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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