40627CAMENABC Effective 1/15

4 Tier Formulary

Select Drug ListPending Regulatory Approval

2B_5215577_1078330 40627CAMENABC 2015 CA Select Drug List SH 09 14

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Anthem Blue Cross Select Drug List

Your prescription drug benefit includes coverage for medicines that you’ll find on the Select Drug List. You can often find more savings when your doctor prescribes medicine that is on our Select Drug List. Here are some commonly asked questions and answers about how the Select Drug List works with your prescription drug plan.

Q. What is a Select Drug List?A. The Select 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 Select 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/ca.

Q. What are Tiers?A. Drugs on the Select 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.

Q. Is this list a complete listing of all covered drugs under the Select Drug List?

A. No. This piece lists the most commonly used drugs that are covered as part of the Select Drug List. If the drug you are looking for is not listed, you may call customer service for more information.

Q. What do I do if I am prescribed or currently taking a prescription drug that is not on the Anthem Select Drug List?

A. If you are prescribed or currently taking a non-formulary drug, you should discuss formulary alternatives your physician. If your physician feels that the medication is medically necessary, it will be necessary to obtain Prior Authorization of Benefits in order for the prescription to be a covered benefit. Information is available to you and your physician through the Certificate or Evidence of Coverage, health plan web site and newsletters. You may also call customer service for more information.

Q. Can I request that a drug be added to the Select Drug List?

A. You or your doctor can put in a request to add a drug to the Select Drug List. You can do this either in writing or on our website. Requests are reviewed by the P&T Process team during the Select 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.

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.

Preventive Care Drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).

Please note: 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. We have criteria that permits a member to obtain a non-covered medication in a closed drug list plan. If specific criteria are met, a member can receive a non-covered drug for a drug list co-pay. 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.

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Tier 1

AbacavirAcebutololAcetasol HCAcetazolamide tab, ER cap

AclometasoneActicinAcyclovir tab, cap, oral susp.

Adapalene 0.1% Afeditab CR QL DOAlbuterol inhl soln., syrupAlendronate QLAlfuzosinAllopurinol tabAlprazolam tabAmantadine Amcinonide Aminophylline tabAmitriptylineAmlodipine QL DOAmlodipine/atorvastatin QL DO

Amlodipine/benazeprilAmmonium lactate cream, lotion

Amnesteem PAAmoxapineAmoxicillin Amoxicillin/clavulanate Amoxicillin/clavulanate ER

Amphetamine/dextroamphetamine salts, ER PA QL

Androxy PAAntipyrine/benzocaine ear drop

ApraclonidineAtenololAtenolol/chlorthalidoneAtorvastatin QL DOAtovaquone/proguanilAzelastine nasal spray, drops QL

Azithromycin tab, susp., packet QL

Bacitracin/polymixin BBaclofen BalsalazideBenazepril

Benazepril/HCTZBenzonatateBenzoyl peroxideBenztropineBetamethasone dipropionate

Betamethasone valerate Betaxolol Birth Control (generic oral contraceptives)

BisoprololBisoprolol/HCTZBrimonidineBromocriptine Budesonide 0.25mg/2mL, 0.5mg/2mL QL

Buprenorphine tab PA QLBupropion QLBupropion SR, XL QL DOBuspirone Butalbital/acetaminophen

Butalbital/acetaminophen/caffeine

Butalbital/acetaminophen/caffeine/codeine QL

Butalbital/aspirin/caffeine

Butalbital/aspirin/caffeine/codeine

Butorphanol nasal spray PA QL

CabergolineCalcipotriene Candesartan/HCTZ PA QL DO

Carbamazepine, ER, XRCarbidopa/Levodopa, ER, ODT

CarteololCartia XT QL DOCefaclor, ERCefadroxilCefdinirCefditoren PivoxilCefprozilCefuroxime AxetilCephalexinChlorhexidine gluconateChlorhexidine RinseChloroquine

Chlorpromazine tab PAChlorthalidoneChlorzoxazoneCiclopiroxCimetidine tab, soln.Ciprofloxacin ear and eye drops

