Drug List — To be used by members
who have a tiered drug plan.
AnThem BLUe CROSS AnD BLUe ShIeLD DRUG LISTYour prescription drug beneit includes coverage for medicines that you’ll ind on the Anthem Drug List. You can often ind 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 Administration you can do the following:
(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 National Pharmacy and Go to anthem.com
Therapeutics (P&T) Process. The P&T Process is performed by an independent group of • Call customer service
practicing doctors and pharmacists in charge of the research and decisions surrounding at the number on your
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 their value. Because the drugs on our list are reviewed from time to time, it’s a good idea to check • Speech and hearing
the list to ind out if any drugs have been added or removed. You can do this by going to impaired users
(TDD/TTY) should call
800-221-6915, Monday
A. Drugs on the Anthem Drug List are grouped into tiers. There are several factors that are – Friday, 8:30 a.m. –
used to determine under which tier a drug will be put in. This can include (but it’s not 5:00 p.m., ET
Bring a copy of this drug
• Cost of the drug in comparison to other drugs used for the same type of treatment list to your next doctor’s
• Availability of over-the-counter options visit to help you and
• Other clinical and cost factors.
your doctor select the
lowest cost medicine
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 the same high standards for purity, quality, safety and strength. With generics, you get KEY FOR DRUG LIST
Tier 1 – Lowest copayment – Drugs
Q. What if my doctor or I choose a brand-name drug when a generic version is available? that offer the greatest value compared to others that treat the same A. In most cases, you would be responsible for the copay that’s listed on the tier the drug is on. This copay may include an added charge 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 speciic 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 irst 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 beneits. Please refer to your insurance Certiicate or Evidence of Coverage to know for sure.
Cartia XT DO, QL
Aviane PA
ethynodiol diacetate PA Glycolax
Granisetron QL
Azelastine QL
norethindrone PA
Azelastine nasal QL
Azithromycin QL
Bacitracin zinc/polymyxin B Cefuroxime QL
Felodopine DO, QL
Diltia XT DO, QL
Diltiazem CD DO, QL
Diltiazem CR DO, QL
Fentanyl PA, QL
Alendronate QL
Diltiazem SR DO, QL
Fexofenadine QL
Hydrocodone/APAP QL
Disopyramide CR 150mg Flunisolide Nasal Spray Ciproloxacin QL
Citalopram DO, QL
Fluoxetine DO, QL
Amlodipine DO, QL
Budeprion XL DO, QL
Amnesteem QL
Budesonide QL
Imiquimod QL
Buprenorphine QL
Fluvoxamine DO
soln/nasal spray QL
Codeine/APAP QL
Fosinopril DO, QL
Amoxicillin/clavulanate, Butorphanol tartrate 10mg/ml N.S. QL
Calcipotriene Oint & Soln. Cyclophosphamide APAP/caffeine/butalbital Carbamazepine, ER Isotretinoin QL
Gianvi PA
Itraconazole PA
norethindrone PA
Ketorolac QL
spray and inj. QL
Propoxyphene/APAP QL
Lansoprazole, ODT QL
Nifedipine ER DO, QL
Terbinaine PA
Nisoldipine DO, QL
Leuprolide PA*
estradiol PA
Ocella PA
Levora PA
Oloxacin QL
Microgestin PA
Omeprazole QL
Omeprazole/bicarb QL
Ondansetron QL
Tramadol, ER QL
Tramadol/APAP QL
Sertraline DO, QL
Pravastatin DO, QL
Simvastatin DO, QL
Morphine SR QL
Tretinoin PA
Losartan DO, QL
Losartan/HCTZ DO, QL
Lovastatin DO, QL
Oxycodone ER QL
Oxycodone/APAP QL
and minerals/iron/folic Sodium sulfacetamide/ Oxymorphone QL
Sotret QL
Pantoprazole QL
Paroxetine, SR DO, QL
Tri-nessa PA
Naratriptan QL
Meloxicam QL
Trivora PA
prednisoloneophth sol. Trypsin/balsam peru/ Plan B 1.5mg QL
