Erythromycin (generic)
INTRODUCTION
APPROVED
FORMULARY
DRUG LIST
Revised 04/2015
LEGEND
In each class, drugs are alphabetically
listed by active ingredient.
If only the word 'generic' appears
within the parenthesis, only the
generic is on Formulary. Example:
Cefaclor (generic) means that the
generic, Cefaclor is covered and the
brand is not covered.
If the word 'generic' does not appear
within the parenthesis, the active
ingredient is only available as a brand
and is on Formulary. The drug name in
parenthesis is the brand name.
Example: Sitagliptin (Januvia) means
that the brand, Januvia is covered and
there is no generic available. Januvia
is the brand name.
If the word 'generic' and the brand
name both appear within the
parenthesis, both the generic and the
brand name drugs are on Formulary.
Example: Warfarin (Coumadin /
generic) means that both the brand
and generic are available. Therefore,
the brand Coumadin and the generic
Warfarin are covered.
* Members should refer to their
Member Handbook for benefit details
regarding applicable copayments or
coinsurance.
Erythromycin/Sulfisoxazole (generic)
Anthem Blue Cross uses a formulary Penicillins ......................................................................
(preferred list of drugs) to help your doctor Amoxicillin (generic)
make prescribing decisions. This list of drugs Amoxicillin/Clavulanate (generic)
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 (generic)
listed on the back of your Anthem Blue Cross Moxifloxacin (generic)
member identification card. Sulfonamides ................................................................
In most cases, if your physician has Erythromycin/Sulfisoxazole (generic)
determined that it is medically necessary for Sulfamethoxazole/Trimethoprim (generic)
you to receive a brand name drug or a drug Sulfisoxazole (generic)
that is not on our list, your physician may Tetracyclines ..................................................................
indicate Dispense as Written or Do Not Doxycycline hyclate (generic)
Substitute on your prescription to ensure Doxycycline monohydrate (generic)
access to the medication through our network Minocycline (generic)
of community pharmacies, excluding drugs Tetracycline (generic)
that require Prior Authorization of Benefits. ANTIFUNGAL AGENTS (ORAL) _________________
Clotrimazole (generic)
Please ask your doctor or pharmacist to refer Fluconazole (generic)
to the Anthem Blue Cross Outpatient
Prescription Drug List for a complete listing of
products.
Flucytosine (generic)
Griseofulvin (generic)
Itraconazole (generic)
Ketoconazole (generic)
Nystatin (generic)
Terbinafine (generic)
USE OF GENERICS
Voriconazole (generic)
Generic drugs are safe and effective
equivalents to brand name medications. In
many cases, if a generic equivalent is
ANTI-MALARIALS____________________________
Atovaquone/Proguanil (generic)
Chloroquine (generic)
available for a brand name product, the brand Mefloquine (generic)
name product will be considered non-preferred Primaquine (Primaquine)
and the generic equivalent will be on the list. Pyrimethamine (Daraprim)
Quinine sulfate (generic)
The FDA has endorsed the use of generic
equivalents and has found their use to be safe ANTI-TUBERCULOSIS AGENTS ________________
and effective. Cycloserine (generic)
Ethambutol (generic)
For medications classified by the FDA as
Isoniazid (generic)
having a narrow therapeutic index (NTI),
Pyrazinamide (generic)
Anthem Blue Cross discourages the use of
Rifabutin (generic)
these generic substitutions.
Rifampin (generic)
OTHER ANTI-INFECTIVES _____________________
Clindamycin (generic)
PRIOR AUTHORIZATION Iodoquinol (Yodoxin)
Ivermectin (generic)
Anthem Blue Cross may require prior Metronidazole (generic)
authorization of benefit (PAB) for certain drugs Tinidazole (generic)
to provide a safe and affordable pharmacy Trimethoprim (generic)
benefit. Drugs which require PAB are often Vancomycin capsule (generic)
medications that are appropriate for only very
specific medical conditions. If your physician
believes that a medication requiring PAB is ANTI-NEOPLASTIC AGENTS
medically appropriate, he or she should
contact Anthems pharmacy benefit manager, All FDA-approved, self-administered injectable
Express Scripts, Inc. in order to initiate the and oral anti-neoplastic agents are eligible for
Prior Authorization Process on your behalf. coverage under the prescription drug benefit.
