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Select Drug List

Subject to Regulatory Approval

4 Tier Formulary

40627NVMENABS Effective 1/15 Rev. 02/15 Anthem Blue Cross and Blue Shield Select Drug List Your benefit includes coverage for Q. What do I do if I am prescribed or currently taking a medicines that you’ll find on the Select Drug List. You can prescription drug that is not on the Anthem Select often find more savings when your doctor prescribes Drug List? medicine that is on our Select Drug List. Here are some A. If you are prescribed or currently taking a non commonly asked questions and answers about how the formulary drug, you should discuss formulary Select Drug List works with your prescription drug plan. alternatives your physician. If your physician feels that the medication is medically necessary, it will be Q. What is a Select Drug List? necessary to obtain Prior Authorization of Benefits in A. The Select Drug List, also called a formulary is a list of order for the prescription to be a covered benefit. U.S. Food and Drug Administration (FDA)-approved Information is available to you and your physician brand-name and generic drugs that have been reviewed through the Certificate or Evidence of Coverage, health and recommended for their quality and how well they plan web site and newsletters. You may also call work. The review is done by the National Pharmacy and customer service for more information. Therapeutics (P&T) Process. The P&T Process is performed by an independent group of practicing Q. Can I request that a drug be added to the doctors and pharmacists in charge of the research and Select Drug List? decisions surrounding our Select Drug List. This group A. You or your doctor can put in a request to add a drug to meets regularly to review new and existing drugs and the Select Drug List. You can do this either in writing or they choose the top drugs for our list—based on their on our website. Requests are reviewed by the P&T safety, how they work and their value. Process team during the Select Drug List review. Please Because the drugs on our list are reviewed from time to note that if a drug request is approved, it does not time, it’s a good idea to check the list to find out if any guarantee coverage. Some drugs, such as those used drugs have been added or removed. You can do this by for cosmetic purposes, may be excluded from your going to anthem.com. benefits. Please refer to your insurance Certificate or Evidence of Coverage to know for sure. Q. What are Tiers? A. Drugs on the Select Drug List are grouped into tiers. Q. What if my medication is not covered? There are several factors that are used to determine A. You may want to first check with your doctor about under which tier a drug will be put in. This can include prescribing a drug that is covered. If your doctor (but it’s not limited to): prescribes a drug that’s not covered, you will need to pay the out of pocket cost that applies to drugs not on }}Cost of the drug the formulary. }}Cost of the drug in comparison to other drugs used for the same type of treatment Preventive Care Drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable }}Availability of over-the-counter options Care Act (ACA). }}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, Please note: In selecting medications for the prescription other drug companies can make their own version of drug list, the therapeutic efficacy and cost effectiveness the drugs (see generic drugs below). You may be more are addressed for each category. All therapeutic familiar with brand-name drugs through advertising or categories are represented on the drug list by at