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INTRODUCTION
Penicillins .
(preferred list of drugs) to help your doctor Amoxicillin/Clavulanate (generic/Augmentin make prescribing decisions. This list of drugs consisting of doctors and pharmacists, so that the list includes drugs that are safe and effective in the treatment of diseases. If you Quinolones .
have any questions about the accessibility of your medication, please call the phone number listed on the back of your Anthem Blue Cross Sulfonamides .
Erythromycin/Sulfisoxazole (generic) Sulfamethoxazole/Trimethoprim (generic) In most cases, if your physician has determined that it is medically necessary for you to receive a brand name drug or a drug Tetracyclines .
that is not on our list, your physician may indicate “Dispense as Written” or “Do Not Substitute” on your prescription to ensure access to the medication through our network ANTIFUNGAL AGENTS (ORAL) _________________
of community pharmacies, excluding drugs that require Prior Authorization of Benefits. Fluconazole (generic) Griseofulvin (generic) Please ask your doctor or pharmacist to refer APPROVED
Prescription Drug List for a complete listing of FORMULARY
ANTI-MALARIALS ____________________________
Chloroquine (generic)
USE OF GENERICS
equivalents to brand name medications. In (CONDENSED VERSION)
available for a brand name product, the brand ANTI-TUBERCULOSIS AGENTS _________________
name product will be considered non-preferred and the generic equivalent will be on the list. Revised 11/2010
equivalents and has found their use to be safe For medications classified by the FDA as having a narrow therapeutic index (NTI), Anthem Blue Cross discourages the use of OTHER ANTI-INFECTIVES ______________________
Metronidazole (generic) Trimethoprim (generic) PRIOR AUTHORIZATION
authorization of benefit (PAB) for certain drugs ANTI-NEOPLASTIC AGENTS
to provide a safe and affordable pharmacy All FDA-approved, self-administered injectable 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 believes that a medication requiring PAB is generic, Cefaclor is covered and the contact WellPoint Pharmacy Management in order to initiate the Prior Authorization Process ANTI-VIRAL AGENTS
on your behalf. The list of drugs is subject to change so please call Customer Service at 1- www.anthem.com/ca.com to obtain a complete means that the brand, Levaquin is available. Levaquin is the brand name. ANTI-INFECTIVE AGENTS
Interferon Alfa-2B/Ribavirin (Rebetron)* Interferon Alfacon-1 (Infergen)* ANTIBIOTICS ________________________________
Cephalosporins .
generic) means that both the brand and generic are available. Therefore, the brand Coumadin and the generic AUTONOMIC & CENTRAL NERVOUS SYSTEM
Member Handbook for benefit details Macrolides .
regarding applicable copayments or ANALGESICS, NARCOTIC ______________________
CEREBRAL STIMULANTS _____________________
Morphine Sulfate (generic /Avinza/MS Contin) CARDIOVASCULAR AGENTS
Methylphenidate ER (Concerta/Methylin ER) ANGIOTENSIN CONVERTING ENZYME
INHIBITORS AND RECEPTOR BLOCKERS ________
MULTIPLE SCLEROSIS AGENTS _______________
Amlodipine/Valsartan/HCTZ (Exforge/ Exforge ANALGESICS, NON-NARCOTIC _________________
OPIOID DEPENDANCE ________________________
Acetaminophen/Caffeine/Butalbital (generic) PSYCHOTHERAPEUTIC AGENTS ______________
Antidepressants .
Sumatriptan (generic/Imitrex Nasal Spray) ANTI-ADRENERGIC BLOCKERS ________________
ANALGESICS, NONSTEROIDAL
ANTI-INFLAMMATORY ________________________
ANTIARRHYTHMICS __________________________
ANALGESICS, SALICYLATES __________________
Antimanic Agents .
ANTICOAGULANTS/ANTITHROMBOTICS _________
Antipsychotic Agents .
