40627MUMENABS 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. What if my medication is not on the Select Drug List?A. You may want to first check with your doctor about

prescribing a drug that is on the Select Drug List. If your doctor prescribes a drug that’s not on the Select Drug List, you will have to pay the amount described in your policy for non-formulary drugs.

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.

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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Tier 1

AcarboseAcebutololAcetasol HCAcetazolamide tab, ER cap

AclometasoneActicinAcyclovir tab, cap, oral susp.

Adapalene Afeditab CR QL DOAlbuterol inhl soln., syrupAlendronate QLAlfuzosinAllopurinol tabAlprazolam tabAmantadine Amcinonide Amiloride tabAminophylline tabAmiodarone 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

BalsalazideBenazeprilBenazepril/HCTZBenzonatateBenzoyl peroxideBenztropineBetamethasone dipropionate

Betamethasone valerate Betaxolol Birth Control (generic oral contraceptives)

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

Bumetanide tabBuprenorphine 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 Calcitriol cap, soln, ointCandesartan/HCTZ PA QL DO

Captopril Captopril/HCTZCarbamazepine, ER, XRCarbidopa/ Levodopa, ER, ODT

CarbinoxamineCarisoprodolCarteololCartia XT QL DOCarvedilolCefaclor, ER

CefadroxilCefdinirCefditoren PivoxilCefprozilCefuroxime AxetilCephalexinCetirizine syrup QLChlorhexidine gluconateChlorhexidine RinseChloroquineChlorothiazide tabChlorpromazine tab PAChlorpropamideChlorthalidoneChlorzoxazoneCholestyramineCiclopiroxCimetidine tab, soln.Ciprofloxacin ear and eye drops

Ciprofloxacin tab QLCitalopram QL DOClaravis PAClarithromycin, ERClemastine 2.68mgClemastine syrupClindamycin cap, oral soln, topical preparations

Clindamycin/Benzoyl Peroxide Gel

ClobetasolClomipramineClonazepam, ODTClonidine tabClopidogrel PA (75mg only) QL

Clotrimazole 1% cream, troche

Clotrimazole/betamethasone

Codeine sulfate tabs QLCodeine/ acetaminophen QL

Codeine/butalbital/aspirin/caffeine

ColestipolCortisone tabCovaryx, H.S.Cromolyn eye drops QLCromolyn neb soln.Cyclobenzaprine tab

Cyproheptadine DepadeDermazeneDesloratadine, ODT QLDesmopressin nasal spray, tab PA

DesonideDesoximetasoneDexamethasone eye dropDexamethasone tab, oral soln.

DexchlorpheneramineDexmethylphenidate PA QL

Dextroamphetamine, ER PA QL

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

DiflorasoneDiflunisalDigoxin tab, oral soln.Diltiazem, ER, XR, CD QL DO

Diphenhydramine 50mg cap

Diphenoxylate/atropineDipyridamole tabDisopyramideDisulfiramDivalproex, ER, DRDonepezil 5mg, 10mg, ODT QL

Dorzolamide eye dropsDorzolamide/timolol eye drops

DoxazosinDoxepin Doxycycline hyclate tab, cap

Doxycycline hyclate, delayed release PA

Doxycycline monohydrate tab, cap

DylixEconazoleEnalaprilEnalapril/HCTZEndocet QLEndodan QL

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.

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EpidrinEpinastine eye drops QLEpitolEprosartan PA QLErgocalciferol (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 DOEstazolamEstradiol patch QLEstradiol tabEstrogen/methyltestosterone

EstropipateEthambutolEthosuximideEtodolac, ERFamciclovirFamotidine tab, oral soln.FelbamateFelodipine ER QLFenofibrateFenofibric acidFenoprofenFentanyl citrate lozenge PA QL

Finasteride 5mg tab PAFlavoxateFluconazole tab, oral soln.

FlucytosineFludrocortisoneFlunisolide 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

Flurbiprofen eye dropFlurbiprofen tabFluticasone nasal spray QL

Fluticasone topicalFluvastatin QL DOFluvoxamine QL DOFolic acid 1mgFosinoprilFosinopril/HCTZFurosemide tab, oral soln.Garamycin eye dropsGemfibrozilGentamycin eye drops, oint.

