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

For more information
about your drug plan,
you can do the following:
• Go to anthem.com
• Call customer service
at the number on your
ID card
• Speech and hearing
impaired users
(TDD/TTY) should call
800-221-6915, Monday
– Friday, 8:30 a.m. –
5:00 p.m., ET
• Bring a copy of this drug
list to your next doctor’s
visit to help you and
your doctor select the
lowest cost medicine
KEY FOR DRUG LIST
Tier 1 – Lower copayment – Drugs that
offer the greatest value compared to
others that treat the same conditions.
Some of these are generic versions of
brand-name drugs.
Tier 2 – Medium copayment – Brand-
name drugs that are generally more
affordable. Drugs may also be on this
tier because they are “preferred”
among other drugs that treat the same
conditions. This may be based on how
well they work, if they have less side
effects, if they’re more affordable, etc.
Tier 3 – Higher copayment – These are
higher cost brand-name drugs. Some
Tier 3 drugs may have generic versions
in Tier 1 and may cost more than the
generic versions on lower tiers.
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.
Q. What is a Drug List?
A. The Anthem Drug List, also called a formulary is a list of U.S. Food and Drug Administration
(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
Therapeutics (P&T) Process. The P&T Process is performed by an independent group of
practicing doctors and pharmacists in charge of the research and decisions surrounding
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.
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 or removed. You can do this by going to
anthem.com.
Q. What are Tiers?
A. Drugs on the Anthem Drug List are grouped into tiers. There are several factors that are
used to determine under which tier a drug will be put in. This can include (but it’s not
limited to):
• Cost of the drug
• Cost of the drug in comparison to other drugs used for the same type of treatment
• Availability of over-the-counter options
• Other clinical and cost factors.
Q. What is a brand-name drug?
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?
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
well. Part of the P&T Process is to review the most current studies to see if multiple drugs
used to treat a disease or a condition have the same effect on a patient. When this is the
case, the Process review team may suggest that we cover only the lower cost drug (so we
can help keep the overall cost of care as low as possible). This means your specific drug
plan may not cover some drugs (indicated by a ^ symbol next to the drug name) that have
clinically equivalent options.
Q. What if my medication is not on the drug list?
A. You may want to first check with your doctor about prescribing a drug that is on the drug
list. If your doctor prescribes a drug that’s not on the drug list, you will need to pay the
copayment that applies to drugs that are not on the list.
Q. Can I request that a drug be added to the drug list?
A. You or your doctor can put in a request to add a drug to the drug list. You can do this either
in writing or on our website. Requests are reviewed by the P&T Process team during the
drug list review. Please note that if a drug request is approved, it does not guarantee
coverage. Some drugs, such as those used for cosmetic purposes, may be excluded
from your benefits. Please refer to your insurance Certificate or Evidence of Coverage
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
Adderall XR neomycin-hc opth oint Cefadroxil Diclofenac potassium Ethinyl estradiol/
Glyburide/metformin
Albuterol Baclofen Cefdinir Diclofenac sodium Ophth. ethynodiol diacetate
Ethinyl estradiol/ Glycolax
Albuterol/ipratropium Balsalazide Cefpodoxime Diclofenac, ER Granisetron QL
Alendronate QL Belladonna/ Cefprozil Diclofenac/misoprostol norethindrone
Ethosuximide Griseofulvin
