Commercial Preferred Medication List (PML)
January 2011
The Capital Health Plan (CHP) Commercial Preferred Medication List (PML) is a guide within select therapeutic
categories for providing cost-effective care. CHP promotes the use of generic drugs when available, and these
agents should be considered the first line of prescribing. When available, generic drugs will be dispensed. If there
is no generic available, there may be more than one brand-name medication to treat a condition. This Preferred
Medication List includes those brand name medications that will result in a Tier 2 copay for the member. While
some generics have also been listed, this is for representational purposes only and should not be interpreted to be
inclusive of all commercially available generics. To distinguish between the brand and generic drugs included on
this list, generic medications are listed in lowercase bolded italics and brand name medications are not listed in
italics.
Brand name drugs (without a generic equivalent) that are not included on this list will require a Tier 3 or Tier 4
copay. Over time, brand names listed may become available as a generic. At that time, the brand version will
require a Tier 3 or Tier 4 copay and usually 100% of the additional cost for the more expensive drug. Different
dosage forms and strengths of a brand name drug may become available generically at different times. Negative
formulary drugs will be filled as required by law. All compounded medications will require a Tier 3 copay. Based
on your benefit plan, a Tier 4 copay or coinsurance may apply to self-injectable or specialty drugs.
The PML was adopted by the CHP Pharmacy Committee which is comprised of pharmacists and physicians, who
review, evaluate and establish guidelines for optimal drug use. The PML represents a summary of prescription
coverage, is not inclusive, and does not guarantee coverage. The PML is subject to change at any time. When
possible, peer-reviewed primary literature is used to evaluate medications.
CAPITAL HEALTH PLAN MEMBERS: Ask your doctor, when medically appropriate, to consider prescribing
a generic or preferred brand medication from this list. Take this list along with you when you see your doctor.
Additional details on prescription drug coverage, exclusions, and limitations can be found at the back of this
document.
HEALTH CARE PRACTITIONERS: As a way to help manage health care costs, we encourage you to use
generic medications as first line prescribing when medically appropriate. However, if you believe a brand name
product is necessary, consider prescribing a brand name drug on this list.
This document represents a summary of coverage, is not inclusive, and does not guarantee coverage. For more detailed information, refer
to your Prescription Drug Endorsement. The Preferred Medication List is subject to change at any time. Please refer to our web site at
www.capitalhealth.com for the most current Preferred Medication List or you may call the Member Services number on your
Identification Card.
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2011 PREFERRED MEDICATION LIST BY THERAPEUTIC CATEGORY
ANTI-INFECTIVES
Relenza
Tamiflu
ANTIBACTERIALS
CARDIOVASCULAR
CEPHALOSPORINS
cefaclor
cefdinir
cephalexin
ERYTHROMYCINS/
MACROLIDES
azithromycin
clarithromycin
clarithromycin ext-rel
erythromycins
FLUOROQUINOLONES
ciprofloxacin ext-rel
ciprofloxacin tab
Levaquin
PENICILLINS
amoxicillin
amoxicillin-clavulanate
dicloxacillin
penicillin VK
TETRACYCLINES
doxycycline hyclate
minocycline
tetracycline
MISCELLANEOUS
metronidazole
sulfamethoxazoletrimethoprim
____________________
ANTIFUNGALS
fluconazole
itraconazole
terbinafine tablet
_____________________
ANTIVIRALS
HERPES AGENTS
acyclovir
famciclovir
valacyclovir
ACE INHIBITORS
benazepril
captopril
enalapril
fosinopril
lisinopril
moexipril
quinapril
ramipril
trandolapril
_____________________
ACE INHIBITOR/
DIURETIC
COMBINATIONS
benazeprilhydrochlorothiazide
fosinoprilhydrochlorothiazide
lisinoprilhydrochlorothiazide
quinaprilhydrochlorothiazide
_____________________
ACE INHIBITOR/
CALCIUM CHANNEL
BLOCKERS
amlodipine/benazepril
_____________________
ANGIOTENSIN II
RECEPTOR
ANTAGONISTS/
