The Local Choice Key Advantage Prescription Drug List by Tier Anthem Blue Cross Blue Shield prescription drug benefits include medications available on the Key Advantage Drug List. Our prescription drug benefits can offer potential savings when your physician prescribes medications on the drug list. The Local Choice Key Advantage Drug List Your prescription drug benefit includes coverage for medicines that you’ll find on the 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. Q. What is a Drug List? A. The Local Choice Key Advantage Drug List is a list of U.S. Food and Drug Administration (FDA)-approved brand-name and generic drugs that have been reviewed and recommended for your Plan. Because the drugs on our list are reviewed from time to time, it’s a good idea to check the list to find out if any drugs have been added, removed, or changed tiers. You can do this by going to anthem.com/tlc. Q. What are Tiers? A. Drugs on the Key Advantage Drug List are grouped into tiers. There are several factors that are used to determine under which tier a drug will be placed. This can include (but it’s not limited to): Key for drug list • Cost of the drug • Cost of the drug in comparison to other drugs used for the same type of treatment TIER 1 – Lower copayment – Drugs • Availability of over-the-counter options that offer the greatest value compared • Other clinical and cost factors to others that treat the same conditions. Some of these are generic Q. What is a brand-name drug? versions of brand-name drugs. 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 TIER 2 – Medium copayment – Brand- drugs below). You may be more familiar with brand-name drugs through advertising or because name drugs that are generally more you know people who take them. affordable. Drugs may also be on this tier because they are “preferred” Q. What is a generic drug? among other drugs that treat the same A. Generics are simply copies of brand-name drugs. Brand-name and generic drugs have the conditions. This may be based on how same active ingredients, strength and dose. And the FDA requires that generic drugs meet well they work, if they have less side the same high standards for purity, quality, safety and strength. With generics, you get the effects, if they’re more affordable, etc. same quality for less money. TIER 3 – Higher copayment – These Q. What if my doctor or I choose a brand-name drug when a generic version is are higher cost brand-name drugs. available? Some Tier 3 drugs may have generic A. In most cases, you would be responsible for the brand name copay plus an additional cost versions in Tier 1 and may cost more difference between the brand-name medication and the generic version. Members who take than the generic versions on lower drugs in the Immunosuppressant, Anticonvulsant and Psychotherapeutic categories will pay no tiers. more than $100 per 34-day supply at retail and $200 per 90-day supply via mail service. TIER 4 – Many drugs on this tier are Q. How are contraceptives now covered under the Affordable Care Act (ACA)? “specialty” drugs used to treat A. Effective July 1, 2013, all FDA approved generic oral contraceptives including the complex, chronic conditions and may Orth-Evra patch and Nuvaring will be covered at 100% with no member copayment. require special handling and/or management. Q. What if my medication is not listed? A. This drug list contains the most commonly prescribed drugs and their associated tier. If your drug is not listed, please call Anthem Member Services at 800-552-2682 or go to anthem.com/tlc for additional information. Page 1 Apri Camrese Cormax ST TIER 1 Asa/codeine Candesartan DO, QL Cromolyn Aspirin/caffeine/butalbital Candesartan/HCTZ DO, QL Cyclobenzaprine Aspirin/caffeine/dihydrocodeine Capecitabine PA Cyclopentolate Abacavir Atenolol Captopril, HCTZ Cyclophosphamide tabs Abacavir/lamivudine/zidovudine Atenolol/chlorthalidone Carbamazepine, ER Cyproheptadine Acamprosate Atorvastaitin DO, QL Carbidopa Danazol Acarbose Atovaquone Carbidopa/levodopa Dantrolene Acebutolol Atovaquone/proguanil Carbidopa/levodopa CR Desipramine Acetaminophen/caffeine/butalb QL Atropine sulfate Carbidopa/levodopa/ Desloratadine, ODT QL Acetaminophen/caffeine/butalbital/ Aviane entacapone Desmopressin acetate Codeine QL Azathioprine Carisoprodol Desonide ST Acetazolamide, SR Azelastine eye drops QL Carteolol hcl Desoximetasone ST Acetic acid Azelastine nasal spray QL Cartia XT DO, QL Dexmethylphenidate, ER Acetic acid/aluminum acetate Azithromycin QL Carvedilol Dextroamphetamine Acetic acid/hydrocortisone Bacitracine zine/polymyxin B Cefaclor Dextromethorphan/guaifenesin