∙ Sodium fluoride tab Fluoride - Sodium fluoride products 0.5mg – 1mg Chemoprevention of Age limit ≤ 6 years of age only, not in combination. ∙ Sodium fluoride chew tab dental cavities 0.25mg – 0.5mg ∙ Sodium fluoride solution Folic Acid - Women planning or Folic acid products only, ∙ Folic Acid tab 0.4mg and Supplementation with capable of pregnancy not in combination. 0.8mg. folic acid Quantity limit: 1/day Vitamin D for fall prevention Age limit ≥ 65 years of Vitamin D age All generic statin products Atorvastatin 10mg, in low to moderate doses, 20mg. Fluvastatin 20mg, Statins Age limit 40-75 years plus additional doses of 40mg. Lovastatin 10mg, generic statin products to 20mg. Rosuvastatin 5mg, the extent determined 10mg. Pravastatin 10mg, preventive by the Plan 20mg. Simvastatin 5mg, Administrator. 10mg, 20mg. Prescribed Anastrozole 1mg, Females only, ages > 35 chemoprevention Exemestane 25mg, Breast Cancer years of age medications for women at Raloxifene 60mg, and increased risk of breast Tamoxifen 10mg, 20mg. cancer. Iron supplements Age limit 6 to 12 months All dosage forms covered. at risk for anemia Emtricitabine and Tenofovir PrEP PrEP diagnosis only disoproxil fumarate Generic Truvada 200mg/300mg Any prescribed Age limit > 50 years of age Immunizations vaccination administered for Shingrix. at a pharmacy. Up to a 90-day supply of The prescriber must prescribed tobacco prescribe all smoking Nicotine patches, gum, Tobacco Cessation cessation drugs two cessation products for use lozenges, and Varenicline. times in 365 calendar within the 90-day days. treatment time frame. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 13 of 15