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Contraceptive Methods
- Persons < age 51 years
(Only one of the available programs described is chosen for coverage by a prescription drug plan.)
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Brand name contraceptives with a generic equivalent are zero cost share only when the prescriber indicates the brand product must be dispensed or generic is not available.
Expanded Product Program:
Covered products include all FDA-approved 16 contraceptive methods available through the prescription drug benefit, including: all OTC contraceptive methods (female condom, spermicides, etc.), all oral
contraceptives (including emergency contraception), and all contraceptive devices.
Preferred Product Program with Step Therapy:
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 prescription drug
benefit. The “Preferred Products” include: generic OTC spermicide and legend diaphragms; Today® contraceptive sponge; female condom; Femcap®; generic oral, transdermal and intramuscular hormonal methods;
contraceptive ring; generic, OTC emergency contraceptives and ella®; the intrauterine systems Mirena® and Paragard®; and the intradermal agent, Nexplanon®.
Step Therapy criteria are applied to select brand oral contraceptives. Zero-dollar coverage of a contraceptive not included as a “Preferred Product” is available after copayment review.
Preferred Product Program:
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 prescription drug
benefit. The “Preferred Products” include: generic OTC spermicide and legend diaphragms; Today® contraceptive sponge; female condom; Femcap®; generic oral, transdermal and intramuscular hormonal methods;
contraceptive ring; generic, OTC emergency contraceptives and ella®; the intrauterine systems Mirena® and Paragard®; and the intradermal agent, Nexplanon®.
Zero-dollar coverage of a contraceptive not included as a “Preferred Product” is available after copayment review.
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Immunizations
- The age for coverage varies based on the vaccine product prescribed and recommendations by the U.S. Centers for Disease Control and Prevention
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Covered immunizations include those that are routine vaccines 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 and/or gender limitations. Coverage also includes non-routine immunizations as defined by ACIP.
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Medications used to prepare for Colonoscopy
- Persons ≥ 50 and ≤ 75 years of age Limit of 2 prescriptions per year
(Only one of the available programs described is chosen for coverage by a prescription drug plan.)
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Generic Only Program:
- Bisacodyl;, Magnesium Citrate; Milk of Magnesia; and PEG 3350 generic
Generic Plus Brand Program:
Covered products include:
- Bisacodyl;, Magnesium Citrate; Milk of Magnesia; and PEG 3350 generic Plus
- GoLytely; MoviPrep; OsmoPrep; Prepopik; and Suprep
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Statins
- Persons ≥ 40 years and ≤ 75 years
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Covered products may include generic low to moderate dose statins:
- Atorvastatin ≤ 20mg
- Pravastatin ≤ 80mg
- Fluvastatin ≤ 80mg
- Rosuvastatin ≤ 10mg
- Lovastatin ≤ 40 mg
- Simvastatin ≤ 40mg
Standard Program “Option 1”:
all generic low/moderate dose statins
Trend Management Program “Option 2”:
Select generic low/moderate dose statins only for members meeting CVD medical history and Rx risk factor requirements (using claims data).
Option includes Co-Pay Exception Review feature.
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Tobacco Cessation
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- Zyban (Brand and Generic)
- Chantix
- Nicotine Products (Rx and OTC; Brand and Generic)
Smoking Cessation
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 co-payment amount.
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