No-cost essential health benefit - 2023 Health Care Reform Preventive Drug List
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No-cost essential health benefit 2023 Health Care Reform Preventive Drug List 917902-01-03 (1/23)
Under the Affordable Care Act, also known as health care reform, you can get some drugs at
no member cost share. But you must have a prescription. Then they are covered 100 percent
by your plan. The list below shows some items that are available. The list even includes some
medicine you can get over-the-counter.
Some drugs not listed are eligible for zero dollar copay only with a medical exception.
Key
UPPERCASE Brand-name medicine
2023 Health Care Reform Drug List
lowercase italics Generic medicine
Effective January 2023
Category Generic name Brand name
Drug class
Aspirin products aspirin tab 81 mg none
Covered for members who are
12-59 years when prescribed by a
doctor.
Bowel-preparation medications gavilyte-h kit CLENPIQ SOL
Limited for members peg-3350/electrolytes/ascorbate solr 7.5-2.691g PLENVU SOL
ages 45 through 74 years. peg-prep kit 5 mg-210 g SUTAB
suprep
Fluoride sodium fluoride chew tab 0.25 mg, 0.5m mg, none
Oral fluoride covered for sodium fluoride tab 0.5 mg,
children ages 6 months through sodium fluoride 1.1 mg/ml drops, 0.275 mg/ml
5 years without fluoride in their drops
water source.
Folic acid folic acid cap 0.8 mg none
Recommended for members folic acid tab 200 mcg
who are or may become pregnant. folic acid tab 400 mcg
Covered for members through
folic acid tab 800 mcg
age 55 years.
Prediabetes metformin 850mg none
Limited for men and women ages
35 – 70.
In Idaho, health benefits and health insurance plans are offered and/or underwritten by Aetna Health
of Utah Inc. and Aetna Life Insurance Company (Aetna). Health benefits and health insurance plans
are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health of California Inc.,
Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna
Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health
Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and
Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford,
CT 06156. Each insurer has sole financial responsibility for its own products.Category Generic name Brand name
Drug class
Prevention of breast cancer anastrozole 1mg none
Primary prevention of breast exemestane tab 25mg
cancer in members 35 years of raloxifene tab 60mg
age and older, who are at an
tamoxifen tab 10mg and 20 mg
increased risk.
Prevention of human emtricitabine/tenofovir disoproxil fumarate none
immunodeficiency tabs 200-300 mg
virus (HIV) infection
Pre-exposure prophylaxis
Statin medications atorvastatin 10 mg none
Covered for members atorvastatin 20 mg
between 40-75 years of age. simvastatin 5 mg
Quantity limits apply.
simvastatin 10 mg
simvastatin 20 mg
simvastatin 40 mg
Tobacco-cessation medications bupropion HCl (smoking deterrent) tab SR* CHANTIX
Covered with a prescription. nicotine TD patch NICOTINE TRANSDERMAL
Limits apply and vary by plan. nicotine polacrilex gum SYSTEM KIT 21-14-7MG
* Only when prescribed for nicotine polacrilex lozenge NICOTROL INHALER
smoking cessation. NICOTROL NS
varenicline tab 0.5mg
varenicline tab 1mg
Women’s contraceptives
May not be included under some plans. Certain religious organizations or religious employers may be exempt from offering
contraceptive services. If these requirements apply to your plan, consult your plan documents for more information.
Biphasic Contraceptives - Oral azurette LO LOESTRIN FE
desogestrel/ethinyl estradiol
kariva
norethindrone & ethinyl estradiol ferrous fumarate
chew 0.8-25(24)
norethindrone acetate/ethinyl estradiol tabs
1.5-0.03mg
norethindrone acetate/ethinyl estradiol tabs
1mg-20mcg
norethindrone acetate/ethinyl estradiol/ferrous
fumarate caps 1mg-20(24)
norethindrone acetate/ethinyl estradiol/ferrous
fumarate chew 1mg-20(24)
norethindrone acetate/ethinyl estradiol/ferrous
fumarate tabs 1.5-30(21)
norethindrone acetate/ethinyl estradiol/ferrous
fumarate tabs 1mg-20(21)
norethindrone/ethinyl estradiol/ferrous fumarate
chew 0.4-35(21)
pimtrea
simliya
viorele
volnea
Cervical Caps none FEMCAPCategory Generic name Brand name
Drug class
Combination Contraceptives - Oral afirmelle BALCOLTRA
altavera NEXTSTELLIS
alyacen 1/35 TYBLUME
apri
aubra
aubra eq
aurovela 1.5/30
aurovela 1/20
aurovela 24 fe
aurovela fe 1.5/30
aurovela fe 1/20
aviane
ayuna
balziva
blisovi 24 fe
blisovi fe 1.5/30
blisovi fe 1/20
briellyn
charlotte 24 fe
chateal
chateal eq
cryselle-28
cyclafem 1/35
cyred
cyred eq
dasetta 1/35
delyla
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
drospirenone/ethinyl estradiol/levomefolate
calcium
elinest
emoquette
enskyce
estarylla
ethynodiol diacetate/ethinyl estradiol
falmina
femynor
gemmily
hailey 1.5/30
hailey 24 fe
