Prescription Documents

Section Banner Image

Prescription medications are an important part of a health benefits package. The below documents and resources help you understand the details of your prescription drug coverage benefit.

Attention Individual Members
: prescription documents for Individual members can be found on coventryone.com by selecting your state, then clicking on Members > Document Library.

Formulary Information

2013 - 2014  Formulary Changes
PDF | 24 KB
This list includes drugs that were added to or deleted from the formulary. This will help you talk with your doctor about the drugs you take and how you might save money.
2014 Formulary Updates
PDF I 231 KB
This document contains updates made to the 2014 Formulary.
2014 Self-Administered Injectable Formulary
PDF | 41 KB
This is a list of drugs that are used for limited medical conditions and are injected. It includes those we cover and formulary alternatives to non-covered drugs. This will help you talk with your doctor about the drugs you take and how you might save money.
2013 Self-Administered Injectable Formulary
PDF | 73 KB
This is a list of drugs that are used for limited medical conditions and are injected. It includes those we cover and formulary alternatives to non-covered drugs. This will help you talk with your doctor about the drugs you take and how you might save money.
Generic Drugs
PDF | 8 KB
This document contains important information concerning generic drugs including myths and facts.
Pharmaceutical Management Procedures - Members
PDF | 80 KB
This document contains important information about how the formulary is developed, the process by which your provider can request a medication coverage exception, and additional pharmacy benefit information which is available online or by calling Customer Service.
Pharmaceutical Management Procedures - Providers
PDF | 76 KB
This document contains important information about how the formulary is developed, the process by which you as the provider can request a medication coverage exception, and additional pharmacy benefit information which is available online or by calling Provider Services.


Prior Auth, Step Therapy & Quantity Information

2014 Standard Prior Authorization List
PDF I 41 KB
Some drugs require prior approval, or prior authorization of coverage, before we will cover their cost. This is the list of drugs that require prior authorization. Your doctor needs to check this list and get approval before prescribing these drugs
2013 Standard Prior Authorization List
PDF | 24 KB
Some drugs require prior approval, or prior authorization of coverage, before we will cover their cost. This is the list of drugs that require prior authorization. Your doctor needs to check this list and get approval before prescribing these drugs.
2014 Standard Step Therapy List
PDF I 134 KB
Stepped therapy means that certain “steps” or actions need to be followed for some drugs to be covered. This document lists the drugs that require stepped therapy. Your doctor needs to check this list and follow the steps before prescribing these drugs.
2013 Standard Step Therapy List
PDF | 39 KB
Stepped therapy means that certain “steps” or actions need to be followed for some drugs to be covered. This document lists the drugs that require stepped therapy. Your doctor needs to check this list and follow the steps before prescribing these drugs.
2014 Select Prior Authorization List
PDF I 38 KB
Some drugs require prior approval, or prior authorization of coverage, before we will cover their cost. This is the list of drugs that require prior authorization. Your doctor needs to check this list and get approval before prescribing these drugs.
2013 Select Prior Authorization List
PDF
Some drugs require prior approval, or prior authorization of coverage, before we will cover their cost. This is the list of drugs that require prior authorization. Your doctor needs to check this list and get approval before prescribing these drugs.
2014 Select Step Therapy List
PDF I 36 KB
Stepped therapy means that certain “steps” or actions need to be followed for some drugs to be covered. This document lists the drugs that require stepped therapy. Your doctor needs to check this list and follow the steps before prescribing these drugs.
2013 Select Step Therapy List
PDF
Stepped therapy means that certain “steps” or actions need to be followed for some drugs to be covered. This document lists the drugs that require stepped therapy. Your doctor needs to check this list and follow the steps before prescribing these drugs.
Prior Authorization Criteria
ZIP | 6 MB
These documents are specific to each drug that requires prior authorization. Each document lists the information we need before we will approve coverage.
Drug Coverage Policies
ZIP | 2 MB
This link contains the Drug Coverage Policies that are referenced in the Prior Authorization Criteria documents.
Prior Authorization Forms
ZIP | 3 MB
These forms are used by providers to request prior authorization for drugs.
Quantity Level Limit List
PDF | 168 KB
For some drugs, we limit the number of pills or units that are covered by the benefit plan within a certain period of time. This list includes drugs that have quantity limits. It will help you understand how fills and refills work.
100 Dose Limit Exceptions (Attachment D)
PDF | 26 KB


Forms & Mail Order

Prescription Drug Direct Claim Form (English)
PDF | 94 KB
Use this form to request reimbursement for prescriptions filled after January 1, 2014.
Prescription Drug Direct Claim Form (Spanish)
PDF I 189 KB
Use this form to request reimbursement for prescriptions filled after January 1, 2014.
Mail Order Exclusion List
PDF | 11 KB
Some prescriptions cannot be filled through the mail-order pharmacy. This document lists those drugs.
Prescription Drug Mail Order Form (English)
PDF | 60 KB
Use this form to submit new prescriptions for mail-order fulfillment.
Prescription Drug Mail Order Form (Spanish)
PDF I 45 KB
Use this form to submit new prescriptions for mail-order fulfillment.
Prescription Drug Health Questionnaire (English)
PDF | 83 KB
Fill out this form and return it with the first mail-order form you send to Express Scripts.  It is not needed for subsequent mail order requests.
Prescription Drug Health Questionnaire (Spanish)
PDF | 85 KB
Fill out this form and return it with the first mail-order form you send to Express Scripts. It is not needed for subsequent mail order requests.

© Copyright 2008-2014 Coventry Health Care