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XL (generic) INTRODUCTION (generic) Erythromycin/Sulfisoxazole (generic) Anthem Blue Cross uses a formulary (preferred list of drugs) to help your doctor ...... make prescribing decisions. This list of drugs (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 (generic) effective in the treatment of . If you (generic) have any questions about the accessibility of Quinolones ...... your , please call the phone number /XR (generic) listed on the back of your Anthem Blue Cross (generic) member identification card. (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 / (generic) that is not on our list, your physician may Sulfisoxazole (generic) indicate “Dispense as Written” or “Do Not ...... Substitute” on your prescription to ensure hyclate (generic) access to the medication through our network Doxycycline monohydrate (generic) of community pharmacies, excluding drugs (generic) that require Prior Authorization of Benefits. (generic) AGENTS (ORAL) ______Please ask your doctor or pharmacist to refer (generic) to the Anthem Blue Cross Outpatient Fluconazole (generic) List for a complete listing of Flucytosine (generic) APPROVED products. (generic) Itraconazole (generic) (generic) (generic) FORMULARY USE OF GENERICS (generic) Generic drugs are safe and effective Voriconazole (generic) DRUG LIST equivalents to brand name . In ANTI-MALARIALS______many cases, if a generic equivalent is / (generic) available for a brand name product, the brand (generic) name product will be considered non-preferred (generic) and the generic equivalent will be on the list. (Primaquine) The FDA has endorsed the use of generic (Daraprim) Revised 01/2016 equivalents and has found their use to be safe sulfate (generic) and effective. ANTI- AGENTS ______Cycloserine (generic) For medications classified by the FDA as Ethambutol (generic) having a narrow therapeutic index (NTI), (generic) Anthem Blue Cross discourages the use of Pyrazinamide (generic) these generic substitutions. (generic) Rifampin (generic) OTHER ANTI-INFECTIVES ______LEGEND PRIOR AUTHORIZATION (generic) In each class, drugs are alphabetically Iodoquinol (Yodoxin) listed by active ingredient. Anthem Blue Cross may require prior (generic) authorization of benefit (PAB) for certain drugs (generic) If only the word 'generic' appears to provide a safe and affordable pharmacy (generic) within the parenthesis, only the benefit. Drugs which require PAB are often (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 (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 ______Entecavir (generic)^ parenthesis, both the generic and the (generic) ...... (generic) brand name drugs are on Formulary. Cefaclor (generic) Alfa-2B (Intron A)*^ Example: (Coumadin / Cefdinir (generic) Interferon Alfacon-1 (Infergen)*^ generic) means that both the brand Cefadroxil (generic) (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) (generic)^ * Members should refer to their (generic) Tenofovir (Viread) Member Handbook for benefit details Cefpodoxamine (generic) Valacyclovir (generic) regarding applicable copayments or Cephalexin (generic) (generic) coinsurance. ...... (generic) , ER (generic) (generic) AUTONOMIC & Selegiline (generic) (generic) AGENTS Tolcapone (generic) (generic) , NARCOTIC ______Trihexyphenidyl (generic) (generic) Acetaminophen/ (generic) ALZHEIMER’S AGENTS ______Triazolam (generic) /Codeine (generic) Donepezil (generic) (generic) Codeine /Sulfate (generic) Memantine (generic, Namenda XR) (generic) Rivastigmine (generic) Fentanyl Citrate (generic) CEREBRAL STIMULANTS ______Hydrocodone/Acetaminophen (generic) BLOOD MODIFIERS Amphet Asp/Amphet/D-Amphet , ER (generic) (Adderall XR/generic) Erythropoietin (Procrit)*^ Meperidine (generic) (Strattera) Darbepoetin (Aranesp)*^ (generic) Dexmethylphenidate (generic) Filgrastim (Neupogen)*^ (generic) Dexmethylphenidate XR (generic) Oprelvekin (Neumega)*^ Morphine Sulfate, ER (generic) (generic) Pegfilgrastim (Neulasta)*^ /Acetaminophen (generic) Lisdexamphetamine (Vyvanse) Oxycodone/Aspirin (generic) Methamphetamine (generic) Oxycododone (Oxycontin) Methylphenidate CD (generic) CARDIOVASCULAR AGENTS , ER (generic) Methylphenidate ER (Methylin ER/generic) CONVERTING ANALGESICS, NON-NARCOTIC ______Methylphenidate (generic) Almotriptan (generic) Modafinil (generic) INHIBITORS AND BLOCKERS ______Amlodipine/ (Azor) APAP/Isometheptene/Dichlphen (generic) MULTIPLE SCLEROSIS AGENTS ______Acetaminophen// (generic) / (generic) Glatiramer (Copaxone 20mg)*^ Acetaminophen/Caffeine/Butalbital/Codeine Amlodipine/Valsartan/HCTZ (generic) Interferon Beta-1A (Avonex)*^ (generic) /HCTZ (generic) Interferon Beta-1B (Betaseron)*^ Aspirin/Caffeine/Butalbital (generic) Benazepril/Amlodipine (generic) Eletriptan (Relpax) DEPENDANCE ______Captopril/HCTZ (generic) /Caffeine (generic) / (generic/Suboxone /HCTZ (generic) (generic) SL Film) /HCTZ (generic) (generic) Buprenorphine (generic) (generic) Rizatriptan, ODT (generic) PSYCHOTHERAPEUTIC AGENTS ______Fosinopril/HCTZ (generic) (generic) /HCTZ (generic) Antidepressants ...... /HCTZ (generic) /-ER (generic) Amitriptyline (generic) , ODT (generic) /HCTZ (generic) /-XL (generic) /HCTZ (generic) ANALGESICS, Citalopram (generic) Olmesartan/amlodipine/HCTZ (Tribenzor) ANTI-INFLAMMATORY ______Desipramine (generic) Olmesartan/HCTZ(Benicar/HCT) (generic) Desvenlafaxine (Pristiq) (generic) (generic/Voltaren ) Doxepin (generic) /HCTZ (generic) (generic) (generic) (generic) (generic) Escitalopram (generic) /amlodipine (generic) (generic) (generic) Telmisartan/HCTZ (generic) Indomethacin (generic) Fluoxetine/ (generic) (generic) (generic) Fluvoxamine, ER (generic) Trandolapril/Verapamil (generic) (generic) Imipramine (generic) Valsartan/HCTZ (generic) Mefenamic (generic) Mirtazapine (generic) (generic) Nortriptyline (generic) ANTI-ADRENERGIC BLOCKERS ______Naproxen (generic) (generic/CR) Alfuzosin (generic) (generic) Phenelzine (generic) Doxazosin (generic) (generic) Sertraline (generic) (generic) (generic) (generic) Dutasteride/Tamsulosin (generic) Prazosin (generic) ANALGESICS, SALICYLATES ______Trazodone (generic) Trimipramine (generic) Terazosin (generic) Aspirin (generic) Tamsulosin (generic) Chol Sal/ Salicylate (generic) Venlafaxine/ER (generic) (generic) Antimanic Agents ...... ANTIARRHYTHMICS ______Salsalate (generic) Carbonate (Eskalith-CR/ (Cordarone/Pacerone/generic) (Lanoxicap/Lanoxin/generic) ANTICONVULSANTS ______Lithobid/generic) Lithium Citrate (Lithonate/generic) Disopyramide (generic) (Tegretol/XR/ Flecainide (generic) Carbatrol/generic) Antipsychotic Agents ...... (generic) (generic) Aripiprazole (generic) Procainamide (generic) (generic/Diastat) (generic) Propafenone (generic) Divalproex Sodium (generic/Depakote/ER) Clomipramine (generic) Gluconate (generic) Ethosuximide (generic) Clozapine (Fazaclo ODT/generic) Sotalol (generic) (generic/Felbatol) Fluphenazine (generic) Gabapentin (generic) (generic) /ANTITHROMBOTICS ______Tiagabine (Gabitril, generic) Loxapine (generic) Anagrelide (generic) Levetiracetam (generics/Keppra/XR) Olanzapine, ODT (generics) Apixaban (Eliquis) , ER (generic/Lamictal) Paliperidone ER (generic) Aspirin/Dipyridamole ER (generic) Lamotrigine ODT (generic) Perphenazine (generic) Cilostazol (generic) (generic) Pimozide (generic) Clopidogrel (generic) (Dilantin/Phenytek/generic) Prochlorperazine (generic) Dabigatran (Pradaxa) (generic) Quetiapine (generic/Seroquel XR) Dalteparin (Fragmin)*^ Oxcarbazepine (generic) (generic/RisperdalConsta) Dipyridamole (generic) (generic/Topamax) Thioridazine (generic) Enoxaparin (generic)*^ Valproic Acid (Depakene/generic) Thiothixene (generic) Fondararinux (generic)*^ Zonisamide (generic) Trifluoperazine (generic) Pentoxifylline (generic) Ziprasidone (generic) Prasugrel (Effient) ANTIPARKINSON AGENTS ______Rivaroxaban (Xarelto) Amantadine (generic) , HYPNOTICS AND ANTI-ANXIETY ____ (Brilinta) Benztropine (generic) (generic) Ticlopidine (generic) Bromocriptine (generic) Buspirone (generic) Tinzaparin (Innohep)*^ Carbidopa (generic) Hydrate (generic) Warfarin (Coumadin/generic) Carbidopa/Levodopa (generic) (generic) Carbidopa/Levodopa/ Entacapone (generic) (generic) ANTILIPEMICS ______Entacapone (generic) Diazepam (generic) Amlodipine/Atorvastatin (generic) , ER (generic) (generic) Atorvastatin (generic) Rasagiline mesylate (Azilect) (generic) Cholestyramine (generic) Colesevelam (Welchol) (Symlin)* Colestipol (generic) ANTIDIABETIC AGENTS-ORAL ______Fenofibrate (generic) DERMATOLOGICALS Acarbose (generic) Fenofibric acid (generic) ______Acetohexamide (generic) Fluvastatin, ER (generic) Chlorpropamide (generic) (generic/Differin 0.1% Lotion) (generic) (generic) (generic) (Finacea) Clindamycin (generic) Glipizide (generic) ER (Generic) Glipizide/ (generic) Clindamycin/ Niacin/Lovastatin (Advicor) Glyburide/Metformin (generic) (generic/Acanya/Onexton) Pravastatin (generic) Glyburide/Micronized (generic) Clindamycin/ (Veltin) (Crestor) (Tradjenta) Erythromycin (generic/Akne-Mycin) (generic) Linagliptin/Metformin (Jentadueto) (generic) BETA-ADRENERGIC BLOCKERS ______Metformin ,ER (generic) Minocycline (generic) /Chlorthalidone (generic) Miglitol (Glyset) Sodium (generic) Bisoprolol/HCTZ (generic) Nateglinide (generic) (Tazorac) (Coreg-CR/generic) (generic) Tretinoin (generic) Labetalol (generic) Pioglitazone/glimepiride (generic) Metoprolol/XL/HCTZ (generic) ANTIBIOTICS/ANTIVIRALS ______Pioglitazone/Metformin (generic/ActoPlus Met Pindolol (generic) Acyclovir (generic) XR) Propranolol/XL/HCTZ (generic) / (Bacitracin) Repaglinide (generic) Sotalol (generic) Metronidazole (generic) Repaglinide/metformin (Generic) Timolol (generic) (Bactroban Nasal/generic) Sitagliptin (Januvia) (Altabax) CHANNEL BLOCKERS ______Sitagliptin/Metformin (Janumet/XR) Sodium Sulfacetamide (generic) Amlodipine (generic) Tolazamide (generic) Amlodipine/Benazepril (generic) FUNGICIDES ______Tolbutamide (generic) Diltiazem (generic) Cicloplrox (generic) ANTIDIABETIC SUPPLIES ______Felodipine (generic) Nystatin/ (generic) Select blood testing supplies, such as (generic) (generic) glucometers, lancets, and test strips, may be (generic) Ketoconazole (generic) covered. Accu-Chek and One Touch are the (generic) TOPICAL ANTI-INFLAMMATORY AGENTS ______only test strips included on formulary. Lifescan Verapamil (generic) Low Potency ...... (One Touch, One Touch Ultra); Roche CENTRALLY ACTING ANTIHYPERTENSIVES______Desonide (generic) Diagnostics (Accu-Chek, Aviva). Quantity Clonidine (generic) (generic) limits apply. test strips are also a Methyldopa (generic) (generic) covered benefit. DIURETICS ______Medium Potency ...... ELEVATING AGENTS ______Acetazolamide (generic) (generic) Diazoxide (Proglycem) (generic) Fluocinolone (generics) (Glucagon) Chlorthalidone (generic) (generic) ANTITHYROID ______Ethacrynic Acid (generic) (generic) Methimazole (generic) (generic) (generic) Propylthiouracil (generic) HCTZ/Triamterene (generic) Triamcinolone (generic) THYROID ______Hydrochlorothiazide (generic) High Potency ...... (Levothroid/Levoxyl/Unithroid/ Indapamide (generic) Dipropionate (generic) Synthroid/generic) Methazolamide (generic) (generic) Liothyronine (Cytomel/generic) Metolazone (generic) Ultra-High Potency ...... Liotrix (Thyrolar) /HCTZ (generic) Thyroid (generic/Armour Thyroid) Torsemide (generic) Augmented Betamethasone (generic) Triamterene (generic) (generic) OTHER ENDOCRINE AGENTS ______Diflorasone (generic) Leuprolide (Eligard/Lupron/generic)*^ VASODILATORS ______Hydralazine (generic) VAGINAL/RECTAL PREPARATIONS ______Isosorbide Dinitrate/Hydralazine (Bidil) Clindamycin (generic) (Ortho-Dienestrol) Isosorbide