CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Results Plus ACA Preventive Drug List

Lists preventive medications and vaccines available under the employer-selected ACA preventive drug coverage, intended for members and providers to verify coverage details and plan requirements.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyResults Plus ACA Preventive Drug List

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateOctober 1, 2023

Next Review DateN/A

Key ActionVerify member benefit materials and the plan website (MyPrime) for current coverage, prior authorization, and generic-before-brand requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MultiplePreventive categories listed

Many listedVaccine products

Truvada listedHIV PrEP included

~17 categoriesContraceptive items

IncludedTobacco cessation

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General ACA preventive coverage

Preventive medications and vaccines may be covered at $0 when they meet ACA evidence-based recommendation criteria and are included on the employer-elected Preventive Drug List.

Coverage general condition: Drug or vaccine is recommended by the USPSTF, HRSA, or ACIP and is included on the employer's Preventive Drug List

Coverage is subject to the terms of the member's health plan and periodic updates; verify with plan benefit materials and the plan website.

General coverage guidance

HRSA/ACA contraceptive coverage guidance and plan verification note.

HRSA/ACA contraceptive coverage: Eligible benefit plans include coverage under the Affordable Care Act for the listed contraceptives; actual cost share and coverage depend on the member's benefit materials and plan website information.

The list is reviewed periodically and is subject to change; verify coverage and cost share via MyPrime.com or the member's benefit materials.

The list includes reference brand names for clarity, but reference brand drugs may not themselves be covered under a member’s plan. Verify the member’s benefit materials and plan website for exclusions and cost-share details before assuming coverage or zero cost-share.

The HRSA-based excerpt does not enumerate specific product exclusions beyond the general guidance. Verify benefits and cost-share with the member’s plan or MyPrime.com because the list is reviewed periodically and subject to change.

Product & Procedure Codes

Vaccines (continued)mixed

TWINRIX	a-hep b vaccine susp syr 720-20 elu-mcg/ml pref
VAXNEUVANCE	pneumococcal 15-valent conjugate vaccine sus syr 0.5 ml pref
VAQTA	hepatitis a vaccine inj susp 25 unit/0.5 ml
VARIVAX	varicella virus vac live for subcutaneous
VAXELIS	diph-tet tox-ac pertad-polio ipv-hib-hep b rec pre syr susp

Cervical CapsmixedCovered

FEMCAP 22 mm	Cervical cap 22 mm
FEMCAP 26 mm	Cervical cap 26 mm
FEMCAP 30 mm	Cervical cap 30 mm

DiaphragmsmixedCovered

CAYA	diaphragm arc-spring OMNIFLEX DIAPHRAGM
WIDE-SEAL SILICONE DIAPHRAGM 60 mm	diaphragm wide seal 60 mm
WIDE-SEAL SILICONE DIAPHRAGM 65 mm	diaphragm wide seal 65 mm
WIDE-SEAL SILICONE DIAPHRAGM 70 mm	diaphragm wide seal 70 mm
WIDE-SEAL SILICONE DIAPHRAGM 75 mm	diaphragm wide seal 75 mm
WIDE-SEAL SILICONE DIAPHRAGM 80 mm	diaphragm wide seal 80 mm
WIDE-SEAL SILICONE DIAPHRAGM 85 mm	diaphragm wide seal 85 mm
WIDE-SEAL SILICONE DIAPHRAGM 90 mm	diaphragm wide seal 90 mm
WIDE-SEAL SILICONE DIAPHRAGM 95 mm	diaphragm wide seal 95 mm

Female CondommixedCovered

FCZ	FEMALE CONDOM condoms - female

Male CondommixedCovered

ALL MALE CONDOMS

male condoms

Spermicide and pH regulatormixedCovered

ENCARE	nonoxynol-9 vaginal suppos 100 mg
GYNOL II	nonoxynol-9 gel 3%
VCF film	nonoxynol-9 film 28%
VCF foam	nonoxynol-9 foam 12.5%
PHEXXI	lactic acid-citric acid-potassium bitartrate gel 1.8-1-0.4%

SpongemixedCovered

TODAY

SPONGE - nonoxynol-9 vaginal sponge 1000 mg

Emergency contraceptionmixedCovered

ELLA	ulipristal acetate tab 30 mg
Levonorgestrel 1.5 mg	Plan B One-Step and multiple generic/brand levonorgestrel emergency progestin products

Injectable ProgestinmixedCovered

Depo-Provera

medroxyprogesterone acetate IM suspension 150 mg/mL (injectable progestin)

