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Preventiverx Drug List: Expanded Plan (National Drug List)

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Preventiverx Drug List: Expanded Plan (National Drug List) PreventiveRx Drug List: Expanded Plan (National Drug List) PreventiveRxSM 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 first capital letter. Nonbrand drugs (generics) are in lowercase letters. Brand-name drugs that have a generic equivalent available are not covered under this PreventiveRx 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. Antibiotics clarithromycin Loteprednol Etabonate- Rifaximin decadron elx, tab Tobramycin Acetic Acid-Oxyquinoline Clindamycin HCL Silver Dexabliss Vaginal mafenide acetate Clindamycin Palmitate Sulfacetamide Sodium dexamethasone elx, sol, tab Aminosalicylic Acid Hydrochloride Methenamine Hippurate (acne) Dexamethasone Intensol amoxicillin Clindamycin Phosphate methenamine mandelate Sulfadiazine (one dose) dexpak amoxicillin & pot clavulanate metronidazole vaginal sulfamethoxazole/ Clindamycin trimethoprim Dxevo Ampicillin Phosphate Vaginal minocycline HCL sulfamethoxazole- Elixophyllin ampicillin trihydrate cycloserine Moxifloxacin HCL trimethoprim Flovent Diskus Azithromycin dapsone Mupirocin Sulfanilamide Vaginal Flovent HFA Aztreonam Lysine dicloxacillin sodium Mupirocin Calcium (topical) Tedizolid Phosphate fluticasone/salmeterol Bacitracin-Polymyxin- Doxycycline (monohydrate) neomycin sulfate Telithromycin Neomycin Hc fluticasone/salmeterol Doxycycline (rosacea) Neomycin Sulfate- Tobramycin bacitracin-poly-neomycin-hc Fluocinolone Acetonide hydrocortisone tab Doxycycline Calcium Tobramycin-Dexamethasone Bedaquiline Fumarate Neomycin-Colistin-Hc- ipratropium sol Doxycycline Hyclate Thonzonium Trimethoprim cefaclor ipratropium/albuterol sol erythromycin base Neomycin-Fluocinolone Trimethoprim HCL Cefaclor Monohydrate & Emollient levalbuterol HFA Erythromycin Base (coated) vancomycin HCL cefadroxil Neomycin-Polymy-Dexameth levalbuterol neb erythromycin ethylsuccinate metaproterenol syp cefdinir Neomycin-Polymyxin-Hc Asthma erythromycin stearate methylprednisolone Cefditoren Pivoxil neomycin-polymyxin-hc Advair HFA ethambutol HCL (ophth) montelukast chw, gran, tab cefixime albuterol HFA Ethionamide neomycin-polymyxin-hc Perforomist cefpodoxime proxetil (otic) albuterol neb, syp, tab, Fidaxomicin ER tab prednisolone ODT cefprozil nitrofurantoin Fosfomycin Tromethamine Arcapta Neohaler prednisolone sol Cefuroxime Axetil nitrofurantoin macrocrystal Gemifloxacin Mesylate Arnuity Ellipta Prednisone Intensol cephalexin nitrofurantoin monohyd gentamicin sulfate (topical) Ciprofloxacin macro Atrovent HFA prednisone pak, sol, tab Gentamicin-Prednisolone ofloxacin Breo Ellipta Ciprofloxacin HCL Acetate ProAir Digihaler penicillin V potassium Brovana ciprofloxacin-ciprofloxacin isoniazid ProAir HFA HCL pyrazinamide budesonide susp Isoniazid & Rifampin ProAir RespiClick Ciprofloxacin- Retapamulin budesonide/formoterol Dexamethasone Isoniazid-Rifampin Proventil HFA with Pyrazinamide Rifabutin Combivent Respimat Ciprofloxacin-Fluocinolone Serevent Diskus Acetonide levofloxacin Rifampin cortisone acetate Spiriva Respimat Ciprofloxacin- Linezolid Rifapentine cromolyn sodium neb terbutaline Hydrocortisone 40775CAMENABC Rev. 10/20 PreventiveRx Drug List: Expanded Plan (National Drug List) Theo-24 peg 3350/electrolytes Janumet probenecid Diuril theophylline sol, tab peg-prep kit Janumet XR probenecid/colchicine doxazosin mesylate Ventolin HFA Plenvu Januvia Zurampic enalapril maleate wixela inhub Prepopik Jardiance enalapril/HCTZ Heart health and Xolair Suprep Jentadueto XR high blood pressure Epaned zafirlukast TriLyte Korlym acebutolol HCL eplerenone Lantus acetazolamide eprosartan Birth control Breast cancer Levemir afeditab CR felodipine ER All generic versions anastrozole are included. metformin HCL aliskiren fosinopril sodium exemestane Annovera metformin HCL ER amiloride HCL fosinopril/HCTZ letrozole Balcoltra miglitol amiloride/HCTZ furosemide Soltamox Falessa Kit nateglinide amlodipine besylate guanfacine HCL tamoxifen citrate Lo Loestrin 1-10-10 Ozempic amlodipine/benazepril hydralazine HCL toremifene citrate