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Anthem Blue Cross and Blue Shield 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.
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. What if my medication is not on the Select Drug List?A. You may want to first check with your doctor about
prescribing a drug that is on the Select Drug List. If your doctor prescribes a drug that’s not on the Select Drug List, you will have to pay the amount described in your policy for non-formulary drugs.
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.
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. 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 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
AcarboseAcebutololAcetasol HCAcetazolamide tab, ER cap
AclometasoneActicinAcyclovir tab, cap, oral susp.
Adapalene Afeditab CR QL DOAlbuterol inhl soln., syrupAlendronate QLAlfuzosinAllopurinol tabAlprazolam tabAmantadine Amcinonide Amiloride tabAminophylline tabAmiodarone tabAmitriptylineAmlodipine QL DOAmlodipine/ atorvastatin QL DO
Amlodipine/benazeprilAmmonium lactate cream, lotion
Amnesteem PAAmoxapineAmoxicillin Amoxicillin/clavulanate Amoxicillin/ clavulanate ER
Amphetamine/dextroamphetamine salts, ER PA QL
Androxy PAAntipyrine/ benzocaine ear drop
ApraclonidineAtenololAtenolol/chlorthalidoneAtorvastatin QL DOAtovaquone/proguanilAzelastine nasal spray, drops QL
Azithromycin tab, susp., packet QL
Bacitracin/polymixin BBaclofen
BalsalazideBenazeprilBenazepril/HCTZBenzonatateBenzoyl peroxideBenztropineBetamethasone dipropionate
Betamethasone valerate Betaxolol Birth Control (generic oral contraceptives)
BisoprololBisoprolol/HCTZBrimonidineBromocriptine Budesonide 0.25mg/2mL, 0.5mg/2mL QL
Bumetanide tabBuprenorphine tab PA QLBupropion QLBupropion SR, XL QL DOBuspirone Butalbital/acetaminophen
Butalbital/acetaminophen/caffeine
Butalbital/acetaminophen/caffeine/codeine QL
Butalbital/aspirin/caffeine
Butalbital/aspirin/caffeine/codeine
Butorphanol nasal spray PA QL
CabergolineCalcipotriene Calcitriol cap, soln, ointCandesartan/HCTZ PA QL DO
Captopril Captopril/HCTZCarbamazepine, ER, XRCarbidopa/ Levodopa, ER, ODT
CarbinoxamineCarisoprodolCarteololCartia XT QL DOCarvedilolCefaclor, ER
CefadroxilCefdinirCefditoren PivoxilCefprozilCefuroxime AxetilCephalexinCetirizine syrup QLChlorhexidine gluconateChlorhexidine RinseChloroquineChlorothiazide tabChlorpromazine tab PAChlorpropamideChlorthalidoneChlorzoxazoneCholestyramineCiclopiroxCimetidine tab, soln.Ciprofloxacin ear and eye drops
Ciprofloxacin tab QLCitalopram QL DOClaravis PAClarithromycin, ERClemastine 2.68mgClemastine syrupClindamycin cap, oral soln, topical preparations
Clindamycin/Benzoyl Peroxide Gel
ClobetasolClomipramineClonazepam, ODTClonidine tabClopidogrel PA (75mg only) QL
Clotrimazole 1% cream, troche
Clotrimazole/betamethasone
Codeine sulfate tabs QLCodeine/ acetaminophen QL
Codeine/butalbital/aspirin/caffeine
ColestipolCortisone tabCovaryx, H.S.Cromolyn eye drops QLCromolyn neb soln.Cyclobenzaprine tab
Cyproheptadine DepadeDermazeneDesloratadine, ODT QLDesmopressin nasal spray, tab PA
DesonideDesoximetasoneDexamethasone eye dropDexamethasone tab, oral soln.
DexchlorpheneramineDexmethylphenidate PA QL
Dextroamphetamine, ER PA QL
Diazepam tab, oral soln.Diclofenac eye dropDiclofenac, ERDicloxacillinDicylomine cap, tab, syrup
DiflorasoneDiflunisalDigoxin tab, oral soln.Diltiazem, ER, XR, CD QL DO
Diphenhydramine 50mg cap
Diphenoxylate/atropineDipyridamole tabDisopyramideDisulfiramDivalproex, ER, DRDonepezil 5mg, 10mg, ODT QL
Dorzolamide eye dropsDorzolamide/timolol eye drops
DoxazosinDoxepin Doxycycline hyclate tab, cap
Doxycycline hyclate, delayed release PA
Doxycycline monohydrate tab, cap
DylixEconazoleEnalaprilEnalapril/HCTZEndocet QLEndodan QL
For more information about your drug plan, you can do the following:
}} Go to anthem.com.
