Enrollment
› › Guide
Coventry Highlights
Large Provider Network
Coventry Health Care (“Coventry”) has an extensive network of physicians, hospitals and health care
providers. Coventry’s high-quality, cost-effective provider network has thousands of physicians and
hundreds of hospitals available. Go online to www.chcoklahoma.com and use our Provider Search tool
to find out more.
Premier Customer Service
Coventry’s customer service and claims paying is among the strongest in the nation. Our team of extensively
trained customer service representatives delivers courteous service, accurate claims payment, as well as
efficient claims turnaround for physicians, hospitals and members. Members can also use secure, password-
protected tools on our website, www.chcoklahoma.com, to order ID cards, change personal information,
view the status of claims and much more.
Proactive Health Management
The Coventry medical management and case management teams work to improve the health and
well-being of those with chronic conditions and severe health issues through education and partnership
with physicians.
Value-Added Programs
Coventry partners with vendors to offer special programs to our members. For example:
• Coventry WellBeingSM offers a full suite of interactive web-based self-care and wellness resources. From
personalized exercise programs and online coaching to educational libraries for children, members are
sure to find valuable information to enhance their lives.
• GlobalFit™ Fitness offers substantial discounts on memberships to a broad range of fitness clubs, making
it easier than ever to stay on your exercise program — or to start a new one.
• EyeMed Vision Care® provides discounts on glasses, contact lenses and eye examinations obtained
through participating optometrists.
• QualSight® offers discounts on LASIK vision correction procedures.
www.chcoklahoma.com • 1
Table of Contents
Make the Most of Your Health and Benefits
Use Online Tools ..............................................................................................................................................................................................3
Find a Provider Online........................................................................................................................................................................................4
Make the Most of Your Health
Take Advantage of Health Management Programs
Coventry WellBeingSM Program ......................................................................................................................................................................5
Make the Most of Your Prescription Benefits
Understanding the Program
Brand-name and Generic Drugs ....................................................................................................................................................................9
About Your Formulary .......................................................................................................................................................................................9
2011 Member/Physician Drug Formulary List ....................................................................................................................................... 11
Important Member Notices ..................................................................................................................................................... 22
How to Contact Us
Once you have registered for My Online ServicesSM, you can send us a secure e-mail by going
to our website, www.chcoklahoma.com.
Customer Service — 866-219-7695
Pharmacy Help Desk — 800-922-1557
EyeMed Customer Care Center — 866-723-0391
Behavioral Health and Substance Abuse Services — 866-607-5970
Net Support Team — 866-213-0807
2 • www.chcoklahoma.com
Make the Most of Your Health and Benefits
Use Online Tools
Our website, www.chcoklahoma.com, has a wealth of information that's just a few clicks away. Access it
whenever it's convenient to you.
My Online ServicesSM is the password-protected member section of the Coventry Health Care website. This
section of the website puts you in control of your health benefits and makes it easier for you to find, use and
control personal health and benefits information.
Access everything you need from a single screen. Take a look at these features:
Personal Health Record (PHR)
• View, store, track and maintain personal
health information
• Print and share with your health care
provider, family member or caregiver
Member Transactions
• View medical/prescription claims
• View Explanation of Benefits (EOBs)
• View/order member ID card
• Secure messaging
Member Health Care
• Health Risk Assessment
• Calendars and reminders
• Coventry WellBeingSM — online
wellness programs
• Disease management information
Cost-saving Tools
• Provider search
• Provider cost
• Procedure cost
• Pharmacy tools
Please note: Your personal health
information is private. That is why you,
personally, should register for My Online
Services. A supervisor, colleague or human
resources contact should not register
on your behalf and have access to your
To register for My Online Services visit
personal health information.
www.chcoklahoma.com. Select "Log In
or Register Now" under "My Online Services"
and follow the steps given to register.
www.chcoklahoma.com • 3
Use Online Tools Make the Most of Your Health and Benefits
Find a Provider Online
Need to find a provider? Our online provider search gives you flexibility in a simple format. We update the
online search weekly. No login is necessary. Just click on the “Locate a Provider” link on the opening page
of our website at www.chcoklahoma.com. Make sure you choose the search tool that applies to the
plan your employer offers: PPO or an out-of-area plan using the Coventry Health Care National Network.
• User-friendly design — makes it easier for you to input search criteria and view results.
• Interactive map and driving directions — based on search criteria, this feature populates a map and
allows you to enter a starting address to obtain directions.
• Condition-based search — allows you to search based on a condition such as diabetes or asthma and
find a provider that specializes in treating the condition.
• Additional search criteria — allows you to search for languages spoken, gender or hospital affiliation.
• Save search criteria — allows you to rename, view or delete previous searches.
Personalize Your Results
• Create a personal provider directory based on search criteria you enter. Click on the “Create a Directory”
icon that displays at the top of the screen when your provider search is complete.
• Search by county and receive a report by e-mail of all providers in that county.
• Search for doctors by location, name or specialty.
• Create a short list of physicians and perform side-by-side comparisons.
If you don’t have access to the Internet, our friendly customer service representatives are available to
assist you. Call toll-free: 866-219-7695.
Our Net Support Team is available weekdays from 7:00 a.m. until 5:00 p.m., CST if
you need helpful guidance or have forgotten or misplaced your login or password.
Call 866-213-0807.
4 • www.chcoklahoma.com
Make the Most of Your Health
Take Advantage of Health Management Programs
Helping you maintain and improve your health is a key goal of Coventry Health Care. We know that no two
members will have the same health care needs so we offer a wide range of services.
If you are generally healthy, our focus is on preventive care and maintaining your health. We encourage
you to visit a PCP for routine and preventive care. This care can help identify medical problems before they
become serious or life-threatening. Also, it may prevent future problems.
Coventry WellBeingSM Program
Our self-care and wellness program, Coventry WellBeing*, can help you make meaningful lifestyle changes
to your diet, fitness level and emotional well-being. Coventry WellBeing makes wellness fun by providing
rewards for participation.
Take a Health Risk Assessment
Many diseases can be minimized by taking steps toward a healthier lifestyle. The first step is to know how
healthy you truly are. That is the starting point for long-lasting healthy behaviors.
To help you, we offer a Health Risk Assessment (HRA) through our Coventry WellBeing program. The HRA is
available to each enrolled family member age 18 or older.
When you take the HRA, you will be asked questions about your personal medical history. You will also be
asked questions about your lifestyle choices. After you complete the HRA, you will receive an immediate
confidential report. The report defines your potential risk factors and offers preventive steps that can be
taken to improve your quality of life. You can take the HRA every six months.
Online Health Management
Once you have identified your top risks and discussed your health status with your doctor, you may be ready
for any of a variety of personal health improvement initiatives we provide. Our online health and wellness
program promotes physical fitness, healthy eating habits and life balance for people of all ages. You can
create highly personalized plans to help achieve goals in the areas of fitness, nutrition and life skills.
Online program tracking and coaching services provide you with ongoing support and motivation to reach
your wellness goals. With Online Health Management, Coventry Health Care members enjoy personalized
access to:
• Customized cardiovascular, strength and flexibility plans built for each member.
• Personalized nutrition plans and meal planner providing menus and shopping lists, and calorie and food
servings tracker.
• Personal self-improvement programs focusing on community and core values, life-skills management and
life challenges assessments.
Because the Health Risk Assessment and Online Health Management are offered exclusively for our members,
you must log in to My Online Services and click on “Wellness Tools” to take advantage of these features.
*From time to time, Coventry Health Care may offer to provide members access to discounts on health care-related goods or services such as
those offered through WellBeing. These services are being offered by a third-party vendor and Coventry Health Care is not liable for the provision
of these services, the failure to provide services or the negligent provision of these services. These services are subject to modification or
discontinuance without notice.
www.chcoklahoma.com • 5
Take Advantage of Health Management Programs Make the Most of Your Health
KidsHealth®
Keeping kids healthy and happy can be challenging, and that is why we teamed with KidsHealth. KidsHealth
educates families and helps them make informed decisions about their children’s health. KidsHealth is a fun
and engaging way to:
• Encourage preventive behaviors
• Encourage kids and teens to become involved in their health
KidsHealth consists of three sites in one: parents, kids and teens. For parents, KidsHealth offers hot topics
and news, recipes, a Q&A section and other information aimed at helping parents understand the health
issues that may affect their children. Condition Centers provide information, tools and practical advice to
help both newly diagnosed individuals and families with ongoing disease management issues. For children,
KidsHealth provides engaging, interactive content such as peer stories and articles on staying healthy in a
fun format for kids. Teens can choose from a wide array of emotional and developmental content.
Wellness Reminders
Coventry sends members reminders about important preventive services. Examples include flu shots,
immunizations and mammography screening reminders.
FirstHelpTM
Coventry offers a round-the-clock nurse call line that provides information to members seeking guidance
on wellness or health-related issues. If FirstHelp is offered as part of your benefits, the telephone number
appears on the member ID card.
FirstHelp Audio Library
Members can call and listen to pre-recorded health and wellness information 24 hours a day.
GlobalFit™ Fitness
GlobalFit offers substantial discounts on memberships to a broad range of fitness clubs, making it easier than
ever to stay on your exercise program — or to start a new one.
EyeMed Vision Care®
EyeMed Vision Care provides discounts on glasses, contact lenses and eye examinations obtained through
participating optometrists. Coventry Health Care members now have new options to save on eyewear through
a materials discount program offered by EyeMed Vision Care.
Accessing Your Vision Care Discount
EyeMed makes it as easy as 1-2-3 to protect your vision.
1. Locate a provider by visiting www.eyemedvisioncare.com. On the homepage, you can select the
Locate a Provider feature and choose the SELECT network to view your providers. You can also locate
providers and review your discount by clicking on the Members tab, Log-In/Register, then click on the
letter "C". Once there you can choose your Coventry plan and then select the option to locate a provider.
2. Schedule an appointment with a simple phone call. Or stop by one of the many providers who offer
walk-in appointments. Inform the office that you are a Coventry Health Care member with an EyeMed
discount plan when you wish to use your discount.
3. Present your Coventry Health Care ID Card when you arrive so the EyeMed provider knows you have a
Coventry Health Care vision discount.
