Rx preventive coverage for Exclusive full

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 preventive coverage List1

Aspirin

Drug name

Coverage criteria

aspirin chew tab

81 mg

aspirin tab delayed release

81 mg

Bowel preparation

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 Preventive

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 Acid

Drug name

Coverage criteria

FA-8 CAP

800MCG

FA-8 TAB

0.8MG

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)

Drug name

Coverage criteria

emtricitabine-tenofovir disoproxil fumarate tab

200-300 mg

Infant eye ointment (for newborns)

Drug name

Coverage criteria

Erythromycin ophth oint

5mg/gm

Iron Supplements

Drug name

Coverage criteria

FEROSUL ELX

220/5ML

FERROUS SUL LIQ

220/5ML

FERROUS SULF DRO

15MG/ML

FERROUS SULF ELX

220/5ML

FERROUS SULF LIQ

44MG/5ML

FERROUS SULF SYP

300/5ML

FE-VITE IRON SOL

15MG/ML

IRON SUPPLMT DRO

15MG/ML

IRON SUPPMNT ELX

220/5ML

IRON UP LIQ

 

NOVAFERRUM DRO

15MG/ML

PEDIA IRON DRO

15MG/ML

PEDIATRIC DRO IRON

 

WEE CARE SUS

15/1.25

Single agent statins

Comprehensive (three statins)

