PPACA No Cost-Share Preventive Medications

Oﬀered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their aﬃliates.

PPACA No Cost-Share

Preventive Medications

By drug category

Preventive medications are used to keep certain conditions from developing or from

coming back.

Certain preventive medications are available

at no cost-share to you

Health care reform under the Patient Protection and

Aordable Care Act (PPACA) requires plans to cover

certain preventive medications and products at 100%, or

no cost-share ($0), to you.

The U.S. Preventive Services

Task Force and the Institute of Medicine provides

guidance on which drug classes should be covered on

this list. These recommendations are meant to help

prevent disease, as well as meet women’s unique health

care needs.

Talk with your doctor to see if one of these

medications may work for you. If your doctor feels

a certain contraceptive product or quit smoking

medication/product on this list isn’t right for you, ask your

doctor to contact Cigna Healthcare

. Together, we’ll

look for other medications that may be available at no

cost-share.

About this drug list

This is a list of the preventive prescription medications

and over-the-counter (OTC) products available to you at

no cost-share (copay, coinsurance and/or deductible).

•

For your plan to cover these medications at 100%,

you’ll need to get a prescription from your doctor

– even for the OTC products, which are typically

available without a prescription.

•

Medications are listed alphabetically by drug

category.

•

Generic medications are listed in all lowercase letters

and brand-name medications are listed in all capital

letters.

•

This drug list is updated as the U.S. Preventive Services

Task Force makes new recommendations. Log in to the

myCigna

App

or myCigna.com

, or check your plan

materials, to learn more about how your plan covers

preventive medications.

Religious exemptions to contraception

coverage

PPACA allows certain employers to not cover (or exclude)

contraceptives from coverage based on their religious

beliefs. For women with a Cigna Healthcare pharmacy

plan through one of these employers, where the law

requires, Cigna Healthcare will pay for contraceptives

and/or certain medications at no cost. This coverage is

private and condential and isn’t administered, funded

by or connected in any way, to the employer’s health

coverage.

PPACA No Cost-Share Preventive Medications

This is a list of the preventive prescription medications and the over-the-counter (OTC) products available to you at no

cost-share under PPACA. This drug list is updated as the U.S. Preventive Services Task Force makes new recommendations.

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

Aspirin Products

Important change: Starting May 1,

2023, aspirin products will no longer be

covered under PPACA as of your plan’s

renewal date (the day your new plan

year starts).

adult aspirin regimen

aspirin 81mg

aspirin ec 81mg

aspirin regimen

aspir-trin

BAYER ASPIRIN 81MG C HEW TAB

children’s aspirin

ecotrin

st. joseph aspirin

st. joseph aspirin ec

Barrier Contraception

CAYA CONTOURED

FC2 FEMALE CONDOM

FEMCAP

gynol ii

MALE CONDOM

TODAY CONTRACEPTIVE SPONGE

VCF FILM, GEL

WIDE SEAL DIAPHRAGM

Bowel Prep Products for

Colorectal Cancer Screenings

Available to adults 45-75 years of age

alophen pills

bisacodyl tablets

bisa-lax

clearlax

CLENPIQ

CORRECTOL

DULCOLAX EC 5 MG TABLET

gavilax powder

gavilyte-c

gavilyte-g

gavilyte-n

gentle laxative tablet

gentlelax

healthylax

laxaclear

laxative

laxative peg 3350

MIRALAX

natura-lax

NULYTE LY SO LUTI ON

peg 3350-electrolyte

peg3350-sodium sulfate-sodium

chloride-potassium chloride-sodium

ascorbate-ascorbic acid

peg-prep

polyethylene glycol 3350

powderlax

purelax

smoothlax

sodium sulfate-potassium sulfate-

magnesium sulfate

SUTAB

women’s gentle laxative

women’s laxative

Breast Cancer Prevention

anastrozole

exemestane

raloxifene

tamoxifen

Cholesterol Related

Available to adults 40-75 years of age

atorvastatin 10mg, 20mg

uvastatin

uvastatin er

lovastatin 20mg, 40mg

pravastatin

rosuvastatin 5mg, 10mg

simvastatin 10mg, 20mg, 40mg

Emergency Contraception

after pill

AFTERA

curae

econtra ez

econtra one-step

ELLA

her style

levonorgestrel

my choice

my way

new day

opcicon one-step

option 2

TAKE ACTION

Folic Acid Supplementation

(only for products containing

0.4 mg–0.8 mg of folic acid)

