLYCEM ............................................................... 56
PROGRAF ......................................................................... 65
PROLENSA ..................................................................... 55
PROMACTA ................................................................... 46
promethazine .................................................................... 21
PROMETHAZINE VC ......................................... 20
PROMETHAZINE VC-CODEINE .......... 51
promethazine-codeine ............................................. 51
promethazine-dm ......................................................... 51
97
promethazine-phenyleph-codeine ............... 51
PROMETRIUM ........................................................... 64
propafenone ...................................................................... 37
propantheline ................................................................... 60
propranolol ........................................................................ 41
propranolol-hydrochlorothiazid .................. 41
propylthiouracil ............................................................ 80
PROSCAR .......................................................................... 82
PROSTIGMIN ............................................................... 32
PROTEOLIN ................................................................... 82
PROTEOLIN DS ......................................................... 82
PROTONIX ...................................................................... 60
PROTOPIC ........................................................................ 65
protriptyline ...................................................................... 72
PROVENTIL HFA .................................................... 11
PROVERA ......................................................................... 64
PROVIGIL ......................................................................... 72
PROZAC .............................................................................. 72
PROZAC WEEKLY ................................................ 72
PULMICORT ................................................................. 11
PULMICORT FLEXHALER ......................... 11
PULMOZYME .............................................................. 82
PURINETHOL .............................................................. 26
PURIXAN .......................................................................... 26
PYLERA .............................................................................. 60
pyrazinamide .................................................................... 16
pyridostigmine bromide ........................................ 33
QNASL .................................................................................. 55
QSYMIA .............................................................................. 27
QUALAQUIN ................................................................ 24
QUARTETTE ................................................................. 50
QUASENSE ..................................................................... 50
QUDEXY XR ................................................................. 45
QUESTRAN .................................................................... 41
QUESTRAN LIGHT ............................................... 41
quetiapine ............................................................................ 72
QUFLORA PEDIATRIC .................................... 85
QUILLIVANT XR .................................................... 72
quinapril ............................................................................... 41
quinapril-hydrochlorothiazide ....................... 41
quinidine gluconate ................................................... 37
quinidine sulfate ........................................................... 37
QUIXIN ................................................................................ 16
QVAR ..................................................................................... 11
rabeprazole ........................................................................ 60
RADIOGARDASE ................................................... 82
raloxifene ............................................................................. 82
ramipril .................................................................................. 41
RANEXA ............................................................................ 37
ranitidine hcl .................................................................... 60
RAPAFLO .......................................................................... 82
RAPAMUNE ................................................................... 65
RASUVO (PF) .................................................................. 9
RAVICTI ............................................................................. 60
RAYOS ................................................................................. 64
RAZADYNE ................................................................... 33
RAZADYNE ER ......................................................... 33
REBETOL .......................................................................... 30
REBIF (WITH ALBUMIN) ............................. 45
REBIF REBIDOSE ................................................... 45
REBIF TITRATION PACK ............................ 45
RECLIPSEN (28) ........................................................ 50
RECOMBINATE ........................................................ 34
RECTIV ................................................................................ 60
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
98
REGIMEX .......................................................................... 27
REGLAN ............................................................................. 60
REGRANEX .................................................................... 77
RELAGARD .................................................................... 24
RELENZA DISKHALER .................................. 30
RELISTOR ........................................................................ 18
RELPAX ................................................................................. 6
REMERON ....................................................................... 72
REMERON SOLTAB ............................................ 72
RENAGEL ......................................................................... 56
RENVELA ......................................................................... 56
repaglinide ......................................................................... 23
REPRONEX ..................................................................... 64
REQUIP ................................................................................ 28
REQUIP XL ..................................................................... 28
RESCRIPTOR ................................................................ 30
RESCULA .......................................................................... 55
reserpine ............................................................................... 41
RESTASIS ......................................................................... 55
RESTORIL ........................................................................ 74
RETIN-A ............................................................................. 77
