Your Coventry Health Care Prescription Benefits
Retail Maintenance Benefit
If you take a medication on a regular basis (maintenance drug), you may be eligible to get a 90-day supply of your medication
either through the mail order program described above or through the retail maintenance program. If you obtain your
maintenance medications at a retail pharmacy instead of through the mail order, you will pay one copayment for up to a 31-day
supply1, two copayments for up to a 60-day supply1 and three copayments for up to a 90-day supply1. To take advantage of
either the mail order benefit or the retail maintenance benefit, ask your doctor to write your prescription for a 90-day supply.
Access to National Pharmacy Network
Designed to provide maximum geographic coverage, the pharmacy network consists of more than 62,000 stores in the United
States, Puerto Rico and the Virgin Islands. The national network includes national chains and independent drug stores. You can
find participating pharmacies on our website,
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.
Online Drug List
Our online Prescription Drug List will provide you with important information such as generic and preferred drug alternatives,
quantity limits and prior authorization requirements. You can also access the mail order program. To use the online formulary,
visit the Services and Support section of and click on the link for Prescription Coverage on the right
side of the page. Your plan coverage may vary slightly from the searchable formulary results. Once you have been enrolled, we
encourage you to use the pharmacy tools on which can be accessed through My Online Services.
Transition Rx Program
Things to Remember
This program provides new members with a transition service for the first 90 • Use your member ID card when days of coverage beginning on your effective date. You may obtain a one- filling a prescription. You may only file a claim for reimbursement for a time fill or refill of certain covered prescription drugs, up to a 30-day supply, at the applicable copayment without being subject to prior authorization, step therapy and/or quantity limit requirements that normally apply to those drugs. Coventry Health Care will then send a letter to your prescribing provider advising that the one-time fill or refill was made available. Most • If you take a specific medicine on a commonly used prior authorization, step therapy and once-daily quantity limit drugs are eligible under the Transition Rx program. Specialty injectables and other quantity limits are excluded from the program. To find out what drugs are subject to prior authorization, step therapy, quantity limits or other 800-627-4872 or the Pharmacy
requirements, you may call Customer Service at 800-627-4872 or visit
Help Desk at 800-378-7040.
Generic Drugs
Coventry Health Care’s program requires “mandatory” generic substitution if the FDA has determined the generic to be
equivalent to the brand-name product. If your physician requires that you take the brand-name drug instead of the generic
drug, or if you elect the brand-name rather than the generic at the point of sale, you will pay the applicable copayment plus the
difference (ancillary charge) in cost between the generic and the brand. The ancillary charge does not apply to any deductible
or maximum out-of-pocket.
Quantity Limits
Some medications on the Prescription Drug List have restrictions on the quantity that Coventry Health Care will cover.
Priorauthorization may be required if the dosage of the medication being prescribed varies from the FDA and manufacturer’s
recommended dose.
The following services are not covered under your prescription drug benefits:
• Drugs which are not Medically Necessary.
• Allergy supplies, including syringes. • Drugs obtained from non-participating pharmacies in a • Experimental and Investigational Drugs; products not non-emergency situation when such pharmacies have approved by the FDA; drugs with no FDA-approved not previously notified the Company, by facsimile or indications, medications prescribed at dosages in excess otherwise, of their agreement to accept as payment in of FDA approval; drugs prescribed for purposes other full reimbursement for their services at rates available to than the FDA approved use, unless a drug is recognized pharmacies that are Participating Providers, including any for treatment of the covered indication in one of the Copayment, Coinsurance and/or Deductible consistently Standard Reference Compendia or in substantially accepted Peer-reviewed Medical Literature. Cancer • Any Prescription Drug which is to be administered, drugs that are FDA approved for a certain cancer type in whole or in part, while a Covered Individual is in a may be used for treatment of other types of cancer, hospital, medical office or other health care facility.
provided the drug has been recognized as safe and effective for treatment of that specific type of cancer in • Any Prescription Drug that is being used or abused in a any of the Standard Reference Compendia. Any drug manner that is determined to be furthering an addiction to approved by the FDA for use in the treatment of cancer pain shall not be denied for coverage on the basis that • Legend drugs for which there is a non-Prescription the dosage is in excess of the recommended dosage Drug alternative (such as over-the-counter) and over- of the pain relieving agent, if the prescription in excess the-counter (OTC) products not requiring a prescription of the recommended dosage has been prescribed in to be dispensed (like aspirin, antacids, herbal products, compliance with Virginia law for a patient with intractable oxygen, medicated soaps, food, food supplements, food replacements, and bandages) with the exception of OTC • Tubing for insulin pumps; Ostomy supplies, including programs sponsored by the Company, such as Prilosec bags, adhesives, and tubing. This is covered as stated in Section Six of the Certificate of Insurance.
• Contraceptive implant systems and intrauterine devices • Vitamins and minerals (both OTC and legend), except (IUDs); Coverage for contraceptive implant systems and legend prenatal vitamins for pregnant and nursing IUDs are covered under Section Six of the Certificate of females, liquid or chewable legend pediatric vitamins for children under age 13, and potassium supplements to • Dietary supplements, appetite suppressants, drugs used to treat obesity or assist in weight reduction or weight • Medical supplies other than those specifically provided herein, medical equipment, and support garments.
• Drugs and products for smoking cessation, including • Biological sera, and Hemophilia blood factors with the Prescription Drugs such as Zyban and Chantix, with the exception of programs sponsored by the Company exception of OTC programs sponsored by the Company.
• Medications used to enhance athletic performance, • Medications prescribed for cosmetic purposes, including including but not limited to, anabolic steroids but not limited to, tretinoin for aging skin and minoxidil lotion.
• Refill of prescriptions resulting from loss or theft or resulting from damage by the Covered Individual.
• Drugs and products used to treat infertility.
• Medications for treatment of diseases of teeth and gums, • Injectable medications, with the exception of Self- Administered Injectable Drugs as described in this Rider or programs sponsored by the Company.


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