Maintenance Drug List - Anthem Marketing Material

[Pages:8]Maintenance Drug List

Depending on the health plan you have with us, you may need to fill maintenance drugs through home delivery or an Rx Maintenance 90 pharmacy. Maintenance drugs are medicines used for long-term health conditions like asthma, heartburn, high blood pressure, allergies and high cholesterol.

Existing members can log in to find out what's covered by your plan at . If you're not a member, you can view our drug lists at pharmacyinformation.

After you log in, you'll be taken to the pharmacy home page, where you can: 1 Choose Price a Medication where you can find out if a drug is covered by your plan and how much you'll pay for it at a retail pharmacy

or through home delivery. 1 Choose Find a Pharmacy, which will take you to the tool to search for an Rx Maintenance 90 pharmacy near you. Want to get started with home delivery? To sign up, fill out the home delivery order form found in the forms section of . Be sure your doctor includes your prescription for a 90-day supply of your medicine and your copay information, and mails it to the address on the form. You can also switch prescriptions you now get filled at your pharmacy to home delivery by calling the phone number on the back of your member ID card.

If you want to use our Home Delivery Pharmacy and are enrolled in a program that helps you with your copay, or if you use manufacturer coupons to help pay for prescriptions, you'll need to give the program or manufacturer detailed claim information and a receipt to get paid back. The company that manages our prescription benefits can't bill us or these third parties for prescriptions you fill through home delivery. To find out the maintenance drugs you may be able to fill through the home delivery pharmacy or at an Rx Maintenance 90 pharmacy,

check out this list:1

ANTI-INFECTIVE

Infection Drugs amantadine

AUTONOMIC AND CENTRAL NERVOUS SYSTEM DRUGS

Alzheimer's Disease Aricept donepezil ergoloid Exelon galantamine galantamine er memantine memantine er Namenda Namenda XR Razadyne Razadyne ER rivastigmine

Anxiety buspirone hcl

Depression Aplenzin Brisdelle bupropion

bupropion er bupropion sr bupropion xl Celexa citalopram Cymbalta desvenlafaxine er desvenlafaxine succinate er duloxetine Effexor XR Emsam escitalopram Fetzima fluoxetine dr fluoxetine fluvoxamine fluvoxamine er Forfivo XL Khedezla Lexapro Marplan Nardil nefazodone Parnate paroxetine er paroxetine hcl

paroxetine mesylate Paxil Paxil CR Pexeva phenelzine Pristiq Prozac Sarafem sertraline tranylcypromine venlafaxine venlafaxine er Viibryd Wellbutrin SR Wellbutrin XL Zoloft

Fibromyalgia Savella

Myasthenia Gravis Mestinon pyridostigmine pyridostigmine er

Parkinson's Disease Azilect carbidopa carbidopa-levodopa

carbidopa-levodopa er carbidopa-levodopaentacapone Comtan entacapone Lodosyn Mirapex Mirapex ER Neupro Osmolex ER pramipexole pramipexole er rasagiline Requip Requip XL ropinirole ropinirole er Rytary selegiline Sinemet Sinemet CR Stalevo Tasmar tolcapone Xadago Zelapar

Smoking Deterrent

Zyban

BIOLOGIC AGENTS

Migraine Prevention Aimovig Ajovy Emgality

CANCER, TRANSPLANT AND OTHER IMMUNOSUPPRESSANT DRUGS

Rheumatoid Arthritis hydroxychloroquine Plaquenil Ridaura

CARDIOVASCULAR DRUGS

Heart Rhythm amiodarone Betapace Betapace AF Corlanor disopyramide flecainide mexiletine Multaq

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Maintenance Drug List

Norpace Norpace CR Pacerone propafenone propafenone er quinidine gluconate quinidine sulfate Rythmol SR Sorine sotalol sotalol af Sotylize

Heart/Angina Dilatrate-SR Isochron Isordil isosorbide dinitrate isosorbide dinitrate er isosorbide dinitrate sa isosorbide mononitrate isosorbide mononitrate er Minitran Nitro-Bid Nitro-Dur nitroglycerin nitroglycerin er Nitro-Time Ranexa ranolazine er

Heart/Blood Pressure Accupril Accuretic acebutolol Adalat CC Afeditab CR aliskiren Altace amiloride amlodipine amlodipine/benazepril amlodipine/olmesartan amlodipine/valsartan amlodipine/valsartan/ hctz Atacand Atacand HCT atenolol atenolol/chlorthalidone Avalide

