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:

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

Rx Contraceptive Medication List

  • AFTERA
  • altavera
  • alyacen
  • amethia
  • amethyst
  • apri
  • aranelle
  • ashlyna
  • aubra
  • aviane
  • azurette
  • balziva
  • bekyree
  • blisovi 24 FE
  • blisovi FE
  • briellyn
  • camila
  • camrese
  • camrese lo
  • CAYA
  • caziant
  • CERVICAL CAP
  • cesia
  • chateal
  • cryselle
  • cyclafem
  • cyred
  • dasetta
  • daysee
  • deblitane
  • delyla
  • DEPO-SUBQ PROVERA 104
  • desogestrel/ethinyl estradiol
  • DIAPHRAGM
  • drospirenone/ethinyl estradiol
  • drospirenone/ethinylestradiol/levomefolate calcium
  • ECONTRA EZ
  • elinest
  • ELLA
  • emoquette
  • ENCARE
  • enpresse
  • enskyce
  • errin
  • estarylla
  • ethinyl estradiol
  • ethynodiol diacetate
  • FALLBACK SOLO
  • falmina
  • fayosim
  • FC FEMALE CONDOM
  • FC2 FEMALE CONDOM
  • FEMCAP
  • femynor
  • gianvi
  • gildagia
  • gildess
  • gildess 24
  • gildess fe
  • heather
  • introvale
  • jencycla
  • jolessa
  • jolivette
  • juleber
  • junel
  • junel fe
  • kaitlib fe
  • kariva
  • kelnor
  • kimidess
  • kurvelo
  • larin
  • larin 24 fe
  • larin fe
  • larissia
  • layolis fe
  • leena
  • lessina
  • levonest
  • levonorgestrel
  • levonorgestrel/ethinyl estradiol
  • levora
  • LILETTA
  • lillow
  • LO LOESTRIN FE
  • lomedia 24 fe
  • loryna
  • low-ogestrel
  • lutera
  • lyza
  • marlissa
  • medroxyprogesterone acetate
  • injection 150mg/ml
  • melodetta 24 fe
  • mibelas 24 fe
  • microgestin
  • microgestin 24 fe
  • microgestin fe
  • MILEX WIDE-SEAL
  • 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
  • NEXT CHOICE ONE DOSE
  • 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 ONE-STEP
  • OPTIONS GYNOL II Gel %
  • orsythia
  • ORTHO-CEPT1
  • ORTHO-CYCLEN
  • philith
  • pimtrea
  • pirmella
  • PLAN B ONE-STEP
  • portia
  • PRENTIF CAVITY-RIM CERVICAL CAP
  • previfem
  • QUARTETTE1
  • quasense
  • rajani
  • REACT
  • reclipsen
  • rivelsa
  • SAFYRAL
  • setlakin
  • sharobel
  • SHUR-SEAL GEL 2%
  • 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-estarylla
  • tri-lo-marzia
  • tri-lo-sprintec
  • trinessa
  • trinessa lo
  • tri-noriynl
  • tri-previfem
  • tri-sprintec
  • trivora
  • TRI-VYLIBRA
  • tulana
  • TYDEMY
  • VCF VAGINAL FILM 28%
  • VCF VAGINAL FOAM 12.5%
  • velivet
  • vestura
  • vienva
  • viorele
  • vyfemla
  • vylibra
  • wera
  • WIDE-SEAL SILICONE
  • DIAPHRAGM
  • wymzya fe
  • xulane
  • zarah
  • zenchent
  • zenchent fe
  • zovia

Rx Preventive Coverage List1

Drug Name

Coverage Criteria

Aspirin2 81mg: Requires prior authorization (duration is seven months) limited to men and women 50-59 years of age, greater than or equal to 12 weeks gestation and at risk for pre-eclampsia.
Bowel Preparation Medications 
gavilyte-H kit, 
MOVIPREP, peg-prep kit, PREPOPIK, SUPREP
Used for colorectal cancer screening. Age limit 50 to 74 years (men and women). Prescription only. 
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 Prevention2
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 Supplements2
Limited to one dose per day of folic acid tablet (0.4mg and 8mg) and folic acid capsule (0.8mg).
Smoking Deterrents
nicotine patch2, nicotine gum2, nicotine lozenge2, NICOTROL Nasal Spray and Inhaler, bupropion hcl SR 150 mg (smoking deterrent)2, and CHANTIX
Limited to 180-day treatment regimen.
Sodium fluoride2 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, FLUARIC, FLUBLOK, FLUBLOK QUAD, FLUCELVAX, FLUCELVAX QUAD, FLULAVAL, FLUVIRIN, 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, MENOMUNE, MENVEO, TRUMENBA
Pnuemonia 65 years and up
PNEUMOVAX, PREVNAR 13
Shingles 50 years and up
ZOSTAVAX, SHINGRIX
Tetanus, Diphtheria, Pertussis 18 years and up ADACEL, BOOSTRIX, TENIVAC, TET/DIP TOXOID
Varicella 19 years and up
VARIVAX

1Requires prescription.

2Generic 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.