ACA HDHP Preventive Care Drug List

Preventive care can help keep you healthy and may even save your life. Getting routine health exams and screenings can help catch problems early, when they’re easier to treat. And getting the right preventive care services can help you manage your health conditions and stay healthy. Under the Affordable Care Act (ACA), pharmacy benefits must cover certain categories of preventive care drugs and products at 100%. That means you don’t have to pay a share of the cost — no copay, deductible or percentage of the cost (coinsurance). How do I get these drugs at no cost? Talk with your doctor about choosing the medication or product that’s right for you. To get these preventive drugs, including over-the-counter (OTC) drugs or products: 1 They must be right for your age and condition. 1 You’ll need to get a prescription from your doctor (even for OTC products). 1 Remember, only you and your doctor can decide on the medications you need and what’s best for your health. Preventive drugs and products, by category Here’s a list of medications Anthem plans will cover with no cost-share for you under the ACA. Keep in mind that this list can change. Brand-name drugs are listed with a first capital letter. Non-brand drugs (generics) are in lowercase letters. ASPIRIN Coverage includes generic over-the- counter 81mg and 325mg aspirin products to prevent preeclampsia in pregnant women and to prevent cardiovascular disease and colorectal cancer in adults 60-69 years old. Aspirin 81mg, 325mg (tab, ec tab, chew) BOWEL PREP Coverage includes generic prescription and over-the-counter products and are limited to two (2) bowel prep kits per year for adults 50 - 75 years old. bisacodyl bisacodyl-peg 3350-pot chloride-sod bicarb- sod chloride magnesium citrate, hydroxide peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic Nulytely) peg 3350-kcl-sod bicarb-sod chloride- sod sulfate (generic Golytely) peg 3350-kcl-nacl-na sulfate-na ascorbate- ascorbic acid (generic Moviprep) polyethylene glycol 3350 BREAST CANCER You may be required to get preapproval for the services associated with the drugs in this category anastrozole 1mg exemestane 25mg letrozole 2.5 mg raloxifene 60mg Soltamox tamoxifen 10mg, 20mg CARDIOVASULAR Full coverage for low-to- moderate dose generic statins will be limited to members 40-75 years old with one or more cardiovascular risk factor such as dyslipidemia, diabetes, hypertension, or smoking but who have not experienced a cardiovascular disease event. atorvastatin (10 - 20 mg) fluvastatin (20 - 80 mg) lovastatin (10 - 40mg) pravastatin (10 - 80mg) rosuvastatin (5 - 10mg) simvastatin (5 - 40mg) CONTRACEPTION This benefit also applies to those younger than age 19. A cost share may apply for other prescription contraceptives, based on your drug benefits. Your cost share may be waived if your doctor decides that using the multisource brand is medically necessary. Oral Contraceptives afirmelle 0.1-0.02 altavera alyacen 7/7/7 amethia amethia lo amethyst 90-20mcg apri aranelle ashlyna aubra 0.1-0.02 aubra eq 0.1-0.02 aurovela 1.5/30 aurovela 1/20 aurovela 24 fe 1/20 aurovela fe 1.5/30 aurovela fe 1/20 aviane ayuna azurette 28 balziva bekyree blisovi 24 fe 1/20 blisovi fe 1.5/30 blisovi fe 1/20 briellyn camila 0.35mg camrese camrese lo caziant chateal 0.15/30 chateal eq 0.15/30 cryselle-28 cyclafem 1/35 cyclafem 7/7/7 cyred cyred eq dasetta 1/35 dasetta 7/7/7 daysee deblitane 0.35mg delyla 0.1-0.02 deso/ethinyl estradio dros/eth est levomefo drospir/ethi 3-0.03mg drospire/eth/estr/lev drospirenone ethy est elinest emoquette enpresse-28 enskyce errin 0.35mg estarylla 0.25-35 ethy eth est 1-35 ethynodiol 1-50 falmina fayosim femynor 0.25-35 gianvi 3-0.02mg hailey 1.5/30 hailey 24 fe heather 0.35mg incassia 0.35mg introvale isibloom isibloom 0.15-30 jaimiess jasmiel 3-0.02mg jencycla 0.35mg jolessa jolivette 0.35mg juleber ACA Preventive Care Drug List

junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 junel fe 24 1/20 kaitlib fe kalliga kariva 28 kelnor 1/35 kelnor 1/50 kimidess kurvelo 0.15/30 larin 1.5/30 larin 1/20 larin 24 fe 1/20 larin fe 1.5/30 larin fe 1/20 larissia layolis fe leena lessina levo-eth est 90-20mcg levonest levonor/ethi levonor/ethi 0.1-0.02 levonor/ethi estradio levora-28 0.15/30 lillow 0.15/30 lojaimiess loryna 3-0.02mg low-ogestrel lo-zumandimi 3-0.02mg lutera lyza 0.35mg marlissa 0.15/30 melodetta 24 fe mibelas 24 fe microgestin 1.5/30 microgestin 1/20 microgestin fe 1/20 microgestin fe1.5/30 mili 0.25/35 mircette 28 day mono-linyah 0.25-35 mononessa myzilra necon 0.5/35 necon 7/7/7 nikki 3-0.02mg nor/est/ff 1.5/30 nora-be 0.35mg nore/eth/fer 0.4mg-35 noreth/ethin fe noreth/ethin fe 1/20 noreth/ethin 1.5/30 noreth/ethin 1/20 noreth/ethin fe 1/20 norethindron 0.35mg norgest/ethi 0.25/35 norgest/ethi/estradio norlyroc 0.35mg nortrel 0.5/35 nortrel 1/35 nortrel 7/7/7 ocella 3-0.03mg ogestrel orsythia philith 0.4-35 pimtrea pirmella 1/35 pirmella 7/7/7 portia-28 previfem quasense rajani reclipsen rivelsa setlakin sharobel 0.35mg simliya 28 simpesse sprintec 28 sronyx syeda 3-0.03mg tarina 24 fe tarina fe 1/20 tarina fe 1/20 eq tilia fe tri femynor tri-estaryll tri-legest fe tri-linyah tri-lo estaryll tri-lo marzia tri-lo- sprintec tri-lo-mili tri-mili trinessa trinessa lo tri-previfem tri-sprintec trivora-28 tri-vylibra tri-vylibra lo tulana 0.35mg tydemy velivet vestura 3-0.02mg vienva 0.1-20 viorele volnea vyfemla 0.4-35 vylibra 0.25-35 wera 0.5/35 wymzya fe chw 0.4mg- 35 zarah 3-0.03mg zenchent zovia 1/35e zumandimine 3-0.03mg Cervical Caps (Rx) Femcap mis 22-30mm Diaphragms Caya dpr Omniflex Wide-seal dpr kit 60-95 Emergency Contraception (Rx or OTC) aftera tab 1.5mg econtra ez tab 1.5mg Ella tab 30mg levonorgestr tab 1.5mg my choice tab 1.5mg my way tab 1.5mg new day tab 1.5mg next choice tab 1.5mg opcicon 1.5mg preventeza tab 1.5mg react tab 1.5mg take action tab 1.5mg Female Condoms (OTC) Fc2 female mis condom Injectables (Rx) depo-sq prov inj medroxypr ac inj 150mg/ml Intrauterine Devices and Vaginal Rings eluryng mis etonogestere mis ethy est Spermicides (OTC) conceptrol gel 4% encare sup 100mg gynol ii gel 3% Shur-Seal gel 2% VCF vaginal aer gel,mis contracp Transdermal xulane dis 150-35 Vaginal Sponge Today sponge mis FLUORIDE (GENERIC ONLY) Coverage for children age 6 months to 16 years. sodium fluoride chew 0.25mg, 0.5mg, 1mg, 2.2mg sodium fluoride tab 0.5mg, 1mg sodium fluoride soln 0.25mg 0.5mg 0.125mg pediatric multivitamin/ fluoride chew, tab, soln 0.25mg, 0.5mg, 1mg,0.125mg, 1.1mg, 2.2mg FOLIC ACID Coverage for generic only, prescription and over-the-counter included for women ages 55 or younger who are planning and able to get pregnant. folic acid tab,cap 400mcg, 800mcg Prenatal and multivitamins w/ folic acid (generic OTC only) HIV PRE-EXPOSURE PROPHYLAXIS Effective 7/1/2020 for group benefits and 1/1/ 2021 for individual benefits. emtricitabine 200mg tenofovir 300mg emtricitabine-tenofovir 200-300mg SMOKING CESSATION Coverage includes prescription and over- the-counter, brand and generic for members greater than 18 years old. OTC (Brand and Generic) Nicotine Replacement Gum, Lozenge and Patch (Prescription) Nicotrol Inhaler Nicotrol Nasal Spray varenicline VACCINES BCG Diphtheria, Tetanus, Pertussis Haemophilus B Polysac Conj Hepatitis A Hepatitis B Human Papillomavirus (HPV) Influenza Virus Measles, Mumps & Rubella Virus Meningococcal Pneumococcal Poliovirus, IPV Rotavirus , Oral Varicella Virus Zoster (shingles) This list may change without notice which may affect your benefit coverage. To be sure your medication is covered under the PreventiveRx benefit, call the member services number located on your ID card. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE ® Managed Care, Inc. (RIT), Healthy Alliance ® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 61088MUMENABS Rev. 1/1/2022 ACA Preventive Care Drug List