Prescription Program Drug List/Formulary — To be used by members who have a tiered drug plan. Anthem Blue Cross and Blue Shield prescription drug benefits include medications available on the Anthem Drug List/Formulary. Our prescription drug benefits can offer potential savings when your physician prescribes medications on the drug list/formulary. 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
Life and Disability products are underwritten by Anthem Life Insurance Company. In Colorado: Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. In Indiana: Anthem Blue Cross and Blue Shield is a trade name of Anthem Insurance Companies, Inc. In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. In Missouri: Anthem Blue Cross and Blue Shield is the trade name RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC) and HMO Missouri, Inc. use to do business in most of Missouri. 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: Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”) underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”) underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association.
® Blue Cross and Blue Shield are registered marks of the Blue Cross and Blue Shield Association. Tier 1 – Lowest copayment – Drugs offering the greatest value within a therapeutic class. Some of these are generic equivalents of brand name drugs. Tier 2 – Medium copayment – Drugs on this tier are generally the more affordable brand-name drugs. Other drugs are on this tier because they are “preferred” within their therapeutic classes, based on clinical effectiveness and value Tier 3 – Highest copayment – These are higher cost brand-name drugs. Some Tier 3 drugs may have generics or equivalents in Tier 1. In addition, some drugs on this tier may have been evaluated to be less cost-effective than equivalent drugs on lower tiers. Tier 4 – Many drugs on this tier are “specialty” drugs used to treat complex, chronic conditions and may require special handling and/or management. For members who do not have a Tier 4 plan, these drugs are found under Tier 1, 2 or 3. Azathioprine Cephalexin Azithromycin QL Chloral hydrate Acarbose Bacitracin zinc/polymyxin B Chlordiazepoxide Acebutolol Bacitracin/polymyxin/ Chlorhexidine gluconate Acetaminophen/ neomycin-hc opth oint Chloroquine 250mg caffeine/butalb Baclofen Chlorothiazide Acetazolamide, SR Balsalazide Chlorphen/pyrilamine/ Acetic acid Belladonna/phenobarbital phenylephrine Acetic acid/hydrocortisone Benazepril, HCTZ Chlorpheniramine/ Acetic acid/aluminum Benzoyl peroxide pseudoephedrine Benzoyl peroxide/ Chlorpromazine tab Acetic acid otic erythromycin Chlorpropamide Acetylcysteine Benztropine Chlorthalidone Acyclovir Betamet diprop/ Chlorzoxazone Albuterol Cholestyramine, light Albuterol/ipratropium Betamethasone Chorionic gonadotropin dipropionate Alendronate QL Betamethasone valerate Ciclopirox Allopurinol Betaxolol Cimetidine Alprazolam Bethanechol Ciprofloxacin QL Amantadine Bisoprolol Citalopram DO, QL Amcinonide Bisoprolol/HCTZ Clemastine fumarate Amiloride Bromocriptine Clindamycin Amiloride/ Budeprion XL DO, QL Clobetasol hydrochlorothiazide Bumetanide Clomiphene Aminophylline Bupropion Clomipramine Amiodarone Buspirone Clonazepam Amitriptyline Butalbital Compound Clonidine Amitriptyline/perphenazine w/Codeine Clorazepate Amitriptyline/ Butorphanol tartrate Clotrimazole/ chlordiazepoxide 10mg/ml N.S. QL betamethasone Amlodipine DO, QL Cabergoline Clozapine Amlodipine/benazepril Calcipotriene Soln. Codeine sulfate Amnesteem QL Calcium Acetate Codeine/APAP QL Amoxapine Captopril, HCTZ Colchicine