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40627CAMENABC Effective 1/14
4 Tier Formulary
Select Drug List
933334 40627CAMENABC Select Drug List 4 Tier Part 2 BK 11 13
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Anthem Blue Cross Select Drug List
Your prescription drug benefit includes coverage for medicines that you’ll find on the Select Drug List. You can often find more savings when your doctor prescribes medicine that is on our Select Drug List. Here are some commonly asked questions and answers about how the Select Drug List works with your prescription drug plan.
Q. What is a Select Drug List?A. The Select Drug List, also called a formulary is a list of
U.S. Food and Drug 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 National Pharmacy and Therapeutics (P&T) Process. The P&T Process is performed by an independent group of practicing doctors and pharmacists in charge of the research and decisions surrounding our Select 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 the list to find out if any drugs have been added or removed. You can do this by going to anthem.com/ca.
Q. What are Tiers?A. Drugs on the Select Drug List are grouped into tiers.
There are several factors that are used to determine under which tier a drug will be put in. This can include (but it’s not limited to):
}} Cost of the drug}} Cost of the drug in comparison to other drugs used for the same type of treatment}} Availability of over-the-counter options}} Other clinical and cost factors.
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 the same high standards for purity, quality, safety and strength.
Q. Is this list a complete listing of all covered drugs under the Select Drug List?
A. No. This piece lists the most commonly used drugs that are covered as part of the Select Drug List. If the drug you are looking for is not listed, you may call customer service for more information.
Q. What do I do if I am prescribed or currently taking a prescription drug that is not on the Anthem Select Drug List?
A. If you are prescribed or currently taking a non formulary drug, you should discuss formulary alternatives your physician. If your physician feels that the medication is medically necessary, it will be necessary to obtain Prior Authorization of Benefits in order for the prescription to be a covered benefit. Information is available to you and your physician through the Certificate or Evidence of Coverage, health plan web site and newsletters. You may also call customer service for more information.
Q. Can I request that a drug be added to the Select Drug List?
A. You or your doctor can put in a request to add a drug to the Select Drug List. You can do this either in writing or on our website. Requests are reviewed by the P&T Process team during the Select 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.
Q. What if my medication is not covered?A. You may want to first check with your doctor about
prescribing a drug that is covered. If your doctor prescribes a drug that’s not covered, you will need to pay the out of pocket cost that applies to drugs not on the formulary.
Preventive Care Drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).
Please note: In selecting medications for the prescription drug list, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the drug list by at least one medication. When a closed drug list is in effect, only medications that are included on the drug list are a covered service. In certain clinical situations, a member may require use of a non-covered product. We have criteria that permits a member to obtain a non-covered medication in a closed drug list plan. If specific criteria are met, a member can receive a non-covered drug for a drug list co-pay. The criteria preserves the clinical integrity of the drug list and provides a process by which deviations from the drug list may be allowed. An appeals process is in place for any medications that do not meet the criteria.
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Tier 1
AbacavirAcebutololAcetasol HCAcetazolamide tab, ER cap
AclometasoneActicinAcyclovir tab, cap, oral susp.
AdapaleneAfeditab CR QL DOAlbuterol inhl soln., syrupAlendronate QLAlfuzosinAllopurinol tabAlprazolam tabAmantadineAmcinonideAminophylline tabAmitriptylineAmlodipine QL DOAmlodipine/ atorvastatin QL DO
Amlodipine/benazeprilAmmonium lactate cream, lotion