6 • www.chcoklahoma.com
Make the Most of Your Health Take Advantage of Health Management Programs
Vision Discounts — Coventry also gives you access to discounts on vision services as shown below:
Vision Care Services Member Cost
Exam with Dilation as Necessary $50
Complete pair of glasses purchase*: frame, lenses and lens options must be purchased
in the same transaction to receive full discount.
Standard Plastic Lenses:
Single Vision $50
Bifocal $70
Trifocal $105
Frames:
Any frame available at provider location 40% off retail price
Lens Options:
UV Coating $15
Tint (Solid and Gradient) $15
Standard Scratch-Resistance $15
Standard Polycarbonate $40
Standard Progressive (Add-on to Bifocal) $65
Standard Anti-Reflective Coating $45
Other Add-ons and Services 20% discount
Contact Lens Materials:
(Discount applied to materials only)
Disposable 0% off retail price
Conventional (Non-disposable) 15% off retail price
Laser Vision Correction**:
LASIK or PRK 15% off retail price OR 5% off promotional price
Frequency:
Examination Unlimited
Frame Unlimited
Lenses Unlimited
Contact Lenses Unlimited
THIS IS NOT INSURANCE.
*Items purchased separately will be discounted 20% off of the retail price.
**Members also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US Laser Network, owned and operated by LCA vision. Since
LASIK or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your
location. For a location near you and the discount authorization, please call 1-877-5LASER6.
Member will receive a 20% discount on those items purchased at participating providers that are not specifically covered by this discount design. The 20%
discount may not be combined with any other discounts or promotional offers, and the discount does not apply to EyeMed provider’s professional services or
contact lenses. Retail prices may vary by location.
This Discount design is offered with the EyeMed Select panel of providers and is based on a 24-month contract term.
Limitations/Exclusions:
• Orthoptic or vision training, subnormal vision aids and any associated supplemental testing
• Medical and/or surgical treatment of the eye, eyes or supporting structures
• Corrective eyeware required by an employer as a condition of employment and safety eyeware unless specifically covered under plan
• Services provided as a result of any Workers’ Compensation law
• Discount is not available on frames for which the manufacturer prohibits a discount Plan # 9240128
www.chcoklahoma.com • 7
Take Advantage of Health Management Programs Make the Most of Your Health
Choice and Convenience
The EyeMed SELECT network offers you the choice of leading optical retailers including LensCrafters, Pearle
Vision, Sears Optical, Target Optical, JCPenney Optical, as well as thousands of private practitioners, all near
where you work and shop.
Preferred LASIK Pricing from QualSight®
QualSight offers a laser vision correction program that is easily accessible and affordable for the millions of
Americans who could benefit from the LASIK procedure. QualSight’s mission is to provide affordable access
to laser vision correction through a national network of credentialed, board-certified ophthalmologists.
Savings are substantial — 40 to 50 percent off the overall national average price for LASIK.
To obtain preferred pricing, call 877-213-3937. A QualSight Care Manager will explain the benefit and
answer any questions.
The QualSight program is not an insured benefit. The QualSight program is available to members to provide access to QualSight preferred pricing for LASIK
surgery. Members are responsible for all costs associated with LASIK services.
Behavioral Health and Substance Abuse Benefits
Coventry provides mental health and substance abuse services through MHNet Behavioral Health. Coventry
and MHNet work with you to address behavioral health issues and to improve your well-being.
MHNet provides confidential support and treatment through a network of licensed and certified
professionals, covering a variety of specialties to address your emotional wellness needs.
Your behavioral health benefit provides you support for a wide range of concerns, such as:
• Managing stress • Anxiety
• Depression • Mental disorders
• Eating disorders • Physical abuse
• Coping with grief and loss • Schizophrenia
• Alcohol or drug dependency • Mood disorders
• Anger management • Compulsive gambling
If you have questions about your behavioral health and/or you would like to request services, please
call 866-607-5970. This number is also on your member ID card. Experienced MHNet personnel are
available around the clock, and calls are kept confidential. You can learn more about MHNet by visiting
www.MHNet.com.
You will be connected with an experienced Behavioral Health Specialist who will help you determine the
type(s) of service you need. Based on your needs, the MHNet Specialist will refer you to a behavioral health
provider. MHNet will provide all the information you need to schedule an appointment and ensure you
receive the services you need to address your behavioral health concerns.
8 • www.chcoklahoma.com
Make the Most of Your Prescription Benefits
Understanding the Program
Formulary, brand-name drug, generic drug. These can be confusing terms. The following information will help
you get the maximum value from your prescription drug benefit.
Brand-name and Generic Drugs
The greatest difference between brand-name and generic drugs is the name. When a drug company
develops a new drug, that drug must be approved by the U.S. Food and Drug Administration (FDA). Once
approved, the company has the exclusive right to sell the drug and profit from the investment it made in
research, testing and advertising. The exclusive selling time can last several years.
When that right runs out, other companies can make and sell the medicine. They can sell it under the
generic name but not under the brand name. Since these companies don’t have to cover the same research
and advertising costs, they can sell the medicine at a lower price.
To get the greatest value from your prescription drug benefit, the next time your doctor prescribes a
medication for you, be sure to ask if a generic is available and appropriate.
About Your Formulary
A formulary is a list of preferred medications available through your pharmacy benefit. Medical Directors
and pharmacists develop the list of preferred medications based on effectiveness, safety, cost and
recommendations from community doctors.
If you or your prescribing physician selects a medication that is not on the formulary, you may still purchase
that prescription. However, you will share in a greater portion of the cost.
If you would like to know if a drug you are taking is on the formulary, you can find this information in this
guide and online at www.chcoklahoma.com. You can also contact your benefits office or call Customer
Service at 866-219-7695.
Shown below is an example of a prescription benefit plan. The example is for illustrative purposes only. Please
consult your Pharmacy Rider for your exact copayments and benefits. Generic drugs are not available for every
prescription, but when they are, you’re sure to save.
Copayment as shown on the Pharmacy
Category of drug dispensed: Definition:
Rider you received with this packet:
If a formulary generic prescription is You pay the lowest-tier copayment shown
Generic prescription
dispensed. on the Pharmacy Rider.
Formulary Brand-Name If a formulary brand-name drug is
You pay the middle-tier copayment shown
prescription — no Generic dispensed and there is no generic
on your Pharmacy Rider.
available equivalent available.
Any nonformulary prescription drug is You pay the nonformulary copayment shown
Any Nonformulary prescription
dispensed. on your Pharmacy Rider.
You pay the brand-name copayment or the
If a formulary brand-name drug or nonformulary copayment (whichever is
a nonformulary brand-name drug is applicable) shown on your Pharmacy Rider
Brand-Name prescription—
dispensed at the request of the member plus the difference between the average
Generic available
or physician, and there is a generic wholesale price of the brand-name
available. prescription drug and the allowed cost of
the generic drug.
www.chcoklahoma.com • 9
Understanding the Program Make the Most of Your Prescription Benefits
Mail Order
The prescription drug benefit may include a mail-order drug program that allows you to obtain up to
a ninety-three (93) day supply of certain drugs. It’s a convenient way to get the medications you need
delivered right to you. Check your benefit documents for copayment information and limitations. You can fill
your mail-order prescription by following these easy steps.
1. Ask your doctor to specifically write your prescription for a three-month supply (versus a one-month
supply with refills). Be sure your doctor actually signs the prescription (versus using a signature stamp).
2. Complete a mail-order pharmacy form. You can get one online at www.chcoklahoma.com or by calling
Customer Service.
3. Send the completed form, along with your written prescription for a three-month supply of the
medication, to the address found on the form.
4. Please note that you will need to allow approximately two (2) weeks for delivery. If you need your
prescription filled before that time, please consider using a retail pharmacy in the meantime.
5. Once you have your initial prescription filled through the mail-order service, refills may be ordered online,
through the mail or by phone.
Please note: Not all drugs can be obtained through a mail-order program. Contact our Customer Service
department for more information.
Important points to remember when accessing your pharmacy benefits
• You must use your ID card or have your membership information available to fill a prescription.
You may only file a claim for reimbursement for a prescription after it was purchased if it is a true
emergency. We may make an exception if you have not yet received your ID card but need to fill a
prescription.
• If “PA” is listed on the formulary next to a drug, preauthorization is required. If preauthorization is not
received, your prescription may not be covered.
• Retail prescriptions must be filled at a participating pharmacy or a non-participating pharmacy
that has agreed to accept Medco’s reimbursement rate as payment in full. You pay the appropriate
copayment or the cost of the medication if it is less than the copayment. You also have a retail
maintenance benefit. Contact the Pharmacy Help Desk at 800-922-1557 for information regarding the
retail maintenance benefit.
• If you take specific maintenance medications on a regular basis, you may be eligible to get your
prescriptions filled through the mail-order program. The mail-order benefit allows up to a 90-day
supply to be delivered directly to your home. Coventry Health Care does not cover certain controlled
substances through the mail-order program. To find out about mail-order coverage, please call the
Pharmacy Help Desk at 800-922-1557.
10 • www.chcoklahoma.com
Member/Physician Reference
2011 Prescription Drug List
With our prescription drug plan, you have three options when a doctor gives you a prescription.
Generic (Tier One) - includes most generic and a few selected OTC (over-the-counter) drugs.
Formulary brand (Tier Two) - formulary brand-name drugs.
Nonformulary (Tier Three) - nonformulary brand-name, and a few nonformulary generic drugs.
These drugs may have a lower cost alternative on Tier One or Tier Two.
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed below are covered.
Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for
example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is
the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity
limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your
coverage or for more information.