ANTICONVULSANTS __________________________
ANTILIPEMICS _______________________________
SEDATIVES, HYPNOTICS AND ANTI-ANXIETY ____
ANTIPARKINSON AGENTS _____________________
Niacin (Nicotinex/SloNiacin/Niaspan/generic) BETA-ADRENERGIC BLOCKERS ________________
ALZHEIMER’S AGENTS ________________________
BLOOD MODIFIERS
CALCIUM CHANNEL BLOCKERS _______________
FUNGICIDES ________________________________
ANTIDIABETIC SUPPLIES ______________________
glucometers, lancets, and test strips, may be covered. Accu-Chek and One Touch are the only test strips included on formulary. Lifescan TOPICAL ANTI-INFLAMMATORY AGENTS ________
Diagnostics (Accu-Chek, Aviva). Quantity CENTRALLY ACTING ANTIHYPERTENSIVES ______
Low Potency .
limits apply. Urine test strips are also a GLUCOSE ELEVATING AGENTS ________________
DIURETICS __________________________________
Medium Potency .
ANTITHYROID________________________________
THYROID ____________________________________
Levothyroxine (Levothroid/Levoxyl/Unithroid/ High Potency .
Ultra-High Potency .
OTHER ENDOCRINE AGENTS __________________
VASODILATORS _____________________________
VAGINAL/RECTAL PREPARATIONS _____________
Isosorbide Dinitrate/Hydralazine (Bidil) GASTROINTESTINAL AGENTS
Isosorbide Dinitrate (Dilatrate SR/generic) ANTIEMETIC/ANTIVERTIGO ____________________
Nitroglycerin (Nitrostat/Nitrobid/Nitrolingual Hydrocortisone/Pramoxine (generic/Analpram Nitroglycerin (Nitrek/Nitro-Dur/generic) HC lotion/Pramosone cream, lotion, oint) VASOPRESSORS ____________________________
MISCELLANEOUS ____________________________
MISCELLANEOUS DERMATOLOGICALS _________
ANTISPASMODIC/GI MOTILITY _________________
CONTRACEPTIVES
Eth Estradiol/Desogestrel (Apri/generic) Eth Estradiol/Ethynodioldiacetate (Zovia) ANTIULCER _________________________________
(Enpresse/Jolessa/Portia/Trivora/generic) Eth Estradiol/Norelgestromin (Ortho-Evra) Eth Estradiol/Norethindrone (Loestrin FE 24) Eth Estradiol/Norethindrone (Necon/generic) Eth Estradiol/Norgestimate (Ortho Tri-Cyclen ENDOCRINE AGENTS
Norethindrone (Nora-BE)
EMERGENCY CONTRACEPTIVES _______________
ANTIDIABETIC AGENTS-INJECTABLE ___________
OTHER GI PRODUCTS _________________________
Levonorgestrel (generic 0.75mg/Plan B 1.5mg) ANTIDIABETIC AGENTS-ORAL _________________
DERMATOLOGICALS
ACNE _______________________________________
Acetohexamide (generic) Chlorpropamide (generic) Pancreatic Lipase (Creon/Pancrease/Ultrase/ GLUCOCORTICOIDS
Tretinoin (generic/Retin-A Micro/Retin-A Micro Pioglitazone/Metformin (ActoPlus Met/XR) ANTIBIOTICS/ANTIVIRALS _____________________
GOUT THERAPY
Levalbuterol (generic/Xopenex Inhalation Soln) ANTI-INFLAMMATORY AGENTS ________________
Xanthine Derivatives .
