2016 Women’s Contraceptive Drugs and Devices List · Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2016 Women’s Contraceptive Drugs

Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions

2016 Women’s Contraceptive Drugs and Devices List

05.03.400.1 J (11/15)

www.aetna.com

Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or 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.Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

Nongrandfathered plans effective or renewing on or after August 1, 2012, and subject to the Affordable Care Act, also known as the health care reform law, will comply with requirements for Women’s Preventive Health Services. This means that for women with reproductive capacity, certain women’s contraceptive drugs and devices approved by the U.S. Food and Drug Administration (FDA) are covered at no member cost share.

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.

The following list of contraceptive drugs and devices are available with no member cost share when prescribed by a doctor and obtained through Aetna’s network. Quantity limits may also apply.

Category Generic medicine Brand-name medicine

Emergency contraception

levonorgestrel tab 0.75mglevonorgestrel tab 1.5 mgmy way tabnext choice tabtake action tab

ELLA

Implanted devices none IMPLANON implantable rodMIRENA intrauterine deviceNEXPLANON implantable rodPARAGARD intrauterine deviceSKYLA intrauterine device

Injectables medroxyprogesterone acetate injection none

Taken by mouth altavera tabalyacen tabamethia tabamethia lo tabamethyst tabapri tabaranelle tabaubra tabaviane tabazurette tab balziva tabbriellyn tabcamila tab camrese lo tabcamrese tabcaziant pakcesia pakchateal tabcryselle tabcyclafem tab dasetta tab daysee tabdeblitane tabdelyla tabdesogestrel-ethinyl

estradiol tab

drospirenone/ethinyl estradiol tab

elinest tabemoquette tabenpresse tabenskyce taberrin tab estarylla tab falmina tab gianvi tab gildagia tabgildess tab gildess fe tabheather tab introvale tabjencycla tabjolessa tabjolivette tab junel tabjunel fe tab kariva tab kelnor tab kurvelo tablarin tablarin fe tableena tab

none

Category Generic medicine Brand-name medicine

Taken by mouth (continued)

lessina tablevonest tablevonorgestrel/ethinyl

estradiol tablevora tab loryna tab low-ogestrel tablutera tablyza tabmarlissa tabmicrogestin tab microgestin tab femononessa tabmono-linyah tabmyzilra tabnecon tab nikki tabnora-be tab norethindron tab norgestimate/ethinyl

estradiol tabnorlyroc tabnortrel tabocella tab ogestrel taborsythia tabphilith tabpimtrea tab

pirmella tabportia tabprevifem tabquasense tabreclipsen tabsharobel tabsolia tabsprintec tab sronyx tabsyeda tab tilia fe tabtri-estarylla tabtri-legest fe tabtri-linyah tabtrinessa tabtri-previfem tabtri-sprintec tabtrivora tabvelivet pakvestura tabviorele tabvyfemla tabwera tabwymzya fe chw zarah tabzenchent fe chw zenchent tabzovia tab

none

Topical patch xulane transdermal patch none

Vaginal barrier none CONCEPTROL spermicideENCARE spermicideFC female condomFC2 female condom FEMCAP cervical capGYNOL spermicideOMNIFLEX diaphragmORTHO-COIL diaphragmORTHO-FLAT diaphragmORTHO-FLEX diaphragmPRENTIF cervical capSHUR-SEAL spermicideTODAY spongeVCF spermicideWIDESEAL diaphragm

Vaginal ring none NUVARING

This document may not be used after December 31, 2016. This list only represents the drugs that fall under women’s preventive health services. It’s not a complete list of medications covered under your plan. To check coverage and copay information for a specific medicine, visit www.aetna.com and log in to your secure member website. For more details, please call the toll-free number on your member ID card. Aetna may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. Information is believed to be accurate as of the production date; however, it is subject to change. For questions, please call the toll-free number on your member ID card.

www.aetna.com

©2015 Aetna Inc. 05.03.400.1 J (11/15)