2014 CoventryOne Prescription Drug List

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1 2014 CoventryOne Prescription Drug List This Prescription Drug List applies to 2014 Individual Health Insurance Marketplace benefit plans Abbreviated Prescription Drug List for Commonly Prescribed Medications 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. We periodically review our Prescription Drug List. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity limits. Please call Customer Service at the number on your member ID card with any questions about your coverage or for more information. A complete Prescription Drug List is available at CoventryOne.com. 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 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. Prior authorization Coventry Health Care has two broad goals for the prescription drug benefit we offer. One is to never compromise the quality or effectiveness of treatment. The second is to provide a comprehensive, affordable pharmacy benefit. One of the tools we use to help control prescription drug costs is to require prior approval, or authorization, before we will cover the cost of certain medications. These medications include those that (1) are not suggested for first-line therapy, (2) may require special tests before starting them or (3) have very limited approval for use. Step Therapy is an automated form of Prior Authorization based on past drug 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. Only your physician can provide the information necessary to complete the prior authorization process. If you have been prescribed a drug that requires prior authorization, make sure your doctor knows that this medication requires prior authorization. Your doctor should contact Coventry s Pharmacy Call Center at Tier = Copay Level PA = Prior Authorization Required LGC = Lowest Generic Copay ST = Step Therapy Required QL = Quantity Limit Applies MO = 90 Day Supply Allowed 11/7/2013 Page 1

2 2nd Generation Antihistamine- Decongestant Alavert D (Requires Doctor's 1 cetirizine-d OTC (Requires Doctor's 1 Claritin-D OTC (Requires Doctor's 1 loratadine-d OTC (Requires Doctor's 1 ACE Inhibitors benazepril 1 captopril 1 enalapril maleate 1 fosinopril 3 lisinopril 1 moexipril 3 perindopril erbumine 3 quinapril 3 ramipril 1 trandolapril 3 Alkylating Agent - Triazenes Temodar 5 Alpha-Beta Blockers carvedilol 1 Coreg CR 3 labetalol 3 Aminopenicillin Antibiotic amoxicillin 1 Aminopenicillin Antibiotic - Betalactamase Inhibitor amoxicillin-potassium clavulanate ER 3 Analgesic Narcotic Agonists fentanyl Lozenge 3 fentanyl Transderm Patch 3 hydromorphone Rectal Suppository 1 hydromorphone tablet 1 meperidine 3 Methadone 3 morphine 20 mg/5 ml Oral Soln 3 morphine concentrate 3 morphine ER capsule 3 morphine ER tablet 1 morphine rectal suppository 3 morphine tablet 1 Nucynta 3 Nucynta ER 3 Opana ER 3 oxycodone capsule 1 oxycodone ER 3 oxycodone Oral Concentrate 3 oxycodone Oral Soln 3 oxycodone tablet 1 Oxycontin 3 oxymorphone 3 oxymorphone ER 3 tramadol 1 tramadol ER 3 Analgesic Narcotic Codeine acetaminophen-codeine 1 Ascomp w/codeine 1 Butalbital Comp-Codeine 1 butalbital-apap-caffeine-codeine 1 codeine-butalbital-asa-caffeine 1 Analgesic Narcotic Hydrocodone hydrocodone-apap 5mg mg/10ml, 2.5mg-167mg/5ml Oral Soln hydrocodone-apap capsule 3 hydrocodone-apap tablet 5/500mg, 1 5/325mg, 10/325mg hydrocodone-ibuprofen tablet 3 Vicodin 3 Vicodin ES 3 Vicodin HP 3 Analgesic Narcotic Oxycodone Endocet tablet 1 oxycodone-apap 2.5 mg-325 mg 3 tablet oxycodone-apap capsule 3 oxycodone-apap tablet 1 Roxicet tablet 1 Analgesic Narcotic Tramadol tramadol-apap 3 Analgesic or Antipyretic Non- Narcotic/Sedative butalbital-apap 3 butalbital-apap-caffeine 1 butalbital-apap-caffeine 50 mg mg-40 mg Androgen - Single Agents Androderm 3 AndroGel 3 Testim 3 testosterone cypionate 1 11/7/2013 Page 2