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

GuanfacineGuanidineHalacHalobetasol 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 pamoateHyomax-FT 0.125 chew melt

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

Irbesartan PA QL DOIrbesartan/HCTZ PA QL DO

Isometheptene/acetaminophen/caffeine

Isometheptene/acetaminophen/dichloralphenazone

IsonarifIsoniazid tab, oral soln.Isosorbide dinitrate, ER tab

Isosorbide mononitrate, ER tablet

IsradipineKetoconazoleKetoprofen, ERKetorolac eye dropsKetorolac tab QLKlor-Con tabLabetolol tabLactuloseLamotrigine tab (immediate release)

Lansoprazole, DR QLLatanoprost

Levobunolol eye dropsLevocetirizine QLLevofloxacin 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

Mefenamic acidMefloquineMegestrolMeloxicam oral suspension

Meloxicam tab QLMeperidine tab, oral soln. QL

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

Methamphetamine PA QLMethanamine MDMethazolamideMethimazoleMethocarbamolMethscopolamine bromide

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

Methylprednisolone tabMetipranolol eye dropsMetoclopramide tab, oral soln.

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

Miconazole 200mg vaginal suppository

MinocyclineMinocycline ER PAMinoxidil tabMirtazapineMisoprostol PAModafinil PA QLMoexiprilMoexipril/HCTZMometasone cream, oint, topical soln.

Montelukast QLMorphine sulfate IR tab QL

Morphine sulfate oral soln. QL

Morphine sulfate suppository

Mupirocin oint.NabumetoneNadololNadolol/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

Nicardipine capsNifedipine capNifedipine tab ER, XL QL DO

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

Nystatin/triamcinoloneOfloxacin ear and eye drops

Ofloxacin tab QLOmeprazole caps QLOrphenadrine EROxaprozinOxcarbazepineOxybutynin, EROxycodone QLOxycodone/acetaminophen tab, cap QL

Oxycodone/aspirin QLOxymorphoneOxymorphone ER QLPaceronePancrelipaseParamomycinParoxetine, CR, ER QL DOPenicillin VKPentazocine/naloxone QLPentoxifylline, ERPerindoprilPermethrin creamPerphenazine PAPhenazopyridinePhenelzinePhenobarbital tab, oral soln.

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Phenytoin ext. capPilocarpine eye dropsPindololPioglitazone QLPiroxicamPodofiloxPolymixin/trimethoprim eye drops

Potassium 25mEq tab effervescent

Potassium chloride ER tab, ER cap

Potassium Citrate ER TabPotassium citrate/citric acid

PramipexolePravastatin 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 QLRamipril

Ranitidine 150, 300mg tab, cap

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

Rizatriptan, ODT QLRopinirole, ERRoxicet tab, caplet QLSelegilineSelenium sulfide 2.5% lotion, shampoo

Sertraline QL DOSilver sulfadiazine creamSimvastatin 80mg PA QL DO

Simvastatin QL DOSodium polystyrene sulfate 30gm/120ml enema

Sodium polystyrene sulfate powder

Sodium polystyrene sulfonate

Sodium sulfacetamide/sulfur

Sodium sulfacetamide/sulfur/urea

SpinosadSpironolactoneSucralfateSulfacetamide eye drops, oint.

Sulfacetamide sodiumSulfacetamide sodium/prednisolone eye drops

Sulfacetamide sodium/sulfur

Sulfacetamide sodium/sulfur/urea

Sulfacetamide sodium/urea

Sulfamethoxazole/trimethoprim, DS

SulfasalazineSulindacSumatriptan tab QLTamsulosinTaztia XT QL DOTerazosinTerbinafine tab PATerbutaline tabTerconazole

Tetracycline capsTheochron ERTheophylline ER, oral soln.

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

TolazamideTolbutamideTolmetinTolterodineTopiramate PATorsemide tabTramadol, ER tab QLTrandolaprilTranexamic acid 650mgTranylcypromineTrazodoneTretinoin cream, gel PATriamcinolone cream, lotion, oint.

Triamcinolone nasal spray QL

Triamcinolone pasteTriamterene/HCTZTrifluoperazine PATrifluridine eye dropsTrihexyphenidylTrimethobenzamide capTrimethoprimTrimipramineTropicamide eye dropsUnithroidValacyclovirValproid 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 QLWarfarin

WesthroidZafirlukastZaleplon ST QLZiprasidone PAZolpidem (immediate release) QL

Tier 2

Accu-Chek ProductsAdvair Diskus, HFA QLAnaspaz ODTAsmanex Twisthaler QLBethanechol tabBromfenac eye dropsBudesonide ECBuprenorphine syringe, vial

Calcitonin QLCalcium acetate tabCefpodoximeCevimelineCilostazolClozapine, ODT PADanazolDantroleneDemeclocyclineDesipramineDronabinolDulera QLEliphosEntacaponeEpipen, Jr.EplerenoneErgoloidEtidronateEvistaFentanyl patch ST QLFlecainideFlovent HFA QLFlovent QLFortical nasal spray QLGabapentinGalantamine, ER QLGlucagenGranisetron tab QLHumalogHumalog MixHumulin N, R, 70-30Itraconazole PAKetorolac inj. QLLantus

Lantus SolostarLeflunomideLevalbuterol neb soln.LevemirLevetiracetamLevetiracetam ER PA QLLevocarnitine tab, oral soln.

