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No-Cost Preventive Drug List and Services

Updated October 2022

Taking the right medicine when you need it is an important part of staying healthy. Your prescription plan provides certain preventive benefits at no cost to you. That means you don’t have to pay a copay* or coinsurance on these medications, regardless of where you are with your deductible.

These no-cost benefits are part of the Affordable Care Act (ACA). However, they still require your doctor to write a prescription for these preventive services to be covered by your plan, even if they are listed as over-the-counter (OTC). They include:

  • Medicine and supplements to prevent certain health conditions for adults, women and children
  • Medicine and products for quitting smoking or chewing tobacco (tobacco cessation)
  • Medicine used prior to screenings for certain health conditions in adults
  • Vaccines and immunizations to prevent certain illnesses in infants, children and adults
  • Contraceptives for women

CVS Caremark® works with your health plan to provide these benefits. The following lists** explain:

  • Which medicines, supplements, health-related products or vaccines are covered
  • Who they are covered for (such as children up to age six or adults age 65 or older)
  • What health condition or illness they help prevent
  • Other important information

Legend

chew: chewable, mL: milliliter, cap: capsule, oral: taken by mouth, FE: ferrous sulfate (iron), OTC: over-the-counter, EE: ethinyl estradiol, Rx: prescription product, hr: hour, soln: solution, IM: intramuscular, SR: sustained release, IU: international unit, susp: suspension, mcg: microgram, tab: tablet, mg: milligram, TD: transdermal

Preventive Services**

Aspirin to help prevent serious heart and blood vessel problems (cardiovascular disease) and colorectal cancer in adults 50 to 59 years old who are at risk.

Generic dosage forms of 81 mg

Aspirin products (OTC):

  • Aspirin chew tab 81 mg
  • Aspirin enteric coated tab 81 mg

Please note: Effective January 1, 2023, this program will be removed from the ACA preventive services coverage and will revert back to standard benefit design.

Aspirin to help prevent illness and death from preeclampsia in women† who are at least 12 years old, after 12 weeks of pregnancy and are at high risk for the condition.

Generic dosage forms of 81 mg

Aspirin products (OTC):

  • Aspirin chew tab 81 mg
  • Aspirin enteric coated tab 81 mg

Fluoride supplements to help prevent cavities (dental caries) in children 5 years or younger whose water is low in fluoride.

All oral dosage forms up to 0.5 mg

Fluoride products (Rx):

  • Sodium fluoride chew tab 0.25 mg to 0.5 mg
  • Sodium fluoride soln 0.125 mg/drop
  • Sodium fluoride soln 0.25 mg/0.6 mL
  • Sodium fluoride soln 0.25 mg/drop
  • Sodium fluoride soln 0.5 mg/mL
  • Sodium fluoride tab 0.5 mg

Folic acid supplements to help prevent birth defects in women† age 55 or younger who are planning to become pregnant or can become pregnant.

Generic dosage forms

Folic acid products (OTC):

  • Folic acid cap 0.8 mg (800 mcg)
  • Folic acid tab 0.4 mg (400 mcg)
  • Folic acid tab 0.8 mg (800 mcg)

Tobacco cessation products to help adults who are not pregnant quit tobacco use to prevent health problems. Tobacco use includes smoking or chewing tobacco.

Generic nicotine replacement products—patch, gum and lozenges

Brand-name Nicotrol (nicotine inhalation system)

Brand-name Nicotrol NS (nicotine nasal spray)

Generic bupropion (generic of brand-name, Zyban)—Zyban is NOT covered

Generic and Brand-name Chantix/Varenicline (varenicline tartrate)

Tobacco cessation products (OTC and Rx):

  • Bupropion HCl tab SR 12 hr 150 mg
  • Nicotine polacrilex gum 2 mg and 4 mg
  • Nicotine polacrilex lozenge 2 mg and 4 mg
  • Nicotine TD patch 24 hr 21 mg, 14 mg and 7 mg
  • Nicotrol inhaler system 10 mg
  • Nicotrol NS nasal spray 10 mg/mL
  • Varenicline/Chantix tab 0.5 mg and 1 mg
  • Varenicline tab 0.5 mg x 11 tabs and 1 mg x 42 pack

Vaccines (immunizations) to prevent certain illnesses in people of all ages. Recommended doses, ages and populations may vary (Rx)

Children

  • COVID-191
  • Dengue (effective 12/1/22)
  • Diphtheria, Tetanus, Pertussis
  • Haemophilus Influenzae Type B
  • Hepatitis A
  • Hepatitis B
  • Human Papillomavirus
  • Inactivated Poliovirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Rotavirus
  • Varicella

1.  Covered for populations recommended by the Centers for Disease Control and Prevention (CDC) at the time of administration. Subject to state allocation guidelines and availability.

 

Vaccines (immunizations) to prevent certain illnesses in people of all ages. Recommended doses, ages and populations may vary (Rx)

Adults

  • COVID-191
  • Hepatitis A
  • Hepatitis B
  • Herpes Zoster
  • Human Papillomavirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, Pertussis
  • Varicella

1.  Covered for populations recommended by the Centers for Disease Control and Prevention (CDC) at the time of administration. Subject to state allocation guidelines and availability.

