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 ...
Select Drug List
4 Tier Formulary
40627CAMENABC Effective 1/14 933334 40627CAMENABC Select Drug List 4 Tier Part 2 BK 11 13
Anthem Blue Cross Select Drug List 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.
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.
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.
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):
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.
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. }} }}
Preventive Care Drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).
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.
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.
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. 1
For more information about your drug plan, you can do the following: Go to anthem.com/ca.
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Call Customer Service at the number on your ID card.
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Speech and hearing impaired users (TDD/TTY) should call 800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.
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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.
Tier 1
Benazepril/HCTZ Benzonatate Benzoyl peroxide Benztropine Betamethasone dipropionate Betamethasone valerate Betaxolol Birth Control (generic oral contraceptives) Bisoprolol Bisoprolol/HCTZ Brimonidine Bromocriptine Budesonide 0.25mg/2mL, 0.5mg/2mL QL Buprenorphine tab PA QL Bupropion QL Bupropion SR, XL QL DO Buspirone Butalbital/ acetaminophen Butalbital/ acetaminophen/caffeine Butalbital/ acetaminophen/ caffeine/codeine QL Butalbital/aspirin/ caffeine Butalbital/aspirin/ caffeine/codeine Butorphanol nasal spray PA QL Cabergoline Calcipotriene Candesartan/HCTZ QL DO Carbamazepine, ER, XR Carbidopa/Levodopa, ER, ODT Carteolol Cartia XT QL DO Cefaclor, ER Cefadroxil Cefdinir Cefditoren Pivoxil Cefprozil Cefuroxime Axetil Cephalexin Chlorhexidine rinse Chloroquine Chlorpromazine tab PA Chlorthalidone
Abacavir Acebutolol Acetasol HC Acetazolamide tab, ER cap Aclometasone Acticin Acyclovir tab, cap, oral susp. Adapalene Afeditab CR QL DO Albuterol inhl soln., syrup Alendronate QL Alfuzosin Allopurinol tab Alprazolam tab Amantadine Amcinonide Aminophylline tab Amitriptyline Amlodipine QL DO Amlodipine/ atorvastatin QL DO Amlodipine/benazepril Ammonium lactate cream, lotion Amnesteem PA Amoxapine Amoxicillin Amoxicillin/clavulanate Amoxicillin/ clavulanate ER Amphetamine/ dextroamphetamine salts, ER PA QL Androxy Antipyrine/benzocaine ear drop Apraclonidine Atenolol Atenolol/chlorthalidone Atorvastatin QL DO Atovaquone/proguanil Azelastine nasal spray, drops QL Azithromycin tab, susp., packet QL Bacitracin/polymixin B Baclofen Balsalazide Benazepril 2
Chlorzoxazone Ciclodan cream, soln. Ciclopirox Cimetidine tab, soln. Ciprofloxacin ear and eye drops Ciprofloxacin tab QL Citalopram QL DO Claravis PA Clarithromycin, ER Clindacin pledgets Clindamycin cap, oral soln, topical preparations Clindamycin/Benzoyl Peroxide gel Clobetasol Clomipramine Clonazepam, ODT Clonidine tab Clopidogrel 300mg Clopidogrel 75mg PA QL Clotrimazole 1% cream, troche Clotrimazole/ betamethasone Codeine sulfate tabs QL Codeine/ acetaminophen QL Codeine/butalbital/ aspirin/caffeine Covaryx, H.S. Cromolyn eye drops QL Cromolyn neb soln. Cyclobenzaprine tab Depade Dermazene Desmopressin nasal spray, tab PA Desonide Desoximetasone Dexamethasone eye drop Dexamethasone tab, oral soln. Dexmethylphenidate PA QL Dextroamphetamine, ER PA QL Diazepam tab, oral soln. Diclofenac eye drop Diclofenac, ER Dicloxacillin
