Rx preventive coverage for Exclusive

Effective January 1, 2022

Under the Patient Protection and Affordable Care Act (PPACA), certain preventive drugs are covered at no cost to you when filled at a participating pharmacy with a valid prescription.

While we strive to provide prompt notice of changes to covered preventive medications, this list (as well as coverage criteria) is subject to change. For more information, visit the drugs page, or contact Member Services at the phone number listed on the back of your member ID card.

Please note that this preventive drug list is only applicable to members of an employer group health plan that is not grandfathered under PPACA. Please consult your employer for questions relating to grandfathered status.

Key:

lowercase = generic  
UPPERCASE = BRAND

Rx contraceptive drug list1

Drug names(s)

afirmelle

aftera

afterpill

altavera

alyacen 1/35

alyacen 7/7/7

amethia

amethia lo

amethyst

apri

aranelle

ashlyna

aubra

aubra eq

aurovela 1.5/30

aurovela 1/20

aurovela 24 fe

aurovela fe 1.5/30

aurovela fe 1/20

aviane

ayuna

azurette

balziva

bekyree

blisovi 24 fe

blisovi fe 1.5/30

blisovi fe 1/20

briellyn

camila

camrese

camrese lo

CAYA

caziant

cesia

charlotte 24 fe

chateal

chateal eq

cryselle-28

cyclafem 1/35

cyclafem 7/7/7

cyred

cyred eq

dasetta 1/35

dasetta 7/7/7

daysee

deblitane

delyla

desogestrel/ethinyl estradiol

dolishale

drospirenone/ethinyl estradiol

drospirenone/ethinyl

estradiol/levomefolate calcium

econtra ez

econtra one-step

elinest

ELLA

emoquette

ENCARE

enpresse-28

enskyce

errin

estarylla

ethynodiol diacetate/ethinyl estradiol

falmina

fayosim

FC FEMALE CONDOM

FC2 FEMALE CONDOM

FEMCAP

femynor

gianvi

hailey 1.5/30

hailey 24 fe

hailey fe 1.5/30

hailey fe 1/20

heather

iclevia

incassia

introvale

isibloom

jaimiess

jasmiel

jencycla

jolessa

juleber

junel 1.5/30

junel 1/20

junel fe 1.5/30

junel fe 1/20

junel fe 24

kaitlib fe

kalliga

kariva

kelnor 1/35

kelnor 1/50

kurvelo

larin 1.5/30

larin 1/20

larin 24 fe

larin fe 1.5/30

larin fe 1/20

larissia

layolis fe

leena

lessina

levonest

levonorgestrel

levonorgestrel and ethinyl estradiol

levonorgestrel/ethinyl estradiol

levora 0.15/30-28

lillow

lo-zumandimine

loestrin 1.5/30-21

loestrin 1/20-21

loestrin fe 1.5/30

loestrin fe 1/20

lojaimiess

loryna

low-ogestrel

lutera

lyleq

lyza

marlissa

medroxyprogesterone acetate

melodetta 24 fe

mibelas 24 fe

microgestin 1.5/30

microgestin 1/20

microgestin 24 fe

microgestin fe 1.5/30

microgestin fe 1/20

mili

mono-linyah

mononessa

my choice

my way

necon 0.5/35-28

necon 1/35

new day

nikki

nora-be

norethindrone

norethindrone & ethinyl estradiol ferrous fumarate

norethindrone acetate/ethinyl estradiol

norethindrone acetate/ethinyl estradiol/ferrous fumarate

norethindrone/ethinyl estradiol/ferrous fumarate

norgestimate/ethinyl estradiol

norlyda

norlyroc

nortrel 0.5/35 (28)

nortrel 1/35

nortrel 7/7/7

NUVARING

nylia 7/7/7

nymyo

ocella

OMNIFLEX DIAPHRAGM

opcicon one-step

option 2

OPTIONS GYNOL II VAGINAL CONTRACEPTIVE

orsythia

philith

pimtrea

pirmella 1/35

pirmella 7/7/7

portia-28

preventeza

previfem

react

reclipsen

rivelsa

setlakin

sharobel

SHUR-SEAL

simliya

simpesse

solia

sprintec 28

sronyx

syeda

take action

tarina 24 fe

tarina fe 1/20

tarina fe 1/20 eq

tilia fe

TODAY SPONGE

tri femynor

tri-estarylla

tri-legest fe

tri-linyah

tri-lo-estarylla

tri-lo-marzia

tri-lo-mili

tri-lo-sprintec

tri-mili

tri-nymyo

tri-previfem

tri-sprintec

tri-vylibra

tri-vylibra lo

trinessa

trivora-28

tulana

tydemy

VCF VAGINAL CONTRACEPTIVE FILM

VCF VAGINAL CONTRACEPTIVE FOAM

VCF VAGINAL CONTRACEPTIVEGEL

velivet

vestura

vienva

viorele

volnea

vyfemla

vylibra

wera

WIDE-SEAL SILICONE DIAPHRAGM KIT

wymzya fe

xulane

zarah

zovia 1/35

zovia 1/35e

zumandimine

 

