Discover a Pill that's Easy to Swallow
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LIFESTYLE RX Discount Drugs Discover a Pill that’s Easy to Swallow CHC Carolinas Lifestyle Drug Discount Program Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) is pleased to announce an expansion of the Coventry WellBeing program that will now give our members access to discounts on certain medications, vitamins and supplements not covered through the prescription drug benefit. Members who would like to take advantage of these discounts related to hair loss, erectile dysfunction, smoking cessation, and more, can begin by visiting our website at www.chccarolinas.com » Health Care Solutions » Special Services » Discount Programs. Coventry Select, Coventry Choice, and CoventryOne are underwritten by Coventry Health Care of the Carolinas, Inc. Coventry Preferred is underwritten by Coventry Health and Life Insurance Company. For more information, visit www.chccarolinas.com. CHCC_Lifestyle_08-12 LIFESTYLE RX Discount Drugs Weight Loss Trade Name Strength Dosage Form Adipex-P 37.5 MG TABLET, CAPSULE Apptrim Program 40MG-101MG CAPSULE (HARD, SOFT, ETC.) Benzphetamine Hcl 50 MG TABLET Bontril Pdm 35 MG TABLET Bontril Slow-Release 105 MG (XR) CAPSULE, EXTENDED RELEASE Didrex 50 MG TABLET Diethylpropion Hcl 25 MG, 75 MG (XR) TABLET Ionamin 15 MG (XR), 30 MG (XR) CAPSULE, EXTENDED RELEASE Meridia 5 MG, 10 MG, 15 MG CAPSULE (HARD, SOFT, ETC.) Phendimetrazine Tartrate 35 MG TABLET Phendimetrazine Tartrate 105 MG CAPSULE, EXTENDED RELEASE Phentermine Hcl 8 MG, 37.5 MG TABLET Phentermine Hcl 15 MG, 18.75 MG, 30 MG, 37.5 MG CAPSULE (HARD, SOFT, ETC.) Xenical 120 MG CAPSULE (HARD, SOFT, ETC.) Trade Name Strength Dosage Form Caverject 10 MCG, 20 MCG KIT Caverject 20 MCG, 40 MCG VIAL (SDV,MDV OR ADDITIVE) (EA) Caverject 40MCG/2ML AMPUL (ML) Cialis 2.5 MG, 5MG, 10MG, 20MG TABLET Edex 10 MCG, 20 MCG, 40 MCG KIT Levitra 2.5 MG, 5MG, 10MG, 20MG TABLET Muse 125 MCG, 250 MCG, 500 MCG, 1000 MCG SUPPOSITORY, URETHRAL Staxyn 10 MG TABLET, RAPID DISSOLVE Viagra 25 MG, 50 MG, 100 MG TABLET Trade Name Strength Dosage Form Clomid 50 MG TABLET Clomiphene Citrate 50 MG TABLET Serophene 50 MG TABLET Impotence Fertility The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. Coventry Select, Coventry Choice, and CoventryOne are underwritten by Coventry Health Care of the Carolinas, Inc. (CHC Carolinas). Coventry Preferred is underwritten by Coventry Health and Life Insurance Company. The listed drugs in the CHC Carolinas Lifestyle Rx Discount Drugs Program, an expansion of our Coventry WellBeing program, gives members access to discounts on certain medications, vitamins and supplements not covered through the prescription drug benefit. For more information, visit www.chccarolinas.com. Coventry Health Care of the Carolinas, Inc. www.chccarolinas.com • 1 LIFESTYLE RX Discount Drugs Vitamins and Minerals Trade Name Strength Dosage Form Advanced AM/PM 400MG-200 COMBINATION PACKAGE (EA) Airavite 1-2.5-25MG