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INTRODUCTION
Penicillins .
(preferred list of drugs) to help your doctor make prescribing decisions. This list of drugs consisting of doctors and pharmacists, so that the list includes drugs that are safe and effective in the treatment of diseases. If you Quinolones .
have any questions about the accessibility of your medication, please call the phone number listed on the back of your Anthem Blue Cross Sulfonamides .
Erythromycin/Sulfisoxazole (generic) Sulfamethoxazole/Trimethoprim (generic) In most cases, if your physician has determined that it is medically necessary for you to receive a brand name drug or a drug Tetracyclines .
that is not on our list, your physician may indicate “Dispense as Written” or “Do Not Substitute” on your prescription to ensure access to the medication through our network of community pharmacies, excluding drugs ANTIFUNGAL AGENTS (ORAL) _________________
that require Prior Authorization of Benefits. Clotrimazole (generic) Fluconazole (generic) Please ask your doctor or pharmacist to refer APPROVED
Prescription Drug List for a complete listing of FORMULARY
Nystatin (generic) Terbinafine (generic) USE OF GENERICS
ANTI-MALARIALS____________________________
equivalents to brand name medications. In available for a brand name product, the brand name product will be considered non-preferred and the generic equivalent will be on the list. Revised 04/2012
equivalents and has found their use to be safe ANTI-TUBERCULOSIS AGENTS ________________
Cycloserine (generic) Ethambutol (generic) For medications classified by the FDA as having a narrow therapeutic index (NTI), Anthem Blue Cross discourages the use of Rifampin (generic)
OTHER ANTI-INFECTIVES _____________________
PRIOR AUTHORIZATION
Clindamycin (generic) Iodoquinol (Yodoxin) authorization of benefit (PAB) for certain drugs to provide a safe and affordable pharmacy benefit. Drugs which require PAB are often generic is on Formulary. Example: medications that are appropriate for only very Cefaclor (generic) means that the specific medical conditions. If your physician ANTI-NEOPLASTIC AGENTS
believes that a medication requiring PAB is generic, Cefaclor is covered and the All FDA-approved, self-administered injectable and oral anti-neoplastic agents are eligible for contact Anthem’s pharmacy benefit manager, coverage under the prescription drug benefit. Express Scripts, Inc. in order to initiate the Prior Authorization Process on your behalf. The list of drugs is subject to change so please call Customer Service at 1-800-700-2541 or ANTI-VIRAL AGENTS
www.anthem.com/ca.com to obtain a complete Example: Sitagliptin (Januvia) means that the brand, Januvia is covered and there is no generic available. Januvia ANTI-INFECTIVE AGENTS
If the word 'generic' and the brand name both appear within the ANTIBIOTICS _______________________________
Interferon Alfa-2A (Roferon-A)* Interferon Alfa-2B (Intron A)*^ Cephalosporins .
Interferon Alfa-2B/Ribavirin (Rebetron)* generic) means that both the brand and generic are available. Therefore, the brand Coumadin and the generic Member Handbook for benefit details regarding applicable copayments or Macrolides .
Azithromycin (generic) Clarithromycin XL (generic) AUTONOMIC & CENTRAL NERVOUS SYSTEM
ANALGESICS, NARCOTIC _____________________
ALZHEIMER’S AGENTS ______________________
Donezepil (generic)
BLOOD MODIFIERS
CEREBRAL STIMULANTS _____________________
CARDIOVASCULAR AGENTS
ANGIOTENSIN CONVERTING ENZYME
MULTIPLE SCLEROSIS AGENTS _______________
INHIBITORS AND RECEPTOR BLOCKERS _______
Amlodipine/Valsartan/HCTZ (Exforge/Exforge ANALGESICS, NON-NARCOTIC ________________
Acetaminophen/Caffeine/Butalbital (generic) OPIOID DEPENDANCE _______________________
PSYCHOTHERAPEUTIC AGENTS ______________
Antidepressants .
ANALGESICS, NONSTEROIDAL
ANTI-INFLAMMATORY ________________________
ANTI-ADRENERGIC BLOCKERS ________________
ANTIARRHYTHMICS _________________________
ANALGESICS, SALICYLATES __________________
Antimanic Agents .