Levorphanol tab QLMethenamine hippurateMexiletineMorphine sulfate ER QLNateglinide PANimodipineNitroglycerin sprayNitrostatNovolin NNovologNovolog MixOlanzapine tab, ODT PAOndansetron tab, ODT, oral soln. QL

One Touch Product LineOxandrolone PAPantoprazole QLPilocarpine tabsProair HFA ST QLPropafenonePrudoxinPulmicort 1mg/2mL respules QL

Pulmicort Flexhaler QLQvar QLRelenza QLRivastigmine QLSerevent Diskus QLSotalol tab, AF tabSulfadiazineSumatriptan inj QLSymbicort QLTamiflu QLTiagabine PATranexamic acid 1000mg/10mL

Trospium chloride ER STUrsodiolValcyte 450mgVancomycin caps PAVoriconazole tab PAZenpepZonisamide

Tier 3

Abilify tab PAAciphex QLActonel ST QLAczoneAggrenox QLAlamast PAAlbenzaAliniaAlocril PA QLAlomide PA QLAltabaxAmitizaAnadrol-50Androgel PA QLAntivert 50mgAnzemet tablet QLApidra, Solostar STApriso ERArcapta Neohaler QLArestinAtacand† PA QL DOAvandia ST QLAvodartAxert ST QLAzelex PAAzilectAzoptBactocillBanzel QLBenicar PA QL DOBepreve PA QLBesivanceBeyaz STBiltricideBrilinta QLBrovana QLBuphenyl tablet PAButrans QLBydureon ST QLBystolicCambia QLCampral†CantilCataflamCedaxCelebrex ST QLCelontinCenestinCesamet PA

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Chantix PA QLChemetCialis 2.5mg, 5mg PACiclodanCipro HC ear dropsCiprodex ear drops PAClindacinClodermCoartemColcrys PA QLColy-Mycin ear dropsCombiganCordran, SPCortisporin cream, oint.Crestor ST QL DOCresylateCuprimineCyclosetCymbalta PA QL DODaliresp QLDapsoneDaraprimDenavirDexilant ST QLDibenzylineDifferin 0.1% lotion, 0.3% gel

Dificid PADiovan PA QL DODipentumDurezol QLDyreniumEdarbi QL DOEdecrinEffient QL DOElidel PAEllaElmironEmadine PA QLEmend caps QLEmsam QLEnablex STEnjuviaEpiduoErgomarErtaczoEstringEuraxExalgo ER ST QLExelderm

Factive QLFanapt PAFinaceaFlector STFluoridexFluoroplexFML S.O.PFocalin XR PA QLFosamax oral soln.†Fosamax Plus D ST QLFosrenol PAFrova ST QLGeneress FeGlysetGynazole 1HalogHectoral capsHorizant PAIntuniv ER PAInvega tab PAJanumet, XR QLJanuvia ST QLKapvay, ER PAKetekLacrisertLanoxin tabLatuda PALevatolLivalo ST QL DOLo Loestrin FeLodosyn STLoestrin 24 FELotemaxLotronex PALovazaLufyllinLumiganLunesta PA QLLyrica PA QLMarplanMaxair QLMaxalt, MLT† QLMenestMentaxMepronMethitestMicardis PA QL DOMigranal nasal spray† QLMorgidox PAMotofen

MoviprepMoxatagMultaqMycobutinMyrbetriq STMytelaseNaftin cream, 1% gelNamenda QLNatacynNatazia STNevanacNexium PA QLNiaspan ERNorinyl 1+50-28Noroxin QLNoxafilNucynta, ER QLNuedextaNuoxNuvaringNuvigil PA QLOmnaris ST QLOnglyza ST QLOraceaOrap PAOrtho EvraOrtho Tri-cyclen LoOsmoprepOxistatOxsoralen-Ultra PAOxycontin ST QLPanretinPaserPataday PA QLPatanase QLPatanol PA QLPeganonePerforomist QLPhisohexPhospholine iodidePicato PA QLPotiga QLPradaxa QLPrandin† PAPred-GPred-G S.O.P Premarin CreamPremarin tab STPremphasePrempro