Acetic acid otic Bacitracin/polymyxin/ Cefaclor ER Diazepam Acetylcysteine neomycin-hc opth ointment Cefadroxil Diclofenac potassium Acitretin Baclofen Cefdinir Diclofenac sodium gel PA, QL Acyclovir capsule, tablet, ointment Balsalazide Cefpodoxime Diclofenac sodium ophth. Adapalene Belladonna/phenobarbital Cefprozil Diclofenac sodium solution Ala-Cort ST Benazepril, HCTZ Ceftibuten Diclofenac, ER Albuterol Benzoyl peroxide Cefuroxime QL Diclofenac/misoprostol ST Albuterol/ipratropium Benzoyl peroxide/clindamycin Cephalexin Dicloxacillin Alendronate QL Benzoyl peroxide/erythromycin Cevimeline Dicyclomine Alfuzosin Benztropine Chloral hydrate Didanosine Allopurinol Betamet diprop/prop gyl Chlordiazepoxide Diflorasone diacetate ST Alprazolam Betamethasone dipropionate ST Chlorhexidine gluconate Diflunisal Amantadine Betamethasone-valerate ST Chloroquine 250mg Digoxin Amcinonide ST Betaxolol Chlorothiazide Dihydroegotamine Nasal Amethia Bethanechol Chlorphen/pyrilamine/ Spray QL Amethia lo Bicalutamide phenylephrine Diltia XT DO, QL Amiloride Bisoprolol Chlorpheniramine/ Diltiazem DO, QL Amiloride/hydrochlorothiazide Bisoprolol/HCTZ pseudoephedrine Diltiazem CD DO, QL Aminophylline Brimonidine Chlorpromazine tablet PA Diltiazem CR DO, QL Amiodarone Bromfenac Chlorpropamide Diltiazem SR DO, QL Amitriptyline Bromocriptine Chlorthalidone Diphenhydramine 50mg Amitriptyline/chlordiazepoxide Budeprion XL DO, QL Chlorzoxazone Diphenoxylate/atropine sulfate Amitriptyline/perphenazine Budesonide 0.25mg/2ml, 0.5mg/ Cholestyramine, light Dipivefrin HCI Amlodipine DO, QL 2ml QL Ciclopirox Dipyridamole Amlodipine/atorvastatin DO Budesonide EC Cimetidine Disopyramide Amlodipine/benazepril Budesonide nasal spray QL Ciprofloxacin QL Disopyramide CR 150mg Amlodipine/valsartan DO, QL Bumetanide Citalopram DO, QL Disulfiram Amlodipine/valsartan/hctz DO, QL Buprenorphine QL Clemastine fumarate Divalproex, ER Amnesteem QL Buprenorphine/naloxone Clindamycin Donepezil Amoxapine tablet QL, PA Clobetasol Dorzolamide Amoxicillin Buproban 150mg QL Clomipramine Dorzolamide/timolol Amoxicillin/clavulanate, ER QL Bupropion QL Clonazepam Doxazosin mesylate Amphetamine Buspirone Clonidine Doxepin Amphetamine­ Butalbital Compound w/Codeine Clonidine ER Doxercalciferol dextroamphetamine Butorphanol tartrate Clopidogrel QL Doxycycline (except 40mg ST Amphetamine­ 10mg/ml N.S. QL Clorazepate capsule) dextroamphetamine ER Cabergoline Clotrimazole/betamethasone Doxycycline DR ST Ampicillin Calcipotriene Clozapine, ODT Doxycycline monohydrate ST Anastrozole Calcipotriene/betamethasone Codeine sulfate tabs Dronabinol Antipyrine/benzocaine Calcium Acetate Codeine/APAP QL Duloxetine DO, QL Page 2 Dyphylline Flutamide Imipramine Loperamide Econazole Fluticasone ST Imiquimod QL Lorazepam Enalapril, HCTZ Fluvastatin DO Indapamide Losartan DO, QL Enoxaparin Fluvoxamine ER, DO, QL Indomethacin, SR Losartan/HCTZ DO, QL Entacapone Fondaparinux Ipratropium Bromide nebulizer Lovastatin DO, QL Entecavir Fosinopril DO, QL solution/nasal spray QL Low-ogestrel Epinastine Fosinopril HCTZ Irbesartan DO, QL Loxapine PA Eprosartan QL Furosemide Irbesartan/HCTZ DO, QL Mebendazole Ergotamine Gebapentin Iron combination capsule Meclizine Ergotamine/belladonna/PB Galantamine, SR Iron/intrinsic factor/B12 Meclofenamate Erythromycin Ganciclovir IV Iron/B12/folic acid Medroxyprogesterone Erthromycin base Gatifloxacin eye drops Isometh/caffeine/APAP Mefenamic acid Erythromycin ethylsuccinate Gemfibrozil Isometh/dichlphen/APAP Mefloquine Erthyromycin/sulfisoxazole Gentamicin Isoniazid Megestrol Escitalopram DO, QL Gianvi Isosorbide dinitrate Meloxicam QL Esomeprazole Magnesium Glatopa PA, ST Isosorbide mononitrate Meperidine Estradiol Glimepiride Isotretinoin QL, PA Meperidine w/promethazine Estradiol/norethindrone PA Glipizide XL Isradipine QL Mercaptopurine Estropipate Glipizide/metformin Itraconazole PA Metaproterenol Eszopiclone QL Glyburide Ivermectin Metaxalone ST Ethambutol Glyburide micronized Jinteli Metformin, ER Ethinyl estradiol/ Glyburide/metformin Ketoconazole Meth/salicylate/atropine/ ethynodiol diacetate Glycolax Ketoprofen, ER hyos benzoic Ethinyl estradiol/norethindrone Granisetron QL Ketorolac QL Methadone PA Ethosuximide Griseofulvin Ketorolac tromethamine Methamphetamine Etodolac Guaifenesin Labetalol Methazolamide Etodolac ER Guaifenesin SR Lactulose Methenamine/hyosc-meth blue/ Etoposide Guaifenesin/dextrometh Lamivudine sod biphos-phenyl sal Exemestane PA Guaifenesin/hydrocodone Lamivudine HBV 100mg Methimazole Famciclovir Guanabenz Lamivudine/zidovudine Methocarbamol Famotidine Guanfacine, ER Lamotrigine,