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

Key:

lowercase = generic  
UPPERCASE = BRAND  

Rx Contraceptive Drug List1

Drug Name(s)

afirmelle aftera altavera
alyacen amethia amethia lo
amethyst ANNOVERA apri
aranelle ashlyna aubra
aubra eq aurovela aurovela 24
aurovela fe aviane ayuna
azurette BALCOLTRA balziva
bekyree blisovi 24 FE blisovi FE
briellyn camila camrese
camrese lo CAYA caziant
cesia charlotte 24 fe 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 eluryng
emoquette ENCARE enpresse
enskyce errin estarylla
ethinyl estradiol ethynodiol diacetate 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 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 lojaimiess
LOMEDIA 24 FE 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 myzilra
NATAZIA necon new day
next choice one day 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 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 simpresse
SLYND solia sprintec 28
sronyx syeda take action
tarina 24 fe tarina fe 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 tri-vylibra lo
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 List2

Drug Name1

Coverage Criteria

Aspirin 81 mg
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 For members who are at high risk for colorectal cancer and do not meet the age limits
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.
anastrazole (effective 9/1/20), Evista, raloxifene, SOLTAMOX, tamoxifen  
Folic Acid Supplements2 Folic acid tablet 0.4 mg and 0.8 mg 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 Limited to children ≤ 18 years of age; 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 10 mg, 20 mg, 40 mg, pravastatin 10 mg, 20 mg, 40 mg, 80 mg, simvastatin 10 mg, 20 mg, 40 mg  
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 Type

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.