The list of drugs is subject to change so please May be subject to PAB.
call Customer Service at 1-800-700-2541 or
check our website at
www.anthem.com/ca.com to obtain a complete
ANTI-VIRAL AGENTS
list of PAB drugs.
Acyclovir (generic)
Amantadine (generic)
Entecavir (generic)^
ANTI-INFECTIVE AGENTS Famciclovir (generic)
Ganciclovir (generic)
ANTIBIOTICS _______________________________
Interferon Alfa-2B (Intron A)*^
Cephalosporins ............................................................ Interferon Alfacon-1 (Infergen)*^
Cefaclor (generic) Lamivudine (generic)^
Cefdinir (generic) Oseltamivir (Tamiflu)
Cefadroxil (generic) Peginterferon Alfa-2B (Peg-Intron)*^
Cefditoren (generic) Peginterferon Alfa-2A (Pegasys)*^
Cefprozil (generic) Ribavirin (generic)^
Ceftibuten (generic) Tenofovir (Viread)
Cefuroxime (generic) Valacyclovir (generic)
Cefpodoxamine (generic) Valganciclovir (generic)
Cephalexin (generic)
Macrolides ......................................................................
Azithromycin (generic)
Clarithromycin XL (generic) AUTONOMIC & CENTRAL NERVOUS SYSTEM
 AGENTS
ANALGESICS, NARCOTIC _____________________
Acetaminophen/Codeine (generic)
Aspirin/Codeine (generic)
Codeine Phosphate/Sulfate (generic)
Fentanyl (generic)
Fentanyl Citrate (generic)
Hydrocodone/Acetaminophen (generic)
Hydromorphone, ER (generic)
Meperidine (generic)
Methadone (generic)
Morphine (generic)
Morphine Sulfate, ER (generic)
Oxycodone/Acetaminophen (generic)
Oxycodone/Aspirin (generic)
Oxycododone (Oxycontin)
Oxymorphone, ER (generic)
ANALGESICS, NON-NARCOTIC ________________
APAP/Isometheptene/Dichlphen (generic)
Acetaminophen/Caffeine/Butalbital (generic)
Acetaminophen/Caffeine/Butalbital/Codeine
(generic)
Aspirin/Caffeine/Butalbital (generic)
Ergotamine/Caffeine (generic)
Lidocaine (generic)
Naratriptan (generic)
Rizatriptan, ODT (generic)
Sumatriptan (generic)
Tramadol/-ER (generic)
Zolmitriptan, ODT (generic)
ANALGESICS, NONSTEROIDAL
ANTI-INFLAMMATORY ________________________
Celecoxib (generic)
Diclofenac (generic/Voltaren Gel)
Etodolac (generic)
Flurbiprofen (generic)
Ibuprofen (generic)
Indomethacin (generic)
Ketoprofen (generic)
Ketorolac (generic)
Mefenamic acid (generic)
Nabumetone (generic)
Naproxen (generic)
Oxaprozin (generic)
Piroxicam (generic)
Sulindac (generic)
ANALGESICS, SALICYLATES __________________
Aspirin (generic)
Chol Sal/Magnesium Salicylate (generic)
Diflunisal (generic)
Salsalate (generic)
ANTICONVULSANTS _________________________
Carbamazepine (Tegretol/XR/
Carbatrol/generic)
Clonazepam (generic)
Diazepam (generic/Diastat)
Divalproex Sodium (generic/Depakote/ER)
Ethosuximide (generic)
Felbamate (generic/Felbatol)
Gabapentin (generic)
Tiagabine (Gabitril, generic)
Levetiracetam (generics/Keppra/XR)
Lamotrigine, ER (generic/Lamictal)
Lamotrigine ODT (generic)
Phenobarbital (generic)
Phenytoin (Dilantin/Phenytek/generic)
Primidone (generic)
Oxcarbazepine (generic)
Topiramate (generic/Topamax)
Valproic Acid (Depakene/generic)
Zonisamide (generic)
ANTIPARKINSON AGENTS ____________________
Amantadine (generic)
Benztropine (generic)
Bromocriptine (generic)
Carbidopa (generic)
Carbidopa/Levodopa (generic)
Carbidopa/Levodopa/ Entacapone (generic)
Entacapone (generic)
Pramipexole, ER (generic)
Rasagiline mesylate (Azilect)