Ciprofloxacin tab QLCitalopram QL DOClaravis PAClarithromycin, ERClindamycin cap, oral soln, topical preparations

Clindamycin/Benzoyl Peroxide Gel

ClobetasolClomipramineClonazepam, ODTClonidine tabClopidogrel QLClotrimazole 1% cream, troche

Clotrimazole/betamethasone

Codeine sulfate tabs QLCodeine/acetaminophen QL

Codeine/butalbital/aspirin/caffeine

Covaryx, H.S.Cromolyn eye drops QLCromolyn neb soln.Cyclobenzaprine tabDepadeDermazeneDesmopressin nasal spray, tab PA

DesonideDesoximetasoneDexamethasone eye dropDexamethasone tab, oral soln.

Dexmethylphenidate, XR PA QL

Dextroamphetamine, ER PA QL

Diazepam tab, oral soln.Diclofenac eye dropDiclofenac, ERDicloxacillinDicylomine cap, tab, syrup

Didanosine DRDiflorasoneDiflunisalDigoxin tab, oral soln.DiltiazemDiltiazem ER, XR, CD QL DO

Diphenhydramine 50mg cap

Diphenoxylate/atropineDipyridamole tabDisopyramideDisulfiramDivalproex, ER, DRDorzolamide eye dropsDorzolamide/timolol eye drops

DoxazosinDoxepin Doxycycline hyclate tab, cap

Doxycycline hyclate, delayed release PA

Doxycycline monohydrate tab, cap

EconazoleEnalaprilEnalapril/HCTZEndocet QLEndodan QLEpidrinEpinastine eye drops QLEpitolErgocalciferol (Vit D2) caps

Ergotamine/caffeineEry-Tab 250mg, 333mg tab

Erythromcyin eye oint.Erythromycin 2% gel, topical solution

Erythromycin ethylsuccinate 400mg Filmtab

Erythromycin Filmtab, 250mg cap

Erythromycin stearateErythromycin/benzoyl peroxide gel

Erythromycin/sulfisoxazole

Escitalopram QL DOEstradiol patch QL

For more information about your drug plan, you can do the following:

}} Go to anthem.com/ca.

}} 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 p.m., ET.

TIER DEFINITIONS

Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions.

Tier 2 drugs have a medium cost share. They may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.

Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.

Tier 4 specialty drugs have the highest cost share. They may cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA. Specialty drugs are used to treat complex, chronic conditions and may need special handling.

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Estradiol tabEstrogen/methyltestosterone

EstropipateEthambutolEthosuximideFamciclovirFamotidine tab, oral soln.FelbamateFelodipine ER QLFenofibrateFenofibric acid, DRFinasteride 5mg tab PAFluconazole tab, oral soln.

FlucytosineFlunisolide nasal spray ST QL

Fluocinolone body oil, scalp oil PA

Fluocinolone cream, topical soln., oint., ear drop

FluocinonideFluorometholone eye drops

Fluorouracil cream, topical solution

Fluoxetine, DR (except 60mg) QL DO

Fluphenazine tab, oral soln. PA

Fluticasone nasal spray QL

Fluticasone topicalFolic acid 1mgFosinoprilFosinopril/HCTZFurosemide tab, oral soln.Garamycin eye dropsGemfibrozilGentamycin eye drops, oint.

GlimepirideGlipizide, ER, XLGlipizide/metforminGlyburideGlyburide/metforminGriseofulvinGuaifenesin/codeine syrup

GuanfacineGuanidine

HalacHalobetasol propionateHaloperidol tab PAHydralazine tabHydrochlorothiazideHydrocodone/acetaminophen QL

Hydrocortisone tabHydrocortisone 2.5% cream, lotion, oint.

Hydrocortisone acetate 2% gel

Hydrocortisone acetate suppository

Hydrocortisone butyrate 0.1% cream, oint., soln.

Hydrocortisone enemaHydrocortisone valerate 0.2% cream, ointment

Hydrocortisone/acetic acid ear drops

Hydrocortisone/pramoxine cream, ointment

Hydromorphone suppository

Hydromorphone tab, oral soln. QL

HydroxychloroquineHydroxyzine HCL tab, oral soln.

