Depauw.edu
Prescription
Program
Drug List — To be used by members
who have a tiered drug plan.
Anthem Blue Cross Blue Shield 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.
ANTHEM BLUE CROSS AND BLUE SHIELD DRUG LISTYour prescription drug benefit includes coverage for medicines that you’ll find on the Anthem Drug List. You can often find more savings when your doctor prescribes medicine that is on our drug list. Here are some commonly asked questions and answers about how the drug list works with your prescription drug plan.
For more information
about your drug plan,
A. The Anthem Drug List, also called a formulary is a list of U.S. Food and Drug Administration
you can do the following:
(FDA)-approved brand-name and generic drugs that have been reviewed and recommended for their quality and how well they work. The review is done by the National Pharmacy and
•
Go to anthem.com
Therapeutics (P&T) Process. The P&T Process is performed by an independent group of
•
Call customer service
practicing doctors and pharmacists in charge of the research and decisions surrounding
at the number on your
our drug list. This group meets regularly to review new and existing drugs and they choose the top drugs for our list—based on their safety, how they work and their value.
Because the drugs on our list are reviewed from time to time, it’s a good idea to check
•
Speech and hearing
the list to find out if any drugs have been added or removed. You can do this by going to
impaired users
(TDD/TTY) should call
800-221-6915, Monday
A. Drugs on the Anthem Drug List are grouped into tiers. There are several factors that are
– Friday, 8:30 a.m. –
used to determine under which tier a drug will be put in. This can include (but it’s not
5:00 p.m., ET
•
Bring a copy of this drug
• Cost of the drug in comparison to other drugs used for the same type of treatment
list to your next doctor’s
• Availability of over-the-counter options
visit to help you and
• Other clinical and cost factors.
your doctor select the
lowest cost medicine
A. These are drugs that are developed by a company who holds the rights to sell them.
When the rights expire, other drug companies can make their own version of the drugs (see generic drugs below). You may be more familiar with brand-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
KEY FOR DRUG LIST
Tier 1 – Lowest copayment – Drugs
Q.
What if my doctor or I choose a brand-name drug when a generic version is available?
that offer the greatest value compared to others that treat the same
A. In most cases, you would be responsible for the copay that’s listed on the tier the drug is
on. This copay may include an added charge for the cost difference between the brand-
name medication and the generic version.
Tier 2 – Medium copayment – Brand-
Q.
What are “clinically equivalent” medications? How does this affect my drug coverage?
A. When drugs are compared in studies, some drugs have been found to be 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 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
effects, if they’re more affordable, etc.
plan may not cover some drugs (indicated by a ^ symbol next to the drug name) that have
Tier 3 – Highest copayment – These are
Q.
What if my medication is not on the drug list?
Tier 3 drugs may have generic versions in Tier 1 and may cost more than the
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.
Tier 4 – Many drugs on this tier
are “specialty” drugs used to treat
Q.
Can I request that a drug be added to the drug list?
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 approved, it does not guarantee
coverage. Some drugs, such as those used for cosmetic purposes, may be excluded
from your benefits. Please refer to your insurance Certificate or Evidence of Coverage
to know for sure.
Gianvi
PA
norethindrone
PA
Atorvastatin
DO,
QL
Cartia XT
DO,
QL
Aviane
PA
ethynodiol diacetate
PA Glyburide micronized
Azelastine
QL
Diclofenac sodium Ophth. norethindrone
PA
Azelastine nasal
QL
Granisetron
QL
Azithromycin
QL
Bacitracin zinc/polymyxin B Cefuroxime
QL
Alendronate
QL
Diltia XT
DO,
QL
Felodopine
DO,
QL
Diltiazem CD
DO,
QL
Diltiazem CR
DO,
QL
Diltiazem SR
DO,
QL
Amethia
PA
Diphenhydramine 50mg Fentanyl
PA,
QL
Amethia lo
PA
Diphenoxylate/atropine Fexofenadine
QL
Hydrocodone/APAP
QL
Ciprofloxacin
QL
Citalopram
DO,
QL
atorvastatin
DO
Fluoxetine
DO,
QL
Amnesteem
QL
Budeprion XL
DO,
QL
Budesonide
QL
Buprenorphine
QL
Imiquimod
QL
Codeine/APAP
QL
Eprosartan
QL
Fluvoxamine
DO
soln/nasal spray
QL
10mg/ml N.S.
QL
Fosinopril
DO,
QL
Calcipotriene Oint & Soln. Cyclophosphamide
APAP/caffeine/butalbital Camrese
PA
Isotretinoin
QL
Itraconazole
PA
Propoxyphene/APAP
QL
spray and inj.
