Anthem Virginia Individual Health Insurance, Family Plans | MyLocalBroker.net

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Roberson Insurance Agency, Inc.
1945 Malbon Road
Virginia Beach, VA 23456
1-(888)-380-2505




Drug Formulary FAQs

Q.) What is a Drug Formulary?
A.) It is a list of FDA-approved brand-name and generic medications currently covered by a health insurance company, although inclusion does not necessarily guarantee coverage. Brand Name drugs are the most expensive. Generic drugs contain the same active ingredients, but at a much lower price.

Q.) What does "Clinically Equivalent" mean?
A.) Clinically Equivalent drugs are drugs determined to have the same effect as more expensive drugs. Anthem may cover only certain clinically equivalent drugs to further reduce your health care costs.

Q.) My medication is not on this list. What does this mean?
A.) While Anthem makes every effort to provide an exhaustive drug coverage list, some drugs may not be currently covered. If drug is not on the drug formulary (list), you must pay the copayment for the non-formulary drug. You should talk to your doctor about getting a medication that is on the drug formulary.

Q.) I'm looking into health coverage options. Should I work with a broker?
A.) Yes. Brokers are much easier to reach and will work to solve your problems and answer your questions. We provide an expert personal touch.

Q.) Will it cost more if I use a broker?
A.) NO! Never. All health insurance plan prices remain the same whether you buy direct from an insurance company or utilize a broker. You have nothing to lose by working with us.

Anthem Blue Cross Blue Shield

Drug Formulary List

Anthem Blue Cross Blue Shield Drug Formulary List
The following is the current (2011) Anthem Blue Cross Blue Shield Drug Formulary List. The Anthem prescription drug formulary list is designed to help Anthem's customers determine which drugs are covered under their health plan. This list may change often, and at any time without notice. Drugs are listed alphabetically. The inclusion of a particular drug on the formulary is not a guarantee of coverage. For example, drugs used for cosmetic purposes may not be covered. For the latest Anthem Blue Cross drug formulary information, check with anthem.com


Anthem Health Insurance
You may also Download the Anthem Drug Formulary in PDF document format.




See the Drug Formulary Key for medication details.

A

A/T/S Topical Solution (erythromycin)*
Abilify
Acanya
Accu-Check product line
Accutane (isotretinoin)*
Aceon (perindopril)*
Aci-Jel Jelly (acetic acid vaginal)*
Actigall (ursodiol)*
Activella 0.1-0.5
Activella 1.0-0.5 (estradiol/norethindrone)*
Actonel
ActoPlus Met, XR
Actos
Acular, LS (ketorolac)*
Akne-Mycin
Adalat CC (nifedipine ER)*
Adderall (amphetamine/dextroamphetamine)*
Adderall XR (amphetamine/dextroamphetamine^#)
Advair
Advicor
Agenerase
Akne-Mycin
Albalon (naphazoline)*
Aldactazide (spironolactone/HCTZ)*
Aldactone (spironolactone)*
Aldara†
Aldomet (methyldopa)*
Aldoril (methyldopa/HCTZ)*
Alesse (aviane)*
Alkeran
Allegra (fexofenadine)*
Allegra D^ (fexofenadine/PSE 12hr)*
Alphagan, P (brimonidine)*
Altace (ramipril)*
Altabax
Alupent
(metaproterenol)*
Amaryl (glimepiride)*
Ambien (zolpidem)*
Amerge (naratriptan)*
Amevive*
Amicar (aminocaproic acid)*
amitriptyline
amitriptyline/perphenazine
Amoxil (amoxicillin)*
Anafranil (clomipramine)*
Analpram HC lotion
Anaprox, DS (naproxen sodium, DS)*
Androderm
Androgel
Anexsia (hydrocodone/APAP)*
Ansaid (flurbiprofen)*
Antabuse
Antivert (meclizine)*
Anturane (sulfinpyrazone)*
Anusol HC 25mg Suppositories (hydrocortisone)*
Apresazide (hydralazine/HCTZ)*
Apresoline (hydralazine)*
apri
Arava (leflunomide)*
Aricept
Arimidex (anastrozole)†
Aristocort Topical (triamcinolone-acetonide)*
Armour Thyroid
Aromasin†
Artane (trihexyphenidyl)*
Asacol, HD
Asendin (amoxapine)*
Asmanex
Astelin (azelastine)†
Astepro
Atarax (hydroxyzine HCL)*
Ativan (lorazepam)*
Atrovent HFA
Atrovent (ipatropiumbromide)*
Augmentin, XR (amoxicillin/clavulanic acid)*
Auralgan (antipyrine/benzocaine)*
Avandamet
Avandaryl
Avandia
Avinza
Avodart
Axid (nizatidine)*
Aygestin (norethindrone)*
Azasan
AzaSite
Azilect
Azopt
Azulfidine, Entabs (sulfasalazine, EC)*

