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Prescription Program

Drug List — To be used by members who have a three (3) tiered drug plan.

Anthem Blue Cross Blue Shield benefits include available on the Anthem Drug List. Our prescription drug benefits can offer potential savings when your physician prescribes medications on the drug list.

MBCEBRO-11-3T Effective 07/13 ANTHEM BLUE CROSS AND BLUE SHIELD DRUG LIST Your prescription drug benefit includes coverage for medicines that you’ll find on the Anthem Drug List. You can often find more savings when your doctor prescribes medicine that is on our drug list. Here are some commonly asked questions and answers about how the drug list works with your prescription drug plan.

For more information Q. What is a Drug List? about your drug plan, A. The Anthem Drug List, also called a formulary is a list of U.S. Food and Drug Administration you can do the following: (FDA)-approved brand-name and generic drugs that have been reviewed and recommended for their quality and how well they work. The review is done by the National Pharmacy and • Go to anthem.com Therapeutics (P&T) Process. The P&T Process is performed by an independent of • Call customer service practicing doctors and pharmacists in charge of the research and decisions surrounding at the number on your our drug list. This group meets regularly to review new and existing drugs and they choose the top drugs for our list—based on their safety, how they work and their value. ID card Because the drugs on our list are reviewed from time to time, it’s a good idea to check • Speech and hearing the list to find out if any drugs have been added or removed. You can do this by going to impaired users anthem.com. (TDD/TTY) should call Q. What are Tiers? 800-221-6915, Monday A. Drugs on the Anthem Drug List are grouped into tiers. There are several factors that are – Friday, 8:30 a.m. – used to determine under which tier a drug will be put in. This can include (but it’s not 5:00 p.m., ET limited to): • Cost of the drug • Bring a copy of this drug • Cost of the drug in comparison to other drugs used for the same type of treatment list to your next doctor’s • Availability of over-the-counter options visit to help you and • Other clinical and cost factors. your doctor select the Q. What is a brand-name drug? lowest cost medicine A. These are drugs that are developed by a company who holds the rights to sell them. When the rights expire, other drug companies can make their own version of the drugs (see generic drugs below). You may be more familiar with brand-name drugs through advertising or because you know people who take them. 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 if my doctor or I choose a brand-name drug when a generic version is available? A. In most cases, you would be responsible for the Tier 1 copay plus an additional cost share for the cost difference between the brand-name and the generic version. Q. What are “clinically equivalent” medications? How does this affect my drug coverage? KEY FOR DRUG LIST A. When drugs are compared in studies, some drugs have been found to be just as effective as others. These drugs are called “clinically equivalent” so it means they work just as Tier 1 – Lower copayment – Drugs that well. Part of the P&T Process is to review the most current studies to see if multiple drugs offer the greatest value compared to used to treat a disease or a condition have the same effect on a patient. When this is the others that treat the same conditions. case, the Process review team may suggest that we cover only the lower cost drug (so we Some of these are generic versions of can help keep the overall cost of care as low as possible). This means your specific drug brand-name drugs. plan may not cover some drugs (indicated by a ^ symbol next to the drug name) that have Tier 2 – Medium copayment – Brand- clinically equivalent options. name drugs that are generally more affordable. Drugs may also be on this Q. What if my medication is not on the drug list? tier because they are “preferred” A. You may want to first check with your doctor about prescribing a drug that is on the drug among other drugs that treat the same list. If your doctor prescribes a drug that’s not on the drug list, you will need to pay the conditions. This may be based on how copayment that applies to drugs that are not on the list. well they work, if they have less side Q. Can I request that a drug be added to the drug list? effects, if they’re more affordable, etc. A. You or your doctor can put in a request to add a drug to the drug list. You can do this either Tier 3 – Higher copayment – These are in writing or on our website. Requests are reviewed by the P&T Process team during the higher cost brand-name drugs. Some drug list review. Please note that if a drug request is approved, it does not guarantee Tier 3 drugs may have generic versions coverage. Some drugs, such as those used for cosmetic purposes, may be excluded in Tier 1 and may cost more than the from your benefits. Please refer to your Certificate or Evidence of Coverage generic versions on lower tiers. to know for sure.

