No-cost
essential health
benefit
2023 Health Care Reform Preventive Drug List
917902-01-05 (10/23)
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.
2023 Health Care Reform Drug List
Effective October 2023
Key
UPPERCASE Brand-name medicine
lowercase italics Generic medicine
Category
Drug class
Generic name Brand name
Aspirin products
Covered for members who are
12-59 years when prescribed by a
doctor.
aspirin tab 81 mg none
Bowel-preparation medications
Limited for members
ages 45 through 74 years.
peg-3350/electrolytes/ascorbate
peg-3350/sodium sulf/naclpotassium cl/na
ascorbate/ascorbic
sodium sulfate/potassium
CLENPIQ SOL
PEG-PREP
PLENVU SOL
SUFLAVE
SUTAB
Fluoride
Oral fluoride covered for
children ages 6 months through
5 years without fluoride in their
water source.
nafrinse drops
sodium fluoride chew tab 0.25 mg, 0.5m mg,
sodium fluoride tab 0.5 mg,
sodium fluoride 1.1 mg/ml drops, 0.275 mg/ml
drops
none
Folic acid
Recommended for members
who are or may become pregnant.
Covered for members through
age 55 years.
folic acid cap 0.8 mg
folic acid tab 200 mcg
folic acid tab 400 mcg
folic acid tab 800 mcg
none
Prediabetes
Limited for men and women ages
35 – 70.
metformin 850mg none
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
Drug class
Generic name Brand name
Prevention of breast cancer
Primary prevention of breast
cancer in members 35 years of
age and older, who are at an
increased risk.
anastrozole 1mg
exemestane tab 25mg
raloxifene tab 60mg
tamoxifen tab 10mg and 20 mg
none
Prevention of human
immunodeficiency
virus (HIV) infection
Pre-exposure prophylaxis
emtricitabine/tenofovir disoproxil fumarate
tabs 200-300 mg
none
Statin medications
Covered for members
between 40-75 years of age.
Quantity limits apply.
atorvastatin 10 mg
atorvastatin 20 mg
simvastatin 5 mg
simvastatin 10 mg
simvastatin 20 mg
simvastatin 40 mg
none
Tobacco-cessation medications
Covered with a prescription.
Limits apply and vary by plan.
* O nly when prescribed for
smoking cessation.
bupropion HCl (smoking deterrent) tab SR*
habitrol
nicotine TD patch
nicotine polacrilex gum
nicotine polacrilex lozenge
thrive
varenicline tab 0.5mg
varenicline tab 1mg
APO-VARENICLINE
NICOTINE TRANSDERMAL
SYSTEM KIT 21-14-7MG
NICOTROL INHALER
NICOTROL NS
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
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
LO LOESTRIN FE
Cervical Caps none FEMCAP
Category
Drug class
Generic name Brand name
Combination Contraceptives - Oral afirmelle
altavera
alyacen 1/35
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
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
jasmiel
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
kaitlib fe
kalliga
kelnor 1/35
kelnor 1/50
kurvelo
larin 1.5/30
larin 1/20
larin 24 fe
larin fe 1.5/30
larin fe 1/20
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
NEXTSTELLIS
TYBLUME
Category
Drug class
Generic name Brand name
Combination Contraceptives - Oral
continued
ocella
orsythia
philith
pirmella 1/35
portia-28
previfem
reclipsen
sprintec 28
sronyx
syeda
tarina 24 fe
tarina fe 1/20 eq
taysofy
tydemy
vestura
vienva
vyfemla
vylibra
wera
wymzya fe
zenchent fe
zovia 1/35
zovia 1/35e
zumandimine
Combination Contraceptives -
Transdermal
xulane
zafemy
TWIRLA
Combination Contraceptives -
Vaginal
eluryng
etonogestrel/ethinyl estradiol
haloette
ANNOVERA
Condoms - Female none FC2 FEMALE CONDOM
Condoms - Male none MALE CONDOMS
Combination Contraceptives -
Vaginal
amethyst
dolishale
levonorgestrel/ethinyl estradiol
NONE
Copper Contraceptives - IUD none PARAGARD INTRAUTERINE COPPER
CONTRACEPTIVE T380A
Diaphragms none CAYA
OMNIFLEX DIAPHRAGM
WIDE-SEAL SILICONE
DIAPHRAGM KIT
Emergency Contraceptives aftera
afterpill
econtra ez
econtra one-step
her style
levonorgestrel
my choice
my way
new day
opcicon one-step
option 2
react
take action
ELLA
Category
Drug class
Generic name Brand name
Extended-Cycle Contraceptives -
Oral
amethia
ashlyna
camrese
camrese lo
daysee
fayosim
iclevia
introvale
jaimiess
jolessa
levonorgestrel/ethinyl estradiol
lojaimiess
rivelsa
setlakin
simpesse
NONE
Four Phase Contraceptives - Oral none NATA ZIA
Progestin Contraceptives -
Implants
none NEXPLANON
Progestin Contraceptives -
Injectables
medroxyprogesterone acetate DEPO-SUBQ PROVERA 104
Progestin Contraceptives - IUD none KYLEENA
LILETTA
MIRENA
SKYLA
Progestin Contraceptives - Oral camila
deblitane
errin
heather
incassia
jencycla
lyleq
lyza
nora-be
norethindrone
norlyda
norlyroc
sharobel
SLYND
Spermicides none ENCARE
OPTIONS GYNOL II VAGINAL
CONTRACEPTIVE
SHUR-SEAL
TODAY SPONGE
VCF VAGINAL
Category
Drug class
Generic name Brand name
Triphasic Contraceptives - Oral alyacen 7/7/7
aranelle
dasetta 7/ 7/ 7
enpresse-28
leena
levonest
levonorgestrel/ethinyl estradiol
norethindrone acetate/ethinyl estradiol
norgestimate/ethinyl estradiol
nor trel 7/ 7/7
nylia 7/7/ 7
pirmella 7/7/7
tilia fe
tri-estarylla
tri-legest fe
tri-linyah
tri-lo-estarylla
tri-lo-marzia
tri-lo-mili
tri-lo-sprintec
tri-mili
tri-nymyo
tri-previfem
tri-sprintec
tri-vylibra
tri-vylibra lo
trivora-28
velivet
NONE
Vaginal Contraceptive PH
Modulators - Combinations
none PHEXXI
Certain 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.
917902-01-05 (10/23)
