Rx preventive coverage for Elite and Exclusive

Effective January 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  

Aspirin

Drug name

Generic/dosage

aspirin chew tab

81 mg

aspirin tab delayed release

81 mg

Bowel preparation

Drug name

Generic/dosage

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

236 gm (Golytely)

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

240 gm (Colyte-flavor packs)

peg 3350-kcl-sod bicarb-nacl for soln 420 gm

(Nulytely/flavor pack)

Breast cancer primary prevention

Drug name

Generic/dosage

anastrozole

anastrozole 1 mg

EVISTA

raloxifene hcl tab 60 mg

raloxifene hcl tab

60 mg (Evista)

SOLTAMOX

tamoxifen citrate oral soln 10 mg/5ml (base equivalent)

tamoxifen citrate tab

10 mg (base equivalent)

tamoxifen citrate tab

20 mg (base equivalent)

Folic acid supplements

Drug name

Generic/dosage

folic acid cap

0.8 mg

folic acid tab

400 mcg

folic acid tab

800 mcg

Human Immuniodeficiency Virus preexposure prophylaxis (HIV prep)

Drug name

Generic/dosage

emtricitabine-tenofovir disoproxil fumarate

tab 200-300 mg

Infant eye ointment (for newborns)

Drug name

Generic/dosage

erythromycin ophth oint

5 mg/gm

Iron supplements

Drug name

Generic/dosage

carbonyl iron susp

15 mg/1.25ml (elemental iron)

FER-IN-SOL

ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)

FERROUS SULFATE

ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe)

FERROUS SULFATE

ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe)

ferrous sulfate elixir

220 mg/5ml (44 mg/5ml elemental fe)

ferrous sulfate soln

75 mg/ml (15 mg/ml elemental fe)

ICAR PEDIATRIC

carbonyl iron susp 15 mg/1.25ml (elemental iron)

IRON UP

polysaccharide iron complex liquid 15 mg/0.5ml (fe equiv)

NOVAFERRUM PEDIATRIC DROP

polysaccharide iron complex liquid 15 mg/ml (fe equiv)

Single agent statins

Comprehensive (three statins)

Drug name

Generic/dosage

lovastatin tab

20 mg

lovastatin tab

40 mg

pravastatin sodium tab

10 mg

pravastatin sodium tab

20 mg (Pravachol)

pravastatin sodium tab

40 mg (Pravachol

pravastatin sodium tab

80 mg (Pravachol)

simvastatin tab

10 mg (Zocor)

simvastatin tab

20 mg (Zocor)

simvastatin tab

40 mg (Zocor)

Tobacco cessation

Drug name

Generic/dosage

All brand/generic OTC nicotine gum, lozenges, patches

 

All brand/generic Rx nicotine gum, lozenges, patches

 


bupropion hcl (smoking deterrent) tab er

12hr 150 mg (Zyban)

CHANTIX

varenicline tartrate tab 0.5 mg (base equiv)

CHANTIX

varenicline tartrate tab 1 mg (base equiv)

CHANTIX CONTINUING MONTH

varenicline tartrate tab 1 mg (base equiv)

CHANTIX STARTING MONTH PACK

varenicline tartrate tab 0.5 mg x 11 and tab 1 mg x 42 pack

COMMIT

nicotine polacrilex lozenge 2 mg

COMMIT

nicotine polacrilex lozenge 4 mg

NICODERM CQ

nicotine td patch 24hr 7 mg/24hr

NICODERM CQ

nicotine td patch 24hr 14 mg/24hr

NICODERM CQ

nicotine td patch 24hr 21 mg/24hr

NICORETTE

nicotine polacrilex gum 2 mg

NICORETTE

nicotine polacrilex gum 4 mg

NICORETTE

nicotine polacrilex lozenge 2 mg

NICORETTE

nicotine polacrilex lozenge 4 mg

NICORETTE MINI

nicotine polacrilex lozenge 2 mg

NICORETTE MINI

nicotine polacrilex lozenge 4 mg

NICORETTE STARTER KIT

nicotine polacrilex gum 2 mg

NICORETTE STARTER KIT

nicotine polacrilex gum 4 mg

NICOTINE TRANSDERMAL SYST

nicotine td patch 24 hr kit 21-14-7 mg/24hr

NICOTROL INHALER

nicotine inhaler system 10 mg (4 mg delivered)