RETIN-A MICRO ...................................................... 77
RETIN-A MICRO PUMP .................................. 77
RETROVIR ....................................................................... 30
REVATIO ........................................................................... 41
REVESTA .......................................................................... 85
REVIA .................................................................................... 18
REVLIMID ....................................................................... 26
REYATAZ ......................................................................... 30
REZIRA ................................................................................ 51
RHINOCORT AQUA ............................................ 55
RHOGAM ULTRA-FILTERED PLUS
......................................................................................................... 34
RIASTAP ............................................................................ 34
RIBASPHERE ............................................................... 30
RIBASPHERE RIBAPAK ................................ 30
ribavirin ................................................................................ 30
RIDAURA ............................................................................. 9
rifabutin ................................................................................. 16
RIFADIN ............................................................................. 16
RIFAMATE ...................................................................... 16
rifampin ................................................................................. 16
RIFATER ............................................................................ 16
RILUTEK ........................................................................... 45
riluzole .................................................................................... 45
rimantadine ....................................................................... 30
risedronate ......................................................................... 82
RISPERDAL .................................................................... 72
RISPERDAL M-TAB ............................................ 72
risperidone ......................................................................... 72
RITALIN ............................................................................. 72
RITALIN LA ................................................................... 72
RITALIN SR ................................................................... 72
RIXUBIS ............................................................................. 34
rizatriptan ............................................................................... 6
ROBAXIN .......................................................................... 67
ROBINUL .......................................................................... 60
ROBINUL FORTE .................................................... 60
ROCALTROL ................................................................ 85
ropinirole ............................................................................. 28
ROSADAN .............................................................. 77, 78
ROSANIL ........................................................................... 16
ROZEREM ........................................................................ 74
RYBIX ODT ....................................................................... 6
RYTARY ............................................................................. 28
RYTHMOL ....................................................................... 37
RYTHMOL SR ............................................................. 37
RYZOLT ................................................................................. 6
SABRIL ................................................................................ 45
SAFYRAL .......................................................................... 50
SAIZEN ................................................................................ 64
SAIZEN CLICK.EASY ........................................ 64
SALAGEN ......................................................................... 33
SALEX .................................................................................. 78
salsalate .................................................................................... 9
SAMSCA ............................................................................. 52
SANCTURA .................................................................... 82
SANCTURA XR ......................................................... 82
SANCUSO ......................................................................... 60
SANDIMMUNE .......................................................... 65
SANDOSTATIN ......................................................... 64
SANTYL .............................................................................. 78
SAPHRIS ............................................................................. 72
SAPHRIS (BLACK CHERRY) ................... 72
SARAFEM ........................................................................ 72
SAVAYSA ........................................................................ 37
SAVELLA .......................................................................... 82
SAXENDA ........................................................................ 27
SEASONALE CONTRACEPTIVE ......... 50
SEASONIQUE .............................................................. 50
SECTRAL .......................................................................... 41
SELECT-OB + DHA .............................................. 68
selegiline hcl ..................................................................... 28
selenium sulfide ............................................................. 78
SELRX ................................................................................... 78
SELZENTRY .................................................................. 30
SEMPREX-D .................................................................. 20
SENSIPAR ........................................................................ 82
SENTRA AM .................................................................. 83
SENTRA PM ................................................................... 83
SEPTRA DS ..................................................................... 16
SEREVENT DISKUS ............................................ 11
SEROMYCIN ................................................................. 16
SEROPHENE ................................................................. 64
SEROQUEL ..................................................................... 72
SEROQUEL XR .......................................................... 72
SEROSTIM ....................................................................... 64
sertraline .................................................................... 72, 73
sevelamer carbonate ................................................ 56
SHOHL'S MODIFIED ........................................... 56
SIGNIFOR ......................................................................... 64
sildenafil ............................................................................... 41
SILENOR ............................................................................ 74
