Depauw.edu

Prescription
Program
Drug List — To be used by members
who have a tiered drug plan.
Anthem Blue Cross Blue Shield prescription drug benefits include medications available on the Anthem Drug List. Our prescription drug benefits can offer potential savings when your physician prescribes medications on the drug list. ANTHEM BLUE CROSS AND BLUE SHIELD DRUG LISTYour prescription drug benefit includes coverage for medicines that you’ll find on the Anthem Drug List. You can often find more savings when your doctor prescribes medicine that is on our drug list. Here are some commonly asked questions and answers about how the drug list works with your prescription drug plan.
For more information
about your drug plan,
A. The Anthem Drug List, also called a formulary is a list of U.S. Food and Drug Administration you can do the following:
(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 • Go to anthem.com
Therapeutics (P&T) Process. The P&T Process is performed by an independent group of • Call customer service
practicing doctors and pharmacists in charge of the research and decisions surrounding at the number on your
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 • Speech and hearing
the list to find out if any drugs have been added or removed. You can do this by going to impaired users
(TDD/TTY) should call
800-221-6915, Monday
A. Drugs on the Anthem Drug List are grouped into tiers. There are several factors that are – Friday, 8:30 a.m. –
used to determine under which tier a drug will be put in. This can include (but it’s not 5:00 p.m., ET
• Bring a copy of this drug
• Cost of the drug in comparison to other drugs used for the same type of treatment list to your next doctor’s
• Availability of over-the-counter options visit to help you and
• Other clinical and cost factors.
your doctor select the
lowest cost medicine
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. With generics, you get KEY FOR DRUG LIST
Tier 1 – Lowest copayment – Drugs
Q. What if my doctor or I choose a brand-name drug when a generic version is available? that offer the greatest value compared to others that treat the same A. In most cases, you would be responsible for the copay that’s listed on the tier the drug is on. This copay may include an added charge for the cost difference between the brand- name medication and the generic version. Tier 2 – Medium copayment – Brand-
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 effects, if they’re more affordable, etc.
plan may not cover some drugs (indicated by a ^ symbol next to the drug name) that have Tier 3 – Highest copayment – These are
Q. What if my medication is not on the drug list? Tier 3 drugs may have generic versions in Tier 1 and may cost more than the A. You may want to first check with your doctor about prescribing a drug that is on the drug list. If your doctor prescribes a drug that’s not on the drug list, you will need to pay the copayment that applies to drugs that are not on the list.
Tier 4 – Many drugs on this tier
are “specialty” drugs used to treat
Q. Can I request that a drug be added to the drug list? A. You or your doctor can put in a request to add a drug to the drug list. You can do this either in writing or on our website. Requests are reviewed by the P&T Process team during the 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.
Gianvi PA
norethindrone PA
Atorvastatin DO, QL
Cartia XT DO, QL
Aviane PA
ethynodiol diacetate PA Glyburide micronized
Azelastine QL
Diclofenac sodium Ophth. norethindrone PA
Azelastine nasal QL
Granisetron QL
Azithromycin QL
Bacitracin zinc/polymyxin B Cefuroxime QL
Alendronate QL
Diltia XT DO, QL
Felodopine DO, QL
Diltiazem CD DO, QL
Diltiazem CR DO, QL
Diltiazem SR DO, QL
Amethia PA
Diphenhydramine 50mg Fentanyl PA, QL
Amethia lo PA
Diphenoxylate/atropine Fexofenadine QL
Hydrocodone/APAP QL
Ciprofloxacin QL
Citalopram DO, QL
atorvastatin DO
