[PDF] National Drug List. Drug list Four (4) Tier Drug Plan - Free Download PDF (2024)

National Drug List Drug list — Four (4) Tier Drug Plan

Anthem Blue Cross and Blue Shield prescription drug benefits include medications available on the Anthem National Drug List. Our prescription drug benefits can offer potential savings when your physician prescribes medications on the drug list.

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Anthem Blue Cross and Blue Shield National Drug List Your prescription drug benefit includes coverage for medicines that you'll find on the Anthem National Drug List. You can find more savings that is describes medicine that is on our formulary drug list of 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 National 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 National 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): 4 Cost of the drug 4 Cost of the drug in comparison to other drugs used for the same type of treatment 4 Availability of over-the-counter options 4 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.

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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 and 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 covered? A. You may want to first check with your doctor about prescribing a drug that is covered. If your doctor prescribes a drug that’s not covered, you will need to pay the out of pocket cost that applies to drugs not on the formulary. Q. Is this list a complete listing of all covered drugs under the National Drug List? A. No. This document lists the most commonly used drugs that are covered as part of the National Drug List. If the drug you are looking for is not listed, you may call customer service for more information. Please note: 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.

For more information about your drug plan, you can do the following: 4 Go to anthem.com 4 Call customer service at the number on your ID card 4 Speech and hearing impaired users (TDD/ TTY) should call 800-221-6915, Monday – Friday, 8:30 a.m. – 5:00 p.m., ET 4 Bring a copy of this drug list to your next doctor's visit to help you and your doctor select the lowest cost medicine Tier Drug List Definition 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. Tier 4 – Many drugs on this tier are "speciality" drugs used to treat complex, chronic conditions and may require special handling and/ or management.

Tier 1

Aviane Azathioprine Azelastine, QL Azelastine nasal, QL Azithromycin, QL Bacitracin zinc/polymyxin B Bacitracin/polymyxin/ neomycin-hc opth oint Baclofen Balsalazide belladonna/PB Belladonna/phenobarbital Benazepril, HCTZ Benzoyl peroxide Benzoyl peroxide/ clindamycin Benzoyl peroxide/ erythromycin Benztropine Betamet diprop/prop gyl Betamethasone dipropionate Betamethasone valerate Betaxolol Bethanechol A248 Bicalutamide Bisoprolol Bisoprolol/HCTZ Brimonidine Bromfenac Bromocriptine Budeprion XL, DO, QL Budesonide 0.25mg/2ml, 0.5mg/2ml, QL Budesonide EC Bumetanide Buprenorphine, QL Buprenorphine/naloxone tablet, QL Bupropion, QL Buspirone Butalbital Compound w/ Codeine Butorphanol tartrate 10mg/ml N.S., QL Cabergoline Calcipotriene Calcium Acetate Camrese Candesartan, DO, QL Candesartan/HCTZ, DO, QL Captopril, HCTZ Carbamazepine, ER Carbidopa/levodopa Carbidopa/levodopa CR Carbidopa/levodopa/ entacapone Carisoprodol Carteolol hcl Cartia XT, DO, QL Carvedilol Cefaclor Cefaclor ER Cefadroxil Cefdinir Cefpodoxime

Abacavir Acamprosate Acarbose Acebutolol Acetaminophen/caffeine/ butalbital, QL Acetaminophen/caffeine/ butalbital/codeine, QL Acetazolamide, SR Acetic acid Acetic acid otic Acetic acid/aluminum acetate Acetic acid/hydrocortisone Acetylcysteine Acitretin Acyclovir cap, tab, oint. Adapalene Adderall XR Albuterol Albuterol/ipratropium Alendronate, QL Alfuzosin Allopurinol Alprazolam Amantadine Amcinonide Amethia Amethia lo Amiloride Amiloride/ hydrochlorothiazide Aminophylline Amiodarone Amitriptyline Amitriptyline/ chlordiazepoxide Amitriptyline/perphenazine Amlodipine, DO, QL Amlodipine/atorvastatin, DO Amlodipine/benazepril Amnesteem, QL Amoxapine Amoxicillin Amoxicillin/clavulanate, ER, QL Amphetamine Amphetaminedextroamphetamine Amphetaminedextroamphetamine ER, ST#^ Ampicillin Anastrozole Antipyrine/benzocaine Apri Asa/codeine Aspirin/caffeine/butalbital Aspirin/caffeine/ dihydrocodeine Atenolol Atenolol/chlorthalidone Atorvastatin, DO, QL Atovaquone/proguanil Atropine sulfate 2