SILVADENE ................................................................... 16
silver sulfadiazine ....................................................... 16
SIMBRINZA ................................................................... 55
SIMCOR .............................................................................. 41
SIMPONI ...................................................................... 9, 10
simvastatin .......................................................................... 41
SINEMET ........................................................................... 28
SINEMET CR ................................................................ 28
SINGULAIR .................................................................... 11
sirolimus ............................................................................... 65
SIRTURO ........................................................................... 16
SIVEXTRO ....................................................................... 16
SKELAXIN ....................................................................... 67
SKELID ................................................................................ 83
SKYLA .................................................................................. 50
SLOESTEROL .............................................................. 56
SMOOTHLAX .............................................................. 60
sodium chloride ............................................................. 83
sodium citrate-citric acid .................................... 56
sodium fluoride .............................................................. 56
sodium phenylbutyrate ........................................... 60
SODIUM POLYSTYRENE (SORB
FREE) ..................................................................................... 56
sodium polystyrene sulfonate .......................... 56
SOLARAZE ..................................................................... 26
SOLODYN ........................................................................ 16
SOLTAMOX ................................................................... 26
SOMA ..................................................................................... 67
SOMATULINE DEPOT ..................................... 64
SOMAVERT ................................................................... 83
SONATA ............................................................................. 74
SOOLANTRA ................................................................ 78
SORIATANE .................................................................. 78
sotalol ...................................................................................... 41
SOTALOL AF ............................................................... 41
SOTYLIZE ........................................................................ 41
SOVALDI ........................................................................... 30
SPECTRACEF .............................................................. 16
SPIRIVA RESPIMAT ........................................... 11
SPIRIVA WITH HANDIHALER .............. 11
spironolactone ................................................................ 52
spironolacton-hydrochlorothiaz ................... 52
SPORANOX .................................................................... 20
SPORANOX PULSEPAK ................................. 20
SPRINTEC (28) ............................................................ 50
SPRIX ........................................................................................ 6
SPRYCEL ........................................................................... 26
SPS ............................................................................................. 56
SRONYX ............................................................................. 50
SSKI ......................................................................................... 56
ST. JOSEPH ASPIRIN ............................................. 6
STALEVO 100 .............................................................. 28
STALEVO 125 .............................................................. 28
STALEVO 150 .............................................................. 28
STALEVO 200 .............................................................. 28
STALEVO 50 ................................................................. 28
STALEVO 75 ................................................................. 28
STARLIX ............................................................................ 24
stavudine .............................................................................. 30
STAVZOR ......................................................................... 45
STAXYN ............................................................................. 83
STELARA .......................................................................... 65
STENDRA ......................................................................... 83
STIMATE ........................................................................... 64
STIVARGA ...................................................................... 26
STRATTERA ................................................................. 73
STRIANT ............................................................................ 64
STRIBILD .......................................................................... 30
STRIVERDI RESPIMAT .................................. 11
STROMECTOL ........................................................... 24
SUBOXONE .................................................................... 83
SUBSYS .................................................................................. 6
SUCLEAR .......................................................................... 60
SUCRAID ........................................................................... 60
sucralfate ............................................................................. 60
SULAR .................................................................................. 37
sulfacetamide sodium .............................................. 16
sulfacetamide sodium-sulfur .................. 16, 17
sulfacetamide sod-sulfur-urea ........................ 17
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
sulfacetamide-prednisolone .............................. 17
sulfacetamide-sulfur-cleansr23 ..................... 17
sulfadiazine ........................................................................ 17
sulfamethoxazole-trimethoprim .................... 17
SULFAMYLON .......................................................... 17
sulfasalazine ..................................................................... 60
SULFAZINE .................................................................... 60
SULFAZINE EC ......................................................... 60
sulfisoxazole ..................................................................... 83
sulindac ................................................................................. 10
SUMADAN ...................................................................... 17
SUMADAN XLT ........................................................ 17
sumatriptan ........................................................................... 6
sumatriptan succinate ................................................ 6
SUMAVEL DOSEPRO ........................................... 6
