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National/Preferred 4 Tier Split Preferred Drug List Drug list — Five Tier Drug Plan Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). We’re here to help. If you are a current Anthem member with questions about your pharmacy benefits, we're here to help. Just call us at the Member Services number on your ID card. The product names to which this formulary applies are shown below. $5/$15/$25/$45/30% to $250 $5/$20/$40/$60/30% to $250 Rx ded $150 $5/$15/$30/$50/30% to $250 $5/$20/$40/$75/30% to $250 $5/$15/$40/$60/30% to $250 $5/$20/$40/$75/30% to $250 Rx ded $250 $5/$15/$50/$65/30% to $250 after deductible $5/$20/$50/$65/30% to $250 Rx ded $500 $5/$20/$30/$50/30% to $250 $5/$20/$50/$70/30% to $250 $5/$20/$40/$60/30% to $250 $5/$20/$50/$70/30% to $250 after deductible Here are a few things to remember: o You can view and search our current drug lists when you visit anthem.com/ca/pharmacyinformation. Please note: The formulary is subject to change and all previous versions of the formulary are no longer in effect. o Additional tools and resources are available for current Anthem members to view the most up-to-date list of drugs for your plan - including drugs that have been added, generic drugs and more – by logging in at anthem.com/ca/pharmacyinformation. o Your coverage has limitations and exclusions, which means there are certain rules about what's covered by your plan and what isn't. Already a member? You can view your Certificate/Evidence of Coverage or your Summary Plan Description by logging in at anthem.com/ca and go to My Plan ->Benefits-> Plan Documents. o You and your doctor can use this list as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket. To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) in this document about how the list is set up and what to do if a drug you take isn't on it. Last Updated: September 1, 2021 LG Preferred Drug List Five-Tier Table of Contents INFORMATIONAL SECTION..................................................................................................................................................................4 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM....................... 11 *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS.........................................................................15 *AMEBICIDES* - DRUGS FOR INFECTIONS....................................................................................................................................19 *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS..................................................................................................................... 20 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER......................................................................... 20 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER.........................................................................................24 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER.........................................................................................................27 *ANDROGENS-ANABOLIC* - HORMONES.......................................................................................................................................31 *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS............................................................................... 32 *ANTACIDS* - DRUGS FOR THE STOMACH....................................................................................................................................32 *ANTHELMINTICS* - DRUGS FOR INFECTIONS........................................................................................................................... 32 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART.................................................................................................................33 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM.......................................................................................... 33 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART......................................................................................................................34 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS......................................................... 35 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD........................................................................................................................ 39 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM................................................................................................40 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM................................................................................................. 45 *ANTIDIABETICS* - HORMONES....................................................................................................................................................... 47 *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH.............................................................................52 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING.............................................. 52 *ANTIEMETICS* - DRUGS FOR THE STOMACH............................................................................................................................54 *ANTIFUNGALS* - DRUGS FOR INFECTIONS.................................................................................................................................55 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS............................................................................................................................57 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART...............................................................................................................58 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART................................................................................................................... 60 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS............................................................................................64 *ANTIMALARIALS* - DRUGS FOR INFECTIONS........................................................................................................................... 68 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...................................................68 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS..............................................................................................69 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER.................................................................. 69 *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM.................................. 87 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM..........................................................89 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS.........................................................................93 *ANTIVIRALS* - DRUGS FOR INFECTIONS.....................................................................................................................................93 *BETA BLOCKERS* - DRUGS FOR THE HEART.............................................................................................................................99 *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART............................................................................................. 101 *CARDIOTONICS* - DRUGS FOR THE HEART............................................................................................................................. 103 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART...................................................................................... 104 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS.......................................................................................................................106 *CONTRACEPTIVES* - DRUGS FOR WOMEN...............................................................................................................................108 *CORTICOSTEROIDS* - HORMONES..............................................................................................................................................115 *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS.............................................................................................................117 *DERMATOLOGICALS* - DRUGS FOR THE SKIN....................................................................................................................... 119 *DIAGNOSTIC PRODUCTS*................................................................................................................................................................131 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH......................................................................................................................131 *DIURETICS* - DRUGS FOR THE HEART.......................................................................................................................................132 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES.........................................................................................133
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