Bowel preparation medicine for cleaning out the bowel before colonoscopy procedures for adults age 45 to 75. Colonoscopies screen for colon and rectal cancers.

Generics are in italics. Brand names are CAPITALIZED.

Generics and brand name only if a generic isn’t available.

Brand name will no longer be supplied at no cost when the generic becomes available.

Bowel preparation products (Rx):

  • CLENPIQ (sodium picosulfate, magnesium oxide and anhydrous citric acid) oral solution
  • PEG-PREP KIT (bisacodyl, PEG 3350, potassium chloride, sodium bicarbonate and sodium chloride) for oral solution
  • PLENVU (polyethylene glycol-3350, sodium sulfate, sodium chloride, potassium chloride, sodium ascorbate and ascorbic acid) for oral solution
  • SUTAB (sodium sulfate, magnesium sulfate and potassium chloride) oral tablet
  • Polyethylene glycol-3350, sodium sulfate, sodium chloride, potassium chloride, sodium ascorbate and ascorbic acid for oral solution
  • Sodium sulfate, potassium sulfate and magnesium sulfate for oral solution

Statins to help prevent serious heart and blood vessel problems (cardiovascular disease) in adults age 40 to 75 who are at risk.

Generic low to moderate intensity statins (Rx):

  • Atorvastatin 10 mg, 20 mg
  • Fluvastatin 20 mg, 40 mg
  • Fluvastatin ER 80 mg
  • Lovastatin 10 mg, 20 mg, 40 mg
  • Pravastatin 10 mg, 20 mg, 40 mg, 80 mg
  • Rosuvastatin 5 mg, 10 mg
  • Simvastatin 5 mg, 10 mg, 20 mg, 40 mg

Antiretroviral therapy for preexposure prevention of human immunodeficiency virus (HIV) infection in people who are at an increased risk.

Generic antiretroviral therapy (Rx):

  • Emtricitabine/tenofovir disoproxil fumarate 200 mg-300 mg

Diabetes prevention medicine for preventing or delaying diabetes for adults age 35 to 70 who have overweight or obesity.

Generic diabetes prevention product (Rx):

  • Metformin 850 mg

Women’s Health Preventive Services**

*Brand-Name Products for Reference Only | **Brand-Name Products Generic Equivalent(s)

*Alesse | **Afirmelle, Aubra, Aubra EQ, Aviane-28, Delyla, Falmina, Lessina, Lutera, Sronyx, Vienva

*Demulen 1/35 | **Kelnor 1/35, Zovia 1/35

*Demulen 1/50 | **Ethynodiol 1/50, Kelnor 1/50

*Desogen | **Apri, Cyred, Cyred EQ, Emoquette, Enskyce, Isibloom, Juleber, Kalliga, Reclipsen

*Estrostep FE | **Tilia FE, Tri-Legest FE

*Femcon FE | **Wymzya FE

*Generess FE | **Kaitlib FE, Layolis FE

*Loestrin 24 FE | **Aurovela 24 FE, Blisovi 24 FE, Hailey 24 FE, Junel 24 FE, Larin 24 FE, Microgestin 24 FE, Tarina 24 FE

*Lo/Ovral | **Cryselle-28, Elinest, Low-Ogestrel

*LoSeasonique | **Camrese Lo, LoJaimiess

*Lybrel | **Amethyst, Dolishale

*Minastrin 24 FE | **Charlotte 24 FE, Finlaza FE

*Mircette | **Azurette, Kariva, Pimtrea, Simliya, Viorele, Volnea

*Modicon | **Necon 0.5/35, Nortrel 0.5/35, Wera

*Nordette | **Altavera, Ayuna, Chateal, Chateal EQ, Kurvelo, Levora, Marlissa, Portia-28

*Ortho-Cyclen | **Estarylla, Femynor, Mili, Mono-linyah, Nymyo, Sprintec, Vylibra

*Ortho Micronor | **Camila, Deblitane, Errin, Heather, Incassia, Jencycla, Lyleq, Lyza, Nora-BE, Norlyroc, Sharobel

*Ortho-Novum 1/35 | **Alyacen 1/35, Dasetta 1/35, Nortrel 1/35, Nylia 1/35, Pirmella 1/35

*Ortho-Novum 7/7/7 | **Alyacen 7/7/7, Dasetta 7/7/7, Nortrel 7/7/7, Nylia 7/7/7, Pirmella 7/7/7

*Ortho Tri-Cyclen | **Tri-Estarylla, Tri-Femynor, Tri-Linyah, Tri-Mili, TriNessa, Tri-Nymyo, Tri-Sprintec, Tri-Vylibra

*Ortho Tri-Cyclen Lo | **Tri-Lo Estarylla, Tri-Lo Marzia, Tri-Lo-Mili, Tri-Lo-Sprintec, Tri-Vylibra Lo

*Ovcon-35 | **Balziva-28, Briellyn, Philith, Vyfemla

*Quartette | **Fayosim, Rivelsa

*Safyral | **Tydemy

*Seasonale | **Iclevia, Introvale, Jolessa, Setlakin

*Seasonique | **Amethia, Ashlyna, Camrese, Daysee, Jaimiess, Simpesse

*Taytulla | **Gemmily, Merzee, Taysofy

*Tri-Norinyl | **Aranelle, Leena

*Triphasil | **Enpresse, Levonest, Trivora

*Yasmin | **Ocella, Syeda, Zumandimine

*Yaz | **Jasmiel, Lo-Zumandimine, Loryna, Nikki, Vestura

Generics and brand name only if a generic isn’t available.

