Page 2 - Anthem PreventiveRx Plus Plan
P. 2
SM
PreventiveRx Drug List:
PreventiveRx Plus Plan
Entresto metoprolol tartrate sotalol hcl fluvastatin Prempro
eplerenone metoprolol/ hctz sotalol hcl af gemfibrozil raloxifene
eprosartan minoxidil spironolactone lovastatin risedronate
ethacrynic acid moexipril hcl spironolactone/ hctz niacin ER
felodipine er moexipril/ hctz Taztia XT pravastatin Stroke
fosinopril sodium nadolol telmisartan Prevalite aspirin- dipyridamole
fosinopril/ hctz nadolol/ telmisartan/ rosuvastatin ER
furosemide bendroflumethiazide amlodipine simvastatin cilostazol
guanfacine hcl nicardipine hcl telmisartan/ hctz Welchol clopidogrel bisulfate
hydralazine hcl nifedical XL terazosin hcl dipyridamole
hydrochlorothiazide nifedipine thalitone Osteoporosis Effient
indapamide nifedipine er timolol maleate alendronate sodium ticlopidine
irbesartan nisoldipine torsemide amabelz
irbesartan/ hctz Nitro-Bid trandolapril calcitonin- salmon *This drug will be
Isordil 40mg Nitro-Dur 0.3, 0. 8mg/ trandolapril/ Climara Pro removed effective
isosorbide dinitrate hr verapamil Combipatch 12/21/16.
isosorbide dinitrate nitroglycerin triamterene/ hctz covaryx
er nitroglycerin 400 mcg Tribenzor* covaryx HS
isosorbide spray valsartan est. estrogens with
mononitrate nitroglycerin er valsartan/ hctz methyltestosterone
isosorbide nitroglycerin lingual verapamil hcl estradiol tab, patch
mononitrate er nitroglycerin spray verapamil hcl er estradiol/
isradipine nitrolglycerin sl tabs norethindrone
labetolol hcl olmesartan/ High cholesterol acetate
Lanoxin amlodipine/ hctz Advicor estropipate
lisinopril perindopril atorvastatin fortical
lisinopril/ hctz pindolol atorvastatin/ Fosamax Plus D
losartan prazosin hcl amlodipine ibandronate sodium
losartan/ hctz propranolol hcl cholestyramine tablets
Matzim LA propranolol hcl er cholestyramine light Jevantique
methazolamide propranolol/ hctz colestipol hcl Jinteli
methyclothiazide quinapril hcl Crestor medroxyprogesterone
methyldopa quinapril/ hctz fenofibrate (43, 67, acetate
methyldopa/ hctz ramipril 130, 134, 200 mg Menest
metolazone Ranexa capsules & 40, 48, norethindrone- ethin
metoprolol succinate reserpine 54, 120, 145, 160mg estradiol
er sorine tablets) Premarin tablets
fenofibric acid Premphase
This list may change without notice which may affect your benefit coverage. To be sure your medication is covered under the PreventiveRx
benefit, call the member services number located on your ID card.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products
underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, 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 affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits
underwritten by HMO Missouri, Inc. RIT and ce rtain affiliates only provide administrative services for self-funded plans and d o not underwrite
benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO
Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are
administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community
Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its
service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. 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.
04320MUMENABS Rev. 12/6/16
04320MUMENABS Rev. 12/6/16
PreventiveRx Drug List:
PreventiveRx Plus Plan
Entresto metoprolol tartrate sotalol hcl fluvastatin Prempro
eplerenone metoprolol/ hctz sotalol hcl af gemfibrozil raloxifene
eprosartan minoxidil spironolactone lovastatin risedronate
ethacrynic acid moexipril hcl spironolactone/ hctz niacin ER
felodipine er moexipril/ hctz Taztia XT pravastatin Stroke
fosinopril sodium nadolol telmisartan Prevalite aspirin- dipyridamole
fosinopril/ hctz nadolol/ telmisartan/ rosuvastatin ER
furosemide bendroflumethiazide amlodipine simvastatin cilostazol
guanfacine hcl nicardipine hcl telmisartan/ hctz Welchol clopidogrel bisulfate
hydralazine hcl nifedical XL terazosin hcl dipyridamole
hydrochlorothiazide nifedipine thalitone Osteoporosis Effient
indapamide nifedipine er timolol maleate alendronate sodium ticlopidine
irbesartan nisoldipine torsemide amabelz
irbesartan/ hctz Nitro-Bid trandolapril calcitonin- salmon *This drug will be
Isordil 40mg Nitro-Dur 0.3, 0. 8mg/ trandolapril/ Climara Pro removed effective
isosorbide dinitrate hr verapamil Combipatch 12/21/16.
isosorbide dinitrate nitroglycerin triamterene/ hctz covaryx
er nitroglycerin 400 mcg Tribenzor* covaryx HS
isosorbide spray valsartan est. estrogens with
mononitrate nitroglycerin er valsartan/ hctz methyltestosterone
isosorbide nitroglycerin lingual verapamil hcl estradiol tab, patch
mononitrate er nitroglycerin spray verapamil hcl er estradiol/
isradipine nitrolglycerin sl tabs norethindrone
labetolol hcl olmesartan/ High cholesterol acetate
Lanoxin amlodipine/ hctz Advicor estropipate
lisinopril perindopril atorvastatin fortical
lisinopril/ hctz pindolol atorvastatin/ Fosamax Plus D
losartan prazosin hcl amlodipine ibandronate sodium
losartan/ hctz propranolol hcl cholestyramine tablets
Matzim LA propranolol hcl er cholestyramine light Jevantique
methazolamide propranolol/ hctz colestipol hcl Jinteli
methyclothiazide quinapril hcl Crestor medroxyprogesterone
methyldopa quinapril/ hctz fenofibrate (43, 67, acetate
methyldopa/ hctz ramipril 130, 134, 200 mg Menest
metolazone Ranexa capsules & 40, 48, norethindrone- ethin
metoprolol succinate reserpine 54, 120, 145, 160mg estradiol
er sorine tablets) Premarin tablets
fenofibric acid Premphase
This list may change without notice which may affect your benefit coverage. To be sure your medication is covered under the PreventiveRx
benefit, call the member services number located on your ID card.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products
underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, 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 affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits
underwritten by HMO Missouri, Inc. RIT and ce rtain affiliates only provide administrative services for self-funded plans and d o not underwrite
benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO
Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are
administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community
Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its
service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. 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.
04320MUMENABS Rev. 12/6/16
04320MUMENABS Rev. 12/6/16