NICOTROL NS

nicotine nasal spray 10 mg/ml (0.5 mg/spray)

ZYBAN

bupropion hcl (smoking deterrent) tab er 12hr 150 mg

Recommendation on contraceptives by Health Resources and Services Administration (HRSA)

Eligible benefit plans include coverage under the Affordable Care Act for the following contraceptives to be covered at $0. To determine cost share for medications not listed below, log in to your secure account. Please refer to your benefit materials for coverage details and the plan website for current information as this publication is subject to change. This list will be reviewed periodically and is subject to change.

Generic prescription drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in all capital letters followed by the generic name. Generic medicines are available for many of the brand-name drugs listed though may not be available in all strengths.

Contraceptives

Barrier Method Types

Cervical Caps

Drug name

Coverage criteria

FEMCAP

cervical cap 22 mm  
cervical cap 26 mm  
cervical cap 30 mm

Diaphragms

Drug name

Coverage criteria

CAYA

diaphragm arc-spring

OMNIFLEX DIAPHRAGM

diaphragms

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 60 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 65 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 70 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 75 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 80 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 85 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 90 mm

WIDE-SEAL SILICONE DIAPHR

diaphragm wide seal 95 mm

Female Condom

Drug name

Coverage criteria

FC FEMALE CONDOM

condoms - female FC2 FEMALE CONDOM 
condoms - female

Spermicide

Drug name

Coverage criteria

ENCARE

nonoxynol-9 vaginal suppos 100 mg 
nonoxynol-9 gel 4%

OPTIONS CONCEPTROL VAGINA

nonoxynol-9 gel 4%

OPTIONS GYNOL II VAGINAL

nonoxynol-9 gel 3% SHUR-SEAL 
nonoxynol-9 gel 2%

VCF Vaginal Contraceptive gel

nonoxynol-9 gel 4%

VCF VAGINAL CONTRACEPTIVE

nonoxynol-9 foam 12.5%

VCF VAGINAL CONTRACEPTIVE

nonoxynol-9 film 28%

Sponge

Drug name

Coverage criteria

TODAY SPONGE

nonoxynol-9 vaginal sponge 1000 mg

Emergency Method Types

Emergency Ella

Drug name

Coverage criteria

ELLA

ulipristal acetate tab 30 mg

Emergency Progestin

Drug name

Coverage criteria

Aftera

levonorgestrel tab 1.5 mg

Econtra Ez

levonorgestrel tab 1.5 mg

Econtra One-Step

levonorgestrel tab 1.5 mg

Fallback Solo

levonorgestrel tab 1.5 mg

levonorgestrel tab

1.5 mg (Plan b one-step)

My Choice

levonorgestrel tab 1.5 mg

My Way

levonorgestrel tab 1.5 mg

New Day

levonorgestrel tab 1.5 mg

Next Choice One Dose

levonorgestrel tab 1.5 mg

Opcicon One-Step

levonorgestrel tab 1.5 mg

Option 2

levonorgestrel tab 1.5 mg

PLAN B ONE-STEP

levonorgestrel tab 1.5 mg

Preventeza

levonorgestrel tab 1.5 mg

React

levonorgestrel tab 1.5 mg

Take Action

levonorgestrel tab 1.5 mg

Hormonal Method Types

Injectable Progestin

Drug name

Coverage criteria

medroxyprogesterone acetate im

susp prefilled syr 150 mg/ml

Oral combined

Drug name

Coverage criteria

Afirmelle levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Altavera levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Alyacen 1/35 norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Alyacen 7/7/7 norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Apri desogestrel and ethinyl estradiol tab

