ACA Preventive Drug List / Preventive Medications and Vaccines Coverage
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List of preventive medications and vaccines that may be provided with $0 cost-share under ACA-compliant benefit plans for members of Blue Cross Blue Shield - North Carolina. It is a formulary-style listing grouped by preventive category and intended for plan members and providers to verify preventive drugs covered under the plan.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered when plan and ACA criteria met
Preventive medications and devices listed may be covered at $0 cost-share under eligible ACA plans when provided in accordance with plan terms and applicable federal guidance.
Providers should confirm plan-specific rules and exceptions at MyPrime.com or the plan website; an exception process exists for medications not listed at zero-dollar cost share (see www.bluecrossnc.com/umdrug).
Covered Contraceptive Products (enumerated)
Covered contraceptive products (enumeration):
No clinical eligibility criteria or medical necessity conditions are provided in these chunks; coverage subject to plan terms and updates.
Covered product listing
Listed products (no decision criteria provided in these chunks)
Listing repeats across pages; no coverage conditions or medical necessity criteria are stated in these chunks.
The preventive drug list is provided for informational purposes and is subject to the terms of each member’s health plan. Coverage of the medications and devices shown depends on enrollment in an eligible ACA-compliant benefit and may change based on ACA guidance and plan updates. Members and providers should verify benefit materials and the plan website for current coverage details and whether any plan-level rules (for example, a requirement to try a generic before a brand) apply.
This section lists barrier contraceptive products included in the preventive drug list. ALL MALE CONDOMS are listed as a covered product group. The document does not list any explicit exclusions for male condoms in these chunks; providers and members should nonetheless confirm plan benefit materials for any plan-specific limits.
The policy includes multiple oral combined contraceptive product names and dose strengths presented as a formulary-style listing. The excerpts show brand/generic combinations and strength notations (for example, entries with ethinyl estradiol and various progestins and dose formats such as 0.18-35/0.215-35/0.25-35 mg-mcg). These chunks do not state explicit coverage exclusions for the listed products.
Oral combined contraceptive products are enumerated across the document with brand and generic names and specific strengths (for example, drospirenone/ethinyl estradiol 3-0.03 mg noted as Ocella/Yasmin 28 and multiple norgestimate/ethinyl estradiol formulations). The listed entries function as a product listing; these chunks do not provide medical-necessity criteria or explicit exclusions for the oral combined contraceptives.
Additional oral combined contraceptive product names and strength formats are presented in continued listing format (examples include Tri-mili, Tri-nymyo, Tri-sprintec and dose notations such as 0.18-35/0.215-35 mg-mcg). The excerpted lines show only product names and strengths and do not state coverage limits or exclusions within these chunks.
The enumerated contraceptive product sections do not include any entries labeled or described as 'not medically necessary' within the provided excerpts.
Coding / Covered Codes
| emtricitabine-tenofovir disoproxil fumarate 200-300 mg | Truvada (HIV PrEP generic listed) |
| bupropion hcl er 12hr 150 mg | bupropion hcl (smoking deterrent) |
| varenicline tartrate pack | CHANTIX STARTING MONTH PACK - varenicline |
| nicotine td patch 21-14-7 mg/24hr | NICOTINE TRANSDERMAL SYSTEM |
| lovastatin 20 mg | lovastatin tab 20 mg |
| pravastatin 40 mg | pravastatin sodium tab 40 mg |
| pravastatin 80 mg | pravastatin sodium tab 80 mg |
| aspirin 81 mg | aspirin chew tab 81 mg; aspirin tab delayed release 81 mg |
| peg 3350 solutions | bowel preparation PEG 3350 solutions (Golytely etc.) |
| anastrozole 1 mg | anastrozole tab 1 mg (Arimidex) |
| sodium fluoride dental products | multiple sodium/stannous fluoride topical products |
| folic acid 0.4-0.8 mg | folic acid tab 400 mcg; folic acid cap 0.8 mg; folic acid tab 800 mcg |
