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Approved Formulary Drug List

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Approved Formulary Drug List Clarithromycin XL (generic) INTRODUCTION Erythromycin (generic) Erythromycin/Sulfisoxazole (generic) Anthem Blue Cross uses a formulary (preferred list of drugs) to help your doctor Penicillins ...................................................................... make prescribing decisions. This list of drugs Amoxicillin (generic) is updated quarterly, by a committee Amoxicillin/Clavulanate (generic) consisting of doctors and pharmacists, so that Ampicillin (generic) the list includes drugs that are safe and Dicloxacillin (generic) effective in the treatment of diseases. If you Penicillin (generic) have any questions about the accessibility of Quinolones ..................................................................... your medication, please call the phone number Ciprofloxacin/XR (generic) listed on the back of your Anthem Blue Cross Levofloxacin (generic) member identification card. Moxifloxacin (generic) In most cases, if your physician has Sulfonamides ................................................................ determined that it is medically necessary for Erythromycin/Sulfisoxazole (generic) you to receive a brand name drug or a drug Sulfamethoxazole/Trimethoprim (generic) that is not on our list, your physician may Sulfisoxazole (generic) indicate “Dispense as Written” or “Do Not Tetracyclines .................................................................. Substitute” on your prescription to ensure Doxycycline hyclate (generic) access to the medication through our network Doxycycline monohydrate (generic) of community pharmacies, excluding drugs Minocycline (generic) that require Prior Authorization of Benefits. Tetracycline (generic) ANTIFUNGAL AGENTS (ORAL) _________________ Please ask your doctor or pharmacist to refer Clotrimazole (generic) to the Anthem Blue Cross Outpatient Fluconazole (generic) Prescription Drug List for a complete listing of Flucytosine (generic) APPROVED products. Griseofulvin (generic) Itraconazole (generic) Ketoconazole (generic) Nystatin (generic) FORMULARY USE OF GENERICS Terbinafine (generic) Generic drugs are safe and effective Voriconazole (generic) DRUG LIST equivalents to brand name medications. In ANTI-MALARIALS____________________________ many cases, if a generic equivalent is Atovaquone/Proguanil (generic) available for a brand name product, the brand Chloroquine (generic) name product will be considered non-preferred Mefloquine (generic) and the generic equivalent will be on the list. Primaquine (Primaquine) The FDA has endorsed the use of generic Pyrimethamine (Daraprim) Revised 01/2016 equivalents and has found their use to be safe Quinine sulfate (generic) and effective. ANTI-TUBERCULOSIS AGENTS ________________ Cycloserine (generic) For medications classified by the FDA as Ethambutol (generic) having a narrow therapeutic index (NTI), Isoniazid (generic) Anthem Blue Cross discourages the use of Pyrazinamide (generic) these generic substitutions. Rifabutin (generic) Rifampin (generic) OTHER ANTI-INFECTIVES _____________________ LEGEND PRIOR AUTHORIZATION Clindamycin (generic) In each class, drugs are alphabetically Iodoquinol (Yodoxin) listed by active ingredient. Anthem Blue Cross may require prior Ivermectin (generic) authorization of benefit (PAB) for certain drugs Linezolid (generic) If only the word 'generic' appears to provide a safe and affordable pharmacy Metronidazole (generic) within the parenthesis, only the benefit. Drugs which require PAB are often Tinidazole (generic) generic is on Formulary. Example: medications that are appropriate for only very Trimethoprim (generic) Cefaclor (generic) means that the specific medical conditions. If your physician Vancomycin capsule (generic) generic, Cefaclor is covered and the believes that a medication requiring PAB is brand is not covered. medically appropriate, he or she should contact Anthem’s pharmacy benefit manager, ANTI-NEOPLASTIC AGENTS If the word 'generic' does not appear Express Scripts, Inc. in order to initiate the within the parenthesis, the active Prior Authorization Process on your behalf. All FDA-approved, self-administered injectable and oral anti-neoplastic agents are eligible for ingredient is only available as a brand The list of drugs is subject to change so please call Customer Service at 1-800-700-2541 or coverage under the prescription drug benefit. and is on Formulary. The drug name in May be subject to PAB. parenthesis is the brand name. check our website at Example: Sitagliptin (Januvia) means www.anthem.com/ca.com to obtain a complete that the brand, Januvia is covered and list of PAB drugs. there is no generic available. Januvia ANTI-VIRAL AGENTS is the brand name. Acyclovir (generic) If the word 'generic' and the brand ANTI-INFECTIVE AGENTS Amantadine (generic) name both appear within the ANTIBIOTICS _______________________________ Entecavir (generic)^ parenthesis, both the generic and the Famciclovir (generic) Cephalosporins ............................................................ Ganciclovir (generic) brand name drugs are on Formulary. Cefaclor (generic) Interferon Alfa-2B (Intron A)*^ Example: Warfarin (Coumadin / Cefdinir (generic) Interferon Alfacon-1 (Infergen)*^ generic) means that both the brand Cefadroxil (generic) Lamivudine (generic)^ and generic are available. Therefore, Cefditoren (generic) Oseltamivir (Tamiflu) the brand Coumadin and the generic Cefixime (generic) Peginterferon Alfa-2B (Peg-Intron)*^ Warfarin are covered. Cefprozil (generic) Peginterferon Alfa-2A (Pegasys)*^ Ceftibuten (generic) Ribavirin (generic)^ * Members should refer to their Cefuroxime (generic) Tenofovir (Viread) Member Handbook for benefit details Cefpodoxamine (generic) Valacyclovir (generic) regarding applicable copayments or Cephalexin (generic) Valganciclovir (generic) coinsurance. Macrolides ...................................................................... Azithromycin (generic) Ropinirole, ER (generic) Lorazepam (generic) AUTONOMIC & CENTRAL NERVOUS SYSTEM Selegiline (generic) Meprobamate (generic) AGENTS Tolcapone (generic) Oxazepam (generic) ANALGESICS, NARCOTIC _____________________ Trihexyphenidyl (generic) Temazepam (generic) Acetaminophen/Codeine (generic) ALZHEIMER’S AGENTS ______________________ Triazolam (generic) Aspirin/Codeine (generic) Donepezil (generic) Zolpidem (generic) Codeine Phosphate/Sulfate (generic) Memantine (generic, Namenda XR) Fentanyl (generic) Rivastigmine (generic) Fentanyl Citrate (generic) CEREBRAL STIMULANTS _____________________ Hydrocodone/Acetaminophen (generic) BLOOD MODIFIERS Amphet Asp/Amphet/D-Amphet Hydromorphone, ER (generic) (Adderall XR/generic) Erythropoietin (Procrit)*^ Meperidine (generic) Atomoxetine (Strattera) Darbepoetin (Aranesp)*^ Methadone (generic) Dexmethylphenidate (generic) Filgrastim (Neupogen)*^ Morphine (generic) Dexmethylphenidate XR (generic) Oprelvekin (Neumega)*^ Morphine Sulfate, ER (generic) Dextroamphetamine (generic) Pegfilgrastim (Neulasta)*^ Oxycodone/Acetaminophen (generic) Lisdexamphetamine (Vyvanse) Oxycodone/Aspirin (generic) Methamphetamine (generic) Oxycododone (Oxycontin) Methylphenidate CD (generic) CARDIOVASCULAR AGENTS Oxymorphone, ER (generic) Methylphenidate ER (Methylin ER/generic) ANGIOTENSIN CONVERTING ENZYME ANALGESICS, NON-NARCOTIC ________________ Methylphenidate (generic) Almotriptan (generic) Modafinil (generic) INHIBITORS AND RECEPTOR BLOCKERS _______ Amlodipine/Olmesartan (Azor) APAP/Isometheptene/Dichlphen (generic) MULTIPLE SCLEROSIS AGENTS _______________ Acetaminophen/Caffeine/Butalbital (generic) Amlodipine/Valsartan (generic) Glatiramer Acetate (Copaxone 20mg)*^ Acetaminophen/Caffeine/Butalbital/Codeine Amlodipine/Valsartan/HCTZ (generic) Interferon Beta-1A (Avonex)*^ (generic) Benazepril/HCTZ (generic) Interferon Beta-1B (Betaseron)*^ Aspirin/Caffeine/Butalbital (generic) Benazepril/Amlodipine (generic) Eletriptan (Relpax) OPIOID DEPENDANCE _______________________ Captopril/HCTZ (generic) Ergotamine/Caffeine (generic) Buprenorphine/Naloxone (generic/Suboxone Candesartan/HCTZ (generic) Lidocaine (generic) SL Film) Enalapril/HCTZ (generic) Naratriptan (generic) Buprenorphine (generic) Eprosartan (generic) Rizatriptan, ODT (generic) PSYCHOTHERAPEUTIC AGENTS ______________ Fosinopril/HCTZ (generic) Sumatriptan (generic) Irbesartan/HCTZ (generic) Antidepressants ........................................................... Lisinopril/HCTZ (generic) Tramadol/-ER (generic) Amitriptyline (generic) Zolmitriptan, ODT (generic) Losartan/HCTZ (generic) Bupropion/-XL (generic) Moexipril/HCTZ (generic) ANALGESICS, NONSTEROIDAL Citalopram (generic) Olmesartan/amlodipine/HCTZ (Tribenzor) ANTI-INFLAMMATORY ________________________ Desipramine (generic) Olmesartan/HCTZ(Benicar/HCT) Celecoxib (generic) Desvenlafaxine (Pristiq) Perindopril (generic) Diclofenac (generic/Voltaren Gel) Doxepin (generic) Quinapril/HCTZ (generic) Etodolac (generic) Duloxetine (generic) Ramipril (generic) Flurbiprofen (generic) Escitalopram (generic) Telmisartan/amlodipine (generic) Ibuprofen (generic) Fluoxetine (generic) Telmisartan/HCTZ (generic) Indomethacin (generic) Fluoxetine/Olanzapine (generic) Trandolapril (generic) Ketoprofen (generic) Fluvoxamine, ER (generic) Trandolapril/Verapamil (generic) Ketorolac (generic) Imipramine (generic) Valsartan/HCTZ (generic) Mefenamic acid (generic) Mirtazapine (generic) Nabumetone (generic) Nortriptyline (generic) ANTI-ADRENERGIC BLOCKERS ________________ Naproxen (generic) Paroxetine (generic/CR) Alfuzosin (generic) Oxaprozin (generic) Phenelzine (generic) Doxazosin (generic)
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