0.15 mg - 30 mcg

Aranelle norethindrone-eth estradiol tab

0.5-35/1- 35/0.5-35 mg-mcg

Aubra levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Aubra Eq levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Aurovela 1.5/30 norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg

Aurovela 1/20 norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg

Aurovela 24 Fe norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Aurovela Fe 1/20 norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg

Aurovela Fe 1.5/30 norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg

Aviane levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Ayuna levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Azurette desogest-eth estrad and eth estrad tab

0.15-0.02/0.01 mg(21/5)

BALCOLTRA levonorgestrel-ethinyl estradiol-fe tab

0.1 mg-20 mcg (21)

Balziva norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Bekyree desogest-eth estrad and eth estrad tab

0.15-0.02/0.01 mg(21/5)

BEYAZ drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg

Blisovi 24 Fe norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Blisovi Fe 1.5/30 norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg

Blisovi Fe 1/20 norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg

Briellyn norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Caziant desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg

Chateal levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Chateal Eq levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Cryselle-28 norgestrel and ethinyl estradiol tab

0.3 mg-30 mcg

Cyclafem 1/35 norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Cyclafem 7/7/7 norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Cyred desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Cyred Eq desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Dasetta 1/35 norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Dasetta 7/7/7 norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Delyla levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

desogest-eth estrad and eth estrad tab

0.15-0.02/0.01 mg(21/5) (Mircette)

desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg

drospirenone-ethinyl estradiol tab

3-0.02 mg (Yaz)

drospirenone-ethinyl estradiol tab

3-0.03 mg (Yasmin 28)

drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg (Beyaz)

drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg (Safyral)

Elinest - norgestrel and ethinyl estradiol tab

0.3 mg-30 mcg

Emoquette - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Enpresse-28 - levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg

Enskyce - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Estarylla - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

ESTROSTEP FE – norethindrone ac-ethinyl estrad-fe tab

1-20/1-30/1-35 mg-mcg

ethynodiol diacetate and ethinyl estradiol tab

1 mg-35 mcg

ethynodiol diacetate and ethinyl estradiol tab

1 mg-50 mcg

Falmina - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Femynor - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

GENERESS FE – norethindrone and ethinyl estradiol-fe chew tab

0.8 mg-25 mcg

Gianvi - drospirenone-ethinyl estradiol tab

3-0.02 mg

Gildagia - norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Hailey 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg

Hailey 24 Fe - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Isibloom - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Jasmiel - drospirenone-ethinyl estradiol tab

3-0.02 mg

Juleber - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Junel 1/20 - norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg

Junel 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg

Junel Fe 1/20 - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg

Junel Fe 1.5/30 - norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg

Junel Fe 24 - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Kaitlib Fe - norethindrone and ethinyl estradiol-fe chew tab

0.8 mg-25 mcg

Kalliga - desogestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Kariva - desogest-eth estrad and eth estrad tab

0.15-0.02/0.01 mg(21/5)

Kelnor 1/35 - ethynodiol diacetate and ethinyl estradiol tab

1 mg-35 mcg

Kelnor 1/50 - ethynodiol diacetate and ethinyl estradiol tab

1 mg-50 mcg

Kimidess - desogest-eth estrad and eth estrad tab

0.15-0.02/0.01 mg(21/5)

Kurvelo - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Larin 1/20 - norethindrone ace and ethinyl estradiol

tab 1 mg-20 mcg

Larin 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg

Larin Fe 1/20 - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg

Larin Fe 1.5/30 - norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg

Larin 24 Fe - norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

Larissia - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Layolis Fe - norethindrone and ethinyl estradiol-fe chew tab

0.8 mg-25 mcg

Leena - norethindrone-eth estradiol tab

0.5-35/1-35/0.5-35 mg-mcg

Lessina - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Levonest - levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg

levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg

levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Levora 0.15/30-28 - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Lillow - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