Amnesteem PAAmoxapineAmoxicillinAmoxicillin/clavulanateAmoxicillin/ clavulanate ER
Amphetamine/dextroamphetamine salts, ER PA QL
AndroxyAntipyrine/benzocaine ear drop
ApraclonidineAtenololAtenolol/chlorthalidoneAtorvastatin QL DOAtovaquone/proguanilAzelastine nasal spray, drops QL
Azithromycin tab, susp., packet QL
Bacitracin/polymixin BBaclofenBalsalazideBenazepril
Benazepril/HCTZBenzonatateBenzoyl peroxideBenztropineBetamethasone dipropionate
Betamethasone valerateBetaxololBirth Control (generic oral contraceptives)
BisoprololBisoprolol/HCTZBrimonidineBromocriptineBudesonide 0.25mg/2mL, 0.5mg/2mL QL
Buprenorphine tab PA QLBupropion QLBupropion SR, XL QL DOBuspironeButalbital/acetaminophen
Butalbital/acetaminophen/caffeine
Butalbital/acetaminophen/caffeine/codeine QL
Butalbital/aspirin/caffeine
Butalbital/aspirin/caffeine/codeine
Butorphanol nasal spray PA QL
CabergolineCalcipotrieneCandesartan/HCTZ QL DOCarbamazepine, ER, XRCarbidopa/Levodopa, ER, ODT
CarteololCartia XT QL DOCefaclor, ERCefadroxilCefdinirCefditoren PivoxilCefprozilCefuroxime AxetilCephalexinChlorhexidine rinseChloroquineChlorpromazine tab PAChlorthalidone
ChlorzoxazoneCiclodan cream, soln.CiclopiroxCimetidine tab, soln.Ciprofloxacin ear and eye drops
Ciprofloxacin tab QLCitalopram QL DOClaravis PAClarithromycin, ERClindacin pledgetsClindamycin cap, oral soln, topical preparations
Clindamycin/Benzoyl Peroxide gel
ClobetasolClomipramineClonazepam, ODTClonidine tabClopidogrel 300mgClopidogrel 75mg PA QLClotrimazole 1% cream, troche
Clotrimazole/betamethasone
Codeine sulfate tabs QLCodeine/ acetaminophen QL
Codeine/butalbital/aspirin/caffeine
Covaryx, H.S.Cromolyn eye drops QLCromolyn neb soln.Cyclobenzaprine tabDepadeDermazeneDesmopressin nasal spray, tab PA
DesonideDesoximetasoneDexamethasone eye dropDexamethasone tab, oral soln.
Dexmethylphenidate PA QL
Dextroamphetamine, ER PA QL
Diazepam tab, oral soln.Diclofenac eye dropDiclofenac, ERDicloxacillin
Dicyclomine cap, tab, syrup
Didanosine DRDiflorasoneDiflunisalDigoxin tab, oral soln.DiltiazemDiltiazem ER, XR, CD QL DO
Diphenhydramine 50mg cap
Diphenoxylate/atropineDipyridamole tabDisopyramideDisulfiramDivalproex, ER, DRDorzolamide eye dropsDorzolamide/timolol eye drops
DoxazosinDoxepinDoxycycline hyclate tab, cap
Doxycycline hyclate, delayed release PA
Doxycycline monohydrate tab, cap, susp.
EconazoleEnalaprilEnalapril/HCTZEndocet QLEndodan QLEpidrinEpinastine eye drops QLEpitolErgocalciferol (Vit D2) caps
Ergotamine/caffeineEry-Tab 250mg, 333mg tab
Erythromcyin eye oint.Erythromycin 2% gel, topical soln.
Erythromycin ethylsuccinate 400mg filmtab
Erythromycin filmtab, 250mg cap
Erythromycin stearateErythromycin/benzoyl peroxide gel
Erythromycin/sulfisoxazole
For more information about your drug plan, you can do the following:
}} Go to anthem.com/ca.
}} Call Customer Service at the number on your ID card.
}} Speech and hearing impaired users (TDD/TTY) should call 800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.
TIEr DEFInITIonS
Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions.
Tier 2 drugs have a medium cost share. They may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.
Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.
Tier 4 specialty drugs have the highest cost share. They may cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA. Specialty drugs are used to treat complex, chronic conditions and may need special handling.
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Escitalopram QL DOEstradiol patch QLEstradiol tabEstrogen/methyltestosterone
EstropipateEthambutolEthosuximideFamciclovirFamotidine tab, oral soln.FelbamateFelodipine ER QL DOFenofibrateFenofibric acidFinasteride 5mg tab PAFluconazole tab, oral soln.
FlucytosineFlunisolide nasal spray ST QL
Fluocinolone body oil, scalp oil
Fluocinolone cream, topical soln., oint., ear drop
FluocinonideFluorometholone eye drops
Fluorouracil cream, topical soln.
Fluoxetine, DR (except 60mg) QL DO
Fluphenazine tab, oral soln. PA
Fluticasone nasal spray QL
Fluticasone topicalFolic acid 1mgFosinoprilFosinopril/HCTZFurosemide tab, oral soln.Garamycin eye dropsGemfibrozilGentamycin eye drops, oint.
GlimepirideGlipizide, ER, XLGlipizide/metforminGlyburideGlyburide/metforminGriseofulvinGuaifenesin/codeine syrup (generic version)
GuanfacineGuanidineHalacHalobetasol propionateHaloperidol tab PAHydralazine tabHydrochlorothiazideHydrocodone/acetaminophen QL
Hydrocortisone tabHydrocortisone 2.5% cream, lotion, oint.
