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Prescription Program
Drug list — To be used by members
who have a formulary drug plan.
Anthem Blue Cross and Blue Shield 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 AND BLUE SHIELD DRUG LIST For more information about
your drug plan, you can do
A. The Anthem Drug List, also called a formulary, is a list of U.S. Food and Drug the following:
Administration (FDA)-approved brand-name and generic drugs that have been • Go to anthem.com
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 • Call customer service
P&T Process is performed by an independent group of practicing doctors and at the number on your
pharmacists in charge of the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and they • Speech and hearing
choose the top drugs for our list — based on their safety, how they work and impaired users
(TDD/TTY) should call
Because the drugs on our list are reviewed from time to time, it’s a good idea 800-221-6915, Monday
to check the list to find out if any drugs have been added or removed. You can – Friday, 8:30 a.m. –
5:00 p.m., ET
Bring a copy of this drug
A. These are drugs that are developed by a company who holds the rights to sell list to your next doctor’s
them. When the rights expire, other drug companies can make their own version visit to help you and your
of the drugs (see generic drugs below). You may be more familiar with brand- doctor select the lowest
name drugs through advertising or because you know people who take them. cost medicine
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 the same quality for less money. Q. What are “clinically equivalent” medications? How does this affect my drug First letter is lower-case – A generic
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 First letter is a capital – A brand-
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 plan may not cover some drugs (indicated by a ^ symbol next to the drug name) that have clinically equivalent options.
drug becomes available and the people affected are given notice, Q. What if my medication is not on the drug list? this brand-name drug will no longer be on our drug list. It will either 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.
* – Brand-name versions of these drugs Q. Can I request that a drug be added to the drug list? are not on our list (these drugs have the highest copay).
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 ^ – This drug has clinically equivalent 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.
Drugs are listed alphabetically by brand name
Aci-Jel Jelly (acetic acid Amoxil (amoxicillin)* Cyclogyl (cyclopentolate)* Diabeta (glyburide)* Casodex (bicalutamide)* Cylert (pemoline)* dextroamphetamine^#) Apresazide (hydralazine/ (mupirocin)* (spironolactone/HCTZ)* Arimidex (anastrozole)* Benzagel, Wash (benzoyl Condylox Solution Cordarone (amiodarone)* Demulen 28 day (ethinyl phenobarbital)* peroxide/erythromycin)* Coreg (carvedilol)* Aromasin (exemestane)* Betagan (levobunolol)* Biaxin, XL (clarithromycin, Cortef (hydrocortisone)* acid)* Bicitra (sodium citrate & (hydrocortisone Bleph-10 (sulfacetamide- (bacitracin - polymyxin/ Derma-Smoothe/FS Dynapen (dicloxacillin)* Extina (ketoconazole)* Glucophage (metformin)* (indomethacin, SR)* Glucotrol XL (glipizide XL)* Intal Inhaler Flexeril (cyclobenzaprine)* (phenyleph/chlorphen/ Entocort EC (budesonide Flonase (fluticasone)* K-Lor (potassium chloride Levsin (hyoscyamine)* Lexapro (escitalopram)* Malarone (atovaquone- Librium (chlordiazepoxide)* Materna (multi-vitamins polystyrene sulfonate)* Lo/Ovral (low-ogestrel)* Gastrocrom (cromolyn)* Imodium (loperamide)* Mydriacyl (tropicamide)* Noctec (chloral hydrate)* Norpace (disopyramide)* Paxil (paroxetine)* ephedrine hcl/chlor-mal)* Percodan (oxycodone/ Pred Forte 1% Phenergan (promethazine)* Prilosec^ (omeprazole)* promethazine/codeine)* Prinzide (lisinopril/hctz)* Razadyne, ER Ortho-Est (estropipate)* Phoslo (calcium acetate)* ProAmatine (midodrine)* Rebetol (ribavirin)* MS Contin (morphine SR)* 0.4, and 0.6mg/hr MSIR (morphine sulfate)* (nitroglycerin patch)* Procardia XL (nifedipine ER)* Requip (ropinirole)* Myambutol (ethambutol)* Nitrolingual spray Nitrostat (nitroglycerin)* oxymorphone ER Retin-A Cream (tretinoin)* Selsun (selenium sulfide)* Symlin Tranxene (clorazepate)* V-Cillin K (penicillin V.K.)* Westcort (hydrocortisone)* Synthroid (levothyroxine) Trental (pentoxifylline)* Valcyte tabs† (methotrexate tablets)* Seroquel (quetiapine)* Tri-Vi-Flor (triple vitamins Valium (diazepam)* Talwin NX (pentazocine nx)* Trilafon (perphenazine)* Vancocin (vancomycin)* Xopenex Neb Soln. Trileptal (oxcarbazepine)* Vantin (cefpodoxime)* Tapazole (methimazole)* Trimox (amoxicillin)* Tavist syrup, 2.68mg tabs Trimpex (trimethoprim)* Vasocidin (sulfacetamide (lidocaine viscous)* Tegretol (carbamazepine) Triphasil (trivora)* (methylphenidate, SR)* Slo-Bid (theophylline)* (guaifenesin/codeine)* Verelan (verapamil SR)* Rocaltrol (calcitriol 0.25, Solaquin Forte Vibramycin (doxycycline)* Zebeta (bisoprolol)* bromphen-DM 45-4-15)* Somophyllin (aminophylline)* Tessalon Perles Tussionex (hydrocodone/ Vicodin (hydrocodone/ Roxicodone (oxycodone)* Spectazole (econazole)* Theo-24 Theochron (theophylline)* Tylox (oxycodone w/ Stadol N.S. (butorphanol (chlorpromazine tab)* tartrate 10mg/ml N.S.)* Ticlid (ticlopidine)* Stelazine (trifluoperazine)* (timololophthalmic)* Ultravate (halobetasol)* Vistaril (hydroxyzine Sanctura, XR (trospium, Subutex (buprenorphine)* dexamethasone)* sulfacetamide/ sulfur)* Tolectin (tolmetin)* Voltaren, XR (diclofenac, ER)* Zonegran (zonisamide)* Surmontil (trimipramine Topicort (desoximetasone)* Anthem is committed to helping you to manage your prescription benefits. Prior Authorization, Quantity Limits, Step Therapy and Dose Optimization are some of the edits recommended by the P&T Committee and approved by your health plan. These edits help ensure you have access to safe, appropriate and effective prescription medications. The lists below are not all-inclusive. PRIOR AUTHORIZATION: medications which require pharmacy benefit manager or plan approval before you may receive benefits.
Actiq (fentanyl citrate)*
QUANTITY LIMIT: affects the frequency or dosage of certain medications for which you receive benefits.
Aciphex*^
Allegra D^ (fexofenadine/ Clarinex (desloratadine)*, D^* Humatrope* Ambien, CR (zolpidem ER)* Diabetic Test Strips STEP THERAPY: requires that you first use a specific medication before alternatives therapies may be tried or prescribed.
Adderall (amphetamine/
DOSE OPTIMIZATION: normally involves the conversion from twice-daily dosing to a once-daily dosing schedule. A once-daily
dosing schedule may increase compliance and decrease expenses for you and your health plan.
Medications in the following categories are included in the dose optimization edits.
Antidepressants 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 Kentucky Residents Only: 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. Anthem has 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 copay. 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.
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 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 affi liates administer non-HMO benefi ts underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi 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://www.cpschools.com/wellness/DOC_AnthemDrugFormulary_ALPHA.pdf

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