Tier One Aranelle
Aspirin/butalbital/caffeine
Carvedilol (CR non-form, ST)
Cefaclor, CD
Clotrimazole Troche
Clozapine
Tier Three)
Doxycycline susp (syrup
A Aspirin/caff/butalbital/
codeine
Cefadroxil
Cefdinir
Codeine
Colchicine
Tier Three)
Acarbose Atenolol Cefprozil Colestipol E
Acebutolol Atenolol/chlorthalidone Cefuroxime Cromolyn sodium ophth Econazole cream/oint
Acetazolamide Atropine Cephalexin Cryselle EnaIapriI
Acetic acid ear drops Aviane Cesia Cyclobenzaprine (Amrix Enalapril HCTZ
Acetic acid-aluminum Azathioprine Cetirizine OTC (Requires not covered) Enoxaparin (PA,PAS)
acetate Azithromycin, XL Doctor’s Prescription) Cyclopentolate Enpresse
Acetohexamide Cetirizine D OTC (Requires Cyproheptadine Epinephrine HCI
Acetylcysteine B Doctor’s Prescription) ErgocaIciferol
Acyclovir (not ointment) Baclofen Chloral hydrate D Errin
Alavert (Requires Doctor’s Balsalazide Chlordiazepoxide (tab Dantrolene Erythromycin
Prescription) Balziva Tier Three) Desipramine Erythromycin/Benzoyl
Alaway (Requires Doctor’s Benazepril Chlordiazepoxide/clidinium Desmopressin acetate Peroxide
Prescription) Benazepril HCTZ Chloroquine Desogestrel-Ethinyl Estradiol Estradiol
Albuterol Benzonatate Chlorothiazide Desonide Estropipate
Albuterol/ipratropium Benzoyl peroxide/ Chlorphen/phenyleph/ Desoximetasone Ethosuximide
Alclometasone Dipropionate erythromycin methscop Dexamethasone Etodolac, XR
Alendronate Benztropine Chlorpromazine (spansule Dexchlorpheniramine
AIlopurinol Betamethasone (cream/oint) Tier Three) Dextroamphetamine F
AIprazolam, XR Betaxolol (ophth) Chlorpropamide Diazepam Famciclovir
Altoprev Bethanechol Chlorthalidone Diclofenac ophth soln Famotidine
Aluminum chloride Bicalutamide Cholestyramine Diclofenac potassium Felodipine
Amantadine Bisoprolol Fumarate Choline & magnesium Diclofenac sodium, XR Fenofibrate
Amiloride Bisoprolol HCTZ Ciclopirox Dicloxacillin Fenoprofen
Amiloride/HCTZ Bromocriptine Cilostazol Dicyclomine Fentanyl patch
Aminocaproic acid Brompheniramine- Cimetidine Diethylstilbestrol Finasteride
Amiodarone Pseudoephedrine Ciprofloxacin soln. Diflorasone diacetate Flavoxate
Amitriptyline Bumetanide Ciprofloxacin (XR Tier Diflunisal Flecainide
Amlodipine (ODT not covered) Bupropion, SR, XL Three) Digoxin Fluconazole (Susp PA)
Amlodipine/benazepril Buspirone Citalopram Diltiazem Fludrocortisone acetate
Amoxapine Citrate/citric acid Diphenoxylate-atropine Flunisolide
AmoxiciIIin C Clarithromycin, ER Dipivefrin Fluocinonide (topical)
Amoxicillin-potassium Calcitonin nasal spray Claritin OTC (Requires Dipyridamole Fluoride/polyvitamins for
clavulanate Calcitriol Doctor’s Prescription) Disopyramide children
Amphetamine/Dextroamphet Camila Claritin D-24 OTC (Requires DisuIfiram Fluoride/vitamins A,D,C for
(XR Tier Three, PA) Captopril Doctor’s Prescription) Divalproex Sodium (DR, ER) children
Ampicillin Captopril/HCTZ Clemastine 2.68mg Dorzolamide Fluorometholone
Anagrelide Carbamazepine, XR Clindamycin Doxazosin mesylate (XL FIuorouraciI
Anastrazole (PA, PAS) Carbidopa/levodopa Clobetasol (cream, oint) Tier Three) Fluoxetine (20mg tablet
Anthralin Carboptic Clomipramine Doxepin Tier Three)
APAP/Butalbital/Caffeine Carisoprodol Clonazepam Doxycycline (20mg, Fluphenazine
Apraclonidine Carisoprodol/aspirin Clonidine (TTS Tier Three) Adoxa, Doryx Flurazepam
Apri Carteolol soln. Clorazepate (SD Tier Three) not covered) (Oracea - Flurbiprofen
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed. Not available as 90-day supply
www.chcoklahoma.com • 11
Flurbiprofen sodium Lessina N Prilosec OTC 20mg Thioridazine
(ophth) Levetiracetam (XR Tier (Requires Doctor’s Thiothixene
Nabumetone
Flutamide Three, PA) Prescription) Ticlopidine
Nadolol
Fluticasone Propionate Levobunolol Primidone Timolol
Naltrexone
(nasal, cream, oint) Levodopa/carbidopa Probenecid Timolol maleate
Naproxen
(lotion Tier 3) Levora Prochlorperazine Tizanidine (caps not covered)
Naproxen sodium
Fluvoxamine Levothyroxine Promethazine Tobramycin
Naratriptan
Folic acid 1 mg Lidocaine viscous Propafenone HCI Tobramycin-Dexamethasone
Necon
Fosinopril Lidocaine/HC Propantheline (Tobra-Dex ST Susp Tier Three)
Neomycin
Fosinopril/HCTZ Lidocaine-prilocaine Propoxyphene Tolazamide
Neomycin/bacitracin
Furosemide Lindane lotion Propoxyphene HCI/APAP Tolbutamide
Nephazoline ophth
Liothyronine Propoxyphene napsylate/ Tolmetin
G LisinopriI
Next Choice (Requires
APAP Topiramate
Doctor’s Prescription)
Gabapentin LisinopriI/HCTZ Propranolol, LA Torsemide
Nifedipine XL
Ganciclovir Lithium Propylthiouracil Tramadol
Nimodipine
GemfibroziI Loratadine D-24 OTC ProtriptylineT Tramadol-acetaminophen
Nisoldipine
Gentamicin (not IV) (Requires Doctor’s Trandolapril
Glimepiride Prescription)
Nitrofurantoin Q Tranylcypromine
Nitroglycerin, all forms
Glipizide, XL Loratadine OTC Quasense Trazodone
Nizatidine
Glipizide/metformin (Requires Doctor’s QuinapriI Tretinoin (topical)
Nor-BE
Glyburide Prescription) QuinapriI/HCTZ Triamcinolone topical
Norethindrone acetate
Griseofulvin Lorazepam Quinidine (cream, lot., oint.)
Norgestrel-ethinyl estradiol
Guaifenesin/codeine Lovastatin Triamterene/HCTZ
Guanabenz acetate Low-Ogestrel
Nortrel R Triazolam
Nortriptyline
Guanfacine Loxapine Ramipril caps (tabs Tier Three) Trifluoperazine
Nystatin
Lutera Ranitidine (Gel & efferdose Trifluridine
H O Tier Three) Trihexyphenidyl
Halobetasol cream/oint M Rifampin Trimethobenzamide
Ocella
Haloperidol Maprotiline Riluzole Trimethoprim
Ofloxacin
HydraIazine Mebendazole (tablets, Rimantadine Trimethoprim-polymyxinB
Ogestrel
Hydrochlorothiazide cream) (ER Tier Three) Risperidone Trinessa
Omeprazole (See Prilosec OTC)
Hydrocodone/APAP Meclofenamate Ropinirole (XL Tier Three, ST) Tri-Previfem
Ondansetron, ODT
Hydrocodone/homatropine Medroxyprogesterone Tri-Sprintec
Hydrocodone/ibuprofen (tab, inj.)
Oxaprozin S Trivora
Oxazepam
Hydrocortisone Ace-Pramoxine Megestrol acetate Salsalate
Hydrocortisone tablets Meloxicam
Oxcarbazepine
Selegiline (patch Tier Three) U
Oxybutynin (XL Tier Three)
Hydromorphone HCI Meperidine Selenium sulfide 2.5% Ursodiol
Oxycodone IR (SR Tier
Hydroxychloroquine Mercaptopurine Sertraline
Hydroxyurea Mesalamine enema
Three, PA, PAS)
Silver sulfadiazine V
Hydroxyzine, pamoate Metaproterenol P Simvastatin Valacyclovir HCl
Hyoscyamine Metformin/Glyburide Sodium fluoride (drops, Valproic acid
Paromomycin
Metformin, XR tablets) Vancomycin inj.