B

Bactrim DS (Sulfamethoxazole/trimethoprim, DS)*
Bactroban
Baraclude
Benadryl (diphenhydramine 50mg)*
Bentyl (dicyclomine)*
Benzac, AC, W (benzoyl peroxide)*
Benzaclin (benxoyl peroxide/clindamycin)*
Benzagel, Wash
(benzoyl peroxide)*
Benzamycin (benzoyl peroxide/erythromycin)*
Betagan (levobunolol)*
Betimol
Betoptic S
Biaxin, XL (clarithromycin, er)*
Bicitra (sodium citrate & citric acid)*
BiDil
Bleph-10 (sulfacetamide-sodium solution)*
Blephamide
Brethine (terbutaline)*
Bumex (bumetanide)*
Buspar (buspirone)*
Byetta

C

Cafergot
Canasa
Cardizem, CD, LA, SR (diltiazem)*
Casodex (bicalutamide)*
Catapres, TTS (clonidine)*
Colazol
colchicine
Colyte (polyethylene glycol-electrolyte solution)*
CombiPatch
Combipres (clonidine/chlorthalidone)*
Combivent
Combivir
Compazine Supp 25mg (prochlorperazine supp 25mg)*
Compazine Tab (prochlorperazine)*
Comtan
Concerta
Condylox Solution (podofilox solution)*
Cordarone (amiodarone)*
Coreg (carvedilol)*
Coreg CR
Corgard (nadolol)*
Cortef (hydrocortisone)*
Cortenema (hydrocortisone enema)*
Cortifoam
Cortisporin Ophth (bacitracin - polymyxin/neomycin- hc opth oint)*
Cortisporin Otic (neomycin/polymixin/hydrocortisone)*
Cosopt (dorzolamide/timolol)*
Coumadin (warfarin)
Cozaar (losartan)*
Creon
Crestor
Crixivan
Crolom (cromolyn sodium)*
Cuprimine
Cyclocort (amcinonide)*
Cyclogyl (cyclopentolate)*
Cylert (pemoline)*
Cymbalta
cyproheptadine
Cytomel (liothyronine)*
Cytotec (misoprostol)*
Cytovene (ganciclovir)*
Cytoxan (cyclophosphamide)*
Cytra-2, Cytra-3
Cytra-K

