CurrentAnthemPolicy N/A

PreventiveRx Plus Plan (CA Select) — PreventiveRx drug list coverage

Defines the PreventiveRx prescription drugs covered under the PreventiveRx Plus Plan (CA Select) benefit and explains member access and limitations to preventive medications and supplies. Applies to members eligible for the PreventiveRx Plus Plan (CA Select).

Policy Summary

PayerAnthem

PolicyPreventiveRx Plus Plan (CA Select) — PreventiveRx drug list coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescribe diabetic supplies with a written prescription; only Accu-Chek meters and test strips are covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug categories listed

CGMs excludedCGMs excluded

Accu-Chek onlyMeter/test strip coverage

availableLanguage assistance

711TTY/TDD

PreventiveRx Coverage Rules

List-based coverage rule

Covered when the prescription drug appears on the PreventiveRx list and member benefit allows

List membership and benefit allowance: Drug is listed in the PreventiveRx document and member's Certificate/Evidence of Coverage allows coverage

Most brand-name drugs that have a generic equivalent available are not covered under this PreventiveRx benefit; some drugs and supplies may be explicitly excluded—refer to the member's Certificate or Evidence for Coverage for limitations and exclusions.

Diabetic supplies special conditions: If the item is a diabetic supply (blood glucose meter, test strips, lancets), a prescription is required for coverage and only Accu-Chek blood glucose meters and test strips are covered; continuous glucose monitors (CGMs) are excluded from PreventiveRx coverage.

Refer to the PreventiveRx diabetes section for listed drugs and the specific supply limitations.

Coverage under PreventiveRx is list-based: a prescription is covered when the drug appears on the PreventiveRx list and the member’s Certificate/Evidence of Coverage allows coverage. The list includes only prescription products and may change over time; all prior versions are no longer in effect. (Brand-name drugs are shown with initial caps; generics are lowercase.)

Policy Summary

PayerAnthem

PolicyPreventiveRx Plus Plan (CA Select) — PreventiveRx drug list coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescribe diabetic supplies with a written prescription; only Accu-Chek meters and test strips are covered.

SourceLink

On This Page

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Provider Requirements, Limitations, and Risks

Denial Risk

Coverage limitations and exclusions

Providers: review plan Certificate/Evidence of Coverage for specific coverage limits and member benefit details. Some drugs and supplies may be excluded from PreventiveRx benefits; items excluded by the plan or by the member's EOC are not payable under this benefit.

Verify member benefits and EOC for plan-specific limits and exclusions before prescribing or dispensing.
PreventiveRx generally excludes most brand-name drugs when a generic equivalent exists; check formulary status.
Continuous Glucose Monitors (CGMs) are not covered under PreventiveRx.

Prior Authorization

Prescriptions and product verification required

Obtain and document a valid prescription where required and confirm the product is an eligible PreventiveRx item prior to billing. For diabetic supplies, ensure prescription presence and that the product is an Accu-Chek meter or Accu-Chek test strips when billing under this benefit.

Obtain prescription for blood glucose meters, test strips, and lancets prior to submission.
Confirm brand: only Accu-Chek meters and test strips are covered under PreventiveRx; other brands may be denied.

Denial Risk

Denial risk for excluded products

Claims for excluded products or products that exceed plan/EOC limits are at high risk for denial. Do not assume PreventiveRx coverage for items outside the listed formulary or for brand-name products with generic equivalents unless the member's benefit specifically allows it.

Billing non-Accu-Chek meters/test strips or CGMs under PreventiveRx will likely be denied.
Brand drugs with available generics may be non-covered under PreventiveRx; verify coverage before dispensing.

Documentation Required

Risk of grievance/complaint for failure to provide language or disability assistance

Failure to provide required language access or disability accommodations may lead to member grievances or regulatory complaints. If a member indicates language or accessibility needs, arrange interpreter or auxiliary aids and document the assistance offered. Members can file complaints with Anthem or with HHS OCR if they believe discrimination occurred.

Offer and document language interpretation and disability accommodations when requested; call Member Services number on the member's ID card for assistance.
If members allege failure to provide required services, they may file a grievance with Anthem or a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.

Key Definitions

PreventiveRx definition — benefit description and variation by plan

DefinitionPreventiveRx coverage — a benefit for prescription drugs that may keep members healthy by preventing illness or other health conditions; coverage is provided at low or no cost depending on the member's benefit.

What is includedThis list includes only prescription products; brand-name drugs are capitalized and generics are listed in lowercase.

Coverage variation by planCoverage depends on the member's specific benefit — products on the PreventiveRx list are covered only if the member's Certificate or Evidence of Coverage allows it.

Brand-name restrictionMost brand-name drugs that have a generic equivalent available are not covered under the PreventiveRx benefit unless specifically listed.

List maintenanceThe PreventiveRx drug list is subject to change and prior versions are no longer in effect.

grievance — civil rights complaint definition/context

DefinitionGrievance — a complaint filed by a member when they believe the plan failed to provide required services or discriminated based on race, color, national origin, sex, age, or disability; also referred to as a civil rights complaint.

When to fileFile a grievance if the member believes required language assistance or disability-related aids and services were not provided, or if discrimination occurred.

How to file with the planSend a written complaint to the Compliance Coordinator at P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279.

How to file with OCRFile 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; call 1-800-368-1019 (TDD: 1-800-537-7697) or file online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

Assistance and contactMembers should call the Member Services number on their ID card for free language assistance or disability-related aids and services (TTY/TDD: 711).

OpenPayer

PreventiveRx Plus Plan (CA Select) — PreventiveRx drug list coverage

PreventiveRx Coverage Rules

Provider Requirements, Limitations, and Risks

Program Background

Key Definitions