Preferred Drug List - Anthem

1 Preferred Drug List Effective May 1, 2017. Table of Contents Analgesics .. 1. Anesthetics .. 1. Antibiotics and Antivirals .. 1. Antineoplastics/Immunosuppressants 2. Cardiovascular Agents 2. Central Nervous System Agents . 3. Dermatologicals .. 4. Eyes, Ears, Nose, Mouth and Throat .. 4. Endocrine Agents 5. Gastrointestinal Agents .. 5. Blood Modifiers, Nutritionals and Electrolytes .. 6. OB/GYN . 6. Respiratory Agents . 7. Skeletal Muscle Relaxants .. 7. Urologicals .. 8. Immunologicals, Vaccines and Biotechnology Drugs 8. Smoking Cessation . 8. 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. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.

2 WEBMAIN-0356-17 May 2017. Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017. Page 1 of 8. ANALGESICS oxycodone IR QLL pyrazinamide rifampin AGENTS FOR MIGRAINE. NARCOTIC ANALGESIC Rifater apap/butalbital QLL. COMBINATIONS. apap/caffeine/butalb QLL. codeine/apap QLL ANTIVIRALS. apap/caffeine/butalbital hydrocodone/apap QLL Abreva OTC. /codeine QLL. hydrocodone acyclovir apap/caffeine/isomethep /ibuprofen QLL amantadine apap/dichloral/caffeine oxycodone/apap QLL Baraclude PA. asa/caffeine/butalbital QLL. oxycodone/aspirin QLL Descovy PA. butalbital compound pentazocine/apap famciclovir w/codeine QLL. pentazocine/naloxone Fuzeon PA. asa/butalbital QLL. Lamivudine asa/dihydrocodeine NONSTEROIDAL Rebetol solution PA QLL. /caffeine QLL. ANTI-INFLAMMATORIES Relenza QLL. butalbital/asa/caffeine/. diclofenac potassium rimantadine codeine QLL. diclofenac ER Selzentry butorphanol NS PA QLL. etodolac ER/IR Tamiflu QLL. divalproex OPT. fenoprofen valacyclovir PA. ergotamine w/caffeine flurbiprofen Valcyte sumatriptan QLL.

3 Ibuprofen Viread PA. indomethacin IR/ER. CHELATING AGENTS. ketoprofen, CEPHALOSPORINS. (WILSON'S DISEASE). IR/ER ketorolac QLL cefaclor ER QLL. Cuprimine meclofenamate cefadroxil QLL. Depen meloxicam QLL cefdinir QLL. Syprine nabumetone cefpodoxime QLL. naproxen EC cefprozil QLL. DMARDS. naproxen sodiumDS cefuroxime QLL. Cuprimine oxaprozin cephalexin QLL. cyclophosphamide piroxicam cephradine Enbrel PA QLL. sulindac ceftriaxone injection Humira PA QLL. tolmetin hydroxychloroquine FLUOROQUINOLONES. leflunomide SALICYLATES ciprofloxacin QLL PA. methotrexate oral aspirin, aspirin cr 800mg levofloxacin QLL. prednisone choline/magnesium ofloxacin QLL PA. sulfasalazine QLL. salicylate diflunisal ANTIRETROVIRALS . GOUT MEDICATIONS. salsalate NUCLEOSIDE REVERSE. allopurinol TRANSCRIPTASE INHIBITOR. colchicine/probenecid ANESTHETICS. (NRTI) ANALOGUES. probenecid QLL. TOPICAL LOCAL abacavir ANESTHETICS adefovir HYLAURONICS. benzocaine OTC dipivoxil Euflexxa PA. lidocaine jelly didanosine Gelsyn PA.