TABLET Albafort 120-1MG TABLET Alba-Lybe STR N/A DROPS Allanfol Rx 1-2.2-25MG TABLET Allantex 2-2.5-25MG TABLET Aminobenzoate Potassium 500 MG CAPSULE (HARD, SOFT, ETC.) Aminobenzoate Potassium 2G PACKET (EA) Anemagen 70-150-10 TABLET Anemagen Forte 151-60-1MG Ascorbic Acid STR N/A Bacmin 27 MG-1 MG TABLET GRANULES;POWDER-LIKE,NONEFFERVESS(GRAM) TABLET Berocca STR N/A TABLET Bifera Rx 22-6-1-25 TABLET Biocel STR N/A TABLET B-Plex 0.5 MG, 500-0.5MG TABLET B-Plex Plus 27-0.8MG TABLET Calafol Rx 600 MG-400 TABLET Calomist 25 MCG SPRAY, NON-AEROSOL (ML) Cardiotek Rx 500-2-50 TABLET Cardiotek Rx 2-500-500 TABLET Cavan-X 2-2.5-25MG TABLET Cefol STR N/A TABLET Cenfol 2.3-24.5-2 TABLET Centratex 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Cerefolin 1-6-50-5MG TABLET Cerefolin Nac 600-2-6 MG TABLET Chromagen 70-150-10 TABLET Chromagen Fa 70-150-1MG TABLET Chromagen Forte 151-60-1MG TABLET Combgen 0.5-2.2-25 TABLET Conison 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Corvita 1.25-2.5MG TABLET Corvita 150-1.25MG TABLET Corvite 1.25-2.5MG, 1.25-35MG TABLET Corvite 150-1.25MG TABLET Corvite Fe 125-25-1MG TABLET Dailyvite 1MG-100MG, 3MG-15MG, 5MG TABLET Deplin 7.5 MG, 15 MG TABLET The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. 2 • www.chccarolinas.com Coventry Health Care of the Carolinas, Inc. LIFESTYLE RX Discount Drugs Vitamins and Minerals continued Trade Name Strength Dosage Form Dexfol 5 MG TABLET Dialyvite 1MG-100MG TABLET Dialyvite 800 With Iron 29-0.8MG TABLET Dialyvite Supreme D 3 MG-2000 TABLET Diatx Zn 5-1.5-25MG TABLET Dualvit F 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Dualvit Plus 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Duleek-Met New 2-3-35 MG TABLET Eldercaps 1 MG CAPSULE (HARD, SOFT, ETC.) Encora 400MG-200 COMBINATION PACKAGE (EA) Enfolast 1-6-50-5MG TABLET Enfolast-N 600-2-6 MG TABLET Eritrogen 120-1MG TABLET Fabb 1-2.2-25MG TABLET Fac-X 2.8MG-500 TABLET Femtabs 1 MG TABLET Feocyte Fa STR N/A TABLET, EXTENDED RELEASE Ferocon 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Fero-Folic 105-500-.8 TABLET, EXTENDED RELEASE Ferotrin 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Ferotrinsic 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Ferralet 90 90-1-50 MG TABLET Ferraplus 90 90-1-50 MG TABLET Ferrex 150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Ferrex 150 Forte Plus 150-25-1 CAPSULE (HARD, SOFT, ETC.) Ferrex 28 151-200-1 TABLET Ferrocite Plus 106 MG-1MG TABLET Ferrocite Plus 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Ferrocite-F 106 MG-1MG TABLET Ferroflex 150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Ferrogels Forte 460-60MG CAPSULE (HARD, SOFT, ETC.) Ferromar 275 MG CAPSULE, EXTENDED RELEASE Ferro-Plex Hematinic 115-1MG TABLET Ferrovite 70-150-10 TABLET Ferrovite Fa 70-150-1MG TABLET Ferrovite Forte 151-60-1MG TABLET Fe-Tinic 150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Fetrin 200-60MG-5 CAPSULE, EXTENDED RELEASE Folamin 2-2.5-25MG TABLET