Ropinirole, ER (generic)
Selegiline (generic)
Trihexyphenidyl (generic)
ALZHEIMERS AGENTS ______________________ Zolpidem (generic)
Donepezil (generic)
Memantine (Namenda/XR)
Rivastigmine (generic, Exelon patch)
CEREBRAL STIMULANTS_____________________ BLOOD MODIFIERS
Amphet Asp/Amphet/D-Amphet Erythropoietin (Procrit)*^
(Adderall XR/generic) Darbepoetin (Aranesp)*^
Atomoxetine (Strattera) Filgrastim (Neupogen)*^
Dexmethylphenidate (generic) Oprelvekin (Neumega)*^
Dexmethylphenidate XR (generic) Pegfilgrastim (Neulasta)*^
Dextroamphetamine (generic) Sargramostim (Leukine)*^
Lisdexamphetamine (Vyvanse)
Methamphetamine (generic)
Methylphenidate CD (generic)
Methylphenidate ER (Methylin ER/generic) CARDIOVASCULAR AGENTS
Methylphenidate (generic)
ANGIOTENSIN CONVERTING ENZYME
Modafinil (generic)
INHIBITORS AND RECEPTOR BLOCKERS _______
MULTIPLE SCLEROSIS AGENTS _______________ Amlodipine/Valsartan (generic)
Glatiramer Acetate (Copaxone 20mg)*^ Amlodipine/Valsartan/HCTZ (generic)
Interferon Beta-1A (Avonex)*^ Benazepril/HCTZ (generic)
Interferon Beta-1A (Rebif)*^ Benazepril/Amlodipine (generic)
Interferon Beta-1B (Betaseron)*^ Captopril/HCTZ (generic)
OPIOID DEPENDANCE _______________________ Candesartan/HCTZ (generic)
Buprenorphine/Naloxone (generic/Suboxone Enalapril/HCTZ (generic)
SL Film) Eprosartan (generic)
Buprenorphine (generic) Fosinopril/HCTZ (generic)
PSYCHOTHERAPEUTIC AGENTS ______________ Irbesartan/HCTZ (generic)
Lisinopril/HCTZ (generic)
Antidepressants ........................................................... Losartan/HCTZ (generic)
Amitriptyline (generic)
Moexipril/HCTZ (generic)
Bupropion/-XL (generic) Perindopril (generic)
Citalopram (generic) Quinapril/HCTZ (generic)
Desipramine (generic) Ramipril (generic)
Desvenlafaxine (Pristiq) Telmisartan/amlodipine (generic)
Doxepin (generic) Telmisartan/HCTZ (generic)
Duloxetine (generic) Trandolapril (generic)
Escitalopram (generic) Trandolapril/Verapamil (generic)
Fluoxetine (generic) Valsartan/HCTZ (generic)
Fluoxetine/Olanzapine (generic)
Fluvoxamine, ER (generic) ANTI-ADRENERGIC BLOCKERS ________________
Imipramine (generic) Alfuzosin (generic)
Mirtazapine (generic) Doxazosin (generic)
Nortriptyline (generic) Dutasteride (Avodart)
Paroxetine (generic/CR) Dutasteride/Tamsulosin (Jalyn)
Phenelzine (generic) Prazosin (generic)
Sertraline (generic) Terazosin (generic)
Tranylcypromine (generic) Tamsulosin (generic)
Trazodone (generic) ANTIARRHYTHMICS _________________________
Trimipramine (generic) Amiodarone (Cordarone/Pacerone/generic)
Venlafaxine/ER (generic) Digoxin (Lanoxicap/Lanoxin/generic)
Antimanic Agents ......................................................... Disopyramide (generic)
Lithium Carbonate (Eskalith-CR/ Flecainide (generic)
Mexiletine (generic)
Lithobid/generic)
Procainamide (generic)
Lithium Citrate (Lithonate/generic)
Propafenone (generic)
Antipsychotic Agents .................................................. Quinidine Gluconate (generic)
Aripiprazole (Abilify) Sotalol (generic)
Chlorpromazine (generic)
Clomipramine (generic) ANTICOAGULANTS/ANTITHROMBOTICS ________
Clozapine (Fazaclo ODT/generic) Anagrelide (generic)
Fluphenazine (generic) Apixaban (Eliquis)
Haloperidol (generic) Cilostazol (generic)
Loxapine (generic) Clopidogrel (generic)
Olanzapine, ODT (generics) Dabigatran (Pradaxa)
