Untitled
Prescription
Program
Drug List — To be used by members
(both National Accounts and Local Group),
who have a tiered drug plan.
Anthem Blue Cross prescription drug benefits include medications available on the Anthem Drug List. Our prescription drug benefits can offer potential savings when your physician prescribes medications on the drug list.
ANTHEM BLUE CROSS DRUG LISTYour prescription drug benefit includes coverage for medicines that you’ll find on the Anthem Drug List. You can often find more savings when your doctor prescribes medicine that is on our drug list. Here are some commonly asked questions and answers about how the drug list works with your prescription drug plan.
For more information
about your drug plan,
A. The Anthem Drug List, also called a formulary is a list of U.S. Food and Drug
you can do the following:
Administration (FDA)-approved brand-name and generic drugs that have been reviewed and recommended for their quality and how well they work. The review is done by the
•
Go to anthem.com/ca
National Pharmacy and Therapeutics (P&T) Process. The P&T Process is performed by an
•
Call customer service
independent group of practicing doctors and pharmacists in charge of the research and
at the number on your
decisions surrounding our drug list. This group meets regularly to review new and existing drugs and they choose the top drugs for our list—based on their safety, how they work and
•
Speech and hearing
Because the drugs on our list are reviewed from time to time, it’s a good idea to check
impaired users
the list to find out if any drugs have been added or removed. You can do this by going to
(TDD/TTY) should call
800-221-6915, Monday
– Friday, 8:30 a.m. –
A. Drugs on the Anthem Drug List are grouped into tiers. There are several factors that are
5:00 p.m., ET
used to determine under which tier a drug will be put in. This can include (but it’s not limited to):
•
Bring a copy of this drug
list to your next doctor’s
• Cost of the drug in comparison to other drugs used for the same type of treatment
visit to help you and
• Availability of over-the-counter options
your doctor select the
• Other clinical and cost factors.
lowest cost medicine
Q.
What is a brand-name drug? A. These are drugs that are developed by a company who holds the rights to sell them.
When the rights expire, other drug companies can make their own version of the drugs (see generic drugs below). You may be more familiar with brand-name drugs through advertising or because you know people who take them.
Q.
What is a generic drug? A. Generics are simply copies of brand-name drugs. Brand-name and generic drugs have the
same active ingredients, strength and dose. And the FDA requires that generic drugs meet
KEY FOR DRUG LIST
the same high standards for purity, quality, safety and strength. With generics, you get the
Tier 1 – Lowest copayment – Drugs that
offer the greatest value compared to others that treat the same conditions.
Q.
What if my doctor or I choose a brand-name drug when a generic version is available?
A. In most cases, you would be responsible for the Tier 1 copay plus an additional cost share
for the cost difference between the brand-name medication and the generic version.
Tier 2 – Medium copayment – Brand-
Q.
What are “clinically equivalent” medications? How does this affect my drug coverage?
A. When drugs are compared in studies, some drugs have been found to be just as effective
as others. These drugs are called “clinically equivalent” so it means they work just as
well. Part of the P&T Process is to review the most current studies to see if multiple drugs
used to treat a disease or a condition have the same effect on a patient. When this is the
case, the Process review team may suggest that we cover only the lower cost drug (so we
can help keep the overall cost of care as low as possible). This means your specific drug
effects, if they’re more affordable, etc.
plan may not cover some drugs (indicated by a ^ symbol next to the drug name) that have
Tier 3 – Highest copayment – These are
Q.
What if my medication is not on the drug list?
Tier 3 drugs may have generic versions in Tier 1 and may cost more than the
A. You may want to first check with your doctor about prescribing a drug that is on the drug
list. If your doctor prescribes a drug that’s not on the drug list, you will need to pay the copayment that applies to drugs that are not on the list.
Tier 4 – Many drugs on this tier
are “specialty” drugs used to treat
Q.
Can I request that a drug be added to the drug list?