D

Dalmane (flurazepam)*
Danocrine (danazol)*
Dantrium (dantrolene)*
Dapsone
Daraprim
Darvocet-N (propoxyphene/APAP)*
Darvon Compound (propoxyphene/aspirin/caffeine)*
Daypro (oxaprozin)*
DDAVP (desmopressin acetate)*
Decadron (dexamethasone)*
Deconamine S.R. (chlorpheniramine/pseudoephedrine)*
Demadex (torsemide)*
Demerol (meperidine)*
Demulen 28 day (ethinyl estradiol/ethynodiol diacetate-zovia)*
Depakene (valproic acid)*
Depakote (divalproex)
Depakote ER
Depo-Provera 150mg (medroxyprogesterone)*
Derma-Smoothe/FS
Desogen (apri)*
Desowen Cream (desonide)*
Desoxyn (methamphetamine)*
Desquam, E, X (benzoyl peroxide)*
Desyrel (trazodone)*
Detrol, LA
Dexedrine, CR (dextroamphetamine)*
Dextrostat (dextroamphetamine)*
Diabeta (glyburide)*
Diamox (acetazolamide)*
Diastat†
Dibenzyline
Differin (adapalene)†
Diflucan (fluconazole)*
diflunisal
Dilacor XR
(diltiazem CR)*
Dilantin (phenytoin)
Dilaudid (hydromorphone)*
diltia XT
Diovan
Diovan HCT
Diprolene Ointment (betamet diprop/
prop gyl)*
Diprosone (betamethasone dipropionate)*
Disalcid (salsalate)*
Ditropan (oxybutynin)*
Dolophine (methadone)*
Domeboro (acetic acid/aluminum acetate)*
Donnatal (belladonna/phenobarbital)*
Dostinex (cabergoline)*
Dovonex cream
Dovonex soln (calcipotriene)*
Duac CS
Duetact
Dulera
Duragesic (fentanyl)*
Duratuss G
(guaifenesin SR)*
Duricef Caps/Tabs (cefadroxil)*
Dyazide (triamterene/HCTZ)*
Dynacin (minocycline)*
Dynapen (dicloxacillin)*

E

E.E.S. (erythromycin ethylsuccinate)*
EC-Naprosyn
(naproxen EC)*
Econopred Plus 1% Eye Drops (prednisolone)*
Effexor (velafaxine)*
Effexor XR (velafaxine ER)†
Effient
Efudex (fluorouracil)*
Eldepryl (selegiline)*
Elidel
Elimite (permethrin)*
Elixophyllin (theophylline syrup)*
Elocon (mometasone)*
Emcyt
Empirin w/Cod (asa/codeine)*
Emtriva
Endal HD (phenyleph hcl/hydrocod bit/cp)*
Entex PSE (guaifenesin/pseudoephedrine)*
Entocort EC
Epifrin (epinephrine HCl)*
Epipen, JR
Epivir
Eryc (erythromycin base)*
Erycette 2% Pledgets (erythromycin)*
Eryderm 2% Topical Solution (erythromycin)*
Erymax 2% Topical Solution (erythromycin)*
EryPed 200 Susp (erythromycin ethylsuccinate)*
Esgic (acetaminophen/caffeine/butalb)*
Eskalith, CR (lithium)*
Estrace (estradiol)*
Estraderm
Estring
Ethmozine
Eulexin (flutamide)*
Evamist
Evista
Evoxac
Exelon (rivastgmine)†
Exforge, HCT

F

Famvir (famciclovir)*
Fansidar
Fast Take Product Line
FazoClo ODT
Felbatol
Feldene (piroxicam)*
Femara†
Fem HRT
Fibricor (fenofibric acid)*
Finacea
Fioricet (APAP/caffeine/butalbital)*
Fiorinal (aspirin/caffeine/butalbital)*
Fiorinal w/Codeine (butalbital compound
w/codeine)*
Flagyl (metronidazole)*
Flexeril (cyclobenzaprine)*
Flomax (tamsulosin)†
Flonase (fluticasone)*
Florinef (fludrocortisone)*
Flovent HFA
Floxin Otic (ofloxacin)*
Floxin tablet (ofloxacin)*
Fluoroplex
fluvoxamine
FML Forte
FML Liquifilm (fluorometholone)*
Folate (folic acid)*
Foradil
Fosamax (alendronate)*
Fosamax Solution
Fosrenol
Furadantin
Furoxone
Fuzeon

G

Gabitril
Gantrisin
Garamycin (gentamicin)*
Gel-Kam Gel (stannous fluoride)*
Geodon
Gleevec
Glucagon
Glucophage (metformin)*
Glucophage XR (metformin ER)*
Glucotrol XL (glipizide XL)*
Glucovance (glyburide/metformin)*
Glynase PresTab (glyburide micronized)*
Glyset
Golytely Solution (PEG– electrolyte for solution)*
Granulex (trypsin/balsam peru/castor oil)*
Gynodiol (estradiol)*

