ACA Preventive Drug List Effective January 1, 2018 Recommendations by United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA), and Advisory Committee on Immunization Practices (ACIP, adopted by the Centers for Disease Control) In accordance with requirements put forth through the Affordable Care Act (ACA), applicable employers elect to provide evidence-based Preventive Drug coverage at $0. Below is the list of medications available for the ACA Standard Preventive Drug List. Check your Blue Cross benefit booklet to find out if the ACA Standard Preventive Drug List applies to your plan. The drugs listed below are grouped into broad categories. Each category includes an alphabetical list of drugs. Generic drugs are available for many of the brands noted on this list. Please verify with your plan if a generic drug must be tried before the brand version of a drug is filled. This list will be reviewed periodically and is subject to change. ASPIRIN All brand/generic aspirin 81 mg ASPIRIN LOW DOSE BOWEL PREPARATION (for colorectal cancer screening) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236, 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 gm BREAST CANCER PRIMARY PREVENTION EVISTA** raloxifene SOLTAMOX tamoxifen FLUORIDE -Dental Products & Combinations- ACT TOTAL CARE DRY MOUTH COLGATE DRY MOUTH RELIEF CREST COMPLETE FLUORIDEX DAILY DEFENSE SENSITIVITY RELIEF gel GEL-KAM** LISTERINE ESSENTIAL CARE LISTERINE NATURALS WITH FLUORIDE LISTERINE RESTORING** LISTERINE SMART RINSE** LISTERINE TOTAL CARE** LISTERINE WHITENING/RESTORING** NAFRINSE OMNI GEL** PARODONTAX PHOS FLUR PHOS-FLUR ORTHO DEFENSE PREVIDENT** REMBRANDT SENSODYNE REPAIR & PROTECT WHITENING sodium fluoride crm, gel, oral rinse, paste sodium fluoride/potassium nitrate stannous fluoride STANNOUS FLUORIDE RINSE THERA-FLUR-N** -Supplements & Combinations- FLORICAL FLORIVA FLUORABON FLUOR-A-DAY chew tabs FLURA-DROPS LOZI-FLUR LURIDE** MONOCAL sodium fluoride chew tabs, drops, soln SODIUM FLUORIDE tabs FOLIC ACID SUPPLEMENTS folic acid caps, 0.8 mg folic acid tabs, 400 mcg, 800 mcg INFANT EYE OINTMENT (for newborns) erythromycin eye oint IRON SUPPLEMENTS carbonyl iron suspension FER-IN-SOL** FERROUS SULFATE liquid, 220 mg/5 ml, syrup ferrous sulfate elixir, solution ICAR PEDIATRIC** suspension IRON UP NOVAFERRUM PEDIATRIC drops SINGLE-AGENT STATINS lovastatin 20 mg, 40 mg pravastatin TOBACCO CESSATION All brand/generic OTC nicotine gum, lozenges, patches bupropion ext-release (smoking cessation) CHANTIX COMMIT** (OTC) NICODERM CQ** (OTC) NICORETTE** (OTC) nicotine gum, lozenges, patches NICOTINE TRANSDERMAL kit (OTC) NICOTROL INHALER NICOTROL NS ZYBAN** VACCINES ACTHIB ADACEL AFLURIA/PF/QUADRIVALENT BEXSERO BOOSTRIX CERVARIX 3160-E Prime Therapeutics LLC 08/17 Product names listed are the property of their respected owners. Page 1 of 5
VACCINES (continued) COMVAX DAPTACEL DIPHTHERIA/TETANUS TOXOID ADSORBED ENGERIX-B FLUAD FLUARIX QUADRIVALENT FLUBLOK/QUADRIVALENT FLUCELVAX/QUADRIVALENT FLULAVAL QUADRIVALENT FLUVIRIN FLUZONE/HIGH-DOSE (PF)/ INTRADERMAL/QUADRIVALENT/ SPLIT GARDASIL GARDASIL 9 HAVRIX HIBERIX INFANRIX IPOL KINRIX M-M-R II MENACTRA MENHIBRIX MENOMUNE-A/C/Y/W-135 MENVEO PEDIARIX PEDVAX HIB PENTACEL PNEUMOVAX 23 PREVNAR 13 PROQUAD QUADRACEL RECOMBIVAX HB ROTARIX ROTATEQ TENIVAC TETANUS/DIPHTHERIA TOXOIDS TRUMENBA TWINRIX VAQTA VARIVAX VITAMIN D SUPPLEMENTS BABY DDROPS** (OTC) BABY SUPER DAILY D3 (OTC) BABY VITAMIN D3 DROPS (OTC) CHOLECALCIFEROL soln, 1200 unit/15 ml; spray, 1000 unit/spray (OTC) cholecalciferol caps, 400 unit, 1000 unit; chew tabs, 400, 1000 unit; drops, 400 unit/0.03 ml, 5000 unit/ml (1000/0.2 ml); soln, 400 unit/ml; tabs, 400, 1000 unit (OTC) D-VI-SOL** (OTC) DDROPS 600 unit/0.028 ml, 1000 unit/0.028 ml, 1000 unit/0.03 ml (OTC) ERGOCALCIFEROL tabs, 400 unit (OTC) SUPER DAILY D3 (OTC) UPSPRINGBABY VITAMIN D3 (OTC) VITAMELTS VITAMIN D (OTC) WELLESSE oral liquid, 1000 unit/10 ml (OTC) ZOSTAVAX 3160-E Prime Therapeutics LLC 08/17 Product names listed are the property of their respected owners. Page 2 of 5
