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Changes to the Altius Preferred Drug List will be based on recommendation from Altius’ Pharmacy and Therapeutics Committee and modifications may occur quarterly. Actual benefits on your plan may vary regarding drug coverage, copays, coinsurance, quantity limits, days supply, and prior authorization. This document is a brief list of the most requested preferred brand name and generic medications and may not be a complete listing of all drugs on the Altius Preferred Drug List.
Making your Preferred Drug
Examples include but are not limited to medications for blood pressure, asthma, antidepressants, oral anticoagulants, diabetes, hormone List work for you.
Non-maintenance medications are not available through mail order and Using your Altius Preferred Drug List can save you time and money! Take include antihistamines (Allegra, Claritin and Zyrtec), antibiotics, pain this list with you when you visit your physician – preferred medications are management (hydrocodone), muscle relaxants, injectables, anti-migraine, available at lower copays. By getting a prescription for a preferred medications for sleep or anxiety (alprazalam, Ambien and diazepam), acne medication at your physician’s office, you can avoid delays at the preparations and topical creams and ointments. What about generics? Ask your physician or pharmacist if your
Mail Order is Easy!
prescription is available in a therapeutically equivalent generic. Most Altius Obtain from your physician a new prescription for a 90-day supply for plans allow for a lower copay for preferred generic medications and your each medication or refill (when the prescription has expired).
physician or pharmacist will be happy to answer any questions.
Fill out and mail the Mail Pharmacy Service form, available from Altius What if my medication is not on the list? Talk to your physician about a
Customer Service at 800-377-4161 or from Caremark Customer Service at
formulary alternative. The Altius Preferred Drug List provides sound clinical 800-378-7040.
choices for all disease states. Non-preferred brand name medications You will receive your medications in about 14 days. Since this can take up require the highest copayment and often there is an equivalent generic to two weeks, make sure you have a sufficient quantity on hand (a two- week supply) so you don’t run out while waiting for your medication to arrive in the mail.
How do I keep my monthly prescription costs under control?
Good question! First, work with your preferred physician to choose
You may access the status of your order by contacting the Caremark Inc. medications that are on the preferred list and choose preferred generics when possible. Second, check out the mail order program. Some maintenance mediations are available through the mail order program at What about refills?
only two or three copayments for a three-month (90-day) supply. Check Three weeks before your medication is gone, simply call the 24-hour refill your benefit brochure for the details of your plan. That’s savings delivered line at 800-378-7040, or to access the status of your order.
If you try to refill your prescription too soon, Caremark will not recognize Changes to the Preferred Drug List
the refill order and you will need to request it again when you are within three weeks of the refill date. This includes new prescriptions being mailed Deletions from the preferred drug list will take place on a bi-annual in or phoned-in requests from your physician.
basis. Changes are based on reviews made on new medications, generic equivalents and clinical therapies introduced by the FDA (Food and Drug If you prefer using the internet, you may visit Caremark’s mail service Administration). Exceptions to this policy will be made only if the FDA or pharmacy at www.caremark.com and follow their online directions.acy at the Pharmacy and Therapeutics Committee deem a medication unsafe, www.caremark.com and follow their online directions.
clinically inferior, or more cost effective therapies become available.
Where can I purchase my prescriptions?
Additions to the Preferred Drug List will be made on a quarterly basis. These additions will be subject to the Pharmacy and Therapeutics Visit Caremark’s website at www.caremark.com, register as a member, go Committee’s decision that the medication’s efficacy, safety, side effects, to “My Caremark,” and use the “Pharmacy locator” link to find a pharmacy adverse reaction and cost effectiveness profile meets Altius’ standards.
convenient to you. You can get up to a 30-day supply at over 350 participating pharmacies that are listed in your Altius Provider Directory. Newly introduced medications by the FDA may be restricted from If you do not have one, please call the Caremark customer service coverage until the drug has been available for 6-8 months and reviewed by department at 800-378-7040.
the Pharmacy and Therapeutics Committee. This will ensure it’s safety for our members.