LOESTRIN 1/20-21 – norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg

LOESTRIN 1.5/30-21 – norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg

LOESTRIN FE 1/20 – norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg

LOESTRIN FE 1.5/30 – norethindrone ace and ethinyl estradiol-fe tab

5 mg-30 mcg

Loryna - drospirenone-ethinyl estradiol tab

3-0.02 mg

Low-Ogestrel - norgestrel and ethinyl estradiol tab

0.3 mg-30 mcg

Lo-Zumandimine - drospirenone-ethinyl estradiol tab

3-0.02 mg

Lutera - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Marlissa - levonorgestrel and ethinyl estradiol tab

0.15 mg-30 mcg

Melodetta 24 Fe - norethindrone ace-eth estradiol-fe chew tab

1 mg-20 mcg (24)

Mibelas 24 Fe - norethindrone ace-eth estradiol-fe chew tab

1 mg-20 mcg (24)

Microgestin 1.5/30 - norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg

Microgestin 1/20 - norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg

Microgestin Fe - norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg

Microgestin Fe 1.5/30 - norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg

Mili - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

MINASTRIN 24 FE – norethindrone ace-eth estradiol-fe chew tab

1 mg-20 mcg (24)

MIRCETTE – desogest-eth estrad and eth estrad tab

0.15-0.02/0.01 mg(21/5)

Mono-Linyah - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Mononessa - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Myzilra - levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg

NATAZIA – estradiol valerate-dienogest tab

3 mg/2-2 mg/2-3 mg/1 mg

Necon 0.5/35-28 - norethindrone and ethinyl estradiol tab

0.5 mg-35 mcg

Necon 1/35 - norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Necon 7/7/7 - norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Nikki - drospirenone-ethinyl estradiol tab

3-0.02 mg

norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

norethindrone and ethinyl estradiol tab

0.5 mg-35 mcg

norethindrone and ethinyl estradiol tab

1 mg-35 mcg

(Ortho-novum 1/35) norethindrone ace and ethinyl estradiol tab

1 mg-20 mcg (Loestrin 1/20-21)

norethindrone ace and ethinyl estradiol tab

1.5 mg-30 mcg (Loestrin 1.5/30-21)

norethindrone and ethinyl estradiol-fe chew tab

0.4 mg-35 mcg

norethindrone and ethinyl estradiol-fe chew tab

0.8 mg-25 mcg (Generess fe)

norethindrone ace and ethinyl estradiol-fe tab

1 mg-20 mcg (Loestrin fe 1/20)

norethindrone ace-ethinyl estradiol-fe tab

1 mg-20 mcg (24)

norethindrone ace and ethinyl estradiol-fe tab

1.5 mg-30 mcg (Loestrin fe 1.5/30)

norethindrone ace-eth estradiol-fe chew tab

1 mg-20 mcg (24) (Minastrin 24 fe)

norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)

norethindrone-eth estradiol tab

0.5-35/1-35/0.5-35 mg-mcg

norethindrone ac-ethinyl estrad-fe tab

1-20/1-30/1-35 mg-mcg (Estrostep fe)

norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg (Ortho tri-cyclen lo)

norgestrel and ethinyl estradiol tab

0.3 mg-30 mcg

Nortrel 0.5/35 (28) - norethindrone and ethinyl estradiol tab

0.5 mg-35 mcg

Nortrel 1/35 - norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Nortrel 7/7/7 - norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

Ocella - drospirenone-ethinyl estradiol tab

3-0.03 mg

OGESTREL – norgestrel and ethinyl estradiol tab

0.5 mg-50 mcg

Orsythia - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

ORTHO-NOVUM 1/35 – norethindrone and ethinyl estradiol tab

1 mg-35 mcg

ORTHO-NOVUM 7/7/7 – norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg

ORTHO TRI-CYCLEN LO – norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg

Philith - norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Pimtrea - desogest-eth estrad and eth estrad tab

0.15-0.02/0.01 mg(21/5)