4 Lidocaine 5% patch QLL PA Emtriva Supartz PA. lidocaine/hydrocortisone lamivudine lidocaine/prilocaine stavudine MISCELLANEOUS. Vitekta ANALGESICS. ANTIBIOTICS AND Ziagen solution acetaminophen ANTIVIRALS zidovudine tramadol IR only QLL. tramadol/APAP QLL AMEBICIDES. metronidazole ANTIRETROVIRAL. paromomycin sulfate COMBINATIONS. NARCOTIC ANALGESICS. abacavir/lamivudine codeine QLL Yodoxin /zidovudine fentanyl citrate lozenge PA QLL. Epzicom fentanyl patch QLL ST ANTI-TUBERCULOSIS. Evotaz hydromorphone QLL ethambutol Genvoya meperidine QLL isoniazid Kaletra methadone QLL Mycobutin lamivudine/zovudine morphine sulfate ER tabs /IRQLL Priftin 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. Express Scripts, Inc.

5 Is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WEBMAIN-0356-17 May 2017. Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017. Page 2 of 8. Prezcobix erythromycin ANTINEOPLASTICS/. Stribild PA ethylsuccinate IMMUNOSUPPRESSANTS. Triumeq erythromycin stearate ALKYLATING AGENTS. Truvada doxycycline Alkeran minocycline (IR). cyclophosphamide ANTIRETROVIRALS monohydrate capsules, suspension Hexalen PROTEASE INHIBITORS only Leukeran Aptivus tetracycline QLL. Myleran Crixivan Norvir ANTIHELMINTICS. ANTINEOPLASTIC . Prezista Albenza HORMONAL AGENTS . Reyataz Biltricide ANTIANDROGEN. Viracept Ivermectin flutamide Pin-X OTC. PENICILLINS Reese Pinworm OTC. ANTINEOPLASTIC . amoxicillin QLL. HORMONAL AGENTS . amoxicillin/clavulanate QLL ANTIMALARIALS. ANTIESTROGEN. ampicillin QLL atovaquone/proguanil letrozole PA GL. dicloxacillin QLL chloroquine phosphate tamoxifen penicillin VK QLL hydroxychloroquine mefloquine ANTINEOPLASTIC.

6 ANTIFUNGAL ORAL primaquine phosphate HORMONAL. clotrimazole troche AGENTS AROMATASE. fluconazole ANTIPROTAZOALS. INHIBITORS. flucytosine pentamidine anastrozole PA GL. griseofulvin ultra tab isoethionate exemestane PA GL. griseofulvin susp itraconazole PA ANTIRETROVIRALS. ANTINEOPLASTIC . ketoconazole INTEGRASE INHIBITORS. HORMONAL. nystatin Isentress AGENTS PROGESTINS. terbinafine tablets PA Tivicay Megestrol voriconazole ANTIRETROVIRALS NON- ANTIMETABOLITES. ANTIFUNGAL TOPICAL NUCLEO-SIDE REVERSE. mercaptopurine Various OTC TRANSCRIPTASE INHIBITOR. methotrexate butenafine OTC. (NNRTI) ANALOGUES. Tabloid ciclodan 8% soln Intelence Trexall ciclopirox 8% crm, soln nevirapine clotrimazole QLL Rescriptor IMMUNO-SUPPRESSANTS/. clotrimazole/betamethasone Viramune XR. PA required age 8 and under IMMUNO-MODULATORS. ketoconazole crm, shampoo azathioprine miconazole nitrate OTC. nystatin TOPICAL ANTIBIOTICS. MISCELLANEOUS. terbinafine gentamicin ANTINEOPLASTICS. tolnaftate crm, powder mupirocin ointment Emcyt PA.

7 Silver sulfadiazine etoposide LEPROSTATICS. imatinib PA. Dapsone URINARY ANTI-INFECTIVES. hydroxyurea methenamine leucovorin MACROLIDES nitrofurantoin caps Lysodren azithromycin tablet QLL trimethoprim Matulane clarithromycin octreotide PA. erythromycin MISCELLANEOUS ANTI- tretinoin erythromycin/sulfisoxazole INFECTIVES. clindamycin CARDIOVASCULAR. SULFONAMIDES neomycin sulfadiazine tinidazole ACE INHIBITORS/ACE I. sulfamethoxazole/trimethoprim DS tobramycin ampules COMBINATIONS. sulfasoxazole vancomycin capsule PA benazepril/benazepril hctz QLL. captopril/captopril hctz TETRACYCLINES ANTIDOTE enalapril/enalapril hctz erythromycin base Evzio QLL fosinopril/fosinopril hctz QLL. 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.