I Methadone
Paroxetine (CR Tier Three, ST)
Sodium polystyrene Velivet
Penicillin VK
Ibuprofen Methazolamide sulfonate Venlafaxine IR (ST)
Pentoxifylline
Imipramine (PM Tier Three) Methenamine Sotalol Verapamil, SR (caps
Permethrin
Indapamide Methimazole Spironolactone Tier Three)
Perphenazine
Indomethacin, SR (not Methocarbamol Spironolactone/HCTZ
suppos.) Methotrexate (oral, inj)
Phenazopyridine
Sprintec W
Phenobarbital
Ipratropium (not inhaler) Methyldopa SucraIfate Warfarin
Phenytoin
Isonarif Methyldopa/HCTZ Sulfacetamide
Isoniazid Methylphenidate
Phenytoin Sodium Extended
Sulfacetamide/phenylephrine Z
Physostigmine sulfate
Isosorbide dinitrate Methylprednisolone Sulfacetamide prednisolone Zaditor OTC (Requires
Pilocarpine
Isosorbide mononitrate Metipranolol (ophth) Sulfacetamide/sulfur Doctor’s Prescription)
Pindolol
Isotretinion (ST, STS) Metoclopramide Sulfamethoxazole/ (Prescription Zaditor
Piroxicam
Itraconazole capsules Metolazone trimethoprim not covered)
Podofilox solution
(PA, PAS) Metoprolol, XL Sulfasalazine, EC Zaleplon
Polyethylene glycol 3350
Metronidazole tablets, SuIfisoxazole Zolpidem (CR Tier Three,
J cream, lotion, gel 0.75%
Portia
Sulindac ST, STS)
Potassium chloride
Jolivette (ER Tier Three) Sumatriptan Zonisamide
Potassium citrate (15mEq
Junel FE Mexiletine Zovia
Minocycline (tabs and
not covered) T Zyrtec OTC (Requires
K Solodyn not covered)
Pramoxine/HC
Tamoxifen citrate Doctor’s Prescription)
Pravastatin
Kariva Minoxidil (not soln) Tamsulosin Zyrtec D OTC (Requires
Prazosin
Ketoconazole Miralax* OTC (Requires Temazepam (7.5mg, 22.5mg Doctor’s Prescription)
Prednisolone
Ketoprofen, ER Doctor’s Prescription) Tier Three)
Prednisolone Acetate
Ketorolac Mirtazapine (Sol Tab Terazosin
Prednisone
Tier Three) Terbinafine (tabs only)
L Misoprostol
Prenatal Vitamins
(4rx/yr then PA required)
(prescription forms only)
Labetalol Moexipril Terbutaline sulfate
(Prenate and Neevo
Lactulose Moexipril-hydrochlorothiazide Terconazole
brands Tier Three)
Lamotrigine (Starter Pack MonaNessa Testosterone inj
Prevacid 24HR™ (Requires
Tier 3, ODT (PA) Tier 3, Morphine IR Tetracycline
Doctor’s Prescription)
XR (PA) tier 3) MPH-A Theophylline, XR
Prilosec*
Leena Mupirocin oint Thioguanine
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed. Not available as 90-day supply
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for
example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity
limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
12 • www.chcoklahoma.com
Tier Two Dilantin
Dostinex
Levlen
Levlite
PreCare Chewables
PreCare Conceive
V
Vagifem
Dritho-Scalp Levothroid PreCare Premier
A Lexapro (ST) Pred G Valcyte
E Lidoderm Premarin tabs (Cream Ventolin HFA
Accolate
LifeScan Test Strips Tier Three) Vexol
Actinex
Elmiron Lindane Shampoo Premesis RX Vfend (PA, PAS)
Actos (ST)
Emcyt Locoid Premphase Vivelle-Dot
Advair
Entocort EC Loestrin (24 FE Tier Three) Prempro Vytorin
Aggrenox
Epipen, Jr Lo/Ovral PrimaCare Vytorin 10/10mg (ST)
Aldara
Alesse Estrace Cream Lotronex PrimaCare ONE
Anakit Estraderm Lumigan Prometrium X
Androgel (PA, PAS) Eurax Lysodren Prostigmin
Antabuse Evista Psoriatec
Apriso Evoxac
M Pulmicort Respules (PA, Y
Aricept (23mg Tier Three) Exelderm PAS >4yrs)
Maxalt, MLT Yasmin
Aromasin (PA, PAS)
Mephyton Yaz
Asacol, HD F Mepron
Q Yodoxin
Asmanex
Astelin Fareston Methergine Quixin
Atrovent Inhaler, HFA FastTake Test Strips Micardis QVAR Z
Avelox Femara (PA, PAS) Micardis HCT
Flovent Diskus, HFA MigranaI Zemplar
Azathioprine
Fluoroplex Mircette
R Zenpep
Azelex
FML Forte Modicon Ranexa Zyvox (PA, PAS)
Azopt
Fosamax D Mycobutin Renvela
Fragmin (PA, PAS) Retin A Micro
B Ridaura
N
Bactroban Cream G Namenda
Benicar
Grifulvin V tabs Nardil
S
Benicar HCT
Betimol Gris-Peg Nasonex Sanctura, XR
Biltricide Nebupent Seasonale
Nexium Seasonique
Blephamide H Niaspan Sensipar
Brevicon
Hectorol Nilandron Serevent
Humalog Nitrolingual Translingual Seroquel, XR
C Humulin (pens/cartridges Spray Simcor
Capex Shampoo - PA) Nitrostat SL Singulair (ST)
Carbatrol Nordette Solia
Norinyl Soriatane
Celontin I NuvaRing Spiriva
Ciloxan oint.
Ciprodex Insulin, Only Lilly Brands Sporanox soln. (PA, PAS)
(Humulin pens/cartridges SSKI
Combivent
PA, Humalog)
O SureStep Test Strips
Comtan
Concerta Intal Inhaler One Touch Test Strips Symbicort
Cortifoam lopidine 1% One Touch Ultra Test Strips Synarel
Coumadin Onglyza (ST)
Opana ER
Crestor J Ortho Cept
T
Crestor 5mg (ST)
Cuprimine Janumet (ST) Ortho Cyclen Tabloid
Cyclessa Januvia (ST) Ortho Micronor Tazorac
Cytadren Jenest Ortho Novum Theo-24
Ortho Tri-Cyclen Tikosyn
Ortho Tri-Cyclen LO Travatan
D K Ovcon-50 TravatanZ
Dapsone Kadian Oxsoralen, Ultra Trilipix
Daranide Tri-Norinyl
Trisoralen
Daraprim L P Twinject
Demulen
Depen Lanoxin P1E1, P2E1
Lantus Phospholine Iodide
Derma-Smoothe/FS
Lantus SoloStar (PA) Plan B (Requires Doctor’s
U
Desogen
Diastat Lessina Prescription) Uroxatral
Dibenzyline Leukeran Plavix
Levemir (pens/cartridges – PA) Poly-Pred
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed. Not available as 90-day supply
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for
example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity
limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
www.chcoklahoma.com • 13
Betoptic* Desowen* Heparin* Mavik*
Brand with Biaxin* , XL* Desyrel* Humatin* Maxitrol *
Generic Bicitra* Dexedrine* Hydrea* Maxzide*
BIeph10* DextroStat* Hytrin* Meclomen*
Equivalent Brethine* Diabeta* Imdur* Medrol *
Bromfed*, PD*, DM* Diabinese* Imitrex* Megace*
Bumex * Diamox* Imuran* MelIariI *
*The following brand name drugs
have generics available at a Tier Buspar* Diflucan* Inderal*, LA* Menest*
One copay. Depending on your Cafergot* Dilacor XR* Indocin, SR* (suppositories Mestinon*
plan, either a Tier Three copay or a Calan*, SR* Dilaudid* (oral soln Tier Three) Metadate ER*
Tier Two copay plus an ancillary
CaIciferol * Tier Three) Intal Neb* Metaglip*
charge will apply if the brand name
drug is selected. Please refer to your Calcitonin Nasal Spray Diprolene*, AF* Iopidine* Metimyd*
certificate or evidence of coverage for Capoten * Diprosone* ISMO* MetroCream*
your specific benefit. Capozide* Disalcid* Isoptin* MetroLotion*
Carafate* Ditropan* (XL* Tier Three) Isopto Atropine* Mevacor*
Cardizem*, SR*, CD* Diuril* Isopto Carbachol* Mexitil*
A/T/S* Cardura* (XL Tier Three) Dolobid* Isopto Carpine* Miacalcin nasal spray*
Accuneb* Cartia XT* Dolophine* Isordil* Microgestin*, FE*
Accupril* Casodex* Domeboro Otic* Karidium * Micronase*
Accuretic* Cataflam* Donnatal (caps Tier Three)* Kayexalate* Microzide*
Aclovate* Catapres* (TTS Tier Three) Dovonex* K-Dur* Midodrine*
Actigall* Ceclor*, CD* Drysol* Keflex* Midamor*
Adalat CC* Ceftin* Duoneb* Kenalog* Midrin*
Adderall* (XR (PA) Tier Three) Cefzil* Duragesic* Keppra* (XR Tier Three, PA) Minipress*
Adrenalin* Celexa* Duricef* Klaron* Minocin* (tabs not covered)
Agrylin* Cheracol* Dyazide* Klonopin* MiraIax*
Aldactazide* Ciloxan Soln* Dynacin* capsules K-Lor* Mobic*
Aldactone * Cipro* (XR Tier Three) (tabs not covered) Klorvess* Monodox* (75mg
Aldomet* Cleocin* , T* , Vag* EC-Naprosyn* K-Lyte* not covered)
Alphagan* (P Tier Three) Climara * EES* K-Phos Neutral* Motrin*
Altace* capsules (tab Tier- Clinoril* Effexor*, XR* (ST) Kristalose* MS Contin*
Three) Clozaril* Efudex* KweIl* MSIR*
Amaryl* Cogentin* EIaviI* Lamictal* (Starter Pack Tier 3, Myambutol *
Ambien* (CR Tier Three, ST, Colazal* Eldepryl* ODT (PA) Tier 3, XR (PA) tier 3) Mycelex Troche*
STS) (ODT not covered) Colestid* Elimite* Lamisil* (tabs only) (4rx/yr Mycostatin*
Amerge* Colyte* Elocon* then PA, PAS required) Mysoline*
Amicar* Compazine* Emla* Lasix* NaIfon*
Amoxil * Condylox Gel*, Soln* Eryc* Levoxyl * Naprosyn* (Naprelan
Anafranil * Cordarone* Ery-Tab* Levsin* (SL Tier Three) Tier Three)
Analpram HC* Coreg* (CR Tier Three, ST) Erythrocin* Levsinex* Navane*
Anaprox*, DS* Corgard * Estrace tabs* Librax* Neosporin ophthalmic*
Anaspaz* Cortef* Estrostep FE* Librium* Neurontin*
Android * Cortisporin* Famvir* Lidex* Nimotop*
Ansaid* Crolom * Feldene* Lioresal* Nitrobid *
Antipyrine/Benzocaine Otic Cutivate* cream, oint Fioricet * Locoid* NitroDur*
Anusol-HC* (lotion Tier 3) Fiorinal w/Codeine* Lodine*, XL* NizoraI *
Apresoline* Cyclogyl* Fiorinal* Lofibra* Nolvadex*
Aralen* Cycrin* Flagyl* (ER Tier Three) Lomotil* Norpace*, CR*
Arava* Cylessa* Flexeril* Loniten* Norpramin *
Arimidex* (PA, PAS) Cystospaz* Flomax* Lopid * Norvasc* (ODT not
Artane* Cytomel* Flonase* Lopressor* covered)
Atarax* Cytotec* Flumadine* Lopressor HCT* Nulytely*
Ativan* Cytovene* FML* Lortab* Ocufen*
Atrovent Soln* Dalmane* Fosamax* Lotensin HCT* Ocuflox*
Augmentin ES* Danazol* Furadantin* Lotensin* Ocupress*
Augmentin ES*, XR* Dantrium* Garamycin* Lotrel* Omnicef*
Axid* Darvocet N100* Genoptic* Lotrisone Cream*, Lotion* Optipranolol*
Aygestin* Darvocet N50* Glucophage*, XR* Lovenox* (PA, PAS) Orasone*
Azulfidine*, EN* Darvon * Glucotrol*, XL* Loxitane* Orinase*
Bacitracin ophthalmic* Daypro* Glucovance* Lozol * Ortho Est*
Bactrim* , DS* DDAVP* Glynase* Ludiomil* Ovcon-35*
Bactroban Oint.* Decadron* Golytely* Luride* OxyIR*
Bentyl* Demadex* Grifulvin V susp* Luvox* (CR Tier Three, ST) Pamelor*
Benzamycin* Demerol* Guiatuss AC* Macrobid * Parlodel *
Betagan* Depakene* Halcion* Macrodantin * Parnate*
Betapace*, AF* Depakote*, ER* Haldol * Mandelamine* Paxil* (CR Tier Three, ST)
* A generic equivalent is available.
