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ASPIRIN
To prevent illness and death from preeclampsia in women after 12 weeks of pregnancy and are at high risk for the condition.
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- 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
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- Aspirin chewable tablets 81mg
- Aspirin enteric coated tablets 81mg
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BREAST CANCER PREVENTION
To prevent cancer in women who are at increased risk.
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- Females 35 years of age and older
- Generic only
- Prescription required
- Limited to the day supply per plan document.
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- anastrozole 1mg
- exemestane 25mg
- raloxifene 60mg
- tamoxifen 10mg and 20mg
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COLORECTAL SCREENING
To clean out the bowel before a colonoscopy. Colonoscopies screen for colon and rectal cancers.
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- Adults, 45 to 75 years of age
- Generics and brands without generic availability
- Prescription required
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- Clenpiq
- Gavilyte
- peg-3350/electrolytes/ascorbate
- Peg-Prep Kit
- Plenvu
- sodium sulfate/potassium sulfate/magnesium sulfate
- Suflave
- Sutab
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| CONTRACEPTIVES |
- Females or members capable of pregnancy
- Generics and brands without generic availability
- Prescription required
- Limited to the day supply per plan document
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- Annovera
- Biphasic contraceptives
- Combination contraceptives
- Condoms (male and female)
- Continuous contraceptives
- Ella
- Extended cycle contraceptives
- Four phase contraceptives
- levonorgestrel 1.5mg
- Monophasic contraceptives
- Phexxi
- Progestin only contraceptives
- Spermicides
- Transdermal patch contraceptives
- Triphasic contraceptives
- Vaginal ring contraceptives
- Vaginal sponges
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DIABETES PREVENTION
To prevent diabetes in adults who are at risk.
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- Persons not currently diagnosed with diabetes who are at risk for developing diabetes.
- Adults, 35 to 70 years of age
- Generic only
- Prescription required.
- Limited to the day supply per plan document.
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FLUORIDE SUPPLEMENTS
To help prevent cavities (dental caries) in children whose water is low in fluoride.
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- Children, 0-5 years of age
- Brand and generic prescription drugs only
- Limited to the day supply per plan document
|
- Sodium fluoride chewable 0.25mg, 0.5mg, 1mg
- Sodium fluoride tablets 0.5mg, 1mg
- Sodium fluoride 0.5mg/mL
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FOLIC ACID SUPPLEMENTS
To help prevent birth defects in persons who are planning on, able to become or are pregnant.
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- 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
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- Folic acid tablets 0.4mg
- Folic acid tablets 0.8mg
- Folic acid capsules 0.8mg
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HIV PRE-EXPOSURE PROPHYLAXIS
To decrease the risk of human immunodeficiency virus (HIV) infection in persons at high risk of acquiring HIV infection.
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- Persons not currently infected with HIV who are at high risk of acquiring HIV infection
- Limited to the day supply per plan document
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- Emtricitabine/tenofovir disoproxil fumarate 200mg/300mg
|
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SMOKING CESSATION
To help adults quit 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 150mg
- Nicotine gum (generic only) 2 and 4mg
- Nicotine inhaler 10mg
- Nicotine lozenges (generic only) 2 and 4mg
- Nicotine nasal spray 10mg/ml
- Nicotine patches (generic only) 7mg, 14mg and 21mg
- Varenicline tartrate 0.5mg and 1mg
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STATIN PREVENTION
To prevent cardiovascular disease in adults who are at risk.
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- Adults, 40 to 75 years of age
- Generics only
- Prescription required
|
- atorvastatin 10mg, 20mg, 40mg, 80mg
- fluvastatin 20mg, 40mg
- fluvastatin ER 80mg
- lovastatin 10mg, 20mg, 40mg
- pitavastatin 1mg, 2mg, 4mg
- pravastatin 10mg, 20mg, 40mg, 80mg
- rosuvastatin 5mg, 10mg, 20mg, 40mg
- simvastatin 5mg, 10mg, 20mg, 40mg, 80mg
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VACCINES-CHILDREN
To prevent certain illnesses.
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- Children, up to 18 years of age
- Prescription only
- Plans may choose to cover vaccines under the medical or pharmacy benefits
|
- COVID-19
- Diphtheria, Tetanus, Pertussis
- Haemophilus influenzae type B
- Hepatitis A
- Hepatitis B
- Human Papillomavirus
- Influenza
- Measles, Mumps, Rubella
- Meningococcal
- Pneumococcal
- Poliovirus, inactivated
- Respiratory Syncytial Virus (RSV)
- Rotavirus
- Varicella
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VACCINES-ADULT
To prevent certain illnesses.
|
- Adults, 19 years of age and older
- Prescription only
- Plans may choose to cover vaccines under the medical or pharmacy benefit
|
- COVID-19
- Hepatitis A
- Hepatitis B
- Herpes Zoster
- Human Papillomavirus
- Influenza
- Measles, Mumps, Rubella
- Meningococcal
- Pneumococcal
- Respiratory Syncytial Virus (RSV)
- Tetanus, Diphtheria, Pertussis
- Varicella
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Reviewed by LJS on 10/15/24
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