Generics are in italics. Brand names are CAPITALIZED.

Brand name will no longer be supplied at no cost when the generic becomes available. Brand names listed in [bold] and in brackets are for your reference only.

Brand-Name Oral Contraceptives (Rx)

  • BALCOLTRA
  • LO LOESTRIN FE
  • NATAZIA
  • NEXTSTELLIS
  • SLYND
  • TYBLUME

 

Barrier Methods (Rx)

Cervical Caps

  • FEMCAP

Diaphragms

  • CAYA
  • MILEX WIDE-SEAL
  • OMNIFLEX COIL SPRING SILICONE

 

Intrauterine Devices, Subdermal Rods and Vaginal Rings (Rx)

  • Ethinyl estradiol 15 mcg/Etonogestrel 120 mcg vaginal ring, EluRyng [NUVARING]
  • ANNOVERA
  • KYLEENA
  • LILETTA
  • MIRENA
  • NEXPLANON
  • PARAGARD T 380A
  • SKYLA

 

Emergency Contraception (Rx or OTC)

  • Levonorgestrel 1.5 mg tablet, AfterPill, Aftera, Econtra EZ, Econtra OS, My Choice, My Way, New Day, Opcicon, Option 2, Take Action, React [PLAN B]
  • ELLA

 

Transdermal Patches (Rx)

  • Xulane
  • Zafemy
  • TWIRLA

 

Female Condoms (OTC)

  • FC-2

 

Injectables (Rx)

  • Medroxyprogesterone acetate 150 mg [DEPO-PROVERA]
  • DEPO-SUBQ-PROVERA 104

 

Vaginal Sponge (OTC)

  • TODAY

 

Vaginal pH Modulators (Rx)

  • PHEXXI

 

Spermicides (OTC)

  • Nonoxynol-9 vaginal gel 4%, VCF Vaginal Contraceptive Gel [CONCEPTROL GEL 4%]
  • ENCARE VAGINAL SUPPOSITORIES
  • GYNOL II GEL 3%
  • SHUR-SEAL GEL 2%
  • VCF VAGINAL FILM 28%
  • VCF VAGINAL FOAM 12.5%

Primary prevention of breast cancer in women†† 35 years of age and older, who are at an increased risk.

Breast cancer prevention products (Rx):

  • Anastrozole tab 1 mg
  • Exemestane tab 25 mg
  • Raloxifene HCl tab 60 mg
  • Tamoxifen citrate tab 10 mg and 20 mg

Additional Information

  • Take these lists with you each time you or your family has a checkup or yearly exam.
  • Your doctor must write a prescription for these preventive services to be covered by your plan, even if they are listed as OTC.
  • The dosage form is how the product is supplied. For example, tablet, capsule, liquid, syrup or chewable tablet.
  • Generic or brand name is listed if only that product type is covered.
  • Treatment recommendations may vary. Please call your doctor or pharmacist if you have questions about your health or medicine**.
  • Other rules, limits and exclusions may apply. Please contact your health plan to learn about your coverage**.
  • An exceptions process is available for circumstances that fall outside the listed preventive services—such as, for example, a request for coverage of a brand name product because the listed generic products are not medically appropriate. A process is also available for coverage of preventive services without cost sharing for plan members identifying with a gender that differs from the member’s sex assigned at birth—such as, for example, a request for coverage of contraceptives or primary prevention of breast cancer for transgender members.

*Copay, copayment or coinsurance means the amount, out-of-pocket, a member is required to pay for a prescription in accordance with a plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a plan. **Recommendations, ages and populations may vary. Products listed may be updated periodically. List does not guarantee coverage. Your prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Vaccines, immunizations and intrauterine devices may be covered through your medical or pharmacy benefit. Consult your plan for complete coverage and list details.
† Female or members capable of pregnancy.
†† Female or members at increased risk of breast cancer.
Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark.
This list represents branded products in CAPS, branded generics in uppercase and lowercase Italics, and generic products in lowercase italics. Some strengths or dosage forms may not be included in the high-deductible health plan-health savings account (HDHP-HSA) Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any question above coverage.
Additional medications may be included in this list from time to time in compliance with ACA requirements and/or Internal Revenue Service (IRS) guidance.
This Preventive Drug List has been adopted by the referenced health plan. This Preventive Services list and the HDHP-HSA Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel.
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