ANTICONVULSANTS _________________________
Antipsychotic Agents .
ANTICOAGULANTS/ANTITHROMBOTICS ________
ANTILIPEMICS ______________________________
ANTIPARKINSON AGENTS ____________________
SEDATIVES, HYPNOTICS AND ANTI-ANXIETY ____
Niacin (Nicotinex/SloNiacin/Niaspan/generic) BETA-ADRENERGIC BLOCKERS _______________
Pioglitazone/Metformin (ActoPlus Met/XR) Tretinoin (generic/Retin-A Micro/Retin-A Micro CALCIUM CHANNEL BLOCKERS _______________
ANTIBIOTICS/ANTIVIRALS ____________________
ANTIDIABETIC SUPPLIES _____________________
FUNGICIDES _______________________________
glucometers, lancets, and test strips, may be covered. Accu-Chek and One Touch are the only test strips included on formulary. Lifescan CENTRALLY ACTING ANTIHYPERTENSIVES______
Diagnostics (Accu-Chek, Aviva). Quantity TOPICAL ANTI-INFLAMMATORY AGENTS _______
limits apply. Urine test strips are also a DIURETICS _________________________________
Low Potency .
GLUCOSE ELEVATING AGENTS _______________
Medium Potency .
ANTITHYROID _______________________________
THYROID ___________________________________
Levothyroxine (Levothroid/Levoxyl/Unithroid/ High Potency .
OTHER ENDOCRINE AGENTS __________________
VASODILATORS _____________________________
Ultra-High Potency .
Isosorbide Dinitrate/Hydralazine (Bidil) Isosorbide Dinitrate (Dilatrate SR/generic) GASTROINTESTINAL AGENTS
VAGINAL/RECTAL PREPARATIONS ____________
ANTIEMETIC/ANTIVERTIGO ___________________
Nitroglycerin (Nitrostat/Nitrobid/Nitrolingual Nitroglycerin (Nitrek/Nitro-Dur/generic) VASOPRESSORS ____________________________
Hydrocortisone/Pramoxine (generic/Analpram HC lotion/Pramosone cream, lotion, oint) MISCELLANEOUS ___________________________
CONTRACEPTIVES
Sulfanilamide (generic) Sulfathiaz/Sulfacet/Sulfabenz (generic) ANTISPASMODIC/GI MOTILITY _________________
Eth Estradiol/Desogestrel (Apri/generic) MISCELLANEOUS DERMATOLOGICALS ________
Eth Estradiol/Ethynodioldiacetate (Zovia) Eth Estradiol/Levonorgestrel (Amethia/Amethia Lo/Camrese/Enpresse/Jolessa/Portia/Trivor ANTIULCER ________________________________
Eth Estradiol/Norelgestromin (Ortho-Evra) Eth Estradiol/Norethindrone (Loestrin FE 24) Eth Estradiol/Norethindrone (Necon/generic) Eth Estradiol/Norgestimate (Ortho Tri-Cyclen ENDOCRINE AGENTS
OTHER GI PRODUCTS ________________________
EMERGENCY CONTRACEPTIVES _______________
ANTIDIABETIC AGENTS-INJECTABLE __________
All forms of insulin are covered.
Levonorgestrel (generic 0.75mg/Plan B 1.5mg) Hydrocortisone (Cortifoam) Lactulose (generic) Pramlintide (Symlin)*
ANTIDIABETIC AGENTS-ORAL ________________
DERMATOLOGICALS
ACNE ______________________________________
Adapalene (generic/Differin 0.1% Lotion, ALPHA-AGONIST____________________________
GLUCOCORTICOIDS
RESPIRATORY
PROSTAGLANDIN AGONIST __________________
ANTI-ASTHMATIC AGENTS ____________________
Asthma Devices .
ANTI-ALLERGY AGENTS
Peak Flow Meter (Personal Best/Pocketpeak) Corticosteroids .
GOUT THERAPY
ANTI-INFECTIVE AGENTS ____________________
Fluticasone/Salmeterol (Advair/Advair HFA) Sympathomimetics .