3 Angiotensin II Receptor Blocker (ARB)-Diuretic Benicar HCT 3 candesartan-hctz 3 Edarbyclor 3 irbesartan-hctz 3 losartan-hctz 1 Micardis HCT 2 valsartan-hctz 3 Angiotensin II Receptor Blockers (ARBs) Atacand 3 Benicar 3 Diovan 3 Edarbi 3 irbesartan 3 losartan 1 Micardis 2 Antianxiety Agent - Benzodiazepines alprazolam disintegrating tablet 3 alprazolam ER 3 alprazolam Intensol Oral Concentrate 3 chlordiazepoxide 3 clonazepam disintegrating tablet 3 clonazepam tablet 1 clorazepate 3 diazepam 1 lorazepam 1 oxazepam 3 Antianxiety Agent - Dicarbamate Type meprobamate 3 Antibacterial Folate Antagonist - Other sulfamethox/trimethoprim 1 Anticoagulants - Coumarin Jantoven 3 warfarin 3 Anticonvulsant - Barbiturates and primidone 1 Anticonvulsant - Carboxylic Acid divalproex ER 3 divalproex sprinkle capsule 3 valproic acid 1 Anticonvulsant - Functionalized Amino Acid Vimpat 3 Anticonvulsant - GABA Analogs gabapentin 1 Lyrica 3 Anticonvulsant - Hydantoins Dilantin 3 phenytoin sodium extended capsule 1 Anticonvulsant - Iminostilbene carbamazepine 1 carbamazepine ER 3 oxcarbazepine 1 Tegretol XR 3 Anticonvulsant - Monosaccharide topiramate 1 Anticonvulsant - Phenyltriazine lamotrigine tablets 1 Anticonvulsant - Pyrrolidine levetiracetam 1 Anticonvulsant - Sulfonamide zonisamide 1 Antidepressant - Alpha-2 Receptor Antagonists (NaSSA) mirtazapine 1 mirtazapine disintegrating tablet 3 Antidepressant - Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) bupropion 1 bupropion SR 1 bupropion XL 1 Antidepressant - Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram 1 citalopram Oral Soln 3 escitalopram 3 fluoxetine Oral Soln 3 fluoxetine 10 mg tablet 1 fluoxetine 20 mg tablet 3 fluoxetine capsule 1 fluoxetine delayed release 3 paroxetine 1 paroxetine ER 3 Antidepressant - Serotonin-2 Antagonist-Reuptake Inhibitors (SARIs) trazodone 1 Antidepressant - Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs) Cymbalta 3 11/7/2013 Page 3

4 Pristiq 3 venlafaxine 1 venlafaxine ER 1 Antidepressant - Tricyclics & Related (Non-Select Reuptake Inhibitors) amitriptyline 1 doxepin 1 doxepin Oral Concentrate 3 nortriptyline capsule 1 nortriptyline Oral Soln 3 Antidiarrheal Antiperistaltic- Anticholinergic diphenoxylate-atropine 1 Antidiuretic and Vasopressor Hormones desmopressin Nasal Spray 1 Antiemetic - Antihistamines meclizine 1 Antiemetic - Selective Serotonin 5- HT3 Antagonists ondansetron 1 Antihistamine - 1st Generation - Phenothiazines promethazine tab 1 Antihistamine - 1st Generation - Piperidines cyproheptadine 1 Antihistamines - 2nd Generation Alavert (Requires Doctor's 1 cetirizine OTC (Requires Doctor's 1 Claritin OTC (Requires Doctor's 1 desloratadine tab 3 fexofenadine tab 1 loratadine OTC (Requires Doctor's 1 Antihyperglycemic - Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Januvia 3 Onglyza 2 Antihyperglycemic - Sulfonylurea and Biguanide glyburide-metformin tablet 1 Antihyperglycemic - Sulfonylurea glimepiride 1 glipizide 1 glipizide ER 1 glyburide tablet 1 Antihyperglycemic, Incretin Mimetic,GLP-1 Receptor Agonist Analog-Type Victoza 3-Pak 3 Antihyperglycemic-Dipeptidyl Peptidase-4 (DPP-4) Inhibitor & Biguanide Janumet 3 Kombiglyze XR 2 Antihyperlipidemic - Bile Acid Sequestrants cholestyramine 1 Cholestyramine Light 1 colestipol 1 Prevalite 1 WelChol 3 Antihyperlipidemic - Fibric Acid Antara 3 fenofibrate 54mg, 160mg 1 fenofibrate micronized 43mg, 130mg 3 fenofibrate micronized 67mg, 1 134mg, 200mg fenofibrate nanocrystallized 3 fenofibric acid 3 Fenoglide 3 gemfibrozil 1 Lipofen 3 Tricor 3 Triglide 3 Trilipix 3 Antihyperlipidemic - HMG CoA Reductase Inhibitor & Niacin Advicor 3 Simcor 3 Antihyperlipidemic - HMG CoA Reductase Inhibitors (statins) Altoprev 3 atorvastatin 1 Crestor 3 fluvastatin 3 Lescol 3 Livalo 3 lovastatin 1 pravastatin 1 simvastatin 1 Antihyperlipidemic - Nicotinic Acid Niaspan extended release 3 11/7/2013 Page 4