SUMAXIN CP ............................................................... 17
SUPPRELIN LA .......................................................... 64
SUPRAX .............................................................................. 17
SUPRENZA ..................................................................... 27
SUPREP BOWEL PREP KIT ........................ 60
SURMONTIL ................................................................. 73
SUSTIVA ............................................................................ 30
SUTENT .............................................................................. 26
SYEDA .................................................................................. 50
SYLATRON .................................................................... 26
SYLATRON 4-PACK ........................................... 26
SYMBICORT ................................................................. 11
SYMBYAX ....................................................................... 73
SYMLIN .............................................................................. 24
SYMLINPEN 120 ...................................................... 24
SYMLINPEN 60 ......................................................... 24
SYNAGIS ........................................................................... 31
SYNALAR ........................................................................ 78
SYNALAR CREAM KIT .................................. 78
SYNALAR OINTMENT KIT ....................... 78
SYNALAR TS ............................................................... 78
SYNALGOS-DC ............................................................ 6
SYNAREL ......................................................................... 64
SYNERA ................................................................................. 8
SYNTHROID ................................................................. 80
SYPRINE ............................................................................ 83
TABLOID ........................................................................... 26
TACLONEX .................................................................... 83
TACLONEX SCALP .............................................. 83
tacrolimus ........................................................................... 65
TAFINLAR ....................................................................... 26
TAKE ACTION ........................................................... 50
TAMBOCOR .................................................................. 37
TAMIFLU .......................................................................... 31
tamoxifen .............................................................................. 26
tamsulosin ........................................................................... 83
TANZEUM ....................................................................... 24
TAPAZOLE ...................................................................... 80
TARCEVA ........................................................................ 27
TARGRETIN .................................................................. 27
TARKA ................................................................................. 41
TASIGNA ........................................................................... 27
TASMAR ............................................................................ 28
TAZORAC ........................................................................ 78
TAZTIA XT ..................................................................... 37
TEARS AGAIN HYDRATE .......................... 61
TECFIDERA ................................................................... 45
TEGRETOL ...................................................................... 45
TEGRETOL XR ........................................................... 45
TEKAMLO ....................................................................... 41
TEKTURNA .................................................................... 41
TEKTURNA HCT ..................................................... 41
telmisartan .......................................................................... 41
telmisartan-amlodipine ......................................... 41
telmisartan-hydrochlorothiazid .................... 41
temazepam .......................................................................... 74
TEMODAR ....................................................................... 27
TEMOVATE ................................................................... 78
temozolomide ................................................................... 27
TENEX .................................................................................. 41
TENORETIC 100 ....................................................... 41
TENORETIC 50 ........................................................... 41
TENORMIN ..................................................................... 41
TERAZOL 3 ..................................................................... 20
TERAZOL 7 ..................................................................... 20
terazosin ............................................................................... 41
terbinafine hcl ................................................................. 20
TERBINEX ....................................................................... 20
terconazole ......................................................................... 20
TESSALON PERLES ............................................ 51
TESTIM ................................................................................ 64
testosterone .............................................................. 64, 65
testosterone cypionate ............................................ 64
testosterone enanthate ............................................ 64
tetracycline ........................................................................ 17
TEVETEN .......................................................................... 41
TEVETEN HCT ........................................................... 41
TEV-TROPIN ................................................................. 65
THALOMID .................................................................... 17
THEO-24 ............................................................................. 11
THEOCHRON ............................................................... 11
theophylline ....................................................................... 11
THERAMINE ................................................................. 83
thioridazine ........................................................................ 73
thiothixene .......................................................................... 73
thyroid ..................................................................................... 80
THYROLAR-1 .............................................................. 80
THYROLAR-1/2 ......................................................... 80
THYROLAR-1/4 ......................................................... 80
THYROLAR-2 .............................................................. 80
THYROLAR-3 .............................................................. 80
tiagabine ............................................................................... 45
TIAZAC ................................................................................ 37
