Transcription of Preferred drug list - Anthem
1 Anthem Blue Cross and Blue Shield Preferred drug List 5/1/2017 Page 1 of 9 Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee 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.
2 Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WEBMAIN-0357-17 May 2017 Preferred drug list Effective May 1, 2017 Table of Contents Analgesics .. 2 Anesthetics .. 2 Antibiotics and Antivirals .. 2 AntiNeoplastics/Immunosuppressants 3 .. Cardiovascular Agents .. 4 Central Nervous System Agents 5 .. Dermatologicals .. 5 Eyes, Ears, Nose, Mouth and Throat .. 6 Endocrine Agents.
3 6 Gastrointestinal Agents .. 7 Blood Modifiers, Nutritionals and Electrolytes .. 7 OB/GYN .. 8 Respiratory Agents .. 9 Skeletal Muscle Relaxants .. 9 Urologicals .. 9 Immunologicals, Vaccines and Biotechnology .. Smoking Cessation .. 10 Anthem Blue Cross and Blue Shield Preferred drug List 5/1/2017 Page 2 of 9 Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.
4 , independent licensee 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. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WEBMAIN-0357-17 May 2017 ANALGESICS AGENTS FOR MIGRAINE apap/butalbital QLL apap/caffeine/butalb QLL apap/caffeine/butalbital/ codeine QLL apap/caffeine/isomethep apap/dichloral/caffeine asa/butalbital QLL asa/caffeine/butalbital QLL butalbital compound w/codeine QLL asa/dihydrocodeine/caffeine QLL butalbital/asa/caffeine/codeine QLL butorphanol NS PA QLL divalproex OPT ergotamine w/caffeine sumatriptan QLL CHELATING AGENTS (WILSON S DISEASE)
5 Cuprimine Depen Syprine DMARDS Cuprimine cyclophosphamide Enbrel PA QLL Humira PA QLL hydroxychloroquine leflunomide methotrexate oral prednisone sulfasalazine QLL GOUT MEDICATIONS allopurinol colchicine/probenecid probenecid QLL HYLAURONICS Euflexxa PA Gelsyn PA Supartz PA MISCELLANEOUS ANALGESICS acetaminophen tramadol IR only QLL tramadol/APAP QLL NARCOTIC ANALGESICS codeine QLL fentanyl patch QLL ST fentanyl citrate lozenge QLL PA hydromorphone QLL meperidine QLL methadone QLL morphine sulfate ER tabs/IR QLL oxycodone IR QLL NARCOTIC ANALGESIC COMBINATIONS codeine/apap QLL hydrocodone/apap QLL hydrocodone/ibuprofen QLL oxycodone/apap QLL oxycodone/aspirin QLL pentazocine/apap pentazocine/naloxone QLL NONSTEROIDAL ANTI-INFLAMMATORIES diclofenac potassium diclofenac ER etodolac ER/IR fenoprofen flurbiprofen ibuprofen indomethacin IR/ER ketoprofen IR/ER ketorolac QLL meclofenamate meloxicam QLL nabumetone naproxen EC naproxen sodium DS oxaprozin piroxicam
6 Sulindac tolmetin SALICYLATES aspirin, aspirin cr 800mg choline/magnesium salicylate diflunisal salsalate ANESTHETICS TOPICAL LOCAL ANESTHETICS benzocaine (OTC) lidocaine jelly lidocaine 5% patch QLL PA lidocaine/hydrocortisone lidocaine/prilocaine ANTIBIOTICS AND ANTIVIRALS AMEBICIDES metronidazole paromomycin sulfate Yodoxin ANTI-TUBERCULOSIS ethambutol isoniazid Mycobutin Priftin pyrazinamide rifampin Rifater ANTIVIRALS Abreva (OTC) acyclovir amantadine Baraclude PA Descovy PA famciclovir Fuzeon PA Lamivudine 100mg PA Rebetol solution PA QLL Relenza QLL rimantadine Selzentry Tamiflu QLL valacyclovir PA Valcyte Viread PA CEPHALOSPORINS cefaclor ER QLL cefadroxil QLL cefdinir QLL cefpodoxime QLL cefprozil QLL cefuroxime QLL cephalexin QLL cephradine ceftriaxone injection FLUOROQUINOLONES ciprofloxacin QLL PA Anthem Blue Cross and Blue Shield Preferred drug List 5/1/2017 Page 3 of 10 Anthem Blue
7 Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee 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. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WEBMAIN-0357-17 May 2017 levofloxacin QLL ofloxacin QLL PA ANTIRETROVIRALS NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITOR (NRTI)
8 ANALOGUES abacavir adefovir dipivoxil didanosine Emtriva lamivudine stavudine Vitekta Ziagen solution zidovudine ANTIRETROVIRAL COMBINATIONS abacavir/lamivudine/zidovudine Epzicom Evotaz Genvoya Kaletra lamivudine/zovudine Prezcobix Stribild Triumeq Truvada ANTIRETROVIRALS PROTEASE INHIBITORS Aptivus Crixivan Norvir Prezista Reyataz Viracept PENICILLINS amoxicillin QLL amoxicillin/clavulanate QLL ampicillin QLL dicloxacillin QLL penicillin VK QLL ANTIFUNGALS ORAL clotrimazole troche fluconazole flucytosine griseofulvin ultra tab griseofulvin susp itraconazole PA ketoconazole nystatin terbinafine tablets PA voriconazole ANTIFUNGALS TOPICAL Various OTC butenafine OTC ciclodan 8% soln ciclopirox 8% crm, soln clotrimazoleQLL ketoconazole crm, shampoo clotrimazole/ betamethasone miconazole nitrate OTC nystatin crm, oint, pow terbinafine tolnaftate crm.
9 Powder LEPROSTATICS Dapsone MACROLIDES azithromycin tablet QLL clarithromycin erythromycin erythromycin/sulfisoxazole SULFONAMIDES sulfadiazine sulfamethoxazole/trimethoprim DS sulfasoxazole TETRACYCLINES erythromycin base erythromycin ethylsuccinate erythromycin stearate doxycycline monohydrate capsules, suspension only minocycline (IR) tetracycline ANTIHELMINTICS Albenza Biltricide Ivermectin Pin-X (OTC) Reese Pinworm (OTC) ANTIMALARIALS atovaquone/proguanil chloroquine phosphate Hydroxychloroquine mefloquine primaquine phosphate ANTIPROTAZOALS pentamidine isoethionate ANTIRETROVIRALS INTEGRASE INHIBITORS Isentress Tivicay Vitekta ANTIRETROVIRALS NON- NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
10 ANALOGUES Intelence nevirapine Rescriptor Viramune XR PA required age 8 and under TOPICAL ANTIBIOTICS gentamicin mupirocin ointment silver sulfadiazine URINARY ANTI-INFECTIVES methenamine nitrofurantoin caps trimethoprim MISCELLANEOUS ANTI-INFECTIVES clindamycin neomycin tinidazole tobramycin ampules vancomycin capsule PA ANTIDOTE Evzio QLL ANTINEOPLASTICS/ IMMUNOSUPPRESSANTS ALKYLATING AGENTS Alkeran cyclophosphamide Hexalen Leukeran Myleran ANTINEOPLASTIC HORMONAL AGENTS ANTIANDROGEN Anthem Blue Cross and Blue Shield Preferred drug List 5/1/2017 Page 4 of 10 Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.