Hydroxyzine pamoateIbandronate ST QLIbuprofenImipramine HCL tabImiquimod PA QLIndapamideIndomethacin , ER capIpratropium bromide neb soln. QL

Irbesartan/HCTZ PA QL DO

Isometheptene/acetaminophen/caffeine

Isometheptene/acetaminophen/dichloralphenazone

IsonarifIsoniazid tab, oral soln.Isosorbide dinitrate, ER tab

Isosorbide mononitrate, ER tablet

Ketoconazole

Ketorolac eye dropsKetorolac tab QLKlor-Con tabLactuloseLamotrigine tab (immediate release)

LamuvidineLamuvidine/zidovudineLansoprazole, DR QLLatanoprostLevofloxacin tab QLLevothroidLevothyroxine tabLevoxylLidocaine viscous soln.Lidocaine/hydrocortisone 3/0.5% cream

Lidocaine/prilocaineLindaneLiothyronine tabLisinoprilLisinopril/HCTZLithium carbonate, ERLithium citrate oral soln.LonoxLosartan QL DOLosartan/HCTZ QL DOlovastatin QL DOLoxapine PAMalathionMaprotilineMatzim LA QL DOMebendazoleMeclizine tabMeclofenamate capMedroxyprogesterone tab

MefloquineMegestrolMeloxicam oral suspension

Meloxicam tab QLMeperidine tab, oral soln. QL

Metadate ER PA QLMetaproterenolMetformin, ERMethadone tab, oral soln. QL

MethazolamideMethimazole

methscopolamine bromide

MethyclothiazideMethyldopaMethyldopa/HCTZMethylergonovine tabMethylphenidate, CD, ER, SR PA QL

Methylprednisolone tabMetipranolol eye dropsMetoclopramide tab, oral soln.

Metoprolol tab, ERMetoprolol/HCTZMetronidazole 0.75% gelMetronidazole tab, capsule, cream, lotion

MinocyclineMinocycline ER PAMinoxidil tabMirtazapineMisoprostol PAMometasone cream, oint, topical soln.

Montelukast QLMorphine sulfate IR tab QL

Morphine sulfate oral soln. QL

Morphine sulfate supppository

Mupirocin oint.NabumetoneNadolol/bendroflumethiazide

NaltrexoneNaphazoline eye dropsNaproxen, DRNaratriptan QLNature-ThroidNefazodoneNeomycin tabNeomycin/polymixin/bacitracin eye oint.

Neomycin/polymixin/bacitracin/hydrocortisone eye oint.

Neomycin/polymixin/dexamethasone eye drops, oint.

Neomycin/polymixin/gramicidin eye drops

Neomycin/polymixin/hydrocortisone ear and eye drops

NevirapineNiacin ERNifedipine capNifedipine tab ER, XL QL DO

Nisoldipine ER QL DONitro-Bid oint.Nitrofurantoin Nitroglycerin, ER, SRNorethindronenortriptylineNP ThyroidNystatin cream, oint., powder, tab

Nystatin/triamcinoloneOfloxacin ear and eye drops

Ofloxacin tab QLOmeprazole caps QLOxcarbazepineOxybutynin, EROxycodone QLOxycodone/acetaminophen tab, cap QL

Oxycodone/aspirin QLOxymorphonePancrelipase, DRParamomycinParoxetine, CR, ER QL DOPenicillin VKPentoxifylline, ERPermethrin creamPerphenazine PAPhenazopyridinePhenelzinePhenobarbital tab, oral soln.

