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.
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- 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
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- Aspirin chewable 81mg
- Aspirin tablets 81mg
- Aspirin delayed-release 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
- peg-3350/electrolytes/ascorbate
- Peg-Prep Kit
- Plenvu
- Suprep
- 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
- Continuous contraceptives
- Ella
- Extended cycle contraceptives
- Female condoms
- 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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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
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- 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
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FOLIC ACID SUPPLEMENTS
To help prevent birth defects in women 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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- Adults, 18 years of age and older
- Persons not currently infected with HIV who are at high risk of acquiring HIV infection
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- Emtricitabine/tenofovir disoproxil fumarate 200mg/300mg
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SMOKING CESSATION
To help adults quite tobacco use in order to prevent health problems. Tobacco use includes smoking and chewing tobacco.
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- Generics and brands without generic availability
- Prescription required
- Limited to 168 days of therapy per year
- Limited to the day supply per plan document
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- 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
- Low to moderate doses only
- Prescription required
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- 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
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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
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- COVID-19
- Diphtheria, Tetanus, Pertussis
- Haemophilus influenzae type B
- Hepatitis A
- Hepatitis B
- Human Papillomavirus
- Influenza
- Measles, Mumps, Rubella
- Meningococcal
- Pneumococcal
- Poliovirus, inactivated
- Rotavirus
- Varicella
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VACCINES-ADULT
To prevent certain illnesses.
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- Adults, 18 years of age and older
- Prescription only
- Plans may choose to cover vaccines under the medical or pharmacy benefit
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- COVID-19
- Diphtheria, Tetanus, Pertussis
- Hepatitis A
- Hepatitis B
- Herpes Zoster
- Human Papillomavirus
- Influenza
- Measles, Mumps, Rubella
- Meningococcal
- Pneumococcal
- Varicella
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