Perphenazine (generic) Dalteparin (Fragmin)*^
Prochlorperazine (generic) Dipyridamole (generic)
Quetiapine (generic/Seroquel XR) Enoxaparin (generic)*^
Risperidone (generic/RisperdalConsta) Fondararinux (generic)*^
Thioridazine (generic) Pentoxifylline (generic)
Thiothixene (generic) Prasugrel (Effient)
Trifluoperazine (generic) Rivaroxaban (Xarelto)
Ziprasidone (generic) Ticagrelor (Brilinta)
Ticlopidine (generic)
SEDATIVES, HYPNOTICS AND ANTI-ANXIETY ____ Tinzaparin (Innohep)*^
Alprazolam (generic) Warfarin (Coumadin/generic)
Buspirone (generic)
Chloral Hydrate (generic) ANTILIPEMICS ______________________________
Chlordiazepoxide (generic) Amlodipine/Atorvastatin (generic)
Clorazepate (generic) Atorvastatin (generic)
Diazepam (generic) Cholestyramine (generic)
Eszopiclone (generic) Colesevelam (Welchol)
Flurazepam (generic) Colestipol (generic)
Lorazepam (generic) Fenofibrate (generic)
Meprobamate (generic) Fenofibric acid (generic)
Oxazepam (generic) Fluvastatin (generic)
Temazepam (generic) Gemfibrozil (generic)
Triazolam (generic) Lovastatin (generic)
Niacin ER (Generic)
Niacin/Lovastatin (Advicor) Clindamycin/benzoyl peroxide Glipizide/Metformin (generic)
Pravastatin (generic) (generic/Acanya/) Glyburide/Metformin (generic)
Rosuvastatin (Crestor) Clindamycin/Tretinoin (Veltin) Glyburide/Micronized (generic)
Simvastatin (generic) Erythromycin (generic/Akne-Mycin) Linagliptin (Tradjenta)
BETA-ADRENERGIC BLOCKERS _______________ Isotretinoin (generic) Linagliptin/Metformin (Jentadueto)
Atenolol/Chlorthalidone (generic) Minocycline (generic) Metformin ,ER (generic)
Bisoprolol/HCTZ (generic) Sodium Sulfacetamide (generic) Miglitol (Glyset)
Carvedilol (Coreg-CR/generic) Tazarotene (Tazorac) Nateglinide (generic)
Labetalol (generic) Tretinoin (generic) Pioglitazone (generic)
Metoprolol/XL/HCTZ (generic) ANTIBIOTICS/ANTIVIRALS ____________________ Pioglitazone/glimepiride (generic)
Pindolol (generic) Acyclovir (generic) Pioglitazone/Metformin (generic/ActoPlus Met
Propranolol/XL/HCTZ (generic) Bacitracin/Polymyxin B (Bacitracin) XR)
Sotalol (generic) Metronidazole (generic) Repaglinide (generic)
Timolol (generic) Mupirocin (Bactroban Nasal/generic) Sitagliptin (Januvia)
Sitagliptin/Metformin (Janumet/XR)
CALCIUM CHANNEL BLOCKERS _______________ Retapamulin (Altabax)
Tolazamide (generic)
Amlodipine (generic) Sodium Sulfacetamide (generic)
Tolbutamide (generic)
Amlodipine/Benazepril (generic) FUNGICIDES _______________________________
Diltiazem (generic) Cicloplrox (generic) ANTIDIABETIC SUPPLIES _____________________
Felodipine (generic) Nystatin/Triamcinolone (generic) Select blood testing supplies, such as
Nicardipine (generic) Econazole (generic) glucometers, lancets, and test strips, may be
Nifedipine (generic) Ketoconazole (generic) covered. Accu-Chek and One Touch are the
only test strips included on formulary. Lifescan
Nisoldipine (generic) TOPICAL ANTI-INFLAMMATORY AGENTS _______ (One Touch, One Touch Ultra); Roche
Verapamil (generic)
Low Potency ................................................................. Diagnostics (Accu-Chek, Aviva). Quantity
CENTRALLY ACTING ANTIHYPERTENSIVES______ Desonide (generic) limits apply. Urine test strips are also a
Clonidine (generic) Fluocinolone (generic) covered benefit.