}} 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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EpidrinEpinastine eye drops QLEpitolEprosartan PA QLErgocalciferol (Vit D2) caps
Ergotamine/caffeineEry-Tab 250mg, 333mg tab
Erythromcyin eye oint.Erythromycin 2% gel, topical solution
Erythromycin ethylsuccinate 400mg Filmtab
Erythromycin Filmtab, 250mg cap
Erythromycin stearateErythromycin/benzoyl peroxide gel
Erythromycin/sulfisoxazole
Escitalopram QL DOEstazolamEstradiol patch QLEstradiol tabEstrogen/methyltestosterone
EstropipateEthambutolEthosuximideEtodolac, ERFamciclovirFamotidine tab, oral soln.FelbamateFelodipine ER QLFenofibrateFenofibric acidFenoprofenFentanyl citrate lozenge PA QL
Finasteride 5mg tab PAFlavoxateFluconazole tab, oral soln.
FlucytosineFludrocortisoneFlunisolide nasal spray ST QL
Fluocinolone body oil, scalp oil PA
Fluocinolone cream, topical soln., oint., ear drop
FluocinonideFluorometholone eye drops
Fluorouracil cream, topical solution
Fluoxetine, DR (except 60mg) QL DO
Fluphenazine tab, oral soln. PA
Flurbiprofen eye dropFlurbiprofen tabFluticasone nasal spray QL
Fluticasone topicalFluvastatin QL DOFluvoxamine QL DOFolic acid 1mgFosinoprilFosinopril/HCTZFurosemide tab, oral soln.Garamycin eye dropsGemfibrozilGentamycin eye drops, oint.
GlimepirideGlipizide, ER, XLGlipizide/metforminGlyburideGlyburide, micronizedGlyburide/metforminGriseofulvinGuaifenesin/ codeine syrup
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 pamoateHyomax-FT 0.125 chew melt
Ibandronate ST QLIbuprofenImipramine HCL tabImiquimod PA QLIndapamideIndomethacin , ER capIpratropium bromide neb soln. QL
Irbesartan PA QL DOIrbesartan/HCTZ PA QL DO
Isometheptene/acetaminophen/caffeine
Isometheptene/acetaminophen/dichloralphenazone
IsonarifIsoniazid tab, oral soln.Isosorbide dinitrate, ER tab
Isosorbide mononitrate, ER tablet
IsradipineKetoconazoleKetoprofen, ERKetorolac eye dropsKetorolac tab QLKlor-Con tabLabetolol tabLactuloseLamotrigine tab (immediate release)
Lansoprazole, DR QLLatanoprost
Levobunolol eye dropsLevocetirizine QLLevofloxacin tab QLLevothroidLevothyroxine tabLevoxylLidocaine viscous soln.Lidocaine/hydrocortisone 3/0.5% cream
Lidocaine/prilocaineLindaneLiothyronine tabLisinoprilLisinopril/HCTZLithium carbonate, ERLithium citrate oral soln.LonoxLosartan QL DOLosartan/HCTZ QL DOLovastatin QL DOLoxapine PAMalathionMaprotilineMatzim LA QL DOMebendazoleMeclizine tabMeclofenamate capMedroxyprogesterone tab
Mefenamic acidMefloquineMegestrolMeloxicam oral suspension
Meloxicam tab QLMeperidine tab, oral soln. QL
Meprobamate QLMetadate ER PA QLMetaproterenolMetaxaloneMetformin, ERMethadone tab, oral soln. QL
Methamphetamine PA QLMethanamine MDMethazolamideMethimazoleMethocarbamolMethscopolamine bromide
MethyclothiazideMethyldopaMethyldopa/HCTZMethylergonovine tabMethylphenidate, CD, ER, SR PA QL
Methylprednisolone tabMetipranolol eye dropsMetoclopramide tab, oral soln.
MetolazoneMetoprolol tab, ERMetoprolol/HCTZMetronidazole 0.75% gelMetronidazole tab, capsule, cream, lotion
Miconazole 200mg vaginal suppository
MinocyclineMinocycline ER PAMinoxidil tabMirtazapineMisoprostol PAModafinil PA QLMoexiprilMoexipril/HCTZMometasone cream, oint, topical soln.