Natazia pioglitazone amlodipine/valsartan hydrochlorothiazide repaglinide indapamide Slynd Diabetes atenolol Soliqua irbesartan Taytulla Diabetic supplies — atenolol/chlorthalidone glucometers/test strips Symlin irbesartan/HCTZ Twirla (Roche and Lifescan benazepril HCL products only), lancets, Synjardy benazepril HCL/HCTZ isosorbide dinitrate control solutions, pen Blood clots needles, insulin syringes. Synjardy XR betaxolol HCL isosorbide dinitrate ER Bevyxxa These products require a prescription to be covered tolazamide bisoprolol fumarate isosorbide mononitrate Brilinta by this plan. tolbutamide bisoprolol fumarate/HCTZ isosorbide mononitrate ER Eliquis acarbose Toujeo bumetanide isradipine enoxaparin Avandia Trulicity Bystolic Kapspargo Sprinkle fondaparinux chlorpropamide Victoza Byvalson Katerzia Fragmin Cycloset Xigduo XR captopril labetalol HCL heparin Farxiga Xultophy captopril/HCTZ lisinopril Pradaxa glimepiride Cardizem LA 120 mg lisinopril/HCTZ Savaysa glipizide Flu cartia XT losartan warfarin glipizide ER/XL oseltamivir carvedilol losartan/HCTZ Xarelto glipizide with metformin HCL Relenza chlorothiazide methazolamide glyburide Xofluza chlorthalidone methyclothiazide Bowel prep glyburide with methyldopa (laxatives) metformin HCL Gout clonidine HCL methyldopa/HCTZ Clenpiq glyburide, micronized allopurinol Corzide metolazone gavilyte Humalog colchicine tab digitek metoprolol succinate ER GoLYTELY packet Humulin Duzallo digoxin metoprolol tartrate MoviPrep Insulin Lispro febuxostat dilt XR metoprolol/HCTZ OsmoPrep Insulin Lispro Protamine Gloperba diltiazem HCL PreventiveRx Drug List: Expanded Plan (National Drug List) minitran tiadylt Malaria Angeliq Stopping smoking minoxidil timolol maleate Arakoda calcitonin spr bupropion HCL SR (generic Zyban only) moexipril HCL torsemide atovaquone/proguanil Climara Pro Chantix moexipril/HCTZ trandolapril chloroquine CombiPatch Nicotrol Inhaler nadolol/ trandolapril/verapamil hydroxychloroquine Dotti bendroflumethiazide Nicotrol NS triamterene mefloquine HCL Duavee nicardipine HCL valsartan primaquine estradiol tab, patch Stroke nifedipine valsartan/HCTZ pyrimethamine estradiol/norethindrone aspirin/dipyridamole nifedipine ER acetate Vecamyl quinine sulfate capsule aspirin/omeprazole nimodipine estropipate verapamil HCL cilostazol nisoldipine Nausea, vomiting Forteo verapamil HCL ER, SR clopidogrel bisulfate Nitro-Bid Akynzeo fortical dipyridamole nitroglycerin, dis, sl, spr High cholesterol Anzemet fyavolv prasugrel Nitro-Time atorvastatin aprepitant ibandronate Zontivity Nymalize cholestyramine Cesamet jenatique lo olmesartan jinteli cholestyramine light chlorpromazine HCL Vaccines olmesartan/HCTZ lopreeza colesevelam HCL Compro All brand and generic perindopril colestipol HCL dimenhydrinate medroxyprogesterone versions are included. acetate pindolol ezetimibe dronabinol Menest Vitamins prazosin HCL fenofibrate capsule doxylamine/pyridoxine (except 50mg and 150mg) mimvey Formulary options Prestalia fosaprepitant fenofibrate micronized mimvey lo prenatal vitamins propranolol HCL (except 43mg and 130mg) granisetron HCL (taken during pregnancy) norethindrone acetate/ propranolol HCL ER fenofibrate tablet ondansetron HCL ethinyl estradiol prescription multivitamins (except 40mg and 120mg) with fluoride propranolol/HCTZ ondansetron ODT Prefest gemfibrozil prescription multivitamins Qbrelis palonosetron HCL Premarin tab with fluoride and iron lovastatin quinapril HCL phenadoz Premphase niacin ER quinapril/HCTZ prochlorperazine Prempro Weight loss niacor ramipril promethazine HCL Prolia benzphetamine HCL omega-3-acid cap 1 gm ranolazine ER Sancuso raloxifene Contrave pravastatin sorine scopolamine patch risedronate diethylpropion HCL prevalite sotalol HCL Syndros Tymlos diethylpropion rosuvastatin sotalol HCL af Tigan inj zoledronic acid Lomaira simvastatin (generic Reclast) Sotylize trimethobenzamide HCL phendimetrazine spironolactone triklo phentermine HCL Varubi RSV spironolactone/HCTZ Vascepa (respiratory Qsymia syncytial virus) taztia XT Osteoporosis Xenical Synagis telmisartan alendronate sodium terazosin HCL amabelz Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. .
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