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Prescription Program Prescription Program To be used by California National Accounts and a few select Local Group accounts. Please contact your pharmacy account manager for details. Anthem Blue Cross 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. MBCEBRO-10-CA Effective 07/13 ANTHEM BLUE CROSS DRUG LIST For more information about Q. What is a Drug List? 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/CA 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 ID card 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 their value. (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. – do this by going to anthem.com/CA. 5:00 p.m., ET Q. What is a brand-name drug? • 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 coverage? KEY A. When drugs are compared in studies, some drugs have been found to be First letter is lower-case – A generic just as effective as others. These drugs are called “clinically equivalent” so it drug that has the lowest copay. means they work just as well. Part of the P&T Process is to review the most Example: levora. current studies to see if multiple drugs used to treat a disease or a condition First letter is a capital – A brand- have the same effect on a patient. When this is the case, the Process review name drug that has a middle copay. team may suggest that we cover only the lower cost drug (so we can help Example: Levothroid®. keep the overall cost of care as low as possible). This means your specific † – A generic version of this drug drug plan may not cover some drugs (indicated by a ^ symbol next to the recently became available or will drug name) that have clinically equivalent options. be available soon. After the generic drug becomes available and the Q. What if my medication is not on the drug list? people affected are given notice, A. You may want to first check with your doctor about prescribing a drug that is this brand-name drug will no longer be on our drug list. It will either on the drug list. If your doctor prescribes a drug that’s not on the drug list, become a Tier 3 drug in your plan you will need to pay the copayment that applies to drugs that are not on the list. or it may no longer be covered. Q. Can I request that a drug be added to the drug list? * – Brand-name versions of these drugs A. You or your doctor can put in a request to add a drug to the drug list. You can are not on our list (these drugs have the highest copay). do this either in writing or on our website. Requests are reviewed by the P&T Process team during the drug list review. Please note that if a drug request is ^ – This drug has clinically equivalent approved, it does not guarantee coverage. Some drugs, such as those used options that are included on the drug list. Because there are these for cosmetic purposes, may be excluded from your benefits. Please refer to options, the drug may not be your insurance Certificate or Evidence of Coverage to know for sure. covered. 1 Drugs are listed alphabetically by brand name A Amaryl (glimepiride)* Ativan (lorazepam)* Buspar (buspirone)* Cosopt (dorzolamide/ Desquam, E, X (benzoyl Ambien, CR (zolpidem, ER)* Atrovent HFA Bydureon timolol)* peroxide)* A/T/S Topical Solution Amerge (naratriptan)* Atrovent (ipatropium Coumadin (warfarin) Desyrel (trazodone)* (erythromycin)* Amevive* bromide)* C Cozaar (losartan)* Detrol (tolterodine)* Abilify Amicar 500mg Augmentin, XR Creon Detrol LA Acanya Caduet (amlodipine/ (aminocaproic acid)* (amoxicillin/clavulanic atorvastatin)* Crestor Dexedrine, CR Accolate (zafirlukast)* Amitiza acid)* Cafergot Crixivan (dextroamphetamine)* Accu-Check product line amitriptyline Auralgan (antipyrine/ Canasa Crolom (cromolyn sodium)* Dextrostat Accutane (isotretinoin)* amitriptyline/perphenazine benzocaine)* Carbatrol Cuprimine (dextroamphetamine)* Aceon (perindopril)* Amoxil (amoxicillin)* Avapro (irbesartan)* (carbamazepine ER) Cyclocort (amcinonide)* Diabeta (glyburide)* Aci-Jel Jelly (acetic acid Anafranil (clomipramine)* Avalide (irbesartan/HCTZ)* Cardizem, CD, LA, SR Cyclogyl (cyclopentolate)* Diamox (acetazolamide)* vaginal)* Analpram HC lotion Avodart (diltiazem)* Cylert (pemoline)* Diastat (diazepam gel) Actigall (ursodiol)* Anaprox, DS (naproxen Axid (nizatidine)* Casodex (bicalutamide)* Cymbalta Dibenzyline Activella (estradiol/ sodium, DS)* Axiron Catapres, TTS (clonidine)* cyproheptadine Differin (adapalene)* norethindrone)* Ancobon (flucytosine)* Aygestin (norethindrone)* Clarinex^ Cytomel (liothyronine)* Differin 0.1% lotion Actonel Androgel Azasan (desloratadine)* Cytotec (misoprostol)* Differin 0.3% gel ActoPlus Met Anexsia (hydrocodone/ AzaSite Cleocin (clindamycin)* Cytovene (ganciclovir)* Diflucan (fluconazole)* (pioglitazone/ Azilect metformin)* APAP)* Clobex shampoo, lotion Cytoxan diflunisal Azopt (clobetasol)* (cyclophosphamide)* ActoPlus Met XR Ansaid (flurbiprofen)* Dilacor XR (diltiazem CR)* Azulfidine, Entabs Colazol Actos (pioglitazone)* Antabuse (disulfiram)* Cytra-2, Cytra-3 Dilantin (phenytoin) (sulfasalazine, EC)* Colcrys Acular, LS (ketorolac)* Antara (fenofibrate)* Cytra-K Dilaudid (hydromorphone)* Colyte (polyethylene Akne-Mycin Antivert (meclizine)* diltia XT Anturane (sulfinpyrazone)* B glycol-electrolyte D Diovan† Adalat CC (nifedipine ER)* solution)* Anusol HC 25mg Bactrim DS Dalmane (flurazepam)* Diovan HCT (valsartan/ Adderall (amphetamine/ Combigan Suppositories (Sulfamethoxazole/ Danocrine (danazol)* HCTZ)* dextroamphetamine)* CombiPatch Adderall XR (hydrocortisone)* trimethoprim, DS)* Dantrium (dantrolene)* Diprolene Ointment Apresazide (hydralazine/ Bactroban cream, oint. Combipres (clonidine/ (betamet diprop/prop gyl)* (amphetamine/ chlorthalidone)* Dapsone dextroamphetamine^#) HCTZ)* (mupirocin)* Diprosone Combivent, Respimat Daraprim Adoxa (doxycycline Apresoline (hydralazine)* Bactroban nasal oint. Daypro (oxaprozin)* (betamethasone monohydrate)* apri Baraclude Combivir (lamivudine/ dipropionate)* zidovudine)* DDAVP (desmopressin Advair Apriso Benadryl Disalcid (salsalate)* Compazine Supp 25mg acetate)* Advicor† Arava (leflunomide)* (diphenhydramine Decadron Ditropan (oxybutynin)* Aricept (donepezil 5, 50mg)* (prochlorperazine supp Dolophine (methadone)* Agenerase 25mg)* (dexamethasone)* Akne-Mycin 10mg)* Bentyl (dicyclomine)* Deconamine S.R. Domeboro (acetic acid/ Aricept 23mg Compazine Tab aluminum acetate)* Albalon (naphazoline)* Benzac, AC, W (benzoyl (prochlorperazine)* (chlorpheniramine/ Arimidex (anastrozole)* peroxide)* Donnatal (belladonna/ Aldactazide Comtan (entacapone)* pseudoephedrine)* (spironolactone/HCTZ)* Aristocort Topical Benzaclin (benxoyl Delzicol† phenobarbital)* (triamcinolone- Concerta Doryx (doxycycline DR)* Aldactone peroxide/clindamycin)* (methylphenidate ER)* Demadex (torsemide)* (spironolactone)* acetonide)* Benzagel, Wash (benzoyl Demerol (meperidine)* Dostinex (cabergoline)* Arixtra (fondaparinux)* Condylox Solution Aldara (imiquimod)* peroxide)* (podofilox solution)* Demulen 28 day (ethinyl Dovonex (calcipotriene)* Armour Thyroid (thyroid) Aldomet (methyldopa)* Benzamycin (benzoyl Cordarone (amiodarone)* estradiol/ethynodiol Duac (clindamycin/ peroxide/erythromycin)* Aldoril (methyldopa/ Aromasin (exemestane)* Coreg (carvedilol)* diacetate-zovia)* benzoyl peroxide gel)* Betagan (levobunolol)* HCTZ)* Artane (trihexyphenidyl)* Coreg CR Depakene (valproic acid)* Duetact (pioglitazone/ glimepiride)* Alesse (aviane)* Arthrotec (diclofenac/ Betoptic S Corgard (nadolol)* Depakote (divalproex) misoprostol)* Alkeran Biaxin, XL (clarithromycin, Cortef (hydrocortisone)* Depakote ER Dulera Asacol†, HD er)* Allegra^ (fexofenadine)* Cortenema Depo-Provera 150mg Duragesic (fentanyl)* Allegra D^ Asendin (amoxapine)* Bicitra (sodium citrate & (hydrocortisone (medroxyprogesterone)* Duratuss G (guaifenesin (fexofenadine/PSE)* Asmanex citric acid)* enema)* Derma-Smoothe/FS SR)* Alphagan, P Astelin (azelastine)* BiDil Cortisporin Ophth (fluocinolone)*
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