If you are traveling outside the service area, you may contact the
Caremark customer service department at 800-378-7040 for the
location of the nearest contracted pharmacy in the continental United
Quantity Levels
States. In an emergency situation, you may pay for a prescription and Some medications have specific limits pertaining to quantity per refill or mail a reimbursement form along with the receipts to Caremark for how often a medication can be refilled. This is to ensure that our reimbursement. Reimbursement forms may be obtained from the Altius or members receive the recommended and proper dose and length of therapy for their specific disease state. a preferred drug list by quantity limits can be found on our website at www.altiushealthplans.com.
Why can’t my local pharmacy provide me with
Prior Authorization
my mail order prescription?
Due to Caremark’ size, they are able to offer medications to Altius at
Some medications need prior authorization from Altius before they can be greater discounts than local pharmacies. Altius passes these savings on to dispensed. These drugs were chosen due to their high potential for adverse its members by offering a 90-day supply for two or three copayments.
reactions, contraindications, potential for abuse and cost. Medications that require prior authorization are listed at the end of this document. You or your physician may contact Coventry’s Prior Authorization Department at Will the mail order substitute my prescription with
877-215-4100 for an authorization form to be faxed to your provider or
a generic?
his/her office. Your provider must complete the request and fax it back to To help keep costs down, Caremark may contact your physician to see the Prior Authorization Department for an authorization review. Approval if they may substitute your brand name prescription with an equivalent or denial will be communicated to your provider. You may also phone the Prior Authorization Department for a status of your request.
Mail-Order
What can cause my mail order prescription to be
The prescription mail order service program allows a member to receive a delayed?
90-day supply of maintenance medication while only paying one, two or Prescriptions may be delayed if a duplicate prescription is filled at a local three copayments, depending upon your prescription benefit. Refer to your pharmacy within 10 days of requesting a mail order prescription. The mail- benefit brochure for the details of your plan.
order prescription will be returned if you are receiving two prescriptions at one time. Members should also avoid ordering a prescription before 75% What does “maintenance medication” mean? A maintenance medication (68 days) of your existing mail order prescription is gone. Caremark will is any prescription that is defined by Altius to be taken on a daily basis. view your order as too early to fill.
A member should always have a 2-week supply of medication on hand. are not available through our prescription mail service. However, certain Caremark has a great track record of filling medication in a timely manner injectables can be purchased through Caremark Specialty Mail Order if there are no issues. However, many members do not take into account Service. This program can help lower members’ out-of-pocket costs and the time for the order to be delivered by the U.S. Postal Service. Altius have the medication and supplies delivered to the member’s home or recommends that members determine if a prescription requires a prior physician’s office within 24 to 48 hours.
authorization or is not available through the mail order prior to placing To find out how to participate and if Caremark Specialty Mail Order their order. Any prescription for an injectable, non-maintenance, or Service provides a specific medication, members can call toll free at medication requiring prior authorization will be returned.
800-237-2767.
From time to time, a manufacturer may not be able to produce enough medication to meet the demand. Caremark will contact our member to Who is responsible for obtaining prior
notify them when to expect shipment of the drug or return the prescription authorization?
if the manufacturer cannot supply the medication.
The prescribing physician is required to contact Altius Health Plans’ Prior Authorization Department to obtain the authorization on the member’s behalf.
Can we buy our prescriptions from Canada or
How long does a prior authorization take?
Mexico and ask Altius to reimburse us?
A completed form that is faxed into the Altius prior authorization desk will Unfortunately, Altius is not able to reimburse prescriptions from outside the take between 24 to 48 hours (during business days). A physician who does continental United States because it violates Federal law. Members should not respond to a request or fails to completely fill out the form will delay use caution if purchasing medications outside the United States. There are concerns that the drugs could be counterfeit or do not meet the regulatory standards of the United States.
How do I find out if an authorization has been
granted?