Avapro Azor benazepril benazepril/hctz Benicar Benicar HCT betaxolol bisoprolol bisoprolol/hctz Bystolic Calan Calan SR candesartan candesartan/hctz captopril captopril/hctz Cardizem Cardizem CD Cardizem LA Cardura Cardura XL Cartia XT carvedilol carvedilol er Catapres Catapres-TTS clonidine Coreg Coreg CR Corgard Cozaar diltiazem cd diltiazem er diltiazem Dilt-XR Diovan Diovan HCT doxazosin Dutoprol Edarbi Edarbyclor enalapril enalapril/hctz Entresto Epaned eprosartan Exforge Exforge HCT felodipine er fosinopril

fosinopril/hctz guanfacine hydralazine Hyzaar Inderal LA Inderal XL Innopran XL irbesartan irbesartan/hctz isradipine Kapspargo Sprinkle labetalol lisinopril lisinopril/hctz Lopressor Lopressor HCT losartan losartan/hctz Lotensin Lotensin HCT Lotrel Matzim LA methyldopa methyldopa/hctz metoprolol succinate metoprolol succinate/ hctz metoprolol tartrate metoprolol tartrate / hctz Micardis Micardis HCT Minipress minoxidil moexipril nadolol nadolol/ bendroflumethiazide nicardipine nifedipine nifedipine er nisoldipine er Norvasc olmesartan olmesartan/ amlodipine/hctz olmesartan/hctz perindopril pindolol prazosin

Prestalia Prinivil Procardia Procardia XL propranolol propranolol er propranolol/hctz Qbrelis quinapril quinapril/hctz ramipril Sular Tarka Taztia XT Tekturna Tekturna HCT telmisartan telmisartan/amlodipine telmisartan/hctz Tenoretic Tenormin terazosin Tiazac timolol maleate Toprol XL trandolapril trandolapril/verapamil Tribenzor Twynsta valsartan valsartan/hctz Vaseretic Vasotec verapamil verapamil cr verapamil er verapamil sa verapamil sr Verelan Verelan PM Zestoretic Zestril Ziac

Heart/Blood Pressure/ Water Pills Aldactazide Aldactone amiloride/hctz bumetanide chlorothiazide

chlorthalidone Demadex Diuril Dyazide Dyrenium Edecrin eplerenone ethacrynic acid furosemide hydrochlorothiazide indapamide Inspra Lasix Maxzide methyclothiazide metolazone Microzide spironolactone spironolactone/hctz torsemide triamterene/hctz

Heart/Congestive Heart Failure Digitek Digox digoxin Lanoxin

High Cholesterol Altoprev ER amlodipine/atorvastatin Antara atorvastatin Caduet cholestyramine cholestyramine light colesevelam Colestid colestipol Crestor Ezallor Sprinkle ezetimibe ezetimibe-simvastatin fenofibrate fenofibric acid Fenoglide Fibricor Flolipid fluvastatin fluvastatin er gemfibrozil

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Maintenance Drug List

Lescol Lescol XL Lipitor Lipofen Livalo Lopid lovastatin Lovaza niacin niacin er Niacor Niaspan ER omega-3 acid ethyl esters Pravachol pravastatin Prevalite Questran Questran Light rosuvastatin simvastatin Tricor Triglide Triklo Trilipix Vascepa Vytorin Welchol Zetia Zocor Zypitamag

Peripheral Artery Disease pentoxifylline

Peripheral Vascular Disease Bidil isoxsuprine

DENTAL/ORAL CARE DRUGS

Dental Products Clinpro 5000 Denta 5000 Plus Dentagel Fluoridex Prevident Prevident 5000 Prevident 5000 Plus SF

SF 5000 Plus sodium fluoride

Dry Mouth cevimeline Evoxac

ENDOCRINE DRUGS

Addison's Disease fludrocortisone

Anti-inflammatory Cortef hydrocortisone

Bed Wetting DDAVP desmopressin

Diabetes acarbose Actoplus Met Actoplus Met XR Actos Adlyxin Admelog Admelog Solostar Afrezza alogliptin alogliptin-metformin alogliptin-pioglitazone Amaryl Apidra Apidra Solostar Avandia Basaglar Bydureon Pen Bydureon Bcise Byetta chlorpropamide Cycloset Duetact Farxiga Fiasp Fortamet glimepiride glipizide glipizide er glipizide xl glipizide-metformin Glucophage Glucophage XR Glucotrol Glucotrol XL