Amoxicillin Carbamazepine Cromolyn Amoxicillin/ Carbidopa/levodopa Cyclobenzaprine clavulanate QL Carbidopa/levodopa CR Cyclopentolate Amphetamine Carisoprodol Cyproheptadine Ampicillin Carteolol hcl Antipyrine/benzocaine Cartia XT DO, QL Dantrolene APAP/caffeine/butalbital Carvedilol Desipramine Cefaclor Desmopressin acetate Asa/codeine Cefaclor ER Desonide Aspirin/caffeine/butalbital Cefadroxil Desoximetasone Atenolol Cefdinir Dexmethylphenidate Atenolol/chlorthalidone Cefpodoxime Dextroamphetamine Atropine sulfate Cefprozil Dextromethorphan/ Aviane PA Cefuroxime QL guaifenesin Diazepam Fludrocortisone Ipratropium bromide neb Diclofenac potassium Flunisolide Nasal soln/nasal spray QL Diclofenac sodium Iron combination capsule Fluocinolone acetonide Iron/intrinsic factor/B12 Diclofenac, ER Fluocinonide Iron/B12/folic acid Dicloxacillin Fluorometholone Isometh/dichlphen/APAP Dicyclomine Fluorouracil Isoniazid Didanosine Fluoxetine DO, QL Isosorbide dinitrate Diflorasone diacetate Fluphenazine Isosorbide mononitrate Diflunisal Flurazepam Isotretinoin QL Flurbiprofen Itraconazole PA Diltia XT DO, QL Flurbiprofen sodium Ketoconazole Diltiazem Flutamide Ketoprofen, ER Diltiazem CD DO, QL Fluticasone Nasal Ketorolac QL Diltiazem CR DO, QL Labetalol Diltiazem SR DO, QL Fluvoxamine DO Lactulose Diphenhydramine 50mg Folic acid Lamotrigine Diphenoxylate/ Fosinopril DO, QL Leflunomide atropine sulfate Leucovorin Dipivefrin HCl Fosinopril HCTZ Leuprolide PA* Dipyridamole Furosemide Levetiracetam Disopyramide Gabapentin Levobunolol Disopyramide CR 150mg Galantamine, SR Levonorgestrel & ethinyl Divalproex Ganciclovir estradiol PA Dorzolamide Gemfibrozil Levora PA Dorzolamide/timolol Gentamicin Doxazosin mesylate Glimepiride Levorphanol tartrate Glipizide XL Lidocaine Doxycycline Glipizide/metformin Lidocaine viscous Doxycycline monohydrate Glyburide Lisinopril, HCTZ Dronabinol Glyburide micronized Dyphylline Glyburide/metformin Loperamide Econazole Glycolax Lorazepam Enalapril, HCTZ Granisetron QL Lovastatin DO, QL Ergotamine Guaifenesin Low-ogestrel Ergotamine/ Guaifenesin SR belladonna/PB Guaifenesin/dextrometh Loxapine Erythromycin Mebendazole Guaifenesin/hydrocodone Erythromycin base Meclizine Guanabenz Erythromycin Meclofenamate Guanfacine ethylsuccinate Medroxyprogesterone Halobetasol Erythromycin/sulfisoxazole Mefloquine Haloperidol Estradiol Megestrol Heparin* Estradiol/ Meloxicam QL norethindrone PA Homatropine Meperidine Estropipate Hydralazine Meperidine w/promethazine Ethambutol Hydralazine/HCTZ Mercaptopurine Ethinyl estradiol/ Hydrochlorothiazide Metaproterenol norethindrone PA Hydrocodone w/ Metformin Ethinyl estradiol/ethynodiol homatropine Metformin ER diacetate PA Hydrocodone/APAP QL Meth/salicylate/atropine/ Ethosuximide Hydrocortisone 2.5% hyos benzoic Etodolac cream, ointment, lotion Methadone Etodolac ER Hydrocortisone enema Methazolamide Etoposide Hydromorphone Methenamine/ Famciclovir Hydroxychloroquine hyosc-meth blue/sod Famotidine Hydroxyurea biphos-phenyl sal Felodopine DO, QL Hydroxyzine HCL Methocarbamol Fenoprofen Hydroxyzine pamoate Methotrexate tablets Fentanyl QL Hyoscyamine Methyclothiazide Fexofenadine, D QL Ibuprofen Methyldopa Finasteride Imipramine Methyldopa/HCTZ Flecainide Indapamide Methylphenidate, SR Fluconazole Indomethacin, SR Methylprednisolone Metoclopramide Oxaprozin Prochlorperazine Metolazone Oxazepam Prochlorperazine supp Metoprolol, SR Oxybutynin Metoprolol/HCTZ Oxycodone Promethazine Metronidazole Oxycodone ER QL Promethazine/codeine Mexiletine Oxycodone/aspirin Promethazine/ Miconazole nitrate Oxycodone/APAP