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Preferred Drug List Effective May 1, 2017

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Preferred Drug List Effective May 1, 2017 Preferred drug list Effective May 1, 2017 Table of Contents 1.0 Analgesics ………………………………………………………………………………………... 1 2.0 Anesthetics ……………………………………………………………………………………….. 1 3.0 Antibiotics and Antivirals ………………………………………………………………………... 1 4.0 Antineoplastics/Immunosuppressants …………………………………………………………… 2 5.0 Cardiovascular Agents …………………………………………………………………………… 2 6.0 Central Nervous System Agents …………………………………………………………………. 3 7.0 Dermatologicals ………………………………………………………………………………….. 4 8.0 Eyes, Ears, Nose, Mouth and Throat …………………………………………………………….. 4 9.0 Endocrine Agents ………………………………………………………………………………… 5 10.0 Gastrointestinal Agents ………………………………………………………………………….. 5 11.0 Blood Modifiers, Nutritionals and Electrolytes ………………………………………………….. 6 12.0 OB/GYN …………………………………………………………………………………………. 6 13.0 Respiratory Agents ………………………………………………………………………………. 7 14.0 Skeletal Muscle Relaxants ……………………………………………………………………….. 8 15.0 Urologicals ……………………………………………………………………………………….. 8 16.0 Immunologicals, Vaccines and Biotechnology Drugs …………………………………………… 8 17.0 Smoking Cessation ………………………………………………………………………………. 8 www.anthem.com/inmedicaid Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee 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. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WEBMAIN-0355-17 May 2017 Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 1 of 8 1.0 ANALGESICS NARCOTIC ANALGESIC rifampin COMBINATIONS Rifater AGENTS FOR MIGRAINE codeine/apap QLL apap/butalbital QLL hydrocodone/apap QLL ANTIVIRALS apap/caffeine/butalb QLL hydrocodone/ibuprofen QLL Abreva (OTC) apap/caffeine/butalbital/ oxycodone/apap QLL acyclovir codeine QLL oxycodone/aspirin QLL amantadine apap/caffeine/isomethep pentazocine/apap Baraclude PA apap/dichloral/caffeine pentazocine/naloxone QLL Descovy PA asa/caffeine/butalbital QLL famciclovir butalbital compound w/codeine QLL NONSTEROIDAL Fuzeon PA asa/butalbital QLL ANTI-INFLAMMATORIES Lamivudine 100mg PA asa/dihydrocodeine/caffeine QLL diclofenac potassium Rebetol solution PA QLL butalbital/asa/caffeine/codeine QLL diclofenac ER Relenza QLL butorphanol NS PA QLL etodolac ER/IR rimantadine divalproex OPT fenoprofen Selzentry ergotamine w/caffeine flurbiprofen Tamiflu QLL sumatriptan QLL ibuprofen valacyclovir PA indomethacin IR/ER Valcyte CHELATING AGENTS ketoprofen IR/ER Viread PA (WILSON’S DISEASE) ketorolac IR/ER QLL Cuprimine meclofenamate CEPHALOSPORINS Depen meloxicam QLL cefaclor ER QLL Syprine nabumetone cefadroxil QLL naproxen EC cefdinir QLL DMARDS naproxen sodium DS cefpodoxime QLL Cuprimine oxaprozin cefprozil QLL cyclophosphamide piroxicam cefuroxime QLL Enbrel PA QLL sulindac cephalexin QLL Humira PA QLL tolmetin cephradine hydroxychloroquine ceftriaxone injection leflunomide SALICYLATES methotrexate oral aspirin, aspirin cr 800mg FLUOROQUINOLONES prednisone choline/magnesium ciprofloxacin QLL PA sulfasalazine QLL salicylate levofloxacin QLL diflunisal ofloxacin QLL PA GOUT MEDICATIONS