H

Halcion (triazolam)*
Halflytely
haloperidol
Hectorol
Histussin HC (phenyleph/chlorphen/hydrocodone)*
Humalog
Humibid DM (dextromethorphan/guaifenesin)*
Humibid LA (guaifenesin)*
Humulin R, N, 50/50, 70/30
Hycodan Syrup (hydrocodone
w/homatropine)*
Hydrea (hydroxyurea)*
hydrochlorothiazide
Hytone (hydrocortisone 2.5% cream, ointment, lotion)*
Hytrin (terazosin)*
Hyzaar (losartan/hctz)*

I, J

Ilotycin (erythromycin)*
Imdur (isosorbide mononitrate)*
Imitrex (sumatriptan tab & inj)*
Imitrex Nasal Spray
Imodium (loperamide)*
Imuran (azathioprine)*
Inderal (propranolol)*
Inderal LA
(propranolol la)*
Inderide (propranolol/HCTZ)*
Indocin, SR
(indomethacin, SR)*
Inflamase Mild, Forte (prednisolone)*
Intal Inhaler
Intal Solution (cromolyn)*
Invirase
ISMO (isosorbide mononitrate)*
isoniazid
Isoptin, SR
(verapamil, SR)*
Isopto Atropine
(atropine sulfate)*
Isopto Carpine
(pilocarpine HCl)*
Isopto Homatropine (homatropine)*
isosorbide dinitrate
Jalyn
Janumet
Januvia

K

K-Lor (potassium chloride 20mEq)*
K-Lyte CL (potassium bicar/chloride 25mEq)
K-Phos
K-Phos Neutral
(phospha 250)*
K-Tab (potassium chloride sr)*
Kaletra
Kayexalate (sodium polystyrene sulfonate)*
Keflex (cephalexin)*
Kenalog in Orabase (triamcinolone acetonide)*
Keppra (levetiracetam)
Keppra XR
Kerlone (betaxolol)*
Klonopin (clonazepam)*
Klor-con
Kuzyme
Kytril (granisetron)*

L

Lamictal chewables 2mg
Lamictal chewables
5 & 25mg (lamotrigine)*
Lamictal tabs (lamotrigine)
Lamisil tablet (terbinafine)*
Lanoxin
Lanoxicaps
Lantus
Lariam (mefloquine)*
Lasix (furosemide)*
leflunimide
leucovorin
Leukeran
Leukine
Levaquin
Levbid (hyoscyamine)*
Levemir
Levlen (levonorgestrel & ethinyl estradiol)*
Levo-Dromoran (levorphanol tartrate)*
levora
Levothroid
Levoxyl
Levsin (hyoscyamine)*
Levsinex (hyoscyamine)*
Lexapro
Lexiva
Lialda
Librium (chlordiazepoxide)*
Lidex, E (fluocinonide)*
Lidoderm
Limbitrol DS (amitriptyline/chlordiazepoxide)*
Lioresal (baclofen)*
Lipitor
Lithobid (lithium)*
Lo/Ovral (low-ogestrel)*
Lodine (etodolac)*
Lodine XL (etodolac ER)*
Loestrin FE (microgestin 1-20, 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)*
Lotemax
Lotensin (benazepril)*
Lotensin HCT
(benazepril HCTZ)*
Lotrel 2.5/10, 5/10, 5/20 & 10/20 (amlodipine/benazepril)*
Lorel 5/40 & 10/40mg
Lotrisone (clotrimazole/betamethasone)*
Lovaza
Lovenox (enoxaparin)*
Loxitane (loxapine)*
Lozol (indapamide)*
Lufyllin (dyphylline)*
Lupron (leuprolide)*
Lumigan
Luride (sodium flouride)*

