Your PreventiveRxSM Drug List:
Basic Plus Plan

PreventiveRx covers drugs that help keep you healthy because they prevent illness and other health conditions.
You can get the products on this list at low or no cost to you.

This list includes only prescription products. Brand-name drugs are listed with a first capital letter. Non-brand drugs (generics) are in lowercase letters.
Birth control
High cholesterol
Blood clots
Bowel prep (laxatives)
Stopping smoking
Nausea, vomiting
Heart health and high
blood pressure
Your PreventiveRxSM Drug List:
Basic Plus Plan

clopidogrel bisulfate
ticlopidine hcl
All brand and generic
versions are included

All generic versions are
Prenatal vitamins (taken
during pregnancy)
multivitamins with
multivitamins with
fluoride and iron
Weight loss
benzphetamine hcl
diethylpropion hcl
diethylpropion hcl er
phentermine hcl
Suprenza ODT
Not all drugs on this list may be covered by your plan. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your Certificate or Evidence of Coverage for coverage limitations and exclusions. ^ 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 for details on coverage. 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 affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. 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 (serving 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”) underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”) underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.



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Microsoft word - formulary.doc

Select Over-the-Counter (OTC) If approved by the Medical Manager an effective 2014 Formulary Prescription Coverage date will be assigned based upon the date signed by the provider on the Medical Necessity Review medications are available at no cost to the of Excluded Drugs/ Override form. The Benefits The following is a listing of drugs broken down by Subscriber with a valid p

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