Contraceptive Coverage

Effective Jan. 1, 2019

Your health plan may provide certain The following contraceptive items and services* may be covered contraceptive coverage at no cost to you when without cost sharing when provided by a pharmacy or doctor in you use a pharmacy or doctor in your health your health plan's network. This list is not all inclusive. Additional plan's network. There is no copay, deductible products may be covered at no additional cost. or coinsurance, even if your deductible • One or more prescribed products within each of the categories or out-of-pocket maximum has not been approved by the Food and Drug Administration (FDA) for use as met. Coverage for contraceptives can vary a method of contraception depending on the type of plan you are enrolled • FDA-approved contraceptives available over the counter (i.e. in, as well as your prescription drug list. foam, sponge, female ) when prescribed by a physician If you use a contraceptive that is not shown on • The morning after pill the Contraceptive Product Coverage list, then • Medical devices such as diaphragm, and copays, coinsurance or deductible may apply. contraceptive implants may be covered under the pharmacy or medical benefit • Female , including and tubal implant

AcademicBlue is offered by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. CONTRACEPTIVE PRODUCT COVERAGE*

CERVICAL CAPS ORAL CONTRACEPTIVES Kelnor 1/35, 1/50 Kimidess FEMCAP – cervical cap 22 mm, 26 mm, 30 mm ORAL COMBINED Kurvelo Altavera DIAPHRAGMS Larin 1/20, 1.5/30 Alyacen 1/35, 7/7/7 CAYA – diaphragm arc-spring Larin Fe 1/20, 1.5/30 Apri OMNIFLEX DIAPHRAGM – diaphragms Larin 24 Fe Aranelle WIDE-SEAL SILICONE DIAPHR – diaphragm Larissia Aubra wide seal 60 mm, 65 mm, 70 mm, 75 mm, Layolis Fe Aviane 80 mm, 85 mm, 90 mm, 95 mm Leena Azurette Lessina EMERGENCY CONTRACEPTIVES Balziva Levonest Aftera Bekyree & ethinyl estradiol tab Econtra Ez Blisovi Fe 1/20, 1.5/30 0.1 mg-20 mcg, 0.15 mg-30 mcg Econtra One-Step Blisovi 24 Fe levonorgestrel-ethinyl estradiol tab ELLA – tab 30 mg Briellyn 0.05-30/0.075-40/0.125-30 mg-mcg Fallback Solo Caziant Levora 0.15/30-28 levonorgestrel tab 1.5 mg (Plan B Chateal Lillow One-Step) Cryselle-28 LO LOESTRIN FE – norethindrone-ethinyl My Choice Cyclafem 1/35, 7/7/7 estradiol-Fe tab 1 mg-10 mcg (24)/ My Way Cyred 10 mcg (2) Next Choice One Dose Dasetta 1/35, 7/7/7 Lomedia 24 Fe Opcicon One-Step Delyla Loryna Option 2 desogestrel & ethinyl estradiol tab Low-Ogestrel React 0.15 mg-30 mcg (Desogen) Lutera Take Action desogestrel/ethinyl estradiol & ethinyl Marlissa estradiol tab 0.15-0.02/0.01 mg (21/5) Melodetta 24 Fe FEMALE CONDOMS (Mircette) Mibelas 24 Fe FC FEMALE – condoms – female drospirenone-ethinyl estradiol tab Microgestin 1/20, 1.5/30 FC2 – condoms – female 3-0.02 mg (Yaz) Microgestin Fe 1/20, 1.5/30 drospirenone-ethinyl estradiol tab IMPLANTABLES Microgestin 24 Fe 3-0.03 mg (Yasmin 28) NEXPLANON – subdermal Mili drospirenone-ethinyl implant 68 mg Mono-Linyah estradiol-levomefolate tab Mononessa 3-0.02-0.451 mg (Beyaz) INJECTIONS Myzilra Elinest DEPO-SUBQ PROVERA 104 – NATAZIA Emoquette medroxyprogesterone acetate suspension Necon 0.5/35-28, 1/35, 7/7/7 Enpresse-28 prefilled syringe 104 mg/0.65 mL NECON 1/50-28 – norethindrone & mestranol Enskyce medroxyprogesterone acetate IM tab 1 mg-50 mcg Estarylla suspension 150 mg/mL (Depo-Provera Nikki ethynodiol diacetate & ethinyl estradiol Contraceptive) norethindrone acetate & ethinyl estradiol tab 1 mg-35 mcg, 1 mg-50 mcg medroxyprogesterone acetate IM tab 1 mg-20 mcg (Loestrin 1/20-21) Falmina suspension prefilled syringe 150 mg/mL norethindrone & ethinyl estradiol-Fe Femynor (Depo-Provera Contraceptive) chew tab 0.4 mg-35 mcg (Femcon Fe), Gianvi 0.8 mg-25 mcg (Generess Fe) INTRAUTERINES Gildagia norethindrone acetate-ethinyl KYLEENA – levonorgestrel releasing IUD Gildess Fe 1/20, 1.5/30 estradiol-Fe chew tab 1 mg-20 mcg (24) 17.5 mcg/day (19.5 mg total) Isibloom (Minastrin 24 Fe) LILETTA – levonorgestrel releasing IUD Juleber norethindrone acetate & ethinyl 18.6 mcg/day (52 mg total) Junel 1/20, 1.5/30 estradiol-Fe tab 1 mg-20 mcg (Loestrin MIRENA – levonorgestrel releasing IUD Junel Fe 1/20, 1.5/30 Fe 1/20) 20 mcg/day (52 mg total) Junel Fe 24 norethindrone acetate-ethinyl PARAGARD INTRAUTERINE COPPER – Kaitlib Fe estradiol-Fe tab 1 mg-20 mcg (24) copper IUD Kariva SKYLA – levonorgestrel releasing IUD 14 mcg/day (13.5 mg total) Generic Drugs = bold Brand Drugs = CAPITAL LETTERS CONTRACEPTIVE PRODUCT COVERAGE* norgestimate & ethinyl estradiol tab Wymzya Fe PATCHES 0.25 mg-35 mcg (Ortho-Cyclen) Zarah XULANE – norelgestromin-ethinyl estradiol norgestimate-ethinyl estradiol tab Zenchent transdermal 150-35 mcg/24hr 0.18-25/0.215-25/0.25-25 mg-mcg Zenchent Fe (Ortho Tri-Cyclen Lo) Zovia 1/35E, 1/50E RINGS norgestimate-ethinyl estradiol tab NUVARING – etonogestrel-ethinyl estradiol 0.18-35/0.215-35/0.25-35 mg-mcg ORAL EXTENDED - CONTINUOUS 0.120-0.015 mg/24hr (Ortho Tri-Cyclen) Amethia Nortrel 0.5/35 (28), 1/35, 7/7/7 Amethia Lo ENCARE – nonoxynol-9 vaginal suppository Ocella Amethyst 100 mg OGESTREL Ashlyna OPTIONS GYNOL II VAGINAL – Orsythia Camrese nonoxynol-9 gel 3% Philith Camrese Lo SHUR-SEAL – nonoxynol-9 gel 2% Pimtrea Daysee VCF VAGINAL CONTRACEPTIVE – Pirmella 1/35, 7/7/7 Fayosim nonoxynol-9 film 28%, foam 12.5% Portia-28 Introvale (91 day) VCF Vaginal Contraceptive Previfem Jolessa (91 day) Gel-nonoxynol-9-gel 4% Rajani levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg Reclipsen SPONGES levonorgestrel & ethinyl estradiol Sprintec 28 TODAY SPONGE – nonoxynol-9 vaginal sponge (91-day) tab 0.15-0.03 mg Sronyx 1000 mg Syeda levonorgestrel-ethinyl estradiol tab Tarina Fe 1/20 0.15-0.03 mg (84) & ethinyl estradiol tab TAYTULLA 0.01 mg (7) (Seasonique) Tilia Fe levonorgestrel-ethinyl estradiol tab Tri-Estarylla 0.1-0.02 mg (84) & ethinyl estradiol tab Tri Femynor 0.01 mg (7) (LoSeasonique) Tri-Legest Fe levonorgestrel-ethinyl estradiol tab Tri-Linyah 0.15-0.02/0.025/0.03 mg & ethinyl Tri-Lo-Estarylla estradiol 0.01 mg (Quartette) Tri-Lo-Marzia Quasense (91 day) Tri-Lo-Sprintec Rivelsa Tri-Mili Setlakin (91 day) Trinessa ORAL PROGESTIN Trinessa Lo Camila Tri-Previfem Deblitane Tri-Sprintec Errin Trivora-28 Heather Tri-Vylibra Jencycla Tydemy Jolivette Velivet Lyza Vestura Nora-BE Vienva norethindrone tab 0.35 mg Viorele (Ortho Micronor) Vyfemla Norlyda Vylibra Norlyroc Wera Sharobel Generic Drugs = bold Brand Drugs = CAPITAL LETTERS

* Some of these products may be covered under your medical benefit if provided by a doctor in your health plan's network. Some generic drugs listed are followed by a reference brand drug in (parentheses). The brand name drug in parentheses is listed for reference and may not be covered under your benefit. This list is not all inclusive. Additional products may be covered at no additional cost. Prescription coverage for contraception may vary according to the terms and conditions of the plan and prescription drug list. A prescription may be required for coverage without cost sharing under the pharmacy benefits for non-grandfathered plans. If your contraception product is not listed, check your drug list or ask your doctor about therapeutic alternatives. Your doctor can also submit a coverage exception from Blue Cross and Blue Shield of Illinois (unless you have a benefit exclusion) for products not covered on your prescription drug list. This information is for informational purposes only, does not constitute legal or other advice and should not be relied upon to determine coverage.

Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sexual orientation, gender identity or sex. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-710-6984 (TTY: 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-855-710-6984 (TTY: 711). 234088.1218