Rx preventive coverage for Elite

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 Capital Blue Cross strives 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 CONTRACEPTIVE GEL

velivet

vestura

vienva

viorele

volnea

vyfemla

vylibra

wera

WIDE-SEAL SILICONE DIAPHRAGM KIT

wymzya fe

xulane

zarah

zovia 1/35

zovia 1/35e

zumandimine

 

 

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.

Vaccine type

Coverage criteria

Vaccine name(s)

Covid-19

12 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

65 and up

PNEUMOVAX 23

PNEUMOVAX 23/1 DOSE

PREVNAR 13

Poliovirus

3 years and up

IPOL INACTIVATED IPV

Rotavirus

3 years and up

ROTARIX

ROTATEQ

Shingles

50 years and up

SHINGRIX

ZASTAVAX

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

Dental products

Drug name

Coverage criteria

FLUORIDE CHEW

0.25MG F

FLUORIDE CHEW

0.5MG F

FLUORIDE CHEW

1MG F

FLUORITAB CHEW

0.25MG F

FLUORITAB CHEW

0.5MG F

FLUORITAB CHEW

1MG F

FLUORITAB CHEW

2.2MG

FLUORITAB DRO

0.125MG

LUDENT CHEW

0.5MG F

LUDENT CHEW

1MG F

NAFRINSE CHEW

1MG F

NAFRINSE DRO

0.125MG

SOD FLUORIDE CHEW

0.25MG

SOD FLUORIDE CHEW

0.25MG F

SOD FLUORIDE CHEW

0.5MG

SOD FLUORIDE CHEW

0.5MG F

SOD FLUORIDE CHEW

1.1MG

SOD FLUORIDE CHEW

1MG

SOD FLUORIDE CHEW

1MG F

SOD FLUORIDE CHEW

2.2MG

SOD FLUORIDE DRO

0.5MG/ML

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.