Formulary

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Formulary

A formulary is a list of medications that are covered by your plan.

Please see the below list to review your plan formulary. Or you can call us at the number listed on your member identification card.

2014 Formulary

Find 2014 Information

2015 Formulary Information




Formulary Change Notice

PENNSYLVANIA
HMO :

Advantra UCPN Plus (HMO) - H3959 (038)

Advantra Silver (HMO) - H3959 (010)
Advantra Silver (HMO) - H3959 (011)
Advantra Silver (HMO) - H3959 (031)
Advantra Silver (HMO) - H3959 (033)

Advantra Silver Plus (HMO) - H3959 (032)
Advantra Silver Plus (HMO) - H3959 (039)

Advantra Gold (HMO) - H3959 (001)
Advantra Gold (HMO) - H3959 (002)

Advantra Northern Pennsylvania Gold (HMO) - H3959 (037)

Advantra Cares (HMO SNP) - H3959 (035)
Advantra Cares (HMO SNP) - H3959 (036)

PPO :

Advantra Silver (PPO) - H5522 (004)
Advantra Silver (PPO) - H5522 (005)
Advantra Silver (PPO) - H5522 (018)

Advantra Silver Plus (PPO) - H5522 (013)

Advantra Gold (PPO) - H5522 (001)
Advantra Gold (PPO) - H5522 (002)
Advantra Gold (PPO) - H5522 (014)
Advantra Gold (PPO) - H5522 (015)

AdvantraOne (PPO) - H5522 (017)
OHIO
Formulary Change Notices for Ohio :

Advantra Silver (PPO) - H8980 (002)
Advantra Gold (PPO) - H8980 (004)


Online Formulary Search

Obtain pricing and coverage information for any medications available through your plan.
Advantra HMO and PPO Plan Online Formulary Search


Printable Formulary

PENNSYLVANIA
HMO Formularies :

Advantra UCPN Plus (HMO) - H3959 (038)

Advantra Silver (HMO) - H3959 (010)
Advantra Silver (HMO) - H3959 (011)
Advantra Silver (HMO) - H3959 (031)
Advantra Silver (HMO) - H3959 (033)

Advantra Silver Plus (HMO) - H3959 (032)
Advantra Silver Plus (HMO) - H3959 (039)

Advantra Gold (HMO) - H3959 (001)
Advantra Gold (HMO) - H3959 (002)

Advantra Northern Pennsylvania Gold (HMO) - H3959 (037)

Advantra Cares (HMO SNP) - H3959 (035)
Advantra Cares (HMO SNP) - H3959 (036)

PPO Formularies :

Advantra Silver (PPO) - H5522 (004)
Advantra Silver (PPO) - H5522 (005)
Advantra Silver (PPO) - H5522 (018)

Advantra Silver Plus (PPO) - H5522 (013)

Advantra Gold (PPO) - H5522 (001)
Advantra Gold (PPO) - H5522 (002)
Advantra Gold (PPO) - H5522 (014)
Advantra Gold (PPO) - H5522 (015)

AdvantraOne (PPO) - H5522 (017)
OHIO
Advantra Silver (PPO) - H8980 (002)

Advantra Gold (PPO) - H8980 (004)


Additional Information

Grievances & Appeals
Grievance & appeal information for members.

Medicare Part D Prescription Drug Benefits

Click here to find more information about Coventry's Part D benefits.

You may have the option to use mail-order. For mail-order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Typically, mail-order drugs arrive within 9 to 12 days. Please call us if you do not receive your mail-order drugs within this timeframe. Coventry members please call the phone number listed on the back of your member ID card

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Page Last Updated: 09/28/2014
CMS Approved Date: Approved 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

© Copyright 2008-2014 Coventry Health Care

Coventry Health Care is a Coordinated Care plan with a Medicare contract. First Health Part D is a Medicare-approved Part D sponsor. Enrollment in our plans depends on contract renewal.