BRAINSTRONG PRENATAL

classic prenatal

FA-8

folic acid 0.4mg, 0.8mg

folitab 500

kpn tablet

MINI PRENATAL

ONE A DAY WOMEN’S PRENATAL DHA

one daily prenatal

ONE-A-DAY PRENATAL

ONE-A-DAY PRENATAL-1

perry prenatal

prenatal

prenatal complete

PRENATAL FORMULA-DHA

PRENATAL GUMMIES

PRENATAL MULTI

prenatal multi-dha

prenatal multivitamin

PRENATAL MULTIVITAMIN-DHA

prenatal one daily

PRENATAL PLUS-DHA

prenatal vitamin

PRENATAL VITAMIN + DHA

prenatal vitamins

SIMILAC PRENATAL

STUART ONE

ULTRA PRENATAL PLUS DHA

Hormonal Contraception

6,7

armelle

altavera

alyacen

PPACA No Cost-Share Preventive Medications

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

Hormonal Contraception

6,7

(Cont.)

amethia

amethia lo

amethyst

apri

aranelle

ashlyna

aubra

aubra eq

aurovela

aurovela 24 fe

aurovela fe

aviane

ayuna

azurette

balziva

bekyree

blisovi 24 fe

blisovi fe

briellyn

camila

camrese

camrese lo

caziant

charlotte 24 fe

chateal

chateal eq

cryselle

cyclafem

cyred

cyred eq

dasetta

daysee

deblitane

desogestrel-ethinyl estradiol

desogestrel-ethinyl estradiol ethinyl

estradiol

dolishale

drospirenone-ethinyl estradiol

drospirenone-ethinyl estradiol-

levomefolate

elinest

eluryng

emoquette

enpresse

enskyce

errin

estarylla

ethynodiol-ethinyl estradiol

etonogestrel-ethinyl estradiol

falmina

femynor

nzala

gemmily

gianvi

hailey

hailey 24 fe

hailey fe

haloette

heather

iclevia

incassia

introvale

isibloom

jaimiess

jasmiel

jencycla

jolessa

juleber

junel

junel fe

junel fe 24

kaitlib fe

kalliga

kariva

kelnor 1-35

kelnor 1-50

kurvelo

larin

larin 24 fe

larin fe

larissia

layolis fe

leena

lessina

levonest

levonorgestrel-ethinyl estradiol

levonorgestrel-ethinyl estradiol ethinyl

estradiol

levora-28

lillow

lojaimiess

loryna

low-ogestrel

lo-zumandimine

lutera

lyleq

lyza

marlissa

medroxyprogesterone 150mg/ml

melodetta 24 fe

merzee

mibelas 24 fe

microgestin

microgestin fe

mili

mono-linyah

necon

NEXPLANON

nikki

nora-be

norethindrone 0.35mg

norethindrone-ethinyl estradiol-iron

norethindrone-ethinyl estradiol 1.5-

0.03mg, 1-0.02mg

norethindrone-ethinyl estradiol-fe

norethindrone-ethinyl estradiol

norlyda

nortrel

nylia

nymyo

ocella

philith

pimtrea

pirmella

portia

previfem

reclipsen

rivelsa

setlakin

sharobel

simliya

simpesse

sprintec

sronyx

syeda

tarina 24 fe

tarina fe

tarina fe 1-20 eq

taysofy

tilia fe

tri femynor

tri-estarylla

tri-legest fe

tri-linyah

PPACA No Cost-Share Preventive Medications

FLUMIST QUAD

FLUZONE HIGH-DOSE QUAD

FLUZONE QUAD

GARDASIL 9

HAVRIX

HEPLISAV-B

HIBERIX

INFANRIX DTAP

IPOL

JANSSEN COVID-19 VACCINE (EUA)

