Rx Preventive Coverage

Effective January 1, 2020

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 BlueCross 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 Rx 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 
Italicized = over-the-counter

Rx Contraceptive Drug List1

Drug Name(s)

afirmelle aftera altavera
alyacen amethia amethia lo
amethyst ANNOVERA apri
aranelle ashlyna aubra
aubra eq aurovela aurovela fe
aviane ayuna azurette
BALCOLTRA balziva bekyree
blisovi 24 FE blisovi FE briellyn
camila camrese camrese lo
CAYA caziant cesia
chateal chateal eq cryselle
cyclafem cyred cyred eq
dasetta daysee deblitane
delyla DEPO-SUBQ PROVERA 104 drospirenone/ethinyl estradiol
drospirenone/ethinyl estradiol/levomefolate calcium drospirenone econtra ez
econtra os ELLA elinest
emoquette ENCARE enpresse
enskyce errin estarylla
ethinyl estradiol ethynodiol falmina
fayosim FC FEMALE CONDOM FC2 FEMALE CONDOM
FEMCAP femynor gianvi
gildagia gildess fe GYNOL II GEL VAGINAL CONTRACEPTIVE
hailey (fe) hailey 24 heather
incassia introvale isibloom
jasmiel jencycla jolessa
jolivette juleber junel
junel fe kaitlib fe kalliga
kariva kelnor kimidess
kurvelo larin larin fe
larissia layolis fe leena
lessina levo-eth est levonest
levonorgestrel levonorgestrel/ethinyl estradiol levora
lillow lo-loestrin lo-zumandimi
loryna low-ogestrel lutera
lyza marlissa medroxyprogesterone acetate injection 150mg/ml
melodetta 24 fe mibelas 24 fe microgestin
microgestin fe mili mono-linyah
mononessa myzilra my choice
my way NATAZIA necon
next choice new day nikki
nora-be norethindrone norethindrone acetate/ethinyl/estradiol
norethindrone acetate/ethinyl estradiol/ferrous fumarate norgestimate/ethinyl estradiol norlyda
norlyroc nortrel NUVARING
ocella OGESTREL OMNIFLEX DIAPHRAGM
opcicon option 2 orsythia
philith pimtrea pirmella
PLAN B portia preventeza
previfem quasense rajani
react reclipsen rivelsa
setlakin sharobel SHUR-SEAL GEL 2%
simliya simpresse SLYND
solia sprintec 28 sronyx
syeda take action tarina fe
TAYTULLA tilia fe TODAY SPONGE
tri-estarylla tri-femynor tri-legest fe
tri-linyah tri-lo tri-lo-estarylla
tri-lo-marzia tri-lo-sprintec tri-lo-mili
tri-mili trinessa trinessa lo
tri-previfem tri-sprintec trivora
tri-vylibra tulana tydemy
VCF VAGINAL FILM velivet vestura
vienva viorele vyfemla
vylibra wera WIDE-SEAL SILICONE DIAPHRAGM
wymzya fe XULANE zarah
zenchent zovia zumandimine

Rx Preventive Coverage List2


Drug Name

Coverage Criteria

Aspirin2

81mg

Bowel Preparation Medications2

gavilyte-C Kit, gavilyte-G kit, gavilyte-N kit, peg-3350 sol, COLYTE, TRILYTE, GOLYTELY, NULYTELY

Used for colorectal cancer screening. Age limit 50 to 74 years (men and women). Prescription only.

Breast Cancer Prevention2

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 0.4mg and 0.8mg and folic acid capsule.

Smoking Deterrents2

nicotine patch, nicotine gum, nicotine lozenge, NICOTROL NASAL SPRAY AND INHALER, bupropion hcl SR 150 mg (smoking deterrent), THRIVE, and CHANTIX

Limited to 180-day treatment regimen.

Sodium Fluoride2

Includes age restrictions to those members between 6 months to 16 years. Over-the-counter products excluded even with a prescription.

Statins2

lovastatin 10mg, 20mg, 40mg

pravastatin 10mg, 20mg, 40mg, 80mg

simvastatin 10mg, 20mg, 40mg

Limited to men and women age 40-75 years for generic low to moderate intensity statins.

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

Coverage Criteria1

Vaccine Name

Influenza

9 years and up

AFLURIA, EZ FLU SHOT, FLUAD, FLUZONE, FLUVIRIN, FLUCELVAX, FLUCELVAX QUAD, FLUBLOK, FLUBLOK QUAD, FLUARIX, FLULAVAL, FLUZONE QUAD, FLUZONE HD

Haemophilus Influenza Type B

18 years and up

ACTIHIB

Hepatitis A

18 years and up

HAVRIX, VAQTA

Hepatitis B

18 years and up

ENGERIX-B, RECOMBIVAX, HEPLISAV-B

Hepatitis A and B

18 years and up

TWINRIX

Human Papillomavirus

18 through 26 years

CERVARIX, GARDASIL, GARDASIL-9

Measles, Mumps, Rubella

18 through 59 years

M-M-R II

Meningitis

18 years and up

BEXSERO, TRUMENBA, MENACTRA, MENVEO, MENOMUNE

Pneumonia

65 years and up

PENUMOVAX, PREVNAR 13

Shingles

50 years and up

ZOSTAVAX, SHINGRIX

Tetanus, Diphtheria, Pertussis

18 years and up

ADACEL, BOOSTRIX, TENIVAC, TET/DIP TOXOID

Varicella

18 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.