COMBINATIONS
Avapro/Avalide
Benicar/Benicar HCT
losartan/losartan HCT
_____________________
ANTILIPEMICS
BILE ACID RESINS
cholestyramine
colestipol
HMG-CoA REDUCTASE
INHIBITORS
lovastatin
pravastatin
simvastatin
Lipitor
NIACINS/
COMBINATIONS
Niaspan
_____________________
BETA-BLOCKERS
atenolol
carvedilol
metoprolol
metoprolol succinate
ext-rel
nadolol
propranolol
_____________________
CALCIUM CHANNEL
BLOCKERS
amlodipine
diltiazem ext-rel
nifedipine ext-rel
verapamil ext-rel
_____________________
CALCIUM CHANNEL
BLOCKER/
ANTILIPEMIC
COMBINATIONS
Caduet
_____________________
DIGITALIS
GLYCOSIDES
digoxin
____________________
DIURETICS
chlorthalidone
furosemide
hydrochlorothiazide
metolazone
spironolactonehydrochlorothiazide
torsemide
triamterenehydrochlorothiazide
CENTRAL NERVOUS
SYSTEM
ANTIDEPRESSANTS
MISCELLANEOUS
AGENTS
bupropion
bupropion ext-rel
mirtazapine
SSRIs
citalopram
fluoxetine
paroxetine
paroxetine ext-rel
sertraline
SNRIs
Venlafaxine
Effexor XR
_____________________
HYPNOTICS,
NONBENZODIAZEPINE
zolpidem
__________
MIGRAINE
SELECTIVE
SEROTONIN AGONISTS
sumatriptan
Maxalt
ENDOCRINE AND
METABOLIC
ANTIDIABETICS
BIGUANIDES
metformin
metformin ext-rel
INSULINS
Apidra
Humalog
Humulin
FIBRATES
Lantus
fenofibrate
Levemir
INFLUENZA AGENTS
gemfibrozil
Novolin
amantadine
Novolog
rimantadine
This document represents a summary of coverage, is not inclusive, and does not guarantee coverage. For more detailed information, refer
to your Prescription Drug Endorsement. The Preferred Medication List is subject to change at any time. Please refer to our web site at
www.capitalhealth.com for the most current Preferred Medication List or you may call the Member Services number on your
Identification Card.
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INSULIN SENSITIZERS
Actos
SULFONYLUREAS
glimepiride
glipizide
glipizide ext-rel
glyburide
SULFONYLUREA/
BIGUANIDE
COMBINATIONS
glipizide-metformin
glyburide-metformin
SUPPLIES
Accu-Chek Strips
And Kits
BD Insulin Syringes
And Needles
OneTouch Strips
And Kits
_____________________
CALCIUM
REGULATORS
BISPHOSPHONATES
Actonel
alendronate
CALCITONINS
calcitonin
Fortical
____________________
CONTRACEPTIVES
MONOPHASIC
ethinyl estradioldrospirenone
Yaz
TRIPHASIC
ethinyl estradiolnorgestimate
____________________
ESTROGENS
ORAL
estradiol
estropipate
Premarin
TRANSDERMAL
Estraderm
estradiol
ORAL ESTROGEN/
PROGESTINS
estradiolnorethindrone
Premphase
Prempro
_____________________
PROGESTINS
medroxyprogesterone
_____________________
SELECTIVE
ESTROGEN
RECEPTOR
MODULATORS
Evista
_____________________
THYROID
SUPPLEMENTS
levothyroxine
Synthroid
GASTROINTESTINAL
H2 RECEPTOR
ANTAGONISTS
ranitidine
famotidine
cimetidine
_____________________
PROTON PUMP
INHIBITORS
omeprazole
lansoprazole
pantoprazole
GENITOURINARY
BENIGN PROSTATIC
HYPERPLASIA
doxazosin
finasteride
terazosin
____________________
URINARY
ANTISPASMODICS
oxybutynin
oxybutynin ext-rel
Detrol
Detrol LA
HEMATOLOGIC
ANTICOAGULANTS
warfarin
LONG ACTING
Serevent
_____________________
NASAL
ANTIHISTAMINES
Astelin
_____________________
NASAL STEROIDS
fluticasone
Nasonex
_____________________
STEROID/BETA
AGONISTS
Advair
____________________
STEROID INHALANTS
Flovent
Pulmicort
TOPICAL
DERMATOLOGY
RESPIRATORY
_____________________
ANTICHOLINERGICS
Spiriva
_____________________
ANTICHOLINERGIC/
BETA AGONISTS
ipratropium-albuterol
inhalation solution
Combivent
_____________________
ANTIHISTAMINES,
NONSEDATING
fexofenadine
_____________________
BETA AGONISTS
SHORT ACTING
albuterol nebulizer
Proair HFA
ACNE
clindamycin solution
erythromycin solution
erythromycinbenzoyl peroxide
tretinoin
_____________________
OPHTHALMIC
BETA-BLOCKERS,
NONSELECTIVE
timolol maleate solution
PROSTAGLANDINS
Travatan
Xalatan
SYMPATHOMIMETICS
brimonidine 0.2%
Alphagan P
This document represents a summary of coverage, is not inclusive, and does not guarantee coverage. For more detailed information, refer
to your Prescription Drug Endorsement. The Preferred Medication List is subject to change at any time. Please refer to our web site at
www.capitalhealth.com for the most current Preferred Medication List or you may call the Member Services number on your
Identification Card.