salsalate allopurinol ANTIRETROVIRALS – colchicine/probenecid NUCLEOSIDE REVERSE probenecid QLL 2.0 ANESTHETICS TRANSCRIPTASE TOPICAL LOCAL INHIBITOR (NRTI) HYLAURONICS ANESTHETICS PA ANALOGUES Euflexxa benzocaine (OTC) PA abacavir Gelsyn lidocaine jelly PA adefovir Supartz QLL PA lidocaine 5% patch dipivoxil lidocaine/hydrocortisone didanosine MISCELLANEOUS lidocaine/prilocaine Emtriva ANALGESICS lamivudine acetaminophen stavudine tramadol IR only QLL 3.0 ANTIBIOTICS AND Vitekta tramadol/APAP QLL ANTIVIRALS Ziagen solution AMEBICIDES zidovudine NARCOTIC ANALGESICS metronidazole codeine QLL paromomycin sulfate ANTIRETROVIRAL fentanyl citrate lozenge QLL PA Yodoxin COMBINATIONS fentanyl patch QLL ST abacavir/lamivudine/zidovudine hydromorphone QLL ANTI-TUBERCULOSIS Epzicom meperidine QLL ethambutol Evotaz methadone QLL isoniazid Genvoya morphine sulfate ER tabs/IR QLL Mycobutin Kaletra oxycodone IR QLL Priftin lamivudine/zovudine pyrazinamide Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 2 of 8 Prezcobix erythromycin base vancomycin capsule PA Stribild erythromycin Triumeq ethylsuccinate ANTIDOTE Truvada erythromycin stearate Evzio QLL doxycycline ANTIRETROVIRALS – monohydrate capsules, 4.0 ANTINEOPLASTICS/ PROTEASE INHIBITORS suspension only IMMUNOSUPPRESSANTS Aptivus minocycline (IR) Crixivan tetracycline ALKYLATING AGENTS Norvir Alkeran cyclophosphamide Prezista ANTIHELMINTICS Reyataz Albenza Hexalen Viracept Biltricide Leukeran Myleran Ivermectin PENICILLINS Pin-X (OTC) ANTINEOPLASTIC – amoxicillin QLL Reese Pinworm (OTC) HORMONAL AGENTS – amoxicillin/clavulanate QLL ANTIANDROGEN ampicillin QLL ANTIMALARIALS flutamide dicloxacillin QLL atovaquone/proguanil penicillin VK QLL chloroquine phosphate hydroxychloroquine ANTINEOPLASTIC – ANTIFUNGALS – ORAL mefloquine HORMONAL AGENTS – clotrimazole troche primaquine phosphate ANTIESTROGEN GL fluconazole letrozole tamoxifen flucytosine ANTIPROTAZOALS griseofulvin ultra tab pentamidine griseofulvin susp isoethionate ANTINEOPLASTIC – HORMONAL AGENTS – itraconazole PA ketoconazole ANTIRETROVIRALS AROMATASE INHIBITORS anastrozole GL nystatin INTEGRASE INHIBITORS GL PA exemestane terbinafine tablets Isentress voriconazole Tivicay ANTINEOPLASTIC – Vitekta HORMONAL ANTIFUNGALS – TOPICAL AGENTS – PROGESTINS Various OTC ANTIRETROVIRALS Megestrol butenafine OTC NON- NUCLEOSIDE REVERSE ciclodan 8% soln TRANSCRIPTASE ANTIMETABOLITES ciclopirox 8% crm, soln INHIBITORS (NNRTI) mercaptopurine clotrimazole QLL ANALOGUES methotrexate ketoconazole crm, shampoo Intelence Tabloid clotrimazole/betamethasone nevirapine Trexall miconazole nitrate OTC Rescriptor nystatin crm, oint, powder Viramune XR IMMUNO- PA required age 8 and under terbinafine SUPPRESSANTS/ IMMUNO- tolnaftate crm, powder MODULATORS TOPICAL ANTIBIOTICS azathioprine LEPROSTATICS gentamicin Dapsone mupirocin ointment MISCELLANEOUS silver sulfadiazine ANTINEOPLASTICS MACROLIDES Emcyt PA azithromycin tablet QLL URINARY ANTI-INFECTIVES etoposide clarithromycin methenamine imatinib PA erythromycin nitrofurantoin caps hydroxyurea erythromycin/sulfisoxazole trimethoprim leucovorin Lysodren SULFONAMIDES