CurrentBlue Cross Blue Shield - North CarolinaPolicy 6756-A

ACA Preventive Drug List / Preventive Medications and Vaccines Coverage

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.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyACA Preventive Drug List / Preventive Medications and Vaccines Coverage

Policy CodePolicy 6756-A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionVerify member benefit materials and the plan website to confirm zero-dollar coverage and whether a generic must be tried before a brand.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$0Zero-dollar coverage

20+Contraceptive entries

3Delivery routes

NCState applicability

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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.

Coverage condition: Drug or device is on the ACA Preventive Drug List and provided under an eligible benefit plan; member's plan terms and benefit materials confirm zero-dollar cost-share; verify if a generic must be tried before the brand and whether any plan-level prior authorization or exception process applies.

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):

enumeration: This section lists covered contraceptive products and brands including cervical caps (FEMCAP sizes 22, 26, 30 mm), diaphragms (CAYA, OMNIFLEX, wide-seal silicone diaphragms in multiple sizes), female and male condoms (FC2 FEMALE CONDOM; ALL MALE CONDOMS), spermicides (nonoxynol-9 products), PHEXXI vaginal pH regulator gel, TODAY SPONGE, emergency contraception (ELLA ulipristal acetate 30 mg and multiple levonorgestrel 1.5 mg products), injectable medroxyprogesterone (Depo‑Provera), and an extensive list of oral combined contraceptive brands and formulations.

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)

Product listing: Repeated entries of oral combined contraceptive product names and formulations including Tri-sprintec (norgestimate/ethinyl estradiol), Tri-nymyo (norgestimate/ethinyl estradiol), Ocella (drospirenone/ethinyl estradiol 3-0.03 mg, e.g., Yasmin 28), Philith (norethindrone & ethinyl estradiol), and dose notations such as 0.18-35 / 0.215-35 / 0.25-35 mg-mcg among many other branded and generic combination formulations listed across these pages.

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

HIV PrEP (generic list)NDC | mixedCovered

emtricitabine-tenofovir disoproxil fumarate 200-300 mg

Truvada (HIV PrEP generic listed)

Smoking cessation medications and NRTNDC | mixedCovered

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

Single agent statinsNDC | mixedCovered

lovastatin 20 mg	lovastatin tab 20 mg
pravastatin 40 mg	pravastatin sodium tab 40 mg
pravastatin 80 mg	pravastatin sodium tab 80 mg

Other preventive medications and devicesNDC | mixedCovered

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)

Vaccines (selected products listed)NDC | mixedCovered

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

Emergency EllaNDC | mixedCovered

ulipristal acetate 30 mg

ELLA - ulipristal acetate tab 30 mg (emergency contraception)

Emergency ProgestinNDC | mixedCovered

levonorgestrel 1.5 mg

Multiple levonorgestrel single-dose emergency contraceptive tablets (Plan B OneStep and generics)

Injectable ProgestinNDC | mixedCovered

medroxyprogesterone acetate 150 mg/ml IM

Depo-provera contraceptive injectable

Barrier MethodsmixedCovered

FC2	FC2 FEMALE CONDOM - female condoms
ALL MALE CONDOMS	Male condoms — listed as all male condoms

Barrier, Spermicide, Vaginal Regulator, SpongeNDC | mixedCovered

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

Oral Combined ContraceptivesNDC | mixedCovered

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

Note

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.

Prior Authorization

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.

Note

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.

Step Therapy

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

Definitions & Formatting Notes

Generic and Brand formatting

Generic formattingGeneric prescription drugs are shown in lower-case boldface (many generics are followed by a reference brand in parentheses)

Brand formattingBrand prescription drugs are shown in ALL CAPITAL LETTERS and are often followed by the generic name

Reference brands may not be coveredReference brand drugs shown in parentheses may not themselves be covered; members must check benefit materials

Purpose of formattingFormatting distinguishes generic vs brand for quick identification on the preventive drug list

Female Condom

Product listedFC2 FEMALE CONDOM — condoms — female

CategoryBarrier method — female condom

Coverage implicationIncluded in the enumerated contraceptive products that may be covered at $0 cost-share under eligible ACA plans

Male Condom

Product group listedALL MALE CONDOMS — male condoms (coverage as a product group)

CategoryBarrier method — male condoms

Coverage implicationListed generically to indicate coverage of male condoms as a group rather than specific brands

Oral Combined — description

DefinitionCombined oral contraceptives contain an estrogen (ethinyl estradiol) and a progestin (examples in the list include drospirenone, norethindrone, norgestimate, levonorgestrel)

Formulation examplesListings include multiple levonorgestrel & ethinyl estradiol, norethindrone & ethinyl estradiol, desogestrel & ethinyl estradiol, and drospirenone combinations

Listing natureThe section enumerates numerous brand and generic oral combined products and strengths without additional clinical eligibility criteria

Oral Combined — brand/generic and strength notation

Brand and generic presentationBrand names appear in ALL CAPITALS (e.g., YASMIN shown as Yasmin 28 in text) and generics shown in lower-case bold in source formatting rules

Strength notationDose formats are shown as mg and mcg combinations (examples: 3-0.03 mg; 0.18-35/0.215-35/0.25-35 mg-mcg)

Repeated entriesMany oral combined entries repeat brand/generic lines with their strength notations across the listing

Oral Combined — tablet examples and components

Example product — Tri-sprintecTri-sprintec — norgestimate & ethinyl estradiol tablets (strength formats shown in listing)

Example product — OcellaOcella — drospirenone & ethinyl estradiol tablet (3-0.03 mg; referenced as Yasmin 28 equivalent)

Typical componentsCombined hormonal oral contraceptive tablets pair ethinyl estradiol with progestins such as norgestimate, drospirenone, norethindrone, levonorgestrel

Oral Combined — formulations and progestin examples

Product formulationsOral combined entries include multiple formulations pairing ethinyl estradiol with progestins (norgestimate, drospirenone, norethindrone, levonorgestrel)

Dose notation examplesNotations include combined dose strings such as 0.18-35/0.215-35/0.25-35 mg-mcg and 3-0.03 mg

Extensive listingThe document contains an extensive enumerated list of oral combined brands and generics across several pages of the listing

Transdermal Combined

Patch examplesXulane — norelgestromin & ethinyl estradiol transdermal patch (150-35 mcg/24hr)

Patch exampleZafemy — norelgestromin & ethinyl estradiol transdermal patch (150-35 mcg/24hr)

RouteTransdermal delivery of progestin and ethinyl estradiol via weekly patch formulations

Vaginal Combined

Vaginal ring exampleNUVARING — etonogestrel & ethinyl estradiol vaginal ring (0.120-0.015 mg/24hr)

Delivery routeVaginal ring delivers etonogestrel and ethinyl estradiol continuously per 24-hour rate

CategoryListed under vaginal combined contraceptive delivery methods

OpenPayer

ACA Preventive Drug List / Preventive Medications and Vaccines Coverage

Coverage Criteria

Coding / Covered Codes

Provider Actions / Billing Notes

Background / Scope

Definitions & Formatting Notes