Cefprozil Ceftibuten Cefuroxime, QL Cephalexin Cevimeline Chloral hydrate Chlordiazepoxide Chlorhexidine gluconate Chloroquine 250mg Chlorothiazide Chlorphen/pyrilamine/ phenylephrine Chlorpheniramine/ pseudoephedrine Chlorpromazine tab Chlorpropamide Chlorthalidone Chlorzoxazone Cholestyramine, light Ciclopirox Cimetidine Ciprofloxacin, QL Citalopram, DO, QL Clemastine fumarate Clindamycin Clobetasol Clomiphene Clomipramine Clonazepam Clonidine Clonidine ER Clopidogrel, QL Clorazepate Clotrimazole/ betamethasone Clozapine, ODT Codeine sulfate tabs Codeine/APAP, QL Cromolyn Cyclobenzaprine Cyclopentolate Cyclophosphamide Cyproheptadine Danazol Dantrolene Desipramine Desloratadine, ODT, QL Desmopressin acetate Desonide Desoximetasone Dexmethylphenidate, ER Dextroamphetamine Dextromethorphan/ guaifenesin Diazepam Diclofenac potassium Diclofenac Sodium Gel, PA, QL Diclofenac sodium Ophth. Diclofenac, ER Diclofenac/misoprostol, ST Dicloxacillin Dicyclomine Didanosine Diflorasone diacetate Diflunisal Digoxin

Dihydroergotamine nasal spray, QL Diltia XT, DO, QL Diltiazem Diltiazem CD, DO, QL Diltiazem CR, DO, QL Diltiazem SR, DO, QL Diphenhydramine 50mg Diphenoxylate/atropine sulfate Dipivefrin HCl Dipyridamole Disopyramide Disopyramide CR 150mg Disulfiram Divalproex, ER Donepezil Dorzolamide Dorzolamide/timolol Doxazosin mesylate Doxepin Doxycycline Doxycycline DR, ST Doxycycline monohydrate Dronabinol Duloxetine, DO, QL Dyphylline Econazole Enalapril, HCTZ Entacapone Epinastine Eprosartan, QL Ergotamine Ergotamine/belladonna/PB Erythromycin Erythromycin base Erythromycin ethylsuccinate Erythromycin/sulfisoxazole Escitalopram, DO, QL Estradiol Estradiol/norethindrone, PA Estropipate Ethambutol Ethinyl estradiol/ ethynodiol diacetate Ethinyl estradiol/ norethindrone Ethosuximide Etodolac Etodolac ER Etoposide Exemestane, PA Famciclovir Famotidine Felbamate Felodopine, DO, QL Fenofibrate Fenofibric acid Fenofibric acid, delayed release, QL Fenoprofen Fentanyl, PA, QL Fexofenadine, QL Fexofenadine/PSE 12hr, QL Finasteride

Flecainide Fluconazole Flucytosine Fludrocortisone Flunisolide Nasal Spray, QL, ST Fluocinolone acetonide Fluocinonide Fluorometholone Fluorouracil Fluoxetine, DO, QL Fluphenazine Flurazepam Flurbiprofen Flurbiprofen sodium Flutamide Fluticasone Nasal Spray, QL Fluvastatin, DO Fluvoxamine, ER, DO, QL Folic acid Fosinopril, DO, QL Fosinopril HCTZ Furosemide Gabapentin Galantamine, SR Gatifloxacin eye drops Gemfibrozil Gentamicin Gianvi Glimepiride Glipizide XL Glipizide/metformin Glyburide Glyburide micronized Glyburide/metformin Glycolax Granisetron, QL Griseofulvin Guaifenesin Guaifenesin SR Guaifenesin/dextrometh Guaifenesin/hydrocodone Guanabenz Guanfacine Halobetasol Haloperidol Heparin Homatropine Hydralazine Hydralazine/HCTZ Hydrochlorothiazide Hydrocodone w/ homatropine Hydrocodone/APAP, QL Hydrocodone/ chlorpheniramine Hydrocortisone 2.5% cream, ointment, lotion Hydrocortisone enema Hydrocortisone/ pramoxine Hydromorphone Hydroxychloroquine Hydroxyurea Hydroxyzine HCL Hydroxyzine pamoate