Dinitrate (Dilatrate SR/generic) GASTROINTESTINAL AGENTS (generic) (Estring/Vagifem) (generic) , Conjugated (Premarin) ANTIEMETIC/ANTIVERTIGO ______Nitroglycerin (Nitrostat/Nitrobid/generic) Hydrocortisone/Pramoxine (generic/Analpram (generic) Nitroglycerin (Nitrek/Nitro-Dur/generic) HC lotion/Pramosone cream, lotion, oint) Granisetron (generic) Ranolazine (Ranexa) Mesalamine (Rowasa) (generic) Metronidazole (generic) , ODT (generic) VASOPRESSORS ______Nystatin (generic) (generic) Epinephrine (Epipen/Jr/Twinject) (Crinone Vaginal Gel)^ Prochlorperazine (generic) (generic) Promethazine (generic) Sulfathiaz/Sulfacet/Sulfabenz (generic) Scopolamine (Transderm-Scop) CONTRACEPTIVES MISCELLANEOUS DERMATOLOGICALS ______Trimethobenzamide (generic) Eth Estradiol/ (Apri/generic) Calcipotriene (generic) /GI MOTILITY ______Eth Estradiol/ (generic) Calcipotriene/betamethasone (generic) Belladonna/Phenobarbital (generic) Eth Estradiol/Ethynodioldiacetate (Zovia) Crotamiton (Eurax) Clidinium/Chlordiazepoxide (generic) Eth Estradiol/ (Nuvaring) Fluorouracil (Fluoroplex/generic) Dicyclomine (generic) Eth Estradiol/ (Amethia/Amethia Imiquimod (generic) Hyoscyamine (generic) Lo/Camrese/Enpresse/Jolessa/Portia/Trivor (generic) Propantheline (generic) a/generic) Methoxsalen (generic) Eth Estradiol/ (Xulane) ANTIULCER ______Permethrin (Elimite) (generic) Eth Estradiol/Norethindrone (generic) (Elidel) Eth Estradiol/Norethindrone (Balziva) magnesium (Nexium packets) Podofilox (generic) Glycopyrolate (generic) Eth Estradiol/Norethindrone (Necon/generic) Sulfide (generic) Eth Estradiol/Norethindrone /Ferrous Lansoprazole/Amoxicillin/Clarithromycin Silver (generic) (generic) Fumarate (generic) ointment (generic) Eth Estradiol/ (Trinessa/ (generic) TriSprintec/generic) Nizatidine (generic) Eth Estradiol/Norgestimate (Ortho Tri-Cyclen (generic) Omeprazole/Sodium Bicarbonate (generic) LO) ENDOCRINE AGENTS Eth Estradiol/ (Low-Ogestrel/ Pantoprazole (generic) Ogestrel) ANTIDIABETIC AGENTS-INJECTABLE ______Ranitidine (generic) Norethindrone (Nora-BE) All forms of are covered. Sucralfate (generic) (Byetta)* OTHER GI PRODUCTS ______EMERGENCY CONTRACEPTIVES ______Exenatide microspheres (Bydureon)* Levonorgestrel (generic) Alosetron (generic) (Victoza)* (generic) EC(generic) SYMPATHOMIMETICS ______Hydrocortisone (Cortifoam) Dipivefrin (generic) (generic) IMMUNOSUPPRESSIVE AGENTS (Linzess) Lubiprostone (Amitiza) All FDA-approved, self-administered injectable Mesalamine (Asacol/Asacol HD/ and oral immunosuppressive agents are OTICS Delzicol/Pentasa/Lialda/Canasa) eligible for coverage under the prescription ANTI-INFECTIVE AGENTS ______Pancreatic Lipase drug benefit. (generic) (Creon/Pancrease/Pancrelipase/Ultrase/ Acetic Acid/Benzethonium (generic) Viokase/Zenpep Ciprofloxacin (generic) (generic) OPHTHALMICS (Floxin Otic/generic) Ursodiol (generic) ANTI-INFECTIVE & ANTI-INFLAMMATORY ALPHA-AGONIST______COMBINATIONS ______Brimonidine Tartrate (generic) Ciprofloxacin/ (Ciprodex) Tartrate/Timolol (Combigan) /Polymxin/HC (generic) ______Dexamethasone (generic) (Lumigan 0.01%, generic) (Florinef) (generic) (generic) (Travatan Z/generic) RESPIRATORY , ODT (generic) ANTI- AGENTS ANTI-ASTHMATIC AGENTS ______Prednisone (generic) (generic) Devices ...... Cromolyn (generic) Asthma Spacer (Aerochamber/InspirEase/ Epinastine (generic) Optichamber) GOUT THERAPY ANTI-INFECTIVE AGENTS ______Peak Flow Meter (Personal Best/Pocketpeak) Azithromycin(AzaSite) ...... Allopurinol (generic) (generic) Beclomethasone (QVAR) Colchicine/Probenecid (generic) Ciprofloxacin (generic) Budesonide (generic/Pulmicort Flexhaler) Indomethacin (generic) Erythromycin (generic) Budesonide/ (Symbicort) Probenecid (generic) (generic) (Arnuity Ellipta) (generic) (Flovent) Moxifloxacin (generic/Moxeza) Fluticasone/ (Advair/Advair HFA) Neomycin/Bacitracin/Polymyxin (generic) Fluticasone/ (Breo Ellipta) HIV