Rx preventive coverage

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 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 names(s)

afirmelle

aftera

altavera

alyacen 1/35

alyacen 7/7/7

amethia

amethia lo

amethyst

ANNOVERA

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

BALCOLTRA

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

DEPO-SUBQ PROVERA 104

desogestrel/ethinyl estradiol

dolishale

drospirenone/ethinyl estradiol

drospirenone/ethinyl estradiol/levomefolate calcium

econtra ez

econtra one-step

elinest

ELLA

eluryng

emoquette

ENCARE

enpresse-28

enskyce

errin

estarylla

ethynodiol diacetate/ethinyl estradiol

etonogestrel/ethinyl estradiol

falmina

fayosim

FC FEMALE CONDOM

FC2 FEMALE CONDOM

FEMCAP

femynor

gemmily

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

LO LOESTRIN FE

lo-zumandimine

loestrin 1.5/30-21

loestrin 1/20-21

loestrin fe 1.5/30

loestrin fe 1/20

lojaimiess

loryna

low-ogestrel

lutera

lyleq

lyza

marlissa

medroxyprogesterone acetate

melodetta 24 fe

merzee

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

NATAZIA

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

nylia 7/7/7

nymyo

ocella

OGESTREL

OMNIFLEX DIAPHRAGM

opcicon one-step

option 2

OPTIONS GYNOL II VAGINAL CONTRACEPTIVE

orsythia

philith

pimtrea

pirmella 1/35

pirmella 7/7/7

PLAN B ONE-STEP

portia-28

preventeza

previfem

react

reclipsen

rivelsa

setlakin

sharobel

SHUR-SEAL

simliya

simpesse

SLYND

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

tri-nymyo

tri-previfem

tri-sprintec

tri-vylibra

tri-vylibra lo

trinessa

trivora-28

tulana

TWIRLA

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 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 Deterrents2

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 Fluoride2

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

Vaccine name

Covid-19

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

Influenza

AFLURIA, FLUARIX QUAD, FLULAVAL QUAD, FLUAD, FLUBLOK QUAD, FLUMIST QUAD, FLUZONE QUAD, FLUAD QUAD, FLUCELVAX QUAD, FLUZONE HD PF

Haemophilus Influenza Type B

ACTIHIB, PEDVAX HIB

Hepatitis A 

HAVRIX, VAQTA

Hepatitis B 

ENGERIX-B, RECOMBIVAX, HEPLISAV-B

Hepatitis A and B

TWINRIX

Human Papillomavirus 

GARDASIL-9

Measles, Mumps, Rubella 

M-M-R II, BEXSERO, MENACTRA, MENVEO, MENOMUNE

Meningitis

TRUMENBA

Pneumonia

PENUMOVAX, PENUMOVAX 1 DOSE, PREVNAR 13

Shingles

SHINGRIX

Tetanus, Diphtheria, Pertussis

ADACEL, BOOSTRIX, TDVAX, TENIVAC

Varicella

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.