Rx Preventive Coverage

Under the Patient Protection and Affordable Care Act

Under the Patient Protection and Affordable Care Act (PPACA), certain preventive medications 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 Drug page, or contact Rx Member Services at the phone number listed on the back of your member ID card.

Please note that this preventive medication 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:

bold lowercase = generic
UPPERCASE = BRAND
Italicized = over-the-counter

Rx Contraceptive Medication List

  • activella
  • AFTERA
  • alora
  • altavera
  • alyacen
  • amabelz
  • amethia
  • amethyst
  • angeliq
  • apri
  • aranelle
  • ashlyna
  • aubra
  • aviane
  • aygestin
  • azurette
  • balcoltra
  • balziva
  • bekyree
  • BEYAZ1
  • biest/progesterone
  • blisovi 24 FE
  • blisovi FE
  • brevicon
  • BREVICON1
  • briellyn
  • camila
  • camrese
  • camrese lo
  • CAYA
  • caziant
  • CERVICAL CAP
  • cesia
  • chateal
  • climara
  • climara pro
  • combipatch
  • covaryx
  • cryselle
  • cyclafem
  • cyclessa
  • CYCLESSA1
  • cyred
  • dasetta
  • daysee
  • deblitane
  • delyla
  • depo-provera
  • DEPO-PROVERA1
  • DEPO-SUBQ PROVERA 104
  • DESOGEN1
  • desogestrel/ethinyl estradiol
  • divigel
  • drospirenone/ethinyl estradiol
  • drospirenone/ethinyl estradiol/
  • levomefolate calcium
  • duavee
  • ECONTRA EZ
  • ELLA
  • emoquette
  • ENCARE
  • enjuvia
  • enpresse
  • enskyce

  • errin
  • estarylla
  • estrace
  • estrdiol
  • ESTROSTEP FE1
  • ethinyl estradiol
  • ethynodiol diacetate
  • evamist
  • FALESSA
  • FALLBACK SOLO
  • falmina
  • fayosim
  • FC FEMALE CONDOM
  • FC-2
  • FC2 FEMALE CONDOM
  • FEMCAP
  • femcon fe
  • FEMCON FE1
  • femynor
  • fyavolv
  • GENERESS FE1
  • gianvi
  • gildagia
  • gildess fe
  • GYNOL II GEL VAGINAL
  • CONTRACEPTIVE
  • heather
  • introvale
  • isibloom
  • jencycla
  • jevantique lo
  • jinteli
  • jolessa
  • jolivette
  • juleber
  • junel
  • junel fe
  • kaitlib fe
  • kariva
  • kelnor
  • kimidess
  • kurvelo
  • larin
  • larin fe
  • larissia
  • layolis fe
  • leena
  • lessina
  • levonest
  • levonorgestrel
  • levonorgestrel/ethinyl estradiol
  • levora
  • liletta
  • lillow
  • LO LOESTRIN FE
  • LOESTRIN FE1
  • LOESTRIN1
  • lomedia 24 fe
  • lopreeza
  • loryna
  • loseasonique
  • LOSEASONIQUE1
  • low-ogestrel
  • lutera
  • lyza
  • makena
  • marlissa
  • medroxyprogesterone acetate
  • injection 150mg/ml
  • megace
  • melodetta 24 fe
  • menest
  • menostar
  • mibelas 24 fe
  • microgestin
  • microgestin fe
  • MILEX WIDE-SEAL
  • mili
  • mimvey
  • mimvey lo
  • MINASTRIN 24 FE1
  • MIRCETTE1
  • mirena
  • MODICON1
  • mono-linyah
  • mononessa
  • MY WAY
  • myzilra
  • NATAZIA
  • NECON
  • necon 0.5/35-28
  • necon 1/35
  • NECON 1/50-28
  • NECON 10/11-28
  • necon 7/7/7
  • nexplanon
  • NEXT CHOICE ONE DOSE
  • nikki
  • nora-be
  • norethindrone
  • norethindrone acetate/ethinyl
  • estradiol
  • norethindrone acetate/ethinyl
  • estradiol/ferrous fumarate
  • norgestimate/ethinyl estradiol
  • NORINYL1
  • norlyda
  • norlyroc
  • NOR-QD1
  • nortrel
  • NUVARING
  • ocella
  • ogestrel
  • OMNIFLEX COIL
  • OMNIFLEX DIAPHRAGM
  • OPSICON ONE-STEP
  • OPTION 2
  • OPTIONS CONCEPTROL
  • VAGINAL CONTRACEPTIVE
  • orsythia
  • ORTHO DIAPHRAGM
  • ORTHO EVRA1
  • ORTHO MICRONOR1
  • ORTHO TRI-CYCLEN LO1
  • ORTHO TRI-CYCLEN1
  • ORTHO-CEPT1
  • ortho-cyclen1
  • ORTHO-NOVUM1
  • OVCON1
  • philith
  • pimtrea
  • pirmella
  • PLAN B ONE-STEP
  • portia
  • PRENTIF CAVITY-RIM
  • previfem
  • QUARTETTE1
  • quasense
  • rajani
  • react
  • reclipsen
  • rivelsa
  • SAFYRAL
  • seasonique
  • setlakin
  • sharobel
  • SHUR-SEAL GEL 2%
  • skyla
  • solia
  • SPRING SILICONE
  • sprintec 28
  • sronyx
  • syeda
  • TAKE ACTION
  • tarina fe
  • TAYTULLA
  • tilia fe
  • TODAY SPONGE
  • tri-estarylla
  • tri-femynor
  • tri-legest fe
  • tri-linyah
  • tri-lo-estarylla
  • tri-lo-marzia
  • tri-lo-sprintec
  • tri-mili
  • trinessa
  • trinessa lo
  • TRI-NORINYL1
  • tri-previfem
  • tri-sprintec
  • trivora
  • tri-vylibra
  • tulana
  • tydemy
  • VCF VAGINAL FILM 28%
  • VCF VAGINAL FOAM 12.5%
  • velivet
  • vestura
  • vienva
  • viorele
  • vivelle-dot
  • vyfemla
  • vylibra
  • wera
  • WIDE-SEAL SILICONE
  • DIAPHRAGM
  • wymzya fe
  • xulane
  • YASMIN1
  • YAZ1
  • zarah
  • zenchent
  • zenchent fe
  • zovia

