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ACA Preventive Drug List Effective January 1, 2018

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ACA Preventive Drug List Effective January 1, 2018 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 NAFRINSE All brand/generic aspirin 81 mg OMNI GEL** ASPIRIN LOW DOSE PARODONTAX IRON SUPPLEMENTS PHOS FLUR carbonyl iron suspension BOWEL PREPARATION PHOS-FLUR ORTHO DEFENSE FER-IN-SOL** PREVIDENT** (for colorectal cancer FERROUS SULFATE liquid, REMBRANDT 220 mg/5 mL, syrup screening) SENSODYNE REPAIR & PROTECT ferrous sulfate elixir, solution peg 3350-kcl-na bicarb-nacl-na WHITENING ICAR PEDIATRIC** suspension sulfate for soln 236, 240 gm sodium fluoride crm, gel, oral IRON UP peg 3350-kcl-sod bicarb-nacl for rinse, paste NOVAFERRUM PEDIATRIC drops soln 420 gm sodium fluoride/potassium nitrate stannous fluoride SINGLE-AGENT STATINS STANNOUS FLUORIDE RINSE BREAST CANCER – PRIMARY lovastatin 20 mg, 40 mg THERA-FLUR-N** PREVENTION pravastatin EVISTA** -Supplements & raloxifene TOBACCO CESSATION SOLTAMOX Combinations- All brand/generic OTC nicotine gum, tamoxifen FLORICAL lozenges, patches FLORIVA bupropion ext-release (smoking FLUORIDE FLUORABON cessation) -Dental Products & FLUOR-A-DAY chew tabs CHANTIX FLURA-DROPS Combinations- COMMIT** (OTC) LOZI-FLUR NICODERM CQ** (OTC) ACT TOTAL CARE DRY MOUTH LURIDE** NICORETTE** (OTC) COLGATE DRY MOUTH RELIEF MONOCAL nicotine gum, lozenges, patches CREST COMPLETE sodium fluoride chew tabs, drops, NICOTINE TRANSDERMAL kit (OTC) FLUORIDEX DAILY DEFENSE soln NICOTROL INHALER SENSITIVITY RELIEF gel SODIUM FLUORIDE tabs NICOTROL NS GEL-KAM** ZYBAN** LISTERINE ESSENTIAL CARE FOLIC ACID SUPPLEMENTS LISTERINE NATURALS WITH folic acid caps, 0.8 mg FLUORIDE VACCINES folic acid tabs, 400 mcg, 800 mcg LISTERINE RESTORING** ACTHIB LISTERINE SMART RINSE** ADACEL LISTERINE TOTAL CARE** INFANT EYE OINTMENT AFLURIA/PF/QUADRIVALENT LISTERINE (for newborns) BEXSERO WHITENING/RESTORING** erythromycin eye oint BOOSTRIX CERVARIX Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available 3160-E © Prime Therapeutics LLC 08/17 Product names listed are the property of their respected owners. Page 1 of 5 VACCINES (continued) VITAMIN D SUPPLEMENTS COMVAX BABY DDROPS** (OTC) DAPTACEL BABY SUPER DAILY D3 (OTC) DIPHTHERIA/TETANUS TOXOID – BABY VITAMIN D3 DROPS (OTC) ADSORBED CHOLECALCIFEROL soln, 1200 unit/15 mL; ENGERIX-B spray, 1000 unit/spray (OTC) FLUAD cholecalciferol caps, 400 unit, 1000 unit; FLUARIX QUADRIVALENT chew tabs, 400, 1000 unit; FLUBLOK/QUADRIVALENT drops, 400 unit/0.03 mL, 5000 unit/mL (1000/0.2 mL); FLUCELVAX/QUADRIVALENT soln, 400 unit/mL; FLULAVAL QUADRIVALENT tabs, 400, 1000 unit (OTC) FLUVIRIN D-VI-SOL** (OTC) FLUZONE/HIGH-DOSE (PF)/ INTRADERMAL/QUADRIVALENT/ DDROPS 600 unit/0.028 mL, 1000 unit/0.028 mL, SPLIT 1000 unit/0.03 mL (OTC) GARDASIL ERGOCALCIFEROL tabs, 400 unit (OTC) GARDASIL 9 SUPER DAILY D3 (OTC) HAVRIX UPSPRINGBABY VITAMIN D3 (OTC) HIBERIX VITAMELTS VITAMIN D (OTC) INFANRIX WELLESSE oral liquid, 1000 unit/10 mL (OTC) 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 ZOSTAVAX Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available 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 Aranelle Larin Barrier