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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. 2011 PREFERRED MEDICATION LIST BY THERAPEUTIC CATEGORY

ANTI-INFECTIVES
fenofibrate
ANTIBACTERIALS
gemfibrozil
CENTRAL NERVOUS
CARDIOVASCULAR
cefaclor
ACE INHIBITORS
ANTIDEPRESSANTS
cefdinir
benazepril
lovastatin
cephalexin
captopril
pravastatin
enalapril
fosinopril
simvastatin
bupropion
lisinopril
bupropion ext-rel
azithromycin
moexipril
mirtazapine
clarithromycin
quinapril
clarithromycin ext-rel
ramipril
erythromycins
trandolapril
citalopram
fluoxetine
ACE INHIBITOR/
paroxetine
BETA-BLOCKERS
ciprofloxacin ext-rel
DIURETIC
paroxetine ext-rel
atenolol
ciprofloxacin tab
COMBINATIONS
sertraline
benazepril-
carvedilol
hydrochlorothiazide
metoprolol
fosinopril-
metoprolol succinate
ext-rel
amoxicillin
hydrochlorothiazide
venlafaxine
nadolol
amoxicillin-clavulanate
lisinopril-
venlafaxine ext-rel
propranolol
dicloxacillin
hydrochlorothiazide
penicillin VK
quinapril-
hydrochlorothiazide
CALCIUM CHANNEL
HYPNOTICS,
BLOCKERS
NONBENZODIAZEPINE
amlodipine
zolpidem
doxycycline hyclate
diltiazem ext-rel
zolpidem ER 6.25mg
minocycline
ACE INHIBITOR/
nifedipine ext-rel
tetracycline
CALCIUM CHANNEL
BLOCKERS
verapamil ext-rel
MIGRAINE
amlodipine/benazepril
CALCIUM CHANNEL
metronidazole
trandolapril/verapamil
BLOCKER/
sulfamethoxazole-
ANTILIPEMIC
naratriptan
trimethoprim
ANGIOTENSIN II
____________________
RECEPTOR
COMBINATIONS
sumatriptan
ANTIFUNGALS
ANTAGONISTS/
fluconazole
COMBINATIONS
DIGITALIS
itraconazole
losartan/losartan HCT
ENDOCRINE AND
GLYCOSIDES
terbinafine tablet
METABOLIC
_____________________
digoxin
ANTIVIRALS
ANTIDIABETICS
DIURETICS
ANTILIPEMICS
chlorthalidone
furosemide
acyclovir
hydrochlorothiazide
famciclovir
metolazone
valacyclovir
cholestyramine
colestipol
spironolactone-
hydrochlorothiazide
torsemide
amantadine
triamterene-
rimantadine
metformin
hydrochlorothiazide
metformin ext-rel
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. GENITOURINARY
ethinyl estradiol-
BENIGN PROSTATIC
ANTIHISTAMINES
norgestimate
HYPERPLASIA
azelastine
doxazosin
ESTROGENS
finasteride
NASAL STEROIDS
tamulosin
fluticasone
terazosin
estradiol
estropipate
ANTISPASMODICS
STEROID/BETA
oxybutynin
AGONISTS
oxybutynin ext-rel
estradiol
STEROID INHALANTS
nateglinide
HEMATOLOGIC
glimepiride
estradiol-
glipizide
norethindrone
ANTICOAGULANTS
glipizide ext-rel
warfarin
glyburide
DERMATOLOGY
PROGESTINS
RESPIRATORY
medroxyprogesterone
clindamycin solution
ANAPHYLAXIS
clindamycin/benzoyl
glipizide-metformin
SELECTIVE
TREATMENTS
peroxide
glyburide-metformin
ESTROGEN
erythromycin solution
RECEPTOR
erythromycin-
MODULATORS
benzoyl peroxide
ANTICHOLINERGICS
tretinoin
OPHTHALMIC
SUPPLEMENTS
ANTICHOLINERGIC/
levothyroxine
BETA AGONISTS
ipratropium-albuterol
inhalation solution
timolol maleate solution
GASTROINTESTINAL
REGULATORS
H2 RECEPTOR
ANTIHISTAMINES,
ANTAGONISTS
NONSEDATING
alendronate
fexofenadine
cimetidine
famotidine
BETA AGONISTS
ranitidine
brimonidine 0.2%
calcitonin
PROTON PUMP
albuterol nebulizer
Fortical
INHIBITORS
lansoprazole
omeprazole
CONTRACEPTIVES
pantoprazole
ethinyl estradiol-
LEUKOTRIENE
drospirenone
RECEPTOR
Gianvi
ANTAGONISTS
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. QUICK REFERENCE PREFERRED MEDICATION LIST