KINRIX

MENACTRA

MENQUADFI

MENVEO A-C-Y-W-135-DIP

M-M-R II VACCINE

MODERNA COVID-19 VACCINE (EUA)

NOVAVAX COVID -19 (EUA)

PEDIARIX

PEDVAXHIB

PENTACEL

PENTACEL ACTHIB

PFIZER COVID-19 VACCINE (EUA)

PNEUMOVA X 23

PREHEVBRIO

PREVNAR 13

PREVNAR 20

PRIORIX

PROQUAD

QUADRACEL DTAP-IPV

RECOMBIVAX HB

ROTARIX

ROTATEQ

SHINGRIX

SPIKEVAX COVID VACCINE

TDVAX

TENIVAC

TRUMENBA

TWINRIX

VAQTA

VARIVA X

VAXELIS

VAXNEUVANCE

ZOSTAVAX

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

Hormonal Contraception

6,7

(Cont.)

tri-lo-estarylla

tri-lo-marzia

tri-lo-sprintec

tri-mili

tri-nymyo

tri-previfem

tri-sprintec

trivora-28

tri-vylibra

tri-vylibra lo

tulana

tydemy

velivet

vestura

vienva

viorele

volnea

vyfemla

vylibra

wera

wymzya fe

zafemy

zarah

zovia 1-35

zumandimine

Human Immunodeciency

Virus (HIV) Infection

Pre-Exposure Prevention

emtricitabine/tenofovir 200mg-

300mg

5,6,8

Implantable Contraception

KYLEENA

LILETTA

MIRENA

PARAGARD T380-A

SKYLA

Pediatric Multivitamins

(containing uoride and

uoride supplements)

Available to children six months –

sixteen years of age

FLORIVA CHEWABLE TABLETS, DROPS

uoride chewable tablets

uoritab

ludent uoride

multi-vitamin w-uoride-iron

multivitamin with uoride

multivitamin-iron-uoride

MULTI-VIT-FLOR

mvc-uoride

POLY-VI-FLOR

POLY-VI-FLOR WITH IRON

QUFLORA PED 0.25MG/ML DROPS,

0.5MG/ML DROPS, 1MG CHEWABLE

TABLET

sodium uoride oral drops and tablets

TRI-VI-FLOR

tri-vitamin with uoride

tri-vite with uoride

vitamins a,c,d and uoride

Quit Smoking Medications

6,9

Available to adults 18 years of age and

older

NICORETTE

nicotine gum

nicotine lozenge

nicotine patch

NICOTROL

NICOTROL NS

quit 2

quit 4

stop smoking aid

varenicline

Vaccines

ABRYSVO

ACTHIB

ADACEL TDAP

AFLURIA QUAD

AREXVY

BEXSERO

BEYFORTUS

BOOSTRIX TDAP

COMIRNATY

DAPTACEL DTAP

DENGVAXIA

DIPHTHERIA-TETANUS TOXOIDS-PED

ENGERIX-B

FLUAD QUAD

FLUARIX QUAD

FLUBLOK QUAD

FLU C ELVA X Q UA D

FLULAVAL QUAD

1. This is a list of the medications and other products covered at 100% under the plan’s pharmacy beneﬁt at this time, based on existing legal requirements, and is subject to plan terms like

limitations and exclusions. For example, this list of medications may change if legal requirements for preventive coverage changes.

2. App/online store terms and mobile phone carrier/data charges apply. Customers under age 13 (and/or their parent/guardian) will not be able to register at myCigna.com.

3. Low-dose aspirin (81 mg/day) will stay covered at 100%, or no cost-share ($0), under PPACA’s preventive services requirement for women who are at least 12 weeks pregnant and at high

risk for pre-eclampsia.