least one because you know people who take them. medication. When a closed drug list is in effect, only Q. What is a generic drug? medications that are included on the drug list are a A. Generics are simply copies of brand-name drugs. covered service. In certain clinical situations, a member Brand-name and generic drugs have the same active may require use of a non-covered product. Anthem has ingredients, strength and dose. And the FDA requires criteria that permits a member to obtain a non-covered that generic drugs meet the same high standards for medication in a closed drug list plan. If specific criteria are purity, quality, safety and strength. met, a member can receive a non-covered drug for a drug list co-pay. The criteria preserves the clinical integrity of Q. Is this list a complete listing of all covered drugs the drug list and provides a process by which deviations under the Select Drug List? from the drug list may be allowed. An appeals process is in A. No. This piece lists the most commonly used drugs that place for any medications that do not meet the criteria. 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 F1 For more information Tier 1 Balsalazide Cefdinir Depade about your drug plan, Acarbose Benazepril Cefditoren Pivoxil Dermazene QL you can do the following: Acebutolol Benazepril/HCTZ Cefprozil Desloratadine, ODT Acetasol HC Benzonatate Cefuroxime Axetil Desmopressin nasal }}Go to anthem.com. Acetazolamide tab, ER Benzoyl peroxide Cephalexin spray, tab PA cap }}Call Customer Service at Benztropine Cetirizine QL Aclometasone the number on your ID card. gluconate Acticin dipropionate Chlorhexidine Rinse }} Speech and hearing Acyclovir tab, cap, oral Betamethasone valerate Chloroquine Dexamethasone tab, oral susp. soln. impaired users (TDD/TTY) Betaxolol Chlorothiazide tab Adapalene Dexchlorpheneramine should call 800-221-6915, Birth Control (generic tab PA Afeditab CR QL DO oral contraceptives) Dexmethylphenidate, ER Monday – Friday, 8:30 a.m. Chlorpropamide Albuterol inhl soln., syrup Bisoprolol PA QL – 5 p.m., ET. Chlorthalidone Alendronate QL Bisoprolol/HCTZ Dextroamphetamine, ER Chlorzoxazone PA QL Alfuzosin Brimonidine Cholestyramine tab, oral soln. tab Bromocriptine Ciclopirox Diclofenac eye drop Alprazolam tab Cimetidine tab, soln. Amantadine 0.25mg/2mL, Diclofenac, ER 0.5mg/2mL QL Ciprofloxacin ear and eye Dicloxacillin Bumetanide tab drops Dicylomine cap, tab, Amiloride tab QL Buprenorphine tab PA QL Ciprofloxacin tab syrup tab QL DO QL Citalopram Diflorasone Amiodarone tab PA TIER DEFINITIONS Bupropion SR, XL QL DO Claravis Diflunisal Buspirone Clarithromycin, ER Digoxin tab, oral soln. Tier 1 drugs have the lowest cost Amlodipine QL DO share. These drugs offer the greatest Butalbital/ 2.68mg Diltiazem Amlodipine/atorvastatin Clemastine syrup value compared to others that treat the QL DO acetaminophen Diltiazem ER, XR, CD Butalbital/ Clindamycin cap, QL DO same conditions. Amlodipine/benazepril acetaminophen/ oral soln, topical 50mg Tier 2 drugs have a medium cost Ammonium lactate Butalbital/ preparations cap , share. They may be preferred drugs, acetaminophen/ Clindamycin/Benzoyl Diphenoxylate/ Amnesteem PA based on their effectiveness and value. caffeine/codeine QL Peroxide tab Some are newer, more expensive Butalbital// Disopyramide generic drugs. Amoxicillin caffeine Disulfiram Tier 3 drugs have a higher cost Amoxicillin/clavulanate Butalbital/aspirin/ Clonazepam, ODT caffeine/codeine Divalproex, ER, DR share. They may cost more than others Amoxicillin/clavulanate Clonidine ER PA ER Butorphanol Donepezil 5mg, 10mg, used to treat the same condition. Tier 3 PA QL Clonidine tab