Contraceptive Services Only

Pharmacy | Contraceptive Services

1,2,3

$0 Cost-share Services, Products and Drugs for Women

Effective: May 1, 2024

Connecticut

Delaware

District of Columbia

Illinois

Maine

Maryland

Massachusetts

Minnesota

New Jersey

New York

Oregon

Washington

U.S. Preventive Services Task Force A & B recommendation

medications and supplements

The health reform law (Affordable Care Act) requires most health plans to pay for birth control

(contraceptives and sterilization) for women at no cost to you. Some organizations can choose not to

cover birth control as part of their group health plan due to sincerely held religious beliefs or moral

convictions. If you are a member of one of these groups (Eligible Organizations), and the group has

elected an optional accommodation, UnitedHealthcare will cover certain birth control products and

services at no cost to you.

You can use your Contraceptive Services Only ID card to get those birth control services, products and

drugs on this list that your group has designated for the optional accommodation for $0 cost-share if

they are:

• Prescribed by a network health care professional such as your doctor.

• For services performed by a network health care professional.

• For products and drugs filled at a network pharmacy.

Birth control

Over-the-counter birth control (contraceptives) for women

Birth control contraceptives

The following forms of birth control (contraceptives) are available OTC and will be covered at $0 cost

share when filled at a network pharmacy. Ask your pharmacy to submit a claim

to UnitedHealthcare.

Contraceptive films Contraceptive suppositories

Contraceptive Emergency birth control (contraceptives) (AfterPill, generic for Plan B, generic for

foams Plan B One-Step)

Contraceptive gels Condoms

Contraceptive

Opill

sponges

Prescription birth control (contraceptives)

KEY

pill.............Hormonal Birth Control Pill (oral contraceptive)

ring...........Hormonal Birth Control Ring (contraceptive vaginal ring)

shot..........Hormonal Birth Control Shot (injectable contraceptive)

patch .......Hormonal Birth Control Patch (contraceptive transdermal patch)

gel ............Non-Hormonal Birth Control Gel (vaginal contraceptive)

Brand birth control (contraceptives)

ring Annovera pill Nextstellis pill Yasmin

shot Depo-Provera 104 mg gel Phexxi pill Yaz

pill Lo Loestrin FE pill Slynd

pill Natazia patch Twirla

Generic birth control (contraceptives)

pill Afirmelle, Aubra, Aubra EQ, Aviane, Delyla, Falmina, Larissia, Lessina, Levonorgestrel/Ethinyl

Estradiol 0.1/0.02 mg, Lutera, Orsythia, Sronyx, Vienva (generic Alesse)

Generic birth control (contraceptives) continued...

pill Altavera, Ayuna, Chateal, Chateal EQ, Kurvelo, Levonorgestrel/Ethinyl Estradiol 0.15/0.03 mg,

Levora-28, Lillow, Marlissa, Portia-28 (generic Nordette)

pill Alyacen 1/35, Cyclafem 1/35, Dasetta 1/35, Nortrel 1/35, Nylia 1/35, Pirmella 1/35 (generic Ortho-

Novum 1/35)

pill Alyacen 7/7/7, Dasetta 7/7/7, Nortrel 7/7/7, Nylia 7/7/7, Pirmella 7/7/7 (generic Ortho-Novum 7/7/7)

pill Amethia, Ashlyna, Camrese, Daysee, Jaimiess, Levonorgestrel/Ethinyl Estradiol 0.15/0.03 mg,

Simpesse (generic Seasonique)

pill Amethyst, Dolishale, Levonorgestrel/Ethinyl Estradiol 0.09/0.02 mg (generic Lybrel)

pill Apri, Cyred, Cyred EQ, Desogestrel/Ethinyl Estradiol 0.15/0.03 mg, Emoquette, Enskyce, Isibloom,

Juleber, Kalliga, Reclipsen, Solia (generic Desogen, Ortho-Cept)

pill Aranelle, Leena (generic Tri-Norinyl)

pill Aurovela, Junel, Larin, Microgestin, Norethindrone/Ethinyl Estradiol 1 mg/20 mcg (generic

Loestrin 1 mg/20 mcg)

pill Aurovela, Hailey, Junel, Larin, Microgestin, Norethindrone/Ethinyl Estradiol 1.5 mg/30 mcg