MISCELLANEOUS ANTI- sulfadiazine INFECTIVES Matulane sulfamethoxazole/trimethoprim DS clindamycin octreotide PA sulfasoxazole neomycin tretinoin tinidazole TETRACYCLINES tobramycin ampules Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 3 of 8 5.0 CARDIOVASCULAR HMG CO A REDUCTASE DIURETICS AGENTS INHIBITORS (STATINS) amiloride, atorvastatin QLL amiloride/hctz ACE INHIBITORS/ACE I lovastatin QLL bumetanide COMBINATIONS pravastatin QLL chlorothiazide benazepril/benazepril hctz QLL simvastatin QLL furosemide captopril/captopril hctz simvastatin 80mg ST hydrochlorothiazide enalapril/enalapril hctz indapamide fosinopril/fosinopril hctz QLL PCSK-9 INHIBITORS methychlothiazide lisinopril/lisinopril hctz QLL Repatha PA QLL metolazone moexipril/moexipril hctz spironolactone; quinapril/quinapril hctz NIACIN spironolactone/hctz ramipril niacinIR/ER (OTC) torsemide trandolapril niacinamide triamterene/hctz slo-niacin BETAADRENERGIC NITRATES ANTAGONISTS FIBRATES isosorbide dinitrate acebutolol fenofibrate isosorbide mononitrate atenolol gemfibrozil primidone QLL atenolol/chlorthalidone Nitro-Bid betaxolol BILE ACID SEQUESTRANTS nitroglycerin ER capsules bisoprolol/ bisoprolol/hctz cholestyramine nitroglycerin ointment metoprolol cholestyramine lite nitroglycerin patch metoprolol/hctz colestipol granules nitroglycerin SL nadolol nitroglycerin spray pindolol CALCIUM ANTAGONISTS Nitro-Stat tablets propranolol AND COMBINATIONS propranolol/hctz amlodipine OPT PERIPHERAL sotalol amlodipine/benazepril VASODILATORS timolol diltiazem; AND COMBINATIONS diltiazem CR OPT hydralazine ALPHA BETA BLOCKERS diltiazem CD OPT hydralazine/hctz carvedilol diltiazem SR OPT minoxidil labetalol felodipine OPT nicardipine OPT PRESSORS ANGIOTENSION RECEPTOR nifedipine Midodrine BLOCKERS (ARB) AND ARB nifedipine ER OPT COMBINATIONS verapamil candesartan QLL 6.0 CENTRAL NERVOUS verapamil SR OPT candesartan/HCTZ QLL SYSTEM AGENTS irbesartan QLL CARDIAC GLYCOSIDES ALCOHOL ANTAGONISTS QLL irbesartan/HCTZ digoxin disulfiram losartan QLL losartan / HCTZ QLL ANTIARRHYTHICS ANTICONVULSANTS QLL valsartan/HCTZ amiodarone HYDANTOINS QLL disopyramide CR phenytoin QLL CENTRALLY ACTING AND flecainide phenytoin extended COMBINATIONS – Mexiletine ANTIADRENERGICS Pacerone ANTICONVULSANTS – OPT clonidine tablets propafenone SUCCINIMIDES QLL guanabenz quinidine ethosuximide OPT guanfacine gluconate methyldopa quinidine sulfate ANTICONVULSANTS – methyldopa hctz Nitro-bid BARBITURATES OPT nitroglycerin ER caps phenobarbital ANTIADRENERGICS – nitroglycerin ointment primidone PERIPHERALLY ACTING nitroglycerin patch doxazosin nitrolycerin SL ANTICONVULSANTS – MISC. OPT QLL prazosin nitrolycerin spray Carbamazepine OPT QLL terazosin Nitro-Stat tablets Carbatrol clonazepam OPT QLL depakene OPT QLL Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017 Page 4 of 8 diazepam OPT QLL benzoyl peroxide OTC solution diazepam rectal gel QLL clindamycin 1% solution, pledgets halobetasol crm, oint divalproex OPT QLL clindamycin-benzoyl peroxide 1.2- epitol QLL 5% gel SCABICIDES/PEDICULCIDES lamotrigine disper tab,
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