Discount Drugs LIFESTYLE RX. Weight Loss. Impotence. Fertility. Trade Name Strength Dosage Form. Trade Name Strength Dosage Form
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1 Weight Loss Adipex-P 37.5 MG TABLET, CAPSULE Apptrim Program 40 MG-101 MG 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, MG, 30 MG, 37.5 MG CAPSULE (HARD, SOFT, ETC.) Xenical 120 MG CAPSULE (HARD, SOFT, ETC.) Impotence Caverject 10 MCG, 20 MCG KIT Caverject 20 MCG, 40 MCG VIAL (SDV, MDV OR ADDITIVE) (EA) Caverject 40 MCG/2 ML AMPUL (ML) Cialis 2.5 MG, 5 MG, 10 MG, 20 MG TABLET Edex 10 MCG, 20 MCG, 40 MCG KIT Levitra 2.5 MG, 5 MG, 10 MG, 20 MG TABLET Muse 125 MCG, 250 MCG, 500 MCG, 1,000 MCG SUPPOSITORY, URETHRAL Staxyn 10 MG TABLET, RAPID DISSOLVE Viagra 25 MG, 50 MG, 100 MG TABLET Fertility Clomid 50 MG TABLET Clomiphene Citrate 50 MG TABLET Serophene 50 MG TABLET The Coventry Lifestyle Rx 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 Coventry Health Care of Georgia 1
2 Vitamins and Minerals Advanced AM/PM 400 MG-200 COMBINATION PACKAGE (EA) Airavite MG TABLET Albafort MG TABLET Alba-Lybe STR N/A DROPS Allanfol Rx MG TABLET Allantex MG TABLET Aminobenzoate Potassium 500 MG CAPSULE (HARD, SOFT, ETC.) Aminobenzoate Potassium 2 G PACKET (EA) Anemagen TABLET Anemagen Forte MG TABLET Ascorbic Acid STR N/A Bacmin 27 MG-1 MG TABLET Berocca STR N/A TABLET Bifera Rx TABLET Biocel STR N/A TABLET B-Plex 0.5 MG, MG TABLET B-Plex Plus MG TABLET Calafol Rx 600 MG-400 TABLET GRANULES;POWDER-LIKE,NON- EFFERVESS(GRAM) Calomist 25 MCG SPRAY, NON-AEROSOL (ML) Cardiotek Rx TABLET Cardiotek Rx TABLET Cavan-X MG TABLET Cefol STR N/A TABLET Cenfol TABLET Centratex 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Cerefolin MG TABLET Cerefolin Nac MG TABLET Chromagen TABLET Chromagen Fa MG TABLET Chromagen Forte MG TABLET Combgen TABLET Conison MG CAPSULE (HARD, SOFT, ETC.) Corvita MG TABLET Corvita MG TABLET Corvite MG, MG TABLET Corvite MG TABLET Corvite Fe MG TABLET Dailyvite 1 MG-100 MG, 3 MG-15 MG, 5 MG TABLET 2 Coventry Health Care of Georgia
3 Deplin 7.5 MG, 15 MG TABLET Dexfol 5 MG TABLET Dialyvite 1 MG-100 MG TABLET Dialyvite 800 With Iron MG TABLET Dialyvite Supreme D 3 MG-2000 TABLET Diatx Zn MG TABLET Dualvit F 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Dualvit Plus 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Duleek-Met New MG TABLET Eldercaps 1 MG CAPSULE (HARD, SOFT, ETC.) Encora 400 MG-200 COMBINATION PACKAGE (EA) Enfolast MG TABLET Enfolast-N MG TABLET Eritrogen MG TABLET Fabb MG TABLET Fac-X 2.8 MG-500 TABLET Femtabs 1 MG TABLET Feocyte Fa STR N/A TABLET, EXTENDED RELEASE Ferocon MG CAPSULE (HARD, SOFT, ETC.) Fero-Folic