Alfuzosin phenobarbital Cefuroxime QL Dicloxacillin
Etodolac Guaifenesin
Allopurinol Benazepril, HCTZ Cephalexin Dicyclomine
Etodolac ER Guaifenesin SR
Alprazolam Benzoyl peroxide Cevimeline Didanosine
Etoposide Guaifenesin/dextrometh
Amantadine Benzoyl peroxide/ Chloral hydrate Diflorasone diacetate
clindamycin Chlordiazepoxide Exemestane PA Guaifenesin/hydrocodone
Amcinonide Diflunisal
Benzoyl peroxide/ Chlorhexidine gluconate Digoxin Famciclovir Guanabenz
Amethia Guanfacine
Amethia lo erythromycin Chloroquine 250mg Dihydroergotamine Famotidine
Benztropine Chlorothiazide nasal spray QL Felbamate Halobetasol
Amiloride
Betamet diprop/prop gyl Chlorphen/pyrilamine/ Diltia XT DO, QL Felodopine DO, QL Haloperidol
Amiloride/
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 Clomipramine Doxepin Fluorouracil Hydroxyurea
Amoxapine tablet QL Clonazepam Doxycycline Fluoxetine DO, QL Hydroxyzine HCL
Amoxicillin Bupropion QL Clonidine Doxycycline DR ST Fluphenazine Hydroxyzine pamoate
Amoxicillin/clavulanate, Buspirone Clopidogrel QL Doxycycline monohydrate Flurazepam Hyoscyamine
ER QL Butalbital Compound Clorazepate Dronabinol Flurbiprofen Ibandronate ST, QL
Amphetamine w/Codeine Clotrimazole/ Dyphylline Flurbiprofen sodium Ibuprofen
Ampicillin Butorphanol tartrate betamethasone Econazole Flutamide Imipramine
Anastrozole 10mg/ml N.S. QL Clozapine, ODT Enalapril, HCTZ Fluticasone Nasal Imiquimod QL
Antipyrine/benzocaine Cabergoline Codeine sulfate tabs Enoxaparin Spray QL Indapamide
APAP/caffeine/butalbital Calcipotriene Codeine/APAP QL Entacapone Fluvastatin DO Indomethacin, SR
2
Ipratropium bromide neb Medroxyprogesterone Naphazoline Oxymorphone, ER QL Prenatal mulitvitamins Sodium citrate &
soln/nasal spray QL Mefenamic acid Naproxen Oxytocin and minerals/iron/ citric acid
Irbesartan DO, QL Mefloquine Naproxen EC Pantoprazole QL folic acid Sodium fluoride
Irbesartan/HCTZ DO, QL Megestrol Naproxen sodium, DS Paroxetine, SR DO, QL Prenatal vitamin Sodium polystyrene
Iron combination capsule Meloxicam QL Naratriptan QL Penicillin V.K. Prenatal w/docusate, sulfonate
Iron/intrinsic factor/B12 Meperidine Nateglinide Pentamidine isethionate iron, folic acid Sodium sulfacetamide/
Iron/B12/folic acid Meperidine Necon Pentazocine nx Primidone sulfur
Isometh/dichlphen/APAP w/promethazine Neomycin Pentazocine/apap Probenecid Sotret QL
Isoniazid Mercaptopurine Neomycin/ Pentoxifylline Probenecid/colchicine Spironolactone
Isosorbide dinitrate Metaproterenol dexamethasone Pergolide Procainamide, SR Spironolactone/HCTZ
Isosorbide mononitrate Metaxalone Neomycin/polymyxin/ Perindopril Prochlorperazine Stannous fluoride
Isotretinoin QL Metformin, ER bacitracin Permethrin Prochlorperazine supp Stavudine
Itraconazole PA Meth/salicylate/ Neomycin/polymyxin/ Perphenazine 25mg Sucralfate
Jinteli atropine/hyos benzoic dexamethasone Phenazopyridine Progesterone caps Sulfacet sod w/sulfur
Ketoconazole Methadone Neomycin/polymyxin/ Phenelzine Promethazine Sulfacetamide sodium
Ketoprofen, ER Methamphetamine gramicidin Phenobarbital Promethazine/codeine solution
Ketorolac QL Methazolamide Neomycin/polymixin/ Phenyleph hcl/hydrocod Promethazine/ Sulfacetamide sodium/
Ketorolac tromethamine Methenamine/hyosc- hydrocortisone bit/cp dextromethorphan prednisoloneophth sol.
Labetalol meth blue/sod biphos- Neosol Phenyleph/chlorphen/ Promethazine/ Sulfamethoxazole/
Lactulose phenyl sal Nevirapine carbeta phenylephrine trimethoprim, DS
Lamivudine Methimazole Next Choice QL Phenyleph/chlorphen/ Propafenone, SR Sulfasalazine, EC
Lamivudine/zidovudine Methocarbamol Nicardipine hydrocodone Propantheline Sulfinpyrazone
Lamotrigine, ER Methotrexate tablets Nifedipine Phenyleph-ephed-cpd Propoxyphene/APAP QL Sulindac
Lansoprazole, ODT QL Methyclothiazide Nifedipine ER DO, QL w/carbetapentane Propranolol, LA Sumatriptan tabs, nasal