Montelukast QLMorphine sulfate IR tab QL
Morphine sulfate oral soln. QL
Morphine sulfate suppository
Mupirocin oint.NabumetoneNadololNadolol/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
Nicardipine capsNifedipine capNifedipine tab ER, XL QL DO
Nisoldipine ER QL DONitro-Bid oint.Nitrofurantoin Nitroglycerin, ER, SRNizatidineNorethindronenortriptylineNP ThyroidNystatin cream, oint., powder, tab
Nystatin/triamcinoloneOfloxacin ear and eye drops
Ofloxacin tab QLOmeprazole caps QLOrphenadrine EROxaprozinOxcarbazepineOxybutynin, EROxycodone QLOxycodone/acetaminophen tab, cap QL
Oxycodone/aspirin QLOxymorphoneOxymorphone ER QLPaceronePancrelipaseParamomycinParoxetine, CR, ER QL DOPenicillin VKPentazocine/naloxone QLPentoxifylline, ERPerindoprilPermethrin creamPerphenazine PAPhenazopyridinePhenelzinePhenobarbital tab, oral soln.
4
Phenytoin ext. capPilocarpine eye dropsPindololPioglitazone QLPiroxicamPodofiloxPolymixin/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 HCTZPropranolol tab, oral soln.PropylthiouracilProtriptylinePyrazinamidePyridostigmineQuetiapine PAQuinaprilQuinapril/HCTZQuinidine sulfate, ERQuinine sulfate PA QLRamipril
Ranitidine 150, 300mg tab, cap
Ranitidine oral soln.RifampinRimantadineRisperidone, ODT, oral soln. PA
Rizatriptan, ODT QLRopinirole, ERRoxicet tab, caplet QLSelegilineSelenium sulfide 2.5% lotion, shampoo
Sertraline QL DOSilver sulfadiazine creamSimvastatin 80mg PA QL DO
Simvastatin QL DOSodium polystyrene sulfate 30gm/120ml enema
Sodium polystyrene sulfate powder
Sodium polystyrene sulfonate
Sodium sulfacetamide/sulfur
Sodium sulfacetamide/sulfur/urea
SpinosadSpironolactoneSucralfateSulfacetamide eye drops, oint.
Sulfacetamide sodiumSulfacetamide sodium/prednisolone eye drops
Sulfacetamide sodium/sulfur
Sulfacetamide sodium/sulfur/urea
Sulfacetamide sodium/urea
Sulfamethoxazole/trimethoprim, DS
SulfasalazineSulindacSumatriptan tab QLTamsulosinTaztia XT QL DOTerazosinTerbinafine tab PATerbutaline tabTerconazole
Tetracycline capsTheochron ERTheophylline ER, oral soln.
Thioridazine PAThiothixene PATiclopidineTimolol eye drops, gelTimolol tabTizanidineTobramycin eye dropsTobramycin/dexamethasone eye drops
TolazamideTolbutamideTolmetinTolterodineTopiramate PATorsemide tabTramadol, ER tab QLTrandolaprilTranexamic acid 650mgTranylcypromineTrazodoneTretinoin cream, gel PATriamcinolone cream, lotion, oint.
Triamcinolone nasal spray QL
Triamcinolone pasteTriamterene/HCTZTrifluoperazine PATrifluridine eye dropsTrihexyphenidylTrimethobenzamide capTrimethoprimTrimipramineTropicamide eye dropsUnithroidValacyclovirValproid acid cap, oral soln.
Valsartan/HCTZ PA QL DOVenlafaxineVenlafaxine, ER QL DOVerapamil tab, ER PM QL DO
Verapamil tab, ER tab, cap
Vicodin, ES, HP QLWarfarin
WesthroidZafirlukastZaleplon ST QLZiprasidone PAZolpidem (immediate release) QL
Tier 2
Accu-Chek ProductsAdvair Diskus, HFA QLAnaspaz ODTAsmanex Twisthaler QLBethanechol tabBromfenac eye dropsBudesonide ECBuprenorphine syringe, vial
Calcitonin QLCalcium acetate tabCefpodoximeCevimelineCilostazolClozapine, ODT PADanazolDantroleneDemeclocyclineDesipramineDronabinolDulera QLEliphosEntacaponeEpipen, Jr.EplerenoneErgoloidEtidronateEvistaFentanyl patch ST QLFlecainideFlovent HFA QLFlovent QLFortical nasal spray QLGabapentinGalantamine, ER QLGlucagenGranisetron tab QLHumalogHumalog MixHumulin N, R, 70-30Itraconazole PAKetorolac inj. QLLantus
Lantus SolostarLeflunomideLevalbuterol neb soln.LevemirLevetiracetamLevetiracetam ER PA QLLevocarnitine tab, oral soln.