| iron supplements (various formulations) | multiple ferrous sulfate and polysaccharide iron products |
| cervical caps | FEMCAP sizes 22, 26, 30 mm |
| diaphragms | CAYA, Omniflex, Wide-seal silicone diaphragms (multiple sizes) |
| ABRYSVO | RSV pre-fusion f a&b vaccine |
| COMIRNATY | COVID-19 mRNA vaccine (Pfizer) |
| GARDASIL 9 | HPV 9-valent vaccine |
| SHINGRIX | Zoster recombinant adjuvanted vaccine |
| PNEUMOVAX 23 | Pneumococcal vaccine polyvalent |
| ulipristal acetate 30 mg | ELLA - ulipristal acetate tab 30 mg (emergency contraception) |
| levonorgestrel 1.5 mg | Multiple levonorgestrel single-dose emergency contraceptive tablets (Plan B OneStep and generics) |
| medroxyprogesterone acetate 150 mg/ml IM | Depo-provera contraceptive injectable |
| FC2 | FC2 FEMALE CONDOM - female condoms |
| ALL MALE CONDOMS | Male condoms — listed as all male condoms |
| FEMCAP 22/26/30 mm | FEMCAP cervical cap sizes 22, 26, 30 mm |
| CAYA | CAYA diaphragm arc-spring |
| OMNIFLEX DIAPHRAGM | OMNIFLEX diaphragm |
| WIDE-SEAL SILICONE DIAPHR | Wide-seal silicone diaphragm various seal sizes (60–95 mm) |
| ENCARE/GYNOL II/VCF | Nonoxynol-9 spermicides: vaginal suppository, gel, film, foam |
| PHEXXI | PHEXXI lactic acid-citric acid-potassium bitartrate gel |
| TODAY SPONGE | Nonoxynol-9 vaginal sponge 1000 mg |
| multiple NDCs/brands | Extensive list of oral combined contraceptive brand/tablet formulations (levonorgestrel & ethinyl estradiol; norethindrone & ethinyl estradiol; desogestrel & ethinyl estradiol; drospirenone combinations; norgestimate combinations; many branded generics and combination formulations) |
Provider Actions / Billing Notes
Plan terms may limit coverage
Plan terms may limit coverage — coverage is subject to the member's plan terms and may change. Providers and members should verify plan-specific coverage details, benefit materials, and the plan website for current information.
- Verify member benefit materials and plan website for current coverage information.
- If a generic must be tried before a brand, verify plan-specific generic-first requirements.
No explicit prior authorization or step therapy policies stated
No explicit prior authorization or step therapy requirements are specified in this section. The content here is a product/formulary list and does not state prior authorization, step edits, or denial triggers for the listed products.
- No prior authorization requirement specified for emergency contraception, oral progestin, or injectable progestin products in this list.
- No step therapy policies or sequencing rules described for oral combined contraceptives in this section.
- No documentation requirements or authorization triggers are provided in this product listing.
Product/formulary listing (names and formulations)
This portion of the document provides product names and formulations (preventive drug list) grouped by category. It is a formulary/product listing intended to identify preventive medications that may be available at $0 under ACA preventive coverage; it is not a coverage decision or an authorization rule set.
- Product names and dosage/formulation details are provided (e.g., emergency contraception: ulipristal acetate 30 mg; levonorgestrel 1.5 mg tablets; injectable medroxyprogesterone acetate 150 mg/ml).
- Generic prescription drugs are shown in lower-case boldface; brand drugs shown in ALL CAPITALS. Reference brands may not be covered—verify benefits.
Generic-first verification and exceptions
Generic-first verification — verify whether a generic must be tried before a brand (possible step therapy or step edits). If an exception is needed for zero dollar cost-share (ACA preventive coverage), an exception process exists via the plan website.
- Check plan for generic-first requirements and any step edits prior to filling a brand product.
- Exception information: www.bluecrossnc.com/umdrug
Background / Scope
This document compiles preventive medications and vaccines recommended by the USPSTF, HRSA, and ACIP that may be provided with no cost sharing under eligible ACA-compliant benefit plans. It is primarily a formulary-style listing to identify potential zero-dollar coverage; clinical treatment decisions should follow clinical guidelines and providers should verify plan-specific application and any required processes on the plan website.
Definitions & Formatting Notes
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