Penicil ins .
(preferred list of drugs) to help your doctor make prescribing decisions. This list of drugs consisting of doctors and pharmacists, so that the list includes drugs that are safe and effective in the treatment of diseases. If you Quinolones .
have any questions about the accessibility of your medication, please call the phone number listed on the back of your Anthem Blue Cross Sulfonamides .
Erythromycin/Sulfisoxazole (generic) Sulfamethoxazole/Trimethoprim (generic) In most cases, if your physician has determined that it is medically necessary for you to receive a brand name drug or a drug Tetracyclines .
that is not on our list, your physician may indicate “Dispense as Written” or “Do Not Substitute” on your prescription to ensure access to the medication through our network of community pharmacies, excluding drugs ANTIFUNGAL AGENTS (ORAL) _________________
that require Prior Authorization of Benefits. Clotrimazole (generic) Fluconazole (generic) Please ask your doctor or pharmacist to refer APPROVED
Prescription Drug List for a complete listing of FORMULARY
Nystatin (generic) Terbinafine (generic) USE OF GENERICS
equivalents to brand name medications. In available for a brand name product, the brand name product will be considered non-preferred and the generic equivalent will be on the list. Revised 04/2013
equivalents and has found their use to be safe ANTI-TUBERCULOSIS AGENTS ________________
Cycloserine (generic) Ethambutol (generic) For medications classified by the FDA as having a narrow therapeutic index (NTI), Anthem Blue Cross discourages the use of Rifampin (generic)
OTHER ANTI-INFECTIVES _____________________
Clindamycin (generic) Iodoquinol (Yodoxin) authorization of benefit (PAB) for certain drugs to provide a safe and affordable pharmacy benefit. Drugs which require PAB are often generic is on Formulary. Example: medications that are appropriate for only very Cefaclor (generic) means that the specific medical conditions. If your physician believes that a medication requiring PAB is generic, Cefaclor is covered and the ANTI-NEOPLASTIC AGENTS
contact Anthem’s pharmacy benefit manager, All FDA-approved, self-administered injectable Express Scripts, Inc. in order to initiate the and oral anti-neoplastic agents are eligible for Prior Authorization Process on your behalf. coverage under the prescription drug benefit. The list of drugs is subject to change so please call Customer Service at 1-800-700-2541 or to obtain a complete Example: Sitagliptin (Januvia) means ANTI-VIRAL AGENTS
that the brand, Januvia is covered and there is no generic available. Januvia ANTI-INFECTIVE AGENTS
If the word 'generic' and the brand name both appear within the ANTIBIOTICS _______________________________
Ganciclovir (generic) Interferon Alfa-2A (Roferon-A)* Cephalosporins .
Interferon Alfa-2B/Ribavirin (Rebetron)* generic) means that both the brand and generic are available. Therefore, the brand Coumadin and the generic Member Handbook for benefit details regarding applicable copayments or Macrolides .
Azithromycin (generic) Clarithromycin XL (generic) AUTONOMIC & CENTRAL NERVOUS SYSTEM
ANALGESICS, NARCOTIC _____________________
ALZHEIMER’S AGENTS ______________________
CEREBRAL STIMULANTS _____________________
Methylphenidate ER (Methylin ER/generic) CARDIOVASCULAR AGENTS
Propoxyphene (generic) Propoxyphene Compound (generic) MULTIPLE SCLEROSIS AGENTS _______________
Amlodipine/Valsartan/HCTZ (Exforge/Exforge Acetaminophen/Caffeine/Butalbital (generic) OPIOID DEPENDANCE _______________________
Buprenorphine/Naloxone (generic/Suboxone PSYCHOTHERAPEUTIC AGENTS ______________
Antidepressants .
ANTI-INFLAMMATORY ________________________
ANTIARRHYTHMICS _________________________
ANALGESICS, SALICYLATES __________________
Antimanic Agents .
ANTICONVULSANTS _________________________
Antipsychotic Agents .
ANTIPARKINSON AGENTS ____________________
ANTILIPEMICS ______________________________
Carbidopa/Levodopa/ Entacapone (generic) DERMATOLOGICALS
Niacin (Nicotinex/SloNiacin/Niaspan/generic) ANTIDIABETIC AGENTS-ORAL _________________
ACNE _____________________________________
Adapalene (generic/Differin 0.1% Lotion, BETA-ADRENERGIC BLOCKERS _______________
Tretinoin (generic/Retin-A Micro/Retin-A Micro CALCIUM CHANNEL BLOCKERS _______________
ANTIBIOTICS/ANTIVIRALS ____________________
Pioglitazone/Metformin (generic/ActoPlus Met FUNGICIDES _______________________________
ANTIDIABETIC SUPPLIES _____________________
glucometers, lancets, and test strips, may be covered. Accu-Chek and One Touch are the TOPICAL ANTI-INFLAMMATORY AGENTS _______
only test strips included on formulary. Lifescan DIURETICS _________________________________
Low Potency .
(One Touch, One Touch Ultra); Roche Diagnostics (Accu-Chek, Aviva). Quantity limits apply. Urine test strips are also a GLUCOSE ELEVATING AGENTS _______________
Medium Potency .
ANTITHYROID _______________________________
THYROID ___________________________________
High Potency .
Levothyroxine (Levothroid/Levoxyl/Unithroid/ Betamethasone Dipropionate (generic) Fluocinonide (generic) VASODILATORS _____________________________
Ultra-High Potency .