Levorphanol tab QLMethenamine hippurateMexiletineMorphine sulfate ER QLNateglinide PANimodipineNitroglycerin sprayNitrostatNovolin NNovologNovolog MixOlanzapine tab, ODT PAOndansetron tab, ODT, oral soln. QL
One Touch Product LineOxandrolone PAPantoprazole QLPilocarpine tabsProair HFA ST QLPropafenonePrudoxinPulmicort 1mg/2mL respules QL
Pulmicort Flexhaler QLQvar QLRelenza QLRivastigmine QLSerevent Diskus QLSotalol tab, AF tabSulfadiazineSumatriptan inj QLSymbicort QLTamiflu QLTiagabine PATranexamic acid 1000mg/10mL
Trospium chloride ER STUrsodiolValcyte 450mgVancomycin caps PAVoriconazole tab PAZenpepZonisamide
Tier 3
Abilify tab PAAciphex QLActonel ST QLAczoneAggrenox QLAlamast PAAlbenzaAliniaAlocril PA QLAlomide PA QLAltabaxAmitizaAnadrol-50Androgel PA QLAntivert 50mgAnzemet tablet QLApidra, Solostar STApriso ERArcapta Neohaler QLArestinAtacand† PA QL DOAvandia ST QLAvodartAxert ST QLAzelex PAAzilectAzoptBactocillBanzel QLBenicar PA QL DOBepreve PA QLBesivanceBeyaz STBiltricideBrilinta QLBrovana QLBuphenyl tablet PAButrans QLBydureon ST QLBystolicCambia QLCampral†CantilCataflamCedaxCelebrex ST QLCelontinCenestinCesamet PA
5
Chantix PA QLChemetCialis 2.5mg, 5mg PACiclodanCipro HC ear dropsCiprodex ear drops PAClindacinClodermCoartemColcrys PA QLColy-Mycin ear dropsCombiganCordran, SPCortisporin cream, oint.Crestor ST QL DOCresylateCuprimineCyclosetCymbalta PA QL DODaliresp QLDapsoneDaraprimDenavirDexilant ST QLDibenzylineDifferin 0.1% lotion, 0.3% gel
Dificid PADiovan PA QL DODipentumDurezol QLDyreniumEdarbi QL DOEdecrinEffient QL DOElidel PAEllaElmironEmadine PA QLEmend caps QLEmsam QLEnablex STEnjuviaEpiduoErgomarErtaczoEstringEuraxExalgo ER ST QLExelderm
Factive QLFanapt PAFinaceaFlector STFluoridexFluoroplexFML S.O.PFocalin XR PA QLFosamax oral soln.†Fosamax Plus D ST QLFosrenol PAFrova ST QLGeneress FeGlysetGynazole 1HalogHectoral capsHorizant PAIntuniv ER PAInvega tab PAJanumet, XR QLJanuvia ST QLKapvay, ER PAKetekLacrisertLanoxin tabLatuda PALevatolLivalo ST QL DOLo Loestrin FeLodosyn STLoestrin 24 FELotemaxLotronex PALovazaLufyllinLumiganLunesta PA QLLyrica PA QLMarplanMaxair QLMaxalt, MLT† QLMenestMentaxMepronMethitestMicardis PA QL DOMigranal nasal spray† QLMorgidox PAMotofen
MoviprepMoxatagMultaqMycobutinMyrbetriq STMytelaseNaftin cream, 1% gelNamenda QLNatacynNatazia STNevanacNexium PA QLNiaspan ERNorinyl 1+50-28Noroxin QLNoxafilNucynta, ER QLNuedextaNuoxNuvaringNuvigil PA QLOmnaris ST QLOnglyza ST QLOraceaOrap PAOrtho EvraOrtho Tri-cyclen LoOsmoprepOxistatOxsoralen-Ultra PAOxycontin ST QLPanretinPaserPataday PA QLPatanase QLPatanol PA QLPeganonePerforomist QLPhisohexPhospholine iodidePicato PA QLPotiga QLPradaxa QLPrandin† PAPred-GPred-G S.O.P Premarin CreamPremarin tab STPremphasePrempro
Prevident 5000 Booster Plus
PriftinPrimaquinePrimsolPristiq QL DOProglycemProlia PAProquin XRProtopic PAProventil HFA ST QLRanexaRapafloRectivRegranex PARelistor PARelpax ST QLRenvela PARestasisRidauraRifaterRosadanRozerem ST QLSabrilSafyral STSamsca PASancusoSantylSaphris PASavella QLScopaceSeroquel XR PASilenor STSkelidSolaraze PA QLSoriatane†Spiriva QLStrattera PA QLStromectolSulfamylonSuprax tab, susp.Symlin PASyneraSyprineTaclonex scalp suspension