(generic Loestrin 1.5 mg/30 mcg)

pill Aurovela 24 FE, Blisovi 24 FE, Hailey 24 FE, Junel 24 FE, Larin 24 FE, Microgestin 24 FE,

Norethindrone/Ethinyl Estradiol 1 mg/20 mcg - FE (24), Tarina 24 FE (generic Loestrin 24 FE)

pill Aurovela FE, Blisovi FE, Gildess FE, Hailey FE, Junel FE, Larin FE, Microgestin FE, Norethindrone/

Ethinyl Estradiol/FE, Tarina FE (generic Loestrin FE)

pill Azurette, Desogestrel/Ethinyl Estradiol 0.15/0.02 mg, Kariva, Pimtrea, Simliya, Viorele, Volnea

(generic Mircette)

pill Balziva, Briellyn, Norethindrone/Ethinyl Estradiol 0.4 mg/35 mcg, Philith, Vyfemla (generic

Ovcon-35)

pill Camila, Deblitane, Errin, Heather, Incassia, Jencycla, Lyleq,Lyza, Nora-BE, Norethindrone 35 mcg,

Norlyda, Norlyroc, Sharobel, Tulana (generic Micronor, Nor-Q-D)

pill Camrese Lo, Levonorgestrel/Ethinyl Estradiol 0.1/0.02 mg (84), LoJaimiess (generic

LoSeasonique)

pill Caziant, Cesia, Velivet (generic Cyclessa)

pill Charlotte 24 FE, Finzala, Mibelas 24 FE, Norethindrone/Ethinyl Estradiol FE 1/0.02 mg Chewable

(generic Minastrin 24 FE)

pill Cryselle-28, Elinest, Low-Ogestrel, Turqoz (generic Lo/Ovral)

pill Drospirenone/Ethinyl Estradiol/Levomefolate 3-0.02-0.451 mg, (generic Beyaz)

pill Drospirenone/Ethinyl Estradiol/Levomefolate 3-0.03-0.451 mg, Tydemy (generic Safyral)

ring Eluryng, Enilloring, Etonogestrel/Ethinyl Estradiol 0.12/0.015 mg/24 hr, Haloette (generic

NuvaRing)

pill Enpresse-28, Levonest, Levonorgestrel/Ethinyl Estradiol 6-5-10, Trivora-28 (generic Triphasil)

pill Estarylla, Femynor, Mili, Mono-Linyah, Mononessa, Norgestimate/Ethinyl Estradiol 0.25/0.035

mg, Nymyo, Previfem, Sprintec-28, Vylibra (generic Ortho-Cyclen)

pill Ethynodiol Diacetate/Ethinyl Estradiol 1/0.035 mg, Kelnor 1/35, Zovia 1/35, Zovia 1/35E (generic

Demulen 1/35)

pill Ethynodiol Diacetate/Ethinyl Estradiol 1/0.05 mg, Kelnor 1/50 (generic Demulen 1/50)

pill Fayosim, Levonorgestrel/Ethinyl Estradiol, Rivelsa (generic Quartette)

pill Gemmily, Merzee, Norethindrone/Ethinyl Estradiol FE, Taysofy (generic Taytulla)

pill Iclevia, Introvale, Jolessa, Levonorgestrel/Ethinyl Estradiol 0.15/0.03 mg, Setlakin (generic

Seasonale)

Generic birth control (contraceptives) continued...

pill Kaitlib FE Chew, Layolis FE Chew, Norethindrone/Ethinyl Estradiol FE 0.8/0.025 mg Chew

(generic Generess FE)

pill Levonorgestrel/Ethinyl Estradiol FE 0.1 mg/20 mcg, Joyeaux (generic Balcoltra)

shot Medroxyprogesterone Acetate 150 mg (generic Depo-Provera 150 mg)

pill Necon 0.5 mg/35 mcg, Nortrel 0.5 mg/35 mcg, Wera 0.5 mg/35 mcg (generic Brevicon,

Modicon)

patch Norelgestromin/Ethinyl Estradiol 150/35 mcg, Xulane, Zafemy (generic Ortho Evra)

pill Norethindrone/Ethinyl Estradiol FE 0.4/0.35 mg, Wymzya FE (generic Femcon FE)

pill Norethindrone/Ethinyl Estradiol FE 1-20/1-30/1-35 mg-mcg, Tilia FE, Tri-Legest FE (generic