Dicyclomine cap, tab, syrup Didanosine DR Diflorasone Diflunisal Digoxin tab, oral soln. Diltiazem Diltiazem ER, XR, CD QL DO Diphenhydramine 50mg cap Diphenoxylate/atropine Dipyridamole tab Disopyramide Disulfiram Divalproex, ER, DR Dorzolamide eye drops Dorzolamide/timolol eye drops Doxazosin Doxepin Doxycycline hyclate tab, cap Doxycycline hyclate, delayed release PA Doxycycline monohydrate tab, cap, susp. Econazole Enalapril Enalapril/HCTZ Endocet QL Endodan QL Epidrin Epinastine eye drops QL Epitol Ergocalciferol (Vit D2) caps Ergotamine/caffeine Ery-Tab 250mg, 333mg tab Erythromcyin eye oint. Erythromycin 2% gel, topical soln. Erythromycin ethylsuccinate 400mg filmtab Erythromycin filmtab, 250mg cap Erythromycin stearate Erythromycin/benzoyl peroxide gel Erythromycin/ sulfisoxazole
Escitalopram QL DO Estradiol patch QL Estradiol tab Estrogen/ methyltestosterone Estropipate Ethambutol Ethosuximide Famciclovir Famotidine tab, oral soln. Felbamate Felodipine ER QL DO Fenofibrate Fenofibric acid Finasteride 5mg tab PA Fluconazole tab, oral soln. Flucytosine Flunisolide nasal spray ST QL Fluocinolone body oil, scalp oil Fluocinolone cream, topical soln., oint., ear drop Fluocinonide Fluorometholone eye drops Fluorouracil cream, topical soln. Fluoxetine, DR (except 60mg) QL DO Fluphenazine tab, oral soln. PA Fluticasone nasal spray QL Fluticasone topical Folic acid 1mg Fosinopril Fosinopril/HCTZ Furosemide tab, oral soln. Garamycin eye drops Gemfibrozil Gentamycin eye drops, oint. Glimepiride Glipizide, ER, XL Glipizide/metformin Glyburide Glyburide/metformin Griseofulvin Guaifenesin/codeine syrup (generic version)
Guanfacine Guanidine Halac Halobetasol propionate Haloperidol tab PA Hydralazine tab Hydrochlorothiazide Hydrocodone/ acetaminophen QL Hydrocortisone tab Hydrocortisone 2.5% cream, lotion, oint. Hydrocortisone acetate 2% gel Hydrocortisone acetate suppository Hydrocortisone butyrate 0.1% cream, oint., soln. Hydrocortisone enema Hydrocortisone valerate 0.2% cream, ointment Hydrocortisone/acetic acid ear drops Hydrocortisone/ pramoxine cream, ointment Hydromorphone suppository Hydromorphone tab, oral soln. QL Hydroxychloroquine Hydroxyzine HCL tab, oral soln. Hydroxyzine pamoate Ibandronate QL Ibuprofen Imipramine HCL tab Imiquimod cream PA QL Indapamide Indomethacin , ER cap Ipratropium bromide neb soln. QL Irbesartan/HCTZ QL DO Isometheptene/ acetaminophen/caffeine Isometheptene/ acetaminophen/ dichloralphenazone Isonarif Isoniazid tab, oral soln. Isosorbide dinitrate, ER tab Isosorbide mononitrate, ER tabs
Methimazole Methscopolamine bromide Methyclothiazide Methyldopa Methyldopa/HCTZ Methylergonovine tab Methylphenidate, CD, ER, SR PA QL Methylprednisolone tab Metipranolol eye drops Metoclopramide tab, oral soln. Metoprolol tab, ER Metoprolol/HCTZ Metronidazole 0.75% gel Metronidazole tab, capsule, cream, lotion Minocycline Minocycline ER PA Minoxidil tab Mirtazapine Misoprostol PA Mometasone cream, oint, topical soln. Montelukast QL Morgidox caps PA Morphine sulfate IR tab QL Morphine sulfate oral soln. QL Morphine sulfate suppository Mupirocin oint. Nabumetone Nadolol/ bendroflumethiazide Naltrexone Naphazoline eye drops Naproxen, DR Naratriptan QL Nature-Throid Nefazodone Neomycin tab Neomycin/polymixin/ bacitracin eye oint. Neomycin/polymixin/ bacitracin/ hydrocortisone eye oint. Neomycin/polymixin/ dexamethasone eye drops, oint.
