CurrentMVP Health CarePolicy N/A

No-Cost Preventive Prescription Drugs (Preventive Services & Screening)

Describes MVP Health Care no-cost prescription drug benefits for preventive services (medications, vaccines, tobacco cessation, contraceptives, and select prevention drugs) and who is eligible to receive them through the plan.

Policy Summary

PayerMVP Health Care

PolicyNo-Cost Preventive Prescription Drugs (Preventive Services & Screening)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document a prescription from a clinician for listed medications to be covered, even for over-the-counter products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4preventive categories listed

≈20individual drug entries listed

multipleage-specific recommendations

metforminprediabetes criteria

Covered No‑Cost Preventive Medications and Products

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Over-the-counter preventive supplements

Covered OTC preventive supplements when specific conditions are met

Aspirin for preeclampsia prevention: Aspirin 81 mg is provided for pregnant individuals 12-49 years of age who are at risk for preeclampsia.age 12-49; at risk for preeclampsia

OTC aspirin covered with prescription

Tobacco cessation

Tobacco cessation products covered for adults quitting tobacco

Tobacco cessation agents: Generic nicotine replacement products (patch, gum, lozenges), brand Nicotrol inhaler and Nicotrol NS nasal spray, bupropion (generic of Zyban), and varenicline (Chantix) are covered to help adults quit tobacco.adult tobacco users

Brand Zyban is not covered

Bowel preparation for colonoscopy

Bowel preparation for colonoscopy screening

Bowel prep coverage: Bowel preparation medicines (e.g., SUTAB, SUPREP) are covered for adults age 45-75 to clean out the bowel before colonoscopy procedures.age 45-75

Brand names covered until a generic becomes available; brand will no longer be supplied at no-cost when a generic is available

Vaccinations

Vaccines covered as preventive services

Vaccines: Recommended vaccines (COVID-19, influenza, meningococcal, pneumococcal, herpes zoster, Tdap) are covered; pharmacist-administered vaccines may be billed through CVS Caremark.per CDC recommended ages/populations for specific vaccines

COVID-19 vaccine coverage limited to populations recommended by CDC at time of administration and subject to state allocation and availability

Breast cancer primary prevention

Primary prevention of breast cancer

Breast cancer prevention meds: Selected generic oral agents (anastrozole 1 mg, exemestane 25 mg, raloxifene 60 mg, tamoxifen 10 mg and 20 mg) are covered for individuals 35 years of age and older who are at increased risk.age >= 35 and increased risk

Prescription required; increased risk should be documented

Prediabetes prevention

Metformin for prediabetes: Metformin 850 mg is offered for members with prediabetes who are age 35-70 and have no claim for another anti-diabetic agent (other than metformin 850 mg) in the prior 180 days.age 35-70; no other anti-diabetic claims in past 180 days

Intended as a preventive intervention; document age and medication history

Primary prevention of breast cancer

Covered for primary prevention of breast cancer when criteria for increased risk and age apply

Breast cancer prevention eligibility: Members 35 years of age and older who are at increased risk may receive listed generic oral agents: anastrozole 1 mg, exemestane 25 mg, raloxifene 60 mg, tamoxifen 10 mg and 20 mg.age >= 35

Increased risk must be established per clinical judgment or plan criteria; document risk status.

Prediabetes prevention

Covered for prediabetes prevention when ALL of the following are met

Prediabetes metformin eligibility: Member is age 35-70 AND has prediabetes AND has no claim for an anti-diabetic agent in the past 180 days other than metformin 850 mg.age 35-70; no other anti-diabetic claims in 180 days

Metformin 850 mg is the listed product for this indication.

Cholesterol (statin) prevention

Covered for primary prevention of cardiovascular disease when age and risk criteria apply

Statin primary prevention eligibility: Adults 40-75 years of age who are at risk for cardiovascular disease may receive listed generic low- to moderate-intensity statins (e.g., atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin at specified doses).age 40-75

Intensity described as low to moderate; clinical decision should guide agent selection.

HIV Pre-exposure Prophylaxis (PrEP)

Covered for HIV prevention when at-risk status is present

PrEP agent options: Emtricitabine/tenofovir disoproxil fumarate (generic Truvada), Truvada (brand, requires prior authorization), and Descovy are listed as PrEP options for persons at risk of HIV acquisition.at-risk for HIV acquisition

Brand Truvada explicitly requires prior authorization; generics and Descovy are listed without an explicit prior authorization requirement in this section.