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QUICK REFERENCE PREFERRED MEDICATION LIST
A___________
○ Actonel
o Actos
o acyclovir
o Advair
o alendronate
o Alphagan P
o amantadine
o Ambien CR
o amlodipine
o amlodipine/benazepril
o amoxicillin
o amoxicillinclavulanate
o Apidra
o Astelin
o atenolol
o Avalide
o Avapro
o azithromycin
B___________
o BD Insulin Syringes
and Needles
o Benicar
o Benicar HCT
o benazepril
o benazeprilhydrochlorothiazide
o Boniva
o brimonidine 0.2%
o bupropion
o bupropion ext-rel
C___________
○ Caduet
o calcitonin
o captopril
o carvedilol
o cefaclor
o cefdinir
o cephalexin
o cholestyramine
o cimetidine
o ciprofloxacin ext-rel
o ciprofloxacin tablet
o citalopram
o clarithromycin
o clarithromycin ext-rel
o clindamycin
o clindamycin-benzoyl
peroxide
o clindamycin solution
o colestipol
o
Combivent
D___________
o Detrol
o Detrol LA
o dicloxacillin
o digoxin
o diltiazem ext-rel
o doxazosin
o doxycycline hyclate
E___________
○ Effexor XR
○ enalapril
o erythromycin solution
o erythromycin-benzoyl
peroxide
o erythromycins
o Estraderm
o estradiol
o estradiolnorethindrone
o estropipate
o ethinyl estradioldrospirenone
o ethinyl estradiollevonorgestrel
o ethinyl estradiolnorgestimate
o Evista
F___________
o famotidine
o fenofibrate
o finasteride
o Flovent
o fluconazole
o fluoxetine
o fluticasone
o Fortical
o fosinopril
o fosinoprilhydrochlorothiazide
o furosemide
G___________
o gemfibrozil
o glimepiride
o glipizide
o glipizide ext-rel
o glipizide-metformin
o glyburide
o glyburide-metformin
H___________
o
o
o
Humalog
Humulin
hydrochlorothiazide
I____________
o ipratropium-albuterol
inhalation solution
o itraconazole
J____________
K___________
○ Kapidex
L___________
o lansoprazole
o Lantus
o Levaquin
o Levemir
o levothyroxine
o Lipitor
o lisinopril
o lisinoprilhydrochlorothiazide
o losartan
o losartan HCT
o lovastatin
M___________
○
Maxalt
o medroxyprogesterone
o metformin
o metformin ext-rel
o metolazone
o metoprolol
o metoprolol succinate
ext-rel
o metronidazole
o minocycline
o mirtazapine
o moexipril
N___________
o nadolol
o Nasonex
o Nexium
o Niaspan
o nifedipine ext-rel
o Novolin
o Novolog
o Nuvaring
O___________
o omeprazole
o
o
o
o
o
OneTouch
Ortho Evra
oxybutynin
oxybutynin ext-rel
Oxytrol
P___________
o pantoprazole
o paroxetine
o paroxetine ext-rel
o penicillin VK
o pravastatin
o Premarin
o Premphase
o Prempro
o Proair HFA
o propranolol
o Pulmicort
Q___________
o quinapril
o quinaprilhydrochlorothiazide
R___________
o ramipril
o ranitidine
o Relenza
o rimantadine
S____________
o Serevent
o sertraline
o simvastatin
o Spiriva
o
o
spironolactonehydrochlorothiazide
sulfamethoxazoletrimethoprim
o
o
o
sumatriptan
Symbicort
Synthroid
T___________
o Tamiflu
o terazosin
o terbinafine tablet
o tetracycline
o timolol maleate
solution
o torsemide
o trandolapril
o Travatan
o tretinoin
o Treximet
This document represents a summary of coverage, is not inclusive, and does not guarantee coverage. For more detailed information,
refer to your Prescription Drug Endorsement. The Preferred Medication List is subject to change at any time. Please refer to our web
site at www.capitalhealth.com for the most current Preferred Medication List or you may call the Member Services number on your
Identification Card.