Methyldopa (generic) Hydrocortisone (generic) GLUCOSE ELEVATING AGENTS _______________
DIURETICS _________________________________ Medium Potency ............................................................ Diazoxide (Proglycem)
Acetazolamide (generic) Desoximetasone (generic) Glucagon (Glucagon)
Amiloride (generic) Fluocinolone (generics)
Chlorthalidone (generic) ANTITHYROID_______________________________
Fluticasone (generic) Methimazole (generic)
Ethacrynic Acid (generic) Mometasone (generic)
Furosemide (generic) Propylthiouracil (generic)
Prednicarbate (generic)
HCTZ/Triamterene (generic) Triamcinolone (generic) THYROID ___________________________________
Hydrochlorothiazide (generic) Levothyroxine (Levothroid/Levoxyl/Unithroid/
Indapamide (generic) High Potency.................................................................. Synthroid/generic)
Methazolamide (generic) Betamethasone Dipropionate (generic) Liothyronine (Cytomel/generic)
Metolazone (generic) Fluocinonide (generic) Liotrix (Thyrolar)
Spironolactone/HCTZ (generic) Ultra-High Potency ........................................................ Thyroid (generic/Armour Thyroid)
Torsemide (generic) Augmented Betamethasone (generic) OTHER ENDOCRINE AGENTS__________________
Triamterene (generic) Clobetasol (generic) Leuprolide (Eligard/Lupron/generic)*^
VASODILATORS _____________________________ Diflorasone (generic)
Hydralazine (generic) VAGINAL/RECTAL PREPARATIONS ____________
Isosorbide Dinitrate/Hydralazine (Bidil) Clindamycin (generic)
Isosorbide Dinitrate (Dilatrate SR/generic) Dienestrol (Ortho-Dienestrol) GASTROINTESTINAL AGENTS
Isosorbide Mononitrate (generic) Estradiol (Estring/Vagifem)
Estrogens, Conjugated (Premarin)
ANTIEMETIC/ANTIVERTIGO ___________________
Minoxidil (generic) Dronabinol (generic)
Nitroglycerin (Nitrostat/Nitrobid/generic) Hydrocortisone/Pramoxine (generic/Analpram
Granisetron (generic)
Nitroglycerin (Nitrek/Nitro-Dur/generic) HC lotion/Pramosone cream, lotion, oint)
Meclizine (generic)
Ranolazine (Ranexa) Mesalamine (Rowasa)
Metoclopramide (generic)
VASOPRESSORS ____________________________ Metronidazole (generic)
Ondansetron (generic)
Epinephrine (Epipen/Jr/Twinject) Nystatin (generic)
Prochlorperazine (generic)
Progesterone (Crinone Vaginal Gel)^
Promethazine (generic)
Sulfanilamide (generic)
Scopolamine (Transderm-Scop)
Sulfathiaz/Sulfacet/Sulfabenz (generic)
CONTRACEPTIVES Trimethobenzamide (generic)
MISCELLANEOUS DERMATOLOGICALS ________
Eth Estradiol/Desogestrel (Apri/generic)
Calcipotriene (generic)
ANTISPASMODIC/GI MOTILITY _________________
Eth Estradiol/Drospirenone (generic) Belladonna/Phenobarbital (generic)
Calcipotriene/betamethasone (generic)
Eth Estradiol/Ethynodioldiacetate (Zovia) Clidinium/Chlordiazepoxide (generic)
Crotamiton (Eurax)
Eth Estradiol/Etonogestrel (Nuvaring) Dicyclomine (generic)
Fluorouracil (Fluoroplex/generic)
Eth Estradiol/Levonorgestrel (Amethia/Amethia Hyoscyamine (generic)
Imiquimod (generic)
Lo/Camrese/Enpresse/Jolessa/Portia/Trivor Propantheline (generic)
Lindane (generic)
a/generic)
Methoxsalen (generic) ANTIULCER ________________________________