Hyoscyamine Ibandronate, QL, ST Ibuprofen Imipramine Imiquimod, QL Indapamide Indomethacin, SR Ipratropium bromide neb soln/nasal spray, QL Irbesartan, DO, QL Irbesartan/HCTZ, DO, QL Iron combination capsule Iron/B12/folic acid Iron/intrinsic factor/B12 Isometh/dichlphen/APAP Isoniazid Isosorbide dinitrate Isosorbide mononitrate Isotretinoin, QL Itraconazole, PA Jinteli Ketoconazole Ketoprofen, ER Ketorolac, QL Ketorolac tromethamine Labetalol Lactulose Lamivudine Lamivudine/zidovudine Lamotrigine, ER Lansoprazole, QL Lansoprazole/amoxicillin/ clarithromycin pack, QL Latanoprost Leflunomide Letrozole Leucovorin Leuprolide PA Levalbuterol neb soln., QL Levetiracetam, ER Levobunolol Levocetirizine, QL Levofloxacin, QL Levonorgestrel & ethinyl estradiol Levonorgestrel (emergency OC) Levora Levorphanol tartrate Levothyroxine Levoxyl Lidocaine Lidocaine Patch Lidocaine viscous Liothyronine Lisinopril, HCTZ Lithium Loperamide Lorazepam Losartan, DO, QL Losartan/HCTZ, DO, QL Lovastatin, DO, QL Low-ogestrel Loxapine Mebendazole Meclizine Meclofenamate

Medroxyprogesterone Mefenamic acid Mefloquine Megestrol Meloxicam, QL Meperidine Meperidine w/ promethazine Mercaptopurine Metaproterenol Metaxalone Metformin, ER Meth/salicylate/ atropine/hyos benzoic Methadone Methamphetamine Methazolamide Methenamine/hyoscmeth blue/sod biphosphenyl sal Methimazole Methocarbamol Methotrexate tablets Methyclothiazide Methyldopa Methyldopa/HCTZ Methylergonovine Methylphenidate, CD, ER, SR Methylprednisolone Metoclopramide Metolazone Metoprolol, SR Metoprolol/HCTZ Metronidazole Mexiletine Miconazole nitrate Microgestin Midodrine Minocycline Minoxidil Mirtazapine Misoprostol Modafinil, DO, PA, QL Moexipril, HCTZ Mometasone ointment, cream Montelukast, QL Morphine ER, QL Morphine sulfate Multivitamins w/fluoride Multivitamins w/folic acid Mupirocin cream, oint Mycophenolate mofetil Nabumetone Nadolol Naltrexone hcl Naphazoline Naproxen Naproxen EC Naproxen sodium, DS Naratriptan, QL Nateglinide Necon Neomycin Neomycin/ dexamethasone

Neomycin/polymixin/ hydrocortisone Neomycin/polymyxin/ bacitracin Neomycin/polymyxin/ dexamethasone Neomycin/polymyxin/ gramicidin Neosol Nevirapine Next Choice, QL Niaspan Nicardipine Nifedipine Nifedipine ER, DO, QL Nimodipine Nisoldipine, DO, QL Nitrofurantoin Nitrofurantoin mono Nitroglycerin Nitroglycerin ointment Nitroglycerin patch Nitroglycerin spray Nitroglycerin SR Nizatidine Norethindrone Nortriptyline Nystatin Nystatin/triamcinolone Ocella Ofloxacin, QL Olanzapine, ODT Olanzapine/fluoxetine Omeprazole, QL Omeprazole/bicarb, QL Ondansetron, QL Orphenadrine Orphenadrine cpd Orphenadrine cpd Forte Oxaprozin Oxazepam Oxcarbazepine Oxybutynin Oxycodone Oxycodone ER, QL Oxycodone/APAP, QL Oxycodone/aspirin Oxymorphone, ER, QL Oxytocin Pantoprazole, QL Paricalcitol Paroxetine, SR, DO, QL Penicillin V.K. Pentamidine isethionate Pentazocine nx Pentazocine/apap Pentoxifylline Pergolide Perindopril Permethrin Perphenazine Phenazopyridine Phenelzine Phenobarbital Phenyleph hcl/hydrocod bit/cp