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed. Not available as 90-day supply
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for
example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity
limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
14 • www.chcoklahoma.com
PEG - electrolyte soln* Proamatine* Rondec, DM* Timoptic*, XE* Vibramycin*
Penlac* Procardia XL* Rowasa Enema* Tobradex (Tobra-Dex ST Vibramycin Susp* (syrup
Pepcid* (RPD Tier Three) Proctocort* Rynatan* Susp Tier Three) Tier Three)
Percocet * Proctocream-HC* Rythmol* (SR Tier Three) Tobrex* Vicodin*, ES*
Percodan* Proctofoam-HC* Salagen* Tofranil* (PM Tier Three) Vicoprofen*
Persantine* Proscar* Seasonale* Topamax* Viroptic*
Phenergan Codeine, DM, Proventil* (Not HFA) Sectral* Topicort* Vistaril*
VC, & VC/Codeine* Provera* Septra*, DS* Toprol XL* Vivactil*
Phenergan* Prozac (20mg non-form) Silvadene* Trandate* Voltaren, XR*
Phenytek* (weekly Tier Three,ST) Sinemet*, CR* Tranxene* (SD, T Tier Three) Voltaren Ophthalmic*
Phoslo* Purinethol* Soma Compound* Trental* Vosol*, HC*
Plan B 0.75mg* Pyrazinamide* Soma* (250mg not covered) Trileptal* Wellbutrin*, SR*, XL*
Plaquenil* Pyridium* Sonata* Trimethobenazmide Westcort*
PIetaI* Questran, Light* Spectazole* Trimethoprim Wigraine*
Polyhistine CS, D, DM* RegIan* Sporanox capsules* (PA, PAS) Trusopt* Xanax*, XR*
Polytrim * Remeron* (sol Tab Sulamyd* Tylenol 2, 3, 4* Xylocaine*
PoIy-Vi-FIor* Tier Three) Sular* Tylox* Zaditor*
Potassium Citrate/Citric Requip*, (XL Tier Three, ST) Synthroid* Ultracet* Zanaflex (caps not covered)
Acid* Restoril* (7.5 & 22.5mg Tagamet* Ultram* (ER, ST Tier Three) Zantac* (efferdose not
Pravachol* Tier Three) Tambocor* Ultravate* cream/oint covered)
Precose* Retin A* Tapazole* Uniphyl* Zarontin*
Pred Forte* Revia* Tegretol*, XR* Uniretic* Zaroxolyn*
Pred Mild* Rifadin* Temovate* Univasc* Zebeta*
Prednisolone, Acetate, Sod Rifamate* Tenex* Urecholine* Ziac*
Phos* Rilutek* Tenoretic* Urocit K* (15 mEq not covered) Zithromax*
Prelone* Risperdal* (M-Tab Tier Three) Tenormin* Valium* Zocor*
Prevalite* Ritalin* , SR* Terazol* Valtrex* Zofran*
Primaquine* RMS suppositories* TessaIon Perles* Vancocin* inj. Zoloft*
Principen* Robaxin* Tiazac* Vaseretic* Zonegran*
Prinivil* Robitussin AC*, DAC* Ticlid* Vasotec* Zovirax* (oint. Tier Three)
Prinzide* Rocaltrol* Tigan* Verelan SR* Zyloprim*
Tier Three Alamast Zaditor OTC (covered with
a prescription for tier 1
Avalide (PA, PAS)
Avandamet (PA)
Benicar HCT, Micardis HCT
Actos (ST) plus Glucophage*
Alternative Tier One Allegraπ , ODT(ST)
copay), Alaway*
Claritin OTC* or Zyrtec OTC*
Avandaryl (PA)
Avandia (PA)
Actos (ST)
Actos (ST)
or Tier Two Drugs (covered with a prescription
for a tier 1 copay)
Avapro (PA, PAS)
Avita Gel
Benicar, Micardis
Retin A*, Retin A Micro
Nonformulary Drugs Formulary Alternative Allegra Dπ Claritin D OTC* or Zyrtec D Avodart Proscar*, Uroxatral
OTC* (covered with a Axert Imitrex* , Maxalt ,
A prescription for a tier 1 Amerge*
copay) Azmacort QVAR, Asmanex, Flovent
Abilify (ST) Clozaril* , Risperdal*, Alocril Zaditor OTC (covered with Azor (PA, PAS) Norvasc* plus Benicar,
Seroquel, Seroquel XR a prescription for tier 1 Norvasc* plus Micardis
Accu-chek brand copay), Alaway*, Crolom*
test strips (PA, PAS) One Touch Test Strips Alomide Zaditor OTC (covered with
B
Accutane* (ST, STS) Doxycycline, Minocycline a prescription for tier 1 Beclovent Flovent, QVAR, Asmanex
Aceonπ Zestril*, Prinivil*, Lotensin*, copay), Alaway*, Crolom* Beconase (ST,STS) Flonase*, Nasalide*,
Accupril* Aloxi Zofran* Nasonex
Aciphex (PA) Prilosec OTC™ (requires Alphagan-P Alphagan* Benzaclinπ OTC Benzoyl Peroxide plus
doctor’s prescription), Ambien CR (PA, PAS) Ambien* , Ativan* , Topical Clindamycin*
omeprazole*, Prevacid Halcion* , oxazepam* ,
24HR™ (requires doctor’s Restoril* , Sonata* Betoptic S Betoptic*, Timoptic*,
prescription), Nexium Amitiza (ST, STS) Miralax OTC*, Chronulac*, Timoptic XE*, Betagan*
Actiq (PA, PAS) Oxy IR* , MSIR* , Colyte* Boniva Fosamax*
Dilaudid* (oral soln tier 3) Androderm (PA, PAS) Androgel (PA, PAS) Brovana (PA) Spiriva, Advair, Symbicort,
Activellaπ Prempro, Premphase (not covered) Serevent
Actonel Fosamax* Anzemet Compazine*, Phenergan*, Byetta (PA, PAS) Amaryl*, Glucophage*,
ACTOplusmet (ST) Actos (ST) Amaryl* Tigan*, Zofran* Actos (ST)
Acular Ocufen*, Voltaren Apidra Humalog Bystolic Inderal LA*, Toprol XL*,
Ophthalmic* Arixtra (PA, PAS) Lovenox* (PA, PAS) Lopressor*, Coreg*
Adderall XR Adderall* , Ritalin* , Fragmin (PA, PAS),
(PA > 17yrs) Ritalin SR* , Metadate Arthrotec Voltaren* plus Cytotec* C
(generic not covered) ER* , Concerta Ascensia Brand Caduet (not covered) Norvasc* plus Zocor*
Advicor Zocor*, Simcor Test Strips (PA, PAS) One Touch Test Strips Cardizem LAπ Cardizem CD*
Aerobid Flovent, QVAR, Asmanex Atacand (PA, PAS) Benicar, Micardis Catapres TTSπ Catapres*, Aldomet*,
Atacand HCT (PA, PAS) Benicar HCT, Micardis HCT Hytrin*, Minipress*,
Auralgan A/B Otic Soln
* A generic equivalent is available.
π Brand-name medications and the generic equivalent are covered at a higher member cost.
The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor.