AGENTS Ofloxacin (Ocuflox/generic) Mometasone (Asmanex/Asmanex HFA) Polymyxin B/Trimethoprim (generic) All oral and self injectable FDA-approved HIV Mometasone/Formoterol (Dulera) agents are eligible for coverage under the Sulfacetamide (generic) prescription drug benefit. May be subject to (generic) Sympathomimetics ...... PAB. Moxifloxacin (Vigamox) Albuterol (generic) Formoterol (Foradil/Perforomist) ANTI-INFLAMMATORY AGENTS ______Isoproterenol (generic) (generic) Levalbuterol neb soln. (generic) Cyclosporine (Restasis) Metaproterenol (generic) Dexamethasone (generic) Albuterol (Proair HFA/Proair Diclofenac (generic) ______Respiclick/Ventolin HFA) Diclofenac/misoprostol (generic) (generic) Salmeterol (Serevent Diskus) (Durezol) (generic) (Brethaire) (generic) (generic) Derivatives ...... (generic) Flurbiprofen (Ocufen) (Truphylline/generic) (generic) Ketorolac (generic) Ketotifen Fumarate (generic) (Theo-Dur/Theo-24/ ESTROGENS ______Loteprednol (Lotemax) Uniphyl/generic) Estradiol (generic/Femtrace) (generic) OTHER AGENTS ______Estradiol gel (Divigel) Nepafenac (Ilevro) Albuterol/Ipratropium (Combivent/-Respimat) Estradiol Patch/Spray (generic / Climara Prednisolone (generic) Albuterol/Ipratropium (generic) Pro/Esclim/ Evamist/) Cromolyn (generic) Estrogens, Conjugated (Premarin/Low Dose) ANTI-INFECTIVE & ANTI-INFLAMMATORY Ipratropium (Atrovent HFA) Estrogens, Esterified (Estratab/Menest) COMBINATIONS ______Montelukast (generic) (generic) /Tobramycin (Zylet) (Tilade) COMBINATIONS ______Na Sulfacetm/Prednisolone (generic) Neomy/Bacitracin/Polymyxin/Hydrocort Iodide (SSKI) Estradiol/Norethindrone Acetate (generic) (Broncho-/generic) (generic/CombiPatch) Neomy/Polymyx B/Prednisolone (Poly-Pred) Tiotropium (Spiriva, Spiriva Respimat) Estrogen, Con/ Neomycin/Dexamethasone (Neo-Dex) Tiotropium/vilanterol (Stiolto Respimat) (Prempro/Premphase) Neomycin/Polymyx B/Dexamethasone Tobramycin (generic)^ Estrogen, / (generic) (generic) Umeclidinium/Vilanterol (Anoro Ellipta) Ethinyl Estradiol/Norethindrone Acetate Tobramycin/Dexamethasone (generic) (generic) (generic) ANTIVIRAL AGENTS ______ANTIHISTAMINES/ ______GROWTH ______Trifluridine (generic) Carbinoxamine//DM Somatropin (Humatrope/Nutropin/Nutropin (generic) AQ)*^ BETA-BLOCKERS ______Desloratadine, ODT (generic) PROGESTINS ______Betaxolol (Betoptic/S/generic) Fexofenadine (generic) Carteolol (generic) Desogestrel (Cyclessa) Fexofenadine/PSE (generic) Levobunolol (generic) Medroxyprogesterone (generic) Hydroxyzine (generic) Metipranolol (generic) (generic) Levocetirizine (generic) Timolol (generic) Micronized Progesterone (generic) Promethazine (generic) Norethindrone (generic) MIOTICS ______Pseudoephed/ (generic) Progesterone (generic, Crinone Vaginal Gel) Brinzolamide (Azopt) EXPECTORANT AND PRODUCTS ______Brinzolamide/Brimonidine (Simbrinza) MISCELLANEOUS HORMONE PRODUCTS ______Benzonatate (generic) Dorzolamide (generic) (generic/Casodex) Chlorpheniramine/ Dorzolamide/Timolol (generic) Cabergoline (Dostinex) (generic/TussiCaps) Pilocarpine (generic) (Danocrine) Guaifenesin/Codeine (generic) Desmopressin (Stimate) MYDRIATICS ______Guaifenesin/Codeine/Pseudoephedrine (generic) Atropine (generic) (generic) (Eulexin) Cyclopentolate (Cyclogyl) Guaifenesin/Pseudoephedrine (generic) Methyltestosterone (generic) Homatropine (Isopto Homatropine) Guaifenesin/Hydrocodone (generic) (Sandostatin)^ (Neo-Synephrine) Hydrocodone/Homatropine (generic) (Oxandrin) Tropicamide (Mydriacyl) Phenylephrine/Hydrocodone (generic) (generic, Axiron/Testim) Promethazine/Dextromethorphan (generic) Promethazine/Codeine (generic) (generic, Rapamune) Promethazine/Phenylephrine (generic) Sodium Polystyrene Sulfonatem (generic) Promethazine/Phenylephrine/Codeine Sevelamer (generic, Renvela) (generic) Tacrolimus (generic) NASAL MEDICATIONS ______Thalidomide (Thalomid) Azelastine (generic/ Astepro) Budesonide (generic)