TABLET, EXTENDED RELEASE Ferotrin MG CAPSULE (HARD, SOFT, ETC.) Ferotrinsic MG CAPSULE (HARD, SOFT, ETC.) Ferralet MG TABLET Ferraplus MG TABLET Ferrex 150 Forte CAPSULE (HARD, SOFT, ETC.) Ferrex 150 Forte Plus CAPSULE (HARD, SOFT, ETC.) Ferrex TABLET Ferrocite Plus 106 MG-1 MG TABLET Ferrocite Plus 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Ferrocite-F 106 MG-1 MG TABLET Ferroflex 150 Forte CAPSULE (HARD, SOFT, ETC.) Ferrogels Forte MG CAPSULE (HARD, SOFT, ETC.) Ferromar 275 MG CAPSULE, EXTENDED RELEASE Ferro-Plex Hematinic MG TABLET Ferrovite TABLET Ferrovite Fa MG TABLET Ferrovite Forte MG TABLET Fe-Tinic 150 Forte CAPSULE (HARD, SOFT, ETC.) Fetrin MG-5 CAPSULE, EXTENDED RELEASE Coventry Health Care of Georgia 3
4 Folamin MG TABLET Folast MG TABLET Folbalin Plus MG TABLET Folbee MG TABLET Folbee Plus 5 MG, MG TABLET Folbic MG TABLET Folcaps TABLET Foleve TABLET Foleve Plus MG TABLET Folgard Rx MG TABLET Folic Acid-Cyancobal-Pyridoxin , MG TABLET Folitab TABLET, EXTENDED RELEASE Folivane-F CAPSULE (HARD, SOFT, ETC.) Folivane-Plus 125 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Folmor TABLET Folnate MG TABLET Folnate Plus MG TABLET Folpace Rx TABLET Folplex TABLET Foltrate MG TABLET Foltrin MG CAPSULE (HARD, SOFT, ETC.) Foltx MG TABLET Formula B Plus MG TABLET Formula-B 0.5 MG TABLET Fortavit STR N/A CAPSULE (HARD, SOFT, ETC.) Fumatinic MG-5 CAPSULE, EXTENDED RELEASE Glutofac-Zx 2.8MG-500 TABLET Hematinic Plus 106 MG-1 MG TABLET Hematinic With Folic Acid 106 MG-1 MG TABLET Hematogen CAPSULE (HARD, SOFT, ETC.) Hematogen Fa MG CAPSULE (HARD, SOFT, ETC.) Hematogen Forte MG CAPSULE (HARD, SOFT, ETC.) Hematron 50-1 MG/5 ML LIQUID (ML) Hematron-Af MG TABLET, EXTENDED RELEASE 24 HR Hemax MG TABLET, EXTENDED RELEASE 24 HR Hemocyte Plus 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Hemocyte-F 106 MG-1 MG TABLET Iberet-Folic MG TABLET, EXTENDED RELEASE Iferex 150 Forte CAPSULE (HARD, SOFT, ETC.) 4 Coventry Health Care of Georgia
5 I-Fol Plus MG TABLET, EXTENDED RELEASE MULTIPHASE Integra F CAPSULE (HARD, SOFT, ETC.) Integra Plus 125MG-1 MG CAPSULE (HARD, SOFT, ETC.) Irofol MG TABLET Irofol MG/5 LIQUID (ML) Iron MG TABLET Irospan 65-1 MG(24) TABLET Ivites Rx 1 MG-60 MG TABLET L-Methylfolate Calcium 7.5 MG TABLET Macutek TABLET, RAPID DISSOLVE Manuvite Sp 1 MG-320 MG TABLET, EXTENDED RELEASE Martinic MG CAPSULE (HARD, SOFT, ETC.) Maxaron Forte CAPSULE (HARD, SOFT, ETC.) Megavite Rx 27 MG-1 MG TABLET Metanx MG TABLET Multi-B-Plus STR N/A TABLET Multichew 20 MG-1 MG TABLET, CHEWABLE Multifol 65 MG-1 MG TABLET Multigen TABLET Multigen Folic MG TABLET Multigen Plus MG TABLET Multi-Ret Folic MG TABLET, EXTENDED RELEASE Myferon-150 