| Drug List – Preventive Items and Services Offering - 2024 |
| Medicine Category and Who is Covered |
Examples of Medicines Covered |
|
Aspirin
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Generic, single-entity aspirin 81 mg
Includes copay exception review process |
|
Breast Cancer – Primary Prevention
- Persons ≥ 35 years who meet criteria.
(Only one of the available options
described is chosen for coverage by a prescription drug plan)
|
Preferred Option: Copay Exception Review only:
Brand and generic tamoxifen (tablet, liquid solution); and for post-menopausal persons: raloxifene, anastrozole, and exemestane
Non-Preferred Option:
Generic tamoxifen, raloxifene, anastrozole, exemestane,
and brand Soltamox are all covered at POS for $0 member-share without review.
For other products not covered at $0 cost-share at the point of service, a memberor
prescriber-initiated copay exception review is available.
|
|
Contraceptive Methods
- Persons of any age capable of pregnancy
(Only one of the available options
described is chosen for coverage by a
prescription drug plan)
|
Brand name contraceptives with a generic equivalent are $0 cost share only
when the prescriber indicates the brand product must be dispensed or generic is
not available.
Expanded Product Option*:
Covered products include all FDA-approved 16 contraceptive methods available through the pharmacy benefit, including: OTC contraceptive methods (condoms, spermicides, etc.), oral contraceptives (including emergency contraception), and contraceptive devices.
Preferred Product with Step Therapy Option*:
Covered products, available at no cost, include one or more Food and Drug Administration (FDA) approved “Preferred Products” from the 16 contraceptive methods available through the pharmacy benefit. The “Preferred Products” include: generic OTC spermicide and legend diaphragms; Today® contraceptive sponge; condoms; Femcap®; generic oral, transdermal and intramuscular hormonal methods; contraceptive ring; generic, OTC emergency contraceptives; the intrauterine system Mirena®; and the intradermal agent, Nexplanon®. Step Therapy criteria are applied to select brand contraceptives.
Preferred Product Option*:
Covered products, available at no cost, include one or more Food and Drug Administration (FDA) approved “Preferred Products” from the 16 contraceptive methods available through the pharmacy benefit. The “Preferred Products” include: generic OTC spermicide and legend diaphragms; Today® contraceptive sponge; condoms; Femcap®; generic oral, transdermal and intramuscular hormonal methods; contraceptive ring; generic, OTC emergency contraceptives; the intrauterine system Mirena®; and the intradermal agent, Nexplanon®.
All options include copay exception review process.
*coverage of medications at $0 cost share is dependent on the list of medications covered by the
member’s drug formulary.
|
|
Fluoride
- Persons 6 months through <17 years
|
- Fluoride Chewable or Drops ≤ 1.0 MG generic
- Multivitamin/Fluoride (≤ 1.0 MG )Chewable/Drops/Suspension generic
Includes copay exception review process
|
|
Folic Acid
|
- Folic Acid Tablet 0.4 MG and 0.8 MG generic
- Prenatal Vitamins with Folic Acid (0.4 MG and 0.8 MG) generic
Includes copay exception review process
|
|
HIV Prep
- Persons of any age
Only for members lacking a history of treatment for HIV (using claims data).
|
- Emtricitabine / tenofovir disoproxil fumarate (TDF) generic - 200 mg / 300 mg dose only
Includes copay exception review process
|
|
Immunizations
- The age for coverage varies based on the vaccine product prescribed and recommendations by the U.S. Centers for Disease Control and Prevention
(Only one of the available options
described is chosen for coverage by a
prescription drug plan)
|
Option 1:
Covered immunizations include those that are routine vaccines and non-routine immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention and that meet the US Food and Drug Administration approved indications for age limitations.
Option 2:
This option only includes routine vaccines as defined by the ACIP.
Both options include copay exception review process.
|
|
Medications used to prepare for Colonoscopy
- Persons ≥ 45 and ≤ 75 years of age Limit of 2 prescriptions per year; Package
size limitations may apply
(Only one of the available options
described is chosen for coverage by a prescription drug plan)
|
Generic Only Option:
Covered products include legend and over-the-counter medicines such as:
Bisacodyl; Magnesium Citrate; Milk of Magnesia; and PEG 3350 generic.
Generic Plus Brand Option:
Covered products include the above listed generics plus select brands.
Both options include copay exception review process.
|
|
Statins
- Persons ≥ 40 years and ≤ 75 years
(Only one of the available options
described is chosen for coverage by a prescription drug plan)
|
Covered products may include generic low to moderate dose statins:
- Atorvastatin ≤ 20mg
- Pravastatin ≤ 80mg
- Fluvastatin ≤ 80mg
- Rosuvastatin ≤ 10mg
- Lovastatin ≤ 40mg
- Simvastatin ≤ 40mg
Standard Program Option 1:
generic low/moderate dose statins
Trend Management Program Option 2:
generic low/moderate dose statins only
for members meeting CVD medical history and Rx risk factor requirements (using claims data).
Both options include copay exception review process.
|
|
Tobacco Cessation
- Persons 18 and older
(Only one of the available options
described is chosen for coverage by a prescription drug plan)
|
Bupropion sustained release 150mg generic; Varenicline; and Nicotine
Smoking Cessation Option 1
All FDA approved products listed above are covered with no limitations.
Smoking Cessation Option 2
All FDA approved products listed above are covered for a maximum of 180 days
therapy per 365 days after which, the member is responsible for a usual copayment
amount.
Smoking Cessation Option 3
All FDA approved products listed above are covered for a maximum of 180 days
therapy per 365 days after which, the member is responsible for 100% of the
prescription cost.
Smoking Cessation Option 4
All Generic FDA approved products listed above are covered for a maximum of
180 days therapy per 365 days after which, the member is responsible for a
usual co-payment amount.
All options include copay exception review process.
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