sign in sign up
<<
Home , Tretinoin

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 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 ? 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)* ()* 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 ()* 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 ()* Cymbalta Dibenzyline Activella (/ sodium, DS)* Axiron Catapres, TTS (clonidine)* cyproheptadine Differin ()* 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 ()* Cytovene (ganciclovir)* Diflucan (fluconazole)* (pioglitazone/ Azilect metformin)* APAP)* Clobex shampoo, lotion Cytoxan diflunisal Azopt (clobetasol)* ()* 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)* dextroamphetamine^#) HCTZ)* (mupirocin)* Diprosone Combivent, Respimat Daraprim Adoxa ( 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)* (/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)* 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)* Durezol (brimonidine)* Astepro Bleph-10 (- (bacitracin - polymyxin/ Dermotic (fluocinolone)* Duricef Caps/Tabs Alphagan P 0.1% Atacand (candesartan)* sodium solution)* neomycin- hc ophth Desogen (apri)* (cefadroxil)* Altace (ramipril)* Atacand HCT Boniva (ibandronate)* oint)* Desowen Cream Dyazide (triamterene/ Altabax (candesartan/HCTZ)* Brethine (terbutaline)* Cortisporin Otic (desonide)* HCTZ)* Alupent Atarax (hydroxyzine Brilinta QL (neomycin/polymixin/ Desoxyn Dynacin ()* (metaproterenol)* HCL)* Bumex (bumetanide)* hydrocortisone)* (methamphetamine)* Dynapen (dicloxacillin)* 2 Gleevec Indocin, SR Lamictal tabs Lortab (hydrocodone/ E F Glucagon (indomethacin, SR)* (lamotrigine) apap)* E.E.S. (erythromycin Famvir (famciclovir)* Glucophage (metformin)* Inflamase Mild, Forte Lamictal XR LoSeasonique ethylsuccinate)* Fansidar Glucophage XR (prednisolone)* (lamotrigine ER)* (amethia lo)* EC-Naprosyn (naproxen EC)* Fast Take Product Line (metformin ER)* Intal Inhaler Lamisil tablet (terbinafine)* Lotemax solution, ointment Econopred Plus 1% Eye FazaClo ODT (clozapine Glucotrol XL (glipizide XL)* Intal Solution (cromolyn)* Lanoxin Lotensin (benazepril)* Drops (prednisolone)* odt) Glucovance (glyburide/ Invirase Lanoxicaps Lotensin HCT Edurant Felbatol (felbamate) metformin)* ISMO (isosorbide Lantus (benazepril HCTZ)* Effexor (velafaxine)* Feldene (piroxicam)* Glynase PresTab mononitrate)* Lariam (mefloquine)* Lotrel (amlodipine/ Effexor XR (velafaxine ER)* Femara (letrozole)* (glyburide micronized)* isoniazid Lasix (furosemide)* benazepril)* Effient Fem HRT 0.5/2.5 Glyset Isoptin, SR (verapamil, SR)* leflunimide Lotrisone (clotrimazole/ Efudex ()* Fem HRT (Jinteli 1-5)* Golytely Solution (PEG– Isopto Atropine (atropine Lescol (fluvastatin)* betamethasone)* Eldepryl (selegiline)* Fencom Fe (Zeosa)* electrolyte for solution)* sulfate)* leucovorin Lovaza Elestat^ (epinastine)* Femtrace Granulex (trypsin/balsam Isopto Carpine Leukeran Lovenox (enoxaparin)* Elidel Fexmid (cyclobenzaprine)* peru/castor oil)* (pilocarpine HCl)* Leukine Loxitane (loxapine)* Elimite (permethrin)* Fibricor (fenofibric acid)* Grifulvin (griseofulvin)* Isopto Homatropine