QL dextromethorphan Microgestin PA Oxytocin Promethazine/ Midodrine Pantoprazole ST, QL^# phenylephrine Minocycline Paroxetine, SR DO, QL Propafenone Minoxidil Penicillin V.K. Propantheline Mirtazapine Pentamidine isethionate Propoxyphene/APAP QL Misoprostol Pentazocine nx Propranolol, LA Moexipril, HCTZ Pentazocine/apap Propranolol/HCTZ Mometasone ointment, Pentoxifylline Propylthiouracil Pergolide Pseudoephed/bromphen- Morphine SR QL Permethrin DM 45-4-15 Morphine sulfate Perphenazine Pseudoephedrine hcl/ Multivitamins w/fluoride Phenazopyridine chlor-mal Multivitamins w/folic acid Phenobarbital Pseudoephedrine/ Nabumetone Phenyleph hcl/hydrocod guaifenesin Pseudoephedrine/ Naltrexone hcl Phenyleph/chlorphen/ carbinoxamine Naphazoline Pyrazinamide Naproxen Phenyleph/chlorphen/ Quinapril, HCTZ Naproxen EC hydrocodone Quinidine gluconate Naproxen sodium, DS Phenyleph-ephed-cpd Quinidine sulfate w/carbetapentane Ramipril Neomycin Phenyleph-pyrilamine Ranitidine w/hydrocodone Neomycin/dexamethasone Ribavirin PA Phenylephrine Neomycin/polymixin/ Rifampin hydrocortisone Phenylephrine/ Risperidone promethazine/codeine Neomycin/polymyxin/ Ropinirole dexamethasone Phenytoin Salsalate Neomycin/polymyxin/ Phospha 250 Selegiline bacitracin Pilocarpine Selenium sulfide Neomycin/polymyxin/ Pindolol Sertraline DO, QL gramicidin Piroxicam Silver sulfadiazine Polyethylene glycol- Simvastatin DO, QL Nicardipine electrolyte solution Sodium citrate & Nifedipine Polymyxin B/trimethoprim citric acid Nifedipine ER DO, QL & Sod. Citrates w/citric Sodium fluoride Nisoldipine DO, QL Sodium polystyrene Nitrofurantoin Potassium chloride sulfonate Nitrofurantoin mono Potassium citrate Sodium sulfacetamide/ Nitroglycerin Potassium citrate-citric Nitroglycerin ointment Sotret QL Nitroglycerin SR Pramoxine/hc/ Spironolactone Nizatidine chloroxylenol Spironolactone/HCTZ Norethindrone Pravastatin DO, QL Stannous fluoride Nortriptyline Prazosin Stavudine Nystatin Prednisolone Sucralfate Nystatin/triamcinolone Prednisolone sodium Sulfacet sod w/sulfur Ocella PA prosphate Ofloxacin QL Prednisone Sulfacetamide sodium Omeprazole 10 & Prenatal mulitvitamins and solution minerals/iron/folic acid Sulfacetamide sodium/ Omeprazole 40mg Prenatal vitamin prednisoloneophth sol. Prenatal w/docusate, iron, Sulfamethoxazole/ Ondansetron QL folic acid trimethoprim, DS Orphenadrine Primidone Sulfasalazine, EC Orphenadrine cpd Probenecid Sulfinpyrazone Orphenadrine cpd Probenecid/colchicine Sulindac Procainamide, SR Sumatriptan QL QuesTions anD answers Q. What is a Drug List/Formulary? a. The Anthem Drug List/Formulary is a list of FDA-approved brand-name
and generic medications that have been reviewed and recommended for their quality and effectiveness by the National Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is an independent group of practicing doctors and pharmacists responsible for the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and choose the top medications for our drug list—based on their safety, effectiveness and value.
Drugs on the Anthem Drug List/Formulary are grouped by ‘tiers.’ A number of factors are considered when classifying drugs into tiers, including, but not limited to: the absolute cost of the drug; the cost of the drug relative to other drugs in the same therapeutic class; the availability of over-the-counter alternatives; and other clinical and cost-effectiveness factors. Because the medications on the drug list/formulary are subject to
periodic review, please ask your physician about the most current drug list additions and deletions or visit anthem.com.