Phenytoin ext. capPodofiloxPolymixin/trimethoprim eye drops

Potassium 25mEq tab effervescent

Potassium chloride ER tab, ER cap

Potassium Citrate ER TabPotassium citrate/citric acid

Pramipexole

Pravastatin QL DOPrazosinPrednicarbatePrednisolone eye dropsPrednisolone oral soln.PrednisonePrenatal Vitamins (all generic covered)

PrimidoneProbenecidProbenecid/colchicineProcentra QLProchlorperazine tabProgesterone, micronized cap

Promethazine tab, suppository, syrup

Promethazine VC syrupPromethazine VC syrup with codeine

Promethazine/codeine syrup

Promethazine-DM syrupPropranolol ERPropranolol HCTZPropranolol tab, oral soln.PropylthiouracilProtriptylinePyrazinamidePyridostigmineQuetiapine PAQuinaprilQuinapril/HCTZQuinidine sulfate, ERQuinine sulfate PA QLRaloxifeneRamiprilRanitidine 150, 300mg tab, cap

Ranitidine oral soln.RifampinRimantadineRisperidone, ODT, oral soln. PA

Ropinirole, ERRoxicet tab, caplet QLSelegilineSelenium sulfide 2.5% lotion, shampoo

Sertraline QL DOSilver sulfadiazine creamSimvastatin QL DO

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Simvastatin 80mg PA QL DO

Sodium polystyrene sulfate 30gm/120ml enema

Sodium polystyrene sulfate powder

Sodium polystyrene sulfonate

Sodium sulfacetamide/sulfur

Sodium sulfacetamide/sulfur/urea

SpinosadSpironolactoneStavudineSucralfateSulfacetamide eye drops, oint.

Sulfacetamide sodiumSulfacetamide sodium/prednisolone eye drops

Sulfacetamide sodium/sulfur

Sulfacetamide sodium/sulfur/urea

Sulfacetamide sodium/urea

Sulfamethoxazole/trimethoprim, DS

SulfasalazineSumatriptan tab QLTaztia XT QL DOTerazosinTerbinafine tab PATerconazoleTetracycline capsTheochron ERTheophylline ER, oral soln.

Thioridazine PAThiothixene PATiclopidineTimolol eye drops, gelTimolol tabTizanidineTobramycin eye dropsTobramycin/dexamethasone eye drops

TolbutamideTopiramate PATorsemide tab

Tramadol tab QLTrandolaprilTranexamic acid 650mgTranylcypromineTrazodoneTretinoin cream, gel PATriamcinolone cream, lotion, oint.

Triamcinolone nasal spray QL

Triamcinolone pasteTriamterene/HCTZTrifluoperazine PATrihexyphenidylTrimethobenzamide capTrimethoprimUnithroidValacyclovirValproid acid cap, oral soln.

Valsartan/HCTZ PA QL DOVenlafaxineVenlafaxine, ER QL DOVerapamil tab, ER PM QL DO

Verapamil tab, ER tab, cap

Vicodin, ES, HP QLWarfarinWesthroidZaleplon ST QLZidovudineZiprasidone PA

Tier 2

Abacavir/Lamivudine/Zidovudine

AcamprosateAccu-Chek ProductsAcitretinAdvair Diskus, HFA QLAnaspaz ODTAptivus Asmanex Twisthaler QLBethanechol tabBudesonide ECBuprenorphine syringe, vial

Calcitonin QLCalcium acetate tabCarbidopa ST

CefpodoximeCeftibutenCevimelineCilostazolClozapine, ODT PACrixivanDanazolDantroleneDemeclocyclineDesipramineDulera QLEdurantEliphosEmtrivaEntacaponeEpipen, Jr.Epivir HBV soln. PAEpzicomErgoloidFentanyl patch ST QLFlecainideFlovent QLFlovent HFA QLFortical nasal spray QLFuzeonGabapentinGalantamine, ER QLGlucagenHumalogHumalog MixHumulin N, R, 70-30IntelenceInviraseIsentressItraconazole PAKaletraLantusLantus SolostarLeflunomideLevemirLevetiracetamLevetiracetam ER PA QLLevocarnitine tab, oral soln.