ticlopidine ........................................................................... 29
TIGAN ................................................................................... 60
TIKOSYN ........................................................................... 37
TILIA FE ............................................................................. 50
timolol maleate .................................................... 41, 55
TIMOPTIC ........................................................................ 55
TIMOPTIC-XE ............................................................. 55
TINDAMAX .................................................................... 24
TIROSINT .......................................................................... 80
TIVICAY ............................................................................. 31
TIVORBEX ...................................................................... 10
tizanidine .............................................................................. 67
TOBI ........................................................................................ 17
TOBI PODHALER ................................................... 17
TOBRADEX .................................................................... 17
TOBRADEX ST .......................................................... 17
tobramycin in 0.225 % nacl .............................. 17
TOBREX ............................................................................. 17
TODAY CONTRACEPTIVE SPONGE
......................................................................................................... 50
99
TOFRANIL ....................................................................... 73
TOFRANIL-PM ........................................................... 73
tolazamide ........................................................................... 24
tolbutamide ........................................................................ 24
tolcapone .............................................................................. 28
tolmetin .................................................................................. 10
tolterodine ........................................................................... 83
TOPAMAX ....................................................................... 45
TOPICORT ....................................................................... 78
TOPIRAGEN .................................................................. 45
topiramate ........................................................................... 45
TOPROL XL ................................................................... 42
torsemide .............................................................................. 52
TOUJEO SOLOSTAR ........................................... 24
TOVIAZ ............................................................................... 83
TOZAL .................................................................................. 83
TRACLEER ..................................................................... 42
TRADJENTA ................................................................. 24
tramadol ............................................................................ 6, 7
tramadol-acetaminophen ........................................ 7
TRANDATE .................................................................... 42
trandolapril ....................................................................... 42
TRANSDERM-SCOP ............................................ 60
TRANXENE T-TAB ............................................... 73
tranylcypromine ............................................................ 73
TRAVATAN Z .............................................................. 55
travoprost (benzalkonium) ................................. 55
trazodone ............................................................................. 73
TRECATOR ..................................................................... 17
TRENTAL .......................................................................... 34
TREPADONE (WITH BROMELAIN)
......................................................................................................... 10
tretinoin ................................................................................. 78
tretinoin (chemotherapy) ..................................... 27
tretinoin microspheres ........................................... 78
TRETIN-X ......................................................................... 78
TRETIN-X (GEL) ...................................................... 78
TRETIN-X CREAM KIT ................................... 78
TRETTEN .......................................................................... 34
TREXIMET .......................................................................... 7
TREZIX .................................................................................... 7
triamcinolone acetonide ............................. 55, 78
triamterene-hydrochlorothiazid .................... 52
triazolam .............................................................................. 74
TRIBENZOR ................................................................... 42
TRICARE PRENATAL DHA ONE ....... 68
TRICITRATES ............................................................. 56
TRICOR ............................................................................... 42
TRI-ESTARYLLA .................................................... 50
trifluoperazine ................................................................ 73
trifluridine ........................................................................... 31
TRIGLIDE ......................................................................... 42
trihexyphenidyl .............................................................. 28
TRI-LEGEST FE ......................................................... 50
TRILEPTAL .................................................................... 45
TRI-LINYAH ................................................................. 50
TRILIPIX ............................................................................ 42
TRILYTE WITH FLAVOR PACKETS
......................................................................................................... 60
trimethobenzamide ..................................................... 60
trimethoprim ..................................................................... 17
trimipramine ..................................................................... 73
TRINATE ........................................................................... 68
TRINESSA (28) ........................................................... 50
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
100
TRI-NORINYL (28) ................................................ 50
TRIOXIN ............................................................................. 17
TRI-PREVIFEM (28) ............................................. 50
TRI-SPRINTEC (28) ............................................... 50
TRIUMEQ .......................................................................... 31
TRI-VI-FLOR ................................................................. 85
TRIVORA (28) .............................................................. 50
TRIZIVIR ........................................................................... 31
TROKENDI XR ........................................................... 45
trospium ................................................................................ 83