5 Antihyperlipidemic - Selective Cholesterol Absorption Inhibitor Veramyst 27.5 mcg/actuation Nasal 3 Spray Antihyperlipidemic Agents - Dietary Source Lovaza 3 Antihyperlipidemic HMG CoA Reduct Inhib & Cholesterol Absorption Inhib Vytorin 3 Antihyperlipidemic-Microsomal Triglyceride Transfer Protein (MTP)Inhib Juxtapid 5 Anti-inflammatory Tumor Necrosis Factor Inhibiting Agnts,Non-SeIective Enbrel 5 Enbrel SureClick 5 Anti-inflammatory Tumor Necrosis Factor Inhibiting Agnts,TNF-alpha Sel Humira 5 Antimetabolite - Folic Acid Analogs methotrexate 1 Antimetabolite - Purine Analogs mercaptopurine 1 Antimetabolite - Pyrimidine Analogs Xeloda 5 Antimetabolite - Urea hydroxyurea 1 Antineoplastic - Antiandrogens bicalutamide 3 Antineoplastic - Aromatase Inhibitors anastrozole 1 exemestane 3 letrozole 1 Antineoplastic - Epidermal Growth Factor Receptor (EGFR) - specific Tarceva 5 Antineoplastic - mtor Kinase Inhibitors Afinitor 5 Antineoplastic - Protein-Tyrosine Kinase Inhibitors Gleevec 5 Sprycel 5 Sutent 5 Tasigna 5 Votrient 5 Antineoplastic - Thalidomide Analogs Revlimid 5 Antiprotozoal-Antibacterial 1st Generation 2-methyl-5- nitroimidazole metronidazole 1 Antithyroid Agents, Thionamides - Imidazole methimazole 1 Antithyroid Agents, Thionamides - Thiouracil propylthiouracil 1 Appetite Stimulants megestrol 1 Asthma Therapy - Beta Adrenergic- Anticholinergic Combivent Inhaler 3 Combivent Respimat 3 ipratropium-albuterol Neb Solution 3 Asthma Therapy - Glucocorticoids Asmanex Twisthaler 3 budesonide Neb Suspension 3 Flovent HFA 3 Pulmicort Flexhaler 3 Qvar 2 Asthma Therapy - Leukotriene Receptor Antagonists montelukast chewable tablet 1 montelukast Oral Granule 1 montelukast tablet 1 Asthma/COPD Therapy - Anticholinergics Spiriva 3 Asthma/COPD Therapy - Beta 2 Adrenergic Agents, Inhaled, Short Acting albuterol sulfate 1.25mg/3ml, mg/3ml Neb Solution albuterol sulfate 5mg/ml (0.5%), 3 2.5mg/3ml (0.083 %), 2.5mg/0.5ml Neb Solution albuterol sulfate HFA 3 levalbuterol Neb Solution 3 ProAir HFA 3 Proventil HFA 3 Ventolin HFA 2 Xopenex HFA 3 Asthma/COPD Therapy - Beta Adrenergic-Glucocorticoid Advair Diskus 3 Advair HFA 3 Dulera 2 Symbicort 3 11/7/2013 Page 5

6 Attention Deficit-Hyperactivity Disorder (ADHD) Therapy, NRI-Type Strattera 3 Beta Blockers Cardiac Selective atenolol 1 betaxolol 3 bisoprolol fumarate 1 Bystolic 3 metoprolol succinate ER 1 metoprolol tartrate 1 Beta Blockers Cardiac Selective, Intrinsic Sympathomimetic Activity acebutolol 3 Beta Blockers Non-Cardiac Select., Intrinsic Sympathomimetic Activity pindolol 1 Beta Blockers Non-Cardiac Selective nadolol 3 propranolol 1 timolol 3 Bipolar Therapy Agents - Anticonvulsant Type lamotrigine dose pack 3 Bipolar Therapy Agents - Lithium lithium carbonate 1 lithium carbonate ER 3 lithium citrate Oral Soln 3 Calcium Channel Blockers - Benzothiazepines Cartia XT 1 diltiazem 1 diltiazem CD 1 diltiazem ER capsule 1 Calcium Channel Blockers - Dihydropyridines Afeditab CR 1 amlodipine 1 Cardene SR 3 felodipine ER 3 isradipine 3 nicardipine 3 Nifediac CC 1 Nifedical XL 1 nifedipine 1 nifedipine ER 1 nisoldipine ER 1 Calcium Channel Blockers - Phenylakylamines verapamil ER 1 Cephalosporin Antibiotics - 1st Generation cephalexin 1 Cephalosporin Antibiotics - 2nd Generation cefuroxime 1 Cephalosporin Antibiotics - 3rd Generation cefdinir 1 Contraceptive Oral - Biphasic Necon 1 Contraceptive Oral - Monophasic Estarylla 1 Gianvi 1 Gildess FE 1 Junel 1 Junel FE 1 Lo Loestrin Fe 3 Loestrin 24 Fe 3 Loryna 1 Low-Ogestrel 1 Lutera 1 Microgestin 1 Microgestin FE 1 Mono-Linyah 1 Mononessa 1 Ocella 1 Orsythia 1 Previfem 1 Sprintec 1 Syeda 1 Vestura 1 Zarah 1 Contraceptive Oral - Triphasic norgestimate ethinyl estradiol 1 Tri-Linyah 1 Trinessa 1 Tri-Previfem 1 Tri-Sprintec 1 Dermatological - Antibacterial Other mupirocin 1 Dermatological - Antineoplastic Antimetabolites Fluoroplex 1 % Topical Cream 3 fluorouracil Topical Cream 1 fluorouracil Topical Soln 1 Dermatological - Antineoplastic or Premalignant Lesions - NSAID's Solaraze 3 11/7/2013 Page 6