M

Macrobid (nitrofurantoin mono)*
Macrodantin (nitrofurantoin)*
Marinol (dronabinol)*
Materna (multi-vitamins w/folic acid)*
Matulane
Mavik (trandolapril)*
Maxalt, MLT
Maxidex
Maxitrol (neomycin/polymyxin/dexamethasone)*
Maxzide (triamterene/HCTZ)*
Mebaral (mephobarbital)*
Meclomen (meclofenamate)*
Medrol 4mg, 8mg (methylprednisolone)*
Medrol 2 mg, 16mg, 32mg
Megace (megestrol)*
Mellaril (thioridazine)*
Menest
meperidine w/promethazine
Mephyton
Mepron
Mestinon timespan
Metaglip (glipizide/metformin)*
methyclothiazide
MetroCream (metronidazole)*
MetroGel
MetroGel Vaginal (metronidazole vag)*
Metrolotion
(metronidazole lot)*
Mevacor (lovastatin)*
Mexitil (mexiletine)*
Micro-K (potassium chloride)*
Micronase (glyburide)*
Microzide (hydrochlorothiazide caps)*
Midamor (amiloride)*
Midrin (isometh/dichlphen/APAP)*
Minipress (prazosin)*
Minocin Capsule (minocycline)*
Mintezol
Miralax (glycolax)*
Mirapex (pramipexole)*
Mircette (kariva)*
Mobic (meloxicam)*
Modicon (ethinyl estradiol/norethindrone)*
Monistat-Derm (miconazole nitrate)*
Monodox (doxycycline monohydrate)*
Monoket (isosorbide mononitrate)*
Monopril (fosinopril)*
Motrin (ibuprofen)*
MS Contin (morphine SR)*
MSIR (morphine sulfate)*
Mucomyst (acetylcysteine)*
Myambutol (ethambutol)*
Mycobutin
Mycolog II (nystatin/triamcinolone)*
Mycostatin (nystatin)*
Mydriacyl (tropicamide)*
Myleran
Mysoline (primidone)*

N

Naldecon (decongestabs)*
Nalfon 600mg (fenoprofen)*
Namenda
Naprosyn (naproxen)*
Nardil
Nasarel (flunisolide)*
Nasonex
Natafort (prenatal vitamin)*
Natalins (prenatal multivitamins and minerals/iron/fa)*
Navane (thiothixene)*
Nebupent
necon
NeoDecadron (neomycin/dexamethasone)*
neomycin
Neoral
Neosporin soln (neomycin/polymyxin/gramicidin)*
Neosporin oint (neomycin/polymyxin/bacitracin)*
NeoSynephrine (phenylephrine)*
Neptazane (methazolamide)*
Neurontin (gabapentin)*
Neurontin Soln
Nexium
Niaspan
Niferex-150 Forte (iron/B12/folic acid)*
Nilandron
Nitro-Bid (nitroglycerin SR)*
Nitro-Dur
Nitrol (nitroglycerin ointment)*
Nitrolingual spray
Nitrostat (nitroglycerin)*
Nizoral (ketoconazole)*
Noctec (chloral hydrate)*
Nolvadex (tamoxifen)*
Nor-QD (norethindrone)*
Nordette (levora)*
Norflex (orphenadrine)*
Norgesic (orphenadrine cpd)*
Norgesic Forte (orphenadrine cpd Forte)*
Norinyl (necon)*
Normodyne (labetalol)*
Norpace (disopyramide)*
Norpace CR 100mg
Norpace CR 150mg (disopyramide CR 150mg)*
Norpramin (desipramine)*
nortriptyline
Norvasc (amlodipine)*
Norvir
Novafed A (pseudo-ephedrine hcl/chlor-mal)*
NuLev (neosol)*
Nuvigil
Nystatin

O

Ocufen (flurbiprofen sodium)*
Ocuflox (ofloxacin)*
Ocupress (carteolol hcl)*
Oforta
Ogen (estropipate)*
Omnicef (cefdinir)*
Omnipen (ampicillin)*
One Touch Product Line
Onglyza
Opticrom (cromolyn)*
Optivar^ (azelastine)*
Orencia*
Ortho-Cept (apri, reclipsen)*
Ortho-Est (estropipate)*
Ortho Evra
Ortho-Novum (necon)*
Ortho Tri-Cyclen (tri-nessa)*
Ortho Tri-Cyclen Lo
Orudis (ketoprofen)*
Oruvail (ketoprofen SA)*
Ovral (ogestrel)*
OxyContin (oxycodone ER)