Hormonal contraceptives (oral, transdermal, vaginal, injectables)mixedCovered

Multiple oral combined contraceptives	List of combined oral contraceptives (various brands and generics, e.g., Aurovela, Blisovi, Junel, Loestrin, Tri-sprintec, etc.)
Oral Progestin	norethindrone 0.35 mg (Camila, Errin, Nora-be, etc.)
Transdermal Combined	Xulane, Zafemy (norelgestromin-ethinyl estradiol patch 150-35 mcg/24hr)
Vaginal Combined	NuvaRing (etonogestrel-ethinyl estradiol ring)
Oral Extended Continuous (91-day)	Iclevia, Introvale, Jolessa, Setlakin (levonorgestrel & ethinyl estradiol 91-day formulations)

What Providers Must Verify

Prior Authorization

Prior authorization — verify with plan

The document lists preventive drugs that may be available under ACA preventive coverage and instructs providers to verify plan-specific prior authorization requirements with the member's health plan, because the list is subject to the terms of the health plan and may change.

Prior Authorization

Prior authorization — check plan

The excerpt does not specify any explicit prior authorization rules; providers must check the member's benefit materials and plan website for any prior authorization requirements that apply to listed preventive drugs.

Step Therapy

Generic-before-brand guidance

Verify with the plan whether a generic formulation must be tried before dispensing a brand product, as the document advises providers to confirm generic-before-brand requirements with the member's plan.

Step Therapy

Step therapy not specified

No step therapy protocols or step-wise treatment requirements are specified in this excerpt; the document states only that providers should check plan materials for any such rules.

Documentation Required

Verify plan-specific requirements

Confirm with the member's plan whether generics must be tried before brand medications and consult benefit materials or the plan website (MyPrime.com) for specific coverage rules and cost-share details.

Check member benefit materials for coverage and cost-share specifics.
Use the plan website (MyPrime.com) for current coverage rules.

Documentation Required

Plan documentation and verification

Refer to the member's benefit materials and the plan website for current coverage details; the preventive drug list is reviewed periodically and is subject to change, so plan documentation is the authoritative source.

List is reviewed periodically and may change.
Benefit materials and plan website provide current information.

Denial Risk

Plan terms and verification

Coverage of the listed preventive drugs is subject to the terms of the member's health plan and may change; providers should verify current coverage and any applicable requirements via the member's benefit materials and the plan website.

Denial Risk

Benefit verification required

Coverage and member cost share for these preventive medications depend on the specific benefit plan and may change; to avoid claim denials or unexpected patient costs, check the member's benefit materials and the plan website (MyPrime) for the most current information.

Coverage and cost share vary by benefit plan.
Check benefit materials and MyPrime for current coverage to reduce denial risk.

Policy Background

This document compiles medications and vaccines recommended by the USPSTF, HRSA, and ACIP that may be provided as preventive services under the Affordable Care Act. When the employer‑elected benefit applies, these items may be available at $0 cost‑share, subject to the terms of the member’s health plan and periodic updates to the list.

The list is organized by preventive indication (for example, aspirin, folic acid, statins, vaccines, HIV PrEP, tobacco cessation, and contraceptives). Providers should verify plan‑specific coverage, prior authorization, and any generic‑before‑brand requirements via the member’s benefit materials or the plan website, as the publication is subject to change.

Terminology & Display Conventions

Generic vs. Brand — display convention

Generic display conventionGeneric prescription drugs are shown in lower-case boldface type.

Brand display conventionBrand prescription drugs are shown in all capital letters and are followed by the generic name.

Reference brand coverage noteReference brand drugs listed may not themselves be covered; check member benefit materials for exclusions and cost-share details.

Generic-followed-by-brand formatMost generic drugs are followed by a reference brand drug in parentheses; some generics have no reference brand.

Plan verification instructionVerify with your plan if a generic must be tried before the brand version and refer to benefit materials and the plan website for current information.

Emergency contraception definitions

Ulipristal acetate (ELLA)ELLA — ulipristal acetate 30 mg tablet (Emergency Ella).

Levonorgestrel 1.5 mg (Plan B and generics)Levonorgestrel 1.5 mg tablet — marketed as Plan B One-Step and multiple generic/brand levonorgestrel emergency progestin products (Emergency Progestin).

Formulation noteBoth types listed as single-dose oral tablets for emergency contraception.

OpenPayer

Results Plus ACA Preventive Drug List

ACA Preventive Drug & Vaccine Coverage

Product & Procedure Codes

What Providers Must Verify

Policy Background

Terminology & Display Conventions