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Phenyleph/chlorphen/ carbeta Phenyleph/chlorphen/ hydrocodone Phenyleph-ephed-cpd w/ carbetapentane Phenyleph-pyrilamine w/ hydrocodone Phenylephrine Phenylephrine/ promethazine/codeine Phenytoin Phospha 250 Pilocarpine Pindolol Pioglitazone, QL Pioglitazone/glimepiride, QL Pioglitazone/Metformin, QL Piroxicam Polyethylene glycolelectrolyte solution Polymyxin B/ trimethoprim Pot. & Sod. Citrates w/ citric acid Potassium chloride Potassium citrate Potassium citrate-citric acid Pramipexole Pramoxine/hc/ chloroxylenol Pravastatin, DO, QL Prazosin Prednisolone Prednisolone sodium prosphate Prednisone Prenatal mulitvitamins and minerals/iron/folic acid Prenatal vitamin Prenatal w/docusate, iron, folic acid Primidone Probenecid Probenecid/colchicine Procainamide, SR Prochlorperazine Prochlorperazine supp 25mg Progesterone caps Promethazine Promethazine/codeine Promethazine/ dextromethorphan Promethazine/ phenylephrine Propafenone, SR Propantheline Propoxyphene/APAP, QL Propranolol, LA Propranolol/HCTZ Propylthiouracil

Pseudoephed/bromphenDM 45-4-15 Pseudoephedrine hcl/ chlor-mal Pseudoephedrine/ carbinoxamine Pseudoephedrine/ guaifenesin Pyrazinamide Quetiapine Quinapril, HCTZ Quinidine gluconate Quinidine sulfate Quinine sulfate, PA, QL Rabeprazole, ST^ Ramipril Ranitidine Repaglinide Rifampin Risperidone, ODT Rivastigmine Rizatriptan, ODT, QL Ropinirole, ER Salsalate Selegiline Selenium sulfide Sertraline, DO, QL Silver sulfadiazine Simvastatin, DO, PA, QL Sodium citrate & citric acid Sodium fluoride Sodium polystyrene sulfonate Sodium sulfacetamide/ sulfur Sotret, QL Spironolactone Spironolactone/HCTZ Stannous fluoride Stavudine Sucralfate Sulfacet sod w/sulfur Sulfacetamide sodium solution Sulfacetamide sodium/ prednisoloneophth sol. Sulfamethoxazole/ trimethoprim, DS Sulfasalazine, EC Sulfinpyrazone Sulindac Sumatriptan tabs, nasal spray and inj., QL Tacrolimus Tamoxifen Tamsulosin Temazepam Temozolomide, PA Terazosin Terbinafine Terbutaline Terconazole Theophylline Theophylline SR Theophylline syrup Thioridazine

Thiothixene Thyroid Tiagabine Ticlopidine Timolol Tinidazole Tizanidine Tobramycin Tobramycin/ Dexamethasone Susp. Tolmetin Tolterodine Topiramate Torsemide Tramadol, ER 100, 200, 300mg, QL Tramadol/APAP, QL Trandolapril Trandolapril/verapamil Tranylcypromine Travoprost drops Trazodone Tretinoin micro gel, PA Tretinoin PA Triamcinolone acetonide topical, nasal Triamterene/HCTZ Triazolam Trifluoperazine Trifluridine Trihexyphenidyl Trimethobenzamide Trimethoprim Trimipramine Tri-nessa Triple sulfa Triple vitamins w/fluoride Trivora Tropicamide Trospium, ER Trypsin/balsam peru/ castor oil Urea Ursodiol Valacyclovir Valproic acid Valsartan/HCTZ, DO, QL Vancomycin caps Venlafaxine, ER Verapamil, SR Voriconazole, PA Warfarin Westhroid Yohimbine Zafirlukast Zaleplon, QL, ST Zeosa Zidovudine Ziprasidone Zolmitriptan, ODT, QL Zolpidem, ER, QL Zonisamide

Tier 2 Abilify Acanya

Accu-chek Product Line, QL Actonel, QL Actonel with Calcium, QL ActoPlus Met XR, QL Advair Diskus, HFA, QL Advicor, DO Agenerase Akne-Mycin Alkeran Alphagan P 0.1% Altabax Amitiza Analpram HC lotion Androgel, PA, QL Apriso Armour Thyroid Asacol, HD Asmanex, QL Astepro, QL Atripla Atrovent HFA, QL Avodart Axiron, PA, QL AzaSite Azilect Azopt Beptoptic S BiDil Brilinta, QL Bydureon, QL, ST Byetta, QL, ST Calciferol drops Canasa Capitrol Carbatrol CeeNU Cellcept Ciprodex Climara Pro Clozaril Colcrys, QL Combigan CombiPatch Combivent Respimat, QL Complera Coreg XR Coumadin Creon Crestor, DO, QL Crixivan Cuprimine Cytadren Dapsone Daraprim Delzicol Depakote, ER Detrol LA Diastat Dibenzyline Differin 0.1% lotion Differin 0.3% gel Dilantin Diovan, DO, QL† Divigel Dulera, QL Durezol, QL

