Erythromycin/Sulfisoxazole (generic) INTRODUCTION Penicillins ...................................................................... Anthem Blue Cross uses a formulary Amoxicillin (generic) (preferred list of drugs) to help your doctor Amoxicillin/Clavulanate (generic/Augmentin make prescribing decisions. This list of drugs chew/XR) is updated quarterly, by a committee Ampicillin (generic) consisting of doctors and pharmacists, so that Dicloxacillin (generic) the list includes drugs that are safe and Penicillin (generic) effective in the treatment of diseases. If you Quinolones ..................................................................... have any questions about the accessibility of Ciprofloxacin/XR (generic) your medication, please call the phone number Levofloxacin (Levaquin) listed on the back of your Anthem Blue Cross Sulfonamides ................................................................ member identification card. Erythromycin/Sulfisoxazole (generic) In most cases, if your physician has Sulfamethoxazole/Trimethoprim (generic) determined that it is medically necessary for Sulfisoxazole (generic) you to receive a brand name drug or a drug Tetracyclines .................................................................. that is not on our list, your physician may Doxycycline hyclate (generic) indicate “Dispense as Written” or “Do Not Minocycline (generic) Substitute” on your prescription to ensure Tetracycline (generic) access to the medication through our network ANTIFUNGAL AGENTS (ORAL) _________________ of community pharmacies, excluding drugs Clotrimazole (generic) that require Prior Authorization of Benefits. Fluconazole (generic) Griseofulvin (generic) Please ask your doctor or pharmacist to refer Itraconazole (generic) to the Anthem Blue Cross Outpatient Ketoconazole (generic) APPROVED Prescription Drug List for a complete listing of Nystatin (generic) products. Terbinafine (generic) ANTI-MALARIALS ____________________________ FORMULARY Chloroquine (generic) USE OF GENERICS Mefloquine (generic) Primaquine (Primaquine) Generic drugs are safe and effective Pyrimethamine (Daraprim) DRUG LIST equivalents to brand name medications. In Pyrimethamine/Sulfadoxine (Fansidar) many cases, if a generic equivalent is Quinine (generic) (CONDENSED VERSION) available for a brand name product, the brand ANTI-TUBERCULOSIS AGENTS _________________ name product will be considered non-preferred Cycloserine (generic) and the generic equivalent will be on the list. Ethambutol (generic) Revised 11/2010 The FDA has endorsed the use of generic Ethionamide (Trecator-SC) equivalents and has found their use to be safe Isoniazid (generic) and effective. Pyrazinamide (generic) Rifabutin (Mycobutin) For medications classified by the FDA as Rifampin (generic) having a narrow therapeutic index (NTI), OTHER ANTI-INFECTIVES ______________________ Anthem Blue Cross discourages the use of these generic substitutions. Clindamycin (generic) Iodoquinol (Yodoxin) Metronidazole (generic) LEGEND Trimethoprim (generic) PRIOR AUTHORIZATION In each class, drugs are alphabetically listed by active ingredient. Anthem Blue Cross may require prior authorization of benefit (PAB) for certain drugs ANTI-NEOPLASTIC AGENTS If only the word 'generic' appears to provide a safe and affordable pharmacy All FDA-approved, self-administered injectable within the parenthesis, only the benefit. Drugs which require PAB are often and oral anti-neoplastic agents are eligible for generic is on Formulary. Example: medications that are appropriate for only very coverage under the prescription drug benefit. Cefaclor (generic) means that the specific medical conditions. If your physician May be subject to PAB. generic, Cefaclor is covered and the believes that a medication requiring PAB is brand is not covered. medically appropriate, he or she should contact WellPoint Pharmacy Management in If the word 'generic' does not appear order to initiate the Prior Authorization Process ANTI-VIRAL AGENTS within the parenthesis, the active on your behalf. The list of drugs is subject to Acyclovir (generic) ingredient is only available as a brand change so please call Customer Service at 1- Amantadine (generic) and is on Formulary. The drug name in 800-700-2541 or check our website at Entecavir (Baraclude) parenthesis is the brand name. www.anthem.com/ca.com to obtain a complete list of PAB drugs. Famciclovir (generic) Example: Levofloxacin (Levaquin) Ganciclovir (generic) means that the brand, Levaquin is Interferon Alfa-2A (Roferon-A)* covered and there is no generic Interferon Alfa-2B (Intron A)* available. Levaquin is the brand name. ANTI-INFECTIVE AGENTS Interferon Alfa-2B/Ribavirin (Rebetron)* Interferon Alfacon-1 (Infergen)* If the word 'generic' and the brand ANTIBIOTICS ________________________________ Lamivudine (Epivir HBV) name both appear within the Cephalosporins ............................................................ Peginterferon Alfa-2B (Peg-Intron)* parenthesis, both the generic and the Cefaclor (generic) Peginterferon Alfa-2A (Pegasys)* brand name drugs are on Formulary. Cefdinir (generic) Ribavirin (generic) Example: Warfarin (Coumadin / Cefadroxil (generic) Tenofovir (Viread) generic) means that both the brand Cefditoren (generic) Valacyclovir (generic/Valtrex) and generic are available. Therefore, Cefprozil (generic) Valganciclovir (Valcyte) the brand Coumadin and the generic Cefuroxime (generic) Warfarin are covered. Cefpodoxamine (generic) Cephalexin (generic) * Members should refer to their Cephradine (generic) AUTONOMIC & CENTRAL NERVOUS SYSTEM Member Handbook for benefit details Macrolides ...................................................................... AGENTS regarding applicable copayments or Azithromycin (generic) ANALGESICS, NARCOTIC ______________________ coinsurance. Clarithromycin XL (generic) Acetaminophen/Codeine (generic) Erythromycin (generic) Aspirin/Codeine (generic) Codeine Phosphate/Sulfate (generic) CEREBRAL STIMULANTS _____________________ Darbepoetin (Aranesp)* Fentanyl (generic) Amphet Asp/Amphet/D-Amphet Filgrastim (Neupogen)* Fentanyl Citrate (generic) (Adderall XR/generic) Oprelvekin (Neumega)* Hydrocodone/Acetaminophen (generic) Armodanafil (Nuvigil) Pegfilgrastim (Neulasta)* Hydromorphone (generic) Atomoxetine (Strattera) Sargramostim (Leukine)* Meperidine (generic) Dexmethylphenidate (generic) Methadone (generic) Dextroamphetamine (generic) Morphine (generic) Lisdexamphetamine (Vyvanse) Morphine Sulfate (generic /Avinza/MS Contin) Methamphetamine (generic) CARDIOVASCULAR AGENTS Oxycodone/Acetaminophen (generic) Methylphenidate ER (Concerta/Methylin ER) ANGIOTENSIN CONVERTING ENZYME Oxycodone/Aspirin (generic) Methylphenidate (generic) INHIBITORS AND RECEPTOR BLOCKERS ________ Oxycododone (Oxycontin/generic) MULTIPLE SCLEROSIS AGENTS _______________ Amlodipine/Valsartan/HCTZ (Exforge/ Exforge Propoxyphene (generic) Glatiramer Acetate (Copaxone)* HCT) Propoxyphene Compound (generic) Interferon Beta-1A (Avonex)* Benazepril/HCTZ (generic) Propoxyphene/Acetaminophen (generic) Interferon Beta-1A (Rebif)* Benazepril/Amlodipine (generic) ANALGESICS, NON-NARCOTIC _________________ Interferon Beta-1B (Betaseron)* Captopril/HCTZ (generic) APAP/Isometheptene/Dichlphen (generic) OPIOID DEPENDANCE ________________________ Enalapril/HCTZ (generic) Acetaminophen/Caffeine/Butalbital (generic) Buprenorphine/Naloxone (Suboxone SL/SL Fosinopril/HCTZ (generic) Aspirin/Caffeine/Butalbital (generic) Film) Lisinopril/HCTZ (generic) Ergotamine (Ergomar) Buprenorphine (generic) Losartan/HCTZ (generic) Ergotamine/Caffeine (generic) PSYCHOTHERAPEUTIC AGENTS ______________ Moexipril/HCTZ (generic) Lidocaine (Lidoderm) Perindopril (generic) Methysergide (Sansert) Antidepressants ........................................................... Quinapril/HCTZ (generic) Naratriptan (generic) Amitriptyline (generic) Ramipril (generic) Rizatriptan (Maxalt/MLT) Bupropion/-XL (generic) Trandolapril (generic) Sumatriptan (generic/Imitrex Nasal Spray) Citalopram (generic) Trandolapril/Verapamil (generic) Tramadol/-ER (generic) Desipramine (generic) Valsartan/HCTZ (Diovan/Diovan HCT) Zolmitriptan (Zomig/ZMT) Desvenlafaxine (Pristiq) ANTI-ADRENERGIC BLOCKERS ________________ Doxepin (generic) ANALGESICS, NONSTEROIDAL Alfuzosin(Uroxatral) Duloxetine (Cymbalta) ANTI-INFLAMMATORY ________________________ Doxazosin (generic) Escitalopram (Lexapro) Diclofenac (generic/Voltaren Gel) Dutasteride (Avodart) Fluoxetine (generic) Etodolac (generic) Dutasteride/Tamsulosin (Jalyn) Fluoxetine/Olanzapine (Symbyax) Flurbiprofen (generic) Prazosin (generic) Fluvoxamine (generic) Ibuprofen (generic) Terazosin (generic) Imipramine (generic) Indomethacin (generic) Tamsulosin (generic/Flomax) Mirtazapine (generic) Ketoprofen (generic) ANTIARRHYTHMICS __________________________ Ketorolac (generic) Nortriptyline (generic) Paroxetine (generic/CR) Amiodarone (Cordarone/Pacerone/generic) Nabumetone (generic) Digoxin (Lanoxicap/Lanoxin/generic) Naproxen (generic) Phenelzine (Nardil) Disopyramide (generic) Naproxen/Sumatriptan (Treximet) Sertraline (generic) Flecainide (generic) Oxaprozin (generic) Tranylcypromine (Parnate) Trazodone (generic) Mexiletine (generic) Piroxicam (generic) Moricizine (Ethmozine) Sulindac (generic) Venlafaxine/ER (generic/Effexor XR) Antimanic Agents ......................................................... Procainamide (generic) ANALGESICS, SALICYLATES __________________ Propafenone (generic) Lithium Carbonate (Eskalith-CR/ Aspirin (generic) Quinidine Gluconate