hailey fe 1.5/30
hailey fe 1/20
isibloom
kalliga
kelnor 1/35
kelnor 1/50
kurvelo
larin 1.5/30Category Generic name Brand name
Drug class
Combination Contraceptives - Oral larin 1/20
continued larin 24 fe
larin fe 1.5/30
larin fe 1/20
larissia
layolis fe
lessina
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
lillow
lo-zumandimine
loestrin 1.5/30-21
loestrin 1/20-21
loestrin fe 1.5/30
loestrin fe 1/20
loryna
low-ogestrel
lutera
marlissa
merzee
microgestin 1.5/30
microgestin 1/20
microgestin 24 fe
microgestin fe 1.5/30
microgestin fe 1/20
mili
mono-linyah
necon 0.5/35-28
nikki
norethindrone acetate/ethinyl estradiol
norethindrone acetate/ethinyl estradiol/ferrous
fumarate
norgestimate/ethinyl estradiol
nortrel 0.5/35 (28)
nortrel 1/35
nylia 1/35
nymyo
ocella
orsythia
philith
pirmella 1/35
portia-28
previfem
reclipsen
sprintec 28
sronyx
syeda
tarina 24 fe
tarina fe 1/20
tarina fe 1/20 eq
taysofyCategory Generic name Brand name
Drug class
Combination Contraceptives - Oral tydemy
continued vestura
vienva
vyfemla
vylibra
wera
wymzya fe
zenchent fe
zovia 1/35
zovia 1/35e
zumandimine
Combination Contraceptives - xulane TWIRLA
Transdermal zafemy
Combination Contraceptives - eluryng ANNOVERA
Vaginal etonogestrel/ethinyl estradiol
Condoms - Female none FC FEMALE CONDOM
FC2 FEMALE CONDOM
Condoms - Male none MALE CONDOMS
Combination Contraceptives - amethyst NONE
Vaginal dolishale
levonorgestrel/ethinyl estradiol
Copper Contraceptives - IUD none PARAGARD INTRAUTERINE COPPER
CONTRACEPTIVE T380A
Diaphragms none CAYA
OMNIFLEX DIAPHRAGM
WIDE-SEAL SILICONE
DIAPHRAGM KIT
Emergency Contraceptives aftera ELLA
afterpill
econtra ez
econtra one-step
levonorgestrel
my choice
my way
new day
opcicon one-step
option 2
react
take actionCategory Generic name Brand name
Drug class
Extended-Cycle Contraceptives - amethia NONE
Oral ashlyna
camrese
camrese lo
daysee
fayosim
iclevia
introvale
jaimiess
jolessa
levonorgestrel/ethinyl estradiol
lojaimiess
rivelsa
setlakin
simpesse
Four Phase Contraceptives - Oral none NATAZIA
Progestin Contraceptives - none NEXPLANON
Implants
Progestin Contraceptives - medroxyprogesterone acetate DEPO-SUBQ PROVERA 104
Injectables
Progestin Contraceptives - IUD none KYLEENA
LILETTA
MIRENA
SKYLA
Progestin Contraceptives - Oral camila SLYND
deblitane
errin
heather
incassia
jencycla
lyleq
lyza
nora-be
norethindrone
norlyda
norlyroc
sharobel
tulana
Spermicides none ENCARE
OPTIONS GYNOL II VAGINAL
CONTRACEPTIVE
SHUR-SEAL
TODAY SPONGE
VCF VAGINALCategory Generic name Brand name
Drug class
Triphasic Contraceptives - Oral alyacen 7/7/7 NONE
aranelle
caziant
cyclafem 7/7/7
dasetta 7/7/7
enpresse-28
leena
levonest
levonorgestrel/ethinyl estradiol
norgestimate/ethinyl estradiol
nortrel 7/7/7
nylia 7/7/7
pirmella 7/7/7
tilia fe
tri femynor
tri-estarylla
tri-legest fe
tri-linyah
tri-lo-estarylla
tri-lo-marzia
tri-lo-mili
tri-lo-sprintec
Triphasic Contraceptives - Oral tri-mili PHEXXI
continued tri-nymyo
tri-previfem
tri-sprintec
tri-vylibra
tri-vylibra lo
trivora-28
velivet
Vaginal Contraceptive PH none PHEXXI
Modulators - CombinationsCertain drugs may not be covered by your particular pharmacy plan or may be subject to additional charges or restrictions, regardless of their appearance in this document. Information is subject to change. To check coverage and copay information for a specific medicine, log into your member website. For questions, please call the toll free number on the back of your member ID card. This document contains trademarks or registered trademarks of CVS Pharmacy, Inc. or one of its affiliates; it may also contain references to products that are trademarks or registered trademarks not affiliated with CVS Health. Policy forms issued in Idaho by Aetna Health of Utah Inc. include: HI ID GrpAg 05; HI SG HGrpAg 03. Policy forms issued in Idaho by Aetna Life Insurance Company include: GR-29/GR-29N, AL HGrpPol 05, AL SG HGrpPol 03. Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAg 05, HO HGrpPol 04, HO GrpPolAmend- ThirdPartyPay 01, AL SG GrpPolAmend 2019 01, HI HGrpAg SG 01R, HI SG GrpAgAmend 2019 01, AL IVL HPOL-1A-2022- EPO-HIX 01, AL IVL HPOL-1A-2022-EPO 01. Policy forms issued in Oklahoma include: AL COC00010, HC COC00010. In accordance with West Virginia’s Health Benefit Plan Network Access and Adequacy Act, we created access plans for our networks. These access plans describe our strategies, policies and procedures to create, maintain and administer adequate networks. You can visit https://www.aetna.com/individuals-families/member-rights-resources/rights/state- specific-information.html to view these plans online. You can also request a copy by calling the number on your ID card or call 800-US-AETNA ©2023 Aetna Inc. 917902-01-03 (1/23)
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