07/23/18 Guidance to help you understand when your member cost share will be waived for preventive medications and devices.

Transcription

1 The Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered group and individual health plans to waive cost share for in-network preventive services, including certain preventive This requirement does not apply to grandfathered plans. If you do not know whether your plan is subject to this requirement, please contact BCBSAZ. There are two important things to remember about this mandate. First, the cost share waiver does not apply if you use an out of network or non-contracted pharmacy provider, so make sure to check your pharmacy provider s network status. Second, there are some medications and devices that can be used for both preventive care and to treat a medical condition. Cost share is waived only when the medication or device is prescribed for preventive care. The United States Preventive Services Task Force has identified the medications listed below as the recommended preventive medications. The medication must be prescribed for a preventive care purpose. The medications followed by PL have Prescription Limitations or Precertification requirements. To learn more about Prescription Limitations and Precertification, please click here. ASPIRIN Aspirin (PL) chew tablet: 75mg, 81mg tablet: 81mg, 162mg, 325mg COLONOSCOPY PREP KITS Generic Bowel Evacuation combinations CONTRACEPTIVES* CERVICAL CAPS (PL) CONTRACEPTIVES, INJECTABLE Medroxyprogesterone Acetate (PL) (generic for Depo Provera) injection: 150mg/ml Depo Provera injection: 104mg/ml CONTRACEPTIVES, EMERGENCY Levonorgestrol, Next Choice (PL) (generic for Plan B) tablet: 0.75mg, Aftera, Econtra OS, Econtra OS, Option 2,Levonorgestrol,Next Choice, My Choice, React, Fallback, My Way, New Day, Take Action, Opcicon (PL) (generic for Plan B One Step) tablet: 1.5mg Plan B, Plan B One Step (PL) tablet: 0.75mg, 1.5mg Ella (PL) tablet: 30mg Option 2 (PL) tablet: 1.5mg CONTRACEPTIVES, NON-ORAL Nuvaring (PL) ring: mg/24hr Xulane (PL) (generic for Ortho Evra) patch: 6/0.75/wk DIAPHRAGMS FEMALE CONDOMS (PL) ORAL CONTRACEPTIVE, MONOPHASIC Amethia, Ashlyna, Camrese, Daysee (91- day), (generic for Seasonique) (PL) tablet mg- 0.01mg Amethia Lo, Comrese Lo, Levonorgestrel/Ethinyl (91-day), (generic for LoSeasonique) (PL) tablet mg- 0.01mg Apri, Emoquette, Enskyce, Reclipsen, Solia, Desogestrel/ethinyl estradiol, Isibloom, Juleber (generic for Desogen, Ortho-Cept) (PL) tablet 0.15mg/30mcg Jolessa, Quasense, Introvale, Setlakin Levonorgestrel/Ethinyl estradiol (91-day) (generic for Seasonale) (PL) tablet: mg Aviane, Aubra, Larissia, Lessina, Lutera, Orsythia, Sronyx, Falmina, Levonorgestrel/Ethinyl estradiol. Delyla, Vienva (generic for Alesse, Levlite) (PL) tablet: 0.1mg/20mcg Altavera, Levora, Marlissa, Portia, Kurvelo, Levonorgestrel-Ethinyl Estradiol, Chateal, Lillow (generic for Nordette) (PL) tablet: 0.15mg/30mcg Alaycen, Necon, Nortrel, Cyclafem, Dasetta, Wera, Pirmella (generic for Brevicon, Modicon, Norinyl, Ortho Novum) (PL) tablet: 0.5/35, 1/35 Microgestin, Junel, Gildess, Larin, Noreth/Ethin, Tarina Fe, Noreth/Ethin FE, Blisovi (generic for Loestrin) (PL) tablet: 1mg/20mcg, 1.5mg/30mcg Ocella, Syeda, Zarah, Drospirenone- Ethinyl Estradiol (generic for Yasmin) (PL) tablet: mg Drospirenone-Ethinyl Estrad-Levomefolate, Tydemy (generic for Safyral) (PL) tablet: mg Sprintec, Mononessa, Mono-Linyah, Norgestimate/Ethinyl, Previfem, Estarylla, Femynor, Vylibra Page 1