Forte CAPSULE (HARD, SOFT, ETC.) Myo Vyt MG TABLET, EXTENDED RELEASE 24 HR Nascobal 500 MCG SPRAY, NON-AEROSOL (ML) Nephplex Rx 1 MG-60 MG TABLET Nephrocaps 1 MG CAPSULE (HARD, SOFT, ETC.) Nephrocaps Qt 1 MG-1750 TABLET, RAPID DISSOLVE Nephron Fa MG TABLET Nephronex 1 MG CAPSULE (HARD, SOFT, ETC.) Nephro-Vite Rx 1MG-60 MG TABLET Neurin-Sl MCG TABLET, SUBLINGUAL Neurodep Nr 0.5 MG TABLET, EXTENDED RELEASE Neurpath-B MG TABLET Nicomide MG TABLET, EXTENDED RELEASE MULTIPHASE Nicotinamide MG TABLET, EXTENDED RELEASE MULTIPHASE Nicotinamide Zcf MG TABLET, EXTENDED RELEASE MULTIPHASE Niferex Gold TABLET Niferex-150 Forte CAPSULE (HARD, SOFT, ETC.) Coventry Health Care of Georgia 5
6 Novaferrum /5 SOLUTION, RECONSTITUTED, ORAL Nufol MG TABLET Nutravance 1 MG TABLET Nutricap 1 MG TABLET Poly-Iron 150 Forte CAPSULE (HARD, SOFT, ETC.) Polysaccharide Iron Forte CAPSULE (HARD, SOFT, ETC.) Potaba 500 MG CAPSULE (HARD, SOFT, ETC.) Potaba 500 MG TABLET Potaba 2 G PACKET (EA) Probarimin Qt 4 MG-0.3 MG TABLET, RAPID DISSOLVE Proferrin-Forte 12-1 MG TABLET Promar STR N/A CAPSULE (HARD, SOFT, ETC.) Protect Bone 1 MG WAFER Protect Cardio 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 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 1 MG-60 MG-5 TABLET Renatabs With Iron MG TABLET Rena-Vite Rx 1 MG-60 MG TABLET Renax 35 U-2.5 MG, 35 U-5.5 MG TABLET Reno Caps 1 MG CAPSULE (HARD, SOFT, ETC.) Reocyte Plus 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Repliva TABLET Req MCG-1.5 TABLET Rexavite CAPSULE (HARD, SOFT, ETC.) Rexavite 150 Forte CAPSULE (HARD, SOFT, ETC.) Rovin-Cf Of MG TABLET Senilezol MG/30 SOLUTION, ORAL Se-Tan Plus 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Se-Vate TABLET Siderol STR N/A LIQUID (ML) Siderol STR N/A TABLET Strovite MG TABLET 6 Coventry Health Care of Georgia
7 Strovite Advance 1 MG TABLET Strovite Advance + D TABLET Strovite Forte 10 MG-1 MG TABLET Strovite Forte 10-1 MG/15 LIQUID (ML) Strovite One TABLET Strovite Plus MG TABLET Supervite 1 MG TABLET, ENTERIC COATED Supervite LIQUID (ML) Supervite STR N/A TABLET Support STR N/A CAPSULE (HARD, SOFT, ETC.) Synagex CAPSULE (HARD, SOFT, ETC.) Tandem F 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Tandem Plus 106 MG-1 MG CAPSULE (HARD, SOFT, ETC.) Taron Forte CAPSULE (HARD, SOFT, ETC.) Therapeutic Hematinic STR N/A TABLET Therapeutic Vitamin W-Minerals 1 MG Therobec MG TABLET Therobec Plus MG TABLET Tl Gard Rx MG TABLET CAPSULE (HARD, SOFT, ETC.) Tl Icon MG CAPSULE (HARD, SOFT, ETC.) Tl Nicotinamide MG TABLET, XR MULTIPHASE Tl-Fol TABLET, EXTENDED RELEASE Tl-Hem MG TABLET, EXTENDED RELEASE 24 HR Tricon MG CAPSULE (HARD, SOFT, ETC.) Triferex 150 Forte