TRUETEST TEST STRIPS ............................. 51
TRUETRACK TEST .............................................. 51
TRULICITY ..................................................................... 24
TRUMENBA ................................................................... 34
TRUSOPT .......................................................................... 55
TRUVADA ....................................................................... 31
TUDORZA PRESSAIR ....................................... 11
TUSSICAPS ..................................................................... 51
TUSSIONEX PENNKINETIC ER ........... 51
TWYNSTA ....................................................................... 42
TYBOST .............................................................................. 83
TYKERB ............................................................................. 27
TYLENOL ............................................................................. 7
TYLENOL-CODEINE #3 ..................................... 7
TYLENOL-CODEINE #4 ..................................... 7
TYLOX ..................................................................................... 7
TYVASO ............................................................................. 42
TYVASO REFILL KIT ........................................ 42
TYVASO STARTER KIT ................................. 42
TYZEKA ............................................................................. 31
UCERIS ................................................................................ 65
ULESFIA ............................................................................. 78
ULORIC ............................................................................... 10
ULTIMATE OB DHA ........................................... 68
ULTRACET ........................................................................ 7
ULTRAM ............................................................................... 7
ULTRAM ER ..................................................................... 7
ULTRAVATE ................................................................ 78
ULTRAVATE PAC ................................................. 78
ULTRAVATE X ......................................................... 78
ULTRESA .......................................................................... 60
UNIRETIC ......................................................................... 42
UNITHROID ................................................................... 80
UNIVASC .......................................................................... 42
URECHOLINE ............................................................. 33
UROCIT-K 10 ................................................................ 56
UROCIT-K 15 ................................................................ 56
UROCIT-K 5 ................................................................... 56
UROXATRAL ............................................................... 83
URSO 250 .......................................................................... 61
URSO FORTE ............................................................... 61
ursodiol .................................................................................. 61
VAGIFEM .......................................................................... 65
VAGINAL CONTRACEPTIVE FILM
......................................................................................................... 50
VAGINAL CONTRACEPTIVE FOAM
......................................................................................................... 50
valacyclovir ....................................................................... 31
VALCHLOR .................................................................... 27
VALCYTE ......................................................................... 31
valganciclovir ................................................................. 31
VALIUM ............................................................................. 73
valproic acid ..................................................................... 45
valproic acid (as sodium salt) ........................ 45
valsartan ............................................................................... 42
valsartan-hydrochlorothiazide ...................... 42
VALTREX ......................................................................... 31
VANCOCIN ..................................................................... 17
vancomycin ........................................................................ 17
VANDAZOLE ............................................................... 17
VANOS ................................................................................. 78
VANOXIDE-HC ......................................................... 78
VASCAZEN .................................................................... 61
VASCEPA .......................................................................... 61
VASCULERA ................................................................ 85
VASERETIC ................................................................... 42
VASOTEC ......................................................................... 42
VAYACOG ....................................................................... 83
VAYARIN ......................................................................... 83
VAYAROL ....................................................................... 42
VCF CONTRACEPTIVE FILM ................. 50
VECAMYL ....................................................................... 42
VECTICAL ....................................................................... 78
VELIVET TRIPHASIC REGIMEN (28)
......................................................................................................... 50
VELPHORO .................................................................... 56
VELTIN ................................................................................ 78
venlafaxine ......................................................................... 73
VENTAVIS ....................................................................... 42
VENTOLIN HFA ....................................................... 11
VERAMYST ................................................................... 55
verapamil ............................................................................. 37
VERDESO ......................................................................... 79
VEREGEN ......................................................................... 31
VERELAN ......................................................................... 37
VERELAN PM .............................................................. 37
VERSACLOZ ................................................................. 73
VESICARE ....................................................................... 83
VESTURA (28) ............................................................ 50
VEXOL ................................................................................. 55
VFEND .................................................................................. 20
VIAGRA .............................................................................. 83
VIBRAMYCIN ............................................................. 17
VICODIN ............................................................................... 7