QL
Ketorolac
QL
Nifedipine ER
DO,
QL
Leuprolide
PA*
Levocetirizine
QL
Levofloxacin
QL
Ocella
PA
Ofloxacin
QL
estradiol
PA
Microgestin
PA
Omeprazole
QL
Omeprazole/bicarb
QL
Ondansetron
QL
Tramadol, ER
QL
Tramadol/APAP
QL
Sertraline
DO,
QL
Pravastatin
DO,
QL
Simvastatin
DO,
QL,
PA – 80mg only
Morphine ER
QL
Tretinoin
PA
Losartan
DO,
QL
Multivitamins w/fluoride Oxycodone ER
QL
Losartan/HCTZ
DO,
QL
Multivitamins w/folic acid Oxycodone/APAP
QL
Lovastatin
DO,
QL
Oxymorphone
QL
Sotret
QL
Pantoprazole
QL
Paroxetine, SR
DO,
QL
Pentamidine isethionate Probenecid/colchicine
Tri-nessa
PA
Naratriptan
QL
Meloxicam
QL
Trivora
PA
Exforge HCT
DO,
QL
Testim
PA,
QL
Thalomid
PA
Maxalt, MLT
QL†
Flovent, HFA
QL
Pristiq
DO,
QL
Colcrys
QL
Medrol 2mg, 16mg, 32mg ProAir HFA
QL
Trilipix
QL
Zaleplon
ST,
QL
Combivent
QL
Foradil
QL
Protopic
ST
Zolpidem, ER
QL
Fosamax Plus D
QL
Proventil HFA
QL
Fosamax solution
QL
Pulmicort Respules
QL†
Valturna
DO,
QL
Crestor
DO,
QL
Veramyst
QL
Accu-chek Product Line
QL Cuprimine
Nasonex
QL
Actonel
QL
Cymbalta
DO,
QL
Actonel with Calcium
QL
Gleevec
PA
Retin-A Micro
PA
ActoPlus Met, XR
QL
Nexavar
PA
Nexium
QL
Advair Diskus, HFA
QL
Advicor
DO
Vyvanse
PA
Xeloda
PA
Savella
QL
Diovan
DO,
QL
Serevent Diskus
QL
Diovan HCT
DO,
QL
Iressa
PA
Androgel
PA,
QL
Singulair
QL
Janumet
QL
Nuvigil
PA,
QL
Spiriva
QL
Duetact
QL
Januvia
QL
Oforta
PA
Sprycel
PA
Dulera
QL
One Touch Product Line
QL Strattera
Durezol
QL
Onglyza
DO,
QL
Suboxone SL Tab
ST,
Asmanex
QL
Kombiglyze
QL
Ortho Evra
PA
SL Film
PA,
QL
Astepro
QL
Effient
DO,
QL
Ortho Tri-Cyclen Lo
PA
Atrovent HFA
QL
Elidel
ST
OxyContin
QL
Sutent
PA
Avinza
QL
Symbicort
QL
Abstral
PA,
QL
Perforomist
QL
Plan B 1.5mg
QL
Tamiflu
QL
Plavix
QL†
Tarceva
PA
Aciphex
ST,
QL^
Leukine
PA*
Actemra
PA*
Pradaxa
QL
Acthar HP
PA,
QL*
Pramosone 1% cream only, Tekturna, HCT
DO,
QL
Lexapro
DO,
QL†
Temodar
PA
Activella
PA
Byetta
ST,
QL
Exforge
DO,
QL
Actiq
PA,
QL
Axiron
PA,
QL
Oxytrol
ST
Azor
DO,
QL
Adcirca
PA
Beconase AQ
ST,
QL
Forteo
PA,
QL*
Lunesta
QL
Benicar, HCT
DO,
QL
Fortesta
PA,
QL
Lupron Depot
PA*
Patanase
QL
Aerobid, M
QL
Benzaclin
ST
Kapidex)
ST,
QL
Fosamax tablets
QL
Aggrenox
QL
Bepreve
ST,
QL^
Lyrica
PA
Pataday
ST,
QL^
Alamast
ST,
QL^
Frova
ST,
QL
Makena
PA*
Patanol
ST,
QL^
Aldara
QL
Betaseron
ST*
Paxil CR
DO,
QL
Gelnique
ST
Pegasys
PA,
QL*
Allegra, D
ST,
QL^
Boniva
ST,
QL
Genotropin
PA,
QL*
Peg-Intron
PA*
Alocril
ST,
QL^
Brilinta
QL
Gilenya
ST,
QL*
Maxair
QL
Alomide
ST,
QL^
Maxaquin
QL
Caduet
DO
Plan B 0.75mg
QL
Cambia
QL
Alsuma
ST,
QL
Edarbi
DO,
QL
Miacalcin Spray
QL
Altoprev
ST,
DO
Edex
PA,
QL
Micardis, HCT
DO,
QL
Edluar SL
ST
Humatrope
PA,
QL*
Migranal
QL
Alvesco
QL
Cardizem CD, LA
DO,
QL Effexor, XR
DO,
QL
Humira
PA,
QL*
Ambien
QL
Elestat
ST,
QL^
Hybolin
PA
Ambien CR
ST,
QL
Hyzaar
DO,
QL
Amerge
QL
Prevacid
ST,
QL^
Amevive
PA*
Caverject
PA,
QL
Emadine
ST,
QL^
Imitrex
QL
Morgidox
ST
Prevpac
QL
Embeda
QL
Imitrex Nasal Spray
QL
Prilosec
ST,
QL^
Ampyra
PA,
QL*
Ceftin
QL
Incivek
PA*
Primaxin
QL
Anadrol-50
PA
Celebrex
ST,
