CurrentAnthemPolicy N/A

PreventiveRx Enhanced Drug List (Basic Plus Plan)

List of prescription preventive drugs covered (at low or no cost depending on benefit) under the PreventiveRx Enhanced Drug List for the Basic Plus / Essential Direct Drug List; affects members of the plan and providers submitting prescriptions in North Carolina.

Policy Summary

PayerAnthem

PolicyPreventiveRx Enhanced Drug List (Basic Plus Plan)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain a prescription for blood glucose meters, test strips and lancets before submitting claims; only Accu-Chek and FreeStyle meters/test strips are covered and CGMs are excluded.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipletherapeutic categories

yesprescription-only

appliesbrand-name exclusion

excludedCGMs

limitedmeter/test strip coverage

Coverage Criteria

This PreventiveRx Enhanced Drug List covers prescription preventive medications provided under the Basic Plus / Essential Direct Drug List in North Carolina. The list is intended to identify drugs used to prevent illness and maintain health and includes only prescription products; coverage and member cost depend on the member’s benefit and Certificate of Coverage. Brand-name drugs that have a generic equivalent available are not covered under this PreventiveRx benefit.

Certain diabetes-related devices and supplies are specifically excluded or limited from PreventiveRx coverage. Continuous Glucose Monitors (CGMs) are not included in PreventiveRx coverage. Blood glucose meters and test strips are covered only for specified manufacturers, and diabetic supplies require a prescription to be covered.

Provider Actions and Billing Rules

Billing Rule

Prescription required; limited supplier/brand coverage

Diabetic supplies (blood glucose meters, test strips, and lancets) require a valid prescription to be covered by this plan. Only Accu-Chek and FreeStyle blood glucose meters and test strips are covered under this benefit. Continuous Glucose Monitors (CGMs) are not covered under PreventiveRx.

Policy Summary

PayerAnthem

PolicyPreventiveRx Enhanced Drug List (Basic Plus Plan)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain a prescription for blood glucose meters, test strips and lancets before submitting claims; only Accu-Chek and FreeStyle meters/test strips are covered and CGMs are excluded.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Affected items: blood glucose meters, blood glucose test strips, lancets
Covered brands: Accu-Chek; FreeStyle
Exclusion: Continuous Glucose Monitors (CGMs)

Denial Risk

Prescription documentation and denial risks

Prescriptions are required for meters, test strips, and lancets — ensure prescriptions are on file and included with claims to avoid denials. Brand-name diabetic supplies that have a generic equivalent may be excluded from PreventiveRx coverage, which can result in claim denial if a non-covered brand is submitted.

Provider action: Verify prescription is current and accompanies the claim
Denial risk: Submission of non-covered brands or brand-name items with available generics may be denied
Denial risk: Submission of CGMs will be denied under PreventiveRx

Note

How members request language or disability assistance

If a member needs language interpretation or disability-related auxiliary aids/services, instruct them to call Member Services at the number on their ID card (TTY/TDD: 711) for assistance. This is the route for operational support and access help.

How to request assistance: Member Services number on member ID card (TTY/TDD: 711)
Services: free language interpretation and auxiliary aids for members with disabilities

Documentation Required

Where to direct complaints or grievances (escalation options)

Members or providers who believe the member did not receive required services or were discriminated against may file a complaint (grievance). Complaints can be submitted to the plan’s Compliance Coordinator (mailing address below) or to the U.S. HHS Office for Civil Rights.

Compliance Coordinator mailing address: Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279
OCR contact: U.S. Dept. of Health and Human Services, Office for Civil Rights; 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201; 1-800-368-1019 (TDD: 1-800-537-7697); https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms: http://www.hhs.gov/ocr/office/file/index.html

Background

PreventiveRx is a curated list of medications intended to keep members healthy by preventing illness or worsening of chronic conditions. The list groups preventive therapies by condition (for example, diabetes, asthma, cardiovascular risk, mental health, osteoporosis) and lists drugs that may be available at low or no cost depending on the member’s benefit.

For diabetes, the PreventiveRx list includes maintenance antidiabetic agents and insulins and notes device/supply rules: diabetic supplies (blood glucose meters, test strips, and lancets require a prescription to be covered) and coverage of meters/test strips is limited to Accu‑Chek and FreeStyle products. The list emphasizes that not all drugs on the list may be covered for every member and directs providers to the member’s Certificate or Evidence of Coverage for limits and exclusions.

Definitions

PreventiveRx — key definitions

TermPreventiveRx

DefinitionA plan-specific Enhanced Drug List of prescription medications intended to prevent illness and maintain health; covered drugs may be available at low or no cost depending on member benefits.

ScopeIncludes only prescription products; not all drugs listed may be covered by every member's plan—refer to the Certificate or Evidence of Coverage for limits and exclusions.

Brand-name policyBrand-name drugs that have a generic equivalent available are not covered under this PreventiveRx benefit.

Presentation conventionBrand-name drugs are shown with an initial capital letter; generics are shown in lowercase.