40627COMENABS Effective 1/14

4 Tier Formulary

Select Drug List

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Anthem Blue Cross and Blue Shield 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.

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. Anthem has 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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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 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.

Tier 1

AcebutololAcetasol HCAcetazolamide tab, ER cap

AclometasoneActicinAcyclovir tab, cap, oral susp.

AdapaleneAfeditab CR QL DOAlbuterol inhl soln., syrupAlendronate QLAlfuzosinAllopurinol tabAlprazolam tabAmantadineAmcinonideAmiloride tabAminophylline tabAmitriptylineAmlodipine QL DOAmlodipine/ atorvastatin QL DO

Amlodipine/benazeprilAmmonium lactate cream, lotion

Amnesteem PAAmoxapineAmoxicillinAmoxicillin/clavulanateAmoxicillin/ clavulanate ER

Amphetamine/dextroamphetamine salts, ER PA QL

AndroxyAntipyrine/benzocaine ear drop

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

Azithromycin tab, susp., packet QL

Bacitracin/polymixin BBaclofenBalsalazideBenazepril

Benazepril/HCTZBenzonatateBenzoyl peroxideBenztropineBetamethasone dipropionate

Betamethasone valerateBetaxololBirth Control (generic oral contraceptives)

Bisoprolol/HCTZBromocriptineBudesonide 0.25mg/2mL, 0.5mg/2mL QL

Buprenorphine tab PA QLBupropion QLBupropion SR, XL QL DOBuspironeButalbital/acetaminophen

Butalbital/acetaminophen/caffeine

Butalbital/acetaminophen/caffeine/codeine QL

Butalbital/aspirin/caffeine

Butalbital/aspirin/caffeine/codeine

Butorphanol nasal spray PA QL

CabergolineCalcipotrieneCandesartan/HCTZ QL DOCarbamazepine, ER, XRCarbidopa/Levodopa, ER, ODT

CarteololCartia XT QL DOCefaclor, ERCefadroxilCefdinirCefditoren PivoxilCefprozilCefuroxime AxetilCephalexinChlorhexidine rinseChloroquineChlorpromazine tab PAChlorthalidoneChlorzoxazoneCiclodan cream, soln.

CiclopiroxCimetidine tab, soln.Ciprofloxacin ear and eye drops

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

Clindamycin/Benzoyl Peroxide gel

ClobetasolClomipramineClonazepam, ODTClonidine tabClopidogrel 300mgClopidogrel 75mg PA 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 PA QL

Dextroamphetamine, ER PA QL

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

Diflorasone

DiflunisalDigoxin tab, oral soln.DiltiazemDiltiazem ER, XR, CD QL DO

Diphenhydramine 50mg cap

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

DoxazosinDoxycycline hyclate tab, cap

Doxycycline hyclate, delayed release PA

Doxycycline monohydrate tab, cap, susp.

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

Ergotamine/caffeineEry-Tab 250mg, 333mg tab

Erythromcyin eye oint.Erythromycin 2% gel, topical soln.

Erythromycin ethylsuccinate 400mg filmtab

Erythromycin filmtab, 250mg cap

Erythromycin stearateErythromycin/benzoyl peroxide gel

Erythromycin/sulfisoxazole

Escitalopram QL DOEstradiol patch QLEstradiol tabEstrogen/methyltestosterone

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EstropipateEthambutolEthosuximideFamciclovirFamotidine tab, oral soln.FelbamateFelodipine ER QL DOFenofibrateFenofibric acidFinasteride 5mg tab PAFluconazole tab, oral soln.

FlucytosineFlunisolide nasal spray ST QL

Fluocinolone body oil, scalp oil

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

FluocinonideFluorometholone eye drops

Fluorouracil cream, topical soln.

