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 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 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
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 opcicion 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
anastazole (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
Pnuemonia 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.