Could my prescription cost less than my
Altius Health Plans will contact your physician’s office with an approval copayment?
or denial. You or your physician may also phone our customer service Sometimes a prescription can cost less than your benefit copayment. When department to inquire about the status of an authorization.
this happens, Altius wants to make sure that you pay the least amount Is prior authorization necessary for injectable
possible for your medication. Altius will allow the pharmacy to charge you only the actual cost of the drug rather than the full copayment required by medications?
Most injectables obtained from a retail pharmacy or the Caremark Specialty Mail Order Service do not require prior authorization. There are some How does my plan work if I have a pharmacy
injectables that do require prior authorization. Please refer to our website or Altius Customer Service for a complete list.
deductible?
A pharmacy deductible is often separate from your regular medical
What if I do not agree with the Altius decision on
deductible. When obtaining your prescription, you pay the pharmacy deductible listed on your membership card and in your Medical Benefits a prior authorization, quantity level, payment or
Brochure. Once your deductible is satisfied, you pay the applicable copay denial of services?
Physicians can write a letter of medical necessity indicating why Altius should consider an exception to their policy. Letters of medical necessity Will Altius pay for a medication that is not listed
on the Preferred Drug List?
Altius will most likely pay for drugs not listed on our Preferred Drug List but Are generics as good as brand name medications?
Members can initiate an appeal after they have exhausted the normal Altius encourages the use of generics because they cost less and they authorization process (prior authorization, letter of medical necessity). An work the same as the name brand drugs. Altius only allows generics on appeal can be sent to the following address: the preferred drug list that have been rated by the FDA as therapeutically equivalent and are as safe and effective as the name brand medication.
What is a preferred generic equivalent benefit?
If you receive a brand name drug when a preferred generic equivalent can If I have further question, whom should I call?
be substituted, you will pay the difference in cost between the generic and the brand name drug, any applicable deductible, and/or the generic copay. Altius Customer Service
800-377-4161
If your benefit has an out-of-pocket maximum, your generic equivalent For general information about your Altius account.
benefit still applies. Regular benefits apply if a preferred generic cannot be Caremark Inc. Customer Service . . . . . . . . . . . . 800-378-7040
For forms and claim status information. For information about your What is Step Therapy?
pharmacy benefits. To find out if your pharmacy is in the Coventry Pharmacy Network.
Step Therapy is an electronic edit or a physician notification which To find pharmacies outside the service area.
documents that a patient has failed or been intolerant to an alternative therapy before a specific medication, injectable drug or medical device is Caremark Inc. Physician Call-in Line . . . . . . . . . 800-378-5697
What if my doctor prescribes the same drug but in
Coventry Prior Authorization Department . . . . . . 877-215-4100
(Physician’s office should make the call)
different strengths?
If a physician individualizes a dose that requires two different strengths of the
Mail order general information . . . . . . . . . . . . . 800-378-7040
same medication, Altius will require a copayment for each dispensed strength.
What about injectables? Are they covered?
Caremark Specialty Mail Order Service . . . . . . . 800-237-2767
For most plans, most injectable medications (with the exclusion of insulin, glucagon, Symlin, Byetta, Imitrex, bee-sting kits and Lovenox) will be http://www.AltiusHealthPlans.com
covered as a medical benefit rather than a pharmacy benefit. Injectables With our prescription drug plan, you have three options when a doctor gives you a prescription.
Preferred Generic (Tier 1) - includes most generic and a few selected OTC (over-the-counter) drugs. This is your lowest copay ($).
Preferred Brand Name (Tier 2) - Preferred brand name drugs are your middle copay ($$).
Non-Preferred (Tier 3) - Non-preferred brand name, and a few non-preferred generic drugs. This is your highest copay ($$$).
These Tier 3 drugs may have a lower cost alternative on Tier 1 or Tier 2. Check the list at the bottom of this page.
This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed here are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded from your plan (for ex-ample, oral contraceptives, growth hormone). We periodically review our Preferred Drug 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. Please contact Customer Service at (801) 323-6200 or at 1-800-377-4161 for any questions about your coverage or for more information. You may also visit our website at www.altiushealthplans.com.