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 (generic version)

GuanfacineGuanidineHalacHalobetasol propionateHaloperidol tab PA

Hydralazine 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 QLIbuprofenImipramine HCL tabImiquimod cream PA QLIndapamideIndomethacin , ER capIpratropium bromide neb soln. QL

Irbesartan/HCTZ QL DOIsometheptene/acetaminophen/caffeine

Isometheptene/acetaminophen/dichloralphenazone

Isoniazid tab, oral soln.Isosorbide dinitrate, ER tab

Isosorbide mononitrate, ER tabs

KetoconazoleKetorolac eye dropsKetorolac tab QLKlor-Con tabLactulose

Lamotrigine tab (immediate release)

Lansoprazole PA QLLatanoprostLevofloxacin tab QLLevonorgestrel tab QLLevothroidLevothyroxine tabLevoxylLidocaine viscous soln.Lidocaine/hydrocortisone 3/0.5% cream

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

MefloquineMeloxicam oral suspension

Meloxicam tab QLMeperidine tab, oral soln. QL

Meprobamate QLMetadate ER PA QLMetaproterenolMetformin, ERMethadone tab, oral soln. QL

MethazolamideMethimazoleMethscopolamine bromide

MethyclothiazideMethyldopaMethyldopa/HCTZMethylergonovine tab

Methylphenidate, 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 QLMorgidox caps PAMorphine sulfate IR tab QL

Morphine sulfate oral soln. QL

Morphine sulfate suppository

Mupirocin oint.Nadolol/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

Nifedipine capNifedipine tab ER, XL QL DO

Nitro-Bid oint.Nitrofurantoin

Nitroglycerin, ER, SRNorethindroneNortriptylineNP ThyroidNystatin cream, oint., powder, tab, susp.

Nystatin/triamcinoloneOfloxacin ear and eye drops

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

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

Phenytoin ext. capPodofiloxPolymixin/trimethoprim eye drops

Potassium chloride ER tab, ER cap

Potassium citrate ER TabPramipexolePravastatin 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 tab, oral soln.Propranolol/HCTZPropylthiouracilProtriptylinePyrazinamidePyridostigmineQuetiapine PAQuinaprilQuinapril/HCTZQuinidine sulfate, ERQuinine sulfate PA QLRamiprilRanitidine 150mg, 300mg tab, cap

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

Ropinirole, ERRosadan cream and gelRoxicet tab, caplet QLSelegilineSelenium sulfide 2.5% lotion, shampoo

Sertraline QL DOSilver sulfadiazine creamSimvastatin 80mg PA QLSimvastatin QL DOSodium polystyrene sulfate 30gm/120ml enema

Sodium polystyrene sulfate powder

Sodium polystyrene sulfonate

Sodium sulfacetamide/sulfur

Sodium sulfacetamide/sulfur/urea

SpinosadSpironolactoneSucralfate

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Sulfacetamide 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 PATerbutaline tabTerconazoleTetracycline capsThioridazine PAThiothixene PATiclopidineTimolol eye drops, gelTimolol tabTizanidineTobramycin eye dropsTobramycin/dexamethasone eye drops

TolbutamideTopiramate PATorsemide tabTramadol QLTrandolaprilTranexamic acid 650mgTranylcypromineTrazodoneTretinoin cream, gel PATriamcinolone cream, lotion, oint.

Triamcinolone nasal spray QL

Triamcinolone pasteTriamterene/HCTZTrifluoperazine PATrihexyphenidylTrimethoprimUnithroidValacyclovir

Valproid acid cap, oral soln.

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

Verapamil tab, ER tab, cap

Vicodin, ES, HP QLWarfarinWesthroidZaleplon QLZenatane PAZenzedi 5mg, 10mg PA QL

Ziprasidone PA

Tier 2

AcamprosateAccu-Chek Product LineAdvair Diskus, HFA QLAnaspaz ODTAsmanex Twisthaler QLBethanechol tabBudesonide ECBuprenorphine syringe, vial

Calcitonin nasal spray QLCalcium acetate tabCefpodoximeCilostazolClozapine, ODT PADanazolDantroleneDihydroergotamine nasal spray QL

Dulera QLEliphosEntacaponeEpipen, Jr.ErgoloidEvistaFentanyl patch ST QLFlecainideFlovent HFA QLFlovent QLFortical nasal spray QLGabapentinGalantamine, ER QLGlucagen

HumalogHumalog MixHumulin N, R, 70-30Itraconazole PALantusLantus SolostarLeflunomideLevalbuterol neb soln.LevemirLevemir FlexpenLevetiracetamLevetiracetam ER PA QLLevocarnitine tab, oral soln.