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 deterrents

Drug name

Coverage criteria

BUPROPION TAB

150MG

BUPROPION TAB

150MG SR

CHANTIX PAK

0.5& 1MG

CHANTIX PAK

1MG

CHANTIX TAB

0.5MG

CHANTIX TAB

1MG

CVS NICOTINE DIS

14MG/24H

CVS NICOTINE DIS

21MG/24H

CVS NICOTINE DIS

7MG/24HR

CVS NICOTINE GUM

2MG CINN

CVS NICOTINE GUM

2MG MINT

CVS NICOTINE GUM

2MG ORIG

CVS NICOTINE GUM

2MGFRUIT

CVS NICOTINE GUM

4MG CINN

CVS NICOTINE GUM

4MG MINT

CVS NICOTINE GUM

4MG ORIG

CVS NICOTINE GUM

4MGFRUIT

CVS NICOTINE LOZ

2MG

CVS NICOTINE LOZ

2MG MINT

CVS NICOTINE LOZ

4MG CINN

CVS NICOTINE LOZ

4MG MINT

EQ NICOTINE DIS

14MG/24H

EQ NICOTINE DIS

21MG/24H

EQ NICOTINE DIS

7MG/24HR

EQ NICOTINE GUM

2MG CINN

EQ NICOTINE GUM

2MG MINT

EQ NICOTINE GUM

2MGFRUIT

EQ NICOTINE GUM

4MG CINN

EQ NICOTINE GUM

4MG MINT

EQ NICOTINE GUM

4MG ORIG

EQ NICOTINE GUM

4MGFRUIT

EQ NICOTINE LOZ

2MG CINN

EQ NICOTINE LOZ

2MG MINT

EQ NICOTINE LOZ

4MG CINN

EQ NICOTINE LOZ

4MG MINT

EQL NICOTINE GUM

2MG

EQL NICOTINE GUM

4MG

EQL NICOTINE LOZ

2MG MINT

EQL NICOTINE LOZ

4MG MINT

GNP NICOTINE DIS

14MG/24H

GNP NICOTINE DIS

21MG/24H

GNP NICOTINE DIS

7MG/24HR

GNP NICOTINE GUM

2MG FRT

GNP NICOTINE GUM

2MG MINT

GNP NICOTINE GUM

2MG ORIG

GNP NICOTINE GUM

4MG FRT

GNP NICOTINE GUM

4MG MINT

GNP NICOTINE GUM

4MG ORIG

GNP NICOTINE LOZ

2MG MINT

GNP NICOTINE LOZ

4MG CHER

GNP NICOTINE LOZ

4MG MINT

GNP NICOTINE LOZ

MINI 2MG

HABITROL DIS

21MG/24H

HM NICOTINE DIS

14MG/24H

HM NICOTINE DIS

21MG/24H

HM NICOTINE DIS

7MG/24HR

HM NICOTINE GUM

2MG

HM NICOTINE GUM

2MG MINT

HM NICOTINE GUM

4MG FRT

HM NICOTINE GUM

4MG MINT

HM NICOTINE LOZ

2MG

HM NICOTINE LOZ

2MG CINN

HM NICOTINE LOZ

2MG MINT

HM NICOTINE LOZ

4MG CINN

HM NICOTINE LOZ

4MG MINT

KLS QUIT2 GUM

2MG

KLS QUIT2 LOZ

2MG

KLS QUIT4 GUM

4MG

KLS QUIT4 LOZ

4MG

NICORELIEF GUM

2MG MINT

NICORELIEF GUM

2MG ORIG

NICOTINE DIS

14MG/24H

NICOTINE DIS

21MG/24H

NICOTINE DIS

7MG/24HR

NICOTINE DIS

STEP 1

NICOTINE GUM

2MG

NICOTINE GUM

2MGFRUIT

NICOTINE GUM

4MG

NICOTINE LOZ

2MG MINT

NICOTINE LOZ

4MG CINN

NICOTINE LOZ

4MG MINT

NICOTINE LOZ

MINI 2MG

NICOTINE POL GUM

2MG

NICOTINE POL GUM

2MG CINN

NICOTINE POL GUM

2MG MINT

NICOTINE POL GUM

2MG ORIG

NICOTINE POL GUM

2MG REF

NICOTINE POL GUM

2MG STRT

NICOTINE POL GUM

2MGFRUIT

NICOTINE POL GUM

4MG

NICOTINE POL GUM

4MG CINN

NICOTINE POL GUM

4MG MINT

NICOTINE POL GUM

4MG ORIG

NICOTINE POL GUM

4MG REF

NICOTINE POL GUM

4MG STRT

NICOTINE POL GUM

4MGFRUIT

NICOTINE POL LOZ

2MG CHRY

NICOTINE POL LOZ

2MG CINN

NICOTINE POL LOZ

2MG MINI

NICOTINE POL LOZ

2MG MINT

NICOTINE POL LOZ

4MG CHRY

NICOTINE POL LOZ

4MG CINN

NICOTINE POL LOZ

4MG MINT

NICOTINE SYS KIT

TRANSDER

NICOTINE TD DIS

14MG/24H

NICOTINE TD DIS

21MG/24H

NICOTINE TD DIS

7MG/24HR

NICOTINE TD DIS

STEP 1

NICOTINE TD DIS

STEP 3

NICOTROL INH

 