Edurant Effient, DO, QL Elidel, ST Eliquis, QL Emcyt, PA Emtriva Epipen, JR. Epzicom Estring Ethmozine Evamist Evista† Exelon Patch Exelon Solution† Exforge, DO, QL Exforge HCT, DO, QL Fansidar FazaClo ODT Felbatol Fem HRT 0.5/2.5 Femara Femtrace Finacea Flovent, HFA, QL Fluoroplex Foradil, QL Fortovase Fosamax Plus D, QL Fosamax solution, QL Furadantin Furoxone Fuzeon Gabitril Gantrisin Geodon inj. Gleevec, PA Glucagon Glyset Halflytely Humalog Humibid Cap Sprinkle Humulin N, R, 50/50, 70/ 30 Intal Inh. Invirase Iressa Jalyn Janumet, XR, QL, ST Januvia, QL, ST Jentadueto, QL, ST Juvisync, QL, ST Kaletra Keppra, XR Kuzyme Lamictal Lanoxicaps Lanoxin Lantus Leukeran Levemir Levothroid Lexiva Lialda Linzess Loestrin 24 FE, QL, ST∞ Lotemax soln, oint Lovaza

Lumigan Matulane Medrol 2mg Menest Mephyton Mepron Mestinon timespan Mintezol Moxeza Mycobutin Myleran Namenda, XR Nasonex, QL Neoral Neosar Nexavar, PA Nexium, QL Nilandron Nitro-Bid Nitro-Dur 0.3, 0.8mg/hr Nitrolingual spray Norpace CR 100mg Norvir Novolin N, R, 70/30 Novolog Nuvaring, QL Oforta, PA One Touch Product Line, QL Ortho Evra Ortho Tri-Cyclen Lo, QL, ST∞ OxyContin, QL Pacerone Pancrelipase Pentasa Perforomist, QL Plexion SCT Pradaxa, QL Pramosone 1% cream only, oint, lotion Premarin oral, vagin*l cream Premphase Prempro Priftin Primaquine Pristiq, DO, QL ProAir HFA, QL Procanbid Prograf Protopic, ST Pulmicort Flexhaler, QL Pulmicort Respules 1mg/ 2ml, QL QVAR, QL Ranexa Rapamune† Renvela† Rescriptor Restasis Retrovir Revlimid, PA, QL Reyataz Ridaura Rifamate Rifater 4

Risperdal Consta Sandimmune Oral Savella, QL Serevent Diskus, QL Seroquel XR Simbrinza Spiriva, QL Sprycel, PA Strattera Stribild Suboxone SL Film, PA, QL Sustiva Sutent, PA Symbicort, QL Symlin Synthroid Tamiflu, QL Tarceva, PA Tasigna, PA Tazorac Tegretol, XR Teslac Testim, PA, QL Thalomid, PA Theo-24 Tilade Tobradex oint. Topamax Toviaz Tradjenta, QL, ST Transderm-Scop Travatan Z Trizivir Truvada TussiCaps Twinject Ultrase Uniphyl Vagifem Valcyte Tabs Valturna, DO, QL Veltin, ST Ventolin HFA, QL Veramyst, QL VESIcare Victoza, QL, ST Videx soln. Vigamox Viracept† Viramune XR Viread Vivelle Dot† Voltaren gel Vyvanse, PA Welchol Xarelto, QL Xeloda, PA Yodoxin Zarontin Zenpep Ziagen soln. Zortress Zylet Zytiga, PA