Morphine sulfate ER QLNitroglycerin sprayNitrostatNovolinNovologNovolog MixOlanzapine tab, ODT PAOndansetron tab, ODT, oral soln. QL

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

Pulmicort Flexhaler QLQvar QLRelenza QLRivastigmine QLSerevent Diskus QLSorineSotalol tab, AF tabSumatriptan inj QLSymbicort QLTamiflu QLTranexamic acid 1000mg/10mL

Vancomycin caps PAZenpepZonisamide

Tier 3

Abilify tab PAActonel ST QLAczoneAggrenox QL

Alamast PAAliniaAlocril PA QLAlomide PA QLAmitizaAndrogel PA QLApriso ERArestinBesivanceBeyazBiltricideCampral†CantilCedaxCelontinCenestinCesamet STChemetCiclodan kitCiprodex ear drops PAClindacin kitCoartemColcrys PA QLCuprimineCystaranDaraprimDibenzylineDyreniumEdecrinEffient QL DOElidel PAEllaElmironEnjuviaErgomarErtaczoEstringFemtraceFinaceaFocalin XR PA QLFosamax Plus D ST QLGeneress FeLacrisertLanoxin tabLo Loestrin FeLo Minastrin FeLoestrin 24 FeLotemaxLovazaLumigan

Maxair QLMigranal nasal spray† QLMinastrin 24 FEMorgidox kit PAMotofenMoviprepMultaqMycobutinNamenda QLNataziaNuedextaNuvaringOraceaOrap PAOrtho EvraOrtho Tri-cyclen LoPataday PA QLPatanol PA QLPhospholine iodidePred-GPred-G S.O.PPremarin creamPremarin tabPremphasePremproPrevident 5000 Booster Plus

PrimaquineProlia PAProtopic PAProventil HFA QLQuartetteRenvela PARestasisRidauraRosadan kitSafyralSavella QLSilenorSpiriva QLStrattera PA QLStromectolSuprax cap, tab, susp.SyprineTikosynTransderm-ScopTravatan ZTrilipix†TyzineVagifem

Ventolin HFA QLVeregenVigamox PAVivelle-Dot QLVoltaren gelVyvanse PA QLWelcholXopenex HFA QLZirganZyvox tab, oral soln. PA QL

Tier 4

AbacavirAdcirca PAAdefovirAfinitor DisperzAfinitor PAAlkeran tabAnastrazole tab PAAptivusAranesp PAAtriplaAzathioprine tabBaraclude PABosulif PACaprelsa PACeeNUCimzia PA QLCometriq PACrixivanCyclophosphamide tabCyclosporine cap, soln.Didanosine DRDroxiaEdurantEmcyt PAEmtrivaEnbrel PA QLEnoxaparin PAEpzicomErivedge PAEtopophosEtoposide capsExemestane PAExtavia PAFarestonFlutamideFondaparinux PAFragmin PA

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GengrafGilotrifGleevec PAHepsera†HexalenHumira PA QLHycamtin capsHydroxyureaIclusig PAInfergenInlyta PAIntelenceInviraseIsentressJakafi PAKaletraKineret PA

Kuvan PALamuvidineLamuvidine/zidovudineLetairis PALetrozoleLeucovorin tabLeukeranLeuprolide PALexivaLomustineLysodrenMatulaneMekinist PAMelphalanMercaptopurineMethotrexate tabMycophenolate

MyleranNeulasta PA QLNevirapineNexavar PANilandronNorvirOfortaOrencia PA QLOrfadinPegasys PA QLPegintron PAPomalystPrezistaPromacta PAPulmozyme PARebif PARebif Rebidose PA

Remicade PARemodulin PARescriptorRevlimid PA QLReyatazRibavirin PARituxan PASelzentrySensiparSildenafil 20mg tab PASimponi Aria PA QLSimponi PA QLSprycel PAStavudineStivarga PASustivaSutent PA

TabloidTafinlarTamoxifenTarceva PATasigna PATemodar cap† PATemozolomide cap PATev-Tropin PAThalomid PATobiTopotecanTrelstar Depot PATrelstar PATretinoin 10mg capsuleTrizivirTruvadaTykerb PA

TysabriTyzeka PAVandetanib PAVentavis PAVictrelis PAViraceptViread PAVotrient PAXalkori PAXeloda PAXtandi PAZelboraf PAZidovudineZolinza PAZytiga 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 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.

40627COMENABS Effective 1/14

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 p.m., ET.

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

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. 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.