Isosorbide Dinitrate/Hydralazine (Bidil) OTHER ENDOCRINE AGENTS __________________
Isosorbide Dinitrate (Dilatrate SR/generic) VAGINAL/RECTAL PREPARATIONS ____________
Nitroglycerin (Nitrostat/Nitrobid/Nitrolingual GASTROINTESTINAL AGENTS
Nitroglycerin (Nitrek/Nitro-Dur/generic) ANTIEMETIC/ANTIVERTIGO ___________________
VASOPRESSORS ____________________________
Hydrocortisone/Pramoxine (generic/Analpram Dronabinol (generic) Granisetron (generic)^ HC lotion/Pramosone cream, lotion, oint) Mesalamine (Rowasa) Metronidazole (generic) Metoclopramide (generic) Ondansetron (generic)^ CONTRACEPTIVES
Nystatin (generic) Progesterone (Crinone Vaginal Gel)^ Eth Estradiol/Desogestrel (Apri/generic) Eth Estradiol/Ethynodioldiacetate (Zovia) MISCELLANEOUS DERMATOLOGICALS ________
Eth Estradiol/Levonorgestrel (Amethia/Amethia ANTISPASMODIC/GI MOTILITY _________________
Lo/Camrese/Enpresse/Jolessa/Portia/Trivor Eth Estradiol/Norelgestromin (Ortho-Evra) Eth Estradiol/Norethindrone (Loestrin FE 24) Eth Estradiol/Norethindrone (Necon/generic) ANTIULCER ________________________________
Eth Estradiol/Norgestimate (Ortho Tri-Cyclen ENDOCRINE AGENTS
OTHER GI PRODUCTS ________________________
Balsalazide (generic) Budesonide EC(generic) IMMUNOSUPPRESSIVE AGENTS
Lactulose (generic) Mesalamine (Apriso/Asacol/Asacol HD/ All FDA-approved, self-administered injectable ANTI-INFECTIVE AGENTS _____________________
eligible for coverage under the prescription ANTI-INFECTIVE & ANTI-INFLAMMATORY
COMBINATIONS _____________________________
Brimonidine Tartrate (generic) Brimonidine Tartrate/Timolol (Combigan) PROSTAGLANDIN AGONIST __________________
ANTI-ASTHMATIC AGENTS ____________________
Asthma Devices .
Peak Flow Meter (Personal Best/Pocketpeak) GOUT THERAPY
Corticosteroids .
ANTI-INFECTIVE AGENTS ____________________
Fluticasone/Salmeterol (Advair/Advair HFA) HIV AGENTS
Sympathomimetics .
All oral and self injectable FDA-approved HIV agents are eligible for coverage under the prescription drug benefit. May be subject to ANTI-INFLAMMATORY AGENTS _______________
ANTIESTROGENS ____________________________
Xanthine Derivatives .
OTHER AGENTS _____________________________
Albuterol/Ipratropium (Combivent/-Respimat) ESTROGENS ________________________________
Albuterol/Ipratropium (generic) Cromolyn (generic) Estradiol Patch/Spray (generic / Climara ANTI-INFECTIVE & ANTI-INFLAMMATORY
Estrogens, Conjugated (Premarin/Low Dose) COMBINATIONS ____________________________
Sodium Chloride (Broncho-Saline/generic) ESTROGEN COMBINATIONS ___________________
Neomy/Polymyx B/Prednisolone (Poly-Pred) ANTIHISTAMINES/DECONGESTANTS ___________
Estrogen, Ester/Methyltestosterone (generic) ANTIVIRAL AGENTS _________________________
GROWTH HORMONE _________________________
BETA-BLOCKERS ___________________________
PROGESTINS _______________________________
MIOTICS ___________________________________
Progesterone (generic, Crinone Vaginal Gel) MISCELLANEOUS HORMONE PRODUCTS _______
MYDRIATICS _______________________________
SYMPATHOMIMETICS ________________________
NASAL MEDICATIONS ________________________
*Members should refer to their Member Handbook for benefit details regarding SKELETAL AGENTS
applicable copayments or coinsurance. ANTIRHEUMATICS ___________________________
^Indicates a drug that is available on tier 4 for members with a four-tier benefit design. Hydroxychloroquine (generic) Methotrexate (generic)^ BONE ENHANCING AGENTS ___________________
Alendronate (Fosamax/-D/generic) Calcitonin-Salmon (generic) Etidronate (generic) Risedronate (Actonel/-with Calcium) SKELETAL MUSCLE RELAXANTS
Metaxalone (generic) Methocarbamol (generic) URINARY AGENTS
ANTI-INFECTIVES ____________________________
Nitrofurantoin (generic) Sulfadiazine (generic) Sulfisoxazole (generic) Trimethoprim/Sulfamethoxazole (generic) CHOLINERGIC AGENTS _______________________
Bethanechol (generic) Flavoxate (generic) OTHER URINARY AGENTS ____________________
Fesoterodine (Toviaz) Phenazopyridine (generic) Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. VITAMINS & ELECTROLYTES
Express Scripts, Inc. is a separate company that benefit management services on behalf of health Ferrous Sulfate/Folate/Vit B comp/C (generic) Vit A, C & D/Fluoride/Iron (generic) Potassium Supplements (generic) Prenatal Vitamins (generic) MISCELLANEOUS AGENTS
Bosentan (Tracleer)^ Etanercept (Enbrel)*^ Cevimeline (generic) Everolimus (Zortress) Leucovorin (generic)^ Methylergonovine (generic) Milnacipran (Savella) Mycophenolate (generic/Cellcept)^ Neostigmine (generic) Pyridostigmine (generic) Sevelamer (Renvela) Tacrolimus (generic)^


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