CAPSULE (HARD, SOFT, ETC.) Trigels-F Forte MG CAPSULE (HARD, SOFT, ETC.) Trimagen TABLET Trimagen Fa MG TABLET Trimagen Forte MG TABLET Trinsicon MG CAPSULE (HARD, SOFT, ETC.) Triphrocaps 1 MG CAPSULE (HARD, SOFT, ETC.) Triveen-Cf Nac MG TABLET Udamin 2 MG TABLET, EXTENDED RELEASE Udamin Sp 1 MG-320 MG TABLET, EXTENDED RELEASE Urosex 0.5 MG-75 MG 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.) Coventry Health Care of Georgia 7
8 Vica-Forte 1 MG CAPSULE (HARD, SOFT, ETC.) Vicap Forte 1 MG CAPSULE (HARD, SOFT, ETC.) Vita S Forte 10 MG-1 MG TABLET Vitacel STR N/A TABLET Vitacon Forte 1 MG CAPSULE (HARD, SOFT, ETC.) Vitafol 65 MG-1 MG TABLET Vitafol MG/5 SYRUP Vitagen Advance TABLET Vitagen Forte MG TABLET Vital-D Rx TABLET Vitamax MCG TABLET, CHEWABLE Vitamin B Complex STR N/A TABLET Vitaplex MG TABLET Vitaplex Plus MG TABLET Vita-Respa TABLET Vitatab Mv 2.8 MG-500 TABLET Vol-Care Rx 1 MG-60 MG TABLET Wheat Germ Oil STR N/A OIL (ML) Zervalx 1 MG TABLET Zycose TABLET Hypopigmentation 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) 8 Coventry Health Care of Georgia
9 Hypopigmentation continued Eldoquin Forte 4% CREAM (GRAM) 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 % CREAM (GRAM) Glyquin Xm 4% SPF 15 CREAM (GRAM) Hydroquinone STR N/A, 4%, 3%-5%-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 CREAM (GRAM) Anti-Aging Avage 0.10% CREAM (GRAM) Refissa 0.05% CREAM (GRAM) Renova 0.02% CREAM (GRAM) Tretinoin 0.05% CREAM (GRAM) Coventry Health Care of Georgia 9
10 Eyelashes Latisse 0.03% DROPS, WITH APPLICATOR (ML) Hair Loss 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) Unwanted Hair Vaniqa 13.90% CREAM (GRAM) Smoking Cessation 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, 1 MG TABLET Commit 2 MG, 4 MG LOZENGE Nicoderm Cq 7 MG/24HR, 14 MG/24HR, 21 MG/24HR PATCH, TRANSDERMAL 24 HOURS Nicorelief 2 MG, 4 MG GUM Nicorette 2 MG, 4 MG GUM Nicorette 2 MG, 4 MG LOZENGE Nicotine 2 MG, 4 MG LOZENGE Nicotine 11 MG/24HR PATCH, TRANSDERMAL 24 HOURS Nicotine 7 MG/24HR, 11 MG/24HR, 14 MG/24HR, 21 MG/24HR, 22 MG/24HR PATCH, TRANSDERMAL 24 HOURS Nicotine MG PATCH, TRANSDERMAL DAILY, SEQUENTIAL Nicotine Gum 2 MG, 4 MG GUM Nicotrol 10 MG CARTRIDGE (EA) Nicotrol Ns 10 MG/ML SPRAY, NON-AEROSOL (ML) Nts 14 MG/24HR, 21 MG/24HR PATCH, TRANSDERMAL 24 HOURS Stop Smoking Aid 2 MG, 4 MG GUM 10 Coventry Health Care of Georgia
11 Smoking Cessation continued Stop Smoking Aid 2 MG, 4 MG LOZENGE Thrive Nicotine 2 MG, 4 MG GUM Zyban 150 MG TABLET, EXTENDED RELEASE The Coventry Lifestyle Rx 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 Coventry Health Care of Georgia 11
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