Fluoxetine DO, QL
Amnesteem QL
Budeprion XL DO, QL
Budesonide QL
Buprenorphine QL
Imiquimod QL
Codeine/APAP QL
Eprosartan QL
Fluvoxamine DO
soln/nasal spray QL
10mg/ml N.S. QL
Fosinopril DO, QL
Calcipotriene Oint & Soln. Cyclophosphamide APAP/caffeine/butalbital Camrese PA
Isotretinoin QL
Itraconazole PA
Propoxyphene/APAP QL
spray and inj. QL
Ketorolac QL
Nifedipine ER DO, QL
Leuprolide PA*
Levocetirizine QL
Levofloxacin QL
Ocella PA
Ofloxacin QL
estradiol PA
Microgestin PA
Omeprazole QL
Omeprazole/bicarb QL
Ondansetron QL
Tramadol, ER QL
Tramadol/APAP QL
Sertraline DO, QL
Pravastatin DO, QL
Simvastatin DO, QL,
PA – 80mg only
Morphine ER QL
Tretinoin PA
Losartan DO, QL
Multivitamins w/fluoride Oxycodone ER QL
Losartan/HCTZ DO, QL
Multivitamins w/folic acid Oxycodone/APAP QL
Lovastatin DO, QL
Oxymorphone QL
Sotret QL
Pantoprazole QL
Paroxetine, SR DO, QL
Pentamidine isethionate Probenecid/colchicine Tri-nessa PA
Naratriptan QL
Meloxicam QL
Trivora PA
Exforge HCT DO, QL
Testim PA, QL
Thalomid PA
Maxalt, MLT QL†
Flovent, HFA QL
Pristiq DO, QL
Colcrys QL
Medrol 2mg, 16mg, 32mg ProAir HFA QL
Trilipix QL
Zaleplon ST, QL
Combivent QL
Foradil QL
Protopic ST
Zolpidem, ER QL
Fosamax Plus D QL
Proventil HFA QL
Fosamax solution QL
Pulmicort Respules QL†
Valturna DO, QL
Crestor DO, QL
Veramyst QL
Accu-chek Product Line QL Cuprimine
Nasonex QL
Actonel QL
Cymbalta DO, QL
Actonel with Calcium QL
Gleevec PA
Retin-A Micro PA
ActoPlus Met, XR QL
Nexavar PA
Nexium QL
Advair Diskus, HFA QL
Advicor DO
Vyvanse PA
Xeloda PA
Savella QL
Diovan DO, QL
Serevent Diskus QL
Diovan HCT DO, QL
Iressa PA
Androgel PA, QL
Singulair QL
Janumet QL
Nuvigil PA, QL
Spiriva QL
Duetact QL
Januvia QL
Oforta PA
Sprycel PA
Dulera QL
One Touch Product Line QL Strattera
Durezol QL
Onglyza DO, QL
Suboxone SL Tab ST,
Asmanex QL
Kombiglyze QL
Ortho Evra PA
SL Film PA, QL
Astepro QL
Effient DO, QL
Ortho Tri-Cyclen Lo PA
Atrovent HFA QL
Elidel ST
OxyContin QL
Sutent PA
Avinza QL
Symbicort QL
Abstral PA, QL
Perforomist QL
Plan B 1.5mg QL
Tamiflu QL
Plavix QL†
Tarceva PA
Aciphex ST, QL^
Leukine PA*
Actemra PA*
Pradaxa QL
Acthar HP PA, QL*
Pramosone 1% cream only, Tekturna, HCT DO, QL
Lexapro DO, QL†
Temodar PA
Activella PA
Byetta ST, QL
Exforge DO, QL
Actiq PA, QL
Axiron PA, QL
Oxytrol ST
Azor DO, QL
Adcirca PA
Beconase AQ ST, QL
Forteo PA, QL*
Lunesta QL
Benicar, HCT DO, QL
Fortesta PA, QL
Lupron Depot PA*
Patanase QL
Aerobid, M QL
Benzaclin ST
Kapidex) ST, QL
Fosamax tablets QL
Aggrenox QL
Bepreve ST, QL^
Lyrica PA
Pataday ST, QL^
Alamast ST, QL^
Frova ST, QL
Makena PA*
Patanol ST, QL^
Aldara QL
Betaseron ST*
Paxil CR DO, QL
Gelnique ST
Pegasys PA, QL*
Allegra, D ST, QL^
Boniva ST, QL
Genotropin PA, QL*
Peg-Intron PA*
Alocril ST, QL^
Brilinta QL
Gilenya ST, QL*
Maxair QL
Alomide ST, QL^
Maxaquin QL
Caduet DO
Plan B 0.75mg QL
Cambia QL
Alsuma ST, QL
Edarbi DO, QL
Miacalcin Spray QL
Altoprev ST, DO
Edex PA, QL
Micardis, HCT DO, QL
Edluar SL ST
Humatrope PA, QL*
Migranal QL
Alvesco QL
Cardizem CD, LA DO, QL Effexor, XR DO, QL
Humira PA, QL*
Ambien QL
Elestat ST, QL^
Hybolin PA
Ambien CR ST, QL
Hyzaar DO, QL
Amerge QL
Prevacid ST, QL^
Amevive PA*
Caverject PA, QL
Emadine ST, QL^
Imitrex QL
Morgidox ST
Prevpac QL
Embeda QL
Imitrex Nasal Spray QL
Prilosec ST, QL^
Ampyra PA, QL*
Ceftin QL
Incivek PA*
Primaxin QL
Anadrol-50 PA
Celebrex ST, QL
Enablex ST
Infergen* PA
Androderm ST, PA, QL
Enbrel PA, QL*
Android PA
Intron A PA*
Procrit PA*
Prolia PA, QL*
Cialis PA, QL
Epogen PA*
Nasacort AQ ST, QL
Anzemet QL
Cimzia PA, QL*
Nasarel QL
Protonix ST, QL^
Apidra ST
Cipro XR QL
Neulasta PA, QL*
Provigil PA, QL
Aplenzin DO, QL
Clarinex, D ST, QL^
Kadian QL
Neumega PA*
Prozac, Weekly QL
Neupogen PA*
Pulmicort Flexhaler QL
Kineret PA*
Aranesp PA*
Exalgo ST
Qualaquin PA, QL
Arcapta QL
Kytril QL
Norditropin PA, QL*
Raptiva PA
Lamictal chew 5 & 25mg, Noroxin QL
Extavia ST*
Norvasc DO, QL
Factive QL
Nucynta, ER QL