P

Pamelor (nortriptyline)*
Pancrease
Panoxyl, AQ (benzoyl peroxide)*
Parafon Forte (chlorzoxazone)*
Paregoric
Parlodel Tab (bromocriptine)*
Parnate (tranylcypromine)*
Pataday
Patanol
Paxil (paroxetine)*
Paxil CR (paroxetine SR)*
Pediapred (prednisolone sodium prosphate)*
Pediazole (erythromycin/sulfisoxazole)*
Pentam (pentamidine isethionate)*
Pentasa
Pepcid (famotidine)*
Percocet (oxycodone/APAP)*
Percodan (oxycodone/aspirin)*
Perforomist
Peridex (chlorhexidine gluconate)*
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)*
phenobarbital
Phoslo (calcium acetate)*
Pilocar (pilocarpine HCl)*
pindolol
Plan B 0.75mg (levonorgestrel)*
Plan B 1.5mg
Plaquenil (hydroxychloroquine)*
Plavix
Plexion SCT
Plexion TS (sulfacet sod w/sulfur10/5%)*
Poly-Vi-Flor (multi-vitamins w/fluoride)*
Polycitra (potassium citrate-citric acid)*
Polycitra-K (Pot. & Sod. Citrates w/citric acid)*
Polysporin (bacitracin zinc/polymyxin B)*
Polytrim (polymyxin B/trimethoprim)*
Potaba Tab (aminobenzoate tab)*
potassium chloride
Pramosone 1% cream only, lotion, oint
Prandin
Pravachol (pravastatin)*
Precose (acarbose)*
Pred Forte 1% (prednisolone)*
prednisone
Pred Mild 0.12%
Prelone (prednisolone)*
Premarin oral, vaginal cream
Premphase
Prempro
Prenate Advance
(prenatal w/docusate,
iron, folic acid)*
Prenate Elite
Prenate Ultra (multi-vitamins w/folic acid)*
Prevacid^ (lansoprazole)*
Prevident (sodium fluoride)*
Priftin
Prilosec^ (omeprazole)*
Primaquine
Prinivil (lisinopril)*
Prinzide (lisinopril/hctz)*
Pristiq
ProAmatine (midodrine)*
ProAir HFA
Pro-Banthine (propantheline)*
probenecid
Procanbid
Procardia (nifedipine)*
Procardia XL (nifedipine ER)*
Proctocort (hydrocortisone)*
Proctocream-HC (hemorhoidal cream)*
Profasi 10,000 (chorionic gonadotropin)*
Prograf (tacrolimus)
Prolixin (fluphenazine)*
Proloprim (trimethoprim)*
Prometrium
Pronestyl, SR
(procainamide, SR)*
Propine (dipivefrin HCl)*
propylthiouracil
Proscar (finasteride)*
Protonix^ (pantoprazole)*
Protopic
Proventil HFA
Proventil, Tab, Syrup (albuterol)*
Provera (medroxy-progesterone)*
Prozac (fluoxetine)*
Psorcon (diflorasone diacetate)*
Pulmicort Respules
Purinethol (mercaptopurine)*
pyrazinamide
Pyridium (phenazopyridine)*

Q

Questran, Lite (cholestyramine, light)*
Quinaglute (quinidine gluconate)*

Quinidex (quinidine sulfate)*

R

Ranexa
Razadyne, ER
(galantamine, sr)*
Rebetol (ribavirin)*
Reglan (metoclopramide)*
Relafen (nabumetone)*
Remeron, SolTab (mirtazapine)*
Remicade*
Renagel
Renvela tab
Requip* (ropinirole)
Rescriptor
Restasis
Restoril (temazepam)*
Retin-A Cream (tretinoin)*
Retin-A Gel (tretinoin)*
Retin-A Micro
Retrovir (zidovudine)
Revia (naltrexone hcl)*
Reyataz
Rheumatrex Tablets (methotrexate tablets)*
Ridaura
Rifadin (rifampin)*
Rifamate
Rifater
Rilutek
Risperdal (risperidone)*
Risperdal Consta
Risperdal 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-cpd w/carbetapentane)*
Rythmol (propafenone)*