Eth Estradiol/Norelgestromin (Xulane) Cimetidine (generic)
Permethrin (Elimite)
Eth Estradiol/Norethindrone (Loestrin FE 24) Esomeprazole magnesium (generic, Nexium
Pimecrolimus (Elidel)
Eth Estradiol/Norethindrone (Balziva) 40mg, packets)
Podofilox (generic)
Eth Estradiol/Norethindrone (Necon/generic) Glycopyrolate (generic)
Selenium Sulfide (generic)
Eth Estradiol/Norethindrone /Ferrous Lansoprazole (generic)
Silver Sulfadiazine (generic)
Fumarate (generic) Lansoprazole/Amoxicillin/Clarithromycin
Tacrolimus ointment (generic)
Eth Estradiol/Norgestimate (Trinessa/ (generic)
TriSprintec/generic) Misoprostol (generic)
Eth Estradiol/Norgestimate (Ortho Tri-Cyclen Nizatidine (generic)
LO) ENDOCRINE AGENTS Omeprazole (generic)
Eth Estradiol/Norgestrel (Low-Ogestrel/ Omeprazole/Sodium Bicarbonate (generic)
Ogestrel) ANTIDIABETIC AGENTS-INJECTABLE __________ Pantoprazole (generic)
Norethindrone (Nora-BE) All forms of insulin are covered. Ranitidine (generic)
EMERGENCY CONTRACEPTIVES _______________ Exenatide (Byetta)* Sucralfate (generic)
Exenatide microspheres (Bydureon)*
Levonorgestrel (generic)
Liraglutide (Victoza)* OTHER GI PRODUCTS ________________________
Pramlintide (Symlin)* Balsalazide (generic)
Budesonide EC(generic)
ANTIDIABETIC AGENTS-ORAL ________________ Hydrocortisone (Cortifoam)
DERMATOLOGICALS Acarbose (generic) Lactulose (generic)
Acetohexamide (generic)
ACNE ______________________________________ Chlorpropamide (generic)
Linaclotide (Linzess)
Adapalene (generic/Differin 0.1% Lotion) Lubiprostone (Amitiza)
Glimepiride (generic) Mesalamine (Apriso/Asacol/Asacol HD/
Azelaic Acid (Finacea)
Glipizide (generic) Delzicol/Pentasa/Lialda/Canasa)
Clindamycin (generic)
Pancreatic Lipase eligible for coverage under the prescription ANTI-INFECTIVE AGENTS _____________________
(Creon/Pancrease/Pancrelipase/Ultrase/ drug benefit. Acetic Acid (generic)
Viokase/Zenpep Acetic Acid/Benzethonium (generic)
Sulfasalazine (generic) Ciprofloxacin (generic)
Ursodiol (generic) Ofloxacin (Floxin Otic/generic)
OPHTHALMICS ANTI-INFECTIVE & ANTI-INFLAMMATORY
ALPHA-AGONIST____________________________ COMBINATIONS _____________________________
Brimonidine Tartrate (generic) Ciprofloxacin/Dexamethasone (Ciprodex)
GLUCOCORTICOIDS
Brimonidine Tartrate/Timolol (Combigan) Neomycin/Polymxin/HC (generic)
Dexamethasone (generic) PROSTAGLANDIN AGONIST __________________
Fludrocortisone (Florinef) Bimatoprost (Lumigan)
Methylprednisolone (generic) Latanoprost (generic)
Prednisolone, ODT (generic) Travoprost (Travatan Z/generic) RESPIRATORY
Prednisone (generic)
ANTI-ALLERGY AGENTS ANTI-ASTHMATIC AGENTS ____________________
Azelastine (generic) Asthma Devices .............................................................
Cromolyn (generic) Asthma Spacer (Aerochamber/InspirEase/
GOUT THERAPY Epinastine (generic) Optichamber)
Allopurinol (generic) ANTI-INFECTIVE AGENTS ____________________ Peak Flow Meter (Personal Best/Pocketpeak)
Colchicine (Colcrys) Azithromycin(AzaSite) Corticosteroids ..............................................................