Neomycin/Bacitracin/Polymyxin (generic) Ofloxacin (Ocuflox/generic) HIV AGENTS
All oral and self injectable FDA-approved HIV Levalbuterol (generic/Xopenex Inhalation Soln) agents are eligible for coverage under the prescription drug benefit. May be subject to ANTI-INFLAMMATORY AGENTS _______________
Xanthine Derivatives .
HORMONES
Aminophylline (Truphylline/generic) Theophylline (Theo-Dur/Theo-24/ ANTIESTROGENS ____________________________
Difluprednate (Durezol) Fluorometholone (generic) OTHER AGENTS _____________________________
ESTROGENS ________________________________
ANTI-INFECTIVE & ANTI-INFLAMMATORY
Estradiol Patch/Spray (generic / Climara COMBINATIONS ____________________________
Sodium Chloride (Broncho-Saline/generic) Estrogens, Conjugated (Premarin/Low Dose) ESTROGEN COMBINATIONS ___________________
Neomy/Polymyx B/Prednisolone (Poly-Pred) ANTIHISTAMINES/DECONGESTANTS ___________
Estrogen, Ester/Methyltestosterone (generic) ANTIVIRAL AGENTS _________________________
GROWTH HORMONE _________________________
BETA-BLOCKERS ___________________________
EXPECTORANT AND COUGH PRODUCTS ________
PROGESTINS _______________________________
MIOTICS ___________________________________
Progesterone (generic, Crinone Vaginal Gel) MISCELLANEOUS HORMONE PRODUCTS _______
MYDRIATICS _______________________________
NASAL MEDICATIONS ________________________
SYMPATHOMIMETICS ________________________
IMMUNOSUPPRESSIVE AGENTS
ANTI-INFECTIVE AGENTS ____________________
All FDA-approved, self-administered injectable SKELETAL AGENTS
eligible for coverage under the prescription ANTIRHEUMATICS ___________________________
ANTI-INFECTIVE & ANTI-INFLAMMATORY
COMBINATIONS ____________________________
OPHTHALMICS
BONE ENHANCING AGENTS___________________
Alendronate (Fosamax/-D/generic)
Ibandronate (generic) Etidronate (generic) SKELETAL MUSCLE RELAXANTS
Carisoprodol (generic) Cyclobenzaprine, ER (generic) Metaxalone (generic) Methocarbamol (generic) URINARY AGENTS
ANTI-INFECTIVES ____________________________
Nitrofurantoin (generic) Sulfadiazine (generic) Sulfisoxazole (generic) Trimethoprim/Sulfamethoxazole (generic) CHOLINERGIC AGENTS _______________________
Bethanechol (generic) Flavoxate (generic) OTHER URINARY AGENTS ____________________
Fesoterodine (Toviaz) Phenazopyridine (generic) Oxybutynin (generic/-XL) Solifenacin (Vesicare) Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue VITAMINS & ELECTROLYTES
Express Scripts, Inc. is a separate company that benefit management services on behalf of health Ferrous Sulfate/Folate/Vit B comp/C (generic) Vit A, C & D/Fluoride/Iron (generic) Potassium Supplements (generic) Prenatal Vitamins (Prenate Elite/generic) MISCELLANEOUS AGENTS
Bosentan (Tracleer)^ Etanercept (Enbrel)*^ Calcium acetate (generic) Cevimeline (Evoxac) Lanthanum Carbonate (Fosrenol) Leucovorin (generic)^ Methylergonovine (generic) Miglustat (Zavesca)^ Mycophenolate (generic/Cellcept)^ Neostigmine (generic) Pyridostigmine (generic) Sodium Polystyrene Sulfonatem (generic) Tacrolimus (generic)^ Thalidomide (Thalomid)^ *Members should refer to their Member Handbook for benefit details regarding applicable copayments or coinsurance. ^Indicates a drug that is available on tier 4 for members with a four-tier benefit design.

Source: http://www.ucop.edu/ucship/campuses/all-campuses-files/Pharmacy-All-Campuses/12-13-Approved-Formulary-Drug-List.pdf