Preferred Generic (Tier 1) - $ (Lower Case) and
Preferred Brand Name (Tier 2) - $$ (UPPER CASE)
EFFEXOR XR (ST)ELMIRONEMCYTEMTRIVA (PA)enaIapriI prescri ption - generic copay) dextroamphetamine Non-Preferred (Tier 3) - $$$
Motrin*, Naprosyn*, Mobic*, Voltaren*, Orudis*, Clinoril*, Generic over-the-counter. Loratadine is covered with a BRAND TEST STRIPS One Touch Test Stri ps ACEON Accupril*, Lotensin*, Prinivil*, Zestril* Valisone*, Kenalog*, Di prosone*, Topicort*, Synalar*, ACLOVATE« Hydrocortisone*, Synalar*, Desowen* ACTIVELLA Prempro, PremphaseACTONEL AlendronateACTOPLUSMET (PA) Actos (PA) plus Glucophage* Adderall*, Ritalin*, Ritalin SR*, Metadate ER*, Concerta Adderall*, Ritalin*, Ritalin SR*, Metadate ER*, Concerta ALTACE Prinivil*, Lotensin*, Accupril*, Vasotec* Zaditor OTC*, Alaway*, Crolom*, Alamast, Alomide Ambien*, Ativan*, Halcion*, Serax*, Restoril*, Sonata* Clindamycin Topical plus OTC Benzoyl Peroxide ANZEMET Compazine*, Phenergan*, Tigan*, Zofran* Valisone*, Kenalog*, Di prosone*, Topicort*, Synalar*, Adderall*, Ritalin*, Ritalin SR*, Metadate ER*, Concerta GABITRIL Phenobarbital*, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Mysoline*, Klonopin*, Zarontin*, Depakene*, OTC Benzoyl Peroxide plus Topical Clindamycin* Amaryl*, Diabeta*, Glucotrol*, Glynase*, Micronase*, Motrin*, Naprosyn*, Mobic*, Voltaren*, Orudis*, Clinoril*, Catapres*, Aldomet*, Hytrin*, Mini press*, Cardura* REMERON SOLTAB« Remeron*, Celexa*, Prozac*, Zoloft*, Paxil* RESCULA Lumigan, TravatanRESTORIL 7.5/22mg Restoril* 15mg & 30mg, Ambien*, Halcion* RHINOCORT Flonase*, Nasonex, Nasalide*RITALIN LA KEPPRA Phenobarbital*, Tegretol*, Tegretol XR, Carbatrol, Adderall*, Ritalin*, Ritalin SR*, Metadate ER*, Concerta Dilantin*, Mysoline*, Klonopin*, Zarontin*, Depakene*, Depakote, Depakote ER, Neurontin* Ambien*, Ativan*, Halcion*, Serax*, Restoril*, Sonata* LAMICTAL Phenobarbital*, Tegretol*, Tegretol XR, Carbatrol, SERZONE Celexa*, Prozac*, Zoloft*, Paxil* Dilantin*, Mysoline*, Klonopin*, Zarontin*, SKELAXIN Flexeril*, Lioresal*, Robaxin*, Soma* Depakene*, Depakote, Depakote ER, Neurontin* Zocor*, Pravachol*, Mevacor*, Crestor (5mg ST), Zocor*, Pravachol*, AltoPrev*, Mevacor*, Crestor (5mg ST), LIPITOR 40mg, 80mg Zocor*, Pravachol*, AltoPrev*, Mevacor*, Yaz, several oral contraceptives are available on the LOVAZA Lofibra*, Lopid*, Niaspan*, Triglide Phenobarbital*, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Mysoline*, Klonopin*, Zarontin*, Depakene*, TOPAMAX Phenobarbitol*, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Mysoline*, Klonopin*, Zarontin*, Depakene*, Depakote, Depakote ER, Neurontin TRILEPTAL* Phenobarbital*, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Mysoline*, Klonopin*, Zarontin*, Depakene*, Depakote, Depakote ER, Neurontin* NAPRELAN Motrin*, Naprosyn*, Voltaren*, Orudis*, Clinoril*, ULTRAVATE Temovate*, Psorcon, Di prolene* NORGESIC/NORFLEX Flexeril*, Lioresal*, Robaxin*, Soma*NOVO BRAND INSULINS Premarin Cream, Estrace Cream, Ogen Cream Calan*, SR*, Cardizem CD*, Adalat CC*, Procardia XL* Dolophine*, MS Contin*, Duragesic*, Opana ER VIGAMOX Tobrex*, Gentamicin*, Ciloxan*, Ocuflox* several oral contraceptives are available on the VYVANSE (PA > 17yrs) Adderall*, Ritalin*, Ritalin SR*, Metadate ER*, Concerta FORTE DSC« Flexeril*, Lioresal*, Robaxin*, Soma* WELLBUTRIN XL* (ST) Wellbutrin SR*, Wellbutrin* Alaway, Zaditor OTC (covered with prescription tier 1 copay) Alaway, Zaditor OTC (covered with prescription tier 1 copay) PRAVACHOL 80mg