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Preventive Care Services: Contraception

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Preventive Care Services: Contraception Preventive Care Services: Contraception Preventive Care Coverage at No Cost to You Effective Jan. 1, 2021 Your health plan may provide certain contraceptive coverage as a benefit of membership, at no cost to you when you use a pharmacy or doctor in your health plan's network. There is no copay, deductible or coinsurance, even if your deductible or out-of-pocket maximum has not been met. Coverage for contraceptives can vary depending on the type of plan you are enrolled in, as well as your prescription drug list. If you are using a contraceptive not listed under the Contraceptive Product Coverage, then copays, coinsurance or deductible may apply. Check your drug list or call the number listed on your member ID card to find out what products are covered at no cost share under your plan. Contraception* The following contraceptive items and services may be covered under the medical or pharmacy benefit without cost-sharing when provided by a pharmacy or doctor in your health plan's network. This list is not all inclusive. Additional products may be covered at no additional cost. • One or more prescribed products within each of the categories approved by the FDA for use as a method of contraception • FDA-approved contraceptives available over the counter (i.e. foam, sponge, female condoms), when prescribed by a physician • The morning after pill • Injections such as IM DEPO-PROVERA and DEPO-SUBQ PROVERA 104 may be covered under the medical or pharmacy benefit • Medical devices such as diaphragms, cervical caps and contraceptive implants may be covered under the pharmacy or medical benefit • Female sterilization, including tubal ligation and tubal implant • Male sterilization bcbsil.com CONTRACEPTIVE PRODUCT COVERAGE* CERVICAL CAPS INJECTIONS Azurette FEMCAP - cervical cap 22 mm, DEPO-SUBQ PROVERA 104 – Balziva 26 mm, 30 mm medroxyprogesterone acetate susp Bekyree pref syr 104 mg/0.65 mL Blisovi Fe 1/20, 1.5/30 DIAPHRAGMS medroxyprogesterone acetate IM Blisovi 24 Fe CAYA – diaphragm arc-spring suspension 150 mg/mL Briellyn OMNIFLEX DIAPHRAGM – diaphragms (Depo-Provera Contraceptive) Caziant WIDE-SEAL SILICONE DIAPHRAGM medroxyprogesterone acetate IM KIT – diaphragm wide seal 60 mm, suspension prefilled syringe 150 mg/ Charlotte 24 Fe mL (Depo-Provera Contraceptive) 65 mm, 70 mm, 75 mm, 80 mm, Chateal 85 mm, 90 mm, 95 mm INTRAUTERINES Chateal EQ EMERGENCY CONTRACEPTIVES KYLEENA – levonorgestrel releasing IUD Cryselle-28 † Aftera 17.5 mcg/day (19.5 mg total) Cyclafem 1/35, 7/7/7 Econtra Ez LILETTA – levonorgestrel releasing IUD Cyred 19.5 mcg/day (52 mg total)† Econtra One-Step Cyred EQ MIRENA – levonorgestrel releasing IUD Dasetta 1/35, 7/7/7 ELLA – ulipristal acetate tab 30 mg 20 mcg/day (52 mg total)† Delyla levonorgestrel tab 1.5 mg PARAGARD INTRAUTERINE COPPER – (Plan B One-Step) copper IUD† desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) My Choice SKYLA – levonorgestrel releasing IUD My Way 14 mcg/day (13.5 mg total)† desogestrel/ethinyl estradiol & ethinyl estradiol tab 0.15-0.02/0.01 mg New Day ORAL CONTRACEPTIVES (21/5) (Mircette) Opcicon One-Step ORAL COMBINED drospirenone-ethinyl estradiol tab Option 2 3-0.02 mg (Yaz) Afirmelle Preventeza drospirenone-ethinyl estradiol tab Altavera React 3-0.03 mg (Yasmin 28) Alyacen 1/35, 7/7/7 Take Action drospirenone-ethinyl estradiol- Apri levomefolate tab 3-0.02-0.451 mg FEMALE CONDOMS Aranelle (Beyaz) FC FEMALE CONDOM – condoms - female Aubra drospirenone-ethinyl estrad- levomefolate tab 3-0.03-0.451 mg FC2 FEMALE CONDOM – condoms - Aubra EQ (Safyral) female Aurovela 1/20, 1.5/30 Elinest IMPLANTABLES Aurovela Fe 1/20, 1.5/30 Emoquette Aurovela 24 Fe NEXPLANON – etonogestrel subdermal Enpresse-28 † implant 68 mg Aviane Enskyce Ayuna Estarylla Generic Drugs = bold Brand Drugs = CAPITAL LETTERS † = Covered under medical benefit bcbsil.com CONTRACEPTIVE PRODUCT COVERAGE* ethynodiol diacetate & ethinyl Low-Ogestrel OGESTREL - norgestrel & ethinyl estradiol tab 0.5 mg - 50 mcg estradiol tab 1 mg-35 mcg, 1 mg- Lo-Zumandimine 50 mcg Lutera Orsythia Falmina Marlissa Philith Femynor Melodetta 24 Fe Pimtrea Gianvi Mibelas 24 Fe Pirmella 1/35, 7/7/7 Hailey 1.5/30 Microgestin 1/20, 1.5/30 Portia-28 Hailey Fe 1/20, 1.5/30 Microgestin Fe 1/20, 1.5/30 Previfem Hailey 24 Fe Mili Reclipsen Isibloom Mono-Linyah Simliya Jasmiel NATAZIA – estradiol valerate-dienogest Sprintec 28 Juleber tab 3 mg /2-2 mg/2-3 mg/1 mg Sronyx Junel 1/20, 1.5/30 Necon 