VICODIN ES ...................................................................... 7
VICODIN HP ..................................................................... 7
VICOPROFEN ................................................................. 7
VICTOZA 2-PAK ...................................................... 24
VICTOZA 3-PAK ...................................................... 24
VICTRELIS ...................................................................... 31
VIDEX 2 GRAM PEDIATRIC .................... 31
VIDEX 4 GRAM PEDIATRIC .................... 31
VIDEX EC ......................................................................... 31
VIEKIRA PAK .............................................................. 31
VIGAMOX ........................................................................ 17
VIIBRYD ............................................................................ 73
VIMOVO ............................................................................. 10
VIMPAT .............................................................................. 45
VINATE DHA ............................................................... 68
VINATE DHA RF ..................................................... 68
VINATE PN CARE .................................................. 68
VIOKACE .......................................................................... 61
VIORELE (28) ............................................................... 50
VIRACEPT ....................................................................... 31
VIRAMUNE .................................................................... 31
VIRAMUNE XR ......................................................... 31
VIREAD ............................................................................... 31
VIROPTIC ......................................................................... 31
VIRT-CAPS ..................................................................... 85
VIRT-VITE FORTE ................................................ 85
VISTARIL .......................................................................... 21
VITACIRC-B .................................................................. 85
VITAMEDMD REDICHEW RX ............... 68
VITAMIN D3 ................................................................. 85
VITAPEARL ................................................................... 68
VITA-RESPA ................................................................. 85
VITEKTA ........................................................................... 31
VITUZ .................................................................................... 51
VIVA DHA ....................................................................... 68
VIVACTIL ........................................................................ 73
VIVELLE ............................................................................ 65
VIVELLE-DOT ............................................................ 65
VOGELXO ........................................................................ 65
VOLTAREN .......................................................... 55, 79
VOLTAREN-XR ......................................................... 10
voriconazole ...................................................................... 20
VOSOL-HC ...................................................................... 55
VOSPIRE ER .................................................................. 11
VOTRIENT ....................................................................... 27
VP-GSTN ............................................................................ 56
VP-PRECIP ....................................................................... 61
VSL#3 ..................................................................................... 61
VSL#3 DS .......................................................................... 61
VSL#3 JUNIOR ........................................................... 61
VYTORIN 10-10 ......................................................... 42
VYTORIN 10-20 ......................................................... 42
VYTORIN 10-40 ......................................................... 42
VYTORIN 10-80 ......................................................... 42
VYVANSE ........................................................................ 73
warfarin ................................................................................. 18
WELCHOL ....................................................................... 42
WELLBUTRIN ............................................................. 73
WELLBUTRIN SR ................................................... 73
WELLBUTRIN XL .................................................. 73
WERA (28) ........................................................................ 50
WESTCORT .................................................................... 79
WESTHROID ................................................................. 80
WIDE-SEAL DIAPHRAGM 60 ................. 50
WIDE-SEAL DIAPHRAGM 65 ................. 50
WIDE-SEAL DIAPHRAGM 70 ................. 50
WIDE-SEAL DIAPHRAGM 75 ................. 50
WIDE-SEAL DIAPHRAGM 80 ................. 50
WIDE-SEAL DIAPHRAGM 85 ................. 50
WIDE-SEAL DIAPHRAGM 90 ................. 50
WIDE-SEAL DIAPHRAGM 95 ................. 50
WILATE .............................................................................. 34
WINRHO SDF ............................................................... 34
WYMZYA FE ................................................................ 50
XALATAN ........................................................................ 55
XALKORI .......................................................................... 27
XANAX ................................................................................ 73
XANAX XR ..................................................................... 73
XARELTO ......................................................................... 18
XARTEMIS XR .............................................................. 7
XELJANZ ........................................................................... 10
XELODA ............................................................................. 27
XENAZINE ...................................................................... 45
XENICAL ........................................................................... 27
XERAC AC ...................................................................... 79
XIFAXAN .......................................................................... 17
XIGDUO XR ................................................................... 24
XODOL 10/300 ................................................................ 7
2015 Coventry Health Prescription Drug List
(Updated 07/01/2015)
XODOL 5/300 ................................................................... 7
XODOL 7.5/300 .............................................................. 7
XOLEGEL ......................................................................... 20
XOPENEX ......................................................................... 11
XOPENEX CONCENTRATE ...................... 11
XOPENEX HFA .......................................................... 11
XTANDI .............................................................................. 27
XULANE ............................................................................. 50
