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. This list is subject to change at any time.

Over-the-counter products (noted with an asterisk (*) below) are covered only 1) if your health care provider provides a written prescription, and 2) if dispensed at an on-site clinic (unless a clinic is not available at your mine/office, in which case it is covered 100% at an In-Network retail pharmacy).

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:

Low-dose aspirin* for the prevention of cardiovascular disease, colorectal cancer, or pregnancy preeclampsia (1 per day, 81mg)

  • 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

Folic acid supplement*

  • Multivitamin with 0.4mg to 0.8mg of folic acid
  • 1 per day
 

 

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 Zyban – up to 360 tablets/year
  • Chantix – up to 360 tablets/year
  • Nicotine TD patch 24-hour kit – up to 180 patches/year
  • Nicotine polacrilex gum 2/4 mg 
  • Nicotine polacrilex lozenge 2/4 mg
  • Nicotrol nasal spray
  • Nicotrol inhaler
 

Adults who use tobacco products

FDA-approved contraceptives
  • FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling
  • Abortifacients are not included as contraceptives
  • 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 (whooping cough)
  • Varicella
 

Children: newborn to age 18

Adult immunizations
  • Hepatitis A and B
  • Human Papillomavirus
  • Influenza
  • Measles, Mumps, & Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, & Pertussis (whooping cough)
  • Varicella (chickenpox)
  • Zoster (Herpes Zoster)
 

Adults: age 19 or older

Low to moderate dose statins for the prevention of cardiovascular disease

 
Adults: ages 40-75

Screening for colorectal cancer - bowel evacuant combinations

  • Over-the-counter (OTC) requires a prescription
  • Oral magnesium citrate
  • Polyethylene glycol 3350
 
Adults: ages 50-75
Breast cancer prevention - Tamoxifen and Raloxifene (Evista)
  • Requires prior authorization
  • 1 per day
 
Women: ages 35 and older
Pre-Exposure Prophylaxis (PrEP) for HIV infection
  • Descovy and Truvada
  • 1 per day
 
Adults: ages 18 and older

* Covered only 1) if your health care provider provides a written prescription, and 2) if dispensed at an on-site clinic (unless a clinic is not available at your mine/office, in which case it is covered 100% at an In-Network retail pharmacy).