A. You or your doctor can put in a request to add a drug to the drug list. You can do this either
in writing or on our website. Requests are reviewed by the P&T Process team during the
drug list review.
Please note that if a drug request is approved, it does not guarantee
coverage. Some drugs, such as those used for cosmetic purposes, may be excluded
from your benefits. Please refer to your insurance Certificate or Evidence of Coverage
to know for sure.
Atenolol/chlorthalidone Cartia XT
DO,
QL
Atorvastatin
DO,
QL
Azelastine
QL
Azelastine nasal
QL
Azithromycin
QL
Felodopine
DO,
QL
Hydrocodone/APAP
QL
Bacitracin zinc/polymyxin B Cefuroxime
QL
Fentanyl
PA,
QL
Diltia XT
DO,
QL
Fexofenadine
QL
Fexofenadine/PSE 12hr
QL Hydrocortisone/
Diltiazem CD
DO,
QL
Diltiazem CR
DO,
QL
Diltiazem SR
DO,
QL
Alendronate
QL
Ibandronate
ST,
QL
Imiquimod
QL
Fluoxetine
DO,
QL
soln/nasal spray
QL
Ciprofloxacin
QL
Irbesartan
DO,
QL
Citalopram
DO,
QL
Irbesartan/HCTZ
DO,
QL
Fluticasone Nasal Spray
QL
Fluvastatin
DO
Fluvoxamine
DO,
QL
Budeprion XL
DO,
QL
Doxycycline DR
ST
0.5mg/2ml
QL
Fosinopril
DO,
QL
Amlodipine
DO,
QL
Amlodipine/atorvastatin
DO Bumetanide
Clopidogrel
QL
Isotretinoin
QL
Buprenorphine
QL
Itraconazole
PA
Amnesteem
QL
Eprosartan
QL
Ketorolac
QL
Codeine/APAP
QL
10mg/ml N.S.
QL
Candesartan/HCTZ
DO,
QL Dantrolene
Lansoprazole, ODT
QL
Escitalopram
DO,
QL
Desloratadine
QL
Estradiol/norethindrone
PA Guaifenesin SR
APAP/caffeine/butalbital Carbidopa/levopa/
Guaifenesin/hydrocodone Levalbuterol Neb. Soln.
QL
Aspirin/caffeine/butalbital Carisoprodol
Levocetirizine
QL
Sertraline
DO,
QL
Levofloxacin
QL
Omeprazole
QL
Simvastatin
DO,
QL,
PA Triamcinolone acetonide
Omeprazole/bicarb
QL
Pravastatin
DO,
QL
(80 mg only)
Orphenadrine cpd Forte Prednisolone sodium
Modafinil
PA,
DO,
QL
Montelukast
QL
Sotret
QL
Morphine ER
QL
Oxycodone ER
QL
Oxycodone/APAP
QL
Multivitamins w/fluoride Oxycodone/aspirin
Multivitamins w/folic acid Oxymorphone
QL
Losartan
DO,
QL
Pantoprazole
QL
Losartan/HCTZ
DO,
QL
Paroxetine, SR
DO,
QL
Lovastatin
DO,
QL
Naratriptan
QL
Valsartan/HCTZ
DO,
QL
Meloxicam
QL
tabs and inj.
