Preventive Drugs 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% 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.	anastrozole 1mg exemestane 25mg raloxifene 60mg tamoxifen 10mg and 20mg
COLORECTAL SCREENING To clean out the bowel before a colonoscopy. Colonoscopies screen for colon and rectal cancers.	Adults, 45 to 75 years of age Generics and brands without generic availability Prescription required	Clenpiq peg-3350/electrolytes/ascorbate Peg-Prep Kit Plenvu Suprep Sutab
CONTRACEPTIVES	Females or members capable of pregnancy Generics and brands without generic availability Prescription required Limited to the day supply per plan document	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
FLUORIDE SUPPLEMENTS To help prevent cavities (dental caries) in children whose water is low in fluoride.	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 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
HIV PRE-EXPOSURE PROPHYLAXIS To decrease the risk of human immunodeficiency virus (HIV) infection in persons at high risk of acquiring HIV infection.	Adults, 18 years of age and older Persons not currently infected with HIV who are at high risk of acquiring HIV infection	Emtricitabine/tenofovir disoproxil fumarate 200mg/300mg
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 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
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	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
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	COVID-19 Diphtheria, Tetanus, Pertussis Hepatitis A Hepatitis B Herpes Zoster Human Papillomavirus Influenza Measles, Mumps, Rubella Meningococcal Pneumococcal Varicella