Levaquin (levofloxacin)* Lozol (indapamide)* Eliquis Finacea Gris-PEG (griseofulvin)* (homatropine)* Levbid (hyoscyamine)* Lufyllin (dyphylline)* Elixophyllin (theophylline Fioricet (APAP/caffeine/ Gynodiol (estradiol)* isosorbide dinitrate Levemir Lupron (leuprolide)* syrup)* butalbital)* Jalyn Levlen (levonorgestrel & Lumigan Elocon (mometasone)* Fiorinal (/caffeine/ H Janumet, XR ethinyl estradiol)* Luride (sodium flouride)* Emcyt butalbital)* Halcion (triazolam)* Januvia Levo-Dromoran Luvox CR (fluvoxamine Empirin w/Cod (asa/ Fiorinal w/Codeine Halflytely Jentadueto (levorphanol tartrate)* ER)* codeine)* (butalbital compound haloperidol Juvisync levora Luxiq (betamethasone Emtriva w/codeine)* Histussin HC Levothroid valerate)* Endal HD (phenyleph hcl/ Flagyl (metronidazole)* (phenyleph/chlorphen/ K Levoxyl hydrocod bit/cp)* Flexeril (cyclobenzaprine)* hydrocodone)* K-Lor (potassium chloride Levsin (hyoscyamine)* M Flomax (tamsulosin)* Entex PSE (guaifenesin/ Humalog 20mEq)* Levsinex (hyoscyamine)* Macrobid (nitrofurantoin Flonase (fluticasone)* pseudoephedrine)* Humibid DM K-Lyte CL (potassium Lexapro (escitalopram)* mono)* Florinef (fludrocortisone)* Entocort EC (dextromethorphan/ bicar/chloride 25mEq) Lexiva Macrodantin (budesonide EC)* Flovent HFA guaifenesin)* K-Phos Lialda (nitrofurantoin)* Epifrin (epinephrine HCl)* Floxin Otic (ofloxacin)* Humibid LA (guaifenesin)* K-Phos Neutral Librium (chlordiazepoxide)* Malarone (atovaquone- Epipen, JR Floxin tablet (ofloxacin)* Humulin R, N, 50/50, (phospha 250)* Lidex, E (fluocinonide)* proguanil)* Epivir (lamivudine)* Fluoroplex 70/30 K-Tab (potassium chloride Lidoderm† Marinol (dronabinol)* Epivir HBV fluvoxamine Hycodan Syrup sr)* Limbitrol DS Materna (multi- Eryc (erythromycin base)* FML Liquifilm (hydrocodone w/ Kadian (morphine sulfate (amitriptyline/ w/folic acid)* Erycette 2% Pledgets (fluorometholone)* homatropine)* ER 20, 30, 50, 60, 80, chlordiazepoxide)* Matulane (erythromycin)* Fortamet ER (metformin Hydrea (hydroxyurea)* 100 mg)* Linzess Mavik (trandolapril)* ER)* Eryderm 2% Topical hydrochlorothiazide Kaletra Lioresal (baclofen)* Maxalt (rizatriptan)* (folic acid)* Solution (erythromycin)* Hytone (hydrocortisone Kayexalate (sodium Lipitor^ (atorvastatin)* Maxalt MLT Foradil Erymax 2% Topical 2.5% cream, ointment, polystyrene sulfonate)* Lithobid (lithium)* (rizatriptan odt)* Fosamax (alendronate)* lotion)* Solution (erythromycin)* Keflex (cephalexin)* Lo/Ovral (low-ogestrel)* Maxitrol (neomycin/ EryPed 200 Susp Fosamax Solution Hytrin (terazosin)* Kenalog in Orabase Lodine (etodolac)* polymyxin/ (erythromycin Furadantin Hyzaar (losartan/hctz)* (triamcinolone Lodine XL (etodolac ER)* dexamethasone)* ethylsuccinate)* (nitrofurantoin)* acetonide)* Loestrin FE (microgestin Maxzide (triamterene/ Esgic (acetaminophen/ Furoxone I, J Keppra (levetiracetam) 1-20, 1.5/30)* HCTZ)* caffeine/butalb)* Fuzeon Ilotycin (erythromycin)* Keppra XR Lomotil (diphenoxylate/ Mebaral Eskalith, CR (lithium)* Imdur (isosorbide (levetiracetam R) atropine sulfate) (mephobarbital)* Estrace (estradiol)* G mononitrate)* Kerlone (betaxolol)* Loniten ()* Meclomen Estring Gabitril (tiagabine) Imitrex (sumatriptan Klonopin (clonazepam)* Lopid (gemfibrozil)* (meclofenamate)* Ethmozine Gantrisin nasal, tab & inj)* Klor-con 25meq Lopressor (metoprolol)* Medrol 2mg Eulexin ()* Garamycin (gentamicin)* Imodium (loperamide)* (potassium chloride)* Lopressor HCT Medrol 4mg, 8mg, Evamist Gastrocrom (cromolyn)* Imuran (azathioprine)* Kuzyme (metoprolol/HCTZ)* 16mg, 32mg Evista Gel-Kam Gel (stannous Inderal (propranolol)* Kytril (granisetron)* Loprox gel (ciclopirox)* (methylprednisolone)* Evoxac (cevimeline)* fluoride)* Inderal LA Loprox Shampoo Megace (megestrol)* Exelon (rivastgmine)* Geodon capsules (propranolol la)* L (ciclopirox)* Mellaril (thioridazine)* Exforge, HCT (ziprasidone)* Inderide (propranolol/ Lamictal chewables 5 & Lorcet (hydrocodone/ Menest meperidine Extina (ketoconazole)* Geodon inj HCTZ)* 25mg (lamotrigine) apap)* w/promethazine 3 Mephyton Mycostatin (nystatin)* Nizoral (ketoconazole)* Poly-Vi-Flor (multi- Profasi 10,000 (chorionic Mepron Mydriacyl (tropicamide)* Noctec (chloral hydrate)* P vitamins w/fluoride)* gonadotropin)* Mestinon timespan Myleran Nolvadex (tamoxifen)* Pamelor (nortriptyline)* Polycitra (potassium Prograf (tacrolimus) Metadate CD Mysoline (primidone)* Nor-QD (norethindrone)* Pancrelipase citrate-citric acid)* Prolixin (fluphenazine)* (methylphenidate CD)* Nordette (levora)* Panoxyl, AQ (benzoyl Polycitra-K (Pot. & Sod. Proloprim (trimethoprim)* Metaglip (glipizide/ N Norflex (orphenadrine)* peroxide)* Citrates w/citric acid)* Prometrium metformin)* Parafon Forte Polysporin (bacitracin (progesterone)* Naldecon Norgesic (orphenadrine Methergine (chlorzoxazone)* zinc/polymyxin B)* Pronestyl, SR (decongestabs)* cpd)* (methylergonovine)* Norgesic Forte Paregoric Polytrim (polymyxin B/ (procainamide, SR)* methyclothiazide Nalfon 600mg trimethoprim)* Propine (dipivefrin HCl)* (fenoprofen)* (orphenadrine cpd Forte)* Parlodel Tab MetroCream Norinyl (necon)* (bromocriptine)* Ponstel (mefenamic propylthiouracil Namenda acid)* (metronidazole)* Normodyne (labetalol)* Parnate (tranylcypromine)* Proscar (finasteride)* Naprosyn (naproxen)* Potaba Tab MetroGel Vaginal Norpace (disopyramide)* Paxil (paroxetine)* Protonix^ (pantoprazole)* (metronidazole vag)* Nardil (phenelzine) (aminobenzoate tab)* Norpace CR 100mg Paxil CR (paroxetine SR)* Protopic Metrolotion Nasacort AQ potassium chloride Norpace CR 150mg Pediapred (prednisolone Proventil, Tab, Syrup (metronidazole lot)* (triamcinolone nasal)* sodium prosphate)* Pradaxa (albuterol)* Nasarel (flunisolide)* (disopyramide CR Pramosone 1% cream Mevacor (lovastatin)* 150mg)* Pediazole (erythromycin/ Provera (medroxy- Mexitil (mexiletine)* Nasonex only, lotion, oint Norpramin (desipramine)* sulfisoxazole)* progesterone)* Micro-K (potassium Natafort (prenatal Pramosone 2.5% oint nortriptyline Pentam (pentamidine Provigil (modafinil)* chloride)* )* isethionate)* and cream (hydrocort/ Norvasc (amlodipine)* Prozac (fluoxetine)* Micronase (glyburide)* Natalins (prenatal Pentasa pramoxine)* Psorcon (diflorasone Norvir Microzide and Pepcid (famotidine)* Prandin