1 Apri Acetate Cromolyn Epinastine Fluvoxamine, ER DO, QL Tier 1 Asa/codeine Camrese Eprosartan QL Folic Abacavir /caffeine/ Candesartan DO, QL Ergotamine Fondaparinux Acarbose butalbital Candesartan/HCTZ Cyclophosphamide Ergotamine/ Fosinopril DO, QL Acebutolol Atenolol DO, QL belladonna/PB Fosinopril HCTZ Acetaminophen/caffeine/ Atenolol/chlorthalidone Captopril, HCTZ Danazol Furosemide butalb Atorvastatin DO, QL Carbamazepine, ER Dantrolene Erythromycin Gabapentin Acetazolamide, SR Atovaquone/proguanil Carbidopa/levodopa Erythromycin Galantamine, SR Acetic acid sulfate Carbidopa/levodopa CR Desloratadine, ODT QL ethylsuccinate Ganciclovir IV Acetic acid/aluminum Aviane Carbidopa/levodopa/ Desmopressin acetate Erythromycin/ Gemfibrozil acetate Azathioprine entacapone Desonide sulfisoxazole Acetic acid/ Azelastine QL Carisoprodol Desoximetasone Escitalopram DO, QL Gianvi hydrocortisone Azelastine nasal QL Carteolol hcl Dexmethylphenidate Acetic acid otic QL Cartia XT DO, QL Estradiol/ Glipizide XL / Carvedilol Dextromethorphan/ norethindrone PA Glipizide/metformin Acyclovir cap, tab, oint. 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Loperamide Montelukast QL Orphenadrine cpd acid Rizatriptan, ODT QL Lorazepam Morphine ER QL Orphenadrine cpd Forte Pramipexole Ropinirole, ER Losartan DO, QL Morphine sulfate Pramoxine/hc/ Topiramate Losartan/HCTZ DO, QL w/fluoride Oxazepam chloroxylenol Torsemide Lovastatin DO, QL Multivitamins w/folic acid Pravastatin DO, QL , ER 100, 200, Low-ogestrel Mupirocin cream, oint Oxcarbazepine Prazosin Sertraline DO, QL 300mg QL Mycophenolate mofetil Oxycodone Prednisolone Sildenafil PA, QL Tramadol/APAP QL Mebendazole Oxycodone ER QL Prednisolone sodium Silver sulfadiazine Trandolapril Nadolol Oxycodone/APAP QL prosphate Simvastatin DO, QL, PA Trandolapril/verapamil Meclofenamate Naltrexone hcl Oxycodone/aspirin Prednisone – 80mg only 3 drops Alphagan P 0.1% Edurant Lanoxin Premarin oral, vaginal Travatan Z Trazodone Amitiza Effient DO, QL Lantus cream Transderm-Scop PA Analpram HC lotion Elidel ST Leukeran Premphase Trilipix QL Tretinoin micro gel PA Androgel PA, QL Eliquis QL Levemir Prempro Trizivir Triamcinolone acetonide Apriso Emcyt PA Levothroid Priftin Truvada topical, nasal Aricept 23mg Emtriva Lexiva Primaquine TussiCaps Triamterene/HCTZ Armour Thyroid Epipen, JR. 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Acuvail Akne-Mycin Diovan† DO, QL Kuzyme Pramosone 1% cream Topamax Adcirca PA Alkeran Dulera QL Lamictal only, oint, lotion Toviaz Adderall Altabax Durezol QL Lanoxicaps Prandin Tradjenta QL, ST Aggrenox QL 4 Alamast ST, QL^ Betaseron ST Depen Fentora PA, QL Kadian QL Monopril/HCT Aldara PA, QL Betimol Depo-Estradiol Fibricor Kazano QL Morgidox ST Alferon-N Beyaz ST∞, QL Depo-Testosterone Firazyr PA Ketek Multaq Allegra, D ST, QL^ Biaxin XL Derma-Smoothe FS First Testosterone Kineret PA Muse PA Alocril ST, QL^ Binosto QL Detrol