Commercial Member Preferred Medication List 2007
| A----------------------
ACCU-CHEK ACTONEL ACTONEL + CALCIUM ACTOS ACTOPLUS MET ADVAIR DISKUS ALORA ALPHAGAN P ALREX ALTACE ARICEPT ARICEPT ODT ASACOL ASTELIN AVALIDE AVANDAMET AVANDIA AVAPRO AZMACORT AZOPT B---------------------- BACTROBAN CREAM BACTROBAN
BETOPTIC S C---------------------- CAPITROL CARAC CELONTIN CENESTIN CILOXAN
COSOPT CUPRIMINE D---------------------- DAPSONE DEPAKOTE |
D cont'd.----------------
DEPAKOTE ER DETROL DETROL LA DIDRONEL DIOVAN DIOVAN HCT DIPENTUM DOVONEX E---------------------- EFFEXOR XR EFUDEX 5% CREAM ESTROSTEP FE EURAX EVISTA F---------------------- FLOVENT HFA FOSAMAX FOSAMAX + D G---------------------- H---------------------- HUMALOG HUMULIN I---------------------- INSULINS (Lilly, Novo Nordisk) INTAL INHALER J---------------------- K---------------------- KEPPRA K-LYTE DS L---------------------- LANTUS LEVAQUIN LIPITOR LIVOSTIN LOPROX GEL LOPROX SHAMPOO LOTEMAX LUMIGAN |
M---------------------
MAXAIR
MAXALT MLT MENEST MEPHYTON MESTINON SYRUP MESTINON TIMESPAN METHERGINE METROGEL MIRAPEX MYCOBUTIN N---------------------- NARDIL NASACORT AQ NASONEX NIASPAN NOVOLIN NOVOLOG O---------------------- ORTHO EVRA ORTHO TRI-CYC LO OVCON-35, 50 P-------------------- PENTASA PHOSLO PLARETASE PLAVIX PRECOSE PREMARIN PREMPHASE PREMPRO PROMETRIUM |
Q----------------
R---------------- REQUIP RHINOCORT
RISPERDAL S---------------- SEREVENT
SKELAXIN SPIRIVA SYNAREL SYNTHROID T---------------- TAZORAC TEGRETOL XR TILADE TOBRADEX TOPROL XL U---------------- V---------------- VAGIFEM TABS VALTREX VENTOLIN HFA VIGAMOX VIOKASE VIRA-A VOLTAREN OPH W---------------- X---------------- XALATAN Y---------------- Z---------------- ZITHROMAX POW ZOMIG ZOMIG ZMT |
3-Tier Prescription Drug Benefit
Each Covered Prescription Drug, when purchased from a Participating Pharmacy, is subject to a Copayment amount. The Copayment amount is determined by the type of Prescription Drug dispensed (Generic Drug, Preferred Brand Name Drug, or any Brand Name Prescription Drug not on the Preferred Medication List).
Tier I Generic Drugs $
Tier II Preferred Brand Drugs $$
Tier III Non-Preferred Brand Drugs $$$
The use of generic drugs and a Preferred Medication List are both effective ways to control costs. If a generic drug is available, it will be dispensed whenever possible at the lowest co-payment, (Tier I). When there is no generic available, there may be more than one brand name drug to treat your condition. This Preferred Medication List includes brand name drugs for which the Tier II co-payment applies. This list was developed by the Capital Health Plan Pharmacy Committee which is comprised of pharmacists and physicians, who review, evaluate and establish guidelines for optimal drug use. The Committee utilized peer-reviewed primary literature whenever possible to evaluate medications. Brand name drugs (without a generic equivalent) that are not included on this list will require the Tier III co-payment amount. Over time, brand names listed may become available as generic. At that time, the brand version will require a Tier III co-payment and usually 100% of the additional cost for the more expensive brand name 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. Oral chemotherapy, immunosuppressive and HIV medications approved by the FDA prior to January 1, 2005 that have no generic equivalent are covered as Preferred Brand Drugs (Tier II copayment). Those approved after January 1, 2005 and having no generic equivalent will be covered as Non-Preferred Brand Drugs (Tier III copayment) and will be evaluated for preferred status during the annual formulary review performed by the Pharmacy and Therapeutics Committee or in one year, whichever comes first. All compounded medications and most injectables will require the Tier III copayment amount.
Limitations
- 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.
- Certain Prescription Drugs require prior coverage authorization. For instructions on how to obtain prior authorization, please contact Member Services at 383-3311 Monday through Friday, 8 a.m. to 5 p.m.
- If a generic drug is available and a more expensive brand name prescription drug is dispensed at the request of the member, the member must pay the Copayment amount for the brand name drug and usually pay the pharmacist 100% of the additional cost for the more expensive brand name drug.
- CHP may limit quantities for medications prescribed to be taken on a p.r.n. (as needed) basis.