Brand-name: A brand-name drug is usually available from only one
manufacturer and may have patent protection.
Generic: A generic drug is required by the FDA to have the same active
ingredients as its brand-name counterpart, but is normally only available after the patent protection expires on a brand-name drug. Although it may look different, a generic drug works the same as its brand-name counterpart. You can save money by using generic medications.
Q. What if my physician or I choose a brand-name drug when a generic equivalent is available? a. In most cases, you would be responsible for the appropriate tier
copay. This copay may include an additional charge that represents the cost difference between the brand-name medication and the generic equivalent. Q. What are ‘clinically equivalent’ medications? How does this affect my drug coverage? a. The P&T Committee reviews the most current research available to
determine if multiple drugs used to treat a disease/condition produce the same clinical effect. When this is the case, the committee may recommend that we cover only the lower cost drug(s) as part of our effort to help reduce the overall cost of care. This means your specific prescription plan may not cover some drugs in classes with ‘clinically equivalent’ alternatives. Q. What if my medication is not on the drug list/formulary? a. An open drug list allows members and their physicians to choose from
a wide variety of prescription medications. Please talk with your doctor about prescribing a Tier 1 or Tier 2 medication. If a Tier 3 medication is selected, you will be responsible for the applicable Tier 3 copayment.
You or your physician may submit a request to add a drug to the drug list/formulary either in writing or on our web site. Requests are taken into consideration by the P&T Committee during the drug list/formulary review process.
Inclusion of a medication on the drug list/formulary is not a guarantee of coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your Certificate or Evidence of Coverage for coverage limitations and exclusions. Tamoxifen Temazepam Effexor XR DO, QL Terazosin Alphagan P Elidel ST Terbinafine PA Altace 2.5, 5 & 10mg Terbutaline Androderm PA, QL Terconazole Androgel PA, QL Entocort EC Theophylline Antabuse Epipen, JR. Theophylline SR Theophylline syrup Estraderm Thioridazine Arimidex Thiothixene Armour Thyroid Ethmozine Ticlopidine Aromasin Tizanidine Asmanex QL Exelderm Tobramycin* Tolmetin Atrovent HFA QL Exforge DO, QL Torsemide Avandamet QL Fansidar Tramadol QL Avandaryl QL FazaClo ODT Tramadol/APAP QL Avandia QL Felbatol Trandolapril Tranylcypromine Trazodone Azmacort QL Tretinoin PA Flovent, HFA QL Triamcinolone acetonide Beptoptic S Fluoroplex Triamterene/HCTZ FML Forte Triazolam Blephamide Trifluoperazine Byetta ST, QL Foradil QL Trifluridine Calciferol drops Fortovase Trihexyphenidyl Capitrol Fosamax solution QL Trimethobenzamide Carbatrol Fosamax Plus D QL Trimethoprim Fosrenol Tri-nessa PA Furadantin Triple sulfa Cellcept Furoxone Triple vitamins w/fluoride Cenestin Trivora PA Ciprodex Gabitril Tropicamide Climara Pro Gantrisin Trypsin/balsam peru/ Clozaril castor oil Combivent QL Gleevec PA Ursodiol Combivir Glucagon Valproic acid Venlafaxine Concerta Verapamil, SR Humibid Cap Sprinkle Warfarin Humulin N, R, 50/50, 70/30 