Latanoprost Methyldopa Nimodipine Phenyleph-pyrilamine Propranolol/HCTZ spray and inj. QL
Leflunomide Methyldopa/HCTZ Nisoldipine DO, QL w/hydrocodone Propylthiouracil Tacrolimus
Letrozole Methylergonovine Nitrofurantoin Phenylephrine Pseudoephed/bromphen- Tamoxifen
Leucovorin Methylphenidate, CD, Nitrofurantoin mono Phenylephrine/ DM 45-4-15 Tamsulosin
Leuprolide PA ER, SR Nitroglycerin promethazine/codeine Pseudoephedrine/ Temazepam
Levalbuterol neb soln. QL Methylprednisolone Nitroglycerin ointment Phenytoin carbinoxamine Terazosin
Levetiracetam, ER Metoclopramide Nitroglycerin patch Phospha 250 Pseudoephedrine/ Terbinafine
Levobunolol Metolazone Nitroglycerin spray Pilocarpine guaifenesin Terbutaline
Levocetirizine QL Metoprolol, SR Nitroglycerin SR Pindolol Pseudoephedrine hcl/ Terconazole
Levofloxacin QL Metoprolol/HCTZ Nizatidine Pioglitazone QL chlor-mal Theophylline
Levonorgestrel Metronidazole Norethindrone Pioglitazone/ Pyrazinamide Theophylline SR
(emergency OC) Mexiletine Nortriptyline glimepiride QL Quetiapine Theophylline syrup
Levonorgestrel & ethinyl Miconazole nitrate Nystatin Pioglitazone/ Quinapril, HCTZ Thioridazine
estradiol Microgestin Nystatin/triamcinolone Metformin QL Quinidine gluconate Thiothixene
Levora Midodrine Ocella Piroxicam Quinidine sulfate Thyroid
Levorphanol tartrate Minocycline Octreotide Polyethylene glycol- Quinine sulfate PA, QL Tiagabine
Levothyroxine Minoxidil Ofloxacin QL electrolyte solution Ramipril Ticlopidine
Levoxyl Mirtazapine Olanzapine, ODT Polymyxin B/trimethoprim Ranitidine Timolol
Lidocaine Misoprostol Olanzapine/fluoxetine Pot. & Sod. Citrates w/ Ribavirin Tinidazole
Lidocaine viscous Modafinil PA, DO, QL Omeprazole QL citric acid Rifampin Tizanidine
Liothyronine Moexipril, HCTZ Omeprazole/bicarb QL Potassium chloride Riluzole Tobramycin
Lisinopril, HCTZ Mometasone ointment, Ondansetron QL Potassium citrate Risperidone, ODT Tobramycin/
Lithium cream Orphenadrine Potassium citrate-citric Rivastigmine Dexamethasone Susp.
Loperamide Montelukast QL Orphenadrine cpd acid Rizatriptan, ODT QL Tolmetin
Lorazepam Morphine ER QL Orphenadrine cpd Forte Pramipexole Ropinirole, ER Tolterodine
Losartan DO, QL Morphine sulfate Oxaprozin Pramoxine/hc/ Salsalate Topiramate
Losartan/HCTZ DO, QL Multivitamins w/fluoride Oxazepam chloroxylenol Selegiline Torsemide
Lovastatin DO, QL Multivitamins w/folic acid Oxybutynin Pravastatin DO, QL Selenium sulfide Tramadol, ER 100, 200,
Low-ogestrel Mupirocin cream, oint Oxcarbazepine Prazosin Sertraline DO, QL 300mg QL
Loxapine Mycophenolate mofetil Oxycodone Prednisolone Sildenafil PA, QL Tramadol/APAP QL
Mebendazole Nabumetone Oxycodone ER QL Prednisolone sodium Silver sulfadiazine Trandolapril
Meclizine Nadolol Oxycodone/APAP QL prosphate Simvastatin DO, QL, PA Trandolapril/verapamil
Meclofenamate Naltrexone hcl Oxycodone/aspirin Prednisone – 80mg only Tranylcypromine
3
Travoprost drops Alphagan P 0.1% Edurant Lanoxin Premarin oral, vaginal Travatan Z
Trazodone Amitiza Effient DO, QL Lantus cream Transderm-Scop
Tretinoin 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. Lialda Pristiq DO, QL Twinject
Triazolam Asacol†, HD Epivir HBV Lidoderm† ProAir HFA QL Ultrase
Trifluoperazine Asmanex QL Epzicom Linzess Procanbid Uniphyl
Trifluridine Astepro QL Estring Loestrin 24 FE ST∞, QL Prograf Vagifem
Trihexyphenidyl Atripla Ethmozine Lotemax soln, oint Protopic ST Valcyte Tabs
Trimethobenzamide Atrovent HFA QL Evamist Lovaza Pulmicort Flexhaler QL Valturna DO, QL
Trimethoprim Avodart Evista Lumigan Pulmicort Respules Veltin ST
Trimipramine Axiron PA, QL Exelon Patch, Solution Matulane 1mg/2ml QL Ventolin HFA QL
Tri-nessa AzaSite Exforge DO, QL Medrol 2mg QVAR QL Veramyst QL
Triple sulfa Azilect Exforge HCT DO, QL Menest Ranexa VESIcare
Triple vitamins w/fluoride
Azopt Fansidar Mephyton Rapamune Victoza ST, QL
Trivora Baraclude FazaClo ODT Mepron Renvela Videx soln.