Relenza QL
Nutropin, AQ PA, QL*
Relpax ST, QL
Arthrotec ST
Lastacaft ST, QL^
Nuvaring PA, QL
Remicade PA*
Astelin QL
Atacand DO, QL
Lazanda PA, QL
Omnaris ST, QL
Atacand HCT DO, QL
Lescol, XL ST, DO, QL
Revatio PA, QL
Augmentin, XR QL
Fentora PA, QL
Levaquin QL
Omnitrope PA, QL*
Avalide DO, QL
Covera HS DO
Levitra PA, QL
Onsolis PA, QL
Avandamet ST, QL
Cozaar DO, QL
Lipitor DO, QL
Rhinocort Aqua ST, QL
Avandaryl ST, QL
Opana ER QL
Roxicet QL
Avandia ST, QL
Flector ST
Livalo ST, DO, QL
Optivar ST, QL^
Rozerem ST, QL
Avapro DO, QL
Avelox QL
Flonase QL
Orencia PA, QL*
Ryzolt QL
Ovidrel PA*
Saizen PA, QL*
Axert ST, QL
Oxandrin PA
Sanctura, XR ST
Sancuso QL
Zorbtive PA, QL*
Enbrel PA, QL
Neupogen PA
Tiazac DO, QL
Viibryd ST, QL
Zyclara QL
Epogen PA
Norditropin PA, QL
Vimovo QL
Sarafem QL
Extavia ST
Nutropin, AQ PA, QL
Seasonale PA
Omnitrope PA, QL
Seasonique PA
Toradol QL
Zyvox PA, QL
Orencia PA
Serostim PA, QL*
Vytorin ST, QL
Simcor QL
Tradjenta QL
Forteo PA, QL
Simponi PA, QL*
Treximet ST, QL
Wellbutrin XL DO, QL
Actemra PA
Peg-Intron PA
Winstrol PA
Acthar HP PA, QL
Pegasys PA, QL
Genotropin PA, QL
Gilenya PA, QL
Procrit PA
Amevive PA
Sonata ST, QL
Xgeva PA, QL*
Ampyra PA, QL
Prolia PA, QL
Xifaxan ST, QL
Humatrope PA, QL
Xolair PA*
Humira PA, QL
Remicade PA
Sporanox Solution PA
Xopenex HFA QL
Aranesp PA
Repronex PA
Stadol QL
Uloric ST
Incivek PA
Roferon-A PA
Ultram, ER QL
Increlex PA
Xyzal ST, QL^
Infergen PA
Striant PA
Yasmin PA
Subutex QL
Caverject PA, QL
Intron-A PA
Serostim PA, QL
Sular DO, QL
Zegerid ST, QL^
Simponi PA, QL
Sumavel Dosepro ST, QL Valcyte soln
Kineret PA
Suprax QL
Cimzia PA, QL
Leukine PA
Stelara PA, QL
Leuprolide PA
Synagis PA
Zetia ST, QL
TevTropin PA, QL
Synarel PA
Ventavis PA
Zithromax QL
Lupron, Depot PA
Ventolin HFA QL
Tekamlo DO, QL
Verelan PM DO, QL
Zocor DO, PA – 80mg
Makena PA
Victrelis PA*
Tequin QL
Tekamlo DO, QL
Zofran QL
Testopel PA
Zoladex PA
Vivaglobulin PA
Testred PA
Viagra PA, QL
Zoloft DO, QL
Edex PA, QL
Xgeva PA, QL
Teveten, HCT DO, QL
Victoza ST, QL
Zolpimist ST, QL
Neulasta PA, QL
Xolair PA
Tev-Tropin PA, QL*
Victrelis PA*
Zomig, ZMT ST, QL
Eligard PA
Neumega PA
Zorbtive PA
KEY
# Non-formulary in Indiana only
† = 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.
* = These drugs are Tier 3 for those members that do not have a Tier 4 plan.
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.
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 formulary, the therapeutic effi cacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the formulary by at least one medication. When a closed formulary is in effect, only medications that are included on the formulary are a covered service. In certain clinical situations, a member may require use of a non-formulary product. Anthem has criteria that permits a member to obtain a non-formulary medication in a closed formulary plan. If specifi c criteria are met, a member can receive a non-formulary drug for a formulary copay. The criteria preserves the clinical integrity of the drug formulary and provides a process by which deviations from the formulary may be allowed. An appeals process is in place for any medications that do not meet the criteria.
For more information, please visit anthem.com.
• If you have additional questions about your prescription
benefi ts 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. – 5:00 p.m., ET
• For the most current version of this prescription drug list,
please visit anthem.com
• Bring a copy of this drug list/formulary 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. In Connecticut: Anthem Health Plans, 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 affi liates administer non-HMO benefi ts underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123): Anthem Health Plans of Virginia, Inc. 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.

Source: http://www.depauw.edu/files/resources/formulary.pdf