Pirmella 1/35 - norethindrone and ethinyl estradiol tab

1 mg-35 mcg

Tri-Vylibra - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg

Tri-Vylibra Lo - norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg

Tydemy - drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg

Velivet - desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg

Vestura - drospirenone-ethinyl estradiol tab

3-0.02 mg

Vienva - levonorgestrel and ethinyl estradiol tab

0.1 mg-20 mcg

Viorele - desogest-eth estrad and eth estrad tab

0.15-0.02/0.01 mg(21/5)

Vyfemla - norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Vylibra - norgestimate and ethinyl estradiol tab

0.25 mg-35 mcg

Wera - norethindrone and ethinyl estradiol tab

0.5 mg-35 mcg

Wymzya Fe - norethindrone and ethinyl estradiol-fe chew tab

0.4 mg-35 mcg

YASMIN 28 – drospirenone-ethinyl estradiol tab

3-0.03 mg

YAZ – drospirenone-ethinyl estradiol tab

3-0.02 mg

Zarah - drospirenone-ethinyl estradiol tab

3-0.03 mg

Zenchent - norethindrone and ethinyl estradiol tab

0.4 mg-35 mcg

Zenchent Fe - norethindrone and ethinyl estradiol-fe chew tab

0.4 mg-35 mcg

Zovia 1/35E - ethynodiol diacetate and ethinyl estradiol tab

1 mg-35 mcg

Zovia 1/50E - ethynodiol diacetate and ethinyl estradiol tab

1 mg-50 mcg

Zumandimine - drospirenone-ethinyl estradiol tab

3-0.03 mg

Oral Extended Continuous

Drug name

Coverage criteria

Amethia

levonorg-eth est tab 0.15-0.03mg(84) and eth est tab 0.01mg(7)

Amethia Lo

levonorg-eth est tab 0.1-0.02mg(84) and eth est tab 0.01mg(7)

Amethyst

levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg

Ashlyna

levonorg-eth est tab 0.15-0.03mg(84) and eth est tab 0.01mg(7)

Camrese

levonorg-eth est tab 0.15-0.03mg(84) and eth est tab 0.01mg(7)

Camrese Lo

levonorg-eth est tab 0.1-0.02mg(84) and eth est tab 0.01mg(7)

Daysee

levonorg-eth est tab 0.15-0.03mg(84) and eth est tab 0.01mg(7)

Fayosim

levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est 0.01 mg

Introvale

levonorgestrel and ethinyl estradiol (91-day) tab 0.15-0.03 mg

Jolessa

levonorgestrel and ethinyl estradiol (91-day) tab 0.15-0.03 mg

levonorg-eth est tab

0.1-0.02mg(84) and eth est tab 0.01mg(7) (Loseasonique)

levonorgestrel and ethinyl estradiol (91-day) tab

0.15-0.03 mg

levonorg-eth est tab

0.15-0.03mg(84) and eth est tab 0.01mg(7) (Seasonique)

levonor-eth est tab

0.15-0.02/0.025/0.03 mg &eth est 0.01 mg (Quartette)

levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg

LOSEASONIQUE – levonorg-eth est tab

0.1-0.02mg(84) and eth est tab 0.01mg(7)

QUARTETTE – levonor-eth est tab

0.15-0.02/0.025/0.03 mg &eth est 0.01 mg

Quasense - levonorgestrel and ethinyl estradiol

(91-day) tab 0.15-0.03 mg

Rivelsa - levonor-eth est tab

0.15-0.02/0.025/0.03 mg &eth est 0.01 mg

SEASONIQUE – levonorg-eth est tab

0.15-0.03mg(84) and eth est tab 0.01mg(7)

Setlakin - levonorgestrel and ethinyl estradiol

(91-day) tab 0.15-0.03 mg

Simpesse - levonorg-eth est tab

0.15-0.03mg(84) and eth est tab 0.01mg(7)