The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. Coventry Health Care of the Carolinas, Inc. www.chccarolinas.com • 3 LIFESTYLE RX Discount Drugs Vitamins and Minerals continued Trade Name Strength Dosage Form Folast 2-2.8-25MG TABLET Folbalin Plus 2-2.5-25MG TABLET Folbee 1-2.5-25MG TABLET Folbee Plus 5 MG, 5-1.5-25MG TABLET Folbic 2-2.5-25MG TABLET Folcaps 0.5-2.2-25 TABLET Foleve 0.5-2.2-25 TABLET Foleve Plus 1-2.2-25MG TABLET Folgard Rx 1-2.2-25MG TABLET Folic Acid-Cyancobal-Pyridoxin 0.5-2.2-25, 1-2.5-25MG TABLET Folitab 105-500-.8 TABLET, EXTENDED RELEASE Folivane-F 125-1-40-3 CAPSULE (HARD, SOFT, ETC.) Folivane-Plus 125MG-1MG CAPSULE (HARD, SOFT, ETC.) Folmor 2.5-2-875 TABLET Folnate 1-2.5-25MG TABLET Folnate Plus 2-2.5-25MG TABLET Folpace Rx 100-2.05 TABLET Folplex 2.2 0.5-2.2-25 TABLET Foltrate 0.5-1MG TABLET Foltrin 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Foltx 2-2.5-25MG TABLET Formula B Plus 27-0.8MG TABLET Formula-B 0.5 MG TABLET Fortavit STR N/A CAPSULE (HARD, SOFT, ETC.) Fumatinic 200-60MG-5 CAPSULE, EXTENDED RELEASE Glutofac-Zx 2.8MG-500 TABLET Hematinic Plus 106 MG-1MG TABLET Hematinic With Folic Acid 106 MG-1MG TABLET Hematogen 200-250-10 CAPSULE (HARD, SOFT, ETC.) Hematogen Fa 200-250MG CAPSULE (HARD, SOFT, ETC.) Hematogen Forte 460-60MG CAPSULE (HARD, SOFT, ETC.) Hematron 50-1MG/5ML LIQUID (ML) Hematron-Af 150-50-1MG TABLET, EXTENDED RELEASE 24 HR Hemax 150-50-1MG TABLET, EXTENDED RELEASE 24 HR Hemocyte Plus 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Hemocyte-F 106 MG-1MG TABLET Iberet-Folic 500 105-0.8MG TABLET, EXTENDED RELEASE Iferex 150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) I-Fol Plus 105-0.8MG TABLET, EXTENDED RELEASE MULTIPHASE The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. 4 • www.chccarolinas.com Coventry Health Care of the Carolinas, Inc. LIFESTYLE RX Discount Drugs Vitamins and Minerals continued Trade Name Strength Dosage Form Integra F 125-1-40-3 CAPSULE (HARD, SOFT, ETC.) Integra Plus 125MG-1MG CAPSULE (HARD, SOFT, ETC.) Irofol 150-1MG TABLET Irofol 100-1MG/5 LIQUID (ML) Iron 90-1-50 MG TABLET Irospan 65-1MG(24) TABLET Ivites Rx 1MG-60MG TABLET L-Methylfolate Calcium 7.5 MG TABLET Macutek 14320-226 TABLET, RAPID DISSOLVE Manuvite Sp 1MG-320MG TABLET, XR Martinic 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Maxaron Forte 150-60-1 CAPSULE (HARD, SOFT, ETC.) Megavite Rx 27 MG-1 MG TABLET Metanx 2-3-35 MG TABLET Multi-B-Plus STR N/A TABLET Multichew 20MG-1MG TABLET, CHEWABLE Multifol 65 MG-1 MG TABLET Multigen 70-150-10 TABLET Multigen Folic 70-150-1MG TABLET Multigen Plus 151-60-1MG TABLET Multi-Ret Folic 500 105-0.8MG TABLET, EXTENDED RELEASE Myferon-150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Myo Vyt 2-2.5-25MG TABLET, EXTENDED RELEASE 24 HR Nascobal 500 MCG SPRAY, NON-AEROSOL (ML) Nephplex Rx 1MG-60MG TABLET Nephrocaps 1 MG CAPSULE (HARD, SOFT, ETC.) Nephrocaps Qt 1 MG-1750 TABLET, RAPID DISSOLVE Nephron Fa 66.6-1MG TABLET Nephronex 1 MG CAPSULE (HARD, SOFT, ETC.) Nephro-Vite