Microsoft word - 2011 commercial pml_10 27 10_atm,spt_ v7_clean_final_.docx
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 Boniva150mg 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.
Lucile Packard Children’s Hospital Clinical Protocol: Revised January 16, 2007 Post-Transplant Primary Immunosuppression Protocol 1) Induction Agents a) Patients with low sensitization risk (peak PRA < 20%, first transplant). i) These patients will receive Zenapax [dacluzimab], administered as follows: (1) Steroid-Based: Zenapax® dose of 1 mg/kg pre-transplant followed by 1 mg