Oral Progestin

Drug name

Coverage criteria

Camila

norethindrone tab 0.35 mg

Deblitane

norethindrone tab 0.35 mg

Errin

norethindrone tab 0.35 mg

Heather

norethindrone tab 0.35 mg

Incassia

norethindrone tab 0.35 mg

Jencycla

norethindrone tab 0.35 mg

Jolivette

norethindrone tab 0.35 mg

Lyza

norethindrone tab 0.35 mg

Nora-Be

norethindrone tab 0.35 mg

norethindrone tab

0.35 mg (Ortho Micronor)

Norlyda

norethindrone tab 0.35 mg

Norlyroc

norethindrone tab 0.35 mg

ORTHO MICRONOR

norethindrone tab 0.35 mg

Sharobel

norethindrone tab 0.35 mg

SLYND

drospirenone tab 4 mg

Tulana

norethindrone tab 0.35 mg

Transdermal Combined

Drug name

Coverage criteria

XULANE

norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr

Vaginal Combined

Drug name

Coverage criteria

NUVARING

etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr

Implantable Method Types

Implantable Progestin (Rods)

Drug name

Coverage criteria

NEXPLANON

etonogestrel subdermal implant 68 mg

IUD Copper

Drug name

Coverage criteria

PARAGARD INTRAUTERINE COP

copper iud IUD Progestin

KYLEENA

levonorgestrel releasing iud 17.5 mcg/day (19.5 mg total)

LILETTA

levonorgestrel releasing iud 19.5 mcg/day(52 mg total)

MIRENA

levonorgestrel releasing iud 20 mcg/day(52 mg total)

SKYLA

levonorgestrel releasing iud 14 mcg/day (13.5 mg total)