First-Lansoprazole Kombiglyze QL Myambutol Alomide ST, QL^ Blephamide ER DO, QL First-Omeprazole Korlym PA Myfortic Alora Boniva IV ST Dexilant ST, QL^ Flector ST K-Phos Myrbetriq ER, ST Alphagan P 0.15% Boniva tab ST, QL Dexpak Flomax Kristalose Mysoline Alsuma ST, QL Byetta ST, QL Diclegis Flonase QL Kytril QL Namenda XR Altace Bystolic Differin 0.1% cream, Floxin Otic Lamictal XR Nardil Altoprev ST, DO Caduet DO gel PA Fluoxetine 60mg Lamisil Spray Nasacort AQ ST, QL Alupent Inhaler Cambia QL Dificid FML Forte Lamisil Tablet Nasarel QL Alvesco QL Capex Dilaudid FML S Lastacaft ST, QL^ Natazia ST∞, QL Ambien CR ST, QL Capoten Diovan HCT DO, QL Focalin, XR Latuda Nesina ST, QL Ambien QL Capozide Dipentum Follistim AQ~ Lazanda PA, QL Neulasta PA, QL Amerge QL Cardene, SR Doryx ST Forfivo XL QL Lescol, XL ST, DO, QL Neumega PA Amevive PA Cardizem CD, LA DO, QL Dovonex Fortamet Letairis Neupogen PA Ampyra PA, QL Cardura, XL Duac Forteo PA, QL Leukine PA Neupro QL Anadrol-50 PA Casodex Duetact QL Fortesta PA, QL Levaquin QL Neurontin Androderm ST, PA, QL Catapres TTS Duexis ST, QL Fosamax tablets QL Levitra PA, QL Niacor Android PA Caverject PA, QL Dutoprol Fosrenol ST Lexapro DO, QL Norditropin PA, QL Antabuse Cedax Dymista QL Fragmin Lipitor DO, QL^ Norinyl 1+50 ST∞, QL Antara Ceftin QL Dynacirc, CR Frova ST, QL Lipofen Noroxin QL Anzemet QL Celebrex ST, QL Edarbi DO, QL Fulyzaq Liptruzet Norvasc DO, QL Apidra ST Cenestin Edarbyclor QL Furadantin Livalo ST, DO, QL Nucynta, ER ST, QL Aplenzin DO, QL Cetrotide Edex PA, QL Ganirelix Lo Loestrin FE ST∞, QL Nutropin~, AQ~ PA, QL Apriso Chemet Edluar SL ST Gastrocrom Loprox gel Nuvigil PA, QL Aquachloral Supprettes Cialis PA, QL Effexor, XR DO, QL Gelnique ST Loprox shampoo Olux E Aranesp PA~ Ciloxan Elestat ST, QL^ Generess FE ST∞, QL Lorabid Omeclamox-Pak Arcapta QL Cimzia PA, QL Eliphos ST Genotropin PA, QL Lorzone Omnaris ST, QL Aricept Cipro XR QL Ella Geodon caps Lotemax gel Omnicef Arimidex PA Clarinex, D ST, QL^ Elmiron Giazo Lotensin, HCT Omnitrope PA, QL Arixtra Cleocin Vaginal Cream Emadine ST, QL^ Gilenya PA, QL Lotrel Onfi Aromasin PA Climara Embeda QL Glumetza Lunesta QL Onglyza QL, ST Arthrotec ST Clobex Emend QL Gonal-f, RFF Lupron Depot PA Onmel Astelin QL Coartem Enablex ST Gralise ER Lupron Depot-Ped PA Onsolis PA, QL Atacand DO, QL Codeine sulfate solution Enbrel PA, QL~ Grifulvin V Luxiq Opana Atacand HCT DO, QL Colazal Entocort EC Hectorol Lyrica PA Opana ER ST, QL Aubagio PA, QL Colestid Epiduo Histex, SR Makena PA Optivar ST, QL^ Augmentin, XR QL Combivir Epivir Horizant ER Malarone Oraxyl Auvi-Q Comtan Epogen PA Humatrope PA, QL~ Marinol Orencia PA, QL Avalide DO, QL Concerta Esclim Humira PA, QL~ Mavik Oseni QL Avandamet ST, QL Conzip ER Estrace vaginal cream Hybolin PA Maxair QL Ovcon-50 ST∞, QL Avandaryl ST, QL Copaxone~ Estraderm Hyzaar DO, QL Maxalt, MLT QL Ovidrel PA Avandia ST, QL Cordran Tape Estrasorb Ilaris