Yohimbine Coumadin Hyzaar DO, QL Zaleplon ST, QL Cozaar QL Imitrex QL Zolpidem QL Intal Inh. Zonisamide Crixivan Invirase Cuprimine Iressa PA Cymbalta DO, QL Janumet QL Cytadren Januvia QL Accu-chek Product Line QL Daraprim Actonel QL Depakote, ER Actonel with Calcium QL Derma-Smoothe, FS Lanoxicaps ActoPlus Met QL Detrol, LA Adderall XR Dibenzyline Leukeran Advair Diskus, HFA QL Differin Leukine PA* Aerobid QL Dilantin Levaquin QL Aerobid M QL Diovan DO, QL Agenerase Diovan HCT DO, QL Levothroid Akne-Mycin Dovonex cream Lexapro DO, QL Aldara QL Lipitor DO, QL Procanbid Viramune Loprox gel, shampoo Lotrel (5/40 & 10/40mg) Prometrium Vivelle, DOT Protopic ST Vyvanse PA Proventil HFA QL Matulane Pulmicort Respules QL Xeloda PA Maxalt, MLT QL Pulmicort Turbuhaler QL Xopenex HFA QL Medrol 2mg, 16mg, 32mg Rapamune Zarontin Mephyton Rescriptor Mestinon timespan Retin-A Micro PA Zomig, ZMT QL Methergine Tabs Retrovir Zovirax Oint Mintezol Zyprexa, Zydis Mycobutin Rifamate Accolate Sandimmune Oral Accupril Nasonex QL Sandostatin* Accuretic Nebupent Serevent Diskus QL Seroquel, XR Aciphex ST, QL^# Simcor QL Actimmune* Neulasta PA, QL* Singulair QL Activella PA Neupogen PA* Somavert* Actiq PA, QL Nexavar PA Spiriva QL Nexium QL Sprycel PA Aggrenox QL Alamast QL^ Nilandron Strattera Alferon-N* Nitro-Bid Subutex QL Allegra, D QL^ Nitro-Dur Sular DO, QL Alocril QL^ Nitrolingual spray Alomide QL^ Norpace CR 100mg Sutent PA Altace 1.25mg Altoprev DO Novolin N, R, 70/30 Symbicort QL Alupent Inhaler Synthroid Alvesco QL One Touch Product Line QL Tarceva PA Ambien QL Ortho Evra PA Tegretol, XR Ambien CR QL, ST Ortho Tri-Cyclen Lo PA Tekturna, HCT DO, QL Amerge QL OxyContin QL Amevive PA Pacerone Pancrease Testim PA, QL Anadrol-50 PA Thalomid PA Analpram - HC Android PA Plavix QL Anzemet QL Plexion SCT Tobradex Topamax PA Aquachloral Supprettes Pred Mild 0.12% Transderm-Scop Aranesp PA* Arixtra* Premarin oral, vaginal Trizivir Arthrotec ST Atacand DO, QL Premphase Twinject Atacand HCT DO, QL Avalide DO, QL Prenate Elite Avapro DO, QL Prevacid QL Avelox QL Prevacid Naprapac QL Avinza QL VESIcare Primaquine Azor DO, QL Pristiq DO, QL Beconase AQ ST, QL ProAir HFA QL Viracept Benicar, HCT DO, QL Betaseron* Flonase QL Omeprazole 40mg Biaxin XL Floxin Otic Boniva QL Foradil QL Omnaris ST, QL Bystolic Fortamet Caduet DO Forteo PA, QL* Omnitrope PA, QL* Fosamax tablets QL Capex Shampoo Fragmin* Opana ER QL Optivar QL^ Capozide Genotropin PA, QL* Ovidrel PA* Cardene, SR Glumetza Oxandrin PA Cardizem CD, LA DO, QL Gonal-f, RFF* Cardura, XL Grifulvin V Panretin Catapres TTS Histex, SR Pantoprozole PA, QL^# Caverject PA, QL Humatrope PA, QL* Pataday QL^ Humira PA, QL* Patanol QL^ Ceftin QL Hybolin PA Patanase QL Celebrex ST, QL Infergen* PA Cetrotide* Innohep* Paxil CR DO, QL Intron A PA* Pegasys PA* Cialis PA, QL Peg-Intron PA* Cimzia PA, QL Kadian QL Penlac PA Cipro XR QL Poly-Histine Elixir Clarinex, D QL^ Kineret PA* Poly-Pred Cleocin Vaginal Cream Kytril QL Pramosone Lamisil Spray Pravigard Lamisil Tablet PA Colestid Lescol, XL DO, QL Combipatch Levitra PA, QL Prilosec 40mg ST, QL^# Combunox QL Primaxin QL Copaxone* Prinivil Cordran Tape Lotensin, HCT Prinzide Lotrel (2.5/10, 5/10, 5/20 Procrit PA* Covera HS DO & 10/20mg) Prostin E2 Supp Crestor DO, QL Lunesta QL Protonix ST, QL^# Lupron Depot