Rx preventive coverage

Effective July 1, 2021

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 the following preventive drug list is applicable to members with coverage through one of our Individual products.

Key:

lowercase = generic  
UPPERCASE = BRAND  

Rx contraceptive drug list

Drug name(s)

afirmelle aftera altavera
alyacen 1/35 alyacen 7/7/7 amethia
amethia lo amethyst ANNOVERA
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 BALCOLTRA 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
DEPO-SUBQ PROVERA 104 desogestrel/ethinyl estradiol dolishale
drospirenone/ethinyl estradiol drospirenone/ethinyl estradiol/levomefolate calcium econtra ez
econtra one-step elinest ELLA
eluryng emoquette ENCARE
enpresse-28 enskyce errin
estarylla ethynodiol diacetate/ethinyl estradiol etonogestrel/ethinyl estradiol
falmina fayosim FC FEMALE CONDOM
FC2 FEMALE CONDOM FEMCAP femynor
gemmily 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
jolivette 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 LOESTRIN FE 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 merzee 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 NATAZIA 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
nylia 7/7/7 nymyo ocella
OGESTREL OMNIFLEX DIAPHRAGM opcicon one-step
option 2 OPTIONS GYNOL II VAGINAL CONTRACEPTIVE orsythia
philith pimtrea pirmella 1/35
pirmella 7/7/7 PLAN B ONE-STEP portia-28
preventeza previfem react
reclipsen rivelsa setlakin
sharobel SHUR-SEAL simliya
simpesse SLYND 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 TWIRLA
TYBLUME 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 60 WIDE-SEAL SILICONE DIAPHRAGM KIT 65
WIDE-SEAL SILICONE DIAPHRAGM KIT 70 WIDE-SEAL SILICONE DIAPHRAGM KIT 75 WIDE-SEAL SILICONE DIAPHRAGM KIT 80
WIDE-SEAL SILICONE DIAPHRAGM KIT 85 WIDE-SEAL SILICONE DIAPHRAGM KIT 90 WIDE-SEAL SILICONE DIAPHRAGM KIT 95
wymzya fe xulane zarah
zovia 1/35 zovia 1/35e zumandimine

Rx preventive coverage list

Drug name(s)1

Coverage criteria

Aspirin 81 mg
Bowel Preparation Medications2 Used for colorectal cancer screening. Age limit 50 to 74 years (men and women) Prescription only
COLYTE, gavilyte-C kit, gavilyte-G kit, gavilyte-N kit, GOLYTELY, NULYTELY, peg-3350 sol, TRILYTE For members who are at high risk for colorectal cancer and do not meet the age limits
Breast Cancer Prevention2
anastrazole (effective 9/1/20), Evista, raloxifene, SOLTAMOX, tamoxifen
Limited to women ≥ 35 years of age with no previous history of breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ.
Folic Acid Supplements2 Folic acid tablet 0.4 mg and 0.8 mg and folic acid capsule
Smoking Deterrents2
bupropion hcl SR 150 mg (smoking deterrent), CHANTIX, nicotine patch, nicotine gum, nicotine lozenge, NICOTROL Nasal Spray and Inhaler, and THRIVE
Limited to 180-day treatment regimen
Sodium Fluoride2 Limited to children ≤ 18 years of age; over-the-counter products excluded even with a prescription.
Statins2
Lovastatin 10 mg, 20 mg, 40 mg, pravastatin 10 mg, 20 mg, 40 mg, 80 mg, simvastatin 10 mg, 20 mg, 40 mg
Limited to men/women age 40-75 years for generic low to moderate intensity statins
Truvada2 (emtricitabine and tenofovir disoproxil fumarate) PrEP Prophylaxis Limited to at-risk adults and adolescents for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 infection

Rx vaccine and immunization preventive coverage list

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 vaccines3.

Vaccine type

Vaccine name

COVID-19 JANSSEN (JOHNSON & JOHNSON), MODERNA, PFIZER-BIONTECH
Influenza AFLURIA, FLUARIX, FLULAVAL QUAD, FLUZONE QUAD, FLUAD, FLUBLOK QUAD, FLUMIST QUAD, FLUAD QUAD, FLUCELVAX QUAD, FLUZONE HD
Haemophilus Influenza Type B ACTIHIB, PEDVAX HIB
Hepatitis A HAVRIX, VAQTA
Hepatitis B ENGERIX-B, HEPLISAV-B, RECOMBIVAX
Hepatitis A and B TWINRIX
Human Papillomavirus GARDASIL-9
Measles, Mumps, Rubella M-M-R II
Meningitis BEXSERO TRUMENBA, MENACTRA, MENVEO, MENOMUNE
Pneumonia PENUMOVAX, PREVNAR 13
Shingles SHINGRIX
Tetanus, Diphtheria, Pertussis ADACEL, BOOSTRIX, TDVAX, TENIVAC
Varicella 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.