2 (generic for Ortho-Cyclen) (PL) tablet: mcg Kelnor (generic for Demulen) (PL) tablet: 1mg-35 mcg Zenchent, Balziva, Briellyn, Philith, Gildagia, Vyfemla ((generic for Ovcon 35) (PL) tablet: 0.4mg-35mcg Zeosa, Zenchent FE, Wymzya FE, Norethindrone/Ethinyl Estradiol-FE (generic for Femcon Fe) (PL) tablet: 0.4 mg-35 mcg norgestrel & ethinyl estradiol, Low-Ogestrel, Elinest, Cryselle-28 (PL) Microgestin FE, Junel FE, Gildess FE, Larin FE, Noreth/Ethin, Noreth/Ethin FE, Blisovi FE (generic for Loestrin FE) (PL) tablet: 1.5mg/30mcg (generic for Lo/Ovral-28) (PL) tablet: 0.3mg-30mcg Norethindrone/Ethinyl estradiol FE, Layolis FE Kaitlib FE (PL) (generic for Generess FE) tablet: 0.8 mg/25 mcg CHW Norethindrone Ace-Eth/Estradiol-FE, Mibelas 24, Melodetta 24 (PL) (generic for Minastrin 24 FE) tablet: 1mg-20mcg CHW Necon (PL) tablet: 1 mg/50 mcg Norinyl (PL) tablet: 1 mg/50 mcg Ogestrel (PL) tablet: 0.5 mg/50 mcg Ortho Cyclen (PL) tablet: 0.25 mg/35 mcg Fayosim, Rivelsa, Levonorgestrel/Ethinyl Estradiol (PL) (generic for Quartette 91-day) tablet: /0.025/0.03 mg &eth est 0.01mg Ethynodiol Diacetate/Ethinyl Estradiol, Kelnor, Zovia (generic for Demulen) (PL) tablet: 1mg-50mcg, 1mg-35mcg Drospirenone-ethinyl estradiol, Gianvi, Nikki, Vestura, Loryna (PL) (generic for Yaz) tablet mg ORAL CONTRACEPTIVE, BIPHASIC Amethyst, Levonogestrel-Ethinyl (PL) (generic for Lybrel) tablet: 90-20mcg) Necon (PL) tablet: 10/11 ORAL CONTRACEPTIVE, TRIPHASIC Velivet, Cesia, Caziant (PL) (generic for Cyclessa) tablet: / / mg Alaycen, Necon, Nortrel, Cyclafem, Dasetta, Pirmella (PL) (generic for Ortho-Novum 7/7/7) tablet: / /1-35 Trivora, Enpresse, Myzilra, Levonorgestrel/Ethinyl Estradiol (PL) (generic for Triphasil, Tri-Levlen) tablet: / / Aranelle, Leena (PL) (generic for Tri-Norinyl) tablet: /1-35/0.5-35mg Tilia FE, Tri-Legest FE (PL) (generic for Estrostep FE) tablet: 1-20/1-30/1-35mg-mcg Norgest/Ethinyl estradiol, Tri-sprintec, Trinessa, Tri-Previfem, Tri-Linyah, Tri- Estarylla, Tri-Vylibra (PL) (generic for Ortho Tri-Cyclen) Norgest/Ethinyl estradiol, Trinessa Lo, Tri- Lo-Estarylla, Tri-Lo-Sprintec, Tri-Lo Marzia (generic for Ortho Tri-Cyclen Lo) (PL) tablet: / / mg-mcg ORAL CONTRACEPTIVE, FOUR-PHASIC Natazia (PL) tablet: 3 mg /2-2 mg/2-3 mg/1 mg ORAL CONTRACEPTIVE, PROGESTINS Camila, Errin, Heather, Incassia, Jencycla, Jolivette, Lyza, Nora BE, Norethindrone, Norlyroc, Sharobel, Deblitane, Norlyda, Tulana (PL) (generic for Ortho-Micronor, Nor-Q-D) tablet: 0.35mg ORAL CONTRACEPTIVE, OTHER Kariva, Azurette, Viorele, Pimtrea, Deso/Ethinyl, Kimidess, Bekyree (PL) (generic for Mircette) tablet: /0.01mg SPERMACIDES (PL) (e.g., vaginal gel/foam/film/suppositories) SPONGES (PL) FLUORIDE Sodium fluoride (PL) chew tablet: 0.2mg, 0.5mg, 1mg cream: 1% drops: 0.125mg, 0.25mg, 0.5mg gel: 1.1% lozenge: 1mg paste: 1.1% rinse 0.05% solution: 0.05%, 0.2%,.5%, 1mg tablet: 0.5mg, 1mg FOLIC ACID Folic Acid (PL) tablet: 1mg HORMONAL ONCOLOGICS tamoxifen tablet: 10mg, 20mg Raloxifene (PL) tablet: 60mg IRON Ferrous sulfate (PL) drops: 75mg/ml, 75mg/0.6ml oral liquid: 5mg/20ml SMOKING CESSATION Bupropion HCL Smoking Deterrent (PL) tablet: 150mg Chantix (PL) tablet: 0.5mg, 1mg Commit (PL) lozenge: 2mg, 4mg Nicoderm CQ(PL) patch: 7mg, 14mg, 21mg Nicorette(PL) gum: 2mg, 4mg Nicotine (multiple generic names) (PL) gum: 2mg, 4mg lozenge: 2mg, 4mg patch: 7mg, 14mg, 24mg Nicotine System Kit (PL) patch: 7mg/14mg/21mg Nicotrol inhaler (PL) inhaler: 10mg Nicotrol NS (PL) Page 2

3 nasal Spray: 10mg/ml Zyban (PL) tablet: 150mg VITAMIN D (PL) Page 3

4 Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call for Spanish and for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ , , TTY/TDD , crc@azblue.com. You can file a grievance in person or by mail or . If you need help filing a grievance BCBSAZ s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at

5 Multi-language Interpreter Services