Ketoconazole Ketorolac eye drops Ketorolac tab QL Klor-Con tab Lactulose Lamotrigine tab (immediate release) Lamuvidine Lamuvidine/zidovudine Lansoprazole PA QL Latanoprost Levofloxacin tab QL Levonorgestrel tab QL Levothroid Levothyroxine tab Levoxyl Lidocaine viscous soln. Lidocaine/hydrocortisone 3/0.5% cream Lidocaine/prilocaine Lindane Liothyronine tab Lisinopril Lisinopril/HCTZ Lithium carbonate, ER Lithium citrate oral soln. Losartan QL DO Losartan/HCTZ QL DO Lovastatin QL DO Loxapine PA Malathion Maprotiline Matzim LA QL DO Mebendazole Meclizine tab Meclofenamate cap Medroxyprogesterone tab Mefloquine Megestrol Meloxicam oral suspension Meloxicam tab QL Meperidine tab, oral soln. QL Metadate ER PA QL Metaproterenol Metformin, ER Methadone tab, oral soln. QL Methazolamide 3
Neomycin/polymixin/ gramicidin eye drops Neomycin/polymixin/ hydrocortisone ear and eye drops Nevirapine Nifedipine cap Nifedipine tab ER, XL QL DO Nisoldipine ER QL DO Nitro-Bid oint. Nitrofurantoin Nitroglycerin, ER, SR Norethindrone Nortriptyline NP Thyroid Nystatin cream, oint., powder, tab, susp. Nystatin/triamcinolone Ofloxacin ear and eye drops Ofloxacin tab QL Omeprazole caps QL Oxcarbazepine Oxybutynin, ER Oxycodone QL Oxycodone/ acetaminophen tab, cap QL Oxycodone/aspirin QL Oxymorphone Pancrelipase Paramomycin Paroxetine, CR, ER QL DO Penicillin VK Pentoxifylline, ER Permethrin cream Perphenazine PA Phenazopyridine Phenelzine Phenobarbital tab, oral soln. Phenytoin ext. cap Podofilox Polymixin/trimethoprim eye drops Potassium 25mEq tab effervescent Potassium chloride ER tab, ER cap Potassium citrate ER Tab Potassium citrate/citric acid
Pramipexole Pravastatin QL DO Prazosin Prednicarbate Prednisolone eye drops Prednisolone oral soln. Prednisone Prenatal Vitamins (all generic covered) Primidone Probenecid Probenecid/colchicine Procentra QL Prochlorperazine tab Progesterone, micronized cap Promethazine tab, suppository, syrup Promethazine VC syrup Promethazine VC syrup with codeine Promethazine/ codeine syrup Promethazine-DM syrup Propranolol ER Propranolol tab, oral soln. Propranolol/HCTZ Propylthiouracil Protriptyline Pyrazinamide Pyridostigmine Quetiapine PA Quinapril Quinapril/HCTZ Quinidine sulfate, ER Quinine sulfate PA QL Ramipril Ranitidine 150mg, 300mg tab, cap Ranitidine oral soln. Rifampin Rimantadine Risperidone, ODT, oral soln. PA Ropinirole, ER Rosadan cream and gel Roxicet tab, caplet QL Selegiline Selenium sulfide 2.5% lotion, shampoo Sertraline QL DO Silver sulfadiazine cream