Recommendations on Contraceptives by Health Resources and Services Administration (HRSA) Eligible benefit plans include coverage under the Affordable Care Act for the following contraceptives to be covered at $0. This list will be reviewed periodically and is subject to change. CONTRACEPTIVES Barrier Method Types -Cervical Caps- FEMCAP PRENTIF CAVITY-RIM CERVICAL CAP PRENTIF FITTING SET -Diaphragms- CAYA OMNIFLEX DIAPHRAGM WIDE-SEAL SILICONE DIAPHRAGM KIT -Female Condom- FC FEMALE CONDOM FC2 FEMALE CONDOM -Spermicide ENCARE nonoxynol-9 gel 4% OPTIONS CONCEPTROL** OPTIONS GYNOL II SHUR-SEAL VCF VAGINAL CONTRACEPTIVE -Sponge TODAY SPONGE Emergency Method Types -Emergency Progestin- Aftera Econtra EZ Fallback Solo levonorgestrel 1.5 mg My Way Next Choice One Dose Opcicon One-Step Option 2 PLAN B ONE-STEP** React Take Action -Emergency Ella- ELLA Hormonal Method Types -Injectable Progestin- DEPO-PROVERA CONTRACEPTIVE** DEPO-SUBQ-PROVERA 104 medroxyprogesterone acetate -Oral Combined- Altavera Alyacen Apri Aranelle Aubra Aviane Azurette Balziva Bekyree BEYAZ** Blisovi Fe Blisovi 24 Fe BREVICON** Briellyn Caziant Chateal Cryselle Cyclafem CYCLESSA** Cyred Dasetta Delyla DESOGEN** desogestrel/ethinyl estradiol drospirenone/ethinyl estradiol drospirenone/ethinyl estradiol/levomefolate Elinest Emoquette Enpresse Enskyce Estarylla ESTROSTEP FE** ethynodiol/ethinyl estradiol FALESSA Falmina FEMCON FE** Femynor GENERESS FE** Gianvi Gildagia Gildess Gildess Fe Gildess 24 Fe Isibloom Juleber Junel Junel Fe Junel Fe 24 Kaitlib Fe Kariva Kelnor Kimidess Kurvelo Larin Larin Fe Larin 24 Fe Larissia Layolis Fe Leena Lessina Levonest levonorgestrel/ethinyl estradiol Levora LOESTRIN** LOESTRIN FE** LO LOESTRIN FE Lomedia 24 Fe Loryna Low-Ogestrel Lutera Marlissa Mibelas 24 Fe Microgestin Microgestin Fe Microgestin 24 Fe MINASTRIN 24 FE** MIRCETTE** MODICON** Mono-Linyah Mononessa Myzilra NATAZIA Necon 0.5/35, 1/35, 7/7/7 NECON 1/50, 10/11 Nikki norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol/fe norgestimate/ethinyl estradiol NORINYL 1+35** NORINYL 1+50 Nortrel Ocella OGESTREL Orsythia ORTHO-CYCLEN** ORTHO-NOVUM** ORTHO TRI-CYCLEN** ORTHO TRI-CYCLEN LO** OVCON-35** Philith Pimtrea Pirmella Portia Previfem 3160-E Prime Therapeutics LLC 08/17 Product names listed are the property of their respected owners. Page 3 of 5
Hormonal Method Types -Oral Combined-(continued) Rajani Reclipsen SAFYRAL Sprintec Sronyx Syeda Tarina Fe TAYTULLA Tilia Fe Tri-Estarylla Tri Femynor Tri-Legest Fe Tri-Linyah Tri-Lo-Estarylla Tri-Lo-Marzia Tri-Lo-Sprintec TRI-NORINYL** Tri-Previfem Tri-Sprintec Trinessa Trinessa Lo Trivora Velivet Vestura Vienva Viorele Vyfemla Wera Wymzya Fe YASMIN** YAZ** Zarah Zenchent Zenchent Fe Zovia -Oral Extended Continuous- Amethia Amethia Lo Amethyst Ashlyna Camrese Camrese Lo Daysee Fayosim Introvale Jolessa levonorgestrel/ethinyl estradiol 0.1-0.02 mg (84) & ethinyl estradiol 0.01 mg (7) levonorgestrel/ethinyl estradiol 0.15-0.03 mg (84) & ethinyl estradiol 0.01 mg (7) levonorgestrel/ethinyl estradiol 0.15-0.03 mg (91) LEVONORGESTREL-ETHINYL ESTRADIOL 90-20 mcg LOSEASONIQUE** QUARTETTE ** Quasense Rivelsa SEASONIQUE** Setlakin -Oral Progestin- Camila Deblitane Errin Heather Jencycla Jolivette Lyza NOR-QD** Nora-Be norethindrone Norlyda Norlyroc ORTHO MICRONOR** Sharobel -Transdermal Combined (patch) - XULANE -Vaginal Combined (ring) - NUVARING Implantable Method Types -Implants Progestin- NEXPLANON -Intrauterine Devices Copper- PARAGARD -Intrauterine Devices Progestin- KYLEENA LILETTA MIRENA SKYLA 3160-E Prime Therapeutics LLC 08/17 Product names listed are the property of their respected owners. Page 4 of 5
Discontinued Categories (obsolete after 12.31.17) BOWEL PREP MEDICATION (2016 version) bisacodyl tab + peg - electrolytes for soln bisacodyl tabs COLYTE-FLAVOR PACKS 227.1 g COLYTE-FLAVOR PACKS 240 g** DULCOLAX BOWEL PREP KIT DULCOLAX tabs** GOLYTELY 227.1 g GOLYTELY 236 g** magnesium citrate soln MIRALAX** MOVIPREP NULYTELY** OSMOPREP PCP 100 polyethylene glycol powder for solution polyethylene glycol/electrolytes powder for solution PREPOPIK SUCLEAR SUPREP 3160-E Prime Therapeutics LLC 08/17 Product names listed are the property of their respected owners. Page 5 of 5