Preventive Services: Covered Contraceptive Products for Washington

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1 PHARMACY SERVICES Preventive Services: Covered Contraceptive Products for Washington Find out if your medication is on the list We are committed to empowering you to know your coverage options for preventive care and make informed health care decisions. Under our Preventive Services benefit*, we cover options in each FDA approved contraceptive method category. Some contraceptives are available from a pharmacy (under your Prescription Medication Benefit ) while others are provided by your doctor (under your Medical Benefit ). If you have preventive benefit coverage*, these products are covered at no cost to you. Specifically, we cover generically available women s contraceptives. When no generic exists for an FDA-approved contraceptive method category, a brand-name women s contraceptive that is on our drug list will be covered at no cost to you. If your doctor believes that our covered contraceptives are medically inappropriate, you may request an exception by contacting Customer Service at the number listed on the back of your member ID card. Beginning 1/1/2019, additional contraceptive products will be covered on certain HSA qualified plans as well.* These products (listed at the end of this flyer) are covered at no cost to you after you meet the minimum IRS deductible. * Check your benefit booklet for specific coverage. 2019

2 Contraceptives Available From a Pharmacy The following contraceptive products are available from an eligible retail pharmacy and will be processed under your pharmacy benefits with a prescription. Please see your health plan s website or contact Customer Service for information on eligible pharmacies. Over-The-Counter (OTC) products can be processed at no cost to you at a pharmacy if you have a prescription from your doctor. If you do not have a prescription and your benefit allows coverage, you will need to purchase at a participating pharmacy and request reimbursement from us by submitting a paper claim. Call the Customer Service number on your member ID card for more information. If you only have coverage under the Affordable Care Act, a prescription from your doctor is required. BARRIER METHODS: Condoms Female condom () Diaphragm Sponges Nonoxynol-9 containing Sponges, including Today Sponge () Cervical Cap Spermicide Nonoxynol-9 containing gel () NON-ORAL HORMONAL METHODS: Patch Xulane Vaginal Contraceptive Ring NuvaRing, Annovera Shot/Injection Medroxyprogesterone acetate 150 mg/ml EMERGENCY CONTRACEPTION: Levonorgestrel-Containing Products Generic Products* for Plan B One-Step : Aftera, EContra EZ, Fallback Solo, Levonorgestrel 1.5mg, My Choice, My Way, Next Choice One Dose, Opcicon One-Step, React 1.5mg, Take Action 2019

3 Ulipristal Acetate-Containing Products Ella *Note: Because Plan B One-Step is a brand name product, it is not covered under our Preventive Services benefit. The generic products listed above are covered under this benefit and have the same active ingredient as Plan B One-Step. ORAL CONTRACEPTIVES (BIRTH CONTROL PILLS): Oral Contraceptive- Mini Pill/Progestin Oral Contraceptive-Combined Pill (cont.) Camila Bekyree Deblitane Blisovi FE Errin Briellyn Heather Camrese Jencycla Camrese Lo Lyza Caziant Nora-BE Cesia Norethindrone 0.35mg Chateal Norlyroc Cryselle 28 Sharobel Cyclafem 1/35 Oral Contraceptive-Extended/Continuous Use Cyclafem 7/7/7 Amethia Cyred Amethia Lo Dasetta 1/35 Ashlyna Dasetta 7/7/7 Camrese Daysee Camrese Lo Delyla Daysee Desogestrel-ethinyl estradiol Introvale Drospirenone-ethinyl estradiol Jolessa Drospirenone-ethinyl estradiol-levomefolate Levonorgestrel-ethinyl estradiol (91-day pack) Elinest Quasense Emoquette Setlakin Enpresse 28 Oral Contraceptive-Combined Pill Enskyce Altavera Estarylla Alyacen 1/35 Ethynodiol diacetate-ethinyl estradiol Alyacen 7/7/7 Falmina Amethia Gianvi Amethia Lo Gildagia Amethyst Gildess 1.5/30 Apri Gildess 1/20 Aranelle Gildess 24 Fe Ashlyna Gildess Fe 1.5/