Colchicine/Probenecid (generic) Chloramphenicol (generic) Beclomethasone (QVAR)
Indomethacin (generic) Ciprofloxacin (generic) Budesonide (generic/Pulmicort Respules
Probenecid (generic) Erythromycin (generic) 1mg/2ml/Pulmicort Flexhaler)
Gatifloxacin (generic) Budesonide/Formoterol (Symbicort)
Gentamicin (generic) Fluticasone furoate (Arnuity Ellipta)
Moxifloxacin (generic/Moxeza) Fluticasone propionate (Flovent)
HIV AGENTS Neomycin/Bacitracin/Polymyxin (generic) Fluticasone/Salmeterol (Advair/Advair HFA)
Ofloxacin (Ocuflox/generic) Fluticasone/Vilanterol (Breo Ellipta)
All oral and self injectable FDA-approved HIV Polymyxin B/Trimethoprim (generic) Mometasone (Asmanex/Asmanex HFA)
agents are eligible for coverage under the Sulfacetamide (generic) Mometasone/Formoterol (Dulera)
prescription drug benefit. May be subject to Tobramycin (generic)
PAB. Sympathomimetics ........................................................
Moxifloxacin (Vigamox) Albuterol (generic)
ANTI-INFLAMMATORY AGENTS _______________ Formoterol (Foradil/Perforomist)
Bromfenac (generic) Isoproterenol (generic)
HORMONES Cyclosporine (Restasis) Levalbuterol neb soln. (generic)
Dexamethasone (generic) Metaproterenol (generic)
ANTIESTROGENS ____________________________ Diclofenac (generic) Albuterol (Proair HFA/Ventolin HFA)
Anastrozole (generic) Diclofenac/misoprostol (generic) Salmeterol (Serevent Diskus)
Exemestane (generic) Difluprednate (Durezol) Terbutaline (Brethaire)
Letrozole (generic) Fluorometholone (generic) Xanthine Derivatives .....................................................
Raloxifene (generic) Flurbiprofen (Ocufen) Aminophylline (Truphylline/generic)
Tamoxifen (generic) Ketorolac (generic) Theophylline (Theo-Dur/Theo-24/
ESTROGENS ________________________________ Ketotifen Fumarate (generic) Uniphyl/generic)
Estradiol (generic/Femtrace) Loteprednol (Lotemax)
Naphazoline (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)
Estropipate (generic) Loteprednol/Tobramycin (Zylet) Nedocromil (Tilade)
ESTROGEN COMBINATIONS ___________________ Na Sulfacetm/Prednisolone (generic) Potassium Iodide (SSKI)
Estradiol/Norethindrone Acetate Neomy/Bacitracin/Polymyxin/Hydrocort Sodium Chloride (Broncho-Saline/generic)
(generic/CombiPatch) (generic) Tiotropium (Spiriva, Spiriva Respimat)
Estrogen, Con/Medroxyprogesterone Neomy/Polymyx B/Prednisolone (Poly-Pred) Tobramycin (generic)^
(Prempro/Premphase) Neomycin/Dexamethasone (Neo-Dex) Umeclidinium/Vilanterol (Anoro Ellipta)
Estrogen, Ester/Methyltestosterone (generic) Neomycin/Polymyx B/Dexamethasone Zafirlukast (generic)
Ethinyl Estradiol/Norethindrone Acetate (generic)
Tobramycin/Dexamethasone (generic) ANTIHISTAMINES/DECONGESTANTS ___________
(generic/Femhrt 1/5)
Carbinoxamine/Pseudoephedrine/DM
GROWTH HORMONE _________________________ ANTIVIRAL AGENTS _________________________ (generic)
Somatropin (Humatrope/Nutropin/Nutropin Trifluridine (generic) Desloratadine, ODT (generic)
AQ)*^ BETA-BLOCKERS ___________________________ Fexofenadine (generic)
PROGESTINS _______________________________ Betaxolol (Betoptic/S/generic) Fexofenadine/PSE (generic)
Desogestrel (Cyclessa) Carteolol (generic) Hydroxyzine (generic)
Medroxyprogesterone (generic) Levobunolol (generic) Levocetirizine (generic)
Megestrol (generic) Metipranolol (generic) Promethazine (generic)
Micronized Progesterone (generic) Timolol (generic) Pseudoephed/Brompheniramine (generic)
