Prescription Formulary

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A formulary is a list of drugs that CoventryCares of Kentucky covers. The list includes prescription drugs and some over-the-counter (OTC) medicines. We have provided the formulary below in two ways. One list is arranged by the alphabet (Alpha Formulary) and the other list arranged by class of drug (Class Formulary).

Formulary Documents

Alpha Formulary 2014
PDF | 84KB
This is a list of the drug formulary in alphabetical order
Class Formulary 2014
PDF | 125KB
This is a list of the drug formulary arranged by drug class
Pharmaceutical Management Procedures - Members
PDF | 80KB
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.

Prior Authorization Forms

Chronic Controlled Substance Agreement
PDF | 198KB
Rx Prior Auth

Prior Authorization Forms

General Prior Auth/Non-Formulary Medication
PDF | 32KB
Rx Prior Authorization
Narcotic Prior Authorization Form
PDF | 244KB
Rx Prior Auth
Non-Formulary ADD/ADHD Therapies
PDF | 32KB
Rx Pre Auth Forms
Non-Formulary Antidepressant
PDF | 32KB
Rx NF Forms
Non-Formulary Atypical Antipyschotics
PDF | 32KB
Rx Pre-Auth
Non-Formulary Fibromyalgia Therapies
PDF | 32KB
Rx Pre Auth
Non-Formulary Opioid Narcotics
PDF | 32KB
Rx Pre Auth
Non-Formulary PPI or High Dose PPI
PDF | 31KB
Rx Pre-Auth
Singulair (montelukast) Prior Auth Form
PDF | 29KB
Rx Pre Auth
Suboxone (buprenorphine/naloxone) Prior Auth Form
PDF | 37KB
Rx Pre Auth
Subutex (buprenorphine) Prior Authorization Form
PDF | 121KB
Rx Pre Auth Form

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