S

Salagen (pilocarpine)*
Sanctura (trospium)*
Sandimmune*
Sandostatin (octreotide acetate)*
Savella
Seasonale (jolessa, quasense)*
Sectral (acebutolol)*
Selsun (selenium sulfide)*
Septra, DS (sulfamethoxazole/trimethoprim, DS)*
Serax (oxazepam)*
Serevent Diskus
Serophene (clomiphene)*
Seroquel, XR
Silvadene (silver sulfadiazine)*
Sinemet (carbidopa/levodopa)*
Sinemet CR (carbidopa/levodopa CR)*
Sinequan (doxepin)*
Singulair
Skelaxin (metaxolone)†
Slo-Bid (theophylline)*
Slo-Phyllin 80 Syrup (theophylline anhydrosl)*
Sodium Sulamyd (sulfacetamide solution)*
Solaquin Forte (hydroquinone)*
Soma (carisoprodol)*
Somavert
Somophyllin (aminophylline)*
Sonata (zaleplon)*
Sorbitrate (isosorbide dinitrate)*
Spectazole (econazole)*
Spectracef (cefditoren)*
Spiriva
Sporanox (itraconazole)*
Stadol N.S. (butorphanol tartrate 10 mg/ml N.S.)*
Starlix (nateglinide)
Stelazine (trifluoperazine)*
Strattera
Suboxone SL tab, SL film
Subutex (buprenorphine)*
Sular 20, 30 & 40mg (nisoldipine)*
Sular 8.5, 17, 25.5 & 34mg
Sulfacet-R (sodium sulfacetamide/sulfur)*
Sultrin (triple sulfa)*
Sustiva
Symbicort
Symbyax
Symlin
Symmetrel (amantadine)*
Synalar (fluocinolone acetonide)*
Synthroid
(levothyroxine)

T

Tagamet (cimetidine)*
Talacen (pentazocine/apap)*
Talwin NX
(pentazocine nx)*
Tambocor (flecainide)*
Tarka (trandolapril/verapamil)*
Tavist syrup, 2.68mg tabs (clemastine fumarate)*
Tazorac
Tegretol (carbamazepine)
Tegretol XR
(carbamazepine ER)
Tekturna, HCT
Temodar†
Temovate (clobetasol)*
Tenex (guanfacine)*
Tenoretic (atenolol/chlorthalidone)*
Tenormin (atenolol)*
Terazol (terconazole)*
Teslac
Tessalon Perles (benzonatate)*
Testim
Theo-24
Theochron (theophylline)*
Thorazine Tab (chlorpromazine tab)*
Ticlid (ticlopidine)*
Tigan (trimethobenzamide)*
Tilade
Timoptic (timololophthalmic)*
Timoptic XE (timolol)*
Tobi
Tobradex oint.
Tobradex susp. (tobramycin/dexamethasone)*
Tobrex Soln (tobramycin)*
Tofranil (imipramine)*
Tolectin (tolmetin)*
Topamax
Topicort (desoximetasone)*
Toprol XL (metoprolol)*
Toradol (ketorolac tromethamine)*
Toviaz
Trandate (labetalol)*
Transderm-Scop
Tranxene (clorazepate)*
Trental (pentoxifylline)*
Treximet
Tricor (fenofibrate)*
TriLeven (levo norgestrel)*
Tri-Vi-Flor (triple vitamins
w/fluoride)*
Tridesilon (desonide)*
Trilafon (perphenazine)*
Trileptal (oxcarbazepine)*
Trilipix
Trimox (amoxicillin)*
Trimpex (trimethoprim)*
Trinsicon (iron/intrinsic factor/B12)*
Triphasil (trivora)*
Trizivir
Trusopt (dorzolamide)*
Tussi-12 (phenyleph/chlorphen/carbeta)*
Tussi-Organidin NR (guaifenesin/codeine)*
Tussi-Organidin NR DM (guaifenesin/dextromethorphan)*
TussiCaps
Tussionex Pennkinetic ER
Twinject
Tylenol w/Cod
(codeine/APAP)*
Tylox (oxycodone
w/acetaminophen)*
Tympagesic (pramoxine/hc/chloroxylenol)*