8 Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WEBMAIN-0356-17 May 2017. Anthem Blue Cross and Blue Shield Preferred Drug List 5/1/2017. Page 3 of 8. lisinopril/lisinopril hctz QLL niacinIR/ER OTC nitroglycerin ER capsules moexipril/moexipril hctz niacinamide nitroglycerin ointment quinapril/quinapril hctz slo-niacin nitroglycerin patch ramipril nitroglycerin SL. trandolapril FIBRATES nitroglycerin spray fenofibrate Nitro-Stat tablets BETAADRENERGIC gemfibrozil ANTAGONISTS PERIPHERAL. acebutolol BILE ACID SEQUESTRANTS VASODILATORS. atenolol cholestyramine AND COMBINATIONS. atenolol/chlorthalidone cholestyramine lite hydralazine;. betaxolol colestipol granules hydralazine/hctz bisoprolol/bisoprolol hctz minoxidil metoprolol /metoprolol hctz CALCIUM ANTAGONISTS. nadolol AND COMBINATIONS CENTRAL NERVOUS. pindolol amlodipine OPT SYSTEM AGENTS. propranolol/propranolol hctz amlodipine/benazepril ALCOHOL ANTAGONISTS.

9 Sotalol diltiazem disulfiram timolol diltiazem CR OPT. diltiazem CD OPT. ALZHEIMERS AGENTS. ALPHA BETA BLOCKERS diltiazem SR OPT. Donepezil ODT QLL. carvedilol felodipine OPT. galatamine QLL. labetalol nicardipine OPT. Namenda QLL. nifedipine rivastigmine ANGIOTENSION RECEPTOR nifedipine ER OPT. BLOCKERS (ARB) AND ARB verapamil ANTI-CONVULSANT. COMBINATIONS verapamil SR OPT. HYDANTOINS. candesartan QLL. phenytoin QLL. candesartan/HCTZ QLL CARDIAC GLYCOSIDES. phenytoin extended QLL. irbesartan QLL digoxin irbesartan/HCTZ QLL. ANTICONVULSANT . losartan QLL ANTIARRHYTHICS. SUCCINIMIDES. losartan / HCTZ QLL amiodarone ethosuximide QLL. valsartan/HCTZ QLL disopyramide CR. flecainide ANTICONVULSANTS . CENTRALLY ACTING AND Mexiletine BARBITURATES. COMBINATIONS Pacerone phenobarbital OPT. ANTIADRENERGICS propafenone clonidine tablets OPT quinidine ANTICONVULSANTS MISC. guanabenz gluconate Carbamazepine OPT QLL. guanfacine OPT quinidine sulfate Carbatrol OPT QLL. methyldopa clonazepam OPT QLL.

10 Methyldopa/hctz DIURETICS. depakene OPT QLL. amiloride diazepam OPT QLL. ANTIADRENERGICS amiloride/hctz diazepam rectal gel QLL. PERIPHERALLY ACTING bumetanide divalproex OPT QLL. doxazosin chlorothiazide epitol QLL. prazosin furosemide lamotrigine disper tab, ER, ODT QLL. terazosin hydrochlorothiazide levetiracetam QLL. indapamide oxcarbazepine QLL. HMG CO A REDUCTASE methychlothiazide roweepra QLL. INHIBITORS (STATINS) metolazone tiagabine (2mg and 4mg) QLL. atorvastatin QLL spironolactone topiramate QLL. lovastatin QLL spironolactone/hctz zonisamide QLL. pravastatin QLL torsemide valproic acid QLL. simvastatin QLL triamterene/hctz simvastatin 80mg QLL ST. ANTIEMETIC AND. NITRATES. ANTIVERTIGOS. PCSK-9 INHIBITORS isosorbide dinitrate dramamine Repatha PA QLL. isosorbide mononitrate dronabinol PA. primidone QLL. meclizine NIACIN Nitro-Bid metoclopramide 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.