 

Aspirin

Drug name

Coverage criteria

aspirin chew tab

81 mg

aspirin tab delayed release

81 mg

Bowel Preparation2

Drug name

Coverage criteria

peg 3350-kcl-na bicarb-nacl-na sulfate for soln

236 gm

peg 3350-kcl-na bicarb-nacl-na sulfate for soln

240 gm

peg 3350-kcl-sod bicarb-nacl for soln

420 gm

Breast Cancer Primary Preventive2

Drug name

Coverage criteria

anastrozole tab

1 mg

raloxifene hcl tab

60 mg

tamoxifen citrate tab

10 mg (base equivalent)

tamoxifen citrate tab

20 mg (base equivalent)

Folic Acid2

Drug name

Coverage criteria

FA-8 CAP

800MCG

FA-8 TAB

0.8 mg

FOLIC ACID CAP

800MCG

FOLIC ACID TAB

400MCG

FOLIC ACID TAB

800MCG

SM FOLIC ACD TAB

400MCG

YL FOLIC ACI TAB

400MCG

Human Immuniodeficiency Virus preexposure prophylaxis (HIV prep)2

Drug name

Coverage criteria

emtricitabine-tenofovir disoproxil fumarate tab

200-300 mg

Infant eye ointment (for newborns)2

Erythromycin ophth oint

5mg/gm

Iron Supplements2

Drug name

Coverage criteria

FEROSUL ELX

220/5ML

FERROUS SUL LIQ

220/5ML

FERROUS SULF DRO

15 mg/ML

FERROUS SULF ELX

220/5ML

FERROUS SULF LIQ

44 mg/5ML

FERROUS SULF SYP

300/5ML

FE-VITE IRON SOL

15 mg/ML

IRON SUPPLMT DRO

15 mg/ML

IRON SUPPMNT ELX

220/5ML

IRON UP LIQ

 

NOVAFERRUM DRO

15 mg/ML

PEDIA IRON DRO

15 mg/ML

PEDIATRIC DRO IRON

 