Olopatadine (generic) *Members should refer to their Member Handbook for benefit details regarding applicable copayments or coinsurance. SKELETAL AGENTS

ANTIRHEUMATICS ______^Indicates a drug that is available on tier 4 Auranofin (Ridaura) for members with a four-tier benefit design. (generic) (generic) (generic)

BONE ENHANCING AGENTS ______Alendronate (Fosamax-D/generic) Calcitonin-Salmon (generic) Ibandronate (generic) Etidronate (generic)

Risedronate (generic, Actonel/-with Calcium)

SKELETAL MUSCLE RELAXANTS

Baclofen (generic) (generic) Cyclobenzaprine, ER (generic) Diazepam (generic) Metaxalone (generic)

Methocarbamol (generic) (generic)

URINARY AGENTS ANTI-INFECTIVES ______Nitrofurantoin (generic) Sulfadiazine (generic) Sulfisoxazole (generic) Trimethoprim/Sulfamethoxazole (generic)

CHOLINERGIC AGENTS ______Bethanechol (generic) (generic) OTHER URINARY AGENTS ______Phenazopyridine (generic)

Oxybutynin (generic/-XL) , ER (generic) Trospium, ER (generic) 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 VITAMINS & ELECTROLYTES and symbol are registered marks of the Blue Calcitriol (Rocaltrol) Cross Association.

Dihydrotachysterol (DHT) Express Scripts, Inc. is a separate company that Ergocalciferol (Vitamin D/generic) provides pharmacy services and pharmacy Ferrous Sulfate/Folate/Vit B comp/C (generic) benefit management services on behalf of health Folic Acid (generic) plan members. Multivitamins/Fluoride (generic) Multivits/Fe/Hematin (B-Complex Plus FABC-CA_01/16 Vitamin/generic) Vit A, C & D/Fluoride/Iron (generic) Paricalcitol (generic) Potassium Supplements (generic) Prenatal Vitamins (generic)

MISCELLANEOUS AGENTS Alprostadil (Caverject/Edex)* (Tracleer)^ (Enbrel)*^ Calcium acetate (generic) Cevimeline (generic) Doxercalciferol (generic) (Zortress)

Leucovorin (generic) Methylergonovine (generic) Miglustat (Zavesca)^ Milnacipran (Savella) Mycophenolate (generic/Cellcept) Neostigmine (generic) Pyridostigmine (generic)