Rx 1MG-60MG TABLET Neurin-Sl 600-600MCG TABLET, SUBLINGUAL Neurodep Nr 0.5 MG TABLET, EXTENDED RELEASE Neurpath-B 2-3-35 MG TABLET Nicomide 0.5-750 MG TABLET, XR MULTIPHASE Nicotinamide 0.5-750 MG TABLET, XR MULTIPHASE Nicotinamide Zcf 0.5-750 MG TABLET, XR MULTIPHASE Niferex Gold 200-50-1 TABLET Niferex-150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Novaferrum 100-1-60/5 SOLUTION, RECONSTITUTED, ORAL The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. Coventry Health Care of the Carolinas, Inc. www.chccarolinas.com • 5 LIFESTYLE RX Discount Drugs Vitamins and Minerals continued Trade Name Strength Dosage Form Nufol 1-2.5-25MG TABLET Nutravance 1 MG TABLET Nutricap 1 MG TABLET Poly-Iron 150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Polysaccharide Iron Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Potaba 500 MG CAPSULE (HARD, SOFT, ETC.) Potaba 500 MG TABLET Potaba 2G PACKET (EA) Probarimin Qt 4MG-0.3MG TABLET, RAPID DISSOLVE Proferrin-Forte 12-1MG TABLET Promar STR N/A CAPSULE (HARD, SOFT, ETC.) Protect Bone 1 MG WAFER Protect Cardio 0.5-30-150 CAPSULE (HARD, SOFT, ETC.) Protect Iron 60 MG-1 MG TABLET Protect Plus STR N/A LIQUID (ML) Protect Plus STR N/A CAPSULE (HARD, SOFT, ETC.) Protect Plus Nr 0.5 MG CAPSULE (HARD, SOFT, ETC.) Pruvate 21-7 151-200-1 TABLET Renal Caps 1 MG CAPSULE (HARD, SOFT, ETC.) Renal Softgel 1 MG CAPSULE (HARD, SOFT, ETC.) Renalpren 1 MG CAPSULE (HARD, SOFT, ETC.) Renatabs 1MG-60MG-5 TABLET Renatabs With Iron 100-1-60MG TABLET Rena-Vite Rx 1MG-60MG TABLET Renax 35 U-2.5MG, 35 U-5.5MG TABLET Reno Caps 1 MG CAPSULE (HARD, SOFT, ETC.) Reocyte Plus 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Repliva 21-7 151-200-1 TABLET Req49+ 200MCG-1.5 TABLET Rexavite 150 150-50-50 CAPSULE (HARD, SOFT, ETC.) Rexavite 150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Rovin-Cf Of 1-6-50-5MG TABLET Senilezol 2.5-6MG/30 SOLUTION, ORAL Se-Tan Plus 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Se-Vate 21-7 151-200-1 TABLET Siderol STR N/A LIQUID (ML) Siderol STR N/A TABLET Strovite 500-0.5MG TABLET Strovite Advance 1 MG TABLET The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. 6 • www.chccarolinas.com Coventry Health Care of the Carolinas, Inc. LIFESTYLE RX Discount Drugs Vitamins and Minerals continued Trade Name Strength Dosage Form Strovite Advance + D 1-1000-15 TABLET Strovite Forte 10MG-1MG TABLET Strovite Forte 10-1MG/15 LIQUID (ML) Strovite One 1-1000-5 TABLET Strovite Plus 27-0.8MG TABLET Supervite 1 MG TABLET, ENTERIC COATED Supervite 1000-1-75 LIQUID (ML) Supervite STR N/A TABLET Support STR N/A CAPSULE (HARD, SOFT, ETC.) Synagex 1.25-30-5 CAPSULE (HARD, SOFT, ETC.) Tandem F 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Tandem Plus 106 MG-1MG CAPSULE (HARD, SOFT, ETC.) Taron Forte 150-60-1 CAPSULE (HARD, SOFT, ETC.) Therapeutic Hematinic STR N/A TABLET Therapeutic Vitamin W-Minerals 1 MG CAPSULE (HARD, SOFT, ETC.) Therobec 500-0.5MG TABLET Therobec Plus 27-0.8MG TABLET Tl Gard Rx 1-2.2-25MG