Zocor*, Mevacor*, Pravachol 40mg (x2) Albuterol Inhaler*, ProAir (generic copay), Maxair PREVACID CAPSULES Prilosec OTC*, omeprazole*, Protonix Calan SR*, Cardizem CD*, Adalat CC*, Procardia XL* PROTOPIC Hydorcortisone*, Betamethasone*, Triamcinolone*, ZETIA Zocor*, Pravachol*, Vytorin (10/10mg ST), Niaspan ZYMAR Tobrex*, Gentamicin*, Ciloxan*, Ocuflox*ZYPREXA (ST) Generic over-the-counter Loratadine is covered Generic over-the-counter Loratadine is covered Brand Name Drugs with Preferred Generic EquivalentsThe following brand name drugs have preferred generic equivalents available. The preferred generic equivalents are available at a Preferred Generic (Tier 1) copay. If you choose to receive the Brand Name version when a Preferred Generic is available, you will pay the Preferred Generic copay plus the difference in cost between the Preferred Generic and the Preferred Brand Name.
* Generic equivalent at Tier One copay. If you choose to receive the Brand Name version when a Preferred Generic is available, you will pay the Preferred
Generic copay plus the difference in cost between the Preferred Generic and the Preferred Brand Name.
* Generic equivalent at Tier One copay. If you choose to receive the Brand Name version when a Preferred
Generic is available, you will pay the Preferred Generic copay plus the difference in cost between the Preferred
Generic and the Preferred Brand Name.
INJECTABLE DRUG LIST WITH PREFERRED ALTERNATIVES
Dependent upon benefit design, Preferred may require the lowest copayment level and Non-Preferred the highest copayment level. Please refer to your Altius member handbook for details.
PREFERRED
PREFERRED ALTERNATIVE
PREFERRED PREFERRED ALTERNATIVE
MIACALCIN INJECTION MIACALCIN NASAL SPRAY, FOSAMAX VANTAS LUPRONZEMAIRA PROLASTINZOVIRAX INJECTION ACYCLOVIR REMICADE MEDICATIONS EXCLUDED FROM ALTIUS’ PHARMACY BENEFIT
Oral and Topical Prior Authorization Agents
Ranexa (ranolazine extended-release) Actoplus Met (pioglitazone/metformin) Adderall XR (mixed amphetamines ext rel)** Ritalin LA (methylphenidate ext rel)** Avandaryl (rosiglitazone/glimepiride) Sporanox capsule* and oral solution (itraconazole) Daytrana (methylphenidate patch)** Duetact (pioglitazone/glimperide) Exubera (insulin human [rDNA origin]) Focalin XR (dexmethylphenidate ext rel)** Testosterone Products (Testim, Androgel, Striant, Androderm, Insulin (intermediate & long-lasting) Pens (Novopen, Humulin Lovaza (formerly Omacor, omega-3 fatty acids) Marinol (dronabinol)Metadate CD (methylphenidate ext rel)** * indicates generic form available;ă lowest copay charged ** indicates Prior Auth required over age 18. Opana IR (oxymorphone immediate release) ^ indicates Prior Auth required over age 4 OxyContin (oxycodone sustained release)Perforomist (formoterol) Under two tier managed formulary benefits, formulary excep- tion criteria must be met in addition to the prior authorization Mail-Order Exclusion List
Medications Not Covered Through Mail-Order
Plan approved maintenance medications are available through mail order if the memberÊs employer has purchased a mail order benefit. Maintenance medications are those drugs that are needed for long-term or chronic conditions such as high blood pressure or diabetes. Examples of some of the drugs that are excluded are listed below and include non-maintenance medications, all controlled substances, and self administered injectables. Members may call Member Services to inquire about whether specific medications are covered through mail order.