ODT QL may also include drugs that were Amphetamine/ QL dextroamphetamine Cabergoline Dorzolamide eye drops recently approved by the FDA. Clotrimazole 1% cream, salts, ER PA QL Calcipotriene Dorzolamide/timolol eye troche drops Tier 4 specialty drugs have the Androxy PA Calcitriol cap, soln, oint Clotrimazole/ Doxazosin highest cost share. They may cost Antipyrine/benzocaine Candesartan QL DO betamethasone ear drop more than others used to treat the Candesartan/HCTZ QL DO Codeine sulfate tabs QL same condition. Tier 4 may also include Apraclonidine Doxycycline hyclate Captopril Codeine/acetaminophen drugs that were recently approved by tab, cap Atenolol Carbamazepine, ER, XR QL the FDA. Specialty drugs are used to Atenolol/chlorthalidone Doxycycline hyclate, Carbidopa/Levodopa, Codeine/butalbital/ delayed release PA treat complex, chronic conditions and Atorvastatin QL DO ER, ODT aspirin/caffeine may need special handling. Doxycycline monohydrate Atovaquone/proguanil Colestipol tab, cap Azelastine nasal spray, Carisoprodol tab Dylix drops QL Carteolol Covaryx, H.S. Econazole Azithromycin tab, susp., Cartia XT QL DO Cromolyn eye drops QL packet QL Enalapril Carvedilol Cromolyn neb soln. Bacitracin/polymixin B Enalapril/HCTZ Cefaclor, ER tab QL Baclofen Endocet Cefadroxil Endodan QL 2 F2 Epidrin cream, butyrate Levofloxacin tab QL Methylergonovine tab /polymixin/ Epinastine eye drops QL topical soln., oint., ear 0.1% cream, oint., soln. Levothroid Methylphenidate, CD, ER, eye drops drop Epitol Hydrocortisone Levothyroxine tab SR PA QL Neomycin/polymixin/ hydrocortisone ear and Eprosartan PA QL Hydrocortisone valerate Levoxyl tab eye 0.2% cream, ointment eye drops Ergocalciferol (Vit D2) viscous soln. Metipranolol eye drops drops Hydrocortisone/acetic Niacin ER caps Lidocaine/hydrocortisone Metoclopramide tab, oral Fluorouracil cream, acid ear drops soln. Nicardipine caps Ergotamine/caffeine topical 3/0.5% cream Hydrocortisone/ Metolazone Nifedipine cap Ery-Tab 250mg, 333mg Fluoxetine, DR (except pramoxine cream, Lidocaine/prilocaine tab Metoprolol tab, ER Nifedipine tab ER, XL 60mg) QL DO ointment Lindane QL DO Erythromcyin eye oint. Metoprolol/HCTZ Fluphenazine tab, oral Hydromorphone Liothyronine tab Nisoldipine ER QL DO Erythromycin 2% gel, soln. PA Lisinopril Metronidazole 0.75% gel topical solution Nitro-Bid oint. Flurbiprofen eye drop Hydromorphone tab, oral Lisinopril/HCTZ Metronidazole tab, Erythromycin QL , cream, lotion Nitrofurantoin Flurbiprofen tab soln. Lithium carbonate, ER ethylsuccinate 400mg Hydroxychloroquine 200mg Nitroglycerin, ER, SR Filmtab Fluticasone nasal spray Lithium citrate oral soln. QL vaginal suppository Nizatidine Hydroxyzine HCL tab, Lonox Erythromycin Filmtab, oral soln. Minocycline Norethindrone 250mg cap Fluticasone topical Losartan QL DO QL DO Hydroxyzine pamoate Minocycline ER PA Erythromycin stearate Fluvastatin Losartan/HCTZ QL DO QL DO Ibandronate ST QL Minoxidil tab NP Thyroid Erythromycin/benzoyl Fluvoxamine Lovastatin QL DO Ibuprofen cream, oint., peroxide gel Folic acid 1mg PA HCL tab Misoprostol PA , tab Erythromycin/ Fosinopril Malathion sulfisoxazole Imiquimod PA QL Modafinil PA QL Nystatin/ Fosinopril/HCTZ Escitalopram QL DO Indapamide Moexipril Ofloxacin ear and eye Furosemide tab, oral soln. Matzim LA QL DO drops patch QL Indomethacin , ER cap Moexipril/HCTZ Garamycin eye drops Ofloxacin tab QL Mebendazole cream, oint, Estradiol tab Gatifloxacin eye drops neb QL soln. QL tab topical soln. Omeprazole caps Estrogen/ Gemfibrozil methyltestosterone Irbesartan QL DO Meclofenamate cap Montelukast QL ER Gentamycin eye drops, Estropipate Irbesartan/HCTZ QL DO Medroxyprogesterone