TABLET Tl Icon 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Tl Nicotinamide 0.5-750 MG TABLET, XR MULTIPHASE Tl-Fol 500 105-500-.8 TABLET, EXTENDED RELEASE Tl-Hem 150 150-50-1MG TABLET, EXTENDED RELEASE 24 HR Tricon 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Triferex 150 Forte 150-25-1 CAPSULE (HARD, SOFT, ETC.) Trigels-F Forte 460-60MG CAPSULE (HARD, SOFT, ETC.) Trimagen 70-150-10 TABLET Trimagen Fa 70-150-1MG TABLET Trimagen Forte 151-60-1MG TABLET Trinsicon 110-0.5MG CAPSULE (HARD, SOFT, ETC.) Triphrocaps 1 MG CAPSULE (HARD, SOFT, ETC.) Triveen-Cf Nac 600-2-6 MG TABLET Udamin 2 MG TABLET, XR Udamin Sp 1MG-320MG TABLET, XR Urosex 0.5MG-75MG TABLET Varidin STR N/A TABLET V-C Forte 1 MG CAPSULE (HARD, SOFT, ETC.) Vg 0.5 MG CAPSULE (HARD, SOFT, ETC.) Vi-C Forte 1 MG CAPSULE (HARD, SOFT, ETC.) Vica-Forte 1 MG CAPSULE (HARD, SOFT, ETC.) The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. Coventry Health Care of the Carolinas, Inc. www.chccarolinas.com • 7 LIFESTYLE RX Discount Drugs Vitamins and Minerals continued Trade Name Strength Dosage Form Vicap Forte 1 MG CAPSULE (HARD, SOFT, ETC.) Vita S Forte 10MG-1MG TABLET Vitacel STR N/A TABLET Vitacon Forte 1 MG CAPSULE (HARD, SOFT, ETC.) Vitafol 65 MG-1 MG TABLET Vitafol 10.4-2MG/5 SYRUP Vitagen Advance 70-150-10 TABLET Vitagen Forte 151-60-1MG TABLET Vital-D Rx 1750-60-1 TABLET Vitamax 200-200MCG TABLET, CHEWABLE Vitamin B Complex STR N/A TABLET Vitaplex 500-0.5MG TABLET Vitaplex Plus 27-0.8MG TABLET Vita-Respa 1.3-2.2-25 TABLET Vitatab Mv 2.8MG-500 TABLET Vol-Care Rx 1MG-60MG TABLET Wheat Germ Oil STR N/A OIL (ML) Zervalx 1 MG TABLET Zycose 1-150-850 TABLET Trade Name Strength Dosage Form Aclaro 4% EMULSION (GRAM) Aclaro Pd 4% EMULSION, ADHESIVE Alphaquin Hp 4%(5-7.5%) CREAM (GRAM) Artra Dry Skin Tone 2% CREAM (GRAM) Artra Normal-Dry Skin 2% CREAM (GRAM) Artra Oily Skin 2% CREAM (GRAM) Benoquin 20% CREAM (GRAM) Black & White Bleaching 2% CREAM (GRAM) Black & White Skin STR N/A SOAP, LIQUID Claripel 4% CREAM (GRAM) Complex B 4% GEL (ML) Elastiderm 4% CREAM (GRAM) Eldopaque 2% CREAM (GRAM) Eldopaque Forte 4% CREAM (GRAM) Eldoquin 2% CREAM (GRAM) Eldoquin Forte 4% CREAM (GRAM) Hypopigmentation The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. 8 • www.chccarolinas.com Coventry Health Care of the Carolinas, Inc. LIFESTYLE RX Discount Drugs Hypopigmentation continued Trade Name Strength Dosage Form Epiquin Micro 4% CREAM, XR (GRAM) Epiquin Micro 4% CREAM, ER MULTIPHASE IN PUMP (GRAM) Epiquin Micro Xd 4% PACKET (EA) Esoterica Medicated STR N/A, 2% CREAM (GRAM) Glyquin 4-8-4-4% CREAM (GRAM) Glyquin Xm 4 %-SPF 15 CREAM (GRAM) Hydroquinone STR N/A, 4%, 3%-5%-4%, 4-8-4-4%, 4%-SPF 15 CREAM (GRAM) Hydroquinone STR N/A POWDER (GRAM) Hydroquinone 4% CREAM, XR (GRAM) Hydroquinone 3%-5%-4% GEL (GRAM) Lustra 4% CREAM (GRAM) Lustra-Af 4 %-SPF 20 CREAM (GRAM) Lustra-Ultra 4 %-SPF 15 CREAM (GRAM) Melanex 30 MG/ML SOLUTION, NON-ORAL Melpaque Hp 4% CREAM (GRAM) Melquin Hp 4% CREAM (GRAM) Melquin-3 30 MG/ML