Norethindrone (generic) MIOTICS ___________________________________ EXPECTORANT AND COUGH PRODUCTS________
Progesterone (generic, Crinone Vaginal Gel) Brinzolamide (Azopt) Benzonatate (generic)
MISCELLANEOUS HORMONE PRODUCTS _______ Brinzolamide/Brimonidine (Simbrinza) Chlorpheniramine/Hydrocodone
Bicalutamide (generic/Casodex) Dorzolamide (generic) (generic/TussiCaps)
Cabergoline (Dostinex) Dorzolamide/Timolol (generic) Guaifenesin/Codeine (generic)
Danazol (Danocrine) Pilocarpine (generic) Guaifenesin/Codeine/Pseudoephedrine
Desmopressin (Stimate) MYDRIATICS _______________________________ (generic)
Finasteride (generic) Atropine (generic) Guaifenesin/Pseudoephedrine (generic)
Flutamide (Eulexin) Cyclopentolate (Cyclogyl) Guaifenesin/Hydrocodone (generic)
Octreotide (Sandostatin)^ Homatropine (Isopto Homatropine) Hydrocodone/Homatropine (generic)
Oxandrolone (Oxandrin) Phenylephrine (Neo-Synephrine) Phenylephrine/Hydrocodone (generic)
Testosterone (Androgel/Axiron/Testim) Tropicamide (Mydriacyl) Promethazine/Dextromethorphan (generic)
Promethazine/Codeine (generic)
SYMPATHOMIMETICS ________________________
Promethazine/Phenylephrine (generic)
Dipivefrin (generic)
Promethazine/Phenylephrine/Codeine
IMMUNOSUPPRESSIVE AGENTS (generic)
All FDA-approved, self-administered injectable NASAL MEDICATIONS ________________________
and oral immunosuppressive agents are OTICS Azelastine (generic/ Astepro)
Budesonide (generic)
Olopatadine (generic)

*Members should refer to their Member

SKELETAL AGENTS Handbook for benefit details regarding
applicable copayments or coinsurance.
ANTIRHEUMATICS ___________________________
Auranofin (Ridaura)
Azathioprine (generic) ^Indicates a drug that is available on tier 4
Hydroxychloroquine (generic) for members with a four-tier benefit design.
Methotrexate (generic)
BONE ENHANCING AGENTS ___________________
Alendronate (Fosamax-D/generic)
Calcitonin-Salmon (generic)
Ibandronate (generic)
Etidronate (generic)
Risedronate (generic, Actonel 30, 35, and
5mg, Actonel/-with Calcium)

SKELETAL MUSCLE RELAXANTS

Baclofen (generic)
Carisoprodol (generic)
Cyclobenzaprine, ER (generic)
Diazepam (generic)
Metaxalone (generic)
Methocarbamol (generic)
Tizanidine (generic)

URINARY AGENTS
ANTI-INFECTIVES ____________________________
Nitrofurantoin (generic)
Sulfadiazine (generic)
Sulfisoxazole (generic)
Trimethoprim/Sulfamethoxazole (generic)
CHOLINERGIC AGENTS _______________________
Bethanechol (generic)
Flavoxate (generic)
OTHER URINARY AGENTS ____________________
Phenazopyridine (generic)
Oxybutynin (generic/-XL)
Tolterodine, 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)
Ergocalciferol (Vitamin D/generic) Express Scripts, Inc. is a separate company that
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_04/15
Vitamin/generic)
Vit A, C & D/Fluoride/Iron (generic)
Paricalcitol (generic)
Potassium Supplements (generic)
Prenatal Vitamins (generic)

MISCELLANEOUS AGENTS
Alprostadil (Caverject/Edex)*
Bosentan (Tracleer)^
Etanercept (Enbrel)*^
Calcium acetate (generic)
Cevimeline (generic)
Doxercalciferol (generic)
Everolimus (Zortress)
Leucovorin (generic)
Methylergonovine (generic)
Miglustat (Zavesca)^
Milnacipran (Savella)
Mycophenolate (generic/Cellcept)
Neostigmine (generic)
Pyridostigmine (generic)
Sirolimus (generic, Rapamune)
Sodium Polystyrene Sulfonatem (generic)
Sevelamer (generic, Renvela)
Tacrolimus (generic)
Thalidomide (Thalomid)