4 Oral Contraceptive-Combined Pill (cont.) Aubra Gildess Fe 1/20 Aviane Introvale Azurette Jolessa Balziva Juleber Juleber Necon 7/7/7 Junel 1.5/30 Nikki Junel 1/20 Norethindrone-ethinyl estra ferrous fumarate Junel Fe 1.5/30 Norethindrone ace-ethinyl estradiol Junel Fe 1/20 Norethindrone ace-ethinyl estradiol-fe Kariva Norgestimate-ethinyl estradiol Kelnor 1/35 Nortrel Kelnor 1/50 Ocella Kimidess Ogestrel Kurvelo Orsythia Larin 1.5/30 Philith Larin 1/20 Pimtrea Larin 24 Fe Pirmella 1/35 Larin Fe 1.5/30 Pirmella 7/7/7 Larin Fe 1/20 Portia 28 Layolis Fe Previfem Leena Quasense Lessina Rajani Levonest Reclipsen Levonorgestrel-ethinyl estradiol Solia Levora 0.15/30-28 Sprintec 28 Lomedia 24 Fe Sronyx Loryna Syeda Low-Ogestrel Tarina Fe 1/20 Lutera Tilia Fe Melodetta 24 Fe Tri-Estarylla Mibelas 24 Fe Tri-Legest Fe Microgestin 1.5/30 Tri-Linyah Microgestin 1/20 Tri-Lo-Estarylla Microgestin Fe Tri-Lo-Marzia Microgestin Fe 1.5/30 Tri-Lo-Sprintec Mono-Linyah TriNessa Mononessa TriNessa Lo Myzilra Tri-Previfem 2019

5 Oral Contraceptive-Combined Pill (cont.) Necon 0.5/35-28 Tri-Sprintec Necon 1/35 Trivora 28 Necon 1/50-28 Tydemy Necon 10/11-28 Velivet Vestura Wymzya Fe Vienva Zarah Viorele Zenchent Vyfemla Zenchent Fe VyLibra Zovia 1/35E Wera Zovia 1/50E Contraceptives Available From a Doctor The following contraceptive products and sterilization services are available from an eligible medical provider and will be processed under your medical benefit. Please see your health plan s website or contact Customer Service for information on eligible medical providers. BARRIER METHODS: Diaphragm Cervical Cap NON-ORAL HORMONAL METHODS: Shot/Injection Medroxyprogesterone acetate 150 mg/ml IMPLANTED DEVICES: IUD Copper Paragard IUD with Progestin Kyleena, Liletta, Mirena, Skyla 2019

6 Implantable Rod Nexplanon OTHER: Surgical Implant Surgical Sterilization Additional Contraceptives Covered Under Washington State Law for Eligible Groups Over-The-Counter (OTC) products can be processed at no cost to you at a pharmacy if you have a prescription from your doctor. If you do not have a prescription and your benefit allows coverage, you will need to purchase OTC products at a participating pharmacy and request reimbursement from us by submitting a paper claim. Call the Customer Service number on your member ID card for more information. BARRIER METHODS: Male condoms () NON-ORAL HORMONAL METHODS: Depo-Provera, Depo-SubQ Provera EMERGENCY CONTRACEPTION: Plan B One-Step ORAL CONTRACEPTIVES (BIRTH CONTROL PILLS): Balcoltra Ortho Micronor Beyaz Estrostep FE FaLessa Generess FE Loestrin Loestrin FE Lo Loestrin FE LoSeasonique Ortho-Novum Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Quartette Safyral Seasonique Taytulla Tri-Norinyl Minastrin 24 FE Yasmin 28 Mircette Natazia Yaz Questions? Call the Customer Service number on your member ID card. 2019