No-cost preventive drug list and services

• Take these lists with you each time you or your family has a checkup or yearly exam.
• For most plans, a prescription for these preventative services is required for coverage with no cost sharing, 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 preventative 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 preventative 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.

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

Aspirin to help prevent illness and death from preeclampsia in persons 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

Bowel Preparation Medicine for cleaning out the bowel before colonoscopy procedures for adults age 45 through 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
• SUFLAVE (polyethylene glycol-3350, sodium sulfate, potassium chloride, magnesium sulfate, and sodium chloride) 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

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

Fluoride Supplements to help prevent cavities (dental caries) in children five 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 0.5 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)

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
• Pitavastatin 1 mg, 2 mg, 4 mg
• Pravastatin 10 mg, 20 mg, 40 mg, 80 mg
• Rosuvastatin 5 mg, 10 mg
• Simvastatin 5 mg, 10 mg, 20 mg, 40 mg

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 varenicline

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 tab 0.5 mg and 1 mg
• Varenicline tab 0.5 mg x 11 tabs and 1 mg x 42 pack

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

Children
 

• COVID-19
• Dengue
• Diphtheria, Tetanus, Pertussis
• Haemophilus Influenzae Type B
• Hepatitis A
• Hepatitis B
• Human Papillomavirus
• Inactivated Poliovirus
• Influenza
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Respiratory Syncytial Virus
• Rotavirus
• Smallpox and Monkeypox
• Varicella

Adults

• COVID-19
• Hepatitis A
• Hepatitis B
• Herpes Zoster
• Human Papillomavirus
• Influenza
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Respiratory Syncytial Virus
• Smallpox and Monkeypox
• Tetanus, Diphtheria, Pertussis
• Varicella

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

Generic oral contraceptives*.

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

• *Alesse | **Afirmelle, Aubra EQ, Aviane-28, Delyla, Falmina, Lessina, Lutera, Sronyx, Vienva
• *Balcoltra | **Joyeaux
• *Demulen 1/35 | **Kelnor 1/35, Zovia 1/35
• *Demulen 1/50 | **Ethynodiol 1/50, Kelnor 1/50
• *Desogen | **Apri, Cyred EQ, 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, Turqoz
• *LoSeasonique | **Camrese Lo, LoJaimiess
• *Lybrel | **Amethyst, Dolishale
• *Minastrin 24 FE | **Charlotte 24 FE, Finlaza FE, Mibelas 24 FE
• *Mircette | **Azurette, Kariva, Pimtrea, Simliya, Viorele, Volnea
• *Modicon | **Necon 0.5/35, Nortrel 0.5/35, Wera
• *Nordette | **Altavera, Ayuna, Chateal EQ, Kurvelo, Levora, Marlissa, Portia-28
• *Ortho-Cyclen | **Estarylla, Mili, Mono-linyah, Nymyo, Sprintec, Vylibra
• *Ortho Micronor | **Camila, Deblitane, Emzahh, 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
• *Ortho-Novum 7/7/7 | **Alyacen 7/7/7, Dasetta 7/7/7, Nortrel 7/7/7, Nylia 7/7/7
• *Ortho Tri-Cyclen | **Tri-Estarylla, Tri-Linyah, Tri-Mili, 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 | **Rivelsa
• *Safyral | **Tydemy
• *Seasonale | **Iclevia, Introvale, Jolessa, Setlakin
• *Seasonique | **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 or OTC)

• LO LOESTRIN FE
• NATAZIA
• NEXTSTELLIS
• OPILL
• 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, EnilloRing, Haloette [NUVARING]
• ANNOVERA
• KYLEENA
• LILETTA
• MIRENA
• NEXPLANON
• PARAGARD T 380A
• SKYLA

Emergency Contraception (Rx or OTC)

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

Transdermal Patches (Rx)

• Xulane
• Zafemy
• TWIRLA

Condoms (OTC)

• FC-2
• MALE CONDOMS

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%
• VCF VAGINAL FILM 28%