Prescription Program
Drug list — To be used by members
who have a formulary drug plan.
Anthem Blue Cross California 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. For more information about
your drug plan, you can do
A. The Anthem Drug List, also called a formulary, is a list of U.S. Food and Drug the following:
Administration (FDA)-approved brand-name and generic drugs that have been Go to
reviewed and recommended for their quality and how well they work. The review is done by the National Pharmacy and Therapeutics (P&T) Process. The Call customer service
P&T Process is performed by an independent group of practicing doctors and at the number on your
pharmacists in charge of the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and they Speech and hearing
choose the top drugs for our list — based on their safety, how they work and impaired users
(TDD/TTY) should call
Because the drugs on our list are reviewed from time to time, it’s a good idea 800-221-6915, Monday
to check the list to find out if any drugs have been added or removed. You can – Friday, 8:30 a.m. –
5:00 p.m., ET
Bring a copy of this drug
A. These are drugs that are developed by a company who holds the rights to sell list to your next doctor’s
them. When the rights expire, other drug companies can make their own version visit to help you and your
of the drugs (see generic drugs below). You may be more familiar with brand- doctor select the lowest
cost medicine
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 the same quality for less money. Q. What are “clinically equivalent” medications? How does this affect my drug A. When drugs are compared in studies, some drugs have been found to be First letter is lower-case – A generic
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 First letter is a capital – A brand-
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 plan may not cover some drugs (indicated by a ^ symbol next to the drug name) that have clinically equivalent options.
be available soon. After the generic drug becomes available and the Q. What if my medication is not on the drug list? 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.
become a Tier 3 drug in your plan or it may no longer be covered.
Q. Can I request that a drug be added to the drug list? * – Brand-name versions of these drugs 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
^ – This drug has clinically equivalent approved, it does not guarantee coverage. Some drugs, such as those used
for cosmetic purposes, may be excluded from your benefits. Please refer to
drug list. Because there are these options, the drug may not be your insurance Certificate or Evidence of Coverage to know for sure.
Drugs are listed alphabetically by brand name
Casodex (bicalutamide)* Cytovene (ganciclovir)* Diastat (diazepam gel) Adalat CC (nifedipine ER)* Ansaid (flurbiprofen)* Adderall (amphetamine/ Antabuse (disulfiram)* Anturane (sulfinpyrazone)* (diphenhydramine 50mg)* Comtan Cortef (hydrocortisone)* Demulen 28 day (ethinyl Dovonex cream Biaxin, XL (clarithromycin, neomycin- hc opth oint)* Depakote (divalproex) Bicitra (sodium citrate & (neomycin/polymixin/ Armour Thyroid (thyroid) Bleph-10 (sulfacetamide- timolol)* Allegra^ (fexofenadine)* Artane (trihexyphenidyl)* Blephamide Cyclocort (amcinonide)* Desyrel (trazodone)* Glucotrol XL (glipizide XL)* Intal Solution (cromolyn)* Lanoxin electrolyte for solution)* Isopto Atropine Fibricor (fenofibric acid)* Granulex (trypsin/balsam (atropine sulfate)* Levaquin (levofloxacin)* Loxitane (loxapine)* Elixophyllin (theophylline Fioricet (APAP/caffeine/ Gynodiol (estradiol)* Levlen (levonorgestrel & Lupron (leuprolide)* Endal HD (phenyleph hcl/ Flagyl (metronidazole)* K-Lor (potassium chloride Levsin (hyoscyamine)* Levsinex (hyoscyamine)* (nitrofurantoin)* Entocort EC (budesonide Flonase (fluticasone)* Epifrin (epinephrine HCl)* (fludrocortisone)* Humibid LA (guaifenesin)* K-Phos Neutral Eryc (erythromycin base)* Floxin tablet (ofloxacin)* 70/30 Fortamet ER (metformin ER)* Hytone (hydrocortisone Kayexalate (sodium Lomotil (diphenoxylate/ Medrol 2 mg, 16mg, 32mg Glucophage (metformin)* Inflamase Mild, Forte Lamictal tabs (lamotrigine) LoSeasonique Norpramin (desipramine)* Pentam (pentamidine (triamcinolone nasal)* Norvasc (amlodipine)* NeoDecadron (neomycin/ Ocuflox (ofloxacin)* Prevacid^ (lansoprazole, Quinidex (quinidine Neurontin (gabapentin)* Ortho-Est (estropipate)* Niferex-150 Forte (iron/ Ortho Tri-Cyclen (tri- Pilocar (pilocarpine HCl)* Prinivil (lisinopril)* Prinzide (lisinopril/hctz)* Rebetol (ribavirin)* Nitro-Bid (nitroglycerin SR)* Orudis (ketoprofen)* ProAmatine (midodrine)* Relafen (nabumetone)* Pamelor (nortriptyline)* Plexion TS (sulfacet sod Profasi 10,000 (chorionic Retin-A Gel (tretinoin)* Norpace (disopyramide)* Paxil CR (paroxetine SR)* Ponstel (mefenamic Pediazole (erythromycin/ (aminobenzoate tab)* Valisone (betamethasone Xalatan (latanoprost)* Risperdal (risperidone)* Skelaxin (metaxolone)* Trimpex (trimethoprim)* Vaseretic (enalapril/ Rocaltrol (calcitriol 0.25, (hydroquinone)* (phenyleph- ephed-cpd Starlix (nateglinide)* Tigan (trimethobenzamide)* w/acetaminophen)* Tympagesic (pramoxine/ Videx EC (didanosine)* atropine/hyos benzoic)* Vosol (acetic acid)* Synthroid (levothyroxine) Toradol (ketorolac Serophene (clomiphene)* Tagamet (cimetidine)* TriLeven (levo norgestrel)* V-Cillin K (penicillin V.K.)* (budeprion XL)* Anthem is committed to helping you to manage your prescription benefits. Prior Authorization, Quantity Limits, Step Therapy and Dose Optimization are some of the edits recommended by the P&T Committee and approved by your health plan. These edits help ensure you have access to safe, appropriate and effective prescription medications.
PRIOR AUTHORIZATION: medications which require pharmacy benefit manager
or plan approval before you may receive benefits.
Actiq (fentanyl citrate)*
QUANTITY LIMIT: affects the frequency or dosage of certain medications for which you
receive benefits.
Allegra D^ (fexofenadine/ Touch brand products Ambien CR (zolpidem ER)* Elestat^ (epinastine)* STEP THERAPY: requires that you first use a specific medication before alternatives therapies
may be tried or prescribed.
Adderall (amphetamine/
DOSE OPTIMIZATION: normally involves the conversion from twice-daily dosing to a once-daily
dosing schedule. A once-daily dosing schedule may increase compliance and decrease
expenses for you and your health plan.
Medications in the following categories are included in the dose optimization edits.
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 more information, please visit
If you have additional questions about your prescription
benefits please call the Member Services number on your
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
Bring a copy of this drug list to your next doctor’s visit to
assist in selecting the lowest cost medications
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 Cross Association.
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WellPoint NextRx, NextRx and PrecisionRx are registered trademarks of WellPoint, Inc. and are used under license by Express Scripts, Inc.


blue cross and blue shield of texas mail order form — primemail® pharmacy iNstructioNs: Please PrINT in CAPITAL letters using black ink only. Fill in the applicable ovals completely ( ). For information about your pharmacy benefits, to preregister or to download additional order forms or a physician fax form, visit the Blue Cross and Blue Shield of Texas Web site at

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