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2013 PersonalCare
Pharmacy Savings Program
The chart below represents approved drug classes for the PersonalCare Pharmacy Savings Program. Examples are provided within each approved drug class to assist you. There may
be generic equivalents for the brand-name examples listed. Talk to your doctor about whether a generic alternative would be right for you. If you have one of these conditions and are
currently taking any of the applicable medications listed, but are not currently enrolled in a Coventry PersonalCare Condition Support program, please contact customer service using the
number on your insurance ID card for more information. Note: The PersonalCare Pharmacy Savings Program does not apply to Tier 3 drugs.
This is the most current list at the time of printing as is subject to change.
Condition
Chronic Obstructive
Pulmonary Disease
Heart Failure
Coronary Artery Disease
Diabetes
Drug class
Inhaled Corticosteroids (COPD Metered Dose Inhalers ONLY)
Beta-Blockers and Combinations
Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol, Metoprolol ER, Nadolol, Methylxanthines
Ace Inhibitors and Combinations
Benazepril, Benazepril/Hydrochlorothiazide, Captopril, Captopril/Hydrochlorothiazide, Enalapril, Enalapril/ Hydrochlorothiazide, Fosinopril, Fosinopril/Hydrochlorothiazide, Lisinopril, Lisinopril/Hydrochlorothiazide, Moexipril, Moexipril/Hydrochlorothiazide, Quinapril, Quinapril/Hydrochlorothiazide, Ramipril, Trandolapril Leukotriene Modifiers
Long Acting Beta Agonists
Angiotensin Receptor Blockers and Combinations
Benicar®, Benicar HCT®, Micardis®, Micardis HCT® Combinations:
Combinations:
Hydralazine with Isosorbide in
Cholesterol/Triglyceride Lowering Therapy
African Americans or Intolerant
to ACEI/ARB
Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Fenofibrate, Gemfibrozil Agonists and Inhaled Corticosteroids Agonists and Inhaled Corticosteroids Niaspan®, Simcor®, Altoprev®, Crestor®, Trilipix® 2012 Coventry Health Care, Inc. All rights reserved. CVTY.PC.RXSAVE.2013.GUIDE.1012 2013 PersonalCare Pharmacy Savings Program – Prescription Drug Guidelines
Condition
Chronic Obstructive
Pulmonary Disease
Heart Failure
Coronary Artery Disease
Diabetes
Drug class
Anticholinergics
Loop Diuretics
Antiplatelets, Thienopyridine,
Biguanides and Combinations
Combinations:
P2Y12 Platelet Inhibitors:
Potassium Sparing Diuretics
Calcium Channel Blockers and
Sulfonylureas
Combinations
Nitroglycerin as Needed and
Thiazolidinediones (TZDs)
Long Acting Nitrates
Glucagon Like Peptide-1s
Dipeptidyl Peptidase-4s (DPP4s)
2012 Coventry Health Care, Inc. All rights reserved. CVTY.PC.RXSAVE.2013.GUIDE.1012 2013 PersonalCare Pharmacy Savings Program – Prescription Drug Guidelines
Condition
Chronic Obstructive
Pulmonary Disease
Heart Failure
Coronary Artery Disease
Diabetes
Drug class
Alpha Glucosidase Inhibitors
Combinations:
Anticholinergics
Potassium Sparing Diuretics
Nitroglycerin as Needed and
Long Acting Nitrates
Glinide’s
Brand versions of generically available drugs are covered according to the member’s Prescription Drug Rider.
Some drugs on this list require Prior Approval and/or have quantity limits. Waiver or reduction of the member copay does not imply that coverage is guaranteed. PLEASE NOTE: This is not meant to be a complete or most updated list of the drugs included in the program and covered under your plan. Brand names are listed for informational reference and there may be generics available. Ask your doctor whether a
generic alternative would be right for you. All information is subject to change.
2012 Coventry Health Care, Inc. All rights reserved. CVTY.PC.RXSAVE.2013.GUIDE.1012

Source: http://www.augusta.k12.va.us/cms/lib01/VA01000173/Centricity/Domain/10/COVENTRY%20Pharmacy%20Savings%20Program%201%2016%2014.pdf

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