Migraine Relief Drugs - Examples include - Amerge, Axert, Cafergot, D.H.E 45, Ergotamine, Frova,
Imitrex, Maxalt, Maxalt MLT, Midrin, Migral, Migranal, Relpax, Sansert, Zomig, Zomig ZMT
Antibiotics - Examples include - Keflex, Duricef, Ceclor, Lorabid, Ceftin, Omnicef, Erythromycin,
Pediazole, Zithromax, Biaxin, Amoxil, Trimox, Princi pen, Dynapen, Pen Vee K, Veetids, Augmentin, Zyvox
Antifungals - Examples include - Diflucan, Griseofulvin, Lamisil, Nizoral, Nystatin, Sporanox, Vfend
Antiemetics - Examples include - Anzemet, Emend, Kytril, Zofran
Controlled Substances - All controlled substances are excluded from mail-order. Examples include drugs in
the following classes:
ĉĆĩÇ Opioids - Oxycontin, MsContin, Percocet, Vicodin, Darvocet, Opana, Opana ERÇ CNS depressants - Valium, Ativan, Xanax, AmbienÇ CNS stimulants - Concerta, Adderall, Ritalin, ProvigilÇ Cannabinoids - MarinolÇ Anabolic Steroids - Androgel, Testim, Androderm Self Administered Injectables - Examples include - Sandostatin, Apokyn, Actimmune, Neupogen, Leukine,
Procrit, Methotrexate, D.H.E. 45, Epogen, Nutropin, Nutropin Depot, Humatrope, Protropin, Genotri pin,
Norditropin, Saizen, Somavert, Serostim, Heparin, Fragmin, Lovenox, Arixtra, Innohep, Normiflo, Orgaran,
Pegasys, PEG-Intron, Intron-A, Roferon A, Infergen, Fuzeon, Edex, Caverject, Avonex, Copaxone, Betaseron,
Rebif, Forteo, Miacalcin, Enbrel, Humira, Vivaglobin, and Kineret.
Miscellaneous Agents
Ana-Kit, Epi pen, Epi pen-JR, Twinject, Copegus, Rebetol. Drugs prohibited from dispensing large quantities
(Xyrem, Clozaril, Accutane & generic). Drugs with total cost over $1,500 require prior authorization.
2009 Standard Stepped Therapy Agents
The following drugs will require prior authorization if the condition is not met when
the pharmacist would attempt to transmit a prescri ption claim.