PA* Provigil PA, QL Cyclophosphamide Prozac Weekly QL DDAVP injection Lyrica PA Pulmozyme Delatestryl* Malarone PA Raptiva PA Razadyne, ER Depo-Estradiol* Maxair QL Relenza QL Depo-Testosterone* Maxaquin QL Relpax QL Methitest Remicade PA Dilaudid Miacalcin Spray QL Restoril Dovonex Soln. Micardis, HCT DO, QL Revatio PA, QL Dynacirc, CR Migranal QL Requip, XL Edex PA, QL Risperdal Elestat QL^ Rhinocort Aqua ST, QL Monopril/HCT Rozerem ST, QL Emadine QL^ Saizen PA, QL* Myambutol Sanctura, XR Myfortic Sarafem QL Enbrel PA, QL* Mysoline Seasonale PA Nasacort AQ ST, QL Serostim PA, QL* Estrace vaginal cream Nasarel QL Skelaxin Estrasorb Neumega PA* Sonata ST, QL Estratest, HS Soriatane Estrogel Norditropin PA, QL* Spectracef Factive QL Noroxin QL Sporanox Solution PA Norvasc DO, QL Stadol QL Fenoglide Nutropin, AQ PA, QL* Striant PA Fentora PA, QL Nuvaring PA Suprax QL First Testosterone Synagis PA Synarel PA Humira PA, QL Tamiflu QL Zetia ST, QL Increlex PA Zithromax QL Infergen PA Tequin QL Testopel PA Intron-A PA Testred PA Zofran QL Teveten, HCT DO, QL Zoladex PA Kineret PA Tev-Tropin PA, QL* Zoloft DO, QL Leukine PA Tiazac DO, QL Zorbtive PA, QL* Leuprolide PA Toprol XL ZyfloTier 4 Toradol QL Lupron, Depot PA Treximet Actimmune Tri-Nasal Alferon-N Methotrexate Triglide Metrodin Trileptal Aranesp PA Miacalcin injection Tussionex Neulasta PA, QL Ultram ER QL Neumega PA Uniretic Betaseron Neupogen PA Bravelle Norditropin PA, QL Urocit-K Caverject PA, QL Uroxatral Cetrotide Nutropin, AQ PA, QL Vaseretic Chorionic Gonadotropin Omnitrope PA, QL Colistimeth Ventolin HFA QL Coly-Mycin Pegasys PA Veramyst ST, QL Copaxone Peg-Intron PA Verelan PM DO, QL Delatestryl Delestrogen Depo Testosterone Procrit PA Viagra PA, QL Depo-Estradiol Raptiva PA Vivactil Voltaren Ophth Edex PA, QL Vytorin ST, QL Eligard PA Repronex PA Enbrel PA, QL Roferon-A PA Wellbutrin, SR Epogen PA Saizen PA, QL Wellbutrin XL DO, QL Fertinex Sandostatin Winstrol PA Follistim AQ Serostim PA, QL Forteo PA, QL Somavert Xolair PA* TevTropin PA, QL Xopenex Nebulizer Soln. Tobramycin Xyzal PA, QL^ Genotropin PA, QL Vitamin B12 Yasmin PA Gonal-f-, RFF Vivaglobulin PA Zegerid ST, QL^# Xolair PA Zestoretic Humatrope PA, QL Zorbtive PA, QL KEY # Non-formulary in Indiana only ^ This product has clinically equivalent alternatives included on the formulary 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.
* = These drugs are Tier 1, 2 or 3 for those members that do not have a Tier 4 plan 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. 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.
K. B. Institute of Pharmaceutical Education and Research Publications 2010 Department of Pharmaceutics Shastri, D. H., Patel P. B., Shelat, P. K., Shukla, A. K. (2010). Ophthalmic drug delivery system: Challenges and Approaches. Systematic Reviews in Pharmacy. 2(1), 113-120. Chaudhari, K. R., Shah, N., Patel, H.K., & Murthy, R.S.R. (2010). Preparation of porous PLGA microspheres
EMIRATES CONFORMITY ASSESSMENT SYSTEM SPECIFIC REQUIREMENTS FOR THE REGISTRATION OF Energy Drinks ACCORDING TO UAE.S/GSO 1926:2009 “Requirements of Handling Energy Drinks” 1. INTRODUCTION: This document defines the Criteria for the product registration under the Emirates Conformity Assessment System (ECAS) being implemented by the Emirates Authority for