Prescription Program - Student Health Services

Prescription ProgramFormulary — To be used by memberswho have a formulary drug plan.Anthem Blue Cross California prescriptiondrug benefits include medicationsavailable on the Anthem Drug List/Formulary. Our prescription drug benefitscan offer potential savings when yourphysician prescribes medications on thedrug list/formulary.MBCEBRO-10_CAEffective 04/11

Efudex (fluorouracil)*Eldepryl (selegiline)*ElidelElimite (permethrin)*Elixophyllin (theophyllinesyrup)*Elocon (mometasone)*EmcytEmpirin w/Cod (asa/codeine)*EmtrivaEndal HD (phenyleph hcl/hydrocod bit/cp)*Entex PSE (guaifenesin/pseudoephedrine)*Entocort ECEpifrin (epinephrine HCl)*Epipen, JREpivirEryc (erythromycin base)*Erycette 2% Pledgets(erythromycin)*Eryderm 2% TopicalSolution (erythromycin)*Erymax 2% TopicalSolution (erythromycin)*EryPed 200 Susp(erythromycinethylsuccinate)*Esgic (acetaminophen/caffeine/butalb)*Eskalith, CR (lithium)*Estrace (estradiol)*EstringEthmozineEulexin (flutamide)*EvamistEvistaEvoxacExelon (rivastgmine) †Exforge, HCTFFamvir (famciclovir)*FansidarFast Take Product LineFazoClo ODTFelbatolFeldene (piroxicam)*Femara †Fem HRT (Jinteli) †FemtraceFibricor (fenofibric acid)*FinaceaFioricet (APAP/caffeine/butalbital)*Fiorinal (aspirin/caffeine/butalbital)*Fiorinal w/Codeine(butalbital compoundw/codeine)*Flagyl (metronidazole)*Flexeril (cyclobenzaprine)*Flomax (tamsulosin)*Flonase (fluticasone)*Florinef (fludrocortisone)*Flovent HFAFloxin Otic (ofloxacin)*Floxin tablet (ofloxacin)*FluoroplexfluvoxamineFML ForteFML Liquifilm(fluorometholone)*Folate (folic acid)*ForadilFosamax (alendronate)*Fosamax SolutionFosrenolFuradantinFuroxoneFuzeonGGabitrilGantrisinGaramycin (gentamicin)*Gel-Kam Gel (stannousfluoride)*GeodonGleevecGlucagonGlucophage (metformin)*Glucophage XR(metformin ER)*Glucotrol XL (glipizide XL)*Glucovance (glyburide/metformin)*Glynase PresTab(glyburide micronized)*GlysetGolytely Solution(PEG– electrolyte forsolution)*Granulex (trypsin/balsamperu/castor oil)*Gynodiol (estradiol)*HHalcion (triazolam)*HalflytelyhaloperidolHectorolHistussin HC(phenyleph/chlorphen/hydrocodone)*HumalogHumibid DM(dextromethorphan/guaifenesin)*Humibid LA (guaifenesin)*Humulin R, N, 50/50,70/30Hycodan Syrup(hydrocodonew/homatropine)*Hydrea (hydroxyurea)*hydrochlorothiazideHytone (hydrocortisone2.5% cream, ointment,lotion)*Hytrin (terazosin)*Hyzaar (losartan/hctz)*I, JIlotycin (erythromycin)*Imdur (isosorbidemononitrate)*Imitrex (sumatriptannasal, tab & inj)*Imodium (loperamide)*Imuran (azathioprine)*Inderal (propranolol)*Inderal LA(propranolol la)*Inderide (propranolol/HCTZ)*Indocin, SR(indomethacin, SR)*Inflamase Mild, Forte(prednisolone)*Intal InhalerIntal Solution (cromolyn)*InviraseISMO (isosorbidemononitrate)*isoniazidIsoptin, SR(verapamil, SR)*Isopto Atropine(atropine sulfate)*3Isopto Carpine(pilocarpine HCl)*Isopto Homatropine(homatropine)*isosorbide dinitrateJalynJanumetJanuviaKK-Lor (potassium chloride20mEq)*K-Lyte CL (potassiumbicar/chloride 25mEq)K-PhosK-Phos Neutral(phospha 250)*K-Tab (potassium chloridesr)*KaletraKayexalate (sodiumpolystyrene sulfonate)*Keflex (cephalexin)*Kenalog in Orabase(triamcinoloneacetonide)*Keppra (levetiracetam)Keppra XRKerlone (betaxolol)*Klonopin (clonazepam)*Klor-conKuzymeKytril (granisetron)*LLamictal chewables 2mgLamictal chewables5 & 25mg (lamotrigine)*Lamictal tabs(lamotrigine)Lamisil tablet (terbinafine)*LanoxinLanoxicapsLantusLariam (mefloquine)*Lasix (furosemide)*leflunimideleucovorinLeukeranLeukineLevaquinLevbid (hyoscyamine)*LevemirLevlen (levonorgestrel &ethinyl estradiol)*Levo-Dromoran(levorphanol tartrate)*levoraLevothroidLevoxylLevsin (hyoscyamine)*Levsinex (hyoscyamine)*LexaproLexivaLialdaLibrium(chlordiazepoxide)*Lidex, E (fluocinonide)*LidodermLimbitrol DS (amitriptyline/chlordiazepoxide)*Lioresal (baclofen)*LipitorLithobid (lithium)*Lo/Ovral (low-ogestrel)*Lodine (etodolac)*Lodine XL (etodolac ER)*Loestrin FE (microgestin1-20, 1.5/30)*Lomotil (diphenoxylate/atropine sulfate)Loniten (minoxidil)*Lopid (gemfibrozil)*Lopressor (metoprolol)*Lopressor HCT(metoprolol/HCTZ)*Loprox gel (ciclopirox)*Loprox Shampoo(ciclopirox)*Lorcet (hydrocodone/apap)*Lortab (hydrocodone/apap)*LotemaxLotensin (benazepril)*Lotensin HCT(benazepril HCTZ)*Lotrel 2.5/10, 5/10, 5/20& 10/20 (amlodipine/benazepril)*Lorel 5/40 & 10/40mg(amlodipine/benazepril) †Lotrisone (clotrimazole/betamethasone)*LovazaLovenox (enoxaparin)*Loxitane (loxapine)*Lozol (indapamide)*Lufyllin (dyphylline)*Lupron (leuprolide)*LumiganLuride (sodium flouride)*MMacrobid (nitrofurantoinmono)*Macrodantin(nitrofurantoin)*Marinol (dronabinol)*Materna (multi-vitaminsw/folic acid)*MatulaneMavik (trandolapril)*Maxalt, MLTMaxidexMaxitrol (neomycin/polymyxin/dexamethasone)*Maxzide (triamterene/HCTZ)*Mebaral (mephobarbital)*Meclomen(meclofenamate)*Medrol 4mg, 8mg(methylprednisolone)*Medrol 2 mg, 16mg, 32mgMegace (megestrol)*Mellaril (thioridazine)*Menest meperidinew/promethazineMephytonMepronMestinon timespanMetaglip (glipizide/metformin)*methyclothiazideMetroCream(metronidazole)*MetroGelMetroGel Vaginal(metronidazole vag)*Metrolotion(metronidazole lot)*Mevacor (lovastatin)*Mexitil (mexiletine)*Micro-K (potassiumchloride)*Micronase (glyburide)*Microzide(hydrochlorothiazidecaps)*

Midamor (amiloride)*Midrin (isometh/dichlphen/APAP)*Minipress (prazosin)*Minocin Capsule(minocycline)*MintezolMiralax (glycolax)*Mirapex (pramipexole)*Mircette (kariva)*Mobic (meloxicam)*Modicon (ethinylestradiol/norethindrone)*Monistat-Derm(miconazole nitrate)*Monodox (doxycyclinemonohydrate)*Monoket (isosorbidemononitrate)*Monopril (fosinopril)*Motrin (ibuprofen)*MS Contin (morphine SR)*MSIR (morphine sulfate)*Mucomyst(acetylcysteine)*Myambutol(ethambutol)*MycobutinMycolog II (nystatin/triamcinolone)*Mycostatin (nystatin)*Mydriacyl (tropicamide)*MyleranMysoline (primidone)*NNaldecon(decongestabs)*Nalfon 600mg(fenoprofen)*NamendaNaprosyn (naproxen)*Nardil (phenelzine) †Nasarel (flunisolide)*NasonexNatafort (prenatalvitamin)*Natalins (prenatalmultivitamins andminerals/iron/fa)*Navane (thiothixene)*NebupentneconNeoDecadron (neomycin/dexamethasone)*neomycinNeoralNeosporin soln(neomycin/polymyxin/gramicidin)*Neosporin oint(neomycin/polymyxin/bacitracin)*NeoSynephrine(phenylephrine)*Neptazane(methazolamide)*Neurontin (gabapentin)*Neurontin SolnNexiumNiaspanNiferex-150 Forte (iron/B12/folic acid)*NilandronNitro-Bid (nitroglycerin SR)*Nitro-DurNitrol (nitroglycerinointment)*Nitrolingual sprayNitrostat (nitroglycerin)*Nizoral (ketoconazole)*Noctec (chloral hydrate)*Nolvadex (tamoxifen)*Nor-QD (norethindrone)*Nordette (levora)*Norflex (orphenadrine)*Norgesic (orphenadrinecpd)*Norgesic Forte(orphenadrine cpdForte)*Norinyl (necon)*Normodyne (labetalol)*Norpace (disopyramide)*Norpace CR 100mgNorpace CR 150mg(disopyramide CR150mg)*Norpramin (desipramine)*nortriptylineNorvasc (amlodipine)*NorvirNovafed A (pseudoephedrinehcl/chlor-mal)*NuLev (neosol)*NuvigilNystatinOOcufen (flurbiprofensodium)*Ocuflox (ofloxacin)*Ocupress (carteolol hcl)*OfortaOgen (estropipate)*Omnicef (cefdinir)*Omnipen (ampicillin)*One Touch Product LineOnglyzaOpana (oxymorphone)*Opticrom (cromolyn)*Optivar^ (azelastine)*Orencia*Ortho-Cept (apri,reclipsen)*Ortho-Est (estropipate)*Ortho EvraOrtho-Novum (necon)*Ortho Tri-Cyclen (trinessa)*Ortho Tri-Cyclen LoOrudis (ketoprofen)*Oruvail (ketoprofen SA)*Ovral (ogestrel)*OxyContin (oxycodone ER)PPamelor (nortriptyline)*PancreasePanoxyl, AQ (benzoylperoxide)*Parafon Forte(chlorzoxazone)*ParegoricParlodel Tab(bromocriptine)*Parnate(tranylcypromine)*PatadayPatanolPaxil (paroxetine)*Paxil CR (paroxetine SR)*Pediapred (prednisolonesodium prosphate)*Pediazole (erythromycin/sulfisoxazole)*Pentam (pentamidineisethionate)*PentasaPepcid (famotidine)*Percocet (oxycodone/APAP)*Percodan (oxycodone/aspirin)*PerforomistPeridex (chlorhexidinegluconate)*Periostat (doxycycline)*Persantine (dipyridamole)*Phenergan DM(promethazine/dextromethorphan)*Phenergan VC syrup(promethazine/phenylephrine)*Phenergan/Codeine(promethazine/codeine)*Phenergan (promethazine)*Phenergan VC/Codeine(phenylephrine/promethazine/codeine)*phenobarbitalPhoslo (calciumacetate)*Pilocar (pilocarpine HCl)*pindololPlan B 0.75mg(levonorgestrel)*Plan B 1.5mgPlaquenil(hydroxychloroquine)*PlavixPlexion SCTPlexion TS (sulfacet sodw/sulfur10/5%)*Poly-Vi-Flor (multivitaminsw/fluoride)*Polycitra (potassiumcitrate-citric acid)*Polycitra-K (Pot. & Sod.Citrates w/citric acid)*Polysporin (bacitracinzinc/polymyxin B)*Polytrim (polymyxin B/trimethoprim)*Ponstel (mefenamic acid)*Potaba Tab(aminobenzoate tab)*potassium chloridePramosone 1% creamonly, lotion, ointPramosone 2.5% ointand cream (hydrocort/pramoxine)*Prandin4Pravachol (pravastatin)*Precose (acarbose)*Pred Forte 1%(prednisolone)*prednisonePred Mild 0.12%Prelone (prednisolone)*Premarin oral, vaginalcreamPremphasePremproPrenate Advance(prenatal w/docusate,iron, folic acid)*Prenate ElitePrenate Ultra (multivitaminsw/folic acid)*Prevacid^ (lansoprazole,ODT)*Prevident (sodiumfluoride)*PriftinPrilosec^ (omeprazole)*PrimaquinePrinivil (lisinopril)*Prinzide (lisinopril/hctz)*PristiqProAmatine (midodrine)*ProAir HFAPro-Banthine(propantheline)*probenecidProcanbidProcardia (nifedipine)*Procardia XL (nifedipineER)*Proctocort(hydrocortisone)*Proctocream-HC(hemorhoidal cream)*Profasi 10,000 (chorionicgonadotropin)*Prograf (tacrolimus)Prolixin (fluphenazine)*Proloprim(trimethoprim)*PrometriumPronestyl, SR(procainamide, SR)*Propine (dipivefrin HCl)*propylthiouracilProscar (finasteride)*Protonix^ (pantoprazole)*ProtopicProventil HFAProventil, Tab, Syrup(albuterol)*Provera (medroxyprogesterone)*Prozac (fluoxetine)*Psorcon (diflorasonediacetate)*Pulmicort RespulesPurinethol(mercaptopurine)*pyrazinamidePyridium(phenazopyridine)*QQuestran, Lite(cholestyramine, light)*Quinaglute (quinidinegluconate)*Quinidex (quinidinesulfate)*RRanexaRazadyne, ER(galantamine, sr)*Rebetol (ribavirin)*Reglan (metoclopramide)*Relafen (nabumetone)*Remeron, SolTab(mirtazapine)*Remicade*RenagelRenvela tabRequip* (ropinirole)RescriptorRestasisRestoril (temazepam)*Retin-A Cream (tretinoin)*Retin-A Gel (tretinoin)*Retin-A MicroRetrovir (zidovudine)Revia (naltrexone hcl)*ReyatazRheumatrex Tablets(methotrexate tablets)*RidauraRifadin (rifampin)*RifamateRifaterRilutekRisperdal (risperidone)*

Risperdal ConstaRisperdal ODT, M-tab(risperidone)*Ritalin, SR(methylphenidate, SR)*RMS Supp (morphine)*Robaxin (methocarbamol)*Rocaltrol (calcitriol 0.25,0.5 mg caps)*Rondec DM syrup(pseudoephed/bromphen-DM 45-4-15)*Rondec, TR(pseudoephedrine/carbinoxamine)*Roxicodone (oxycodone)*Rynatan (chlorphen/pyrilamine/phenylephrine)*Rynatuss tablets,pediatric susp(phenyleph- ephed-cpdw/carbetapentane)*Rythmol, SR(propafenone, ER)*SSalagen (pilocarpine)*Sanctura (trospium)*Sandimmune*Sandostatin (octreotideacetate)*SavellaSeasonale (jolessa,quasense)*Sectral (acebutolol)*Selsun (selenium sulfide)*Septra, DS(sulfamethoxazole/trimethoprim, DS)*Serax (oxazepam)*Serevent DiskusSerophene (clomiphene)*Seroquel, XRSilvadene (silversulfadiazine)*Sinemet (carbidopa/levodopa)*Sinemet CR (carbidopa/levodopa CR)*Sinequan (doxepin)*SingulairSkelaxin (metaxolone) †Slo-Bid (theophylline)*Slo-Phyllin 80 Syrup(theophyllineanhydrosl)*Sodium Sulamyd(sulfacetamidesolution)*Solaquin Forte(hydroquinone)*Soma (carisoprodol)*SomavertSomophyllin(aminophylline)*Sonata (zaleplon)*Sorbitrate (isosorbidedinitrate)*Spectazole (econazole)*SpirivaSporanox (itraconazole)*Stadol N.S. (butorphanoltartrate 10 mg/ml N.S.)*Starlix (nateglinide) †Stelazine(trifluoperazine)*StratteraSuboxone SL tab, SL filmSubutex(buprenorphine)*Sular 20, 30 & 40mg(nisoldipine)*Sular 8.5, 17, 25.5 & 34mg(nisoldipine) †Sulfacet-R (sodiumsulfacetamide/sulfur)*Sultrin (triple sulfa)*SustivaSymbicortSymbyaxSymlinSymmetrel (amantadine)*Synalar (fluocinoloneacetonide)*Synthroid (levothyroxine)TTagamet (cimetidine)*Talacen (pentazocine/apap)*Talwin NX (pentazocine nx)*Tambocor (flecainide)*TamifluTarka (trandolapril/verapamil)*Tavist syrup, 2.68mg tabs(clemastine fumarate)*TazoracTegretol (carbamazepine)Tegretol XR(carbamazepine ER)Tekturna, HCTTemodar †Temovate (clobetasol)*Tenex (guanfacine)*Tenoretic (atenolol/chlorthalidone)*Tenormin (atenolol)*Terazol (terconazole)*TeslacTessalon Perles(benzonatate)*TestimTheo-24Theochron(theophylline)*Thorazine Tab(chlorpromazine tab)*Ticlid (ticlopidine)*Tigan(trimethobenzamide)*TiladeTimoptic(timololophthalmic)*Timoptic XE (timolol)*TobiTobradex oint.Tobradex susp.