Simvastatin 80mg PA QL Simvastatin QL DO Sodium polystyrene sulfate 30gm/120ml enema Sodium polystyrene sulfate powder Sodium polystyrene sulfonate Sodium sulfacetamide/ sulfur Sodium sulfacetamide/ sulfur/urea Spinosad Spironolactone Stavudine Sucralfate Sulfacetamide eye drops, oint. Sulfacetamide sodium Sulfacetamide sodium/ prednisolone eye drops Sulfacetamide sodium/sulfur Sulfacetamide sodium/ sulfur/urea Sulfacetamide sodium/urea Sulfamethoxazole/ trimethoprim, DS Sulfasalazine Sumatriptan tab QL Taztia XT QL DO Terazosin Terbinafine tab PA Terconazole Tetracycline caps Theochron ER Theophylline ER, oral soln. Thioridazine PA Thiothixene PA Ticlopidine Timolol eye drops, gel Timolol tab Tizanidine Tobramycin eye drops Tobramycin/ dexamethasone eye drops Tolbutamide Topiramate PA Torsemide tab
Tramadol QL Trandolapril Tranexamic acid 650mg Tranylcypromine Trazodone Tretinoin cream, gel PA Triamcinolone cream, lotion, oint. Triamcinolone nasal spray QL Triamcinolone paste Triamterene/HCTZ Trifluoperazine PA Trihexyphenidyl Trimethobenzamide cap Trimethoprim Unithroid Valacyclovir Valproid acid cap, oral soln. Valsartan/HCTZ QL DO Venlafaxine Venlafaxine ER QL DO Verapamil tab, ER PM QL DO Verapamil tab, ER tab, cap Vicodin, ES, HP QL Warfarin Westhroid Zaleplon QL Zenatane PA Zenzedi 5mg, 10mg PA QL Zidovudine Ziprasidone PA Tier 2
Acamprosate Accu-Chek Product Line Acitretin Advair Diskus, HFA QL Anaspaz ODT Aptivus Asmanex Twisthaler QL Atripla Bethanechol tab Budesonide EC Buprenorphine syringe, vial Calcitonin nasal spray QL
Morphine sulfate ER QL Nitroglycerin spray Nitrostat Norvir Novolin Novolog Mix Olanzapine tab, ODT PA Ondansetron tab, ODT, oral soln. QL One Touch Product Line Oxandrolone PA Prezista Proair HFA QL Propafenone Prudoxin Pulmicort 1mg/2mL respules QL Pulmicort Flexhaler QL Qvar QL Relenza QL Rescriptor Reyataz Rivastigmine QL Selzentry Serevent Diskus QL Sorine Sotalol tab, AF tab Sulfadiazine Sumatriptan inj QL Sustiva Symbicort QL Tamiflu QL Tiagabine Tranexamic acid 1000mg/10mL Trizivir Truvada Vancomycin caps PA Viracept Viread PA Zenpep Zonisamide
Calcium acetate tab Cefpodoxime Cevimeline Cilostazol Clozapine, ODT PA Crixivan Danazol Dantrolene Demeclocycline Desipramine Dihydroergotamine nasal spray QL Dulera QL Edurant Eliphos Emtriva Entacapone Epipen, Jr. Epivir HBV soln. PA Epzicom Ergoloid Evista Fentanyl patch ST QL Flecainide Flovent HFA QL Flovent QL Fortical nasal spray QL Fuzeon Gabapentin Galantamine, ER QL Glucagen Humalog Humalog Mix Humulin N, R, 70-30 Intelence Invirase Isentress Itraconazole PA Kaletra Lantus Lantus Solostar Leflunomide Levemir Levemir Flexpen Levetiracetam Levetiracetam ER PA QL Levocarnitine tab, oral soln. Lexiva Mexiletine
Tier 3
Abilify tab PA Actonel ST QL Aczone Aggrenox QL Alamast PA Alinia Alocril PA QL 4
Alomide PA QL Altabax Amitiza Androgel PA QL Apriso ER Arestin Azilect Besivance Beyaz Biltricide Buphenyl tablet PA Campral† Cantil Cedax Cesamet ST Chemet Ciclodan kit Clindacin kit Coartem Colcrys PA QL Cuprimine Cystaran Daliresp QL Dapsone Daraprim Dibenzyline Edecrin Effient QL DO Elidel PA Ella Elmiron Ergomar Estring Femtrace Finacea Focalin XR PA QL Fosamax Plus D ST QL Generess Fe Lacrisert Lanoxin tab Lo Loestrin Fe Lo Minastrin Fe Lodosyn ST Loestrin 24 Fe Lotemax Lovaza Lumigan Maxair QL Methitest Migranal nasal spray† QL