Glumetza glyburide glyburide micronized glyburide-metformin hcl Glynase Glyset Glyxambi Humalog Humalog Mix 50-50 Humalog Mix 75-25 Humulin 70-30 Humulin N Humulin R Insulin Lispro Insulin Needles (Brand and generic) Insulin Pen Needles (Brand and generic) Insulin Syringes (Brand and generic) Invokamet Invokamet XR Invokana Janumet Janumet XR Januvia Jardiance Jentadueto Jentadueto XR Kazano Kombiglyze XR Lantus Lantus Solostar Levemir metformin metformin er Miglitol nateglinide Nesina Novolin 70-30 Novolin N Novolin R Novolog Novolog Mix 70-30 Onglyza Oseni Ozempic pioglitazone pioglitazone-glimepiride pioglitazone-metformin

Prandin Precose Proglycem Qtern repaglinide repaglinide-metformin Riomet Segluromet Soliqua 100-33 Starlix Steglatro Steglujan Symlinpen Synjardy Synjardy XR tolazamide tolbutamide Toujeo Max Solostar Toujeo Solostar Tresiba Trulicity Victoza Xigduo XR Xultophy 100-3.6

Gout allopurinol febuxostat probenecid probenecid/colchicine Uloric Zyloprim

High Prolactin Levels cabergoline

Nocturia Nocdurna Noctiva

Osteoporosis Actonel alendronate Atelvia Binosto Boniva calcitonin Fosamax Fosamax Plus D ibandronate risedronate risedronate dr

Paget Disease

etidronate

Thyroid Armour Thyroid Cytomel Euthyrox Levo-T levothyroxine Levoxyl liothyronine methimazole Nature-Throid Np Thyroid propylthiouracil Synthroid Tapazole thyroid Thyrolar Tirosint Unithroid Westhroid Wp Thyroid

EYE DRUGS

Dry Eye Cequa

Glaucoma Drugs acetazolamide Alphagan P Azopt betaxolol Betimol Betoptic S bimatoprost brimonidine carteolol Combigan Cosopt Cosopt PF dorzolamide dorzolamide-timolol Isopto Carpine Istalol latanoprost levobunolol Lumigan methazolamide metipranolol Phospholine pilocarpine Rhopressa

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Maintenance Drug List

Rocklatan Simbrinza timolol Timoptic Timoptic-XE Travatan Z Trusopt Vyzulta Xalatan Xelpros Zioptan

Other Eye Drugs atropine Cyclogyl Cyclomydril cyclopentolate Homatropaire homatropine isopto atropine Mydriacyl tropicamide

GASTROINTESTINAL DRUGS

Gallstones Actigall Urso Urso Forte ursodiol

Proton Pump Inhibitors Aciphex Aciphex Sprinkle Dexilant esomeprazole magnesium esomeprazole strontium lansoprazole Nexium Omeppi omeprazole omeprazole-sodium bicarbonate pantoprazole Prevacid Prilosec Protonix rabeprazole Zegerid

Ulcer Carafate

cimetidine Cytotec famotidine misoprostol nizatidine Pepcid ranitidine sucralfate Zantac

Ulcerative Colitis Apriso Asacol HD Azulfidine Delzicol Dipentum Lialda mesalamine mesalamine dr Pentasa sulfasalazine sulfasalazine dr

MUSCULOSKELETAL DRUGS

Pain/Inflammation Arthrotec diclofenac topical diclofenac-misoprostol diflunisal Duexis Vimovo Voltaren gel

NUTRITION, BLOOD MODIFIERS, ELECTROLYTES

Chronic Kidney Disease calcitriol doxercalciferol Hectorol paricalcitol Rayaldee Rocaltrol Zemplar

Potassium Supplements Effer-K Klor-Con Klor-Con M Klor-Con Sprinkle Klor-Con-EF K-Tab

potassium chloride potassium chloride er potassium chloride micro er potassium citrate er Urocit-K

Stroke/Peripheral Artery Disease Aggrenox Agrylin anagrelide aspirin-dipyridamole er Brilinta cilostazol clopidogrel dipyridamole Effient Eliquis Plavix Pradaxa prasugrel Savaysa Xarelto Zontivity