QL
Propoxyphene/APAP
QL
Zaleplon
ST,
QL
Zolpidem, ER
QL
Nifedipine ER
DO,
QL
Nisoldipine
DO,
QL
Accu-chek Product Line
QL
Actonel
QL
Actonel with Calcium
QL
ActoPlus Met, XR
QL
Quinine sulfate
PA,
QL
Advair Diskus, HFA
QL
Advicor
DO
Androgel
PA,
QL
Tramadol/APAP
QL
Ofloxacin
QL
Atacand HCT
DO,
QL
Retin-A Micro
PA
Xarelto
QL
Augmentin, XR
QL
Asmanex
QL
Maxalt, MLT
QL
Avalide
DO,
QL
Astepro
QL
Avandamet
ST,
QL
Exforge
DO,
QL
Avandaryl
ST,
QL
Atrovent HFA
QL
Exforge HCT
DO,
QL
Avandia
ST,
QL
Avinza
QL
Avapro
DO,
QL
Savella
QL
Avelox
QL
Axert
ST,
QL
Serevent Diskus
QL
Axiron
PA,
QL
Azor
DO,
QL
Spiriva
QL
Beconase AQ
ST,
QL
Flovent, HFA
QL
Nasonex
QL
Abstral
PA,
QL
Benicar, HCT
DO,
QL
Bydureon
ST,
QL
Benzaclin
ST
Foradil
QL
Nexium
QL
Suboxone SL Tab
ST, SL Accupril
Bepreve
ST,
QL^
Fosamax Plus D
QL
Film
PA,
QL
Fosamax solution
QL
Betaseron
ST*
Symbicort
QL
Aciphex
ST,
QL^
Activella
PA
Beyaz
QL,
ST∞
Actiq
PA,
QL
ActoPlus Met
QL
Colcrys
QL
Tamiflu
QL
Boniva
ST,
QL
Nuvaring
QL
Brilinta
QL
Combivent, Respimat
QL Glyset
One Touch Product Line
QL Teslac
Byetta
ST,
QL
Testim
PA,
QL
Aggrenox
QL
Aldara
QL
Caduet
DO
QL,
ST∞
Alamast
ST,
QL^
Cambia
QL
OxyContin
QL
Allegra, D
ST,
QL^
Crestor
DO,
QL
Alocril
ST,
QL^
Alomide
ST,
QL^
Tradjenta
ST,
QL
Perforomist
QL
Cymbalta
DO,
QL
Cardizem CD, LA
DO,
QL
Pradaxa
QL
Trilipix
QL
Altoprev
ST,
DO
Janumet
QL
Ceftin
QL
Janumet XR
QL
Alvesco
QL
Celebrex
ST,
QL
Januvia
QL,
ST
Ambien
QL
Jentadueto
QL
Ambien CR
ST,
QL
Juvisync
QL
Amerge
QL
Cialis
PA,
QL
Valturna
DO,
QL
Anadrol-50
PA
Cipro XR
QL
Veltin
ST
Androderm
ST,
PA,
QL
Clarinex, D
ST,
QL^
Diovan
DO,
QL†
Lamictal tab, chew 2 mg Pristiq
DO,
QL
Ventolin HFA
QL
Android
PA
Duetact
QL†
ProAir HFA
QL
Veramyst
QL
Dulera
QL
Durezol
QL
Protopic
ST
Victoza
ST,
QL
Apidra
ST
Pulmicort Flexhaler
QL
Aplenzin
DO,
QL
Effient
DO,
QL
Elidel
ST
1mg/2ml
QL
Arcapta
QL
Arthrotec
ST
Loestrin 24 FE
QL,
ST∞
Astelin
QL
Vyvanse
PA
Atacand
DO,
QL
Pataday
ST,
QL^
Flector
ST
Lunesta
QL
Patanol
ST,
QL^
Simcor
QL
Flonase
QL
Paxil CR
DO,
QL
Singulair
QL
Viagra
PA,
QL
Covera HS
DO
Lyrica
PA
Cozaar
DO,
QL
Solodyn
PA,
ST
Viibryd
ST,
QL
Vimovo
QL
Sonata
ST,
QL
Maxair
QL
Plavix
QL
Maxaquin
QL
Dexilant
ST,
QL^
Forfivo XL
QL
Sporanox Solution
PA
Fortesta
PA,
QL
Stadol
QL
Vytorin
ST,
QL
Fosamax tablets
QL
Frova
ST,
QL
Striant
PA
Wellbutrin XL
DO,
QL
Miacalcin Spray
QL
Subsys
PA
Winstrol
PA
Micardis, HCT
DO,
QL
Subutex
QL
Diovan HCT
DO,
QL
Gelnique
ST
Migranal
QL
Sular
DO,
QL
Sumavel Dosepro
ST,
QL Xifaxan
ST,
QL
QL,
ST∞
Suprax
QL
Xopenex HFA
QL
Prevacid
ST,
QL^
Symbyax (except 3/25mg) Xopenex Neb. Soln.