Morphine sulfate IR Oxaprozin oint. tab QL Ethambutol Isometheptene/ tab Oxcarbazepine Glimepiride Mefenamic acid Ethosuximide acetaminophen/caffeine Morphine sulfate oral , ER Glipizide, ER, XL Mefloquine soln. QL QL Etodolac, ER Isometheptene/ Oxycodone Glipizide/metformin acetaminophen/ Meloxicam oral Morphine sulfate Eszopiclone PA QL Oxycodone/ Glyburide dichloralphenazone supppository acetaminophen tab, Famciclovir Glyburide, micronized Isonarif Meloxicam tab QL Mupirocin oint. cap QL Famotidine tab, oral soln. Glyburide/metformin Isoniazid tab, oral soln. Meperidine tab, oral Nabumetone Oxycodone/aspirin QL QL Felbamate Griseofulvin Isosorbide dinitrate, soln. Nadolol Oxymorphone QL Felodipine ER Guaifenesin/codeine ER tab Meprobamate QL Nadolol/ Oxymorphone ER QL Fenofibrate syrup Isosorbide mononitrate, Metadate ER PA QL bendroflumethiazide Pacerone Fenofibric acid, DR Guanfacine ER Metaproterenol Naltrexone Pancrelipase, DR Fenoprofen Guanidine Isradipine Metaxalone Naphazoline eye drops Paramomycin Fentanyl citrate lozenge Halac Metformin, ER Naproxen, DR QL DO PA QL , CR, ER Halobetasol propionate Ketoprofen, ER Methadone tab, oral Naratriptan QL Penicillin VK Finasteride 5mg tab PA PA QL Haloperidol tab eye drops soln. Nature-Throid , ER QL PA QL Hydralazine tab Ketorolac tab Methamphetamine Nefazodone Perindopril Fluconazole tab, oral Hydrochlorothiazide Klor-Con tab Methanamine MD Neomycin tab soln. Permethrin cream Hydrocodone/ Labetolol tab Methazolamide Neomycin/polymixin/ Perphenazine PA Flucytosine acetaminophen QL bacitracin eye oint. Lactulose Methimazole Phenazopyridine Hydrocortisone tab Lamotrigine tab Methocarbamol Neomycin/polymixin/ Phenelzine nasal spray Hydrocortisone 2.5% (immediate release) Methscopolamine bacitracin/ ST QL cream, lotion, oint. QL hydrocortisone eye oint. Phenobarbital tab, oral Lansoprazole, DR bromide soln. Fluocinolone body oil, Hydrocortisone acetate Latanoprost Methyclothiazide Neomycin/polymixin/ scalp oil PA 2% gel dexamethasone eye Phenytoin ext. cap Levobunolol eye drops Methyldopa drops, oint. eye drops Hydrocortisone acetate Levocetirizine QL Methyldopa/HCTZ suppository Pindolol

3 F3 Pioglitazone QL Ranitidine oral soln. caps Gabapentin Sulfadiazine Piroxicam Rifampin Theochron ER Westhroid Galantamine, ER QL Sumatriptan inj QL Podofilox Rimantadine ER, oral Zafirlukast Glucagen Symbicort QL Polymixin/trimethoprim Risperidone, ODT, oral soln. Zaleplon ST QL Granisetron tab QL Tamiflu QL eye drops soln. PA PA Ziprasidone PA Humalog Tiagabine PA Potassium 25mEq tab Rizatriptan, ODT QL Thiothixene PA Zolmitriptan QL Humalog Mix Tranexamic acid effervescent Ropinirole, ER Ticlopidine Zolpidem (immediate Humulin N, R, 70-30 1000mg/10mL Potassium chloride ER Roxicet tab, caplet QL Timolol eye drops, gel release) QL ST QL ER ST tab, ER cap Hydromorphone ER Selegiline Timolol tab PA Ursodiol Potassium Citrate ER Tab Itraconazole Selenium sulfide 2.5% Tier 2 Ketorolac inj. QL Valcyte 450mg Potassium citrate/citric lotion, PA acid Tobramycin eye drops Acamprosate Lantus Vancomycin caps Sertraline QL DO PA Pramipexole Tobramycin/ Accu-Chek Products Lantus Solostar Voriconazole Silver sulfadiazine cream dexamethasone eye Pravastatin QL DO Acitretin Levalbuterol neb soln. Zonisamide Simvastatin QL DO drops Advair Diskus, HFA QL Levemir Prazosin PA Tolazamide Simvastatin 80mg Anaspaz ODT Tier 3 QL DO Tolbutamide Levetiracetam Asmanex Twisthaler QL PA QL Abilify tab PA eye drops Sodium polystyrene Tolmetin Levetiracetam ER Atovaquone PA Actonel ST QL Prednisolone oral soln. sulfate 30gm/120ml Levocarnitine tab, oral enema tab soln. Aczone Topiramate PA Sodium