Therapeutic Vitamins/ Minerals and Dietary Supplements Carnitor Carnitor SF folic acid levocarnitine Nascobal Potaba

OBSTETRICAL AND GYNECOLOGICAL DRUGS

Birth Control Afirmelle Altavera Alyacen Amethia Amethia LO Amethyst Apri Aranelle Ashlyna Aubra Aubra EQ Aurovela Aurovela 24 FE

Aurovela FE Aviane Ayuna Azurette Balcoltra Balziva Bekyree Beyaz Blisovi 24 FE Blisovi FE Brevicon Briellyn Camrese Camrese LO Caziant Chateal Chateal EQ Cryselle Cyclafem Cyclessa Cyred Cyred EQ Dasetta Daysee Delyla desogestrel-ethinyl estradiol desogestr-eth estrad/ eth estrad drospirenone-eth estralevomef drospirenone-ethinyl estradiol Elinest Emoquette Enpresse Enskyce Estarylla Estrostep FE ethynodiol-ethinyl estradiol Falmina Fayosim Femynor Gianvi Hailey 24 FE Introvale Isibloom Jasmiel Jolessa

Juleber Junel Junel 24 FE Junel FE Kaitlib FE Kalliga Kariva Kelnor Kurvelo Larin Larin 24 FE Larin FE Larissia Layolis FE Leena Lessina Levonest levonorgestrel-eth estradiol levonorg-eth estrad eth estrad Levora Lillow Lo Loestrin FE Loestrin Loestrin 21 Loestrin FE Loryna Loseasonique Low-Ogestrel Lo-Zumandimine Lutera Marlissa Melodetta 24 FE Mibelas 24 FE Microgestin Microgestin 24 FE Microgestin FE Mili Minastrin 24 FE Mircette Mono-Linyah Natazia Necon Nikki norethindrone-ethin estradiol norethin-eth estra ferrous fum

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Maintenance Drug List

norgestimate-ethinyl estradiol norgestrel-ethiny estra Nortrel Nuvaring Ocella Ogestrel Orsythia Ortho-Novum Philith Pimtrea Pirmella Portia Previfem Quartette Rajani Reclipsen Rivelsa Safyral Seasonique Setlakin Simliya Simpesse Sprintec Sronyx Syeda Tarina 24 FE Tarina FE Tarina FE EQ Taytulla Tilia FE Tri Femynor Tri-Estarylla Tri-Legest FE Tri-Linyah Tri-Lo-Estarylla Tri-Lo-Marzia Tri-Lo-Mili Tri-Lo-Sprintec Tri-Mili Tri-Previfem Tri-Sprintec Trivora Tri-Vylibra Tri-Vylibra LO

Tydemy Velivet Vienva Viorele Vyfemla Vylibra Wera Wymzya FE Xulane Yasmin Yaz Zarah Zenchent Zovia Zumandimine

Birth Control/Progestin Only Camila Deblitane Errin Heather Incassia Jencycla Jolivette Lyza Nora-Be Norlyda Norlyroc Sharobel Tulana

Breast Cancer/ Osteoporosis Evista raloxifene

Estrogen Drugs Alora Climara Divigel Dotti Elestrin Estrace estradiol Femring Menest

Minivelle Premarin Vagifem Vivelle-Dot Yuvafem

Estrogen/Progestin Combinations Activella Amabelz Angeliq Climara Pro Combipatch estradiol-norethindrone acetate Femhrt Fyavolv Jinteli Lopreeza Mimvey Mimvey LO Prefest Premphase Prempro

Progestin Drugs Aygestin medroxyprogesterone acetate norethindrone acetate Provera

RESPIRATORY DRUGS

Asthma Bronchodilator/Steroid Combo Advair Diskus Advair HFA Airduo Respiclick Dulera fluticasone-salmeterol Symbicort Wixela Inhub

Asthma ? Inhaled Corticosteroids Aerospan Alvesco

Armonair Respiclick Arnuity Ellipta Asmanex Asmanex HFA budesonide Flovent Diskus Flovent HFA Pulmicort Pulmicort Flexhaler Qvar Redihaler

Asthma/Allergies Accolate cromolyn sodium montelukast Singulair zafirlukast zileuton er

Bronchodilators albuterol Atrovent HFA Brovana Elixophyllin ipratropium metaproterenol Perforomist Serevent Diskus Spiriva Handihaler Spiriva Respimat terbutaline Theo-24 Theochron theophylline theophylline cr theophylline er theophylline sr Tudorza Pressair