LexivaMexiletineMorphine sulfate ER QLNitroglycerin sprayNitrostatNorvir

Novolin NOlanzapine tab, ODT PAOndansetron tab, ODT, oral soln. QL

One Touch Product LineOxandrolone PAPrezistaProair HFA ST QLPropafenonePrudoxinPulmicort 1mg/2mL respules QL

Pulmicort Flexhaler QLQvar QLRelenza QLRescriptorReyatazRifabutinRivastigmine QLSelzentrySerevent Diskus QLSotalol tab, AF tabSulfadiazineSumatriptan inj QLSustivaSymbicort QLTamiflu QLTiagabine PATranexamic acid 1000mg/10mL

TruvadaVancomycin caps PAViraceptViread PAZonisamide

Tier 3

Abilify tab PAActonel ST QLAczoneAggrenox QLAlamast PAAliniaAlocril PA QLAlomide PA QLAltabaxAmitizaAndrogel PA QLApriso ERArestinAzilect

BactocillBesivanceBeyaz STBiltricideBuphenyl tablet PACantilCesamet PAChemetCiclodanClindacinCoartemColcrys PA QLCuprimineDaliresp QLDapsoneDaraprimDibenzylineEdecrinElidel PAEllaElmironErgomarEstringFinaceaFluoridexFosamax Plus D ST QLGeneress FeLacrisertLanoxin tabLo Loestrin FeLotemaxLovazaLumiganMaxair QLMethitestMigranal nasal spray† QLMorgidox PAMotofenMoviprepMultaqMyrbetriq STNamenda QLNatazia STNuedextaNuvaringOraceaOrap PAOrtho Tri-cyclen LoOsmoprepOxsoralen-Ultra PA

PanretinPataday PA QLPatanol PA QLPeganonePhospholine iodidePred-GPred-G S.O.P Premarin CreamPremarin tab STPremphasePremproPrevident 5000 Booster Plus

PrimaquineProlia PAProtopic PAProventil HFA ST QLRenvela PARestasisRidauraRifaterRosadanSafyral STSavella QLScopaceSilenor STSpiriva QLStrattera PA QLStromectolSuprax tab, susp.SyprineTikosynTransderm-Scop PATravatan ZTyzineVagifemVentolin HFA ST QLVeregenVigamox PAVisicolVivelle-Dot PA QLVoltaren gelVyvanse PA QLWelcholXopenex HFA ST QLZirganZyvox tab, oral soln. PA QL

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Tier 4

Adcirca PAAdefovir DipivoxilAfinitor PAAlkeran tabAmevive PAAmpyra PA QLAnagrelideAnastrazole tab PAApokyn PAAranesp PAAzathioprine tabBosulif PACapecitabine PACaprelsa PACarbaglu PACeeNUCimzia PA QLCometriq PACyclophosphamide tabCyclosporine Cyclosporine cap, soln.DroxiaEmcyt PA

Enbrel PA QLEnoxaparin PAErivedge PAEtopophosEtoposide capsExemestane PAExtavia STFarestonFlutamideFondaparinux PAForteo PAGengrafGleevec PAHexalenHumira PA QLHycamtin capsHydroxyureaIclusig PAInfergen PAInlyta PAIntron A PAIressaJakafi PAKineret PA

Kuvan PALetairis PALetrozoleLeucovorin tabLeukeranLeuprolide PALysodrenMatulaneMelphalanMercaptopurineMethotrexate tabMycophenolateMyleranNeulasta PA QLNexavar PANilandronOforta PAOrencia PAQLOrfadinPegasys PA QLPegintron PAPomalystPromacta PARebif PA

Remicade PARemodulin PARevlimid PA QLRibavirin PARituxan PASensiparSimponi PA QLSirolimusSprycel PAStivarga PASutent PATabloidTamoxifenTarceva PATasigna PATemozolomide cap PATev-Tropin PAThalomid PATopotecanTrelstar PATrelstar Depot PATretinoin 10mg capsuleTykerb PATysabri

Tyzeka PAVandetanib PAVentavis PAVictrelis PAVotrient PAXalkori PAXtandi PAZelboraf PAZolinza PAZoledronic AcidZytiga PA

KEY

† = 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 may no longer be covered by your prescription drug plan. Check anthem.com/ca to find out about changes in tier status.

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.

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.

40627CAMENABC Effective 1/15

For more information, please visit anthem.com/ca. }} 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 p.m., ET.

}} For the most current version of this Selected Drug List, please visit anthem.com/ca.

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.