polystyrene Bromfenac eye drops Levorphanol tab QL Aggrenox QL Prenatal Vitamins (all Torsemide tab generic covered) sulfate powder Budesonide EC Mafenide Acetate Alamast PA , ER tab QL Primidone Sodium polystyrene Buprenorphine , Methenamine hippurate Albenza sulfonate Trandolapril Probenecid vial Mexiletine Alinia Sodium sulfacetamide/ Tranexamic acid 650mg QL Probenecid/colchicine Calcitonin Morphine sulfate ER QL Alocril PA QL sulfur Tranylcypromine Procentra QL acetate tab Nateglinide PA Alomide PA QL Sodium sulfacetamide/ Trazodone Carbidopa ST Nimodipine Prochlorperazine tab sulfur/urea PA Altabax Tretinoin cream, gel Cefpodoxime , micronized Spinosad Nitroglycerin spray Amitiza cap Triamcinolone cream, Ceftibuten Spironolactone lotion, oint. Nitrostat Anadrol-50 tab, PA QL Sucralfate Triamcinolone nasal Novolin N Androgel suppository, syrup Sulfacetamide eye drops, spray QL Novolog Antivert 50mg Promethazine VC syrup PA oint. Triamcinolone , ODT tab, ODT PA Anzemet tablet QL Promethazine VC syrup Sulfacetamide sodium Triamterene/HCTZ Ondansetron tab, ODT, Apriso ER with codeine QL Sulfacetamide sodium/ Trifluoperazine PA Dantrolene oral soln. Arcapta Neohaler QL Promethazine/codeine prednisolone eye drops Demeclocycline One Touch Product Line syrup Trifluridine eye drops Arestin Sulfacetamide sodium/ Oxandrolone PA Promethazine-DM syrup Avandia ST QL sulfur Diclofenac Sodium Gel Pantoprazole QL Propranolol ER Trimethobenzamide cap Avodart Sulfacetamide sodium/ PA QL Paricalcitol Propranolol HCTZ Trimethoprim Axert ST QL sulfur/urea Doxercalciferol caps Pilocarpine tabs Propranolol tab, oral soln. Azelex PA Sulfacetamide sodium/ Dronabinol Proair HFA ST QL Propylthiouracil urea Tropicamide eye drops Azilect Dulera QL Propafenone Sulfamethoxazole/ Unithroid Azopt Duloxetine PA QL DO trimethoprim, DS Valacyclovir Prudoxin Bactocill Pyrazinamide Eliphos Sulfasalazine Valproid acid cap, oral Pulmicort 1mg/2mL Banzel QL Pyridostigmine Entacapone respules QL PA Sulindac soln. Benicar PA QL DO Epipen, Jr. Pulmicort Flexhaler QL Sumatriptan tab QL Valsartan QL DO Bepreve PA QL Quinapril Eplerenone Qvar QL Tamsulosin Valsartan/HCTZ QL DO Besivance Quinapril/HCTZ Ergoloid Rabeprazole QL Taztia XT QL DO Venlafaxine Beyaz ST sulfate, ER Etidronate Relenza QL PA QL Telmisartan QL DO Venlafaxine, ER QL DO Biltricide Quinine sulfate Fentanyl patch ST QL Repaglinide PA Terazosin Verapamil tab, ER PM Brilinta QL Raloxifene QL DO Flecainide Rifabutin Terbinafine tab PA Brovana QL Ramipril Flovent QL Rivastigmine QL Terbutaline tab Verapamil tab, ER tab, Buphenyl tablet PA Ranitidine 150, 300mg cap Flovent HFA QL Serevent Diskus QL tab, cap Terconazole Butrans QL Vicodin, ES, HP QL Fortical nasal spray QL Sotalol tab, AF tab 4 F4 Bydureon ST QL Exelderm Noroxin QL Renvela PA Viibryd ST Didanosine DR Bystolic Factive QL Noxafil Restasis Vimpat QL Droxia Cantil Fanapt PA Nucynta, ER QL Rifater Visicol Edurant Celebrex ST QL Finacea Nuedexta Rosadan Vivelle-Dot PA QL Emcyt PA Celontin Flector ST Nuvaring Rozerem ST QL Voltaren gel Emtriva Cenestin Fluoridex Nuvigil PA QL Sabril Vyvanse PA QL Enbrel PA QL Cesamet PA Fluoroplex Omnaris ST QL Safyral ST Welchol Enoxaparin PA Chantix PA QL Fosamax Plus D ST QL Onglyza ST QL Samsca PA Xarelto PA QL Epivir HBV soln. PA Chemet Fosrenol PA Oracea Sancuso Xenazine PA Epzicom Cialis 2.5mg, 5mg PA Frova ST QL Orap PA Santyl Xifaxan PA QL Erivedge PA Ciclodan Generess Fe Ortho Tri-cyclen Lo Saphris PA Xopenex HFA ST QL Etoposide caps Cipro HC ear drops Glyset Osmoprep Savella QL Xyrem PA Exemestane PA Ciprodex ear drops PA Gynazole 1 Oxistat Scopace Zetia PA QL Exjade PA Clindacin Halog