Page 1 - Anthem PreventiveRx Plus Plan
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PreventiveRx Drug List:
PreventiveRx Plus Plan
PreventiveRx covers drugs that may keep you healthy because they may prevent illness and other health conditions.
You can get the products on this list at low or no cost to you depending on your benefit.
This list includes only prescription products. Brand-name drugs are listed with a fir st capital letter. Non-brand drugs (generics)
are in lowercase letters.
Most brand-name drugs that have a generic equivalent available are not covered under this Preventive Rx benefit.
All drugs* listed below are covered for plans with the National Drug List. If your plan has a different drug list, please check
to see if these drugs are included on your drug list. PreventiveRx Plus drugs are only covered if they are included on your
specific drug list.
*Some drugs may be excluded from your benefits. Please refer to your Certificate or Evidence for Coverage for coverage
limitations and exclusions.
Asthma Theochron Janumet XR amlodipine besylate
Advair theophylline Januvia amlodipine/ benazepril
Advair HFA Ventolin HFA Jardiance amlodipine/ olmesartan
albuterol sulfate zarfirlukast Jentadueto amlodipine/ valsartan
nebulization soln, syrup, Jentadueto XR amlodipine/ valsartan/ hctz
tabs Blood clots Juvisync atenolol
aminophylline Brilinta Lantus atenolol/ chlorthalidone
Arnuity Ellipta Coumadin Lantus Solostar Azor*
Asmanex Eliquis Levemir benazepril hcl
Asmanex HFA heparin Levemir Flexpen benazepril hcl/ hctz
Breo Ellipta warfarin Levemir FlexTouch Benicar
budesonide inhalation Xarelto metformin hcl Benicar HCT
suspension metformin hcl er betaxolol hcl
cromolyn sodium Diabetes miglitol Bidil
nebulization soln Diabetic supplies including nateglinide bisoprolol fumarate
difil- G blood glucose meters, test Novolin bisoprolol fumarate/ hctz
strips and lancets require a
Dulera prescription to be covered Novolog bumetanide
dyphylline/ guaifenesin by this plan. Only blood pioglitazone candesartan
elixophylline glucose meters & blood pioglitazone- glimepiride candesartan/ hctz
Flovent Diskus glucose test strips by pioglitazone- metformin captopril
Flovent HFA Lifescan & Roche will be repaglinide captopril/ hctz
Foradil covered by this benefit. repaglinide- metformin cartia xt
levalbuterol nebulization acarbose Symlin carvedilol
soln ActoPlusMet XR Synjardy chlorthiazide
metaproterenol sulfate Bydureon tolazamide chlorthalidone
syrup, tabs Byetta tolbutamide clonidine tabs, patches
montelukast chlorpropamide Toujeo Clorpres 0.1, 0.2mg
Perforomist glimepiride Tradjenta Coreg CR
ProAir HFA glipizide Trulicity digitek
ProAir RespiClick glipizide er/xl Victoza digoxin
Pulmicort Flexhaler glipizide with metformin hcl Dilatrate SR
QVAR glyburide Heart health and high dilt-cd
Serevent Diskus glyburide with metformin blood pressure diltia XT
Spiriva Respimat hcl acebutolol hcl diltiazem hcl
Symbicort glyburide, micronized acetazolamide diltiazem hcl er
terbutaline sulfate injection, Humalog afeditab cr doxazosin mesylate
tabs Humulin amiloride hcl enalapril maleate
Theo- 24 Janumet amiloride/ hctz enalapril/ hctz
04320MUMENABS Rev. 12/6/16
PreventiveRx Drug List:
PreventiveRx Plus Plan
PreventiveRx covers drugs that may keep you healthy because they may prevent illness and other health conditions.
You can get the products on this list at low or no cost to you depending on your benefit.
This list includes only prescription products. Brand-name drugs are listed with a fir st capital letter. Non-brand drugs (generics)
are in lowercase letters.
Most brand-name drugs that have a generic equivalent available are not covered under this Preventive Rx benefit.
All drugs* listed below are covered for plans with the National Drug List. If your plan has a different drug list, please check
to see if these drugs are included on your drug list. PreventiveRx Plus drugs are only covered if they are included on your
specific drug list.
*Some drugs may be excluded from your benefits. Please refer to your Certificate or Evidence for Coverage for coverage
limitations and exclusions.
Asthma Theochron Janumet XR amlodipine besylate
Advair theophylline Januvia amlodipine/ benazepril
Advair HFA Ventolin HFA Jardiance amlodipine/ olmesartan
albuterol sulfate zarfirlukast Jentadueto amlodipine/ valsartan
nebulization soln, syrup, Jentadueto XR amlodipine/ valsartan/ hctz
tabs Blood clots Juvisync atenolol
aminophylline Brilinta Lantus atenolol/ chlorthalidone
Arnuity Ellipta Coumadin Lantus Solostar Azor*
Asmanex Eliquis Levemir benazepril hcl
Asmanex HFA heparin Levemir Flexpen benazepril hcl/ hctz
Breo Ellipta warfarin Levemir FlexTouch Benicar
budesonide inhalation Xarelto metformin hcl Benicar HCT
suspension metformin hcl er betaxolol hcl
cromolyn sodium Diabetes miglitol Bidil
nebulization soln Diabetic supplies including nateglinide bisoprolol fumarate
difil- G blood glucose meters, test Novolin bisoprolol fumarate/ hctz
strips and lancets require a
Dulera prescription to be covered Novolog bumetanide
dyphylline/ guaifenesin by this plan. Only blood pioglitazone candesartan
elixophylline glucose meters & blood pioglitazone- glimepiride candesartan/ hctz
Flovent Diskus glucose test strips by pioglitazone- metformin captopril
Flovent HFA Lifescan & Roche will be repaglinide captopril/ hctz
Foradil covered by this benefit. repaglinide- metformin cartia xt
levalbuterol nebulization acarbose Symlin carvedilol
soln ActoPlusMet XR Synjardy chlorthiazide
metaproterenol sulfate Bydureon tolazamide chlorthalidone
syrup, tabs Byetta tolbutamide clonidine tabs, patches
montelukast chlorpropamide Toujeo Clorpres 0.1, 0.2mg
Perforomist glimepiride Tradjenta Coreg CR
ProAir HFA glipizide Trulicity digitek
ProAir RespiClick glipizide er/xl Victoza digoxin
Pulmicort Flexhaler glipizide with metformin hcl Dilatrate SR
QVAR glyburide Heart health and high dilt-cd
Serevent Diskus glyburide with metformin blood pressure diltia XT
Spiriva Respimat hcl acebutolol hcl diltiazem hcl
Symbicort glyburide, micronized acetazolamide diltiazem hcl er
terbutaline sulfate injection, Humalog afeditab cr doxazosin mesylate
tabs Humulin amiloride hcl enalapril maleate
Theo- 24 Janumet amiloride/ hctz enalapril/ hctz
04320MUMENABS Rev. 12/6/16