COPD Anoro Ellipta Arcapta Neohaler Bevespi Aerosphere Breo Ellipta Incruse Ellipta Lonhala Magnair Seebri Neohaler

Stiolto Respimat Striverdi Respimat Trelegy Ellipta Utibron Neohaler Yupelri

UROLOGICAL DRUGS

Erectile Dysfunction Stendra

Kidney Function Cuprimine Depen D-Penamine penicillamine

Overactive Bladder darifenacin er Detrol Detrol LA Ditropan XL Enablex flavoxate Gelnique oxybutynin oxybutynin er Oxytrol solifenacin tolterodine tolterodine er trospium trospium er Vesicare

Prostate alfuzosin er Avodart dutasteride dutasteride-tamsulosin finasteride Flomax Jalyn Proscar Rapaflo silodosin tamsulosin Uroxatral

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Maintenance Drug List

Disclaimer/note/source: 1 This list does not include all maintenance drugs and is not a guarantee of benefits. Please check your drug list for coverage. Generic drugs are lower case and trade/brand name drugs are capitalized. Some medications, like Insulin Needles, are listed as a category and not with a specific brand or generic name. Over-the-counter drugs are not included on this list. This list may change without notice, which may affect your benefit coverage. For more information about your benefits or to get started with home delivery, you can go to or call Pharmacy Member Services at the phone number on your member ID card. Members who are speech- or hearing-impaired should call 1-800-221-6915 (TDD/TTY), Monday to Friday, 8:30 a.m. to 5 p.m., Eastern time.

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. Copies of Colorado network access plans are available on request from member services or can be obtained by going to co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan 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 certain affiliates only provide administrative services for self-funded plans and do 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. 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), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 24804MUMENABS Rev. 7/1/2019

Get help in your language

Curious to know what all this says? We would be too. Here's the English version: You have the right to get this information and help in your language for free. Call the Member Services number on your ID card for help. (TTY/TDD: 711)

Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card.

Spanish Tiene el derecho de obtener esta informaci?n y ayuda en su idioma en forma gratuita. Llame al n?mero de Servicios para Miembros que figura en su tarjeta de identificaci?n para obtener ayuda. (TTY/TDD: 711)

Chinese ID (TTY/TDD: 711)

Vietnamese Qu? v c? quyn nhn min ph? th?ng tin n?y v? s tr gi?p bng ng?n ng ca qu? v. H?y gi cho s Dch V Th?nh Vi?n tr?n th ID ca qu? v c gi?p . (TTY/TDD: 711)

Korean . ID . (TTY/TDD: 711)

Tagalog May karapatan kayong makuha ang impormasyon at tulong na ito sa ginagamit ninyong wika nang walang bayad. Tumawag sa numero ng Member Services na nasa inyong ID card para sa tulong. (TTY/TDD: 711)

Russian . , . (TTY/TDD: 711)

Arabic

. . (711 :TDD/TTY)

Armenian

: ID : (TTY/TDD: 711)

Farsi .

(TTY/TDD: 711).

French Vous avez le droit d'acc?der gratuitement ? ces informations et ? une aide dans votre langue. Pour cela, veuillez appeler le num?ro des Services destin?s aux membres qui figure sur votre carte d'identification. (TTY/TDD: 711)

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Japanese ID (TTY/TDD: 711) Haitian Ou gen dwa pou resevwa enf?masyon sa a ak asistans nan lang ou pou gratis. Rele nimewo Manm S?vis la ki sou kat idantifikasyon ou a pou jwenn ?d. (TTY/TDD: 711) Italian Ha il diritto di ricevere queste informazioni ed eventuale assistenza nella sua lingua senza alcun costo aggiuntivo. Per assistenza, chiami il numero dedicato ai Servizi per i membri riportato sul suo libretto. (TTY/TDD: 711) Polish Masz prawo do bezplatnego otrzymania niniejszych informacji oraz uzyskania pomocy w swoim jzyku. W tym celu skontaktuj si z Dzialem Obslugi Klienta pod numerem telefonu podanym na karcie identyfikacyjnej. (TTY/TDD: 711) Punjabi (TTY/TDD: 711)

It's important we treat you fairly That's why we follow federal civil rights laws in our health programs and activities. We don't discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn't English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at . Complaint forms are available at .

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