Brand-name Zyban® is explicitly excluded from coverage under the tobacco cessation list. Generic bupropion (the generic equivalent of Zyban) is included as a covered tobacco cessation agent, but brand Zyban is not covered and should not be provided at no-cost through this preventive benefit.

Bowel preparation products are provided at no-cost while a branded product remains the only available option; however, when a generic formulation becomes available the plan will no longer supply the brand at no-cost. Providers should expect the covered option to transition to the generic once it is marketed.

Inclusion on this list does not guarantee coverage for every presentation of a product. Some strengths or dosage forms may not be included and certain products or categories may not be covered, regardless of their appearance in the document. Providers and members should verify coverage with the plan for specific formulations or billing questions.

Relevant Billing and Product Codes

Over-the-counter preventive medicationsNDC | mixedCovered

Aspirin 81 mg	Aspirin 81 mg (various dosage forms) for pregnant individuals 12-49 at risk for preeclampsia
Fluoride oral forms ≤0.5 mg	All oral fluoride dosage forms up to 0.5 mg for children ≤5 with low-fluoride water
Folic acid 0.4 mg, 0.8 mg	Folic acid tablets 0.4 mg and 0.8 mg for women ≤55 planning or able to become pregnant

Tobacco cessation (OTC and Rx)NDC | mixedCovered

Nicotine patch/gum/lozenge	Generic nicotine replacement products (patch, gum, lozenges)
Bupropion HCl SR 150 mg	Bupropion HCl SR 12 hr 150 mg (generic of Zyban); brand Zyban not covered
Chantix (varenicline)	Chantix tablets 0.5 mg and 1 mg
Nicotrol inhaler/NS	Nicotrol inhaler system 10 mg; Nicotrol NS nasal spray 10 mg/ml

VaccinesCPT | HCPCS | NDC | mixedCovered

COVID-19 vaccine	COVID-19 vaccine (populations per CDC recommendations at time of administration)
Influenza vaccine	Influenza vaccine
Meningococcal vaccine	Meningococcal vaccine
Pneumococcal vaccine	Pneumococcal vaccine
Herpes Zoster vaccine	Herpes Zoster vaccine
Tdap	Tdap (Tetanus, Diphtheria, Pertussis)

Bowel preparation medicines (Rx)NDC | mixedCovered

SUTAB	SUTAB (sodium sulfate, magnesium sulfate, potassium chloride) tablets — bowel preparation
SUPREP	SUPREP BOWEL PREP KIT (sodium sulfate, potassium sulfate, magnesium sulfate) oral solution

Contraceptives and related productsNDC | mixedCovered

Oral contraceptives (examples)	LO LOESTRIN FE; NATAZIA
IUDs/implants/rings	NEXPLANON; MIRENA; SKYLA; LILETTA; KYLEENA; PARAGARD T 380A
Transdermal patch	Xulane
Injectables	DEPO-SUBQ-PROVERA 104; Medroxyprogesterone acetate 150 mg (DEPO-PROVERA)
Cervical caps	FEMCAP
Diaphragms	MILEX WIDE-SEAL; OMNIFLEX COIL SPRING SILICONE; CAYA
Emergency contraception	ELLA (Rx); Levonorgestrel 1.5 mg (Rx or OTC) with brand examples
Female condoms	FC-2
Vaginal sponge	TODAY
Spermicides	ENCARE vaginal suppositories; GYNOL II gel 3%; Nonoxynol-9 products; SHUR-SEAL gel; VCF film/foam

Other preventive agents (breast cancer prevention, prediabetes)NDC | mixedCovered

Anastrozole 1 mg	Anastrozole tablet 1 mg for primary prevention of breast cancer in those ≥35 at increased risk
Exemestane 25 mg	Exemestane tablet 25 mg
Raloxifene 60 mg	Raloxifene HCl tablet 60 mg
Tamoxifen 10 mg/20 mg	Tamoxifen citrate tablets 10 mg and 20 mg
Metformin 850 mg	Metformin 850 mg for prediabetes prevention (members 35-70 with no other antidiabetic claims in prior 180 days)

Bowel prep age range

Age rangeAdults age 45-75

IndicationBowel preparation for cleaning the bowel before colonoscopy procedures

Coverage noteBrand names supplied at no-cost until a generic becomes available; brand will no longer be supplied at no-cost once generic is available