Estrostep FE)

pill Norgestimate/Ethinyl Estradiol 0.18-0.215-0.25/0.035 mg, Tri-Estarylla, Tri Femynor, Tri-Linyah,

Tri-Mili, Trinessa, Tri-Nymyo, Tri-Sprintec, Tri-Vylibra (generic Ortho Tri-Cyclen)

pill Norgestimate/Ethinyl Estradiol 0.18-0.215-0.25/0.025 mg, Tri-Lo-Estarylla, Tri-Lo-Marzia, Tri-Lo-

Mili, Tri-Lo-Sprintec,

Tri-Vylibra Lo (generic Ortho Tri-Cyclen Lo)

pill Tyblume

Prescription cervical caps and diaphragms for birth control (contraceptives)

Brand cervical caps

Femcap

Brand diaphragms

Caya Wide-Seal

Omniflex

Prescription emergency birth control (contraceptives)

Brand emergency birth control (contraceptives)

AfterPill Plan B One-Step

ella

Generic emergency birth control (contraceptives)

Aftera, Curae, EContra EZ, EContra One Step, Her Style, Levonorgestrel 1.5 mg, My Choice, My Way, New

Day, Opcicon One-Step, Option 2, React, Take Action (generic Plan B One-Step)

What if my doctor prescribes a similar preventive medication that is not on this list?

The health reform law allows plans to use reasonable medical management to decide which product/

medications are provided at $0 cost share. If you choose a no-cost product from the list applicable to your

plan, your cost at the pharmacy will be $0. If you choose a covered product/medication that is not on the

list, a copay or coinsurance may be required. And this cost will apply to your deductible if you have one.

You can ask your doctor for a prescription for one of the medications on this list that your doctor

feels would work for you. For some medical reasons, your doctor may decide you need a medication

that is not on this list. If so, you can request the medication you need by calling the number on

your health plan ID card, and asking how to obtain coverage at no additional cost. Medical reasons

may include side effects, and whether you can use the medication/product as required. Your doctor

may visit uhcprovider.com for details on how to submit and what information to include with

Patient Protection and Affordable Care Act $0 Cost-Share Preventive Medications Exemption Requests.

Medical birth control

These medical birth control services will be covered at no cost to you when prescribed and performed

by a network health care professional. However, birth control products or drugs used as part of these

services may be billed at full cost, unless they appear on this list.

Medical birth control

Contraceptive counseling

To start, keep or stop the use of birth control services, products and drugs.

Diaphragms and cervical caps

IUDs (intrauterine devices)

Implantable rods

These flexible rods are implanted under the skin, and can provide birth control for up to 3 years.

Injectable contraceptives

Getting sterilized and anesthesia

(including cutting or blocking the Fallopian tubes or oviducts, i.e. getting your tubes tied)

Surgical sterilization (getting your tubes tied)

Questions?

or call the number on your health plan ID card.

1 Please note this list is subject to change.

2 Always refer to your Contraceptive Services Only Booklet to determine your coverage for contraceptives. Where differences are noted, the Contraceptive Services

Only Booklet will govern. For example, your Contraceptive Services Only Booklet may only cover medical birth control, and not pharmacy birth control.

3 All brand-name medications are trademarks or registered trademarks of their respective owners.

4 Additional products not listed on this document are covered at $0 if your pharmacy benefit plan is administered in Connecticut, Oregon or Washington. Sign in to

myuhc.com and go to Pharmacy Information or call the number on your member ID card.

5 In certain scenarios, your pharmacy may ask you to contact your healthcare provider for a prescription.

6 Prior Authorization required unless your pharmacy benefit plan is administered in Maryland, New York, Oregon, or Washington.

7 When informed by a member’s health care provider, UnitedHealthcare will accommodate a coverage exception request for any member when one of the $0

cost medications listed on the Preventive Care Medications list may be medically inappropriate as determined by the health care provider for that member and

UnitedHealthcare will waive the otherwise applicable cost-sharing for a medication not represented on the Preventive Care Medications list.

8 If a member is admitted to an inpatient facility for another reason (for example during maternity/delivery) and has a sterilization procedure performed during that

admission, the sterilization or other contraceptive procedure fees are covered under the preventive benefit. However, the facility fees are not covered under the

preventive care benefit since the sterilization or other contraceptive procedure is incidental to, and is not the primary reason, for the inpatient admission.

508 Compliant