7 Diagnostic - Blood Glucose Tests Accu-Chek Compact Test Strips 3 Breeze 2 Test Strips 3 FreeStyle Lite Strips 2 FreeStyle Test Strips 2 One Touch Ultra Test Strips 3 One Touch Verio Strips 3 Diagnostic - Blood Test Others Precision Xtra B-Ketone Strips 2 Diagnostic - Urine Glucose-Acetone Combination Tests Keto-Diastix Strips 3 Diagnostic - Urine Test Others KetoCare Test Strips 3 Ketone Care Strips 3 Ketone Urine Test Strips 3 Ketostix Strips 3 Direct Factor Xa Inhibitors Eliquis 3 Xarelto 3 Diuretic - Aldosterone Receptor Antagonist, Non-selective spironolactone 1 Diuretic - Aldosterone Receptor Antagonist, Selective eplerenone 3 Diuretic - Carbonic Anhydrase Inhibitors methazolamide 1 Diuretic - Loop bumetanide 1 furosemide 1 torsemide 1 Diuretic - Potassium Sparing amiloride 1 Dyrenium 3 Diuretic - Potassium Sparing- Thiazide & Related Aldactazide 3 amiloride-hctz 1 spironolactone-hctz 1 triamterene 37.5 mg-hctz 25 mg 1 capsule triamterene 50 mg-hctz 25 mg 3 capsule triamterene-hctz tablet 1 Diuretic - Thiazides and Related chlorthalidone 1 hydrochlorothiazide 1 indapamide 1 metolazone 1 DMARD - Pyrimidine Synthesis Inhibitors leflunomide 1 Estrogen-Progestin estradiol-norethindrone 3 Prempro 3 Estrogens estradiol tablet 1 estradiol Transderm Patch 1 Minivelle 3 Premarin tablets 1 Vivelle-Dot 3 Fluoroquinolone Antibiotics ciprofloxacin 1 levofloxacin 1 Gastric Acid Secretion Reducers - Histamine H2-Receptor Antagonists famotidine 1 nizatidine 1 Pepcid AC 20 mg tablet 1 ranitidine 1 Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (PPIs) Aciphex 3 Dexilant 3 lansoprazole 3 Nexium 3 omeprazole 1 pantoprazole 1 Prevacid 24Hr (Requires Doctor's 1 Prilosec OTC (Requires Doctor's 1 Gastric Acid Secretion Reducing- Proton Pump Inhibitor & Antacid Comb. Zegerid OTC (Requires Doctor's 1 Gastric Mucosa - Cytoprotective Prostaglandin Analogs misoprostol 1 Gastrointestinal Prokinetic Agents - D2 Antagonist/5-HT4 Agonists metoclopramide 1 GI Antispasmodic - Belladonna Alkaloids hyoscyamine 1 GI Antispasmodic - Synthetic Tertiary Amines dicyclomine 1 11/7/2013 Page 7

8 Gout Acute Therapy - Antimitotics Colcrys 3 Growth Hormones Omnitrope 4 Heparins heparin 5 Hyperuricemia Therapy - Xanthine Oxidase Inhibitors allopurinol 1 Uloric 3 Hypnotics - Melatonin M1/M2 Receptor Agonists Rozerem 3 Immune Globulin - gamma globulin (IgG), human Gammagard 5 Hizentra 5 Immune Globulin - Rho(D) RhoGam 5 Indirect Factor Xa Inhibitors fondaparinux 5 Inflammatory Bowel Agent - Glucocorticoids budesonide DR, ER capsule 3 Insulin Analogs - Fixed Humalog Mix 2 Humalog Mix KwikPen 2 Humalog Mix Pen 2 Insulin Analogs - Long Acting Lantus 3 Lantus Solostar 3 Levemir 2 Levemir Flexpen 2 Insulin Analogs - Rapid Acting Humalog 2 Insulin Response Enhancers - Biguanides metformin 1 metformin ER 1 Insulin Response Enhancers - Thiazolidinediones (PPAR-gamma agonists) pioglitazone 1 Lincosamide Antibiotics clindamycin 1 clindamycin oral solution 1 Low Molecular Weight Heparins enoxaparin 5 Fragmin 5 Macrolides azithromycin 1 clarithromycin 1 erythromycin 3 erythromycin delayed release 1 erythromycin ethylsuccinate 1 erythromycin stearate 1 Medical Supplies & DME - Glucose Monitoring Test Supplies FreeStyle Freedom Lite Kit 2 Freestyle InsuLinx Misc 2 Medical Supply, FDB Superset Freestyle InsuLinx Test Strips 2 FreeStyle Lite Meter Kit 2 FreeStyle Lite Strips 2 Migraine Therapy - Analgesic- Vasoconstrictors acetaminophen-isometheptenecaffeine 3 Narcolepsy & Cataplexy Therapy Agents - Sedative-Type Xyrem 5 Nasal Anticholinergics ipratropium bromide Nasal Spray 3 Nasal Antihistamines Astepro 0.15% Nasal Spray 3 azelastine Nasal Spray 3 Patanase 3 Nasal Corticosteroids Beconase AQ 3 flunisolide Nasal Spray 1 fluticasone Nasal Spray 1 Nasonex 3 Omnaris 3 QNASL 3 Rhinocort Aqua 3 triamcinolone acetonide Nasal Spray 3 Veramyst 3 Zetonna 3 NSAID Analgesic & Prostaglandin Analog diclofenac-misoprostol tablet 3 NSAID Analgesic, Cyclooxygenase-2 (COX-2) Selective Inhibitors Celebrex 3 NSAID Analgesics (COX Non- Specific) - Other nabumetone tablet 1 sulindac 1 NSAID Analgesics (COX Non- Specific) - Oxicam meloxicam Oral Susp 1 meloxicam tablet 1 11/7/2013 Page 8