QL
Duexis
ST,
QL
Prevpac
QL
Xyzal
ST,
QL^
Morgidox
ST
Prilosec
ST,
QL^
Dymista
QL
Primaxin
QL
Tekamlo
DO,
QL
Tekturna, HCT
DO,
QL
Zegerid
ST,
QL^
Edarbi
DO,
QL
Tequin
QL
Edarbyclor
QL
Hybolin
PA
Myrbetriq ER
ST
Testopel
PA
Edluar SL
ST
Hyzaar
DO,
QL
Testred
PA
Effexor, XR
DO,
QL
Imitrex
QL
Protonix
ST,
QL^
Teveten, HCT
QL
Zetia
ST,
QL
Elestat
ST,
QL^
Imitrex Nasal Spray
QL
Nasacort AQ
ST,
QL
Proventil HFA
QL
Tiazac
DO,
QL
Intermezzo
ST,
QL
Nasarel
QL
Provigil
PA,
DO,
QL
Natazia
QL,
ST∞
Prozac, Weekly
QL
Emadine
ST,
QL^
Kadian
QL
Toradol
QL
Zithromax
QL
Embeda
QL
0.5mg/2ml
QL
Tramadol 150mg
QL
Enablex
ST
Kombiglyze
QL
Norinyl 1+50
QL,
ST∞
Qnasl
ST,
QL
Treximet
ST,
QL
Zocor
DO,
PA (80mg
Noroxin
QL
Qualaquin
PA,
QL
Lamictal chew 5 & 25mg, XR Norvasc
DO,
QL
Zoloft
DO,
QL
Nucynta, ER
QL
Zolpimist
ST,
QL
Lamisil Tablet
PA
Nuvigil
PA,
QL
Zomig, ZMT
ST,
QL
Lastacaft
ST,
QL^
Relenza
QL
Zyclara
QL
Relpax
ST,
QL
Lazanda
PA,
QL
Omnaris
ST,
QL
Tudorza Pressair
QL
Lescol, XL
ST,
DO,
QL
Levaquin
QL
Zyvox
PA,
QL
Exalgo
ST,
QL
Levitra
PA,
QL
Onglyza
QL,
ST
Uloric
ST
Lexapro
DO,
QL
Rhinocort Aqua
ST,
QL
Ultram, ER
QL
Opana ER
QL
Roxicet
QL
Factive
QL
Lipitor
DO,
QL,
PA
Optivar
ST,
QL^
Rozerem
ST,
QL
Acthar HP
PA,
QL*
Livalo
ST,
DO,
QL
Ovcon 50
QL,
ST∞
Ryzolt
QL
Adcirca
PA
Lo Loestrin FE
QL,
ST∞
Oxandrin
PA
Safyral
QL,
ST∞
Afinitor
PA
Sanctura, XR
ST
Fentora
PA,
QL
Oxytrol
ST
Patanase
QL
Ampyra
PA,
QL*
Verelan PM
DO,
QL
Anzemet
QL
Eligard
PA
Humatrope
PA,
QL*~
Aranesp
PA*~
Humira
PA,
QL*~
Tarceva
PA
Enbrel
PA,
QL*~
Targretin
PA
Tasigna
PA
Temodar
PA
Aromasin
PA
Epogen
PA*
Tev-Tropin
PA,
QL*
Aubagio
PA
Incivek
PA*
Thalomid
PA
Increlex
PA
Neulasta
PA,
QL*
Repronex
PA
Neumega
PA*
Revatio
PA,
QL
Exemestane
PA
Neupogen
PA*
Revlimid
PA,
QL
Intron A
PA*
Nexavar
PA
Beta-Seron
ST
Extavia
ST*
Jakafi
PA
Tretinoin
PA
Kineret
PA*
Norditropin
PA,
QL*
Tykerb
PA
Bravelle
ST
Korlym
PA
Tyvaso
PA
Caprelsa
PA
Kytril
QL
Nutropin, AQ
PA,
QL*~
Saizen
PA,
QL*
Sancuso
QL
Ventavis
PA
Forteo
PA,
QL*
Oforta
PA
Omnitrope
PA,
QL*
Leukine
PA*
Ondansetron
QL
Victrelis
PA*
Leuprolide
PA*
Ondansetron Odt
QL
Serostim
PA,
QL*
Votrient
PA
Cimzia
PA,
QL*
Gammaked
PA
Onsolis
PA,
QL
Xalkori
PA
Lupron
PA
Orencia syringe
PA,
QL*
Revatio)
PA,
QL
Xeljanz
PA
Simponi
PA,
QL*~
Xeloda
PA
Ovidrel
PA*
Xenazine
PA
Genotropin
PA,
QL*
Gilenya
PA,
QL*
Sprycel
PA
Gleevec
PA
Peg-Intron
PA*
Gonal-F
ST
Pegasys
PA,
QL*~
Granisetron
QL
Pentamidine isethionate Sutent
PA
Zavesca
PA
Zelboraf
PA
Synarel
PA
Procrit
PA*~
Zolinza
PA
Egrifta
PA,
QL
Zorbtive
PA,
QL*
KEY
† = A generic equivalent of this drug recently became available or will be available soon. After the generic drug becomes available and notification