Minastrin 24 FE Morgidox kit PA Motofen Moviprep Multaq Mycobutin Myrbetriq ST Namenda QL Natazia Niaspan ER Nuedexta Nuvaring Oracea Orap PA Ortho Evra Ortho Tri-cyclen Lo Osmoprep Oxsoralen-Ultra PA Panretin Pataday PA QL Patanol PA QL Peganone Phospholine iodide Pred-G Pred-G S.O.P Premarin cream Premarin tab Premphase Prempro Prevident 5000 Booster Plus Primaquine Prolia PA Protopic PA Proventil HFA QL Quartette Renvela PA Restasis Ridaura Rifater Rosadan kit Safyral Savella QL Silenor Soriatane† Spiriva QL Strattera PA QL Stromectol Suprax cap, tab, susp. Syprine
Tikosyn Transderm-Scop Travatan Z Trilipix† Tyzine Vagifem Ventolin HFA QL Veregen Vigamox PA Visicol Vivelle-Dot QL Voltaren gel Vyvanse PA QL Welchol Xopenex HFA QL Zirgan Zyvox tab, oral soln. PA QL Tier 4
Actemra PA Adcirca PA Adefovir Afinitor Disperz
Afinitor PA Alkeran tab Amevive PA Ampyra PA QL Anagrelide Anastrazole tab PA Apokyn PA Aranesp PA Avonex PA Avonex Pen PA Azathioprine tab Baraclude PA Bosulif PA Caprelsa PA Carbaglu PA CeeNU Cimzia PA QL Cometriq PA Cyclophosphamide tab Cyclosporine cap, soln. Droxia Emcyt PA Enbrel PA QL Enoxaparin PA
Erivedge PA Etopophos Etoposide caps Exemestane PA Extavia PA Fareston Flutamide Fondaparinux PA Forteo PA QL Gengraf Gilotrif Gleevec PA Hepsera† Hexalen Humira PA QL Hycamtin caps Hydroxyurea Iclusig PA Infergen Inlyta PA Intron A PA Jakafi PA Kalydeco PA QL Kineret PA
Kuvan PA Letairis PA Letrozole Leucovorin tab Leukeran Leuprolide PA Lomustine Lysodren Matulane Mekinist PA Melphalan Mercaptopurine Methotrexate tab Mycophenolate Myleran Neulasta PA QL Nexavar PA Nilandron Oforta Orencia PA QL Orfadin Pegasys PA QL Pegintron PA Pomalyst
Promacta PA Pulmozyme PA Rapamune Rebif PA Rebif Rebidose PA Reclast† Remicade PA Remodulin PA Revlimid PA QL Ribavirin PA Rituxan PA Sensipar Simponi Aria PA QL Simponi PA QL Sprycel PA Stivarga PA Sutent PA Tabloid Tafinlar Tamoxifen Tarceva PA Tasigna PA Temodar cap† PA Temozolomide cap PA
Tev-Tropin PA Thalomid PA Tobi Topotecan Trelstar Depot PA Trelstar PA Tretinoin 10mg capsule Tykerb PA Tysabri Tyzeka PA Vandetanib PA Ventavis PA Victrelis PA Votrient PA Xalkori PA Xeloda PA Xtandi PA Zelboraf PA Zoledronic Acid (generic Reclast) Zolinza PA Zytiga 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.
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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.
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Speech and hearing impaired (TDD/TTY users) should call 800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.
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For the most current version of this Selected Drug List, please visit anthem.com/ca.
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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. 40627CAMENABC Effective 1/14