Condition
Aciphex (rabeprazole) . Trial & failure of Prilosec OTC or omeprazole AND ProtonixAmbien CR (zolpidem extended release) . Trial & failure of Ambien* or Sonata*, AND LunestaAmitiza (lubiprostone) . Trial & failure of Lactulose*, Miralax*Azor (amlodipine/olmesartan) . Trial & failure of Benicar/Benicar HCT or Micardis/Micardis HTC or LotrelCelebrex (celecoxib) . Trial & failure of 2 NSAIDsClarinex (desloratadine) .Trial & failure of Claritin* AND Zyrtec OTCCoreg 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/Ditropan XL* or Sanctura/Sanctura XLEffexor (venlafaxine) . Trial & failure of an SSRIEffexor XR (venlafaxine extended rel) .Trial & failure of an SSRIEnablex (darifenacin) . Trial & failure of Ditropan/Ditropan XL* or Sanctura/Sanctura XLExforge (amlodipine/valsartan) . .Trial & failure of Trial & failure of Benicar/Benicar HCT or Lescol/Lescol XL (fluvastatin) . Trial & failure of Zocor*Lexapro (escitalopram) . Trial & failure of a generic SSRILipitor (atorvastatin) 10mg & 20mg only . Trial & failure of Zocor*Lunesta (eszopiclone) . Trial & failure of Ambien* or Sonata*Luvox CR (fluvoxamine extended release) . Trial & failure of an SSRIMetrogel 1% (metronidazole) . Trial & failure of Metrogel 0.75%*Nexium (esomeprazole) . Trial & failure of Prilosec OTC or omeprazole AND ProtonixNiravam ODT (alprazolam immediate rel) . Trial of Xanax*Oxytrol (oxybutynin transdermal) . Trial & failure of Ditropan/Ditropan XL* or Sanctura/Sanctura XLPaxil CR* (paroxetine extended release) . Trial of Paxil*Prevacid (lansoprazole) . Trial of Prilosec OTC or omeprazole AND ProtonixPristiq (desvenlafaxine) .Trial of any SSRI and Effexor Prozac Weekly (fluoxetine extended rel) . Trial of Prozac*Requip XL (ropinirole) . Trial of Requip*Rozerem (ramelteon) . Trial & failure of Ambien* or Sonata*, AND LunestaSensipar (cinacalcet) . Trial & failure of Vitamin D analogs & PhosloSingulair (montelukast) . Prior prescription for an asthma medicationUltram ER (tramadol extended release) . Trial of Ultram*Vancocin (vancomycin) 250mg only . Trial & failure of Vancocin 125mgVesicare (solifenacin) . Trial & failure of Ditropan/Ditropan XL* or Sanctura/Sanctura XLVytorin (simvastatin/ezetimibe) 10/10 only . Trial & failure of Zocor*Wellbutrin XL (buproprion ext rel) 150mg only . Trial of Wellbutrin* or Wellbutrin SR*Xyzal (levocetirizine) . Trial & failure of Claritin* AND Zyrtec OTCZelapar ODT (selegeline) . Trial of Eldepryl* Italics indicate non-formulary agents* indicates generic form available – lowest copay charged ^ indicates agent is not covered The Physician Call-in Line is a safe, reliable way for your physician to order your prescription through Mail Order. If your physician is planning to fax a prescription or refill through Mail Order, have him/her use the Call-in Line and phone in your order to ensure your prescriptions are received safely, accurately and timely, as faxes can be unreadable or lost in transmittal.
For authorization, physicians please call Coventry’s Prior Authorization For authorization, physicians please fax prior authorization form to Altius Health Plans’ Prior Authorization Desk at 1-801-323-6160 or 1-800-434-6250. Each request will be answered by a return fax.
For questions, please feel free to call Altius Health Plans’ For recent updates and changes, you may visit our web site at Altius Customer Service . . . . . . . . . . . . . . . . . . . . . . . . 800-377-4161 For general information about your Altius account.
Caremark Inc. Customer Service . . . . . . . . . . . . . . . . . 800-378-7040 For forms and claim status information.
For information about your pharmacy benefits.
To find out if your pharmacy is in the Coventry Pharmacy Network.
To find pharmacies outside the service area.
Caremark Inc. Physician Call-in Line . . . . . . . . . . . . . 800-378-5697 Prior Authorization Department . . . . . . . . . . . . . . . . . 800-377-4161 (Physician’s office should make the call) Mail order general information . . . . . . . . . . . . . . . . . . 800-378-7040 Caremark Specialty Mail Order Service . . . . . . . . . . 800-237-2767

Source: http://www.continsurance.com/images/2009_Altius_Formulary.pdf