Rx Preventive Coverage

Effective January 1, 2020

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 the following preventive drug list is applicable to members with coverage through one of our Individual products.

Key:

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

Rx Contraceptive Drug List

Drug Name(s)

afirmelle aftera altavera
alyacen amethia amethia lo
amethyst ANNOVERA apri
aranelle ashlyna aubra
aubra eq aurovela aurovela fe
aurovela 24 aviane ayuna
azurette BALCOLTRA 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
desogestrel/ethinyl estradiol drospirenone drospirenone/ethinyl estradiol
drospirenone/ethinyl estradiol/levomefolate calcium econtra ez elinest
ELLA emoquette ENCARE
enpresse enskyce errin
estarylla ethinyl estradiol ethynodiol diacetate
falmina fayosim FC FEMALE CONDOM
FC2 FEMALE CONDOM FEMCAP femynor
gianvi gildagia gildess fe
GYNOL II GEL hailey hailey 24 fe
heather incassia introvale
isibloom jasmiel jencycla
jolessa jolivette juleber
junel junel fe junel fe 24
kaitlib fe kalliga kariva
kelnor kimidess kurvelo
larin larin 24 fe larin fe
larissia layolis fe leena
lessina levo-eth est levonest
levonorgestrel levonorgestrel/ethinyl estradiol levora
lillow LO LOESTRIN lo zumandimi
LOMEDIA 24 FE loryna low-ogestrel
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 myzilra NATAZIA
necon new day 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 philith pimtrea
pirmella PLAN B ONE-STEP portia
preventeza previfem quasense
rajani react reclipsen
rivelsa setlakin sharobel
SHUR-SEAL GEL 2% simliya simpesse
SLYND solia sprintec 28
sronyx syeda take action
tarina fe tarina fe 24 TAYTULLA
tilia fe TODAY SPONGE tri-estarylla
tri-femynor tri-legest fe tri-linyah
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 velivet
vestura vienva viorele
vyfemla vylibra wera
WIDE-SEAL SILICONE DIAPHRAGM wymzya fe XULANE
zarah zenchent zovia
zumandimine    

Rx Preventive Coverage List1


Drug Name

Coverage Criteria

Aspirin1

81mg

Bowel Preparation Medications1

COLYTE, gavilyte-C, gavilite-G, gavilite-N Kit, GOLYTELY, NULYTELY, peg-3350 sol, TRILYTE

Used for colorectal cancer screening. Age limit 50-74 years (men and women). Prescription only.

Breast Cancer Prevention1

EVISTA, raloxifene, SOLTAMOX, tamoxifen

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 Supplements1

Folic acid tablet 0.4mg and folic acid capsule 0.8mg.

Smoking Deterrents1

nicotine patch, nicotine gum, nicotine lozenge, NICOTROL Nasal Spray and Inhaler, bupropion hcl SR 150 mg (smoking deterrent), CHANTIX, and THRIVE

Limited to 180-day treatment regimen.

Sodium Fluoride1

Includes age restrictions to those members between 6 months-16 years. Over-the-counter products excluded even with a prescription.

Statins1

lovastatin 10mg, 20mg, 40mg

pravastatin 10mg, 20mg, 40mg, 80mg

simvastatin 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


With Capital BlueCross’ 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 vaccines2

Vaccine Type

Coverage Criteria3

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, HEPLISAV-B, RECOMBIVAX

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

Pneumonia

65 years and up

PENUMOVAX, PREVNAR 13

Shingles

50 years and up

SHINGRIX, ZOSTAVAX

Tetanus, Diphtheria, Pertussis

18 years and up

ADACEL, BOOSTRIX, TENIVAC, TET/DIP TOXOID

Varicella

18 years and up

VARIVAX


1Requires prescription.

2Certain 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.

3Refer to your Policy or Subscriber Agreement for specific information about your prescription drug benefit. You can visit your secure account to view the formulary and formulary status of your drugs.

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.