PreventiveRxSM Drug List: Expanded 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. Brand-name drugs that have a generic equivalent available are not covered under this Preventive Rx benefit. 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.

Birth control Breast cancer Janumet XR probenecid/colchicine Clorpres All generic versions are anastrozole Januvia Uloric Coreg CR included: exemestane Jardiance Covera-HS Heart health and high Beyaz Fareston Jentadueto digitek blood pressure Generess-FE letrozole Juvisync digoxin acebutolol hcl Lomedia 24 FE tamoxifen citrate Kazano Dilatrate SR acetazolamide medroxyprogesterone Kombiglyze XR dilt-cd Diabetes afeditab cr 150mg/ml Korlym diltiazem hcl Aldactazide 50-50mg Minastrin 24 Fe Diabetic supplies, Lantus diltiazem hcl er amiloride hcl Natazia including blood sugar Levemir Diuril amiloride/hctz Nuvaring meters, test strips and metformin hcl doxazosin mesylate amlodipine besylate Quartette lancets require a metformin hcl er Dutoprol amlodipine/benazepril Skyla prescription to be nateglinide Dynacirc CR covered by this plan. Nesina amlodipine/valsartan Dyrenium Blood clots acarbose Novolin amlodipine/valsartan/ Edarbi Brilinta ActoPlusMet XR Novolog hctz Edarbyclor Coumadin Afrezza Onglyza Amturnide Edecrin Eliquis Apidra Oseni atenolol enalapril maleate enoxaparin Avandamet pioglitazone atenolol/chlorthalidone enalapril/hctz fondaparinux Avandaryl pioglitazone-glimepiride Avalide 300/25mg Epaned Fragmin Avandia pioglitazone-metformin Azor eplerenone heparin Bydureon Prandimet benazepril hcl eprosartan Innohep Byetta repaglinide benazepril hcl/hctz felodipine er Pradaxa chlorpropamide Riomet Benicar fosinopril sodium Savaysa Cycloset Symlin Benicar HCT fosinopril/hctz warfarin Farxiga Tanzeum betaxolol hcl furosemide Xarelto glimepiride tolazamide Bidil guanabenz acetate glipizide tolbutamide bisoprolol fumarate guanfacine hcl Bowel prep (laxatives) glipizide er/xl Tradjenta bisoprolol fumarate/ Hemangeol Colyte glipizide with metformin Trulicity hctz hydralazine hcl Golytely hcl Victoza bumetanide hydralazine/hctz Halflytely Glumetza Xigduo XR Bystolic hydrochlorothiazide Moviprep glyburide candesartan indapamide OCL glyburide with Flu candesartan/hctz Inderal XL Osmoprep metformin hcl Relenza captopril Innopran XL peg 3350/electrolytes glyburide, micronized Tamiflu captopril/hctz irbesartan Prepopik Glyset Cardene SR irbesartan/hctz Gout Suclear Glyxambi Cardizem LA 120mg Isordil 40mg allopurinol Suprep Humalog cartia xt isosorbide dinitrate Colchicine Trilyte Humulin carvedilol isosorbide dinitrate er Colcrys Visicol Invokana chlorothiazide isosorbide mononitrate Invokamet Mitigare chlorthalidone Janumet probenecid clonidine hcl

13017VAMENABS Rev. 2/15 PreventiveRxSM Drug List: Expanded Plan

isosorbide mononitrate sotalol hcl af Simcor estradiol/norethindrone Prescription er spironolactone simvastatin acetate multivitamins with isradipine spironolactone/hctz Triglide estropipate fluoride and iron labetalol hcl Tarka Vascepa FemHRT 0.5mg/2.5mcg Lanoxin Taztia XT Vytorin Femtrace levatol Tekamlo Welchol Forteo lisinopril Tekturna Zetia fortical lisinopril/hctz Tekturna HCT Fosamax Plus D losartan telmisartan Malaria ibandronate losartan/hctz telmisartan/amlodipine atovaquone/proguanil medroxyprogesterone Matzim LA telmisartan/hctz chloroquine acetate methazolamide terazosin hcl Daraprim Menest methyclothiazide Teveten 400mg hydroxychloroquine Menostar methyldopa Teveten HCT mefloquine hcl Miacalcin methyldopa/hctz thalitone primaquine Minivelle metolazone timolol maleate quinine sulfate capsule Ogen metoprolol succinate er torsemide Prefest Nausea, vomiting metoprolol tartrate trandolapril Premarin tablets Aloxi metoprolol/hctz triamterene/hctz Premphase Akynzeo minoxidil Tribenzor Prempro Antivert 50mg moexipril hcl valsartan Prolia Anzemet moexipril/hctz valsartan/hctz raloxifene Cesamet nadolol Vecamyl risedronate chlorpromazine hcl nadolol/ verapamil hcl zoledronic acid (generic Diclegis bendroflumethiazide verapamil hcl er Reclast) dimenhydrinate Nexiclon XR dronabinol nicardipine hcl High cholesterol RSV (respiratory Emend nifedipine Advicor syncytial virus) granisetron hcl nifedipine er Altoprev Synagis ondansetron hcl nimodipine Antara 30, 90mg ondansetron odt Stroke nisoldipine atorvastatin prochlorperazine Aggrenox Nitro-Bid atorvastatin/amlodipine promethazine hcl cilostazol Nitro-Dur 0.3, 0.8mg/hr cholestyramine Scopace clopidogrel bisulfate nitroglycerin cholestyramine light Transderm-Scop dipyridamole Nitroglycerin 400mcg colestipol hcl trimethobenzamide hcl Effient Spray Crestor Zuplenz ticlopidine hcl nitroglycerin er fenofibrate fenofibric acid, dr Zontivity Nitroglycerin Lingual Osteoporosis Fenoglide nitroglycerin spray alendronate sodium Vaccines fluvastatin Nitrostat Alora gemfibrozil All brand and generic Nymalize Angeliq Lescol XL versions are included. perindopril Atelvia Lipofen pindolol Binosto Vitamins Liptruzet prazosin hcl Cenestin Livalo All generic versions are propranolol hcl Climara Pro lovastatin included: propranolol hcl er Combipatch niacin ER Prenatal vitamins (taken propranolol/hctz Duavee Niacor during pregnancy) quinapril hcl Enjuvia omega-3 ethyl ester 1 Prescription quinapril/hctz est. estrogens with gram capsule multivitamins with ramipril methyltestosterone pravastatin fluoride Ranexa Estraderm Prevalite sotalol hcl estradiol tab, patch

13017VAMENABS Rev. 2/15 PreventiveRxSM Drug List: Expanded Plan

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 Fairfac, the Town of Vienna, and the area east of State Road 123. Independent licensee 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.

13017VAMENABS Rev. 2/15