XYNTHA ............................................................................ 34
XYNTHA SOLOFUSE ........................................ 34
XYREM ................................................................................ 74
XYZAL ................................................................................. 21
YASMIN (28) ................................................................. 50
YAZ (28) ............................................................................. 50
YODOXIN ......................................................................... 24
ZADITOR ........................................................................... 21
zafirlukast ............................................................................ 11
ZAMICET .............................................................................. 7
ZANAFLEX ..................................................................... 67
ZANTAC ............................................................................. 61
ZANTAC 25 EFFERDOSE ............................. 61
ZARAH ................................................................................. 50
ZARONTIN ...................................................................... 45
ZAROXOLYN .............................................................. 52
ZAVESCA ......................................................................... 83
ZEBETA .............................................................................. 42
ZEGERID ........................................................................... 61
ZEGERID OTC ............................................................ 61
ZELAPAR .......................................................................... 28
ZELBORAF ..................................................................... 27
ZEMPLAR ......................................................................... 83
ZENATANE .................................................................... 79
ZENCHENT (28) ........................................................ 51
ZENCHENT FE ........................................................... 51
ZENPEP ............................................................................... 61
ZENZEDI ............................................................................ 33
ZEOSA .................................................................................. 51
ZERIT ..................................................................................... 31
ZESTORETIC ................................................................ 42
ZESTRIL ............................................................................. 42
ZETIA ..................................................................................... 42
ZETONNA ........................................................................ 55
ZIAC ........................................................................................ 42
ZIAGEN ............................................................................... 31
ZIANA ................................................................................... 79
zidovudine ........................................................................... 31
ZIOPTAN (PF) .............................................................. 55
ziprasidone hcl ............................................................... 73
ZIPSOR .................................................................................... 7
ZIRGAN ............................................................................... 31
ZITHRANOL .................................................................. 79
ZITHROMAX ................................................................ 17
ZITHROMAX TRI-PAK .................................... 18
ZITHROMAX Z-PAK ........................................... 18
ZMAX .................................................................................... 18
ZOCOR ................................................................................. 42
ZOFRAN (AS HYDROCHLORIDE) .... 61
ZOFRAN ODT .............................................................. 61
ZOHYDRO ER ................................................................. 7
ZOLINZA ........................................................................... 27
zolmitriptan ........................................................................... 7
ZOLOFT .............................................................................. 73
zolpidem ................................................................................ 74
ZOLPIMIST ..................................................................... 74
ZOMACTON .................................................................. 65
ZOMIG ..................................................................................... 7
ZOMIG ZMT ...................................................................... 7
ZONATUSS ..................................................................... 51
ZONEGRAN ................................................................... 45
zonisamide .......................................................................... 46
ZONTIVITY .................................................................... 29
ZORBTIVE ....................................................................... 65
ZORTRESS ....................................................................... 66
ZORVOLEX .................................................................... 10
ZOVIA 1/35E (28) ..................................................... 51
ZOVIA 1/50E (28) ..................................................... 51
ZOVIRAX .......................................................................... 31
Z-PRAM ............................................................................... 61
ZUBSOLV ......................................................................... 83
ZUPLENZ .......................................................................... 61
ZUTRIPRO ....................................................................... 51
ZYBAN ................................................................................. 79
ZYCLARA ........................................................................ 79
ZYDELIG ........................................................................... 27
ZYFLO .................................................................................. 11
ZYFLO CR ........................................................................ 11
ZYKADIA .......................................................................... 27
ZYLET ................................................................................... 18
ZYLOPRIM ...................................................................... 10
ZYMAXID ........................................................................ 18
ZYPRAM ............................................................................ 61
ZYPREXA ......................................................................... 73
ZYPREXA ZYDIS .................................................... 73
ZYRTEC .............................................................................. 21
ZYRTEC-D ....................................................................... 20
ZYTAZE .............................................................................. 83
ZYTIGA ............................................................................... 27
ZYVOX ................................................................................. 18
101