Taclonex suspensionTasmarTazorac PATekturna QL DO
Teveten 400mg QLThyrolarTikosynTobradex eye oint.Toviaz ER STTradjenta ST QLTransderm-Scop PATravatan ZTrecatorTrilipix†TyzineUlesfiaUloric STVagifemValcyte 50mg/mL solution
Ventolin HFA ST QLVeregenVesicare STVexolVfend oral susp. PAVictoza ST QLVigamox PAViibryd STVimpat QLVisicolVivelle-Dot PA QLVoltaren gelVoltaren-XRVyvanse PA QLWelcholXarelto QLXenazine PAXifaxan PA QLXopenex HFA ST QLXyrem PAZemplar capsZetia PA QLZiana STZinoticZioptanZipsorZirganZomig tab PA QLZomig ZMT PA QLZyflo, CR PAZymaxidZyvox tab, oral soln. PA QL
Tier 4
AbacavirActemra PAAdagenAdcirca PAAfinitor PAAldurazyme PAAlkeran tabAmevive PAAmpyra PA QLAnagrelideAnastrazole tab PAApokyn PAAptivus Aranesp PAAtriplaAubagio PA QLAzathioprine tabBaraclude PABenlysta PABicalutamideBosulif PACaprelsa PACarbaglu PACeeNUCimzia PA QLCometriq PACopaxone PACrixivanCyclophosphamide tabCyclosporine Cyclosporine cap, soln.Didanosine DRDroxiaEdurantEmcyt PAEmtrivaEnbrel PA QLEnoxaparin PAEpivir HBV soln. PAEpzicomErivedge PAEtopophosEtoposide capsExemestane PAExjade PAExtavia STFarestonFerriprox PAFlutamide
6
Fondaparinux PAForteo PAFragmin PAFuzeonGengrafGilenya PA QLGleevec PAHepseraHexalenHumira PA QLHycamtin capsHydroxyureaIclusig PAIncivek PAInfergen PAInlyta PAInnohep PAIntelenceIntron A PAInviraseIressa
IsentressJakafi PAKaletraKalydeco PA QLKineret PAKuvan PALamuvidineLamuvidine/zidovudineLetairis PALetrozoleLeucovorin tabLeukeranLeuprolide PALexivaLysodrenMatulaneMelphalanMercaptopurineMethotrexate tabMycophenolateMyfortic
MyleranNebupentNeulasta PA QLNeupogen PANevirapineNexavar PANilandronNorvirOforta PAOmontys PAOrencia PA QLOrfadinPegasys PA QLPegintron PAPomalystPrezistaProcrit PAPromacta PA QL DORapamuneRebif PAReclast†
Remicade PARemodulin PARescriptorRevlimid PA QLReyatazRibavirin PARilutek†Rituxan PASandostatin LAR PASelzentrySensiparSimponi PA QLSildenafil 20mg tab PASimulectSomatulineSomavert PASprycel PAStavudineStelara PA QLStivarga PASustiva
Sutent PASynarel PASynriboTabloidTacrolimusTamoxifenTarceva PATargretin PATasigna PATemodar cap† PATev-Tropin PAThalomid PATopotecanToriselTracleerTrelstar Depot PATrelstar PATretinoin 10mg capsuleTrizivirTruvadaTykerb PA
TysabriTyzeka PAVandetanib PAVentavis PAVictrelis PAViraceptViread PAVotrient PAVPRIV PAXalkori PAXeloda PAXtandi PAZavesca PAZelboraf PAZidovudineZolinza 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 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.
40627MUMENABS Effective 1/14
For more information, please visit anthem.com. }} 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.
Anthem Blue Cross and Blue Shield is the trade name of: 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 affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. 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 the registered marks of the Blue Cross and Blue Shield Association.
(IN, KY, ME, MO, OH, NH, VA)