WEE CARE SUS

15/1.25

Single agent statins Comprehensive (three statins)2

Drug name

Coverage criteria

lovastatin tab

20mg

lovastatin tab

40mg

pravastatin tab

10mg

pravastatin tab

20mg

pravastatin tab

40mg

pravastatin tab

80mg

simvastatin tab

10mg

simvastatin tab

20mg

simvastatin tab

40mg

Smoking deterrents2

Drug name

Coverage criteria

BUPROPION TAB

150 mg

BUPROPION TAB

150 mg SR

CHANTIX PAK

0.5 and 1 mg

CHANTIX PAK

1 mg

CHANTIX TAB

0.5 mg

CHANTIX TAB

1 mg

CVS NICOTINE DIS

14 mg/24H

CVS NICOTINE DIS

21 mg/24H

CVS NICOTINE DIS

7 mg/24HR

CVS NICOTINE GUM

2 mg cinnamon

CVS NICOTINE GUM

2 mg mint

CVS NICOTINE GUM

2 mg original

CVS NICOTINE GUM

2 mg fruit

CVS NICOTINE GUM

4 mg cinnamon

CVS NICOTINE GUM

4 mg mint

CVS NICOTINE GUM

4 mg original

CVS NICOTINE GUM

4 mg fruit

CVS NICOTINE lozenge

2 mg

CVS NICOTINE lozenge

2 mg mint

CVS NICOTINE lozenge

4 mg cinnamon

CVS NICOTINE lozenge

4 mg mint

EQ NICOTINE DIS

14 mg/24H

EQ NICOTINE DIS

21 mg/24H

EQ NICOTINE DIS

7 mg/24HR

EQ NICOTINE GUM

2 mg cinnamon

EQ NICOTINE GUM

2 mg mint

EQ NICOTINE GUM

2 mg fruit

EQ NICOTINE GUM

4 mg cinnamon

EQ NICOTINE GUM

4 mg mint

EQ NICOTINE GUM

4 mg original

EQ NICOTINE GUM

4 mg fruit

EQ NICOTINE lozenge

2 mg cinnamon

EQ NICOTINE lozenge

2 mg mint

EQ NICOTINE lozenge

4 mg cinnamon

EQ NICOTINE lozenge

4 mg mint

EQL NICOTINE GUM

2 mg

EQL NICOTINE GUM

4 mg

EQL NICOTINE lozenge

2 mg mint

EQL NICOTINE lozenge

4 mg mint

GNP NICOTINE DIS

14 mg/24H

GNP NICOTINE DIS

21 mg/24H

GNP NICOTINE DIS

7 mg/24HR

GNP NICOTINE GUM

2 mg fruit

GNP NICOTINE GUM

2 mg mint

GNP NICOTINE GUM

2 mg original

GNP NICOTINE GUM

4 mg fruit

GNP NICOTINE GUM

4 mg mint

GNP NICOTINE GUM

4 mg original

GNP NICOTINE lozenge

2 mg mint

GNP NICOTINE lozenge

4 mg cherry

GNP NICOTINE lozenge

4 mg mint

GNP NICOTINE lozenge

MINI 2 mg

HABITROL DIS

21 mg/24H

HM NICOTINE DIS

14 mg/24H

HM NICOTINE DIS

21 mg/24H

HM NICOTINE DIS

7 mg/24HR

HM NICOTINE GUM

2 mg

HM NICOTINE GUM

2 mg mint

HM NICOTINE GUM

4 mg fruit

HM NICOTINE GUM

4 mg mint

HM NICOTINE lozenge

2 mg

HM NICOTINE lozenge

2 mg cinnamon

HM NICOTINE lozenge

2 mg mint

HM NICOTINE lozenge

4 mg cinnamon

HM NICOTINE lozenge

4 mg mint

KLS QUIT2 GUM

2 mg

KLS QUIT2 lozenge

2 mg

KLS QUIT4 GUM

4 mg

KLS QUIT4 lozenge

4 mg

NICORELIEF GUM

2 mg mint

NICORELIEF GUM

2 mg original

NICOTINE DIS

14 mg/24H

NICOTINE DIS

21 mg/24H

NICOTINE DIS

7 mg/24HR

NICOTINE DIS

STEP 1

NICOTINE GUM

2 mg

NICOTINE GUM

2 mg fruit

NICOTINE GUM

4 mg

NICOTINE lozenge

2 mg mint

NICOTINE lozenge

4 mg cinnamon

NICOTINE lozenge

4 mg mint

NICOTINE lozenge

MINI 2 mg

NICOTINE POL GUM

2 mg

NICOTINE POL GUM

2 mg cinnamon

NICOTINE POL GUM

2 mg mint

NICOTINE POL GUM

2 mg original

NICOTINE POL GUM

2 mg REF

NICOTINE POL GUM

2 mg STRT

NICOTINE POL GUM

2 mg fruit

NICOTINE POL GUM

4 mg

NICOTINE POL GUM

4 mg cinnamon

NICOTINE POL GUM

4 mg mint

NICOTINE POL GUM

4 mg original

NICOTINE POL GUM

4 mg REF

NICOTINE POL GUM

4 mg STRT

NICOTINE POL GUM

4 mg fruit

NICOTINE POL lozenge

2 mg cherry

NICOTINE POL lozenge

2 mg cinnamon

NICOTINE POL lozenge

2 mg MINI

NICOTINE POL lozenge

2 mg mint

NICOTINE POL lozenge

4 mg cherry

NICOTINE POL lozenge

4 mg cinnamon

NICOTINE POL lozenge

4 mg mint

NICOTINE SYS KIT

TRANSDER

NICOTINE TD DIS

14 mg/24H

NICOTINE TD DIS

21 mg/24H

NICOTINE TD DIS

7 mg/24HR

NICOTINE TD DIS

STEP 1

NICOTINE TD DIS

STEP 3

NICOTROL

INH

NICOTROL NS SPR

10 mg/ML

QC NICOTINE DIS

14 mg/24H

QC NICOTINE DIS

21 mg/24H

RA NICOTINE DIS

14 mg/24H

RA NICOTINE DIS