diacetate)* minerals/iron/fa)* Novafed A (pseudo- (hydrochlorothiazide Percocet (oxycodone/ Pravachol (pravastatin)* Pulmicort Flexhaler caps)* Navane (thiothixene)* ephedrine hcl/chlor- APAP)* Precose (acarbose)* mal)* Pulmicort Respules Midamor (amiloride)* Nebupent Percodan (oxycodone/ Pred Forte 1% 0.25mg/2ml, 0.5mg/2ml Midrin (isometh/ necon NuLev (neosol)* aspirin)* (prednisolone)* (budesonide)* dichlphen/APAP)* NeoDecadron (neomycin/ Nuvaring Perforomist prednisone Pulmicort Respules 1mg/2ml Migranal dexamethasone)* Nystatin Peridex (chlorhexidine Prelone (prednisolone)* Purinethol ()* (dihydroergotamine neomycin gluconate)* Premarin oral, vaginal pyrazinamide nasal spray)* Neoral O Periostat (doxycycline)* cream Pyridium (phenazopyridine)* Minipress (prazosin)* Neosporin soln Ocufen (flurbiprofen Persantine Premphase Minocin Capsule (neomycin/polymyxin/ sodium)* (dipyridamole)* Prempro Q (minocycline)* gramicidin)* Prenate Advance Ocuflox (ofloxacin)* Phenergan DM Qualaquin (quinine Mintezol Neosporin oint Ocupress (carteolol hcl)* (promethazine/ (prenatal w/docusate, (neomycin/polymyxin/ iron, folic acid)* sulfate)* Miralax (glycolax)* Oforta dextromethorphan)* Mirapex (pramipexole)* bacitracin)* Prenate Ultra (multi- Questran, Lite Ogen (estropipate)* Phenergan VC syrup (cholestyramine, light)* Mircette (kariva)* NeoSynephrine vitamins w/folic acid)* Omnicef (cefdinir)* (promethazine/ Quinaglute (quinidine (phenylephrine)* phenylephrine)* Prevacid^ Mobic (meloxicam)* Omnipen (ampicillin)* gluconate)* Modicon (ethinyl Neptazane Phenergan/Codeine (lansoprazole, ODT)* (methazolamide)* One Touch Product Line Prevident (sodium fluoride)* Quinidex (quinidine estradiol/ (promethazine/ sulfate)* norethindrone)* Neurontin (gabapentin)* Opana ER codeine)* Priftin Nexium (oxymorphone)* Prilosec^ (omeprazole)* Monistat-Derm Phenergan (promethazine)* R (miconazole nitrate)* Niaspan† Opticrom (cromolyn)* Phenergan VC/Codeine Primaquine Monodox (doxycycline Niferex-150 Forte (iron/ Optivar^ (azelastine)* (phenylephrine/ Prinivil (lisinopril)* Ranexa monohydrate)* B12/folic acid)* Ortho-Cept (apri, promethazine/codeine)* Prinzide (lisinopril/hctz)* Razadyne, ER Monoket (isosorbide Nilandron reclipsen)* phenobarbital Pristiq (galantamine, sr)* mononitrate)* Nitro-Bid (nitroglycerin Ortho-Est (estropipate)* Phoslo (calcium acetate)* ProAmatine (midodrine)* Rebetol (ribavirin)* Monopril (fosinopril)* SR)* Ortho Evra Pilocar (pilocarpine HCl)* ProAir HFA Reglan (metoclopramide)* Motrin ()* Nitro-Dur 0.3, 0.8mg/hr Ortho-Novum (necon)* pindolol Pro-Banthine Relafen (nabumetone)* Moxeza Nitro-Dur 0.1, 0.2, Ortho Tri-Cyclen Plan B (levonorgestrel)* (propantheline)* Remeron, SolTab MS Contin (morphine SR)* 0.4, and 0.6mg/hr (tri-nessa)* Plan B One Step (next probenecid (mirtazapine)* MSIR (morphine sulfate)* (nitroglycerin patch)* Ortho Tri-Cyclen Lo choice)* Procanbid Remicade* Mucomyst Nitrol (nitroglycerin Orudis (ketoprofen)* Plaquenil Procardia (nifedipine)* Renvela (acetylcysteine)* ointment)* Oruvail (ketoprofen SA)* (hydroxychloroquine)* Procardia XL (nifedipine ER)* Requip (ropinirole)* Myambutol (ethambutol)* Nitrolingual spray Ovral (ogestrel)* Plavix (clopidogrel)* Proctocort Requip XL (ropinirole ER)* Mycobutin Nitromist (nitroglycerin OxyContin Plexion SCT (hydrocortisone)* Rescriptor Mycolog II (nystatin/ spray)* (oxycodone ER) Plexion TS (sulfacet sod Proctocream-HC Restasis triamcinolone)* Nitrostat (nitroglycerin)* oxymorphone ER w/sulfur10/5%)* (hemorhoidal cream)* Restoril (temazepam)* 4 Retin-A Cream (tretinoin)* Sectral (acebutolol)* Symmetrel (amantadine)* Transderm-Scop V Westcort (hydrocortisone)* Retin-A Gel (tretinoin)* Selsun (selenium sulfide)* Synalar (fluocinolone Tranxene (clorazepate)* Xalatan (latanoprost)* Retin-A Micro (tretinoin Septra, DS acetonide)* Travatan Z V-Cillin K (penicillin V.K.)* Xanax (alprazolam)* micro gel)* (sulfamethoxazole/ Synthroid (levothyroxine) travoprost Vagifem Xarelto Retrovir (zidovudine) trimethoprim, DS)* Trental (pentoxifylline)* Valcyte tabs Xeloda Revia (naltrexone hcl)* Serax (oxazepam)* T Tricor (fenofibrate)* Valisone (betamethasone Xibrom (bromfenac)* valerate)* Reyataz Serevent Diskus Tagamet (cimetidine)* TriLeven (levo norgestrel)* Xodol (hydrocodone/ Rheumatrex Tablets Serophene (clomiphene)* Tri-Vi-Flor (triple vitamins Valium (diazepam)* apap)* Talacen (pentazocine/ Valtrex (valacyclovir)* ( tablets)* Seroquel (quetiapine)* apap)* w/fluoride)* Xopenex Neb Soln. Ridaura Seroquel XR Tridesilon (desonide)* Valturna (levalbuterol)* Talwin NX (pentazocine nx)* Vancocin (vancomycin)* Rifadin (rifampin)* Silvadene (silver Trilafon (perphenazine)* Xylocaine (lidocaine)* Tambocor (flecainide)* Vantin (cefpodoxime)* Rifamate sulfadiazine)* Trileptal (oxcarbazepine)* Xylocaine viscous Tamiflu Vaseretic (enalapril/ Rifater Sinemet (carbidopa/ Tapazole (methimazole)* Trilipix (lidocaine viscous)* levodopa)* hydrochlorothiazide)* Rilutek (riluzole)* Tavist syrup, 2.68mg tabs Trimox (amoxicillin)* Vasocidin (sulfacetamide Xyzal^ (levocetirizine)* Risperdal (risperidone)* Sinemet CR (carbidopa/ (clemastine fumarate)* Trimpex (trimethoprim)* sodium-prednisolone Risperdal Consta levodopa CR)* Tazorac Trinsicon (iron/intrinsic ophth sol.)* Y, Z Sinequan (doxepin)* Risperdal ODT, M-tab Tegretol (carbamazepine) factor/B12)* Vasocon (naphazoline)* Yasmin (ocella)* Singulair (montelukast)* (risperidone)* Tegretol XR Triphasil (trivora)* Vasotec (enalapril)* Yaz (gianvi)* Skelaxin (metaxolone)* Ritalin, SR (carbamazepine ER) Trizivir Veltin Yodoxin Slo-Bid (theophylline)* (methylphenidate, SR)* Temodar† Trusopt (dorzolamide)* Ventolin HFA Yocon (yohimbine)* Slo-Phyllin 80 Syrup Ritalin LA 20mg, Temovate (clobetasol)* Tussi-12 (phenyleph/ Vepesid ()* Zanaflex (tizanidine)* 30mg, 40mg (theophylline anhydrosl)* chlorphen/carbeta)* Tenex (guanfacine)* Veramyst Zantac (ranitidine)* (methylphenidate er)* Sodium Sulamyd Tussi-Organidin NR Tenoretic (atenolol/ Verelan (verapamil SR)* Zarontin (ethosuximide)* RMS Supp (morphine)* (sulfacetamide solution)* chlorthalidone)* (guaifenesin/codeine)* Vermox (mebendazole)* Robaxin (methocarbamol)* Solaquin Forte Tenormin (atenolol)* Tussi-Organidin NR Zaroxolyn (metolazone)* VESIcare Zebeta (bisoprolol)* Rocaltrol ( 0.25, (hydroquinone)* Terazol (terconazole)* DM (guaifenesin/ Vfend (voriconazole)* 0.5mg caps)* Soma (carisoprodol)* Teslac dextromethorphan)* Zegerid^ (omeprazole/ Vibramycin (doxycycline)* bicarb)* Rondec DM syrup Somavert Tessalon Perles TussiCaps Vicodin (hydrocodone/ Zemplar (pseudoephed/ Somophyllin (aminophylline)* (benzonatate)* Tussionex (hydrocodone/ APAP)* bromphen-DM 45-4-15)* Sonata (zaleplon)* Testim chlorpheniramine)* Vicodin E.S. Zenate (multi-vitamins Rondec, TR Sorbitrate (isosorbide Teveten (eprosartan)* Twinject (hydrocodone/apap)* w/folic acid)* (pseudoephedrine/ dinitrate)* Theo-24 Tylenol w/Cod (codeine/ Victoza Zenpep carbinoxamine)* Spectazole (econazole)* Theochron (theophylline)* APAP)* Videx Zephrex LA (pseudo- ephedrine/guaifenesin)* Roxicodone (oxycodone)* Spiriva Thorazine Tab Tylox (oxycodone w/ Videx EC (didanosine)* Rynatan (chlorphen/ Sporanox (itraconazole)* (chlorpromazine tab)* acetaminophen)* Vigamox Zerit (stavudine)* pyrilamine/ Stadol N.S. (butorphanol Ticlid (ticlopidine)* Tympagesic (pramoxine/ Viokase Zestril (lisinopril)* phenylephrine)* tartrate 10mg/ml N.S.)* Tigan (trimethobenzamide)* hc/chloroxylenol)* Viracept Zestoretic (lisinopril/hctz)* Rynatuss tablets, Stalevo (carbidopa/ Tilade Viramune (nevirapine)* Zetacet (sulfacetsod w/ pediatric susp levodopa/entacapone)* Timoptic U Viramune XR 10/5%)* (phenyleph-ephed-cpd Starlix (nateglinide)* (timololophthalmic)* Ultracet (tramadol/APAP)* Viread Ziac (bisoprolol/HCTZ)* w/carbetapentane)* Stelazine (trifluoperazine)* Timoptic XE (timolol)* Ultram, ER (tramadol)* Viroptic (trifluridine)* Ziagen solution Rythmol, SR Strattera Tindamax (tinidazole)* Ultrase (pancrelipase) Vistaril (hydroxyzine Ziagen tab (abacavir)* (propafenone, ER)* Suboxone SL tab Tobi Ultravate (halobetasol)* pamoate)* Zithromax (azithromycin)* Ryzolt (tramadol er)* (buprenorphine/naloxone)* Tobradex oint. Uniphyl (theophylline SR) Vivelle Dot† Zocor (simvastatin)* Suboxone SL film Tobradex susp. (tobramycin/ Uniretic (moexipril/hctz)* Voltaren Gel Zofran (ondansetron)* S Subutex (buprenorphine)* dexamethasone)* Unithroid (levothyroxine) Voltaren Ophth Zoloft (sertraline)* (diclofenac sodium)* Salagen (pilocarpine)* Sular (nisoldipine)* Tobrex Soln (tobramycin)* Univasc (moexipril)* Zomig, ZMT (zolmitriptan, Voltaren, XR (diclofenac, ER)* Sanctura, XR Sulfacet-R (sodium Tofranil (imipramine)* Urecholine (bethanechol)* odt)* Vosol (acetic acid)* (trospium, ER)* sulfacetamide/ sulfur)* Tolectin (tolmetin)* Urised (meth/salicylate/ Zonegran (zonisamide)* Vosol HC (acetic acid/ Sandimmune* Sultrin (triple sulfa)* Topamax atropine/hyos benzoic)* Zortress Sandostatin (octreotide Surmontil (trimipramine Topicort (desoximetasone)* hydrocortisone)* zovia Urocit-K (potassium Vyvanse acetate)* maleate)* Toprol XL (metoprolol)* citrate)* Zovirax Cap (acyclovir)* Savella Sustiva Toradol (ketorolac Zovirax Ointment Urogesic Blue W, X Seasonale (jolessa, Symbicort tromethamine)* (methenamine/hyosc- (acyclovir)* quasense)* Symbyax (olanzapine/ Toviaz meth blue/sod biphos- Welchol Zylet Seasonique (amethia, fluoxetine)* Tradjenta