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed. Not available as 90-day supply
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for
example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity
limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
www.chcoklahoma.com • 15
Caverject (ST) no alternative available Fentora (PA, PAS) Morphine oral sol, OxylR* Lunesta (ST, STS) Halcion* , oxazepam ,
Celebrex (ST) Motrin*, Naprosyn*, Focalin Adderall* , Ritalin* , Restoril* , Sonata*
Mobic*, Voltaren*, Clinoril*, Concerta Luvox CR (ST) Luvox*, Celexa*, Prozac*,
Disalcid*, Relafen* Focalin XR (PA > 17yrs) Adderall* , Ritalin* , Paxil*, Zoloft*, Lexapro (ST)
Cenestin Premarin, Ogen* Ritalin SR* , Metadate ER* Lyrica (PA, PAS) Neurontin*, Keppra*,
Cialis (2.5mg not covered) no alternative available , Concerta Lamictal*, Trileptal*,
Clarinex (ST) Claritin* OTC or Zyrtec* Foradil Serevent Tegretol*, Tegretol XR*,
OTC are covered with a Frova Amerge* , Imitrex* , Topamax*, Depakene*,
Doctor’s prescription Maxalt Depakote*, Depakote ER*
Clarinex D (ST) Claritin D* OTC or Zyrtec
D* OTC are covered with a G M
Doctor’s prescription Gabitril Nuerontin*, Keppra*, Marinol (PA, PAS) Requires Prior Auth
Colcrys (PA, PAS) colchicine* Lamictal*, Trileptal*, Maxair Ventolin HFA
Coreg CR (ST) Coreg* Tegretol*, Tegretol XR*, Metadate CD Adderall* , Ritalin* ,
Cosoptπ Timoptic* plus Azopt Topamax*, Depakene*, (PA > 17yrs) Ritalin SR* , Metadate ER*
Cozaarπ Benicar, Micardis Depakote*, Depakote ER* , Concerta
Creon Zenpep, Ultrase Geodon (PA) Risperdal*, Seroquel, Metrogel 1% (ST) Metronidazole 0.75% Gel
Cymbalta (PA, PAS) Celexa*, Prozac*, Zoloft*, Seroquel XR Miacalcin Injection (PA) Miacalcin Nasal Spray*
Paxil*, Effexor* (ST), Effexor
XR* (ST) H Mirapex
Multaq
Requip*
Cordarone*
HalfLyte CoLyte*
D N
HyperRho no alternative available
Daytrana Adderall* , Ritalin* , Hyzaarπ Benicar HCT, Micardis HCT Naprelanπ Motrin*, Naprosyn*,
(PA, PAS > 17yrs) Ritalin SR* , Metadate ER* Voltaren*, Clinoril*,
, Concerta I Disalcid*, Relafen*, Mobic*
Detrol/Detrol LA (ST) Ditropan*, Sanctura, Innohep (PA, PAS) Lovenox* (PA, PAS), Nasacort (ST, STS) Flonase*, Nasalide*,
Sanctura XR Fragmin (PA, PAS) Nasonex
Dexilant (PA) Prilosec OTC™ (requires Innopran XL Inderal LA*, Toprol XL*, Neevo Multiple prenatal vitamins
doctor’s prescription), Lopressor*, Coreg* on formulary Tier 1
omeprazole*, Prevacid Insulins Lilly Brand Insulins Neevo DHA Multiple prenatal vitamins
24HR™ (requires doctor’s Novo Brand on formulary Tier 1
prescription), Nexium Intuniv Ritalin* , Adderall* , Niravam (ST) Xanax*
D.H.E. 45 Amerge* , Migranal , Concerta Noroxin Cipro* , Avelox
Imitrex* , Maxalt Invega (PA) Risperdal*, Seroquel, Norgesic/Norflex Flexeril*, Lioresal*,
Differin Retin-A* Seroquel XR Robaxin*, Soma* (250mg
Diovan (PA, PAS) Benicar, Micardis Iprivask (PA required Lovenox* (PA, PAS), not covered)
Diovan HCT (PA, PAS) Benicar HCT, Micardis HCT for > than 20 doses) Fragmin (PA, PAS) Novo Brand
Dipentum Azulfidine*, Asacol Insulins Lilly Brand Insulins
Ditropan XLπ Ditropan*, Sanctura, J Noxafil (PA, PAS) Requires Prior Auth
Sanctura XR Nucynta (PA, PAS) MSIR* , Oxycodone IR*
Duac OTC Benzoyl Peroxide plus K Nuvigil (PA, PAS) Ritalin* , Dexedrine* ,
Topical Clindamycin* Adderall*
Duetact (ST) Actos (ST) plus Amaryl* Keppra XR (PA) Keppra*, Neurontin*,
Dynacirc CR Norvasc* Lamictal*, Trileptal*, O
Tegretol*, Tegretol XR*,
E Topamax*, Depakene*, Omnaris (ST, STS) Flonase*, Nasalide*, Nasonex
Depakote*, Depakote ER* Opana IR (PA, PAS) MSIR* , Oxycodone IR*
Edex (ST) no alternative available Ketek First Line Generic Antibiotics Ortho Evra Several oral contraceptives
Effient Plavix Kytril Zofran* are available on the
Elidel (PA) Kenalog*, Diprosone*, Formulary
Topicort*, Locoid*, L Oxistat Nizoral* or Nystatin*
Wescort*, Elocon* Oxycontin (PA, PAS) MS Contin* , Duragesic* ,
Embeda (PA, PAS) Dolophine* , MS Contin* , Lamictal ODT (PA), XR Lamictal*, Neurontin*,
(PA), Starter Pack Keppra*, Trileptal*, Kadian , Opana ER
Kadian* , Duragesic* , Oxytrol (ST) Ditropan*, Sanctura,
Opana ER* Tegretol*, Tegretol XR*,
Topamax*, Depakene*, Sanctura XR
Emsam (PA) Celexa*, Prozac*, Zoloft*,
Paxil* Depakote*, Depakote ER* P
Enablex (ST) Ditropan*, Sanctura, Lamisil Granules (PA) Lamisil* tab
Lescol, XL (ST) Zocor*, Pravachol*, Pancreaze Zenpep, Ultrase
Sanctura XR
Mevacor* Parafon Forte Flexeril*, Lioresal*,
Exelon Aricept, Namenda
Levaquin Cipro* , Avelox DSCπ Robaxin*, Soma* (250 mg
Exforge (PA, PAS) Norvasc* plus Benicar,
Levitra no alternative available not covered)
Norvasc* plus Micardis
Lialda (ST) Colazal*, Apriso, Asacol, Pataday Alaway*, Zaditor OTC
F Asacol HD (covered with a prescription
Lipitor 10mg, 20mg (ST) Zocor*, Pravachol* for tier 1 copay)
Fanapt (PA) Risperdal*, Seroquel, Lipitor 40mg, 80mg (ST) Crestor (5mg ST), Vytorin Patanol Alaway*, Zaditor OTC
Seroquel XR (10/10mg ST) (covered with a prescription
Loestrin 24 FE Yaz, Several other oral for tier 1 copay)
contraceptives are available Paxil CRπ (ST) Celexa*, Prozac*, Zoloft*,
Femcon Desogen*, Necon*, on the Formulary Paxil*
Nordette*, Norinyl*, Ortho Loproxπ Nizoral* or Nystatin* Pentasa Asacol
Cept*, Ortho Cyclen*, Ortho Perforomist (PA) Spiriva, Advair, Symbicort,
Novum*, Yasmin*, Yaz Lotemax Pred Forte*, Decadron*, Serevent
FemHRT Prempro, Premphase FML Liquifilm* Prandin Diabeta*, Glucotrol*,
FemPatch Estraderm*, Vivelle Lovaza (PA) Lofibra*, Tilipix, Niaspan Amaryl*
Fenoglide Lofibra*, Trilipix Prefest Prempro, Premphase
* A generic equivalent is available.
π Brand-name medications and the generic equivalent are covered at a higher member cost.
The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor.
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed. Not available as 90-day supply
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for
example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity
limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
16 • www.chcoklahoma.com
Premarin Vag Cream Estrace Vag Crm, Vagifem Rogaine Benefit exclusion Vimpat Neurontin*, Keppra*,
Prenate DHA Multiple prenatal vitamins Rozerem (ST, STS) Ambien* , Sonata* Lamictal*, Trileptal*,
on formulary Tier 1 Ryzolt (ST) Ultram* Tegretol*, Tegretol XR*,
Prenate Elite Multiple prenatal vitamins Topamax*, Depakene*,
on formulary Tier 1 S Depakote*, Depakote ER*
Prevacid (Solutab Prilosec OTC™ (covered Saphris (ST) Clozaril* , Risperdal*, Vyvanse (ST, STS) Adderall* , Ritalin* ,
not covered) with a prescription for tier Seroquel, Seroquel XR Ritalin SR* , Metadate ER*
1 copay), omeprazole*, Sarafem (tabs not covered) π Prozac Capsules* , Concerta
Prevacid24HR™ (covered Serzoneπ Celexa*, Prozac*, Zoloft*,
with a prescription for tier Paxil*
W
1 copay), Nexium Skelaxinπ Flexeril*, Lioresal*, Welchol Questran/Colestid*
Prevpac Prilosec OTC™* 20mg Robaxin*, Soma* (250 mg WinRho
plus amoxicillin and not covered)
clarithromycin Stadol NSπ Tylenol with Codeine* , X
Pristiq (ST) Effexor*(ST), Effexor XR (ST), Darvocet-N 100* , Ultram* Xalatan Lumigan, Travatan
Celexa*, Prozac*, Paxil*, Starlixπ Diabeta*, Glucotrol*, Xifaxan (550mg PA, PAS) Lactulose
Zoloft*, Lexapro (ST), Luvox* Amaryl* Xopenex, HFA Ventolin HFA, albuterol neb
ProAir HFA Ventolin HFA Striant (PA, PAS) Androgel (PA, PAS) Xyzal (ST) Claritin OTC or Zyrtec OTC
Procardia Capsulesπ Calan SR*, Cardizem CD*, Strattera Ritalin* , Adderall* , (covered with a prescription
Adalat CC*, Procardia XL* Concerta for a tier 1 copay)
Protonixπ (PA) Prilosec OTC™ (covered Suboxone (PA, PAS) Requires Prior Auth
with a prescription for tier 1 Subutex (PA, PAS) Requires Prior Auth Z
copay), omeprazole*, Symbyax (ST) Prozac* plus Risperdal*
Prevacid24HR™ (covered Zantac Efferdose Zantac tab/cap*, Tagamet*,
Symlin (PA, PAS) Humulin, Humalog, Lantus,
with a prescription for tier 1 (not covered) Pepcid*
Levemir
copay), Nexium Zegerid (PA) Prilosec OTC™ (covered
Protopic Hydorcortisone*, T with a prescription for a
Betamethasone*, tier 1 copay), omeprazole*,
Tamiflu Prevacid 24HR™ (covered
Triamcinolone*, Elocon*, Tarka Mavik* plus Calan SR* with a prescription for a tier
Temovate*, Sinalar*, Tasmar Comtan 1 copay), Nexium
Topicort* Tekturna (PA, PAS) Benicar, Micardis Zelapar ODT (ST) Eldepryl*
Proventil HFA Ventolin HFA Tekturna HCT (PA, PAS) Benicar HCT, Micardis HCT ZMax Zithromax*
Provigil (PA, PAS) Ritalin* , Dexedrine* , Testim (not covered) Androgel (PA, PAS) Zetia Zocor*, Pravachol*, Vytorin
Adderall* Teveten (PA, PAS) Benicar, Micardis (10/10mg ST), Niaspan
Prozac Weekly (ST) Prozac Capsules* Teveten HCT (PA, PAS) Benicar HCT, Micardis HCT Zomig Imitrex* , Maxalt
Pulmicort Flexhaler/ Flovent, QVAR, Asmanex Tofranil PM Tofranil* Zovirax Ointment Oral Zovirax*
Turbuhaler Toviaz Ditropan*, Sanctura, Zybanπ Benefit exclusion
Q Sanctura XR Zylet Tobradex*
Tricor Lofibra*, Trilipix Zymar Tobrex* , Gentamicin* ,
Qualaquin (PA, PAS) Aralen*, Lariam*, Triglide Lofibra*, Trilipix Ciloxan* , Ocuflox*
Plaquenil*, Primaquine* Tussionex Robitussin AC Zyprexa (ST) Risperdal*, Seroquel,
Twynsta (PA, PAS) Benicar plus amlodipine,
R Micardis plus amlodipine
Seroquel XR
Renagel Phoslo*, Renvela
Regranex (PA, PAS) Requires Prior Auth U
Relistor (PA, PAS) Lactulose*, Miralax* OTC Ulesfia Elimite*, Lindane*
(covered with a prescription Uloric (ST) Zyloprim*
for tier 1 copay) Ultram ER (ST) Ultram*
Relpax Maxalt , Imitrex*
Remeron Soltabπ Remeron*, Celexa*, V
Ludiomil*, Desyrel* Valturna (PA, PAS) Benicar, Micardis
Razadyne Aricept, Namenda Veramyst (ST, STS) Flonase*, Nasalide*,
Requip XL (ST) Requip* Nasonex
Rescula Lumigan, Travatan Verelan PM Calan*, SR*, Cardizem CD*,
Restasis Various OTC artificial tears Adalat CC*, Procardia XL*
available Vesicare (ST) Ditropan*, Sanctura,
Restoril 7.5mg, 22mg Restoril* 15mg & 30mg , Sanctura XR
Ambien* , Halcion* Viagra no alternative available
Rhinocort (ST, STS) Flonase*, Nasalide*, Victoza (PA, PAS) Amaryl*, Diabeta*,
Nasonex Glucotrol*, Glynase*,
Rhogam no alternative available Micronase*, Glucophage*
Ritalin LA (PA > 17yrs) Adderall* , Ritalin* , Vigamox Tobrex* , Gentamicin* ,
Ritalin SR* , Metadate ER* Ciloxan* , Ocuflox*
, Concerta
* A generic equivalent is available.