requirements are met, this brand-name drug will become Tier 3 or may no longer be covered by your prescription drug plan. Check anthem.com/ca to find out about changes in tier status.
^ = This product has clinically equivalent alternatives included on the drug list and, as a consequence, such product may not be covered under
your pharmacy benefit. Please consult your on-line pharmacy account through your health plan website, anthem.com/ca, for details on coverage.
* = These drugs are Tier 1, 2 or 3 for those members that do not have a Tier 4 plan.
** = These drugs will be in a different tier for those members that do not have a 4-Tier plan. Members should refer to their Member Handbook for benefit
details regarding applicable copayments or coinsurance.
~ = Preferred step therapy drug: drug has been chosen to be tried first when treating some conditions.
PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.
QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month.
ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized.
Please note: Foradil and Serevent are safety edits that prevent duplication of therapy.
ST∞ = STEP THERAPY MAY BE REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized.
This step therapy may not be required if there is a history of a paid claim for this medication in the prior 6 months.
DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.
Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization
or quantity limits, contact Member Services at the telephone number listed on your identification card.
For more information, please visit anthem.com/ca.
•
If you have additional questions about your prescription
benefi ts please call the Member Services number on your
ID card
•
Speech and hearing impaired (TDD/TTY users) should call
800-221-6915, Monday – Friday, 8:30 a.m. – 5:00 p.m., ET
•
For the most current version of this prescription drug list,
please visit anthem.com/ca
•
Bring a copy of this drug list to your next doctor’s visit to
assist in selecting the lowest cost medications
Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.
Express Scripts, Inc. is a separate company that manages the pharmacy benefi t services for members of our health plans.
Source: http://community.pepperdine.edu/hr/benefits/benefit-package/tierrx.pdf
WEST ESSEX REGIONAL SCHOOLS Part 1: To be completed by Physician Student’s Name:_____________________________________ D.O.B._____________ Grade (in September)_____ ALLERGY TO:________________________________________________________________________________ Medical Diagnosis (CIRCLE) Asthmatic: Yes * No (*Higher risk for severe reaction) STEP 1: TREATMENT Symptoms: Give Check
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