(tobramycin/dexamethasone)*Tobrex Soln(tobramycin)*Tofranil (imipramine)*Tolectin (tolmetin)*TopamaxTopicort(desoximetasone)*Toprol XL (metoprolol)*Toradol (ketorolactromethamine)*ToviazTrandate (labetalol)*Transderm-ScopTranxene (clorazepate)*Trental (pentoxifylline)*Tricor (fenofibrate)*TriLeven (levo norgestrel)*Tri-Vi-Flor (triple vitaminsw/fluoride)*Tridesilon (desonide)*Trilafon (perphenazine)*5Trileptal (oxcarbazepine)*TrilipixTrimox (amoxicillin)*Trimpex (trimethoprim)*Trinsicon (iron/intrinsicfactor/B12)*Triphasil (trivora)*TrizivirTrusopt (dorzolamide)*Tussi-12 (phenyleph/chlorphen/carbeta)*Tussi-Organidin NR(guaifenesin/codeine)*Tussi-Organidin NRDM (guaifenesin/dextromethorphan)*TussiCapsTussionex PennkineticER (hydrocodone/chlorpheniramine) †TwinjectTylenol w/Cod(codeine/APAP)*Tylox (oxycodonew/acetaminophen)*Tympagesic (pramoxine/hc/chloroxylenol)*UUltracet (tramadol/APAP)*Ultram, ER (tramadol)*Ultrase (pancrelipase)Ultravate (halobetasol)*Uniphyl (theophylline SR)Uniretic (moexipril/hctz)*Unithroid (levothyroxine)Univasc (moexipril)*Urecholine (bethanechol)*Urised (meth/salicylate/atropine/hyos benzoic)*Urocit-K (potassiumcitrate)*Urogesic Blue(methenamine/hyoscmethblue/sod biphosphenylsal)*UroxatralVV-Cillin K (penicillin V.K.)*VagifemValcyte tabsValisone (betamethasonevalerate)*Valium (diazepam)*Valtrex (valacyclovir)* †ValturnaVantin (cefpodoxime)*Vaseretic (enalapril/hydrochlorothiazide)*Vasocidin (sulfacetamidesodium-prednisoloneophth sol.)*Vasocon (naphazoline)*Vasotec (enalapril)*VeltinVepesid (etoposide)*VeramystVerelan (verapamil SR)*Vermox (mebendazole)*VESIcareVfend (voriconazole)*Vibramycin(doxycycline)*Vicodin (hydrocodone/APAP)*Vicodin E.S.(hydrocodone/apap)*VidexVidex EC (didanosine)*VigamoxViokaseViraceptViramuneVireadViroptic (trifluridine)*Vistaril (hydroxyzinepamoate)*VivelleVivelle DotVoltaren GelVoltaren Ophth(diclofenac sodium)*Voltaren, XR(diclofenac, ER)*Vosol (acetic acid)*Vosol HC (acetic acid/hydrocortisone)*VyvanseW, XWelcholWellbutrin, SR(bupropion)*Wellbutrin XL(budeprion XL)*Westcort(hydrocortisone)*Xalatan †Xanax (alprazolam)*XelodaXodol (hydrocodone/apap)*Xopenex Neb Soln1.25/0.5ml(levalbuterol)*Xopenex Neb Solnexcept 1.25/0.5mlXylocaine (lidocaine)*Xylocaine viscous(lidocaine viscous)*Xyzal^ (levocetirizine)*Y, ZYasmin (ocella)*Yaz (gianvi)*YodoxinYocon (yohimbine)*Zanaflex (tizanidine)*Zantac (ranitidine)*Zarontin(ethosuximide)*Zaroxolyn (metolazone)*Zebeta (bisoprolol)*Zegerid^ (omeprazole/bicarb)*Zenate (multi-vitaminsw/folic acid)*Zephrex LA (pseudoephedrine/guaifenesin)*Zerit (stavudine)*Zestril (lisinopril)*Zestoretic (lisinopril/hctz)*Zetacet (sulfacetsodw/sulfur 10/5%)*Ziac (bisoprolol/HCTZ)*ZiagenZithromax(azithromycin)*Zocor (simvastatin)*Zofran (ondansetron)*Zoloft (sertraline)*Zonegran (zonisamide)*ZortresszoviaZovirax Cap (acyclovir)*Zovirax OintZyletZyloprim (allopurinol)*Zyprexa

