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. 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.

2 Dermatologicals .. 5 Eyes, Ears, Nose, Mouth and Throat .. 6 Endocrine Agents .. 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., 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.

3 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) 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

4 Ketorolac QLL meclofenamate meloxicam QLL nabumetone naproxen EC naproxen sodium DS oxaprozin piroxicam 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 Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.

5 , 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) 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.

6 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) 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.

7 , 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 flutamide ANTINEOPLASTIC HORMONAL AGENTS ANTIESTROGEN letrozole GL tamoxifen ANTINEOPLASTIC HORMONAL AGENTS AROMATASE INHIBITORS anastrozole GL exemestane GL ANTINEOPLASTIC HORMONAL AGENTS PROGESTINS Megestrol ANTIMETABOLITES mercaptopurine methotrexate Tabloid Trexall IMMUNOSUPPRESSANTS/ IMMUNOMODULATORS azathioprine MISCELLANEOUS ANTINEOPLASTICS Emcyt PA etoposide imatinib PA hydroxyurea leucovorin Lysodren Matulane octreotide PA tretinoin CARDIOVASCULAR AGENTS ACE INHIBITORS/ACE I COMBINATIONS benazepril/benazepril hctz QLL captopril/captopril hctz enalapril/enalapril hctz fosinopril/fosinopril hctz QLL lisinopril/lisinopril hctz QLL moexipril/moexipril hctz quinapril/quinapril hctz ramipril trandolapril BETAADRENERGIC ANTAGONISTS acebutolol atenolol atenolol/chlorthalidone betaxolol bisoprolol/ bisoprolol/hctz

8 Metoprolol metoprolol/hctz nadolol pindolol propranolol propranolol/hctz timolol ANGIOTENSION RECEPTOR BLOCKERS (ARB) AND ARB COMBINATIONS candesartan QLL candesartan/HCTZ QLL irbesartan QLL irbesartan/HCTZ QLL losartan QLL losartan / HCTZ QLL valsartan/HCTZ QLL ALPHA BETA BLOCKERS carvedilol labetalol CENTRALLY ACTING AND COMBINATIONS ANTIADRENERGICS clonidine tablets OPT guanabenz guanfacine OPT methyldopa methyldopa hctz ANTIADRENERGICS PERIPHERALLY ACTING doxazosin prazosin terazosin HMG CO A REDUCTASE INHIBITORS (STATINS) atorvastatin QLL lovastatin QLL pravastatin QLL simvastatin QLL simvastatin 80mg ST PCSK-9 INHIBITORS Repatha PA QLL NIACIN niacinIR/ER (OTC) niacinamide slo-niacin FIBRATES fenofibrate gemfibrozil BILE ACID SEQUESTRANTS cholestyramine cholestyramine lite colestipol granules CALCIUM ANTAGONISTS AND COMBINATIONS amlodipine OPT amlodipine/benazepril diltiazem diltiazem CR OPT diltiazem CD OPT diltiazem SR OPT felodipine OPT nicardipine OPT nifedipine nifedipine ER OPT verapamil verapamil SR OPT CARDIAC GLYCOSIDES digoxin ANTIARRHYTHICS amiodarone disopyramide CR flecainide Mexiletine Pacerone propafenone quinidine gluconate quinidine sulfate Nitro-bid nitroglycerin ER caps nitroglycerin ointment nitroglycerin patch nitrolycerin SL nitrolycerin spray Nitro-Stat tablets sotalol PERIPHERAL VASODILATORS AND COMBINATIONS hydralazine.

9 Hydralazine/hctz minoxidil Anthem Blue Cross and Blue Shield Preferred drug List 5/1/2017 Page 5 of 10 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. WEBMAIN-0357-17 May 2017 PRESSORS Midodrine DIURETICS amiloride, amiloride/hctz bumetanide chlorothiazide furosemide hydrochlorothiazide indapamide methychlothiazide metolazone spironolactone; spironolactone/hctz torsemide triamterene/hctz NITRATES isosorbide dinitrate isosorbide mononitrate primidone QLL Nitro-Bid nitroglycerin ER capsules nitroglycerin ointment nitroglycerin patch nitroglycerin SL nitroglycerin spray Nitro-Stat tablets PERIPHERAL VASODILATORS AND COMBINATIONS hydralazine hydralazine/hctz minoxidil PRESSORS Midodrine CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL ANTAGONISTS disulfiram ANTICONVULSANTS HYDANTOINS phenytoin QLL phenytoin extended QLL ANTICONVULSANTS SUCCINIMIDES Ethosuximide ANTICONVULSANTS BARBITURATES phenobarbital OPT primidone ANTICONVULSANTS MISC.

10 Carbamazepine OPT QLL Carbatrol OPT QLL clonazepam OPT QLL depakene OPT QLL diazepam OPT QLL diazepam rectal gel QLL divalproex OPT QLL epitol QLL lamotrigine disper tab, ER, ODT QLL levetiracetam QLL oxcarbazepine QLL roweepra QLL tiagabine (2mg and 4mg) QLL topiramate QLL zonisamide QLL valproic acid QLL ANTIPARKINSON AGENTS dramamine amantadine benztropine bromocriptine carbidopa/levodopa IR, ER, ODT diphenhydramine 50mg entacapone pramipexole ropinirole selegiline trihexyphenidyl ALZHEIMERS AGENTS Donepezil ODT QLL galatamine QLL Namenda QLL rivastigmine QLL ANTIEMETIC AND ANTIVERTIGOS dronabinol PA meclizine metoclopramide ondansetron QLL prochlorperazine promenthazine age 2 & up Transderm Scop PA Trimethobenzamide ANTIMANIA AGENTS lithium OPIOID DEPENDANCE buprenorphine/naloxone sl tabs QLL PA naloxone inj QLL naltrexone tabs Narcan 4mg nasal spray QLL Suboxone film QLL PA MISCELLANEOUS CNS pyridostigmine DERMATOLOGICALS ANTI-ACNE adapalene PA QLL benzoyl peroxide OTC clindamycin 1% soln, pledgets clindamycin-benzoyl peroxide gel erythromycin 2% soln.