9 piroxicam 1 NSAID Analgesics (COX Non- Specific) - Phenylacetic Acid diclofenac sodium tablet 1 NSAID Analgesics (COX Non- Specific) - Propionic Acid ibuprofen 1 ketoprofen capsule 3 naproxen Oral Susp 3 naproxen sodium tablet 1 naproxen tablet 1 oxaprozin 1 NSAID Analgesics, (COX Nonspecific) - Indole Acetic Acid etodolac capsule 3 etodolac tablet 3 indomethacin capsule 3 indomethacin ER capsule 3 Ophthalmic - Antibacterial- Glucocorticoid sulfacetamide-prednisolone 10 % % (0.25 %) Ophthalmic - Anti-inflammatory, Glucocorticoids Durezol 0.05 % Eye Drops 3 fluorometholone 0.1 % 3 Lotemax 0.5 % 3 prednisolone acetate 1 % 1 prednisolone sodium phosphate 1 % 1 Ophthalmic - Anti-inflammatory, Immunomodulators Restasis 0.05 % 3 Ophthalmic - Anti-inflammatory, NSAIDs diclofenac 0.1 % 1 ketorolac 0.4 % 1 ketorolac 0.5 % 1 Nevanac 0.1 % 3 Ophthalmic - Beta blockers-carbonic Anhydrase Inhibitor dorzolamide-timolol 2%-0.5% 1 Ophthalmic - Carbonic Anhydrase Inhibitors Azopt 1 % 3 dorzolamide 2 % 1 Ophthalmic - Intraocular Pressure Reducing Agents, Beta-blockers timolol maleate 0.25 % 1 timolol maleate 0.5 % 1 Ophthalmic-Intraocular Pressure Reducing Agents, Prostaglandin Analogs latanoprost % 1 Lumigan 0.01 % 3 Travatan Z % 3 Otic - Anti-infective Mixtures acetic acid-aluminum acetate Ear 1 Drops Otic - Anti-infectives other acetic acid Ear Soln 1 Otic - Glucocorticoids fluocinolone acetonide oil Ear Drops 3 hydrocortisone-acetic acid Ear Drops 1 Otic - Local Anesthetic-Analgesic antipyrine-benzocaine Ear Drops 1 Penicillin Antibiotic - Natural (i.e. Pen G, Pen V) penicillin V potassium 1 Peptic Ulcer - Gastric Lumen Adherent Cytoprotectives Carafate 3 Periodontal Product - Tetracycline- Type, Collagenase Inhibitors doxycycline 3 Platelet Aggregation Inhib - Cyclopentyl-triazolo-pyrimidines (CPTPs) Brilinta 3 Platelet Aggregation Inhib - PDEsterase &Adenosine deaminase Inhibitor dipyridamole 3 Platelet Aggregation Inhibitor Aggrenox 3 Platelet Aggregation Inhibitors - Phosphodiesterase III Inhibitors cilostazol 3 Platelet Aggregation Inhibitors - Thienopyridine Agents clopidogrel 3 Effient 3 ticlopidine 3 Progestins medroxyprogesterone 1 norethindrone acetate 1 progesterone micronized capsule 1 Prostatic Hypertrophy Agent - alpha- 1-Adrenoceptor Antagonists alfuzosin ER 3 11/7/2013 Page 9

10 Rapaflo 3 tamsulosin ER 1 Prostatic Hypertrophy Agent - Type I & II 5-alpha Reductase Inhibitors Avodart 3 Prostatic Hypertrophy Agent - Type II 5-alpha Reductase Inhibitors finasteride 5 mg 1 Renin Inhib, Direct - Calcium Channel Blocker & Thiazide Amturnide 3 Renin Inhibitor, Direct and Diuretic Tekturna 3 Salicylate Analgesic and Sedative Butalbital Comp 1 butalbital-asa-caffeine 1 butalbital-asa-caffeine 1 Sedative-Hypnotic - Barbiturates Butisol tablet 3 ButisolElixir 3 phenobarbital Elixir 1 phenobarbital tablet 1 Sedative-Hypnotic - Benzodiazepines Doral 3 estazolam 3 flurazepam 1 midazolam Syrup 3 triazolam 3 Sedative-Hypnotic - GABA-Receptor Modulators Lunesta 3 zaleplon 1 zolpidem 1 zolpidem ER 1 Tetracycline Antibiotics minocycline 1 Thrombin Inhibitor - Selective Direct & Reversible Pradaxa 3 Thyroid Hormones - Animal Source (Porcine) Armour Thyroid 3 Nature-Throid 3 NP Thyroid 3 Westhroid 3 Thyroid Hormones - Synthetic T3 (Triiodothyronine) liothyronine 1 Thyroid Hormones - Synthetic T4 (Thyroxine) Levothroid 1 levothyroxine 1 Levoxyl 1 Tirosint 3 Unithroid 1 Urinary Antibacterial - Nitrofuran nitrofurantoin 1 Urinary Antibacterial - Quinolones ciprofloxacin ER 3 Urinary Antispasmodic - Smooth Muscle Relaxants Detrol LA 3 flavoxate 1 Gelnique 3 oxybutynin chloride ER tablet 3 oxybutynin chloride Syrup 1 oxybutynin chloride tablet 1 Oxytrol 3 tolterodine 3 Toviaz 3 trospium 1 trospium ER 3 Vaccine Bacterial - Gram Positive Cocci Pneumovax 2 Vaccine Viral - Human Papillomavirus (HPV) Vaccines Gardasil 2 Vaccine Viral - Influenza A & B Flu Vaccine 2 Vaccine Viral - Varicella Zostavax 2 Vaginal Estrogens Estrace 0.01% Vaginal Cream 3 Premarin Vaginal Cream 3 Vagifem 3 11/7/2013 Page 10