SOLUTION, NON-ORAL Nu-Derm 4% CREAM (GRAM) Nu-Derm 4 %-SPF 15 CREAM (GRAM) Nuquin Hp 3%-5%-4% GEL (GRAM) Nuquin Hp 3%-5%-4% CREAM (GRAM) Obagi-C 4% CREAM (GRAM) Obagi-C 4%-10% LIQUID (ML) Remergent Hq 4% CREAM (MILLILITERS) Solage 0.01 %-2 % SOLUTION, NON-ORAL Solaquin 3-5-2% CREAM (GRAM) Solaquin Forte 3%-5%-4% CREAM (GRAM) Solaquin Forte 3%-5%-4% GEL (GRAM) Tri-Luma 0.01-.05-4 CREAM (GRAM) Trade Name Strength Dosage Form Avage 0.10% CREAM (GRAM) Refissa 0.05% CREAM (GRAM) Renova 0.02% CREAM (GRAM) Tretinoin 0.05% CREAM (GRAM) Anti-Aging The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. Coventry Health Care of the Carolinas, Inc. www.chccarolinas.com • 9 LIFESTYLE RX Discount Drugs Eyelashes Trade Name Strength Dosage Form Latisse 0.03% DROPS, WITH APPLICATOR (ML) Trade Name Strength Dosage Form Hair Regrowth 2%, 5% SOLUTION, NON-ORAL Minoxidil 2%, 5% SOLUTION, NON-ORAL Propecia 1 MG TABLET Rogaine 2%, 5% SOLUTION, NON-ORAL Rogaine 5% KIT Rogaine 5% FOAM (GRAM) Trade Name Strength Dosage Form Vaniqa 13.90% CREAM (GRAM) Trade Name Strength Dosage Form Buproban 150 MG TABLET, EXTENDED RELEASE Bupropion Hcl Er 150 MG TABLET, EXTENDED RELEASE Bupropion Sr 150 MG TABLET, EXTENDED RELEASE Chantix 0.5(11)-1 TABLET, DOSE PACK Chantix 0.5 MG, 1MG TABLET Commit 2 MG, 4MG LOZENGE Nicoderm Cq 7MG/24HR, 14MG/24HR, 21 MG/24HR PATCH, TRANSDERMAL 24 HOURS Nicorelief 2 MG, 4MG GUM Nicorette 2 MG, 4MG GUM Nicorette 2 MG, 4MG LOZENGE Nicotine 2 MG, 4MG LOZENGE Nicotine 11MG/24HR PATCH, TRANSDERMAL 24 HOURS Nicotine 7MG/24HR, 11MG/24HR, 14MG/24HR, 21MG/24HR, 22MG/24HR PATCH, TRANSDERMAL 24 HOURS Nicotine 21-14-7MG PATCH, TRANSDERMAL DAILY, SEQUENTIAL Nicotine Gum 2 MG, 4MG GUM Nicotrol 10 MG CARTRIDGE (EA) Nicotrol Ns 10 MG/ML SPRAY, NON-AEROSOL (ML) Nts 14MG/24HR, 21MG/24HR PATCH, TRANSDERMAL 24 HOURS Stop Smoking Aid 2 MG, 4MG GUM Hair Loss Unwanted Hair Smoking Cessation The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. 10 • www.chccarolinas.com Coventry Health Care of the Carolinas, Inc. LIFESTYLE RX Discount Drugs Smoking Cessation continued Trade Name Strength Dosage Form Stop Smoking Aid 2 MG, 4MG LOZENGE Thrive Nicotine 2 MG, 4MG GUM Zyban 150 MG TABLET, EXTENDED RELEASE The above drugs are not covered under the Coventry Health Care of the Carolinas, Inc. prescription drug benefits. Charges that a member pays do not apply to any benefit year deductible or maximum out-of-pocket amounts. Coventry Select, Coventry Choice, and CoventryOne are underwritten by Coventry Health Care of the Carolinas, Inc. (CHC Carolinas). Coventry Preferred is underwritten by Coventry Health and Life Insurance Company. The listed drugs in the CHC Carolinas Lifestyle Rx Discount Drugs Program, an expansion of our Coventry WellBeing program, gives members access to discounts on certain medications, vitamins and supplements not covered through the prescription drug benefit. For more information, visit www.chccarolinas.com. Coventry Health Care of the Carolinas, Inc. www.chccarolinas.com • 11