Anthem is committed to helping you to manage your prescription benefits. PriorAuthorization, Quantity Limits, Step Therapy and Dose Optimization are some of the editsrecommended by the P&T Committee and approved by your health plan. These edits helpensure you have access to safe, appropriate and effective prescription medications.PRIOR AUTHORIZATION: medications which require pharmacy benefit manageror plan approval before you may receive benefits.Actiq (fentanyl citrate)*Amevive*Androderm*GleevecHumatrope*Humira*OfortaOrencia*Pegasys*Sporanox (itraconazole)*Temodar †TestimAndroGelLamisil tabletPeg-Intron*Tev-Tropin*Botox*(terbinafine)*Penlac*XelodaEnbrel*Fentora*Forteo*Genotropin*Lyrica*Norditropin*Nutropin, AQ*NuvigilProvigil*Remicade*Saizen*Serostim*Xolair*Xyzal*^Zorbtive*Zyvox*QUANTITY LIMIT: affects the frequency or dosage of certain medications for which youreceive benefits.Aciphex*^CymbaltaKytril (granisetron)* Rozerem*Actiq (fentanyl citrate)* Dexilant*Lunesta*Saizen*AdvicorDiabetic Test Strips Maxalt, MLTSavellaAllegra^ (fexofenadine)* (Accu-Chek and One Migranal*Serostim*Allegra D^ (fexofenadine/ Touch brand products Nasarel (flunisolide)* Simcor*PSE)*are formulary)NasonexSonata (zaleplon)*Ambien (zolpidem)* EffientNexiumStadol N.S. (butorphanol)*Ambien CR (zolpidem ER)* Elestat*^Norditropin*SymbicortAmerge (naratriptan)* Emend*Nutropin, AQ*AndroGelEnbrel*TestimNuvigilAnzemet*Fentora*Optivar^ (azelastine)*Tev-Tropin*Astelin (azelastine) † Flonase (fluticasone)* PatadayTreximet*AsteproForteo*PatanolVeramystAvinzaFrova*PlavixXyzal^ (levocetirizine)*Axert*Genotropin*Prevacid^ (lansoprazole)* Zegerid^ (omeprazole/ByettaHumatrope*Prilosec^ (omeprazole)* bicarb)*Bepreve^*Humira*PristiqZofran (ondansetron)*Clarinex, D^*Imitrex (sumatriptan Protonix^ (pantoprazole)* Zomig, ZMT*Crestornasal, tab & inj)* Relpax*Zorbtive*STEP THERAPY: requires that you first use a specific medication before alternatives therapiesmay be tried or prescribed.Adderall (amphetamine/ Betaseron*Nasacort AQ*Rozerem*dextroamphetamine^) ByettaNasarel (flunisolide)* Sonata*– generic onlyCelebrex*Omnaris*Vytorin*Aciphex*^Dexilant*Prevacid*^Xyzal*^Ambien CR (zolpidem ER)* Diabetic Test Strips (Accu- Prilosec*^Zegerid*^Apidra*Chek and One Touch brand Protonix*^Zetia*Arthrotec*Beconase AQ*products are formulary)ElidelProtopicRhinocort Aqua*DOSE OPTIMIZATION: normally involves the conversion from twice-daily dosing to a once-dailydosing schedule. A once-daily dosing schedule may increase compliance and decreaseexpenses for you and your health plan.Medications in the following categories are included in the dose optimization edits.Antidepressants Cholesterol reducing medications Certain blood pressure medications6

Not all medications and not all plans are subject to prior authorization and quantity limits. For moreinformation regarding prior authorization or quantity limits, contact Member Services at the telephonenumber listed on your identification card.For more information, please visit anthem.com/CA.• If you have additional questions about your prescriptionbenefits please call the Member Services number on yourID card• Speech and hearing impaired (TDD/TTY users) should call800-221-6915, 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/CA• Bring a copy of this drug list/formulary to your next doctor’svisit to assist in selecting the lowest cost medicationsEffective 04/11Anthem 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.MBCEBRO-10_CA