QL
Enablex
ST
Infergen*
PA
Androderm
ST,
PA,
QL
Enbrel
PA,
QL*
Android
PA
Intron A
PA*
Procrit
PA*
Prolia
PA,
QL*
Cialis
PA,
QL
Epogen
PA*
Nasacort AQ
ST,
QL
Anzemet
QL
Cimzia
PA,
QL*
Nasarel
QL
Protonix
ST,
QL^
Apidra
ST
Cipro XR
QL
Neulasta
PA,
QL*
Provigil
PA,
QL
Aplenzin
DO,
QL
Clarinex, D
ST,
QL^
Kadian
QL
Neumega
PA*
Prozac, Weekly
QL
Neupogen
PA*
Pulmicort Flexhaler
QL
Kineret
PA*
Aranesp
PA*
Exalgo
ST
Qualaquin
PA,
QL
Arcapta
QL
Kytril
QL
Norditropin
PA,
QL*
Raptiva
PA
Lamictal chew 5 & 25mg, Noroxin
QL
Extavia
ST*
Norvasc
DO,
QL
Factive
QL
Nucynta, ER
QL
Relenza
QL
Nutropin, AQ
PA,
QL*
Relpax
ST,
QL
Arthrotec
ST
Lastacaft
ST,
QL^
Nuvaring
PA,
QL
Remicade
PA*
Astelin
QL
Atacand
DO,
QL
Lazanda
PA,
QL
Omnaris
ST,
QL
Atacand HCT
DO,
QL
Lescol, XL
ST,
DO,
QL
Revatio
PA,
QL
Augmentin, XR
QL
Fentora
PA,
QL
Levaquin
QL
Omnitrope
PA,
QL*
Avalide
DO,
QL
Covera HS
DO
Levitra
PA,
QL
Onsolis
PA,
QL
Avandamet
ST,
QL
Cozaar
DO,
QL
Lipitor
DO,
QL
Rhinocort Aqua
ST,
QL
Avandaryl
ST,
QL
Opana ER
QL
Roxicet
QL
Avandia
ST,
QL
Flector
ST
Livalo
ST,
DO,
QL
Optivar
ST,
QL^
Rozerem
ST,
QL
Avapro
DO,
QL
Avelox
QL
Flonase
QL
Orencia
PA,
QL*
Ryzolt
QL
Ovidrel
PA*
Saizen
PA,
QL*
Axert
ST,
QL
Oxandrin
PA
Sanctura, XR
ST
Sancuso
QL
Zorbtive
PA,
QL*
Enbrel
PA,
QL
Neupogen
PA
Tiazac
DO,
QL
Viibryd
ST,
QL
Zyclara
QL
Epogen
PA
Norditropin
PA,
QL
Vimovo
QL
Sarafem
QL
Extavia
ST
Nutropin, AQ
PA,
QL
Seasonale
PA
Omnitrope
PA,
QL
Seasonique
PA
Toradol
QL
Zyvox
PA,
QL
Orencia
PA
Serostim
PA,
QL*
Vytorin
ST,
QL
Simcor
QL
Tradjenta
QL
Forteo
PA,
QL
Simponi
PA,
QL*
Treximet
ST,
QL
Wellbutrin XL
DO,
QL
Actemra
PA
Peg-Intron
PA
Winstrol
PA
Acthar HP
PA,
QL
Pegasys
PA,
QL
Genotropin
PA,
QL
Gilenya
PA,
QL
Procrit
PA
Amevive
PA
Sonata
ST,
QL
Xgeva
PA,
QL*
Ampyra
PA,
QL
Prolia
PA,
QL
Xifaxan
ST,
QL
Humatrope
PA,
QL
Xolair
PA*
Humira
PA,
QL
Remicade
PA
Sporanox Solution
PA
Xopenex HFA
QL
Aranesp
PA
Repronex
PA
Stadol
QL
Uloric
ST
Incivek
PA
Roferon-A
PA
Ultram, ER
QL
Increlex
PA
Xyzal
ST,
QL^
Infergen
PA
Striant
PA
Yasmin
PA
Subutex
QL
Caverject
PA,
QL
Intron-A
PA
Serostim
PA,
QL
Sular
DO,
QL
Zegerid
ST,
QL^
Simponi
PA,
QL
Sumavel Dosepro
ST,
QL Valcyte soln
Kineret
PA
Suprax
QL
Cimzia
PA,
QL
Leukine
PA
Stelara
PA,
QL
Leuprolide
PA
Synagis
PA
Zetia
ST,
QL
TevTropin
PA,
QL
Synarel
PA
Ventavis
PA
Zithromax
QL
Lupron, Depot
PA
Ventolin HFA
QL
Tekamlo
DO,
QL
Verelan PM
DO,
QL
Zocor
DO,
PA – 80mg
Makena
PA
Victrelis
PA*
Tequin
QL
Tekamlo
DO,
QL
Zofran
QL
Testopel
PA
Zoladex
PA
Vivaglobulin
PA
Testred
PA
Viagra
PA,
QL
Zoloft
DO,
QL
Edex
PA,
QL
Xgeva
PA,
QL
Teveten, HCT
DO,
QL
Victoza
ST,
QL
Zolpimist
ST,
QL
Neulasta
PA,
QL
Xolair
PA
Tev-Tropin
PA,
QL*
Victrelis
PA*
Zomig, ZMT
ST,
QL
Eligard
PA
Neumega
PA
Zorbtive
PA
KEY
# Non-formulary in Indiana only
† = A generic equivalent of this drug recently became available or will be available soon. After the generic drug becomes available and notification
requirements are met, this brand-name drug will become Tier 3 or may no longer be covered by your prescription drug plan. Check anthem.com to find out about changes in tier status.
