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At Capital Rx, your health is our top priority. We prepared formularies (drug list) to ensure that you have access to a robust offering that meets your needs and lowers your overall prescription drug cost. This list of drugs is covered by your pharmacy prescription benefit. Some drugs on this list that display as covered on the formulary, may not be covered if your plan does not include coverage of certain categories. If you have any questions regarding your specific coverage, please call the number on the back of your member ID card.

What is a Formulary?

A formulary is a list of drugs that may be covered by your pharmacy benefit.

The formulary is:

• Based on the recommendations of a committee of highly skilled physicians and pharmacists that review drugs regulated by the United States Food and Drug Administration (FDA)
• Inclusive of drugs regulated by the United States Food and Drug Administration (FDA)
• Developed with considerations of clinical efficacy and safety
• Evaluated for financial considerations based on the review of market trends and driving the lowest net cost products where applicable
• Subject to change throughout the year

Please note: drugs that are newly approved by the FDA may not be covered until the committee has been able to fully evaluate them.

Your pharmacy prescription benefit covers many prescription drugs, but some exclusions may apply. If a drug is not covered, an alternative covered drug will be available. Drugs that have not received FDA approval or that have over the counter (OTC) equivalents may not be covered.

Please use this list as a guide to talk to your doctor about prescribing covered medications that are appropriate for you, as this may lower your out of pocket costs.

How To Use This List

Each prescription drug product is placed in a Tier from 1 to 3 that determines your cost-share:
• Generic (Tier 1)
• Preferred Brands (Tier 2)
• Non-Preferred Brands (Tier 3)

Generic drugs are displayed in lowercase italicized lettering. Brand drugs are displayed in UPPERCASE LETTERING. Brand drugs may be removed from your drug list after a generic equivalent becomes available. Generic drugs generally have the lowest cost share.

Drugs that do not appear on this list are excluded under the formulary. If your prescribed medication is not covered, please contact your doctor to see if a covered alternative is right for you. If your prescriber determines that you require a drug that is not covered on the formulary, a drug exception request with clinical documentation may be submitted.

If your plan offers a prescription drug benefit for preventive drugs listed under the Affordable Care Act or a Health Savings Account, the drugs will be flagged below. These drugs may be available at $0 or a lower cost share than regularly tiered drugs depending on your benefit.

Additional restrictions may apply and will be indicated next to the drug on the list below. Some drugs may only be covered for members within a certain age range or gender due to recommendations based on FDA-approved labeling and clinical practice guidelines. Some drugs are subject to prior authorization, step therapy, or quantity limits. Please reference the legend below for more information.

Medications with a Specialty Drug flag are used to treat complex medical conditions (e.g. hepatitis, multiple sclerosis, and hemophilia) and require special handling, administration, and member care management. Depending on your pharmacy benefit design, specialty drugs may be part of a benefit with specific coverage and copay requirements that differ from drugs in Tiers 1 – 3. If you do not have a defined specialty benefit, your copay may be based on whether the drug is generic or BRAND, therefore Tier 1 or Tier 3 copays may apply.

Note that some drug classes may be excluded by your plan or not covered on your pharmacy benefit. If you have questions about your coverage, please call the number on the back of your member ID card.

How To Search:

• Use the alphabetical list to search by the first letter of your medication.
• Search by typing part of the generic (chemical) and brand (trade) names.
• Search by selecting the therapeutic class of the medication you are looking for.