11 Index 2014 CoventryOne Prescription Drug List Accu-Chek Compact Test Strips 7 acebutolol 6 acetaminophen-codeine 2 acetaminophen-isometheptenecaffeine 8 acetic acid Ear Soln 9 acetic acid-aluminum acetate Ear 9 Drops Aciphex 7 Advair Diskus 5 Advair HFA 5 Advicor 4 Afeditab CR 6 Afinitor 5 Aggrenox 9 Alavert (Requires Doctor's 4 Alavert D (Requires Doctor's 2 albuterol sulfate 1.25mg/3ml, mg/3ml Neb Solution albuterol sulfate 5mg/ml (0.5%), 5 2.5mg/3ml (0.083 %), 2.5mg/0.5ml Neb Solution albuterol sulfate HFA 5 Aldactazide 7 alfuzosin ER 9 allopurinol 8 alprazolam disintegrating tablet 3 alprazolam ER 3 alprazolam Intensol Oral Concentrate 3 Altoprev 4 amiloride 7 amiloride-hctz 7 amitriptyline 4 amlodipine 6 amoxicillin 2 amoxicillin-potassium clavulanate 2 ER Amturnide 10 anastrozole 5 Androderm 2 AndroGel 2 Antara 4 antipyrine-benzocaine Ear Drops 9 Armour Thyroid 10 Ascomp w/codeine 2 Asmanex Twisthaler 5 Astepro 0.15% Nasal Spray 8 Atacand 3 atenolol 6 atorvastatin 4 Avodart 10 azelastine Nasal Spray 8 azithromycin 8 Azopt 1 % 9 Beconase AQ 8 benazepril 2 Benicar 3 Benicar HCT 3 betaxolol 6 bicalutamide 5 bisoprolol fumarate 6 Breeze 2 Test Strips 7 Brilinta 9 budesonide DR, ER capsule 8 budesonide Neb Suspension 5 bumetanide 7 bupropion 3 bupropion SR 3 bupropion XL 3 Butalbital Comp 10 Butalbital Comp-Codeine 2 butalbital-apap 2 butalbital-apap-caffeine 2 butalbital-apap-caffeine 50 mg mg-40 mg butalbital-apap-caffeine-codeine 2 butalbital-asa-caffeine 10 Butisol tablet 10 ButisolElixir 10 Bystolic 6 candesartan-hctz 3 captopril 2 Carafate 9 carbamazepine 3 carbamazepine ER 3 Cardene SR 6 Cartia XT 6 carvedilol 2 cefdinir 6 cefuroxime 6 Celebrex 8 cephalexin 6 cetirizine OTC (Requires Doctor's 4 cetirizine-d OTC (Requires Doctor's 2 chlordiazepoxide 3 chlorthalidone 7 cholestyramine 4 Cholestyramine Light 4 cilostazol 9 ciprofloxacin 7 ciprofloxacin ER 10 citalopram 3 citalopram Oral Soln 3 clarithromycin 8 Claritin OTC (Requires Doctor's 4 Claritin-D OTC (Requires Doctor's 2 clindamycin 8 clindamycin oral solution 8 clonazepam disintegrating tablet 3 clonazepam tablet 3 clopidogrel 9 clorazepate 3 codeine-butalbital-asa-caffeine 2 Colcrys 8 colestipol 4 Combivent Inhaler 5 Combivent Respimat 5 Coreg CR 2 Crestor 4 Cymbalta 3 cyproheptadine 4 desloratadine tab 4 desmopressin Nasal Spray 4 Detrol LA 10 Dexilant 7 diazepam 3 diclofenac 0.1 % 9 diclofenac sodium tablet 9 diclofenac-misoprostol tablet 8 dicyclomine 7 Dilantin 3 diltiazem 6 diltiazem CD 6 diltiazem ER capsule 6 Diovan 3 diphenoxylate-atropine 4 dipyridamole 9 divalproex ER 3 divalproex sprinkle capsule 3 Doral 10 dorzolamide 2 % 9 dorzolamide-timolol 2%-0.5% 9 doxepin 4 doxepin Oral Concentrate 4 doxycycline 9 Dulera 5 Durezol 0.05 % Eye Drops 9 Dyrenium 7 Edarbi 3 Edarbyclor 3 Effient 9 Eliquis 7 enalapril maleate 2 Enbrel 5 Enbrel SureClick 5 Endocet tablet 2 enoxaparin 8 eplerenone 7 erythromycin 8 erythromycin delayed release 8 erythromycin ethylsuccinate 8 erythromycin stearate 8 escitalopram 3 Estarylla 6 estazolam 10