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o
triamterenehydrochlorothiazide
U___________
V___________
○ valacyclovir
o venlafaxine
o verapamil ext-rel
W___________
o warfarin
Y___________
○ Yaz
X___________
o Xalatan
Z___________
○ zolpidem
o Zomig
This document represents a summary of coverage, is not inclusive, and does not guarantee coverage. For more detailed information,
refer to your Prescription Drug Endorsement. The Preferred Medication List is subject to change at any time. Please refer to our web
site at www.capitalhealth.com for the most current Preferred Medication List or you may call the Member Services number on your
Identification Card.
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Additional Benefit Information
3-Tier or 4-Tier Prescription Drug Benefit
Each covered prescription drug, when purchased from a participating network pharmacy, is subject to a copay
amount. The copay amount is determined by the tier status of the prescription drug dispensed. Most generic
drugs are Tier 1, preferred brands are Tier 2, and nonpreferred brands are Tier 3 (a nonpreferred brand is any
brand name drug not found on the Preferred Medication List). Self-injectable or specialty drugs may be Tier
4.
Tier 1 drugs = $
Tier 2 drugs = $$
Tier 3 drugs = $$$
Tier 4 drugs = $$$$$
Limitations
o A prescription unit or refill will be covered for up to a 30-day supply. Refills on prescriptions will not be
covered until at least 75% of the previous prescription has been used based on the dosage schedule
prescribed by the physician.
o Certain drugs may be subject to additional requirements or limits on coverage. These requirements and
limits may include prior authorization, quantity limits, and/or step therapy. The drugs listed as requiring
prior authorization, quantity limits, and or step therapy are subject to change at any time.
o If a generic drug is available and a more expensive brand name prescription drug is dispensed, you must pay
the copay amount for the brand name drug plus 100% of the additional cost for the more expensive brand
name drug.
Specific Exclusions and Limitations
o Avage
o Claritin/Claritin-D/loratadine
o Cosmetic drugs
o Dental fluoride products
o Depigmentation agents
o Drugs for treatment of onychomycosis
o Experimental drugs
o Fertility drugs
o Flumist
o Injectables (except insulin vials, EpiPen, EpiPen Jr., Glucagon, Heparin, Lovenox)
o Over-the-counter drugs (OTC)
o Pepcid/famotidine 20mg
o Propecia
o Renova
o Smoking cessation products
o Vaniqa
o Weight loss drugs
This document represents a summary of coverage, is not inclusive, and does not guarantee coverage. For more detailed information,
refer to your Prescription Drug Endorsement. The Preferred Medication List is subject to change at any time. Please refer to our web
site at www.capitalhealth.com for the most current Preferred Medication List or you may call the Member Services number on your
Identification Card.
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Prescription Quantity Limits
Most Capital Health Plan Prescription Drug benefits have up to a 30-day supply limit per copayment. The
following agents have more specific quantity limits.