Prevident 5000 Booster Plus

PriftinPrimaquinePrimsolPristiq QL DOProglycemProlia PAProquin XRProtopic PAProventil HFA ST QLRanexaRapafloRectivRegranex PARelistor PARelpax ST QLRenvela PARestasisRidauraRifaterRosadanRozerem ST QLSabrilSafyral STSamsca PASancusoSantylSaphris PASavella QLScopaceSeroquel XR PASilenor STSkelidSolaraze PA QLSoriatane†Spiriva QLStrattera PA QLStromectolSulfamylonSuprax tab, susp.Symlin PASyneraSyprineTaclonex scalp suspension

Taclonex suspensionTasmarTazorac PATekturna QL DO

Teveten 400mg QLThyrolarTikosynTobradex eye oint.Toviaz ER STTradjenta ST QLTransderm-Scop PATravatan ZTrecatorTrilipix†TyzineUlesfiaUloric STVagifemValcyte 50mg/mL solution

Ventolin HFA ST QLVeregenVesicare STVexolVfend oral susp. PAVictoza ST QLVigamox PAViibryd STVimpat QLVisicolVivelle-Dot PA QLVoltaren gelVoltaren-XRVyvanse PA QLWelcholXarelto QLXenazine PAXifaxan PA QLXopenex HFA ST QLXyrem PAZemplar capsZetia PA QLZiana STZinoticZioptanZipsorZirganZomig tab PA QLZomig ZMT PA QLZyflo, CR PAZymaxidZyvox tab, oral soln. PA QL

Tier 4

AbacavirActemra PAAdagenAdcirca PAAfinitor PAAldurazyme PAAlkeran tabAmevive PAAmpyra PA QLAnagrelideAnastrazole tab PAApokyn PAAptivus Aranesp PAAtriplaAubagio PA QLAzathioprine tabBaraclude PABenlysta PABicalutamideBosulif PACaprelsa PACarbaglu PACeeNUCimzia PA QLCometriq PACopaxone PACrixivanCyclophosphamide tabCyclosporine Cyclosporine cap, soln.Didanosine DRDroxiaEdurantEmcyt PAEmtrivaEnbrel PA QLEnoxaparin PAEpivir HBV soln. PAEpzicomErivedge PAEtopophosEtoposide capsExemestane PAExjade PAExtavia STFarestonFerriprox PAFlutamide

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Fondaparinux PAForteo PAFragmin PAFuzeonGengrafGilenya PA QLGleevec PAHepseraHexalenHumira PA QLHycamtin capsHydroxyureaIclusig PAIncivek PAInfergen PAInlyta PAInnohep PAIntelenceIntron A PAInviraseIressa

IsentressJakafi PAKaletraKalydeco PA QLKineret PAKuvan PALamuvidineLamuvidine/zidovudineLetairis PALetrozoleLeucovorin tabLeukeranLeuprolide PALexivaLysodrenMatulaneMelphalanMercaptopurineMethotrexate tabMycophenolateMyfortic

MyleranNebupentNeulasta PA QLNeupogen PANevirapineNexavar PANilandronNorvirOforta PAOmontys PAOrencia PA QLOrfadinPegasys PA QLPegintron PAPomalystPrezistaProcrit PAPromacta PA QL DORapamuneRebif PAReclast†

Remicade PARemodulin PARescriptorRevlimid PA QLReyatazRibavirin PARilutek†Rituxan PASandostatin LAR PASelzentrySensiparSimponi PA QLSildenafil 20mg tab PASimulectSomatulineSomavert PASprycel PAStavudineStelara PA QLStivarga PASustiva

Sutent PASynarel PASynriboTabloidTacrolimusTamoxifenTarceva PATargretin PATasigna PATemodar cap† PATev-Tropin PAThalomid PATopotecanToriselTracleerTrelstar Depot PATrelstar PATretinoin 10mg capsuleTrizivirTruvadaTykerb PA

TysabriTyzeka PAVandetanib PAVentavis PAVictrelis PAViraceptViread PAVotrient PAVPRIV PAXalkori PAXeloda PAXtandi PAZavesca 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.

40627MUMENABS 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: 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 New Hampshire: 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. 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 the registered marks of the Blue Cross and Blue Shield Association.

(IN, KY, ME, MO, OH, NH, VA)