12 Estrace 0.01% Vaginal Cream 10 estradiol tablet 7 estradiol Transderm Patch 7 estradiol-norethindrone 7 etodolac capsule 9 etodolac tablet 9 exemestane 5 famotidine 7 felodipine ER 6 fenofibrate 54mg, 160mg 4 fenofibrate micronized 43mg, 130mg 4 fenofibrate micronized 67mg, 4 134mg, 200mg fenofibrate nanocrystallized 4 fenofibric acid 4 Fenoglide 4 fentanyl Lozenge 2 fentanyl Transderm Patch 2 fexofenadine tab 4 finasteride 5 mg 10 flavoxate 10 Flovent HFA 5 Flu Vaccine 10 flunisolide Nasal Spray 8 fluocinolone acetonide oil Ear Drops 9 fluorometholone 0.1 % 9 Fluoroplex 1 % Topical Cream 6 fluorouracil Topical Cream 6 fluorouracil Topical Soln 6 fluoxetine Oral Soln 3 fluoxetine 10 mg tablet 3 fluoxetine 20 mg tablet 3 fluoxetine capsule 3 fluoxetine delayed release 3 flurazepam 10 fluticasone Nasal Spray 8 fluvastatin 4 fondaparinux 8 fosinopril 2 Fragmin 8 FreeStyle Freedom Lite Kit 8 Freestyle InsuLinx Misc 8 Freestyle InsuLinx Test Strips 8 FreeStyle Lite Meter Kit 8 FreeStyle Lite Strips 7 FreeStyle Test Strips 7 furosemide 7 gabapentin 3 Gammagard 8 Gardasil 10 Gelnique 10 gemfibrozil 4 Gianvi 6 Gildess FE 6 Gleevec 5 glimepiride 4 glipizide 4 glipizide ER 4 glyburide tablet 4 glyburide-metformin tablet 4 heparin 8 Hizentra 8 Humalog 8 Humalog Mix 8 Humalog Mix KwikPen 8 Humalog Mix Pen 8 Humira 5 hydrochlorothiazide 7 hydrocodone-apap 5mg mg/10ml, 2.5mg-167mg/5ml Oral Soln hydrocodone-apap capsule 2 hydrocodone-apap tablet 5/500mg, 2 5/325mg, 10/325mg hydrocodone-ibuprofen tablet 2 hydrocortisone-acetic acid Ear Drops 9 hydromorphone Rectal Suppository 2 hydromorphone tablet 2 hydroxyurea 5 hyoscyamine 7 ibuprofen 9 indapamide 7 indomethacin capsule 9 indomethacin ER capsule 9 ipratropium bromide Nasal Spray 8 ipratropium-albuterol Neb Solution 5 irbesartan 3 irbesartan-hctz 3 isradipine 6 Jantoven 3 Janumet 4 Januvia 4 Junel 6 Junel FE 6 Juxtapid 5 KetoCare Test Strips 7 Keto-Diastix Strips 7 Ketone Care Strips 7 Ketone Urine Test Strips 7 ketoprofen capsule 9 ketorolac 0.4 % 9 ketorolac 0.5 % 9 Ketostix Strips 7 Kombiglyze XR 4 labetalol 2 lamotrigine dose pack 6 lamotrigine tablets 3 lansoprazole 7 Lantus 8 Lantus Solostar 8 latanoprost % 9 leflunomide 7 Lescol 4 letrozole 5 levalbuterol Neb Solution 5 Levemir 8 Levemir Flexpen 8 levetiracetam 3 levofloxacin 7 Levothroid 10 levothyroxine 10 Levoxyl 10 liothyronine 10 Lipofen 4 lisinopril 2 lithium carbonate 6 lithium carbonate ER 6 lithium citrate Oral Soln 6 Livalo 4 Lo Loestrin Fe 6 Loestrin 24 Fe 6 loratadine OTC (Requires Doctor's 4 loratadine-d OTC (Requires Doctor's 2 lorazepam 3 Loryna 6 losartan 3 losartan-hctz 3 Lotemax 0.5 % 9 lovastatin 4 Lovaza 5 Low-Ogestrel 6 Lumigan 0.01 % 9 Lunesta 10 Lutera 6 Lyrica 3 meclizine 4 medroxyprogesterone 9 megestrol 5 meloxicam Oral Susp 8 meloxicam tablet 8 meperidine 2 meprobamate 3 mercaptopurine 5 metformin 8 metformin ER 8 Methadone 2 methazolamide 7 methimazole 5 methotrexate 5 metoclopramide 7 metolazone 7 metoprolol succinate ER 6 metoprolol tartrate 6 metronidazole 5 Micardis 3 Micardis HCT 3 Microgestin 6 Microgestin FE 6 midazolam Syrup 10 Minivelle 7 minocycline 10 mirtazapine 3 mirtazapine disintegrating tablet 3 misoprostol 7 moexipril 2