Tier 3 Abilify Maintena

Abstral, PA, QL Accolate Accupril Accuretic Aceon Aciphex, QL, ST^ Aciphex Sprinkles, ST^ Actiq, PA, QL Activella, PA ActoPlus Met, QL Actos, QL Acular, LS Acuvail Adderall Aggrenox, QL Alamast, QL, ST^ Aldara, PA, QL Allegra, D, QL, ST^ Alocril, QL, ST^ Alomide, QL, ST^ Alora Alphagan P 0.15% Alsuma, QL Altace Altoprev, DO, ST Alupent Inhaler Alvesco, QL Ambien, QL Ambien CR, QL, ST Amerge, QL Anadrol-50, PA Androderm, PA, QL, ST Android, PA Antabuse Antara Anzemet, QL Apidra, ST Aplenzin, DO, QL Apriso Aquachloral Supprettes Arcapta, QL Aricept Arimidex, PA Aromasin, PA Arthrotec, ST Astagraf XL Astelin, QL Atacand, DO, QL Atacand HCT, DO, QL Augmentin, XR, QL Auvi-Q Avalide, DO, QL Avandamet, QL, ST Avandaryl, QL, ST Avandia, QL, ST Avapro, DO, QL Avelox, QL Avinza, QL Axert, QL, ST Azor, DO, QL Beconase AQ, QL, ST Benicar, HCT, DO Benzaclin, ST Bepreve, QL, ST^ Besivance Betimol Beyaz, QL, ST∞

Biaxin XL Binosto, QL Blephamide Boniva tab, QL, ST Breo Ellipta, QL Brintellix, DO, ST Brisdelle Bupap Butrans Bystolic Caduet, DO Cambia, QL Capex Shampoo Capoten Capozide Cardene, SR Cardizem CD, LA, DO, QL Cardura, XL Casodex Catapres TTS Caverject, PA, QL Cedax Ceftin, QL Celebrex, QL, ST Cenestin Chemet Cialis, PA, QL Ciloxan Cipro XR, QL Clarinex, D, QL, ST^ Cleocin vagin*l Cream Climara Clobex Coartem Codeine sulfate solution Colazal Colestid Combivir Comtan Concerta Conzip ER Cordran Tape Coreg Cortifoam Cosopt, PF Covera HS, DO Cozaar, DO, QL Cycloset Cymbalta, DO, QL Cytoxan Daliresp, QL DDAVP injection Delatestryl Denavir Depen Depo-Estradiol Depo-Testosterone Derma-Smoothe FS Desvenlafaxine ER, DO, QL Detrol Dexilant, QL, ST^ Dexpak Diclegis, PA, QL Differin 0.1% cream, gel, PA Dificid

Dilaudid Diovan HCT, DO, QL Dipentum Doryx, ST Dovonex Duac Duetact, QL Duexis, QL Dutoprol Dymista, QL Dynacirc, CR Edarbi, DO, QL Edarbyclor, QL Edex, PA, QL Edluar SL, ST Effexor, XR, DO, QL Elestat, QL, ST^ Eliphos, ST Ella Elmiron Emadine, QL, ST^ Embeda, QL Emend, QL Enablex, ST Entocort EC Epaned Epiduo Epivir Esclim Esomeprazole Strontium, QL, ST^ Estrace vagin*l cream Estraderm Estrasorb Estrogel Evoxac Exalgo, QL, ST Exelderm Exelon Fabior foam Factive, QL Fanapt Fem HRT 1/5 Femara Femring Fenoglide Fentora, PA, QL Fetzima ER, DO, PA, QL Fibricor Fioricet Fioricet with Codeine First Testosterone First-Lansoprazole First-Omeprazole Flector, ST Flomax Flonase, QL Floxin Otic Fluoxetine 60mg FML Forte FML S Focalin, XR Forfivo XL, QL Fortamet Fortesta, PA, QL Fosamax tablets, QL Fosrenol, ST

Frova, QL, ST Fulyzaq, PA Furadantin Gastrocrom Gelnique, ST Generess FE, QL, ST∞ Geodon caps Giazo Gilotrif, PA Glumetza Gralise ER Grifulvin V Hectorol Histex, SR Horizant ER Hybolin, PA Hyzaar, DO, QL Ilevro Imbruvica Imitrex, QL Imitrex Nasal Spray, QL Intermezzo, QL, ST Intuniv Invega, Sustenna Invokana, QL, ST Juxtapid, PA Kadian, QL Kazano, QL, ST Ketek Khedezla ER, DO, QL Kombiglyze, QL, ST K-Phos Kristalose Kytril, QL Lamictal XR Lamisil Spray Lamisil Tablet Lastacaft, QL, ST^ Latuda Lazanda, PA, QL Lescol, XL, DO, QL, ST Levaquin, QL Levitra, PA, QL Lexapro, DO, QL Lidoderm Patch Lipitor, DO, QL, ST^ Lipofen Liptruzet, QL, ST Livalo, DO, QL, ST Lo Loestrin FE, QL, ST∞ Lo Minastrin FE, ST∞ Loprox gel Loprox shampoo Lorabid Lorzone Lotemax gel Lotensin, HCT Lotrel Lunesta, QL Lupron Depot 7.5, 22.5, 30, and 45mg, PA Luxiq Lyrica, PA, QL Malarone Marinol Mavik Maxair, QL