Maxaquin QL Oxandrin PA Avapro DO, QL Coreg Estrogel Ilevro Maxidex Oxecta Avelox QL Cortifoam Evoxac Imitrex Nasal Spray QL Methergine Oxtellar XR Avinza QL Cosopt, PF Exalgo ST, QL Imitrex QL Methitest Oxytrol ST Avonex~ Covera HS DO Exelderm Incivek PA MetroGel Pancreaze Axert ST, QL Cozaar DO, QL Exelon Infergen MetroLotion Panretin Azor DO, QL Crinone Extavia ST Innohep Miacalcin Spray QL Parnate Beconase AQ ST, QL Cycloset Factive QL Intermezzo ST, QL Micardis, HCT DO, QL Pataday ST, QL^ Benicar, HCT DO, QL Cytoxan Fanapt Intron A PA Migranal QL Patanase QL Benlysta PA Daliresp QL Fem HRT 1/5 Intuniv Minivelle Patanol ST, QL^ Benzaclin ST DDAVP injection Femara Invega, Sustenna Mirapex, ER Paxil CR DO, QL Bepreve ST, QL^ Delatestryl Femring Invokana Moban Pegasys PA, QL~ Besivance Denavir Fenoglide Juxtapid Mobic QL Peg-Intron PA 5 Penlac Pulmozyme Seroquel Tarka Univasc Xerac AC Pertzye DR Qnasl ST, QL Serostim PA, QL TecfideraPA , QL Urocit-K Xgeva PA, QL Phoslo ST Qualaquin PA, QL Simbrinza Tekamlo DO, QL Uroxatral Xifaxan ST, QL Picato PA, QL Quillivant XR Simcor QL Tekturna, HCT DO, QL Valcyte soln Xolair PA Plan B QL Rayos DR Simponi PA, QL~ Tequin QL Valtrex Xopenex HFA QL Plavix QL Razadyne, ER Singulair QL Testopel PA Vascepa Xopenex Neb. Soln. QL Poly-Histine Elixir Rebif~ Sirturo Testred PA Vaseretic Xyzal ST, QL^ Poly-Pred Rectiv Skelaxin Teveten, HCT QL Vasotec Yasmin Potiga Relenza QL Solodyn ST, PA Tev-Tropin PA, QL Vecamyl Yaz Pramosone 2.5% Relpax , Soma Thyrogen Ventavis Prandimet ST QL PA Zegerid ST, QL^ Remicade PA Somatuline Tiazac DO, QL Verelan PM DO, QL Zerit Pravigard Somavert TOBI Podhaler Precose Renagel ST Vesanoid Zestoretic Requip, XL Sonata ST, QL Tobradex susp. Vexol Zestril Pred Mild 0.12% Soriatane CK Tobrex Rescula Vfend PA Zetia ST, QL Pred-G Sorilux foam Toprol XL Restoril Viagra PA, QL Zetonna ST, QL Prefest Spectracef Toradol QL Retin-A Micro PA Victrelis PA Ziagen tabs Prenate Elite Sporanox Solution PA Tracleer Prevacid , ^ Revatio PA, QL Videx EC Zioptan ST QL Stadol QL Tramadol ER 150mg QL Prevpac QL Rhinocort Aqua ST, QL Viibryd ST, QL Zithranol Starlix Treximet ST, QL Prilosec ST, QL^ Risperdal, M Vimovo Stelara PA, QL~ Tricor QL Zithromax QL Primaxin QL Roxicet QL Striant PA Triglide Vimpat Zmax QL Prinivil Rozerem ST, QL Viokace Zocor DO, PA – Prinzide Subsys PA Trileptal Rythmol, SR Suboxone SL Tab ST Tri-Nasal Viramune 80mg only Procrit PA~ Ryzolt QL Virasal Zofran QL Prolensa Subutex QL Trovan Safyral ST∞, QL Suclear Trusopt Vituz Zoloft DO, QL Prolia PA, QL Saizen PA, QL Vivactil Zolpimist ST, QL Prometrium Sular DO, QL Tudorza Pressair QL Sanctura, XR ST Voltaren Ophth Zomig, ZMT ST, QL Prostin E2 Supp Sumavel Dosepro ST, QL Tussionex ER Sancuso QL Vytorin ST, QL Zorbtive PA, QL Protonix ST, QL^ Suprax QL Twynsta Proventil HFA QL Sandonstatin LAR Sylatron Uceris Wellbutrin XL DO, QL Zovirax Oint Provigil PA, DO, QL Sandostatin