13 Mono-Linyah 6 Mononessa 6 montelukast chewable tablet 5 montelukast Oral Granule 5 montelukast tablet 5 morphine 20 mg/5 ml Oral Soln 2 morphine concentrate 2 morphine ER capsule 2 morphine ER tablet 2 morphine rectal suppository 2 morphine tablet 2 mupirocin 6 nabumetone tablet 8 nadolol 6 naproxen Oral Susp 9 naproxen sodium tablet 9 naproxen tablet 9 Nasonex 8 Nature-Throid 10 Necon 6 Nevanac 0.1 % 9 Nexium 7 Niaspan extended release 4 nicardipine 6 Nifediac CC 6 Nifedical XL 6 nifedipine 6 nifedipine ER 6 nisoldipine ER 6 nitrofurantoin 10 nizatidine 7 norethindrone acetate 9 norgestimate ethinyl estradiol 6 nortriptyline capsule 4 nortriptyline Oral Soln 4 NP Thyroid 10 Nucynta 2 Nucynta ER 2 Ocella 6 omeprazole 7 Omnaris 8 Omnitrope 8 ondansetron 4 One Touch Ultra Test Strips 7 One Touch Verio Strips 7 Onglyza 4 Opana ER 2 Orsythia 6 oxaprozin 9 oxazepam 3 oxcarbazepine 3 oxybutynin chloride ER tablet 10 oxybutynin chloride Syrup 10 oxybutynin chloride tablet 10 oxycodone capsule 2 oxycodone ER 2 oxycodone Oral Concentrate 2 oxycodone Oral Soln 2 oxycodone tablet 2 oxycodone-apap 2.5 mg-325 mg 2 tablet oxycodone-apap capsule 2 oxycodone-apap tablet 2 Oxycontin 2 oxymorphone 2 oxymorphone ER 2 Oxytrol 10 pantoprazole 7 paroxetine 3 paroxetine ER 3 Patanase 8 penicillin V potassium 9 Pepcid AC 20 mg tablet 7 perindopril erbumine 2 phenobarbital Elixir 10 phenobarbital tablet 10 phenytoin sodium extended capsule 3 pindolol 6 pioglitazone 8 piroxicam 9 Pneumovax 10 Pradaxa 10 pravastatin 4 Precision Xtra B-Ketone Strips 7 prednisolone acetate 1 % 9 prednisolone sodium phosphate 1 % 9 Premarin tablets 7 Premarin Vaginal Cream 10 Prempro 7 Prevacid 24Hr (Requires Doctor's 7 Prevalite 4 Previfem 6 Prilosec OTC (Requires Doctor's 7 primidone 3 Pristiq 4 ProAir HFA 5 progesterone micronized capsule 9 promethazine tab 4 propranolol 6 propylthiouracil 5 Proventil HFA 5 Pulmicort Flexhaler 5 QNASL 8 quinapril 2 Qvar 5 ramipril 2 ranitidine 7 Rapaflo 10 Restasis 0.05 % 9 Revlimid 5 Rhinocort Aqua 8 RhoGam 8 Roxicet tablet 2 Rozerem 8 Simcor 4 simvastatin 4 Solaraze 6 Spiriva 5 spironolactone 7 spironolactone-hctz 7 Sprintec 6 Sprycel 5 Strattera 6 sulfacetamide-prednisolone 10 % % (0.25 %) sulfamethox/trimethoprim 3 sulindac 8 Sutent 5 Syeda 6 Symbicort 5 tamsulosin ER 10 Tarceva 5 Tasigna 5 Tegretol XR 3 Tekturna 10 Temodar 2 Testim 2 testosterone cypionate 2 ticlopidine 9 timolol 6 timolol maleate 0.25 % 9 timolol maleate 0.5 % 9 Tirosint 10 tolterodine 10 topiramate 3 torsemide 7 Toviaz 10 tramadol 2 tramadol ER 2 tramadol-apap 2 trandolapril 2 Travatan Z % 9 trazodone 3 triamcinolone acetonide Nasal Spray 8 triamterene 37.5 mg-hctz 25 mg 7 capsule triamterene 50 mg-hctz 25 mg 7 capsule triamterene-hctz tablet 7 triazolam 10 Tricor 4 Triglide 4 Tri-Linyah 6 Trilipix 4 Trinessa 6 Tri-Previfem 6 Tri-Sprintec 6 trospium 10 trospium ER 10 Uloric 8 Unithroid 10 Vagifem 10 valproic acid 3 valsartan-hctz 3 venlafaxine 4

14 venlafaxine ER 4 Ventolin HFA 5 Veramyst 8 Veramyst 27.5 mcg/actuation Nasal 5 Spray verapamil ER 6 Vestura 6 Vicodin 2 Vicodin ES 2 Vicodin HP 2 Victoza 3-Pak 4 Vimpat 3 Vivelle-Dot 7 Votrient 5 Vytorin 5 warfarin 3 WelChol 4 Westhroid 10 Xarelto 7 Xeloda 5 Xopenex HFA 5 Xyrem 8 zaleplon 10 Zarah 6 Zegerid OTC (Requires Doctor's 7 Zetonna 8 zolpidem 10 zolpidem ER 10 zonisamide 3 Zostavax 10

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