Maxalt, MLT, QL Maxaquin, QL Maxidex Methergine Methitest MetroGel MetroLotion Micardis, HCT, DO, QL Migranal, QL Minastrin 24 FE, ST∞ Minivelle, ST∞ Mirapex, ER Mirvaso Gel Moban Mobic, QL Morgidox, ST Multaq Muse, PA Myambutol Myfortic Myrbetriq ER, ST Mysoline Naftin Nardil Nasacort AQ, QL, ST Nasarel, QL Natazia, QL, ST∞ Nesina, QL, ST Neupro, QL Neurontin Niacin ER, ST^ Niacor Norinyl 1+50, QL, ST∞ Noroxin, QL Norvasc, DO, QL Noxafil Nucynta, ER, QL, ST Nuvigil, PA, QL Nymalize Olux E Omeclamox-Pak Omnaris, QL, ST Omnicef Onfi Onglyza, QL, ST Onmel, PA Onsolis, PA, QL Opana Opana ER, ST Optivar, QL, ST^ Oraxyl Oseni, QL, ST Ovcon-50, QL, ST∞ Oxandrin, PA Oxecta Oxtellar XR Oxytrol, ST Pancreaze Panretin Parnate Pataday, ST^ Patanase Patanol, ST^ Paxil CR, DO, QL Penlac Pertzye DR Phoslo, ST 5

Picato, PA, QL Plan B, QL Plavix, QL Poly-Histine Elixir Poly-Pred Potiga Pramosone 2.5% Prandimet Prandin Pravigard Precose Pred Mild 0.12% Pred-G Prefest Prenate Elite Prevacid, QL, ST^ Prevpac, QL Prilosec, QL, ST^ Primaxin, QL Prinivil Prinzide Prolensa Prolia, PA, QL Prometrium Prostin E2 Supp Protonix, QL, ST^ Proventil HFA, QL Provigil, DO, PA, QL Prozac, Weekly, QL Pulmicort Respules 0.25mg/2ml, 0.5mg/ 2ml, QL Qnasl, QL, ST Qualaquin, PA, QL Quartette, ST∞ Quillivant XR Rayos DR Razadyne, ER Rectiv Relenza, QL Relpax, QL, ST Renagel, ST Requip, XL Rescula Restoril Retin-A Micro, PA Rhinocort Aqua, QL, ST Riax Foam Risperdal, M Roxicet, QL Rozerem, QL, ST Rythmol, SR Ryzolt, QL Safyral, QL, ST∞ Sanctura, XR, ST Sancuso, QL Saphris Sarafem Seasonale Seasonique Seroquel Simcor, QL Singulair, QL Sirturo Skelaxin Solodyn, PA, ST Soma

Sonata, QL, ST Soriatane CK Sorilux foam Spectracef Sporanox Solution, PA Stadol, QL Starlix Striant, PA Subsys, PA Subutex, QL Suclear Sular, DO, QL Sumavel Dosepro, QL, ST Suprax, QL Sylatron Symbyax Synalar Tapazole Tarka Tekamlo, DO, QL Tekturna, HCT, DO, QL Temodar, PA Tequin, QL Testopel, PA Testred, PA Teveten, HCT, QL Thyrogen Tiazac, DO, QL Tivicay Tobradex susp. Tobrex Toprol XL Toradol, QL Tramadol ER 150mg, QL Treximet, QL, ST Tricor Triglide Trileptal Trilipix, QL Tri-Nasal Trokendi XR Trovan Trusopt Tudorza Pressair, QL Tussionex ER Twynsta Uceris Uloric, ST Ultram, ER, QL Ultravate X Ultresa Uniretic Univasc Urocit-K Uroxatral Valcyte soln Valtrex Vascepa Vaseretic Vasotec Vecamyl Verelan PM, DO, QL Vesanoid Vexol Vfend, PA Viagra, PA, QL Videx EC