Plavix QL
Tamilu QL
Tarceva PA
Lipitor DO, QL
Pradaxa QL
Zaleplon ST, QL
Flovent, HFA QL
Tekturna, HCT DO, QL
Temodar PA
Zolpidem, ER QL
Combivent QL
Maxalt, MLT QL
Testim PA, QL
Foradil QL
Thalomid PA
Fosamax Plus D QL
Fosamax solution QL
Pristiq DO, QL
Accu-chek Product Line QL Creon
Activel a 0.1-0.5 PA
Crestor DO, QL
Actonel QL
Actonel with Calcium QL
Trilipix QL
ActoPlus Met, XR QL
Protopic ST
Proventil HFA QL
Gleevec PA
Pulmicort Respules QL
Advicor DO
Neulasta PA, QL*
Neupogen PA*
Nexavar PA
Valturna DO, QL
Nexium QL
Androgel PA, QL
Diovan DO, QL
Retin-A Micro PA
Diovan HCT DO, QL
Veramyst QL
Iressa PA
Duetact QL
Asmanex QL
Dulera QL
Janumet QL
Astepro QL
Januvia QL
Efient DO, QL
Avinza QL
Elidel ST
Savel a QL
Kombiglyze QL
Serevent Diskus QL
Oforta PA
Vyvanse PA
One Touch Product Line QL
Singulair QL
Onglyza DO, QL
Xeloda PA
Spiriva QL
Ortho Evra PA
Sprycel PA
Ortho Tri-Cyclen Lo PA
OxyContin QL
SL Film PA, QL
Leukine PA*
Byetta ST, QL
Levaquin QL
Pataday QL
Sutent PA
Exforge DO, QL
Patanol QL
Symbicort QL
Exforge HCT DO, QL
Lexapro DO, QL
Perforomist QL
Arthrotec ST
Astelin QL
Flonase QL
Malarone PA
Plan B 0.75mg QL
Abstral PA, QL
Atacand DO, QL
Atacand HCT DO, QL
Covera HS DO
Augmentin, XR QL
Cozaar DO, QL
Forteo PA, QL*
Maxair QL
Avalide DO, QL
Fortesta PA, QL
Maxaquin QL
Avandamet ST, QL
Fosamax tablets QL
Aciphex ST, QL^
Avandaryl ST, QL
Actemra PA*
Avandia ST, QL
Acthar HP PA, QL*
Avapro DO, QL
Gelnique ST
Miacalcin Spray QL
Avelox QL
Genotropin PA, QL*
Micardis, HCT DO, QL
Prevacid ST, QL^
Activella 1.0-0.5 PA
Gilenya PA, QL*
Migranal QL
Prevpac QL
Actiq PA, QL
Axert ST, QL
Prilosec ST, QL^
Axiron PA, QL
Primaxin QL
Azor DO, QL
Kapidex) ST, QL
Adcirca PA
Beconase AQ ST, QL
Benicar, HCT DO, QL
Differin PA
Humatrope PA, QL*
Procrit PA*
Aerobid, M QL
Benzaclin ST
Humira PA, QL*
Prolia PA, QL*
Aggrenox QL
Bepreve ST, QL^
Hybolin PA
Alamast ST, QL^
Hyzaar DO, QL
Protonix ST, QL^
Aldara QL
Betaseron ST*
Provigil PA, QL
Imitrex QL
Nasacort AQ ST, QL
Prozac, Weekly QL
Allegra, D ST, QL^
Boniva ST, QL
Edarbi DO, QL
Imitrex Nasal Spray QL
Nasarel QL
Pulmicort Flexhaler QL
Alocril ST, QL^
Edex PA, QL
Infergen* PA
Neumega PA*
Alomide ST, QL^
Caduet DO
Edluar SL ST
Qualaquin PA, QL
Cambia QL
Effexor, XR DO, QL
Intron A PA*
Raptiva PA
Elestat ST, QL^
Norditropin PA, QL*
Alsuma ST, QL
Noroxin QL
Kadian QL
Norvasc DO, QL
Relenza QL
Altoprev ST, DO
Emadine ST, QL^
Nucynta QL
Relpax ST, QL
Cardizem CD, LA DO, QL Embeda QL
Kineret PA*
Nutropin, AQ PA, QL*
Remicade PA*
Alvesco QL
Nuvaring PA, QL
Ambien QL
Enablex ST
Kytril QL
Ambien CR ST, QL
Enbrel PA, QL*
Lamictal chew 5 & 25mg, Omnaris ST, QL
Revatio PA, QL
Amerge QL
Caverject PA, QL
Amevive PA*
Epogen PA*
Omnitrope PA, QL*
Ceftin QL
Lamisil Tablet PA
Onsolis PA, QL
Rhinocort Aqua ST, QL
Ampyra PA, QL*
Celebrex ST, QL
Lastacaft ST, QL
Roxicet QL
Anadrol-50 PA
Opana ER QL
Rozerem ST, QL
Androderm ST, QL
Lescol, XL ST, DO, QL
Optivar ST, QL^
Android PA
Levitra PA, QL
Ryzolt QL
Cialis PA, QL
Orencia PA*
Saizen PA, QL*
Anzemet QL
Cimzia PA, QL*
Livalo ST, DO, QL
Ovidrel PA*
Sanctura, XR ST
Apidra ST
Cipro XR QL
Extavia ST*
Oxandrin PA
Sancuso QL
Aplenzin DO, QL
Clarinex, D ST, QL^
Factive QL
Oxytrol ST
Sarafem QL
Patanase QL
Seasonale PA
Aranesp PA*
Serostim PA, QL*
Fentora PA, QL
Lunesta QL
Paxil CR DO, QL
Simcor QL
Lupron Depot PA*
Pegasys PA, QL*
Simponi PA, QL*
Peg-Intron PA*
Flector ST
Lyrica PA
Penlac PA
Treximet ST, QL
Vytorin ST, QL
Nutropin, AQ PA, QL
Sonata ST, QL
Wellbutrin XL DO, QL
Actemra PA
Forteo PA, QL
Omnitrope PA, QL
Winstrol PA
Acthar HP PA, QL
Orencia PA
Sporanox Solution PA
Genotropin PA, QL
Peg-Intron PA
Stadol QL
Xgeva PA, QL*
Amevive PA
Gilenya PA, QL
