The following is a list of the most commonly prescribed drugs. It represents an abbreviated
version of the drug list (formulary) that is at the core of your pharmacy benefit plan. The list
is not all inclusive and does not guarantee coverage. In addition to using the list, you are
encouraged to ask your doctor to prescribe generic drugs whenever appropriate.
PLEASE NOTE: Drugs listed on this document may become non-Preferred if a generic
equivalent product becomes available throughout the year.* Not all the drugs listed are
covered by all pharmacy benefit programs. Check your benefit materials for the specific
drugs covered and the copay information for your pharmacy benefit program. For specific
2009 Pharmacy Services Formulary
questions about your coverage, please call the phone number printed on your ID card.
Examples of Non-Preferred Medications with Their Preferred Alternatives
The following is a list of some non-Preferred brand medications with examples of Preferred alternatives that are on the formulary. Column 1 lists examples of non-Preferred medications.
Column 2 lists some alternatives that can be prescribed. Thank you for your compliance.
Preferred Alternative
Preferred Alternative
benazepril, enalapril, lisinopril, ramipril benazepril, enalapril, lisinopril, ramipril citalopram, fluxotine (daily), paroxetine Key:
Brand name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
* all brand drugs will convert to non-Preferred status when generic is available throughout the year.
The symbol [inj] next to a drug indicates that the drug is available in injectable form only.
The symbol [PA] next to a drug stands for Prior Authorization, which is needed prior to coverage of this drug, plan dependent.
The symbol [ST] next to a drug name stands for Step Therapy which is in place on this drug, plan dependent.
The symbol [DQ] next to a drug stands for Drug Quantity, which is a limitation on amount dispensed.
For the member: Generic medications contain the same active ingredients as their corresponding brand name medications, although they may look different in color or shape. They have been FDA-
approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.
You can get more information and updates to this document at the EmblemHealth Web site at
Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York (HIPIC) and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.



Prescription Program Drug List — To be used by members (both National Accounts and Local Group), who have a tiered drug plan. Anthem Blue Cross 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 DRUG LISTYour prescription

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