21 mg/24H

RA NICOTINE GUM

2 mg

RA NICOTINE GUM

2 mg mint

RA NICOTINE GUM

4 mg

RA NICOTINE GUM

4 mg mint

RA NICOTINE lozenge

2 mg mint

RA NICOTINE lozenge

4 mg mint

SM NICOTINE DIS

14 mg/24H

SM NICOTINE DIS

21 mg/24H

SM NICOTINE DIS

7 mg/24HR

SM NICOTINE GUM

2 mg

SM NICOTINE GUM

2 mg mint

SM NICOTINE GUM

4 mg

SM NICOTINE GUM

4 mg mint

SM NICOTINE lozenge

2 mg cherry

SM NICOTINE lozenge

2 mg cinnamon

SM NICOTINE lozenge

2 mg mint

SM NICOTINE lozenge

4 mg

SM NICOTINE lozenge

4 mg cinnamon

SM NICOTINE lozenge

4 mg mint

SR NICOTINE GUM

2 mg

STOP SMOKING GUM

2 mg mint

STOP SMOKING GUM

2 mg original

STOP SMOKING GUM

4 mg

STOP SMOKING lozenge

2 mg

STOP SMOKING lozenge

2 mg mint

STOP SMOKING lozenge

4 mg mint

TGT NICOTINE DIS

14 mg/24H

TGT NICOTINE DIS

21 mg/24H

TGT NICOTINE DIS

7 mg/24HR

TGT NICOTINE GUM

2 mg mint

TGT NICOTINE GUM

2 mg original

TGT NICOTINE GUM

2 mg fruit

TGT NICOTINE GUM

4 mg

TGT NICOTINE GUM

4 mg original

TGT NICOTINE lozenge

2 mg cherry

TGT NICOTINE lozenge

2 mg mint

TGT NICOTINE lozenge

4 mg cherry

TGT NICOTINE lozenge

4 mg mint

THRIVE GUM

2 mg mint

Rx vaccine and immunization preventive coverage list3

With our prescription drug benefits, you can receive preventive immunizations at no cost from your provider or pharmacy of choice–because prevention is key to living healthy. Simply present your member ID card to your primary care physician (PCP) or your favorite in-network retail pharmacy to receive any of the following preventive seasonal and nonseasonal vaccines. 3

Vaccine type3

Coverage criteria

Vaccine name(s)

COVID-19

5 years and up

JANSSEN (JOHNSON & JOHNSON)

MODERNA

PFIZER-BIONTECH

Haemophilus B

3 years and up

ACTHIB

HIBERIX

PEDVAX HIB

Hepatitis A

3 years and up

HAVRIX

VAQTA

Hepatitis A and B

3 years and up

TWINRIX

Hepatitis B

3 years and up

ENGERIX-B

HEPLISAV-B

RECOMBIVAX HB

Human Papillomavirus

3 years and up

GARDASIL 9

Influenza

 

AFLURIA QUAD

FLUAD

FLUAD QUAD

FLUARIX QUAD

FLUBLOK QUAD

FLUCELVAX QUAD

FLULAVAL QUAD

FLUMIST QUAD

FLUZONE HIGH-DOSE PF

FLUZONE QUAD

Measles, Mumps, Rubella

3 years and up

M-M-R II

PROQUAD

Meningitis

3 years and up

BEXSERO

MENACTRA

MENQUADFI

MENVEO

TRUMENBA

Pneumonia

18 and up

PNEUMOVAX 23

PNEUMOVAX 23/1 DOSE

PREVNAR 13

PREVNAR 20

VAXNEUVANCE

Poliovirus

3 years and up

IPOL INACTIVATED IPV

Rotavirus

3 years and up

ROTARIX

ROTATEQ

Shingles

19 years and up

SHINGRIX

Tetanus, Diphtheria, Pertussis

3 years and up

ADACEL

BOOSTRIX

DAPTACEL

DIPHTHERIA/TETANUS TOXOIDS

ADSORBE  
INFANRIX

KINRIX

PEDIARIX

PENTACEL

QUADRACEL

TDVAX

TENIVAC

VAXELIS

Varicella

3 years and up

VARIVAX

1Depending on your prescription drug plan, some drugs listed may not be covered. Refer to your Certificate of Coverage for specific information about your prescription drug benefit. You can login to your secure account to view the formulary and formulary status of your drugs.

2Requires prescription.

3Certain vaccines may not be available at all pharmacies. Members should contact their pharmacy to confirm vaccine availability and administration before their visit. Age restrictions may apply. Refer to your Certificate of Coverage for benefit details.

The Healthcare Reform mandate does not apply to inpatient medications or to medications obtained from and/or administered by a physician or a home health agency. The information contained herein is current at the time of posting and may be subject to change. Customers should refer to their coverage documents for specific terms, conditions, exclusions, and limitations relating to coverage.