Vaccines

Drug name

Coverage criteria

ACTHIB

haemophilus b polysaccharide conjugate vaccine for inj

ADACEL

tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml

AFLURIA PF

influenza virus vaccine split pf susp pref syringe 0.5 ml

AFLURIA QUADRIVALENT

influenza virus vaccine split quadrivalent im inj

AFLURIA QUADRIVALENT

influenza virus vac split quadrivalent susp pref syr 0.5ml

AFLURIA

influenza virus vaccine split im susp

BEXSERO

meningococcal vac b (recomb omv adjuv) inj prefilled syringe

BOOSTRIX

tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

DAPTACEL

diph, acellular pert and tet tox inj 15 lf-23 mcg-5 lf/0.5ml

DIPHTHERIA/TETANUS TOXOID

diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml

ENGERIX-B

hepatitis b vaccine (recombinant) 10 mcg/0.5ml

ENGERIX-B

hepatitis b vaccine (recombinant) 20 mcg/ml

ENGERIX-B

hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml

ENGERIX-B

hepatitis b vaccine (recombinant) susp 20 mcg/ml

FLUAD

nfluenza vac type aandb surface ant adj susp pref syr 0.5 ml

FLUARIX QUADRIVALENT

influenza virus vac split quadrivalent susp pref syr 0.5ml

FLUBLOK QUADRIVALENT

influenza vac recomb ha quad pf soln pref syr 0.5 ml

FLUCELVAX QUADRIVALENT

influenza vac tissue-cultured subunit quadrivalent im susp

FLUCELVAX QUADRIVALENT

influenza vac tiss-cult subunt quad susp pref syr 0.5 ml

FLULAVAL QUADRIVALENT

influenza virus vaccine split quadrivalent im inj

FLULAVAL QUADRIVALENT

influenza virus vac split quadrivalent susp pref syr 0.5ml

FLUMIST QUADRIVALENT

influenza virus vaccine live quadrivalent intranasal susp

FLUZONE HIGH-DOSE PF

influenza virus vac split high-dose pf susp pref syr 0.5ml

FLUZONE QUADRIVALENT

influenza virus vaccine split quadrivalent im inj

FLUZONE QUADRIVALENT

influenza virus vaccine split quadrivalent inj 0.5 ml

FLUZONE QUADRIVALENT

influenza virus vac split quadrivalent susp pref syr 0.25 ml

FLUZONE QUADRIVALENT

influenza virus vac split quadrivalent susp pref syr 0.5ml

GARDASIL 9

human papillomavirus (hpv) 9-valent recomb vac im susp

GARDASIL 9

human papillomavirus (hpv) 9-valent recomb vac susp pref syr

HAVRIX

hepatitis a vaccine inj susp 720 el unit/0.5ml

HAVRIX

hepatitis a vaccine inj susp 1440 el unit/ml

HEPLISAV-B

hepatitis b vaccine recomb adjuvanted pref syr 20 mcg/0.5ml

HEPLISAV-B

hepatitis b vaccine recombinant adjuvanted 20 mcg/0.5ml

HIBERIX

haemophilus b polysaccharide conjugate vac for inj 10 mcg

INFANRIX

diph, acellular pert and tet tox inj 25 lf-58 mcg-10 lf/0.5ml

IPOL INACTIVATED IPV

poliovirus vaccine, ipv injection

KINRIX

diph-tetanus tox ad-acell pert and polio virus, ipv vac inj

M-M-R II

measles, mumps and rubella virus vaccines for inj

MENACTRA

meningococcal (a, c, y, and w-135) conjugate vaccine inj

MENVEO

meningococcal (a, c, y, and w-135) oligo conj vac for inj

PEDIARIX

diph-tetanus tox-acell pert-hepatitis b-polio ipv vac injPEDVAX HIB – haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml

PENTACEL

diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp

PNEUMOVAX 23

pneumococcal vaccine polyvalent inj 25 mcg/0.5ml

PNEUMOVAX 23/1 DOSE

pneumococcal vaccine polyvalent inj 25 mcg/0.5ml

PREVNAR 13

pneumococcal 13-valent conjugate vaccine inj

PROQUAD

measles-mumps-rubella-varicella virus vaccines for susp

QUADRACEL

diph-tetanus tox ad-acell pert and polio virus, ipv vac inj

RECOMBIVAX HB

hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml

RECOMBIVAX HB

hepatitis b vaccine (recombinant) susp 10 mcg/ml

RECOMBIVAX HB

hepatitis b vaccine (recombinant) susp 40 mcg/ml

ROTARIX

rotavirus vaccine, live for oral susp ROTATEQ – rotavirus vaccine, live oral pentavalent soln

SHINGRIX

zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml

TDVAX

tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml

TENIVAC

tetanus-diphtheria toxoids (td) inj 5-2 lfu

TRUMENBA

meningococcal group b vac (recomb) im susp prefilled syr

TWINRIX

hep a-hep b vaccine susp pref syr 720­20 elu-mcg/ml

VAQTA

hepatitis a vaccine inj susp 25 unit/0.5ml

VAQTA

hepatitis a vaccine inj susp 50 unit/ml VARIVAX – varicella virus vac live for subcutaneous inj 1350 pfu/0.5ml

ZOSTAVAX

zoster vaccine live for subcutaneous susp 19400 unit/0.65ml

Fluoride

Drug name

Coverage criteria

CREST COMPLETE

sodium fluoride paste 0.243%

EQL TRAVEL TOOTHBRUSH/TOO

sodium monofluorophosphate paste 0.15%

GEL-KAM

stannous fluoride gel 0.4%

LISTERINE ESSENTIAL CARE

sod monofluorophosph-eucal-men-methyl sal-thymol gel 0.76%

LISTERINE HEALTHY WHITE GENTLE

sodium fluoride rinse 0.02%

LISTERINE HEALTHY WHITE VIBRANT

sodium fluoride rinse 0.02%

LISTERINE NATURALS WITH FLUORIDE

sodium fluoride rinse 0.02%

LISTERINE NIGHTLY RESET

sodium fluoride rinse 0.02%

LISTERINE RESTORING

sodium fluoride rinse 0.0221% (0.01% f)

LISTERINE SMART RINSE

sodium fluoride rinse 0.0221% (0.01% f)