Abilify limited to 30 tablets per month
Aciphex limited to 30 tablets per month
Amerge limited to 18 tablets per month
Ambien/zolpidem limited to 30 tablets per month
Ambien CR limited to 30 tablets per month
Anzemet limited to 5 tablets per month
Axert limited to 18 tablets per month
Boniva 150mg limited to 1 tablet per month
Celebrex limited to 30 capsules per month
Cialis limited to 4 tablets per month
Combunox limited to 30 tablets per 180 days
Butorphanol Injection limited to 2ml per month
Butorphanol Nasal Spray limited to 1 unit per
month
Edluar limited to 30 tablets per month
Emend limited to 5 tablets per month
Emend limited to 1 combo pack per month
Estring limited to 1 ring per month
Femring limited to 1 ring per month
Frova limited to 18 per month
Glucagon limited to 1 kit per month
Glucometer limited to 1 meter every 999 days
Glucometer strips limited to 102 per month
Imitrex/sumatriptan Kits limited to 6 kits (12
syringes) per month
Imitrex/sumatriptan Nasal Spray limited to 18
dosage units per month
Imitrex/sumatriptan Tablets limited to 18 tablets
per month
Imitrex/sumatriptan Vials limited 10 vials per
month
Insulin Syringes limited to 100 per month
Kapidex limited to 30 capsules per month
Ketorolac limited to 20 tablets per month
Kytril/granisetron limited to 10 tablets per month
Kytril/granisetron Solution limited to 30ml per
month
Levitra limited to 4 tablets per month
Lunesta limited to 30 tablets per month
Maxalt/MLT limited to 18 tablets per month
Migranal Nasal Spray limited to 8 dosage units
per month
Muse Urethral Inserts limited to 6 dosage units
per month
Nexium limited to 30 capsules per month
Nuvaring limited to 1 ring per month
Ortho Evra limited to 4 patches per month
Prevacid/lansoprazole limited to 30 capsules per
month
Prevpac limited to 14 per month
Prilosec/omeprazole limited to 30 capsules per
month
Protonix/pantoprazole limited to 30 tablets per
month
Relenza limited to 1 unit per 365 days
Relpax limited to 18 tablets per month
Restasis limited to 64 per month
Rozerem limited to 30 tablets per month
Sarafem limited to 28 tablets per month
Seroquel limited to 60 tablets per month
Seroquel XR limited to 60 tablets per month
Sonata/zaleplon limited to 30 tablets per month
Tamiflu limited to 20 tablets per 180 days
Tamiflu Suspension limited to 100ml per 180 days
Treximet limited to 18 tablets per month
Vagifem limited to 18 tablets per month
Valtrex limited to 30 tablets per month
Viagra limited to 4 tablets per month
Zofran/ondansetron limited to 6 tablets per month
Zofran/ondansetron ODT limited to 5 tablets per
month
Zofran/ondansetron Solution limited to 50ml per
month
Zomig/ZMT limited to 18 tablets per month
Zomig Nasal Spray limited to 18 dosage units per
month
Zyprexa limited to 30 tablets per month
This document represents a summary of coverage, is not inclusive, and does not guarantee coverage. For more detailed information,
refer to your Prescription Drug Endorsement. The Preferred Medication List is subject to change at any time. Please refer to our web
site at www.capitalhealth.com for the most current Preferred Medication List or you may call the Member Services number on your
Identification Card.
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Prior Authorization Requirements
o Actiq
o Adcirca
o Anticonvulsants (e.g. Gabitril, Keppra/Keppra XR, Lamictal/Lamictal XR, Lyrica,
oxcarbazepine, Topamax, topiramate, Trileptal, Vimpat)
o Buprenex
o Fentora
o Insulin pens
o Nuvigil
o Propoxyphene (e.g. Darvon, Darvocet) for ages 65 and over
o Provigil
o Qualaquin
o Regranex
o Suboxone
o Subutex
o Tracleer
o Ventavis
o Vivitrol
o Xolair
o Xyrem
o Most injectable drugs
This document represents a summary of coverage, is not inclusive, and does not guarantee coverage. For
more detailed information, refer to your Prescription Drug Endorsement. The Preferred Medication List is
subject to change at any time. Please refer to our web site at www.capitalhealth.com for the most current
Preferred Medication List or you may call the Member Services number on your Identification Card.
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