STANDARD Stepped Therapy Agents ~ 2013
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list.
Drug Condition Abilify (aripiprazole) ODT or solution
Trial & failure of Abilify oral tablet
Trial & failure of metformin/ER (at least 1500mg/d)
ActoPLUS Met* (pioglitazone / metformin)
Trial & failure of metformin/ER (at least 1500mg/d)
ActoPLUS Met XR (pioglitazone / metformin ext rel)
Trial & failure of metformin/ER (at least 1500mg/d)
Ambien CR* (zolpidem extended release)
Trial & failure of Ambien* or Sonata*
Trial & failure of Lactulose* or Miralax*
Apidra (insulin glulisine) vial, pen
Trial of Aricept 10mg QD for at least 3 months
Trial & failure of Imitrex*, Amerge* or Maxalt
Trial & failure of Flonase* or Nasalide*, AND Nasonex
Trial & failure of a Imitrex* or Amerge*
Trial & failure of 2: Claritin OTC*, Zyrtec OTC*, Allegra OTC
Coreg CR (carvedilol extended rel) Cosopt PF (dorzolamide / timolol) preservative free
Trial & failure of Abreva or oral acyclovir
Detrol / Detrol LA (tolterodine / extended release)
Trial & failure of Ditropan* or Sanctura*
Ditropan XL (oxybutynin extended release)
Trial & failure of Ditropan* or Sanctura*
Dovonex cream, ointment, solution (calcipotriene)
Trial & failure of a medium to high potency topical steroid
Trial & failure of metformin/ER (at least 1500mg/d)
Trial & failure of Ditropan* or Sanctura*
Epiduo gel (adapalene/benzoyl peroxide)
Trial & failure of 2: Risperdal*, Seroquel*, Geodon*
Trial & failure of metformin/ER (at least 1500mg/d)
Trial & failure of Imitrex*, Amerge* or Maxalt
Gelnique (oxybutynin topical gel)
Trial & failure of Ditropan* or Sanctura*
Trial & failure of metformin/ER (at least 1500mg/d)
* indicates generic available Italics indicate Non-Formulary agents # indicates Step Therapy required for age 18yr and under
This is the most current list at the time of printing and is subject to change. Last update September 28, 2012
STANDARD Stepped Therapy Agents ~ 2013
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list.
Drug Condition
For Post-Herpetic Neuralgia: trial & failure of Neurontin*
For Restless Leg Syndrome: Trial & failure of 2: Neurontin*, Requip*, Mirapex*
Trial & failure of Rocaltrol* For Post-Herpetic Neuralgia: trial & failure of Neurontin*
For Restless Leg Syndrome: Trial & failure of 2: Neurontin*, Requip*, Mirapex*
Trial & failure of 2: Risperdal*, Seroquel*, Geodon*
Janumet (sitagliptin / metformin)
Trial & failure of metformin/ER (at least 1500mg/d)
Janumet XR (sitagliptin / metformin ext rel)
Trial & failure of metformin/ER (at least 1500mg/d)
Trial & failure of metformin/ER (at least 1500mg/d) Trial & failure of metformin/ER (at least 1500mg/d), AND
Jentadueto (linagliptin / metformin)
Trial & failure of metformin/ER (at least 1500mg/d)
Trial & failure of Levemir vial or pen
Trial & failure of 2: Risperdal*, Seroquel*, Geodon*
Lescol* / Lescol XL (fluvastatin)
Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor
Trial & failure of Apriso, Asacol or Asacol HD
Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor
Trial & failure of Ambien* or Sonata*
Luvox CR (fluvoxamine extended release)
Trial & failure of Lotrimin* and Spectazole*
Trial & failure of Flonase* or Nasalide*, AND Nasonex Trial & failure of 2: Neurontin*, Requip*, Mirapex* (covered without
* indicates generic available Italics indicate Non-Formulary agents # indicates Step Therapy required for age 18yr and under
This is the most current list at the time of printing and is subject to change. Last update September 28, 2012
STANDARD Stepped Therapy Agents ~ 2013
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list.
Drug Condition
Trial & failure of Flonase* or Nasalide*, AND Nasonex
Trial & failure of metformin/ER (at least 1500mg/d)
Trial & failure of Ditropan* or Sanctura*
Paxil CR* (paroxetine extended release)
Trial & failure of Flonase* or Nasalide*, AND Nasonex
Trial & failure of Imitrex*, Amerge* or Maxalt
Trial & failure of Flonase* or Nasalide*, AND Nasonex
Trial & failure of Risperdal* oral tablet
Sanctura XR (trospium extended release)
Trial & failure of Ditropan* or Sanctura*
Trial & failure of 2: Risperdal*, Seroquel*, Geodon* Trial & failure of Rocaltrol* (covered without trials for
hyperparathyroidism & parathyroid carcinoma)
Symbyax (olanzapine / fluoxetine)
Trial & failure of 2: Risperdal*, Seroquel*, Geodon*
Taclonex (calcipotriene/betamethasone dip)
Trial & failure of Dovonex AND a medium to high potency topical steroid
Trial & failure of Retin-A Micro (covered without trials for psoriasis)
Trial & failure of Ditropan* or Sanctura* Trial & failure of metformin/ER (at least 1500mg/d), AND
Tretin-X 0.0375% cream (Combo pack not covered) Ultram ER* (tramadol extended release)
Trial & failure of 2 medium to high potency topical steroids
Trial & failure of a medium to high potency topical steroid
Veltin gel (tretinoin/clindamycin)
Trial & failure of Flonase* or Nasalide*, AND Nasonex
Trial & failure of Ditropan* or Sanctura*
* indicates generic available Italics indicate Non-Formulary agents # indicates Step Therapy required for age 18yr and under
This is the most current list at the time of printing and is subject to change. Last update September 28, 2012
STANDARD Stepped Therapy Agents ~ 2013
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list.
Drug Condition Vytorin (simvastatin/ezetimibe) 10/10, 10/20, 10/40
Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor
Trial & failure of 2: Claritin OTC*, Zyrtec OTC*, Allegra OTC
Trial & failure of Imitrex*, Amerge* or Maxalt
Trial & failure of Flonase* or Nasalide*, AND Nasonex
Ziana gel (tretinoin/clindamycin)
Trial & failure of Abreva or oral acyclovir, AND Denavir
Trial & failure of 2: Risperdal*, Seroquel*, Geodon*
* indicates generic available Italics indicate Non-Formulary agents # indicates Step Therapy required for age 18yr and under
This is the most current list at the time of printing and is subject to change. Last update September 28, 2012
(Generic) Opioid Analgesics 3 – Tiered Prescription Drug Formulary October 2013 This formulary listing is to serve as a reference guide for the selection of cost-effective medications and does not guarantee coverage or imply therapeutic equivalence. Certain products may be excluded from Anesthetics your plan or require additional
Université Chouaïb Doukkali Faculté des Sciences Département de Physique Travaux dirigés de Physique Nuclèaire Série II Exercice I - L’électron et le neutron sont deux particules très utilisées pour étudier la structure des noyaux par diffusion. a) Calculer la quantité de mouvement de chacune d’elle pour que leur longueur d’onde réduite de De Broglie, λ_ ,
STANDARD Stepped Therapy Agents ~ 2013 
STANDARD Stepped Therapy Agents ~ 2013 
STANDARD Stepped Therapy Agents ~ 2013 
STANDARD Stepped Therapy Agents ~ 2013