4. Male condoms that are stocked behind the pharmacy counter and given to you by the pharmacist will be available at no cost-share to you. Quantity limits apply.

5. PPACA coverage requirements don’t apply to all plans. Log in to the myCigna App or myCigna.com, or check your plan materials, to ﬁnd out how your plan covers these medications

and how much they’ll cost you.

6. If your doctor feels these medications aren’t right for you, ask him or her to call Cigna Healthcare. There may be other generics/brands available at no cost-share to you

7. Generic hormonal contraceptives are available at no cost-share to you, even though they may not be listed here.

8. This medication will only be covered at no cost-share ($0) if used alone instead of in combination with other HIV medications.

9. Quantity limits apply. Also, generic nicotine replacement therapy (known as “store-brands”) are available at no cost-share to you, even though they may not be listed here.

10. Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to ﬁnd out how your speciﬁc plan covers them. You can also see a

current list of covered vaccines and pharmacies in your plan’s network. Most immunizations for travel aren’t covered. Call your pharmacy to make sure your plan covers the vaccine and it’s

available at their location. You shouldn’t need to make an appointment to get a vaccination. If you use an out-of-network pharmacy, vaccines may not be covered or may be subject to your

plan’s copay, coinsurance, and/or deductible.

Para obtener ayuda en español llame al número en su tarjeta de Cigna Healthcare.

Cigna Healthcare reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna Healthcare

does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna Healthcare may receive payments from manufacturers of certain preferred brand medications, and in

limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna Healthcare. Depending upon plan design, market

conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost

brand medication within its class for you and/or your plan.

Health beneﬁt plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a

licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to ﬁll the prescription.

If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible

requirements. Certain features described in this document may not be applicable to your speciﬁc health plan, and plan features may vary by location and plan type. Refer to your plan documents for

costs and complete details of your plan’s prescription drug coverage.

Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health beneﬁt plans contain exclusions and limitations. For costs and details

of coverage, review your plan documents or contact a Cigna Healthcare representative.

Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna

Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company,

Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or

service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos,

and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other

than English, language assistance services, free of charge are available to you. For current Cigna customers,

call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY:Dial 711). ATENCIÓN: Si usted

habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un

cliente actual de Cigna, llame al número que ﬁgura en el reverso de su tarjeta de identiﬁcación. Si no lo es, llame

al 1.800.244.6224 (losusuarios de TTY deben llamar al 711).

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race,

color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently

because of race, color, national origin, age, disability, or sex.

Cigna:

• Provides free aids and services to people with disabilities to communicate eectively with us,

suchas:

– Qualiﬁed sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats,

otherformats)

• Provides free language services to people whose primary language is not English, such as:

– Qualiﬁed interpreters

– Information written in other languages

If you need these services, contact customer service at the toll-free number shown on your IDcard, and

ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the

basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email

toACAGrievance@Cigna.com or by writing to the following address:

Cigna

Nondiscrimination Complaint Coordinator

PO Box 188016

Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card

or send an email to ACAGrievanc[email protected]. You can also file a civil rights complaint with the

U.S.Department of Health and Human Services, Office for Civil Rights electronically through the

Officefor Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,

or by mail orphone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, DC 20201

1.800.368.1019, 800.537.7697 (TDD)

Complaint forms are available at

http://www.hhs.gov/ocr/oce/ﬁle/index.html.

DISCRIMINATION IS AGAINST THE LAW

Medical coverage

Proﬁciency of Language Assistance Services

English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna

customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente

actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame

al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其

他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese



Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna

가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224

(TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga

kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa

1.800.244.6224 (TTY: I-dial ang 711).

Russian









Cigna – Arabic

711

:TTY) 1.800.244.6224

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele

nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un

client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez

appeler le numéro 1.800.244.6224 (ATS: composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para

clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso

contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy

Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby

prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaの

お客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）

まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali,

chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero

1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung.

Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer

Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).





Cigna– Persian (Farsi)

7111.800.244.6224



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