π Brand-name medications and the generic equivalent are covered at a higher member cost.
The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor.
Initial therapy of 21 days will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed. Not available as 90-day supply
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan
(for example, oral contraceptives, growth hormone, erectile dysfunction drugs). We periodically review our Drug Formulary listing. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have
quantity limits (see page 19). Please consult with your Prescription Drug Plan Customer Service Representative for any questions about your coverage or for more information.
www.chcoklahoma.com • 17
Specialty Medications
Specialty medications are typically high-cost drugs, including but not limited to the oral, topical, inhaled, inserted or implanted, and injected routes of
administration used to treat rare and complex diseases (see list of Specialty medications listed below).
Specialty medications require prior authorization unless otherwise indicated. Your doctor should contact Coventry’s Pharmacy Call Center at
877-215-4100 to request prior authorization.
Except in urgent situations, all specialty medications are distributed through a participating specialty pharmacy. Specialty drugs are limited to a 30-day
supply at a time or the quantity prescribed in the prescription order, whichever is less. Please call Customer Service at the number on your member ID
card for a referral to a participating specialty pharmacy or with questions regarding your pharmacy benefit. Please refer to your health plan documents
regarding coverage of and any limitations or exclusions that may apply to your specialty drug benefit.
Formulary (Preferred)
Actimmune (PA, PAS) Enbrel (PA, PAS) Leukine (PA, PAS) Pulmozyme (PA, PAS) Tracleer (PA, PAS)
Adcirca (PA, PAS) Epivir Lexiva Rapamune Tretinoin - Cancer (PA, PAS)
Alkeran Epivir Hbv Matulane Rebetol (PA, PAS) Vesanoid
Apokyn (PA, PAS) Etoposide Myleran Retrovir Videx
Arcalyst (PA, PAS) Fuzeon (PA, PAS) Neoral Reyataz Videx Ec
Avonex (PA, PAS) Gleevec (PA, PAS) Neupogen (PA, PAS) Ribavirin (PA, PAS) Viracept
Ceenu Hepsera Norvir Sandimmune Viramune
Cellcept Hexalen Octreotide (PA, PAS) Sandostatin (PA, PAS) Viread
Copaxone (PA, PAS) Humira (PA, PAS) Omnitropei (PA, PAS) Sustiva Xeloda (PA, PAS)
Copegus (PA, PAS) Intelence Pegasys (PA, PAS) Tarceva (PA, PAS) Xenazine (PA, PAS)
Crixivan Intron-A (PA, PAS) Prezista Targretin (PA, PAS) Zerit
Cyclophosphamide Invirase Procrit (PA, PAS) Temodar (PA, PAS) Ziagen
Cyclosporine Isentress (PA, PAS) Prograf Thalomid (PA, PAS)
Emtriva Kaletra Tobi Neb (PA, PAS)
Nonformulary Formulary Alternatives Nonformulary Formulary Alternatives Nonformulary Formulary Alternatives
(Nonpreferred) (Preferred) (Nonpreferred) (Preferred) (Nonpreferred) (Preferred)
Afinitor (PA, PAS) no alternative available Hizentra (PA, PAS) refer to medical benefit Sabril Powder For Oral multiple formulary
Agenerase Lexiva for IVIG Solution (PA, PAS) antiepileptic agents
Ampyra (PA, PAS) no alternative available Humatropei (PA, PAS) Omnitropei (PA, PAS) available
Aptivus Norvir, Prestiza, Reyataz Hycamtin (PA, PAS) no alternative available Sabril Tablets (PA, PAS) multiple formulary
Aranesp (PA, PAS) Procrit (PA, PAS) Ilaris (PA, PAS) Arcalyst (PA, PAS) antiepileptic agents
Atripla Sustiva plus Emtriva plus Increlex (PA, PAS) no alternative available available
Viread Infergen (PA, PAS) Pegasys (PA, PAS) Saizeni (PA, PAS) Omnitropei (PA, PAS)
Baraclude Epivir HBV, Hepsera Iressa (PA, PAS) Tarceva (PA, PAS) Samsca (PA, PAS) no alternative available
Betaseron (PA, PAS) Avonex (PA, PAS), Kineret (PA, PAS) Enbrel (PA, PAS), Selzentry (PA, PAS) multiple formulary first
Copaxone (PA, PAS) Humira (PA, PAS) line HIV agents
Bravelle coverage varies by Kuvan (PA, PAS) no alternative available available
benefit Letairis (PA, PAS) Tracleer (PA, PAS) Serostimi (PA, PAS) Omnitropei (PA, PAS)
Buphenyl (PA, PAS) no alternative available Lupron 1 Mg/0.2 Ml refer to medical benefit Simponi (PA, PAS) Enbrel (PA, PAS) ,
Cayston (PA, PAS) Tobi Neb (PA, PAS) (PA, PAS) Humira (PA, PAS)
Chenodal (PA, PAS) Actigall* Menopur coverage varies by Somavert (PA, PAS) Sandostatin (PA, PAS)
Chorionic Gonadotropin coverage varies by benefit Sprycel (PA, PAS) Gleevec (PA, PAS)
benefit Myfortic Mycophenolate, Stelara (PA, PAS) Enbrel (PA, PAS),
Cimzia (PA, PAS) Enbrel (PA, PAS), Cellcept Humira (PA, PAS)
Humira (PA, PAS) Neulasta (PA, PAS) Neupogen (PA, PAS) Sutent (PA, PAS) no alternative available
Combivir Epivir plus Retrovir Nexavar (PA, PAS) no alternative available Tasigna (PA, PAS) Gleevec (PA, PAS)
Cystadane no alternative available Norditropini (PA, PAS) Omnitropei (PA, PAS) Tev-Tropini (PA, PAS) Omnitropei (PA, PAS)
Egrifta (PA, PAS) no alternative available Novarel coverage varies by Trizivir Epivir plus Ziagen plus
Epogen (PA, PAS) Procrit (PA, PAS) benefit Retrovir
Epzicom Epivir plus Ziagen Nutropini (PA, PAS) Omnitropei (PA, PAS) Truvada Emtriva plus Viread
Exjade (PA, PAS) no alternative available Nutropin AQi (PA, PAS) Omnitropei (PA, PAS) Tykerb (PA, PAS) no alternative available
Extavia (PA, PAS) Avonex (PA, PAS), Oforta (PA, PAS) no alternative available Tyvaso (PA, PAS) no alternative available
Copaxone (PA, PAS) Orfadin no alternative available Tyzeka (PA, PAS) Epivir HBV, Hepsera
Follistim Aq coverage varies by Ovidrel coverage varies by Ventavis (PA, PAS) no alternative available
benefit benefit Vivaglobin (PA, PAS) refer to medical benefit
Forteo (PA, PAS) Fosamax*, Fosamax Peg-Intron (PA, PAS) Pegasys (PA, PAS) for IVIG
plus D, Miacalcin Pregnyl coverage varies by Votrient (PA, PAS) no alternative available
nasal spray* benefit Xyrem (PA, PAS) Adderall*, Ritalin*
Gammunex-C refer to medical benefit Promacta (PA, PAS) no alternative available Zavesca (PA, PAS) no alternative available
for IVIG Protropini (PA, PAS) Omnitropei (PA, PAS) Zolinza (PA, PAS) Targretin (PA, PAS)
Ganirelix coverage varies by Rebif (PA, PAS) Avonex (PA, PAS), Zorbtive (PA, PAS) no alternative available
benefit Copaxone (PA, PAS) Zortress Rapamune, Prograf
Genotropini (PA, PAS) Omnitropei (PA, PAS) Repronex coverage varies by
Gilenya (PA, PAS) Avonex(PA, PAS), benefit
Copaxone (PA, PAS) Rescriptor Sustiva
Gonal-F RFF coverage varies by Revatio (PA, PAS) Adcirca (PA, PAS)
benefit Revlimid (PA, PAS) no alternative available
* Generic is on the Formulary
i Some plans cover only one growth hormone product — Omnitrope. Under these plans, Nutropin, Nutropin AQ, Humatrope, Genotropin, Saizen, Tev-Tropin and comparable
agents are not covered. Please contact Member Services with questions if your doctor prescribes a growth hormone agent that is not covered.
For some benefit plans, specialty medications may be included under a member’s medical benefit, not the pharmacy benefit plan. Please refer to your health plan documents
regarding coverage of and any limitations or exclusions that may apply to your specialty medication benefit.