^ = This product has clinically equivalent alternatives included on the drug list and, as a consequence, such product may not be covered under
your pharmacy benefit. Please consult your on-line pharmacy account through your health plan website, anthem.com, for details on coverage.
* = These drugs are Tier 3 for those members that do not have a Tier 4 plan.
PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may
be filled.
QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month.
ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized.
Please note: Foradil and Serevent are safety edits that prevent duplication of therapy.
DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.
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 Kentucky Residents Only:
In selecting medications for the prescription drug formulary, the therapeutic effi cacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the formulary by at least one medication. When a closed formulary is in effect, only medications that are included on the formulary are a covered service. In certain clinical situations, a member may require use of a non-formulary product. Anthem has criteria that permits a member to obtain a non-formulary medication in a closed formulary plan. If specifi c criteria are met, a member can receive a non-formulary drug for a formulary copay. The criteria preserves the clinical integrity of the drug formulary and provides a process by which deviations from the formulary may be allowed. An appeals process is in place for any medications that do not meet the criteria.
For more information, please visit anthem.com.
•
If you have additional questions about your prescription
benefi ts please call the Member Services number on your
ID card
•
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 anthem.com
•
Bring a copy of this drug list/formulary to your next doctor’s
visit to assist in selecting the lowest cost medications
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-HMO benefi ts underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees 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.
Source: http://www.depauw.edu/files/resources/formulary.pdf
Parcours universitaire Hochschule für Musik de Freiburg im Breisgau (Allemagne)Cursus de chant dans la classe de T. Sato-Schöllhorn et d’opéra auprès de Gerd Heinz et Alexander Schulin Diplômes obtenus: “ Künstlerische Ausbildung” : Double-diplôme artistique en chant mention Opéra et mention Lied/OratorioDiplôme de pédagogie en enseignement du chant. « Musiklehrer Diplom »
Georganiseerd Overleg Sector Defensie Technische Werkgroep Arbo & Veiligheid (TWAV) d.d. 17 september 2012 J. Tholenaar inlichtingen j.tholenaar@caop.nl 070-3765705 bijlagen TWAV/12.00740 nummer ZD.931.2 zaaknummer 9 oktober 2012 Verzenddatum Verslag van het overleg met de Technische Werkgroep Arbo + Veiligheid (TWAV) gehouden op 17 september 2012 in d