HIV AGENTS
All oral and self injectable FDA-approved HIV agents are eligible for coverage under the prescription drug benefit. May be subject to OTHER AGENTS______________________________
HORMONES
ANTIESTROGENS ____________________________
ANTI-INFECTIVE & ANTI-INFLAMMATORY
COMBINATIONS _____________________________
Sodium Chloride (Broncho-Saline/generic) ESTROGENS ________________________________
ANTIHISTAMINES/DECONGESTANTS ____________
Estradiol Patch/Spray (generic /Alora/Climara Pro/Esclim/Estraderm/Evamist/Vivelle/Dot) Neomy/Polymyx B/Prednisolone (Poly-Pred) Estrogens, Conjugated (Premarin/Low Dose) Synthetic conjugated estrogens (Cenestin) ESTROGEN COMBINATIONS ___________________
ANTIVIRAL AGENTS __________________________
EXPECTORANT AND COUGH PRODUCTS ________
BETA-BLOCKERS ____________________________
Estrogen, Ester/Methyltestosterone (generic) GROWTH HORMONE __________________________
MIOTICS ____________________________________
PROGESTINS ________________________________
Brinzolamide (Azopt) Dorzolamide (generic) MYDRIATICS ________________________________
NASAL MEDICATIONS _________________________
MISCELLANEOUS HORMONE PRODUCTS ________
Homatropine (Isopto Homatropine) Phenylephrine (Neo-Synephrine) Cabergoline (Dostinex) Danazol (Danocrine) SYMPATHOMIMETICS ________________________
SKELETAL AGENTS
ANTIRHEUMATICS ____________________________
Testosterone (Androderm/Androgel/Testim) ANTI-INFECTIVE AGENTS _____________________
BONE ENHANCING AGENTS ___________________
IMMUNOSUPRESSIVE AGENTS
ANTI-INFECTIVE & ANTI-INFLAMMATORY
Alendronate (Fosamax/-D/generic) Calcitonin-Salmon (generic) All FDA-approved, self-administered injectable COMBINATIONS _____________________________
eligible for coverage under the prescription RESPIRATORY
SKELETAL MUSCLE RELAXANTS
OPHTHALMICS
ANTI-ASTHMATIC AGENTS ____________________
ALPHA-AGONIST _____________________________
Asthma Devices .
PROSTAGLANDIN AGONIST ___________________
Peak Flow Meter (Personal Best/Pocketpeak) Corticosteroids .
ANTI-ALLERGY AGENTS
URINARY AGENTS
ANTI-INFECTIVE AGENTS ______________________
Fluticasone/Salmeterol (Advair/Advair HFA) ANTI-INFECTIVES ____________________________
Sympathomimetics .
CHOLINERGIC AGENTS _______________________
Bethanechol (generic) Flavoxate (generic) OTHER URINARY AGENTS _____________________
Fesoterodine (Toviaz) Phenazopyridine (generic) Solifenacin (Vesicare) Tolterodine (Detrol/-LA) VITAMINS & ELECTROLYTES
Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the registered trademark. ® The Blue Cross name Ferrous Sulfate/Folate/Vit B comp/C (generic) and symbol are registered marks of the Blue Express Scripts, Inc. is a separate company that benefit management services on behalf of health Vit A, C & D/Fluoride/Iron (generic) plan members. WellPoint NextRx, NextRx and PrecisionRx are registered trademarks of Prenatal Vitamins (Prenate Elite/generic) WellPoint, Inc. and are used under license by Express Scripts, Inc. MISCELLANEOUS AGENTS
Etanercept (Enbrel)* Calcium acetate (generic) Cevimeline (Evoxac) Everolimus (Zortress) Lanthanum Carbonate (Fosrenol) Leucovorin (generic) Miglustat (Zavesca) Milnacipran (Savella) Mycophenolate (generic/Cellcept) Neostigmine (generic) Sodium Polystyrene Sulfonatem (generic) Sevelamer (Renagel) (Renvela tabs) Tacrolimus (generic) Thalidomide (Thalomid) *Members should refer to their Member Handbook for benefit details regarding applicable copayments or coinsurance.

Source: http://www.chico.ca.us/human_resources_and_risk_management/documents/AnthemBlueCrossDrugFormulary.pdf

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