18 • www.chcoklahoma.com
Quantity Limits
Some of the drugs listed in this formulary are subject to Quantity limits. For a complete list of drugs that are subject to quantity limits for your benefit plan,
please refer to your health plan website or the customer service number which is listed on your member ID card.
Prior Authorization
Coventry Health Care has two broad goals for the prescription drug benefit we offer. One is to never compromise the quality or effectiveness of treatment.
The second is to provide a comprehensive, affordable pharmacy benefit. One of the tools we use to help control prescription drug costs is to require prior
approval, or authorization, before our organization will cover the cost of certain medications. These medications include those that (1) are not suggested
for first-line therapy, (2) may require special tests before starting them or (3) have very limited approval for use. Drugs that could require Prior Authorization
are identified by (PA) for members with the Standard Prior Authorization Program and (PAS) for members with the RxSelect Prior Authorization Program.
Step Therapy is an automated form of Prior Authorization based on previous pharmaceutical treatment. Drugs designated as stepped therapy will require
prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Drugs that could require Step Therapy
are identified by (ST) for members with the Standard Step Therapy Program and (STS) for members with the RxSelect Step Therapy Program.
Only your physician can provide the information necessary to complete the prior authorization process. If you have been prescribed one of the drugs
identified by (PA), (PAS), (ST) or (STS), make sure your doctor knows that this medication requires prior authorization. Your doctor should contact Coventry’s
Pharmacy Call Center at 877-215-4100.
www.chcoklahoma.com • 19
Step Therapy Drug List
STANDARD Stepped Therapy Agents — 2011
The following drugs will require prior authorization if the condition is not met when the pharmacist
would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the
prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment.
If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means
that you are responsible for paying the prescription in full.
Self-administered injectable agents also require prior authorization and can be found on a separate list.
Drug Condition
Accutane* (isotretinoin) Trial & failure of two oral antibiotics for acne
Actos (pioglitazone) Trial & failure of metformin/ER (at least 1500mg/d)
ActoPLUS Met (pioglitazone/ metformin) Trial & failure of metformin/ER (at least 1500mg/d)
ActoPLUS Met XR (pioglitazone/ metformin ext rel) Trial & failure of metformin/ER (at least 1500mg/d)
Allegra ODT (fexofenadine) Trial & failure of Claritin* AND Zyrtec OTC
Ambien CR (zolpidem extended release) Trial & failure of Ambien* or Sonata*, AND Lunesta
Amitiza (lubiprostone) Trial & failure of Lactulose* or Miralax*
Aricept 23mg (donepezil) Trial of Aricept 10mg QD for at least 3 months
Avandia (rosiglitazone) Trial & failure of metformin/ER (at least 1500mg/d)
Avandamet (rosiglitazone/metformin) Trial & failure of metformin/ER (at least 1500mg/d)
Avandaryl (rosiglitazone/ glimepiride) Trial & failure of metformin/ER (at least 1500mg/d)
Beconase AQ (beclomethasone) Trial & failure of Flonase* or Nasalide*, AND Nasonex
Caverject (alprostadil) Trial & failure of an oral ED drug
Celebrex (celecoxib) Trial & failure of 2 NSAIDs
Clarinex (desloratadine) Trial & failure of Claritin* AND Zyrtec OTC
Coreg CR (carvedilol extended rel) Trial of Coreg*
Crestor (rosuvastatin) 5mg only Trial & failure of Zocor*
Detrol/Detrol LA (tolterodine/ extended release) Trial & failure of Ditropan* or Sanctura/Sanctura XL
Duetact (pioglitazone/ glimepiride) Trial & failure of metformin/ER (at least 1500mg/d)
Edex (alprostadil) Trial & failure of an oral ED drug
Effexor* (venlafaxine) Trial & failure of an SSRI
Effexor XR* capsules (venlafaxine extended rel) Trial & failure of an SSRI
Enablex (darifenacin) Trial & failure of Ditropan* or Sanctura/Sanctura XL
Fanapt (iloperdone) Trial & failure of Risperdal* or Seroquel
Fortamet (metformin ER) Trial & failure of metformin/ER (at least 1500mg/d)
Geodon (ziprasidone) Trial & failure of Risperdal* or Seroquel
Gelnique (oxybutynin topical gel) Trial & failure of Ditropan* or Sanctura/Sanctura XL
Glumetza (metformin ER) Trial & failure of metformin/ER (at least 1500mg/d)
Invega (paliperidone) Trial & failure of Risperdal* or Seroquel
Italics indicate nonformulary agents. * Indicates generic available. This list is subject to change.
20 • www.chcoklahoma.com
Step Therapy Drug List
Drug Condition
Janumet (sitagliptin/metformin) Trial & failure of metformin/ER (at least 1500mg/d)
Januvia (sitagliptin) Trial & failure of metformin/ER (at least 1500mg/d)
Lescol/Lescol XL (fluvastatin) Trial & failure of Zocor*
Lexapro (escitalopram) Trial & failure of a generic SSRI
Lialda (mesalamine) Trial & failure of Apriso, Asacol or Asacol HD
Lipitor (atorvastatin) 10mg & 20mg Trial & failure of Zocor*
Lipitor (atorvastatin) 40mg & 80mg Trial & failure of Crestor or Vytorin
Livalo (pitavastatin) Trial & failure of Zocor*
Lunesta (eszopiclone) Trial & failure of Ambien* or Sonata*
Luvox CR (fluvoxamine extended release) Trial & failure of an SSRI
Metrogel 1% (metronidazole) Trial & failure of Metrogel 0.75%*
Mirapex ER (pramipexole ext rel) Trial of Mirapex*
Nasacort AQ (triamcinolone) Trial & failure of Flonase* or Nasalide*, AND Nasonex
Niravam ODT (alprazolam immediate rel) Trial of Xanax*
Omnaris (ciclesonide) Trial & failure of Flonase* or Nasalide*, AND Nasonex
Onglyza (saxagliptin) Trial & failure of metformin/ER (at least 1500mg/d)
Oxytrol (oxybutynin transdermal) Trial & failure of Ditropan* or Sanctura/Sanctura XL
Paxil CR* (paroxetine extended release) Trial of Paxil*
Pristiq (desvenlafaxine) Trial & failure of any SSRI AND Effexor
Prozac Weekly* (fluoxetine extended rel) Trial of Prozac*
Requip XL (ropinirole) Trial of Requip*
Rhinocort Aqua (budesonide) Trial & failure of Flonase* or Nasalide*, AND Nasonex
Rozerem (ramelteon) Trial & failure of Ambien* or Sonata*, AND Lunesta
Ryzolt (tramadol extended release) Trial of Ultram*
Saphris (asenapine) Trial & failure of Risperdal* or Seroquel
Symbyax (olanzapine/fluoxetine) Trial & failure of Risperdal* or Seroquel
Toviaz (fesoterodine) Trial & failure of Ditropan* or Sanctura/Sanctura XL
Uloric (febuxostat) Trial & failure of allopurinol
Ultram ER (tramadol extended release) Trial of Ultram*
Vancocin (vancomycin) 250mg only Trial & failure of Vancocin 125mg
Venlafaxine ER tablets Trial & failure of an SSRI
Veramyst (fluticasone furoate) Trial & failure of Flonase* or Nasalide*, AND Nasonex
Vesicare (solifenacin) Trial & failure of Ditropan* or Sanctura/Sanctura XL
Vytorin (simvastatin/ezetimibe) 10/10 only Trial & failure of Zocor*
Vyvanse (lisdexamphetamine) Trial & failure of Adderall XR
Xyzal (levocetirizine) Trial & failure of Claritin* AND Zyrtec OTC
Zelapar ODT (selegeline) Trial of Eldepryl*
Zyprexa (olanzapine) Trial & failure of Risperdal* or Seroquel
www.chcoklahoma.com • 21
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Important Member Notices
Enrollment Notice to Eligible Participants
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires an employee to receive this
notice. Retain a copy of this notice for your records.
Special Enrollment Rights
If you refuse enrollment for yourself or your dependents, you may later enroll within 31 days of a change
in family status or loss of other heath coverage. Loss of health coverage includes separation, divorce,
death, termination of employment, reduction in work hours, exhaustion of COBRA continuation or state
continuation or if employer contribution toward your coverage has terminated.
Change in family status includes marriage, birth, adoption or placement for adoption of a child. If you or
your dependent spouse are not enrolled for this coverage, you can also enroll during the special enrollment
period when a change in family status occurs. If enrollment is not made at the time these special enrollment
opportunities occur, you will be deferred to the next open enrollment.
Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009
Your group health plan must permit employees and dependents who are eligible but not enrolled for
coverage to enroll in two additional circumstances: (1) the employee's or dependent's Medicaid or CHIP
coverage is terminated as a result of loss of eligibility, and the employee requests coverage under the plan
within 60 days after the termination, or (2) the employee or dependent become eligible for a premium
assistance subsidy under Medicaid or CHIP, and the employee requests coverage under the plan within
60 days after eligibility is determined.
If enrollment is not made at the time these special enrollment opportunities occur, you will be deferred to
the next open enrollment.
Using the Services of an Out-of-Network Provider
Can Mean Higher Costs for You
Out-of-network services are those delivered by physicians, hospitals and other clinical providers who
have not contracted with Coventry. Because Coventry does not have a contracted discount rate with
out-of-network providers, these providers generally charge a higher fee for their services. As a result, any
coinsurance amounts that you pay are higher if you receive services from an out-of-network provider.
We pay non-contracted providers based on our out-of-network reimbursement rates. If the provider charges
Coventry more than that rate, you will be responsible for the amount above our reimbursement rate. These
amounts can be substantial. The decision to receive care from an out-of-network provider can have financial
consequences for you.
The good news is that Coventry has a very broad network and you have many options when seeking care.
Using an in-network provider will save you money.
To find an in-network provider, please visit our website, www.chcoklahoma.com, or call Customer
Service at 866-219-7695. Our representatives will be happy to assist you with finding an in-network
provider.
22 • www.chcoklahoma.com
Notes
Notes
Coventry Health and Life Insurance Company, Inc.
3030 NW Expressway
Suite 625
Oklahoma City, OK 73112
5727 S. Lewis Avenue
Suite 450
Tulsa, OK 74105
405-945-1200
www.chcoklahoma.com
CHOK150 (03/11)