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 2015
PDF | 84KB
This is a list of the drug formulary in alphabetical order
Class Formulary 2015
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.

Controlled Substances

Chronic Controlled Substance Agreement
PDF | 198KB
Rx Prior Auth

Prior Authorization Forms

General Prior Auth/Non-Formulary Medication
PDF | 32 KB
Rx Prior Authorization
ADD/ADHD Prior Authorization Form
PDF | 32 KB
Rx Pre Auth Forms
Antidepressant Prior Authorization Form
PDF | 263 KB
Rx NF Forms
Atypical Antipyschotics Prior Authorization Form
PDF | 263 KB
Rx Pre-Auth
Fibromyalgia Prior Authorization Form
PDF | 128 KB
Rx Pre Auth
Hepatitis C Prior Authorization Form
RX Prior Auth
PPI or High Dose PPI Prior Authorization Form
PDF | 31KB
Rx Pre-Auth
Singulair (montelukast) Prior Auth Form
PDF | 137 KB
Rx Pre Auth
Suboxone (buprenorphine/naloxone) Prior Auth Form
PDF | 2668 KB
Rx Pre Auth
Subutex (buprenorphine) Prior Authorization Form
PDF | 469 KB
Rx Pre Auth Form

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