Preventive Drug List

In accordance with requirements of the Affordable Care Act (ACA - also known as health care reform), the following drugs are provided to you at no cost if your plan meets the requirements. This means that the costs are covered 100 percent by your health plan with no co-pay or coinsurance involved. Step therapy, quantity limits and preauthorization may apply. Please refer to your Individual Policy (also known as Certificate of Coverage, Master Contract or Plan Document) for information regarding coverage determination.

**This list does not guarantee coverage and is subject to change.**

How do I identify if my plan covers the preventive drugs at no cost? Review your Summary of Benefits and Coverage, page three. Your pharmacy benefits identify if Tier 0 or Tier 1 Preventive Drugs are free or if you will have a co-pay and/or need to meet a deductible.

  Restrictions What is Covered

ASPIRIN

To help prevent serious heart and blood vessel problems (cardiovascular disease) and colorectal cancer in adults who are at risk.

To prevent illness and death from preeclampsia in women after 12 weeks of pregnancy and are at high risk for the condition.

  • Males, 50-59 years of age
  • Females or members capable of pregnancy, 12-59 years of age
  • Generics only
  • Prescription required
  • Limited to the day supply per plan document or maximum quantity of 100 per fill
  • Aspirin chewable 81mg
  • Aspirin tablets 81mg
  • Aspirin delayed-release 81mg

BREAST CANCER PREVENTION

To prevent cancer in women who are at increased risk.

  • Females 35 years of age and older
  • Generic only
  • Prescription required
  • Limited to the day supply per plan document.
  • raloxifene 60mg*
  • tamoxifen 10mg and 20mg

COLORECTAL SCREENING

To clean out the bowel before a colonoscopy. Colonoscopies screen for colon and rectal cancers.

  • Adults, 50 to 74 years of age
  • Generics and brands without generic availability
  • Prescription required
  • Clenpiq
  • Gavilyte-H Kit
  • Moviprep
  • Peg-Prep Kit
  • Plenvu
  • Prepopik
  • Suprep
CONTRACEPTIVES
  • Females or members capable of pregnancy
  • Generics and brands without generic availability
  • Prescription required
  • Limited to the day supply per plan document
  • Biphasic contraceptives
  • Combination contraceptives
  • Continuous contraceptives
  • Ella
  • Extended cycle contraceptives
  • Female condoms
  • Four phase contraceptives
  • levonorgestrel 1.5mg
  • Monophasic contraceptives
  • NuvaRing
  • Progestin only contraceptives
  • Spermicides
  • Triphasic contraceptives
  • Vaginal sponges
  • Xulane

FLUORIDE SUPPLEMENTS

To help prevent cavities (dental caries) in children whose water is low in fluoride.

  • Children, 0-5 years of age
  • Oral dosage forms up to 0.5mg
  • Brand and generic prescription drugs only
  • Limited to the day supply per plan document
  • Sodium fluoride chewable 0.25mg
  • Sodium fluoride chewable 0.5mg
  • Sodium fluoride tablets 0.5mg
  • Sodium fluoride 0.125mg/drop
  • Sodium fluoride 0.25mg/drop
  • Sodium fluoride 0.25mg/0.6mL
  • Sodium fluoride 0.5mg/mL

FOLIC ACID SUPPLEMENTS

To help prevent birth defects in women who are planning on, able to become or are pregnant.

  • Females or members capable of pregnancy, up to 55 years of age
  • Generics only
  • Prescription required
  • Limited to the day supply per plan document or maximum quantity of 100 per fill
  • Folic acid tablets 0.4mg
  • Folic acid tablets 0.8mg
  • Folic acid capsules 0.8mg

SMOKING CESSATION

To help adults quite tobacco use in order to prevent health problems. Tobacco use includes smoking and chewing tobacco.

  • Generics and brands without generic availability
  • Prescription required
  • Limited to 168 days of therapy per year
  • Limited to the day supply per plan document
  • bupropion SR*
  • Chantix 0.5mg and 1mg
  • Nicotine gum (generic only) 2 and 4mg
  • Nicotine lozenges (generic only) 2 and 4mg
  • Nicotine patches (generic only) 7mg, 14mg and 21mg

STATIN PREVENTION

To prevent cardiovascular disease in adults who are at risk.

  • Adults, 40 to 75 years of age
  • Generics only
  • Low to moderate doses only
  • Prescription required
  • atorvastatin 10mg and 20mg
  • fluvastatin 20mg and 40mg
  • fluvastatin ER 80mg
  • lovastatin 10mg, 20mg and 40mg
  • pravastatin 10mg, 20mg, 40mg and 80mg
  • rosuvastatin 5mg and 10mg
  • simvastatin 5mg, 10mg, 20mg and 40mg

VACCINES-CHILDREN

To prevent certain illnesses.

  • Children, up to 18 years of age
  • Prescription only
  • Plans may choose to cover vaccines under the medical or pharmacy benefits
  • Diphtheria, Tetanus, Pertussis
  • Haemophilus influenzae type B
  • Hepatitis A
  • Hepatitis B
  • Human Papillomavirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Poliovirus, inactivated
  • Rotavirus
  • Varicella

VACCINES-ADULT

To prevent certain illnesses.

  • Adults, 18 years of age and older
  • Prescription only
  • Plans may choose to cover vaccines under the medical or pharmacy benefit
  • Diphtheria, Tetanus, Pertussis
  • Hepatitis A
  • Hepatitis B
  • Herpes Zoster
  • Human Papillomavirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Varicella

*Medical exception must be provided.

Reviewed by LJS on October 17, 2018