Approved Preventive Drugs

The following drugs are covered at the Approved Preventive Drugs benefit level shown in "Highlights of the Plan," within the frequency, dosage, and patient age limits described below. Over-the-counter products are covered only 1) at an on-site health Center, and 2) if your health care provider provides a written prescription for you. This list is subject to change at any time.

The Approved Preventive Drugs benefit level is 100% coverage for eligible generic drugs. Eligible brand-name preventive drugs are covered at 100% only if there is no generic alternative available. If you choose a brand-name preventive drug when a generic is available, you are subject to cost-sharing as shown in "Highlights of the Plan."

Preventive DrugCoverage for:

Covered only when dispensed at an on-site Health Center (unless a center is not available at your mine/office, in which case it is covered 100% at an In-Network retail pharmacy):

Aspirin for the prevention of cardiovascular disease or pregnancy preeclampsia (1 per day, 81mg to 325mg)

  • Aspirin tablet
  • Aspirin chew
  • Aspirin delayed release
  • Aspirin dispersible tablet

Men (ages 45-79);
Women (ages 55-79); and
Pregnant women who are at high risk for preeclampsia

Covered only when dispensed at an on-site Health Center (unless a center is not available at your mine/office, in which case it is covered 100% at an In-Network retail pharmacy):

Prescribed Vitamin D supplement

Adults age 65 and older who do not reside in a nursing home or other long-term facility

Covered only when dispensed at an on-site Health Center (unless a center is not available at your mine/office, in which case it is covered 100% at an In-Network retail pharmacy):

Folic acid supplement

  • Multivitamin with 0.4mg to 0.8mg of folic acid

Women who are planning or capable of pregnancy

Oral fluoride supplement

  • Sodium fluoride products only, not in combination
  • Sodium fluoride tablet 0.5mg
  • Sodium fluoride chew tablet 0.25mg to 0.5mg
  • Sodium fluoride solution

Children – newborn to five years whose primary water source is deficient in fluoride

Tobacco-cessation drugs listed as preventive in the Coverage Tiers (Formulary)

See list of tobacco-cessation drugs under "Approved Disease-Management Drugs"

Adults who use tobacco products

FDA-approved contraceptives
  • FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling
  • Products covered:
    • Oral contraceptives
    • Patch and vaginal contraceptives
    • Emergency contraceptives
    • Injectable
    • Diaphragms
    • Spermicides
    • Sponges
    • Cervical caps
    • Female condoms
    • Progestin IUD
    • Progestin implants

Women

Child immunizations
  • Haemophilus Influenza Type B
  • Hepatitis A and B
  • Human Papillomavirus
  • Inactivated Poliovirus
  • Influenza
  • Measles, Mumps, & Rubella
  • Meningococcal
  • Pneumococcal
  • Rotavirus
  • Tetanus, Diphtheria, & Pertussis (<g class="gr_ gr_75 gr-alert gr_gramm gr_inline_cards gr_run_anim Grammar multiReplace" id="75" data-gr-id="75">whooping cough</g>)
  • Varicella

Children: newborn to age 18

Adult immunizations
  • Hepatitis A and B
  • Human Papillomavirus
  • Influenza
  • Measles, Mumps, & Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, & Pertussis (<g class="gr_ gr_76 gr-alert gr_gramm gr_inline_cards gr_run_anim Grammar multiReplace" id="76" data-gr-id="76">whooping cough</g>)
  • Varicella (chickenpox)
  • Zoster (Herpes Zoster)

Adults: age 19 or older