Rx preventive coverage

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 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 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 drospirenone/ethinyl estradiol drospirenone/ethinyl estradiol/levomefolate calcium
econtra ez econtra os elinest
ELLA  emoquette ENCARE
enpresse enskyce errin
estarylla ethinyl estradiol ethynodiol
etonogestrel/ethinyl estradiol falmina fayosim
FC FEMALE CONDOM FC2 FEMALE CONDOM FEMCAP
femynor gianvi gildagia
gildess fe GYNOL II GEL VAGINAL CONTRACEPTIVE hailey
hailey 24 hailey fe 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 loryna
low-ogestrel LO-ZUMANDIMI  lutera
lyza marlissa medroxyprogesterone acetate injection 150mg/ml
melodetta 24 fe mibelas 24 fe microgestin
microgestin fe mili mono-linyah
mononessa my choice my way
myzrila NATAZIA necon
new day next choice nikki
nora-be norethindrone norethindrone acetate/ethinyl estradiol
norethindrone acetate/ethinyl estradiol/ferrous fumarate norgestimate/ethinyl estradiol norlyda
norlyroc nortrel ocella
OGESTREL OMNIFLEX DIAPHRAGM Opcicon
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-mili
tri-lo-sprintec 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

Aspirin 81mg
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

 

Breast Cancer Prevention2 Limited to women ≥ 35 years of age with no previous history of breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ
anastrozole (effective 9/1/20), Evista, raloxifene, SOLTAMOX, tamoxifen

 

Folic Acid Supplements2 Folic acid tablet 0.4mg and 0.8mg and folic acid capsule
Smoking Deterrents 2 Limited to 180-day treatment regimen
BUPROPION HCL SR 150 mg (smoking deterrent), CHANTIX, nicotine patch, nicotine gum, nicotine lozenge, NICOTROL Nasal Spray and Inhaler, and THRIVE

 

Sodium Fluoride 2 Includes age restrictions to those members between 6 months to 16 years. Over-the-counter products excluded even with a prescription.
Statins2 Limited to men/women age 40-75 years for generic low to moderate intensity statins.
Lovastatin 10mg, 20mg, 40mg, pravastatin 10mg, 20mg, 40mg, 80mg, simvastatin 10mg, 20mg, 40mg

 

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 type3

Coverage criteria1

Vaccine name

Influenza 3 years and up AFLURIA, FLUVIRIN, FLUBLOK QUAD, FLUZONE HD
EZ FLU SHOT FLUCELVAX FLUARIX
FLUAD FLUCELVAX QUAD FLULAVAL
FLUZONE FLUBLOK FLUZONE QUAD
Haemophilus Influenza Type B 3 years and up ACTIHIB
Hepatitis A  3 years and up HAVRIX, VAQTA
Hepatitis B  3 years and up ENGERIX-B, RECOMBIVAX, HEPLISAV-B
Hepatitis A and B 3 years and up TWINRIX
Human Papillomavirus  3 years and up CERVARIX, GARDASIL, GARDASIL-9
Measles, Mumps, Rubella  3 years and up M-M-R II
Meningitis 3 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 3 years and up ADACEL, BOOSTRIX, TENIVAC, TET/DIP TOXOID
Varicella 3 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.