Oxsoralen-Ultra PA Seroquel XR PA Ziana ST Extavia ST Cloderm Horizant PA Oxycontin ST QL Silenor ST Zioptan Fareston Coartem Intuniv ER PA Panretin Skelid Zipsor Ferriprox PA Colcrys PA QL Invega tab PA Paser Spiriva QL Zirgan Flutamide Coly-Mycin ear drops Janumet, XR QL Pataday PA QL Strattera PA QL Zyflo, CR PA PA Combigan Januvia ST QL Patanase QL Stromectol Zyvox tab, oral soln. Forteo PA Cordran, SP Kapvay PA Patanol PA QL Suprax tab, susp. PA QL Fragmin PA Cortisporin cream, oint. Ketek Peganone Symlin PA Fuzeon Crestor ST QL DO Lacrisert Perforomist QL Synera Tier 4 Gengraf Cuprimine Lanoxin tab Phisohex Syprine Abacavir Gilenya PA QL Cycloset Latuda PA Phospholine iodide Taclonex scalp Adagen Gleevec PA Daliresp QL Levatol Picato PA QL suspension Adcirca PA Hexalen Dapsone Livalo ST QL DO Potiga QL Taclonex suspension Adefovir Dipivoxil Humira PA QL Daraprim Lo Loestrin Fe Pradaxa QL Tasmar Afinitor PA Hycamtin caps Denavir Lotemax Pred-G Tazorac PA Aldurazyme PA Hydroxyurea Dexilant ST QL Lotronex PA Pred-G S.O.P Tekturna QL DO Alkeran tab Iclusig PA Dibenzyline Lufyllin Premarin Cream Teveten 400mg QL Amevive PA Incivek PA Differin 0.1% lotion Lumigan Premarin tab ST Thyrolar Ampyra PA QL Infergen PA Dificid PA Lyrica PA QL Premphase Tikosyn Anagrelide Inlyta PA Dipentum Marplan Prempro Tobradex eye oint. Anastrazole tab PA Innohep PA Durezol QL Maxair QL Prevident 5000 Booster Toviaz ER ST Apokyn PA Intelence Dyrenium Menest Plus Tradjenta ST QL Aptivus Intron A PA Edarbi QL DO Mentax Priftin Transderm-Scop PA Aranesp PA Invirase Edecrin Methitest Primaquine Travatan Z tab Iressa Elidel PA Migranal nasal spray† QL Primsol Trecator Bicalutamide Isentress Ella Morgidox PA Pristiq QL DO Tyzine Bosulif PA Jakafi PA Elmiron Motofen Proglycem Ulesfia Capecitabine PA Kaletra Emadine PA QL Moviprep Prolia PA Uloric ST Caprelsa PA Kineret PA Emend caps QL Multaq Proquin XR Vagifem Carbaglu PA Kuvan PA Emsam QL Myrbetriq ST Protopic PA Valcyte 50mg/mL CeeNU Lamuvidine solution Enablex ST Mytelase Proventil HFA ST QL Cimzia PA QL Lamuvidine/zidovudine Ventolin HFA ST QL Enjuvia Naftin cream, 1% gel Ranexa Cometriq PA Letairis PA Veregen Epiduo Namenda QL Rapaflo Crixivan Letrozole Vesicare ST Ergomar Natacyn Rectiv Cyclophosphamide tab Leucovorin tab Vexol Ertaczo Natazia ST Regranex PA Cyclosporine Leukeran Victoza ST QL Estring Nevanac Relistor PA Cyclosporine cap, soln. Leuprolide PA Vigamox PA Eurax Nexium PA QL Relpax ST QL Cystagon Lexiva

5 F5 Lysodren Rebif PA Tamoxifen VPRIV PA Matulane Remicade PA Tarceva PA Xalkori PA Mercaptopurine Remodulin PA Targretin PA Xtandi PA tab Rescriptor Tasigna PA Zavesca PA Mycophenolate Revlimid PA QL Temozolomide cap PA Zelboraf PA Reyataz Tev-Tropin PA Zidovudine Myleran Ribavirin PA Thalomid PA Zoledronic Acid Nebupent Riluzole Torisel Zolinza PA Neulasta PA QL Rituxan PA Tracleer Zortress PA Neupogen PA Selzentry Trelstar PA Zytiga PA Nevirapine Sensipar Trelstar Depot PA Nexavar PA Simponi PA QL Tretinoin 10mg capsule Nilandron Sildenafil 20mg tab PA Trizivir Norvir Sirolimus Truvada Oforta PA Somatuline Tykerb PA Omontys PA Sprycel PA Tysabri Orfadin Stavudine Tyzeka PA Pegasys PA QL Stivarga PA Vandetanib PA Pegintron PA Sustiva Ventavis PA Pomalyst Sutent PA Victrelis PA Prezista Synarel PA Viracept Procrit PA Tabloid Viread PA Promacta QL DO Tacrolimus Votrient 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.

6 F6 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 Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. 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.

40627NVMENABS Effective 1/15

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