Hydrocortisone acetate 2% gel
Hydrocortisone acetate suppository
Hydrocortisone butyrate 0.1% cream, oint., soln.
Hydrocortisone enemaHydrocortisone valerate 0.2% cream, ointment
Hydrocortisone/acetic acid ear drops
Hydrocortisone/pramoxine cream, ointment
Hydromorphone suppository
Hydromorphone tab, oral soln. QL
HydroxychloroquineHydroxyzine HCL tab, oral soln.
Hydroxyzine pamoateIbandronate QLIbuprofenImipramine HCL tabImiquimod cream PA QLIndapamideIndomethacin , ER capIpratropium bromide neb soln. QL
Irbesartan/HCTZ QL DOIsometheptene/acetaminophen/caffeine
Isometheptene/acetaminophen/dichloralphenazone
IsonarifIsoniazid tab, oral soln.Isosorbide dinitrate, ER tab
Isosorbide mononitrate, ER tabs
KetoconazoleKetorolac eye dropsKetorolac tab QLKlor-Con tabLactuloseLamotrigine tab (immediate release)
LamuvidineLamuvidine/zidovudineLansoprazole PA QLLatanoprostLevofloxacin tab QLLevonorgestrel tab QLLevothroidLevothyroxine tabLevoxylLidocaine viscous soln.Lidocaine/hydrocortisone 3/0.5% cream
Lidocaine/prilocaineLindaneLiothyronine tabLisinoprilLisinopril/HCTZLithium carbonate, ERLithium citrate oral soln.Losartan QL DOLosartan/HCTZ QL DOLovastatin QL DOLoxapine PAMalathionMaprotilineMatzim LA QL DOMebendazoleMeclizine tabMeclofenamate capMedroxyprogesterone tab
MefloquineMegestrolMeloxicam oral suspension
Meloxicam tab QLMeperidine tab, oral soln. QL
Metadate ER PA QLMetaproterenolMetformin, ERMethadone tab, oral soln. QL
Methazolamide
MethimazoleMethscopolamine bromide
MethyclothiazideMethyldopaMethyldopa/HCTZMethylergonovine tabMethylphenidate, CD, ER, SR PA QL
Methylprednisolone tabMetipranolol eye dropsMetoclopramide tab, oral soln.
Metoprolol tab, ERMetoprolol/HCTZMetronidazole 0.75% gelMetronidazole tab, capsule, cream, lotion
MinocyclineMinocycline ER PAMinoxidil tabMirtazapineMisoprostol PAMometasone cream, oint, topical soln.
Montelukast QLMorgidox caps PAMorphine sulfate IR tab QL
Morphine sulfate oral soln. QL
Morphine sulfate suppository
Mupirocin oint.NabumetoneNadolol/bendroflumethiazide
NaltrexoneNaphazoline eye dropsNaproxen, DRNaratriptan QLNature-ThroidNefazodoneNeomycin tabNeomycin/polymixin/bacitracin eye oint.
Neomycin/polymixin/bacitracin/hydrocortisone eye oint.
Neomycin/polymixin/dexamethasone eye drops, oint.
Neomycin/polymixin/gramicidin eye drops
Neomycin/polymixin/hydrocortisone ear and eye drops
NevirapineNifedipine capNifedipine tab ER, XL QL DO
Nisoldipine ER QL DONitro-Bid oint.NitrofurantoinNitroglycerin, ER, SRNorethindroneNortriptylineNP ThyroidNystatin cream, oint., powder, tab, susp.
Nystatin/triamcinoloneOfloxacin ear and eye drops
Ofloxacin tab QLOmeprazole caps QLOxcarbazepineOxybutynin, EROxycodone QLOxycodone/acetaminophen tab, cap QL
Oxycodone/aspirin QLOxymorphonePancrelipaseParamomycinParoxetine, CR, ER QL DOPenicillin VKPentoxifylline, ERPermethrin creamPerphenazine PAPhenazopyridinePhenelzinePhenobarbital tab, oral soln.