0.5/35-28 Syeda Junel Fe 1/20, 1.5/30 Nikki Tarina Fe 1/20 Junel Fe 24 norethindrone & ethinyl estradiol-Fe Tarina Fe 1/20 EQ Kaitlib Fe chew tab 0.4 mg-35 mcg, 0.8 mg-25 Tarina 24 Fe mcg (Generess Fe) Kalliga TAYTULLA - norethindrone acetate- Kariva norethindrone acetate/ethinyl ethinyl estradioal-fe cap 1 mg-20 mcg estradiol (24) Kelnor 1/35, 1/50 norethindrone acetate & ethinyl Tilia Fe Kurvelo estradiol tab 1 mg-20 mcg (Loestrin Larin 1/20, 1.5/30 1/20-21) Tri-Estarylla Larin Fe 1/20, 1.5/30 norethindrone acetate & ethinyl Tri Femynor estradiol-fe tab 1.5 mg-30 mcg Larin 24 Fe Tri-Legest Fe (Loestrin Fe 1.5/30) Larissia Tri-Linyah norethindrone acetate-ethinyl Tri-Lo-Estarylla Layolis Fe estradiol-Fe chew tab 1 mg-20 mcg Leena (24) (Minastrin 24 Fe) Tri-Lo-Marzia Lessina norethindrone acetate & ethinyl Tri-Lo-Mili estradiol-Fe tab 1 mg-20 mcg (Loestrin Tri-Lo-Sprintec Levonest Fe 1/20) Tri-Mili levonorgestrel & ethinyl estradiol tab norethindrone acetate-ethinyl 0.1 mg-20 mcg, 0.15 mg-30 mcg estradiol-Fe tab 1 mg-20 mcg (24) Tri-Previfem levonorgestrel-ethinyl estradiol tab norgestimate & ethinyl estradiol tab Tri-Sprintec 0.05-30/0.075-40/0.125-30 mg-mcg 0.25 mg-35 mcg (Ortho-Cyclen) Trivora-28 Levora 0.15/30-28 norgestimate-ethinyl estradiol tab Tri-Vylibra 0.18-25/0.215-25/0.25-25 mg-mcg Lillow Tri-Vylibra Lo LO LOESTRIN FE – norethindrone- norgestimate-ethinyl estradiol tab Tydemy ethinyl estradiol-Fe tab 1 mg-10 mcg 0.18-35/0.215-35/0.25-35 mg-mcg (24)/10 mcg (2) Velivet Nortrel 0.5/35 (28), 1/35, 7/7/7 Vienva Loryna Ocella Generic Drugs = bold Brand Drugs = CAPITAL LETTERS † = Covered under medical benefit bcbsil.com CONTRACEPTIVE PRODUCT COVERAGE* Viorele levonorgestrel-ethinyl estradiol tab PATCHES 0.1-0.02 mg (84) & ethinyl estradiol tab Volnea XULANE – norelgestromin-ethinyl 0.01 mg (7) (LoSeasonique) Vyfemla estradiol transdermal 150-35 mcg/24hr levonorgestrel-ethinyl estradiol tab Vylibra 0.15-0.02/0.025/0.03 mg & ethinyl RINGS Wera estradiol 0.01 mg (Quartette) ANNOVERA - segesterone acetate- Wymzya Fe Lojaimiess ethinyl estradiol vaginal ring 0.15- Zarah Rivelsa 0.013 mg/24hr Zovia 1/35E Setlakin (91 day) NUVARING – etonogestrel-ethinyl estradiol vaginal ring 0.120-0.015 Simpesse Zumandimine mg/24hr ORAL PROGESTIN ORAL EXTENDED - CONTINUOUS SPERMICIDES Camila Amethia ENCARE – nonoxynol-9 vaginal Amethia Lo Deblitane suppository 100 mg Amethyst Errin OPTIONS GYNOL II VAGINAL – nonoxynol-9 gel 3% Ashlyna Heather SHUR-SEAL – nonoxynol-9 gel 2% Camrese Incassia VCF VAGINAL CONTRACEPTIVE – Camrese Lo Jencycla nonoxynol-9 film 28%, foam 12.5% Daysee Lyza VCF Vaginal Contraceptive Gel- Nora-BE Fayosim nonoxynol-9-gel 4% Introvale (91 day) norethindrone tab 0.35 mg (Ortho Micronor) Jaimiess SPONGES Norlyda TODAY SPONGE – nonoxynol-9 vaginal Jolessa (91 day) Norlyroc sponge 1000 mg levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg Sharobel levonorgestrel & ethinyl estradiol SLYND – drospirenone tab 4 mg (91 day) tab 0.15-0.03 mg Tulana levonorgestrel-ethinyl estradiol tab 0.15-0.03 mg (84) & ethinyl estradiol tab 0.01 mg (7) (Seasonique) Generic Drugs = bold Brand Drugs = CAPITAL LETTERS † = Covered under medical benefit * Some of these products may be covered under your medical benefit if provided by a doctor in your health plan's network. Most 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 prescription drug list or ask your doctor about therapeutic alternatives. Your doctor can also submit a coverage exception from BCBSIL (unless you have a benefit exclusion) for products not covered on your prescription drug list. * Certain group health plans established or maintained by organizations that qualify as religious employers may be exempt. These services may be covered under a plan’s Pharmacy benefits. This information is for informational purposes only, does not constitute legal or other advice and should not be relied upon to determine coverage. Affordable Care Act regulations provide for an exemption from the requirement to cover contraceptive services for certain group health plans established or maintained by organizations that qualify as religious employers. Also, federal regulatory agencies have established an accommodation for religious affiliated eligible organizations, in which case separate payment may be available for certain contraceptive services. For more information about the religious employer exemption or eligible organization accommodation, please contact us at the phone number on your member ID card. 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 233345.0920 bcbsil.com.
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