U

Ultracet (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 (potassium citrate)*
Urogesic Blue (methenamine/hyosc-meth blue/sod biphos-phenyl sal)*
Uroxatral

V

V-Cillin K (penicillin V.K.)*
Vagifem
Valcyte tabs
Valisone (betamethasone valerate)*
Valium (diazepam)*
Valtrex (valacyclovir)†
Vantin (cefpodoxime)*
Vaseretic (enalapril/hydrochlorothiazide)*
Vasocidin (sulfacetamide sodium-prednisolone
ophth sol.)*
Vasocon (naphazoline)*
Vasotec (enalapril)*
Veltin
Venlafaxine ER (velafaxine er)†
Vepesid (etoposide)*
Veramyst
Verelan (verapamil SR)*
Vermox (mebendazole)*
VESIcare
Vibramycin (doxycycline)*
Vicodin (hydrocodone/APAP)*
Vicodin E.S. (hydrocodone/apap)*
Videx
Videx EC (didanosine)*
Vigamox
Viokase
Viracept
Viramune
Viread
Viroptic (trifluridine)*
Vistaril (hydroxyzine pamoate)*
Vivelle
Vivelle Dot
Voltaren Gel
Voltaren Ophth
(diclofenac sodium)*
Voltaren, XR
(diclofenac, ER)*
Vosol (acetic acid)*
Vosol HC (acetic acid/hydrocortisone)*
Vyvanse

W, X

Welchol
Wellbutrin, SR (bupropion)*
Wellbutrin XL
(budeprion XL)*
Westcort (hydrocortisone)*
Xalatan†
Xanax (alprazolam)*
Xeloda
Xopenex Neb Soln
1.25/0.5ml (levalbuterol)*
Xopenex Neb Soln
except 1.25/0.5ml
Xylocaine (lidocaine)*
Xylocaine viscous
(lidocaine viscous)*

Y, Z

Yasmin (ocella)*
Yaz (gianvi)†
Yodoxin
Yocon (yohimbine)*
Zanaflex (tizanidine)*
Zantac (ranitidine)*
Zarontin
(ethosuximide)*
Zaroxolyn (metolazone)*
Zebeta (bisoprolol)*
Zegerid^ (omeprazole/bicarb)*
Zenate (multi-vitamins
w/folic acid)*
Zephrex LA (pseudo-ephedrine/guaifenesin)*
Zerit (stavudine)*
Zestril (lisinopril)*
Zestoretic (lisinopril/hctz)*
Zetacet (sulfacetsod
w/sulfur 10/5%)*
Ziac (bisoprolol/HCTZ)*
Ziagen
Zithromax (azithromycin)*
Zocor (simvastatin)*
Zofran (ondansetron)*
Zoloft (sertraline)*
Zomig, ZMT
Zonegran (zonisamide)*
Zortress
zovia
Zovirax Cap (acyclovir)*
Zovirax Oint
Zylet
Zyloprim (allopurinol)*
Zyprexa
 
 
 
 

Formulary Key

 
Generic Medications
– (lowest copay) — listed in all lower-case letters
 

Brand-name Medications – (middle copay) — listed with a leading capital letter
 

– A generic equivalent of this drug has become available or will be available soon. After the generic drug becomes available and notification requirements are met, this brand-name drug will become non-formulary/Tier 3 or may no longer be covered by your prescription drug plan. Check with anthem.com to find out about changes in formulary status.

* – Brand versions of these drugs are non-formulary (highest copay)

^ – This product has clinically equivalent alternatives included on the formulary and, as a consequence, such product may not be covered under your pharmacy benefit. Check anthem.com for details.
 
# – Non-formulary in Indiana only
 
 
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Anthem Health Insurance
You may also Download the Anthem Drug Formulary in PDF document format.






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