Pegasys PA, QL
Xifaxan ST, QL
Ampyra PA, QL
Stelara PA, QL*
Xolair PA*
Procrit PA
Striant PA
Uloric ST
Xopenex HFA QL
Humatrope PA, QL
Subutex QL
Ultram, ER QL
Aranesp PA
Humira PA, QL
Sular DO, QL
Prolia PA, QL
Sumavel Dosepro ST, QL Univasc
Xyzal ST, QL^
Increlex PA
Suprax QL
Yasmin PA
Infergen PA
Remicade PA
Repronex PA
Synagis PA
Zegerid ST, QL^
Caverject PA, QL
Intron-A PA
Roferon-A PA
Synarel PA
Saizen PA, QL
Kineret PA
Tekamlo DO, QL
Ventavis PA
Cimzia PA, QL
Leukine PA
Serostim PA, QL
Tequin QL
Ventolin HFA QL
Zetia ST, QL
Leuprolide PA
Simponi PA, QL
Tekamlo DO, QL
Verelan PM DO, QL
Zithromax QL
Testopel PA
Lupron, Depot PA
Stelara PA, QL
Testred PA
Teveten, HCT DO, QL
Zofran QL
TevTropin PA, QL
Tev-Tropin PA, QL*
Viagra PA, QL
Zoladex PA
Zoloft DO, QL
Tiazac DO, QL
Zolpimist ST, QL
Viibryd ST, QL
Zomig, ZMT ST, QL
Edex PA, QL
Vimovo QL
Zorbtive PA, QL*
Eligard PA
Neulasta PA, QL
Vivaglobulin PA
Zyclara QL
Enbrel PA, QL
Neumega PA
Xgeva PA, QL
Toradol QL
Epogen PA
Neupogen PA
Xolair PA
Tradjenta QL
Extavia ST
Norditropin PA, QL
Zorbtive PA
† = A generic equivalent of this drug recently became available or wil be available soon. After the generic drug becomes available and notiication requirements are met, this brand-name drug wil become Tier 3 or may no longer be covered by your prescription drug plan. Check anthem.com to ind 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 beneit. Please consult your on-line pharmacy account through your health plan website, anthem.com, for details on coverage.
* = These drugs are Tier 4 for those members that do not have a Tier 4 plan.
PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of beneits before certain prescriptions may
be illed.
QL = QUANTITY LIMITS. Certain prescription drugs have speciic quantity limits per prescription or per month.
ST = STEP THERAPY REQUIRED. You may need to use one medication before beneits for the use of another medication can be authorized.
Please note: Foradil and Serevent are safety edits that prevent duplication of therapy.
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 identiication card.
For Kentucky Residents Only:
In selecting medications for the prescription drug formulary, the therapeutic efi cacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the formulary by at least one medication. When a closed formulary is in effect, only medications that are included on the formulary are a covered service. In certain clinical situations, a member may require use of a non-formulary product. Anthem has criteria that permits a member to obtain a non-formulary medication in a closed formulary plan. If specii c criteria are met, a member can receive a non-formulary drug for a formulary copay. The criteria preserves the clinical integrity of the drug formulary and provides a process by which deviations from the formulary may be allowed. An appeals process is in place for any medications that do not meet the criteria.
For more information, please visit anthem.com.
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
Bring a copy of this drug list/formulary to your next doctor’s
visit to assist in selecting the lowest cost medications
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain afi liates administer non-HMO benei ts underwritten by HALIC and HMO benei ts underwritten by HMO Missouri, Inc. RIT and certain afi liates only provide administrative services for self-funded plans and do not underwrite benei ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Source: http://images.pcmac.org/Uploads/JenningsSD/JenningsSD/Divisions/DocumentsCategories/Documents/RX%20Formulary%20072011.pdf

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