LISTERINE SMART RINSE ANTICAVITY

sodium fluoride rinse 0.02%

LISTERINE TOTAL CARE

sodium fluoride rinse 0.0221% (0.01% f)

LISTERINE TOTAL CARE PLUS

sodium fluoride rinse 0.0221% (0.01% f)

LISTERINE TOTAL CARE ZERO

sodium fluoride rinse 0.02%

LISTERINE WHITENING/RESTORING

sodium fluoride rinse 0.0221% (0.01% f)

NAFRINSE DAILY/ACIDULATED

sodium fluoride-phosphoric acid for soln 1 mg/5m l (f equiv)

NAFRINSE DAILY/NEUTRAL

sodium fluoride for soln rinse 0.05%

NAFRINSE WEEKLY

sodium fluoride for soln rinse 0.2%

OMNI GEL

stannous fluoride gel 0.4%

PARODONTAX

stannous fluoride paste 0.454%

PREVIDENT FLUORIDE

sodium fluoride gel 1.1% (0.5% f)

PREVIDENT RINSE

sodium fluoride rinse 0.2%

PREVIDENT 5000 BOOSTER PLUS

sodium fluoride paste 1.1%

PREVIDENT 5000 DRY MOUTH

sodium fluoride gel 1.1% (0.5% f)

PREVIDENT 5000 ENAMEL PRO

sodium fluoride-potassium nitrate paste 1.1-5%

PREVIDENT 5000 ORTHO DEFENSE

sodium fluoride paste 1.1%

PREVIDENT 5000 PLUS

sodium fluoride cream 1.1%

PREVIDENT 5000 SENSITIVE

sodium fluoride-potassium nitrate paste 1.1-5%

SENSODYNE COMPLETE PROTECTION

stannous fluoride paste 0.454%

SENSODYNE RAPID RELIEF

stannous fluoride paste 0.454%

SENSODYNE REPAIR and PROTECT

stannous fluoride paste 0.454%

sodium fluoride cream 1.1%

(Prevident 5000 plus)

sodium fluoride gel 1.1%

(0.5% f) (Prevident fluoride)

sodium fluoride paste 1.1%

(Prevident 5000 boost)

sodium fluoride rinse 0.02%

(Listerine Smart Rinse Anticavity)

sodium fluoride rinse 0.0221%

(0.01% f) (Listerine Smart Rinse)

sodium fluoride rinse

0.05%

sodium fluoride rinse 0.2%

(Prevident)

sodium fluoride-potassium nitrate paste 1.1-5%

(Prevident 5000 sensi)

stannous fluoride conc

0.63%

stannous fluoride gel 0.4%

(Gel-kam)

STANNOUS FLUORIDE RINSE

stannous fluoride liq 0.1%

Supplements and Combinations

Drug name

Coverage criteria

sodium fluoride w/ calcium carb

cap 8.3-364 mg

sodium fluoride w/ calcium carb

tab 8.3-364 mg

sodium fluoride-vitamin d

liquid drops 0.25 mg/ml-400 unit/ml

sodium fluoride

soln 0.25 mg/0.6ml(from 0.55 mg/0.6ml naf)

sodium fluoride

soln 0.25 mg/drop f (from 0.55 mg/drop naf)

sodium monofluorophosphate-calcium carb

tab 22.75-625 mg

SODIUM FLUORIDE

sodium fluoride tab 0.5 mg f (from 1.1 mg naf)

SODIUM FLUORIDE

sodium fluoride tab 1 mg f (from 2.2 mg naf)

sodium fluoride chew tab

0.25 mg f (from 0.55 mg naf)

sodium fluoride chew tab

0.5 mg f (from 1.1 mg naf)

sodium fluoride chew tab

1 mg f (from 2.2 mg naf)

sodium fluoride soln

0.125 mg/drop f (0.275 mg/drop naf)

sodium fluoride soln

0.5 mg/ml f (from 1.1 mg/ml naf)