Rx Preventive Coverage List2

Drug Name

Coverage Criteria

aspirin2 81mg: limited to men and women 50-59 years of age. Also, requires prior authorization for women at risk of pre-eclampsia, who are greater than or equal to 12 weeks gestation (duration is seven months).
bowel preparation medications
Used for colorectal cancer screening. Age limit 50 to 74 years (men and women). Prescription only.
gavilyte-H kit, MOVIPREP, peg-prep kit, PREPOPIK, SUPREP
For members who are at high risk for colorectal cancer and do not meet the age limits, a prior authorization is required for inclusion at $0.
breast cancer prevention3 tamoxifen and raloxifene
Requires prior authorization; 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 Supplements3
Limited to one dose per day of folic acid tablet (0.4mg and 8mg) and folic acid capsule (0.8mg).
Smoking Deterrents
nicotine patch3, nicotine gum3, nicotine lozenge3, NICOTROL Nasal Spray and Inhaler, bupropion hcl SR 150 mg (smoking deterrent)3, and CHANTIX
Limited to 180-day treatment regimen.
sodium fluoride3
Limited to children ≤ 18 years of age; over-the-counter products excluded even with a prescription.
statins
atorvastatin 10mg, 20mg, fluvastain 20mg, 40mg, fluvastatin er 80mg, lovastatin 10mg, 20mg, 40mg, pravastatin 10mg, 20mg, 40mg, 80mg, rosuvastatin 5mg, 10mg, simvastatin 5mg, 10mg, 20mg, 40mg

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

Rx Vaccine and Immunization Preventive Coverage List

Members of an employer group health plan gained access to the following preventive vaccines upon their group’s 2019
benefit renewal date. Simply present your member ID card at a participating pharmacy to receive a vaccine. Please refer to
your Certificate of Coverage for benefit details.

Vaccine Type

Coverage Criteria

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
Pnuemonia 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

1To initiate a request to have this medication covered at no cost, please contact Rx Member Services at the phone number listed on the back of your member ID card to begin the prior authorization process.

2Requires prescription.

3Generic only.

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 printing and may be subject to change. Customers should refer to their coverage documents for specific terms, conditions, exclusions, and limitations relating to coverage.