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.  

2016 Formulary Information




Formulary Change Notice

PENNSYLVANIA
This is where you will find any changes to your covered drugs. See the Printed Formulary section below to find your formulary document for your plan.
HMO :

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 Choice Plan (HMO) - H3959 (043)
Advantra Fayette Prime (HMO) - H3959 (044)

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) - H1608 (029)
Advantra Gold (PPO) - H1608 (030)


Online Formulary Search

Online Formulary Search

Search for drugs in a plan using an online search tool.



Printable Formulary

PENNSYLVANIA
HMO Formularies :

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 Choice Plan (HMO) - H3959 (043)
Advantra Fayette Prime (HMO) - H3959 (044)

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) - H1608 (029)

Advantra Gold (PPO) - H1608 (030)


Additional Information

Grievances & Appeals
Grievance & appeal information for members.

Medicare Part D Prescription Drug Benefits

Find more information about Coventry's Part D benefits.

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 7 to 14 days. Please call us if you do not receive your mail-order drugs within this timeframe.

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More Information

Y0022_PDPCCP_2013_4006_1202b Approved
CMS Approved Date: 02/08/2013
Page Last Updated: 03/09/2016

© Copyright 2008-2016 Coventry Health Care

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.