Prescription Program Drug List — To be used by members who have a three (3) tiered drug plan. Anthem Blue Cross Blue Shield prescription drug benefits include medications 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 group 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 generic drug? 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 medication 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 insurance Certificate or Evidence of Coverage generic versions on lower tiers. to know for sure. 1 Apri Calcium Acetate Cromolyn Epinastine Fluvoxamine, ER DO, QL Tier 1 Asa/codeine Camrese Cyclobenzaprine Eprosartan QL Folic acid Abacavir Aspirin/caffeine/ Candesartan DO, QL Cyclopentolate Ergotamine Fondaparinux Acarbose butalbital Candesartan/HCTZ Cyclophosphamide Ergotamine/ Fosinopril DO, QL Acebutolol Atenolol DO, QL Cyproheptadine belladonna/PB Fosinopril HCTZ Acetaminophen/caffeine/ Atenolol/chlorthalidone Captopril, HCTZ Danazol Erythromycin Furosemide butalb Atorvastatin DO, QL Carbamazepine, ER Dantrolene Erythromycin base Gabapentin Acetazolamide, SR Atovaquone/proguanil Carbidopa/levodopa Desipramine Erythromycin Galantamine, SR Acetic acid Atropine 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 Gentamicin Acetic acid/ Azelastine QL Carisoprodol Desoximetasone Escitalopram DO, QL Gianvi hydrocortisone Azelastine nasal QL Carteolol hcl Dexmethylphenidate Estradiol Glimepiride Acetic acid otic Azithromycin QL Cartia XT DO, QL Dextroamphetamine Estradiol/ Glipizide XL Acetylcysteine Bacitracin zinc/ Carvedilol Dextromethorphan/ norethindrone PA Glipizide/metformin Acyclovir cap, tab, oint. polymyxin B Cefaclor guaifenesin Estropipate Glyburide Adapalene Bacitracin/polymyxin/ Cefaclor ER Diazepam Ethambutol Glyburide micronized Ethinyl estradiol/ Adderall XR neomycin-hc opth oint Cefadroxil Diclofenac potassium Glyburide/metformin ethynodiol diacetate Albuterol Baclofen Cefdinir Diclofenac sodium Ophth. Glycolax Cefpodoxime Ethinyl estradiol/ Albuterol/ipratropium Balsalazide Diclofenac, ER Granisetron QL Cefprozil norethindrone Alendronate QL Belladonna/ Diclofenac/misoprostol Griseofulvin phenobarbital Cefuroxime Dicloxacillin Ethosuximide Alfuzosin QL Guaifenesin Benazepril, HCTZ Cephalexin Dicyclomine Etodolac Allopurinol Guaifenesin SR Benzoyl peroxide Cevimeline Didanosine Etodolac ER Alprazolam Guaifenesin/dextrometh Benzoyl peroxide/ Chloral hydrate Diflorasone diacetate Etoposide Amantadine Guaifenesin/hydrocodone Amcinonide clindamycin Chlordiazepoxide Diflunisal Exemestane PA Benzoyl peroxide/ Chlorhexidine gluconate Digoxin Famciclovir Guanabenz Amethia Guanfacine Amethia lo erythromycin Chloroquine 250mg Dihydroergotamine Famotidine Halobetasol Amiloride Benztropine Chlorothiazide nasal spray QL Felbamate Haloperidol Amiloride/ Betamet diprop/prop gyl Chlorphen/pyrilamine/ Diltia XT DO, QL Felodopine DO, QL hydrochlorothiazide Betamethasone phenylephrine Diltiazem Fenofibrate Heparin Aminophylline dipropionate Chlorpheniramine/ Diltiazem CD DO, QL Fenofibric acid Homatropine Amiodarone Betamethasone valerate pseudoephedrine Diltiazem CR DO, QL Fenoprofen Hydralazine Amitriptyline Betaxolol Chlorpromazine tab Diltiazem SR DO, QL Fentanyl PA, QL Hydralazine/HCTZ Amitriptyline/ Bethanechol Chlorpropamide Diphenhydramine 50mg Fexofenadine QL Hydrochlorothiazide chlordiazepoxide Bicalutamide Chlorthalidone Diphenoxylate/atropine Fexofenadine/PSE Hydrocodone Amitriptyline/ Bisoprolol Chlorzoxazone sulfate 12hr QL w/homatropine perphenazine Bisoprolol/HCTZ Cholestyramine, light Dipivefrin HCl Finasteride Hydrocodone/APAP QL Amlodipine DO, QL Brimonidine Chorionic gonadotropin Dipyridamole Flecainide Hydrocodone/ Amlodipine/ Bromfenac Ciclopirox Disopyramide Fluconazole chlorpheniramine atorvastatin DO Bromocriptine Cimetidine Disopyramide CR 150mg Flucytosine Hydrocortisone 2.5% Amlodipine/benazepril Budeprion XL DO, QL Ciprofloxacin QL Disulfiram Fludrocortisone cream, ointment, lotion Amnesteem QL Budesonide 0.25mg/2ml, Citalopram DO, QL Divalproex, ER Flunisolide Nasal Hydrocortisone enema Amphetamine- 0.5mg/2ml QL Clemastine fumarate Donepezil Spray ST, QL Hydrocortisone/ dextroamphetamine Budesonide EC Clindamycin Dorzolamide Fluocinolone acetonide pramoxine Amphetamine- Bumetanide Clobetasol Dorzolamide/timolol Fluocinonide Hydromorphone dextroamphetamine Buprenorphine QL Clomiphene Doxazosin mesylate Fluorometholone Hydroxychloroquine ER ST^# Buprenorphine/naloxone