NICOTROL NS SPR

10MG/ML

QC NICOTINE DIS

14MG/24H

QC NICOTINE DIS

21MG/24H

RA NICOTINE DIS

14MG/24H

RA NICOTINE DIS

21MG/24H

RA NICOTINE GUM

2MG

RA NICOTINE GUM

2MG MINT

RA NICOTINE GUM

4MG

RA NICOTINE GUM

4MG MINT

RA NICOTINE LOZ

2MG MINT

RA NICOTINE LOZ

4MG MINT

SM NICOTINE DIS

14MG/24H

SM NICOTINE DIS

21MG/24H

SM NICOTINE DIS

7MG/24HR

SM NICOTINE GUM

2MG

SM NICOTINE GUM

2MG MINT

SM NICOTINE GUM

4MG

SM NICOTINE GUM

4MG MINT

SM NICOTINE LOZ

2MG CHRY

SM NICOTINE LOZ

2MG CINN

SM NICOTINE LOZ

2MG MINT

SM NICOTINE LOZ

4MG

SM NICOTINE LOZ

4MG CINN

SM NICOTINE LOZ

4MG MINT

SR NICOTINE GUM

2MG

STOP SMOKING GUM

2MG MINT

STOP SMOKING GUM

2MG ORIG

STOP SMOKING GUM

4MG

STOP SMOKING LOZ

2MG

STOP SMOKING LOZ

2MG MINT

STOP SMOKING LOZ

4MG MINT

TGT NICOTINE DIS

14MG/24H

TGT NICOTINE DIS

21MG/24H

TGT NICOTINE DIS

7MG/24HR

TGT NICOTINE GUM

2MG MINT

TGT NICOTINE GUM

2MG ORIG

TGT NICOTINE GUM

2MGFRUIT

TGT NICOTINE GUM

4MG

TGT NICOTINE GUM

4MG ORIG

TGT NICOTINE LOZ

2MG CHRY

TGT NICOTINE LOZ

2MG MINT

TGT NICOTINE LOZ

4MG CHRY

TGT NICOTINE LOZ

4MG MINT

THRIVE GUM

2MG MINT

Rx contraceptive drug list2

Drug names(s)

afirmelle

aftera

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

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

loestrin 1.5/30-21

loestrin 1/20-21

loestrin fe 1.5/30

loestrin fe 1/20

lojaimiess

loryna

low-ogestrel

lo-zumandimine

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

trinessa

tri-nymyo

tri-previfem

tri-sprintec

trivora-28

tri-vylibra

tri-vylibra lo

tulana

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 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 type3

Vaccine name(s)

Covid-19

MODERNA, PFIZER-BIONTECH, JANSSEN (JOHNSON & JOHNSON)

Haemophilus B

ACTHIB, HIBERIX, PEDVAX HIB

Hepatitis A

HAVRIX, VAQTA

Hepatitis A and B

TWINRIX

Hepatitis B

ENGERIX-B, HEPLISAV-B, RECOMBIVAX HB

Human Papillomavirus

GARDASIL 9

Influenza

AFLURIA, AFLURIA PF, AFLURIA QUAD, FLUAD, FLUAD QUAD, FLUARIX QUAD, FLUBLOK QUAD, FLUCELVAX QUAD, FLULAVAL QUAD, FLUMIST QUAD, FLUZONE HIGH-DOSE PF, FLUZONE QUAD

Measles, Mumps, Rubella

M-M-R II, PROQUAD

Meningitis

BEXSERO, MENACTRA, MENQUADFI, MENVEO, TRUMENBA

Pneumonia

PNEUMOVAX 23, PNEUMOVAX 23/1 DOSE, PREVNAR 13

Poliovirus

IPOL INACTIVATED IPV

Rotavirus

ROTARIX, ROTATEQ

Shingles

SHINGRIX

Tetanus, Diphtheria, Pertussis

ADACEL, BOOSTRIX, DAPTACEL, DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC, INFANRIX, KINRIX, PEDIARIX, PENTACEL, QUADRACEL, TDVAX, TENIVAC, VAXELIS

Varicella

VARIVAX

Dental products

Drug name

Coverage criteria

FLUORIDE CHW

0.25MG F

FLUORIDE CHW

0.5MG F

FLUORIDE CHW

1MG F

FLUORITAB CHW

0.25MG F

FLUORITAB CHW

0.5MG F

FLUORITAB CHW

1MG F

FLUORITAB CHW

2.2MG

FLUORITAB DRO

0.125MG

LUDENT CHW

0.5MG F

LUDENT CHW

1MG F

NAFRINSE CHW

1MG F

NAFRINSE DRO

0.125MG

SOD FLUORIDE CHW

0.25MG

SOD FLUORIDE CHW

0.25MG F

SOD FLUORIDE CHW

0.5MG

SOD FLUORIDE CHW

0.5MG F

SOD FLUORIDE CHW

1.1MG

SOD FLUORIDE CHW

1MG

SOD FLUORIDE CHW

1MG F

SOD FLUORIDE CHW

2.2MG

SOD FLUORIDE DRO

0.5MG/ML

1Requires prescription.

2Depending 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.

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.