Fluoride supplement age

Age rangeChildren age 5 or younger

ProductFluoride supplements (all oral dosage forms up to 0.5 mg)

IndicationPrevent dental caries in children whose water is low in fluoride

Aspirin for preeclampsia prevention age

Age rangePregnant individuals 12-49 years of age

ProductAspirin 81 mg (various dosage forms)

IndicationFor those at risk for preeclampsia; OTC aspirin covered with prescription

Metformin age range

Age rangeMembers age 35-70 years old

ProductMetformin 850 mg

Eligibility constraintNo claim for another anti-diabetic agent (other than metformin 850 mg) in the prior 180 days

Provider Responsibilities, Documentation, and Authorization

Prior Authorization

Prior Authorization Required

PrEP prior authorization: Brand Truvada requires prior authorization. Obtain and document prior authorization when prescribing Truvada (brand) per plan requirements.

Truvada (brand) requires prior authorization

Documentation Required

Prescription Required for Coverage

Prescription requirement: A prescription from a licensed provider must be written and documented for listed medications to be covered by the plan, even if the product is available over-the-counter. Include dosing and formulation in the prescription.

Provider must write and document prescription for coverage
Document dosing and formulation on the prescription

Documentation Required

Prediabetes Documentation & Medication History

Prediabetes medication-history constraint: To qualify for the listed prediabetes benefit (metformin 850 mg), document that the member is age 35–70 and has no claims for other anti-diabetic agents in the prior 180 days (metformin 850 mg is allowed).

Member age documented: 35–70 years
No claim for other anti-diabetic agents in past 180 days (metformin 850 mg allowed)

Step Therapy

Bowel Prep Brand-to-Generic Step

Bowel preparation step-to-generic: Brand bowel preparation products are covered until a generic becomes available. When a generic version becomes available, the brand product will no longer be supplied at no-cost — providers should step to the generic when available and document the change.

Brand bowel preps covered only until generic availability
Step to generic when available; brand will not be supplied at no-cost thereafter
Examples: SUTAB; SUPREP BOWEL PREP KIT

Policy Background and Scope

This document identifies medications and products that MVP Health Care, in coordination with CVS Caremark, provides at no-cost as preventive services under the Affordable Care Act. It covers categories such as vaccines, tobacco cessation, contraceptives, bowel preparation for colorectal cancer screening, select agents for breast cancer primary prevention and prediabetes, and age‑specific preventive items (for example, bowel prep for adults age 45-75, aspirin for pregnant individuals 12-49, and fluoride for children age 5 or younger). Items listed are intended to be used according to the plan rules and require appropriate provider prescriptions or documentation when specified.

Key Definitions and Eligibility Criteria

No-cost preventive benefit

DefinitionPreventive medications, vaccines, and products covered without copay or coinsurance under the ACA when provided according to plan rules and prescriptions

IncludesMedications and supplements to prevent certain health conditions, tobacco cessation products, pre-screening medicines, vaccines, and contraceptives

Administration/Billing notePharmacist-administered vaccines may be billed through CVS Caremark per plan procedures

Breast cancer prevention agents

Eligible populationWomen 35 years of age and older who are at increased risk

Medications listedAnastrozole 1 mg; Exemestane 25 mg; Raloxifene 60 mg; Tamoxifen 10 mg and 20 mg (generic oral tablets)

PurposePrimary prevention to reduce incidence of breast cancer

Prediabetes prevention with metformin

Age rangeMembers age 35-70 years old

ProductMetformin 850 mg

Eligibility requirementMember has prediabetes AND no claim for another anti-diabetic agent in the past 180 days (other than metformin 850 mg)

Statin primary prevention

Age rangeAdults 40-75 years of age

TherapyGeneric low- to moderate-intensity statins (examples listed in policy)

PurposePrimary prevention of cardiovascular disease in adults at risk

HIV PrEP

IndicationPersons at risk of HIV acquisition

Medications listedEmtricitabine/tenofovir disoproxil fumarate (generic Truvada); Truvada (brand—requires prior authorization); Descovy

Prior authorization noteBrand Truvada explicitly requires prior authorization; generics and Descovy are listed without an explicit prior authorization statement in this section

Document Revision History

publication noteLatest

Document may be modified as necessary by MVP and lists may be updated periodically; additional medications may be added in compliance with ACA requirements.