Phenytoin ext. capPodofiloxPolymixin/trimethoprim eye drops
Potassium 25mEq tab effervescent
Potassium chloride ER tab, ER cap
Potassium citrate ER TabPotassium citrate/citric acid
PramipexolePravastatin QL DOPrazosinPrednicarbatePrednisolone eye dropsPrednisolone oral soln.PrednisonePrenatal Vitamins (all generic covered)
PrimidoneProbenecidProbenecid/colchicineProcentra QLProchlorperazine tabProgesterone, micronized cap
Promethazine tab, suppository, syrup
Promethazine VC syrupPromethazine VC syrup with codeine
Promethazine/ codeine syrup
Promethazine-DM syrupPropranolol ERPropranolol tab, oral soln.Propranolol/HCTZPropylthiouracilProtriptylinePyrazinamidePyridostigmineQuetiapine PAQuinaprilQuinapril/HCTZQuinidine sulfate, ERQuinine sulfate PA QLRamiprilRanitidine 150mg, 300mg tab, cap
Ranitidine oral soln.RifampinRimantadineRisperidone, ODT, oral soln. PA
Ropinirole, ERRosadan cream and gelRoxicet tab, caplet QLSelegilineSelenium sulfide 2.5% lotion, shampoo
Sertraline QL DOSilver sulfadiazine cream
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Simvastatin 80mg PA QLSimvastatin QL DOSodium polystyrene sulfate 30gm/120ml enema
Sodium polystyrene sulfate powder
Sodium polystyrene sulfonate
Sodium sulfacetamide/sulfur
Sodium sulfacetamide/sulfur/urea
SpinosadSpironolactoneStavudineSucralfateSulfacetamide eye drops, oint.
Sulfacetamide sodiumSulfacetamide sodium/prednisolone eye drops
Sulfacetamide sodium/sulfur
Sulfacetamide sodium/sulfur/urea
Sulfacetamide sodium/urea
Sulfamethoxazole/trimethoprim, DS
SulfasalazineSumatriptan tab QLTaztia XT QL DOTerazosinTerbinafine tab PATerconazoleTetracycline capsTheochron ERTheophylline ER, oral soln.
Thioridazine PAThiothixene PATiclopidineTimolol eye drops, gelTimolol tabTizanidineTobramycin eye dropsTobramycin/dexamethasone eye drops
TolbutamideTopiramate PATorsemide tab
Tramadol QLTrandolaprilTranexamic acid 650mgTranylcypromineTrazodoneTretinoin cream, gel PATriamcinolone cream, lotion, oint.
Triamcinolone nasal spray QL
Triamcinolone pasteTriamterene/HCTZTrifluoperazine PATrihexyphenidylTrimethobenzamide capTrimethoprimUnithroidValacyclovirValproid acid cap, oral soln.
Valsartan/HCTZ QL DOVenlafaxineVenlafaxine ER QL DOVerapamil tab, ER PM QL DO
Verapamil tab, ER tab, cap
Vicodin, ES, HP QLWarfarinWesthroidZaleplon QLZenatane PAZenzedi 5mg, 10mg PA QL
ZidovudineZiprasidone PA
Tier 2
AcamprosateAccu-Chek Product LineAcitretinAdvair Diskus, HFA QLAnaspaz ODTAptivus Asmanex Twisthaler QLAtriplaBethanechol tabBudesonide ECBuprenorphine syringe, vial
Calcitonin nasal spray QL
Calcium acetate tabCefpodoximeCevimelineCilostazolClozapine, ODT PACrixivanDanazolDantroleneDemeclocyclineDesipramineDihydroergotamine nasal spray QL
Dulera QLEdurantEliphosEmtrivaEntacaponeEpipen, Jr.Epivir HBV soln. PAEpzicomErgoloidEvistaFentanyl patch ST QLFlecainideFlovent HFA QLFlovent QLFortical nasal spray QLFuzeonGabapentinGalantamine, ER QLGlucagenHumalogHumalog MixHumulin N, R, 70-30IntelenceInviraseIsentressItraconazole PAKaletraLantusLantus SolostarLeflunomideLevemirLevemir FlexpenLevetiracetamLevetiracetam ER PA QLLevocarnitine tab, oral soln.