Symbyax Uloric ST Wellbutrin, SR DO Zyclara PA, QL Prozac, Weekly QL Saphris Synagis PA Ultram, ER QL Westhroid-P Zyflo Pulmicort Respules Sarafem Synalar Ultravate X Winstrol PA Zyprexa Relprevv 0.25mg/2ml, Seasonale Synarel PA Ultresa Xalatan Zyprexa, Zydis 0.5mg/2ml QL Seasonique Tapazole Uniretic Xeljanz PA, QL Zyvox PA, QL KEY # Non-formulary in only † = A generic equivalent of this drug recently became available or will be available soon. After the generic drug becomes available and notification requirements are met, this brand-name drug will become Tier 3 or may no longer be covered by your prescription drug plan. Check anthem.com to find out about changes in tier status. ^ = This product has clinically equivalent alternatives included on the drug list and, as a consequence, such product may not be covered under your pharmacy benefit. Please consult your on-line pharmacy account through your health plan website, anthem.com, for details on coverage. ~ = Preferred step therapy drug: drug has been chosen to be tried first when treating some conditions. PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month. ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized. Please note: Foradil and Serevent are safety edits that prevent duplication of therapy. ST∞= STEP THERAPY MAY BE REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized. This step therapy may not be required if there is a history of a paid claim for this medication in the prior 6 months. DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule. 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 Residents Only: In selecting medications for the prescription drug formulary, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the formulary by at least one medication. When a closed formulary is in effect, only medications that are included on the formulary are a covered service. In certain clinical situations, a member may require use of a non-formulary product. Anthem has criteria that permits a member to obtain a non-formulary medication in a closed formulary plan. If specific criteria are met, a member can receive a non-formulary drug for a formulary copay. The criteria preserves the clinical integrity of the drug formulary and provides a process by which deviations from the formulary may be allowed. An appeals process is in place for any medications that do not meet the criteria.

For more information, please visit anthem.com. • 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 • Bring a copy of this drug list/formulary to your next doctor’s visit to assist in selecting the lowest cost medications

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In : Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In : Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® , Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross Effective 07/13 and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. MBCEBRO-11-3T