Method Types Aubra Larin Fe Aviane Larin 24 Fe -Cervical Caps- Azurette Larissia FEMCAP Balziva Layolis Fe PRENTIF CAVITY-RIM CERVICAL CAP Bekyree Leena PRENTIF FITTING SET BEYAZ** Lessina -Diaphragms- Blisovi Fe Levonest CAYA Blisovi 24 Fe levonorgestrel/ethinyl estradiol OMNIFLEX DIAPHRAGM BREVICON** Levora WIDE-SEAL SILICONE DIAPHRAGM KIT Briellyn LOESTRIN** -Female Condom- Caziant LOESTRIN FE** FC FEMALE CONDOM Chateal LO LOESTRIN FE FC2 FEMALE CONDOM Cryselle Lomedia 24 Fe -Spermicide – Cyclafem Loryna CYCLESSA** Low-Ogestrel ENCARE Cyred Lutera nonoxynol-9 gel 4% Dasetta Marlissa OPTIONS CONCEPTROL** Delyla Mibelas 24 Fe OPTIONS GYNOL II DESOGEN** Microgestin SHUR-SEAL desogestrel/ethinyl estradiol Microgestin Fe VCF VAGINAL CONTRACEPTIVE drospirenone/ethinyl estradiol Microgestin 24 Fe -Sponge – drospirenone/ethinyl MINASTRIN 24 FE** TODAY SPONGE estradiol/levomefolate MIRCETTE** Elinest MODICON** Emergency Method Types Emoquette Mono-Linyah -Emergency Progestin- Enpresse Mononessa Aftera Enskyce Myzilra Econtra EZ Estarylla NATAZIA Fallback Solo ESTROSTEP FE** Necon 0.5/35, 1/35, 7/7/7 levonorgestrel 1.5 mg ethynodiol/ethinyl estradiol NECON 1/50, 10/11 My Way FALESSA Nikki Next Choice One Dose Falmina norethindrone/ethinyl estradiol Opcicon One-Step FEMCON FE** norethindrone/ethinyl estradiol/fe Option 2 Femynor norgestimate/ethinyl estradiol PLAN B ONE-STEP** GENERESS FE** NORINYL 1+35** React Gianvi NORINYL 1+50 Take Action Gildagia Nortrel -Emergency Ella- Gildess Ocella ELLA Gildess Fe OGESTREL Gildess 24 Fe Orsythia Hormonal Method Types Isibloom ORTHO-CYCLEN** -Injectable Progestin- Juleber ORTHO-NOVUM** Junel ORTHO TRI-CYCLEN** DEPO-PROVERA CONTRACEPTIVE** Junel Fe ORTHO TRI-CYCLEN LO** DEPO-SUBQ-PROVERA 104 Junel Fe 24 OVCON-35** medroxyprogesterone acetate Kaitlib Fe Philith -Oral Combined- Kariva Pimtrea Altavera Kelnor Pirmella Alyacen Kimidess Portia Apri Kurvelo Previfem Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available 3160-E © Prime Therapeutics LLC 08/17 Product names listed are the property of their respected owners. Page 3 of 5 Hormonal Method Types Rivelsa -Oral Combined-(continued) SEASONIQUE** Setlakin Rajani Reclipsen -Oral Progestin- SAFYRAL Camila Sprintec Deblitane Sronyx Errin Syeda Heather Tarina Fe Jencycla TAYTULLA Jolivette Tilia Fe Lyza Tri-Estarylla NOR-QD** Tri Femynor Nora-Be norethindrone Tri-Legest Fe Norlyda Tri-Linyah Norlyroc Tri-Lo-Estarylla ORTHO MICRONOR** Tri-Lo-Marzia Sharobel Tri-Lo-Sprintec -Transdermal Combined (patch) - TRI-NORINYL** XULANE Tri-Previfem Tri-Sprintec -Vaginal Combined (ring) - Trinessa NUVARING Trinessa Lo Trivora Implantable Method Types Velivet -Implants Progestin- Vestura NEXPLANON Vienva -Intrauterine Devices Copper- Viorele PARAGARD Vyfemla Wera -Intrauterine Devices Progestin- Wymzya Fe KYLEENA YASMIN** LILETTA YAZ** MIRENA Zarah SKYLA 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 Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available 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 Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available 3160-E © Prime Therapeutics LLC 08/17 Product names listed are the property of their respected owners. Page 5 of 5 .
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