LexivaMexiletine
Morphine sulfate ER QLNitroglycerin sprayNitrostatNorvirNovolinNovolog MixOlanzapine tab, ODT PAOndansetron tab, ODT, oral soln. QL
One Touch Product LineOxandrolone PAPrezistaProair HFA QLPropafenonePrudoxinPulmicort 1mg/2mL respules QL
Pulmicort Flexhaler QLQvar QLRelenza QLRescriptorReyatazRivastigmine QLSelzentrySerevent Diskus QLSorineSotalol tab, AF tabSulfadiazineSumatriptan inj QLSustivaSymbicort QLTamiflu QLTiagabineTranexamic acid 1000mg/10mL
TrizivirTruvadaVancomycin caps PAViraceptViread PAZenpepZonisamide
Tier 3
Abilify tab PAActonel ST QLAczoneAggrenox QLAlamast PAAliniaAlocril PA QL
Alomide PA QLAltabaxAmitizaAndrogel PA QLApriso ERArestinAzilectBesivanceBeyazBiltricideBuphenyl tablet PACampral†CantilCedaxCesamet STChemetCiclodan kitClindacin kitCoartemColcrys PA QLCuprimineCystaranDaliresp QLDapsoneDaraprimDibenzylineEdecrinEffient QL DOElidel PAEllaElmironErgomarEstringFemtraceFinaceaFocalin XR PA QLFosamax Plus D ST QLGeneress FeLacrisertLanoxin tabLo Loestrin FeLo Minastrin FeLodosyn STLoestrin 24 FeLotemaxLovazaLumiganMaxair QLMethitestMigranal nasal spray† QL
Minastrin 24 FEMorgidox kit PAMotofenMoviprepMultaqMycobutinMyrbetriq STNamenda QLNataziaNiaspan ERNuedextaNuvaringOraceaOrap PAOrtho EvraOrtho Tri-cyclen LoOsmoprepOxsoralen-Ultra PAPanretinPataday PA QLPatanol PA QLPeganonePhospholine iodidePred-GPred-G S.O.PPremarin creamPremarin tabPremphasePremproPrevident 5000 Booster Plus
PrimaquineProlia PAProtopic PAProventil HFA QLQuartetteRenvela PARestasisRidauraRifaterRosadan kitSafyralSavella QLSilenorSoriatane†Spiriva QLStrattera PA QLStromectolSuprax cap, tab, susp.Syprine
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TikosynTransderm-ScopTravatan ZTrilipix†TyzineVagifemVentolin HFA QLVeregenVigamox PAVisicolVivelle-Dot QLVoltaren gelVyvanse PA QLWelcholXopenex HFA QLZirganZyvox tab, oral soln. PA QL
Tier 4
Actemra PAAdcirca PAAdefovirAfinitor Disperz
Afinitor PAAlkeran tabAmevive PAAmpyra PA QLAnagrelideAnastrazole tab PAApokyn PAAranesp PAAvonex PAAvonex Pen PAAzathioprine tabBaraclude PABosulif PACaprelsa PACarbaglu PACeeNUCimzia PA QLCometriq PACyclophosphamide tabCyclosporine cap, soln.DroxiaEmcyt PAEnbrel PA QLEnoxaparin PA
Erivedge PAEtopophosEtoposide capsExemestane PAExtavia PAFarestonFlutamideFondaparinux PAForteo PA QLGengrafGilotrifGleevec PAHepsera†HexalenHumira PA QLHycamtin capsHydroxyureaIclusig PAInfergenInlyta PAIntron A PAJakafi PAKalydeco PA QLKineret PA
Kuvan PALetairis PALetrozoleLeucovorin tabLeukeranLeuprolide PALomustineLysodrenMatulaneMekinist PAMelphalanMercaptopurineMethotrexate tabMycophenolateMyleranNeulasta PA QLNexavar PANilandronOfortaOrencia PA QLOrfadinPegasys PA QLPegintron PAPomalyst
Promacta PAPulmozyme PARapamuneRebif PARebif Rebidose PAReclast†Remicade PARemodulin PARevlimid PA QLRibavirin PARituxan PASensiparSimponi Aria PA QLSimponi PA QLSprycel PAStivarga PASutent PATabloidTafinlarTamoxifenTarceva PATasigna PATemodar cap† PATemozolomide cap PA
Tev-Tropin PAThalomid PATobiTopotecanTrelstar Depot PATrelstar PATretinoin 10mg capsuleTykerb PATysabriTyzeka PAVandetanib PAVentavis PAVictrelis PAVotrient PAXalkori PAXeloda PAXtandi PAZelboraf PAZoledronic Acid (generic Reclast)
Zolinza PAZytiga PA
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 may no longer be covered by your prescription drug plan. Check anthem.com/ca to find out about changes in tier status.
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.
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.
40627CAMENABC Effective 1/14
For more information, please visit anthem.com/ca. }} If you have additional questions about your prescription benefits, 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 p.m., ET.
}} For the most current version of this Selected Drug List, please visit anthem.com/ca.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.