Tropicamide Beptoptic S Felbatol Rescriptor Vigamox
Mestinon timespan
Trospium, ER BiDil Fem HRT 0.5/2.5 Restasis Viracept
Mintezol
Trypsin/balsam peru/ Brilinta QL Femara Retrovir Viramune XR
castor oil Moxeza
Bydureon ST, QL Femtrace Revlimid PA, QL Viread
Urea Mycobutin Reyataz
Calciferol drops Finacea Vivelle Dot†
Ursodiol Myleran Ridaura Voltaren gel
Canasa Flovent, HFA QL
Valacyclovir Namenda Rifamate Vyvanse PA
Capitrol Fluoroplex
Valproic acid Nasonex QL Rifater Welchol
Carbatrol Foradil QL
Valsartan/HCTZ DO, QL CeeNU Nebupent Rilutek Xarelto QL
Fortovase
Vancomycin caps Cellcept Neoral Risperdal Consta Xeloda PA
Fosamax Plus D QL
Venlafaxine, ER Ciprodex Fosamax solution QL Neosar Sandimmune Oral Yodoxin
Verapamil, SR Climara Pro Furadantin Nexavar PA Savella QL Zarontin
Voriconazole Clozaril Furoxone Nexium QL Serevent Diskus QL Zemplar
Warfarin Colcrys QL Fuzeon Niaspan† Seroquel XR Zenpep
Westhroid Combigan Gabitril Nilandron Spiriva QL Ziagen soln.
Yohimbine CombiPatch Gantrisin Nitro-Bid Sprycel PA Zortress
Zafirlukast Combivent Respimat QL Geodon inj. Nitro-Dur 0.3, 0.8mg/hr Strattera Zylet
Zaleplon ST, QL Complera Gleevec PA Nitrolingual spray Stribild Zytiga PA
Zeosa Coreg XR Glucagon Norpace CR 100mg Suboxone SL Film PA, QL
Zidovudine Coumadin Glyset Norvir Sustiva Tier 3
Ziprasidone Creon Halflytely Novolin N, R, 70/30 Sutent PA Abilify Maintena
Zolmitriptan, ODT ST, QLCrestor DO, QL Humalog Novolog Symbicort QL Abstral PA, QL
Zolpidem, ER QL Crixivan Humibid Cap Sprinkle Nuvaring QL Symlin Accolate
Zonisamide Cuprimine Humulin N, R, 50/50, Oforta PA Synthroid Accupril
Cymbalta DO, QL 70/30 One Touch Product Tamiflu QL Accuretic
Tier 2 Cytadren Intal Inh. Line QL Tarceva PA Aceon
Abilify Dapsone Invirase Ortho Evra Tazorac Aciphex ST, QL^
Acanya Daraprim Iressa Ortho Tri-Cyclen Lo Tegretol, XR Actemra PA
Accu-chek Product Delzicol† Jalyn ST∞, QL Temodar† PA Acthar HP PA, QL
Line QL Depakote, ER Janumet, XR QL OxyContin QL Teslac Actimmune
Actonel QL Detrol LA Januvia ST, QL Pacerone Testim PA, QL Actiq PA, QL
Actonel with Calcium QL Diastat Jentadueto QL Pancrelipase Thalomid PA Activella PA
ActoPlus Met XR QL Dibenzyline Juvisync QL Pentasa Theo-24 ActoPlus Met QL
Advair Diskus, HFA QL Differin 0.1% lotion Kaletra Perforomist QL Tilade Actos QL
Advicor† DO Differin 0.3% gel Keppra, XR Plexion SCT TOBI Acular, LS
Agenerase Dilantin Kuvan PA Pradaxa QL Tobradex oint. 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 Desvenlafaxine 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 Shampoo 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 Tecfidera PA, 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 Solodyn ST, PA Tev-Tropin PA, QL
Relenza QL Vecamyl Yaz
Pramosone 2.5% Soma Thyrogen
Relpax ST, QL Ventavis PA Zegerid ST, QL^
Prandimet Somatuline Tiazac DO, QL
Pravigard Remicade PA Verelan PM DO, QL Zerit
Renagel ST Somavert TOBI Podhaler Vesanoid Zestoretic
Precose Sonata ST, QL Tobradex susp.
Pred Mild 0.12% Requip, XL Vexol Zestril
Rescula Soriatane CK Tobrex Vfend PA Zetia ST, QL
Pred-G Sorilux foam Toprol XL
Prefest Restoril Viagra PA, QL Zetonna ST, QL
Spectracef Toradol QL
Prenate Elite Retin-A Micro PA Victrelis PA Ziagen tabs
Sporanox Solution PA Tracleer
Prevacid ST, QL^ Revatio PA, QL Videx EC Zioptan
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 QL Zithromax QL
Stelara PA, QL~ Tricor
Primaxin QL Roxicet QL Vimpat Zmax QL
Striant PA Triglide
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 Sumavel Dosepro ST, QL Tussionex ER Voltaren Ophth Zomig, ZMT ST, QL
Prostin E2 Supp
Sancuso QL Suprax QL Twynsta Vytorin ST, QL Zorbtive PA, QL
Protonix ST, QL^
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 Indiana 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 Kentucky 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 Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance
Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE®
Managed Care, 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