phenyl sal)* Wellbutrin, SR (bupropion)* Zyloprim (allopurinol)* camprese)* Symlin Trandate (labetalol)* Uroxatral (alfuzosin)* Wellbutrin XL (budeprion XL)* Zyprexa (olanzapine)* 5 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)* Genotropin* Nuvigil* Serostim* Xyzal (levocetirizine)*^ Amevive* Gleevec Oforta Sporanox (itraconazole)* Zocor (simvastatin 80)* Androderm* Humatrope* Orencia* Temodar Zorbtive* AndroGel Humira* Pegasys* Testim Zyvox* Botox* Incivek* Peg-Intron* Tev-Tropin* Enbrel* Lyrica* Provigil (modafinil)* Victrelis* Fentora* Norditropin* Remicade* Xeloda Forteo* Nutropin, AQ* Saizen* Xolair*

QUANTITY LIMIT: affects the frequency or dosage of certain medications for which you receive benefits. Aciphex*^ Brilinta Forteo* Nutropin, AQ* erostim* Actiq (fentanyl citrate)* Bydureon Frova* Nuvigil* Simcor* Advicor Byetta* Genotropin* Optivar^ (azelastine)* Sonata (zaleplon)* Allegra^ (fexofenadine)* Bepreve^* Humatrope* Orencia Stadol N.S. Allegra D^ (fexofenadine/ Clarinex (desloratadine)*, D^* Humira* Pataday^* (butorphanol)* PSE)* Cymbalta Imitrex (sumatriptan Patanol^* Symbicort Ambien (zolpidem)* Dexilant^* nasal, tab & inj)* Plavix (clopidogrel)* Testim Ambien, CR (zolpidem ER)* Diabetic Test Strips Kytril (granisetron)* Pradaxa Tev-Tropin* (Accu-Chek and One Lexapro (escitalopram)* Treximet* Amerge (naratriptan)* Prevacid^ (lansoprazole)* Touch brand products Lunesta* Veramyst Androderm* are formulary) Maxalt, MLT (rizatriptan, odt)* Prilosec^ (omeprazole)* Xyzal^ (levocetirizine)* AndroGel Effient Migranal (dihydroergotamine Pristiq Zegerid^ (omeprazole/ Anzemet* Elestat^ (epinastine)* nasal spray)* Protonix^ (pantoprazole)* bicarb)* Astelin (azelastine)* Emend* Nasarel (flunisolide)* Relpax* Zofran (ondansetron)* Astepro Enbrel* Nasonex Rozerem* Zomig, ZMT Avinza* Fentora* Nexium Saizen* (zolmitriptan, odt)* Axert* Flonase (fluticasone)* Norditropin* Savella Zorbtive*

STEP THERAPY: requires that you first use a specific medication before alternatives therapies may be tried or prescribed. Adderall (amphetamine/ Betaseron* Elidel Prevacid*^ Vytorin* dextroamphetamine^#) Bydureon Lipitor*^ Prilosec*^ Xyzal*^ – generic only Byetta* Nasacort AQ* Protonix*^ Zegerid*^ Aciphex*^ Celebrex* Nasarel Protopic Zetia* Ambien, CR (zolpidem ER)* Dexilant^* (flunisolide)* Rhinocort Aqua* Apidra* Diabetic Test Strips (Accu- Omnaris* Rozerem* Arthrotec* Chek and One Touch brand Pataday^* Sonata* Beconase AQ* products are formulary) Patanol^* Suboxone SL Tab

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 Cholesterol reducing medications Certain blood pressure medications

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 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 • 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/CA • Bring a copy of this drug list to your next doctor’s visit to assist in selecting the lowest cost medications

Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. Effective 07/13 WellPoint NextRx, NextRx and PrecisionRx are registered trademarks of WellPoint, Inc. and are used under license by Express Scripts, Inc. MBCEBRO-10-CA