Viibryd, QL, ST Vimovo, QL Vimpat Viokace Viramune Virasal Vituz Vivactil Voltaren Ophth Vytone Vytorin, QL, ST Wellbutrin XL, DO, QL Wellbutrin, SR, DO Westhroid-P Winstrol, PA WP Thyroid Xalatan Xerac AC Xgeva, PA, QL Xifaxan, QL, ST Xopenex HFA, QL Xopenex Neb. Soln., QL Xyzal, QL, ST^ Yasmin Yaz Zegerid, QL, ST^

Zemplar caps Zenzedi, PA Zerit Zestoretic Zestril Zetia, QL, ST Zetonna, QL, ST Ziagen tabs Zioptan Zithranol Zithromax, QL Zmax, QL Zocor, DO, PA Zofran, QL Zoloft, DO, QL Zolpimist, QL, ST Zomig, ZMT, QL, ST Zorvolex Zovirax Oint Zubsolv, PA, QL Zyclara, PA, QL Zyflo Zyprexa Relprevv Zyprexa, Zydis Zyvox, PA, QL

Tier 4

Epivir HBV Epogen, PA Extavia, ST Firazyr, PA Follistim AQ~ Fondaparinux Forteo, PA, QL Fragmin Ganciclovir IV Ganirelix Genotropin, PA, QL Gilenya, PA, QL Gonal-f, RFF Granix Humatrope, PA, QL~ Humira, PA, QL~ Ilaris, PA Incivek, PA Infergen Innohep Intron A, PA Kineret, PA Korlym, PA Kuvan, PA Letairis Leukine, PA

Actemra, PA Acthar HP, PA, QL Actimmune Adcirca, PA Adempas Alferon-N Amevive, PA Ampyra, PA, QL Aranesp, PA~ Arixtra Aubagio, PA, QL Avonex~ Baraclude Benlysta, PA Betaseron, ST Bethkis Boniva IV, QL, ST Cetrotide Chorionic gonadotropin Cimzia, PA, QL Copaxone~ Crinone Enbrel, PA, QL~ Enoxaparin

Lupron Depot 3.75mg, 11.25mg, PA Lupron Depot-Ped, PA Makena, PA Miacalcin Spray, QL Nebupent Neulasta, PA, QL Neumega Neupogen, PA Norditropin, PA, QL Nutropin, AQ, PA, QL~ Octreotide Olysio Omnitrope, PA, QL Opsumit Orencia, PA, QL Ovidrel, PA Pegasys, PA, QL~ Peg-Intron, PA Procrit, PA~ Pulmozyme Rebif~ Remicade, PA Revatio, PA, QL Ribavirin Rilutek

Riluzole Saizen, PA, QL Sandonstatin LAR Sandostatin Serostim, PA, QL Sildenafil, PA, QL Simponi, PA, QL~ Simponi Aria, PA, QL~ Somatuline Somavert Stelara, PA, QL~ Synagis, PA Synarel, PA Tecfidera, PA, QL Tev-Tropin, PA, QL TOBI TOBI Podhaler Tobramycin Ampule for Neb. Tracleer Ventavis, PA Victrelis, PA Xeljanz, PA, QL Xolair, PA Zorbtive, PA, QL

KEY # †=

Tier 3 for Indiana 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. For Kentucky Residents Only: In selecting medications for the prescription drug list, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the drug list by at least one medication. When a closed drug list is in effect, only medications that are included on the drug list are a covered service. In certain clinical situations, a member may require use of a non-covered product. Anthem has criteria that permits a member to obtain a noncovered medication in a closed drug list plan. If specific criteria are met, a member can receive a non-covered drug for a drug list copay. The criteria preserves the clinical integrity of the drug list and provides a process by which deviations from the drug list may be allowed. An appeals process is in place for any medications that do not meet the criteria. 6

For more information, please visit anthem.com. 4 If you have additional questions about your prescription benefits please call the Member Services number on your ID card 4 Speech and hearing impaired (TDD/TTY users) should call 800-221-6915, Monday – Friday, 8:30 a.m. – 5:00 p.m., ET 4 For the most current version of this prescription drug list, please visit anthem.com 4 Bring a copy of this drug list 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. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, 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. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. 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 and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans.

39525ANMENABS 01/1/2014