A___________

clarithromycin ext-
fosinopril
metoprolol succinate
Actonel
rel
fosinopril-
ext-rel
clindamycin
hydrochlorothiazide
metronidazole
clindamycin solution
furosemide
minocycline
clindamycin/benzoyl
mirtazapine
peroxide
G___________
moexipril
acyclovir
colestipol
gemfibrozil
N___________
albuterol nebulizer
glimepiride
nadolol
alendronate
glipizide
glipizide ext-rel
amantadine
glipizide-metformin
amlodipine
D___________
glyburide
amlodipine/
glyburide-metformin
benazepril
amoxicillin
dicloxacillin
H___________
nifedipine ext-rel
amoxicillin-
digoxin
clavulanate
diltiazem ext-rel
doxazosin
hydrochlorothiazide
atenolol
doxycycline hyclate
I____________
O___________
ipratropium-
omeprazole
azelastine
E___________
albuterol inhalation
azithromycin
enalapril
solution
itraconazole
oxybutynin
B___________
oxybutynin ext-rel
J____________
erythromycin
P___________
solution
pantoprazole
erythromycin-benzoyl
paroxetine
benazepril
peroxide
K___________
paroxetine ext-rel
benazepril-
erythromycins
penicillin VK
hydrochlorothiazide
L___________
pravastatin
estradiol
lansoprazole
brimonidine 0.2%
estradiol-
bupropion
norethindrone
bupropion ext-rel
estropipate
ethinyl estradiol-
levothyroxine
propranolol
C___________
drospirenone
ethinyl estradiol-
calcitonin
norgestimate
lisinopril
Q___________
captopril
lisinopril-
quinapril
carvedilol
hydrochlorothiazide
quinapril-
cefaclor
F___________
losartan
hydrochlorothiazide
cefdinir
famciclovir
losartan HCT
cephalexin
famotidine
lovastatin
chlorthalidone
fenofibrate
cholestyramine
fexofenadine
M___________
R___________
cimetidine
finasteride
ramipril
ciprofloxacin ext-rel
medroxyprogesterone
ranitidine
ciprofloxacin tablet
fluconazole
metformin
citalopram
fluoxetine
metformin ext-rel
rimantadine
clarithromycin
fluticasone
metolazone
Fortical
metoprolol
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. S____________
T___________
triamterene-
W___________
hydrochlorothiazide
warfarin
sertraline
tamulosin
simvastatin
terazosin
U___________
X___________
terbinafine tablet
tetracycline
V___________
spironolactone-
timolol maleate
valacyclovir
Y___________
hydrochlorothiazide
solution
venlafaxine
sulfamethoxazole-
torsemide
venlafaxine ext-rel
trimethoprim
trandolapril
verapamil ext-rel
Z___________
sumatriptan
zolpidem
zolpidem ER 6.25mg
tretinoin
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.
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
o High-Risk Medications for ages 65 and over*
*High-Risk Medications in the Elderly as defined by the National Committee for Quality Assurance (NCQA) www.ncqa.com 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. 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
Muse Urethral Inserts limited to 6 dosage units
Amerge limited to 18 tablets per month
Ambien/zolpidem limited to 30 tablets per month
Nexium limited to 30 capsules per month
Ambien CR limited to 30 tablets per month
Nuvaring limited to 1 ring per month
Anzemet limited to 5 tablets per month
Ortho Evra limited to 4 patches per month
Axert limited to 18 tablets per month
Prevacid/lansoprazole limited to 30 capsules per
Boniva 150mg limited to 1 tablet per month
Butorphanol Injection limited to 2ml per month
Prevpac limited to 14 per month
Butorphanol Nasal Spray limited to 1 unit per
Prilosec/omeprazole limited to 30 capsules per
Celebrex limited to 30 capsules per month
Protonix/pantoprazole limited to 30 tablets per
Cialis limited to 4 tablets per month
Combunox limited to 30 tablets per 180 days
Relenza limited to 1 unit per 365 days
Dexilant limited to 30 capsules per month
Relpax limited to 18 tablets per month
Edluar limited to 30 tablets per month
Restasis limited to 64 per month
Emend limited to 5 tablets per month
Rozerem limited to 30 tablets per month
Emend limited to 1 combo pack per month
Sarafem limited to 28 tablets per month
Estring limited to 1 ring per month
Seroquel limited to 60 tablets per month
Femring limited to 1 ring per month
Seroquel XR limited to 60 tablets per month
Frova limited to 18 per month
Sonata/zaleplon limited to 30 tablets per month
Glucagon limited to 1 kit per month
Tamiflu limited to 20 tablets per 180 days
Glucometer limited to 1 meter every 999 days
Tamiflu Suspension limited to 100ml per 180 days
Glucometer strips limited to 102 per month
Treximet limited to 18 tablets per month
Imitrex/sumatriptan Kits limited to 6 kits (12
Vagifem limited to 18 tablets per month
Valtrex limited to 30 tablets per month
Imitrex/sumatriptan Nasal Spray limited to 18
Viagra limited to 4 tablets per month
Zofran/ondansetron limited to 6 tablets per month
Imitrex/sumatriptan Tablets limited to 18 tablets
Zofran/ondansetron ODT limited to 5 tablets per
Imitrex/sumatriptan Vials limited 10 vials per
Zofran/ondansetron Solution limited to 50ml per
Insulin Syringes limited to 100 per month
Zomig/ZMT limited to 18 tablets per month
Ketorolac limited to 20 tablets per month
Zomig Nasal Spray limited to 18 dosage units per
Kytril/granisetron limited to 10 tablets per month
Kytril/granisetron Solution limited to 30ml per
Zyprexa limited to 30 tablets per month
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
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. 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
Step Therapy Requirements
o Byetta
o Singulair
o Victoza


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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