Coverage of Affordable Care Act (ACA) Preventive Prescription Medications

Providence Health Plan, in accordance with The Patient Protection and Affordable Care Act (PPACA), provides coverage of the following preventive medication categories without imposing a copayment, coinsurance, or deductible. Coverage of these medications, including over-the-counter (OTC) medications, requires a prescription from a licensed health care provider. Not all medications are covered in full under these categories and may be subject to medical management techniques to determine frequency, method, treatment, setting or medical necessity for non-formulary medications. Coverage is determined under the terms of your medical plan. For more information about your coverage, please call 1-877-216-3644. Access to your formulary drug list is available on our website at https://providencehealthplan.com/members/pharmacy-resources.

ASPIRIN 81 MG Recommended to prevent cardiovascular disease when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Also recommended in pregnant women who have preeclampsia (high blood pressure during pregnancy).

Coverage is restricted to  Men age 50 to 59 years  Women age 12 to 59 years

BOWEL PREPARATION Recommended as a part of preventive screening colonoscopy procedure for PRODUCTS adults ages 50 years and older.

Coverage is restricted to formulary generic bowel preparation products to adults ages 50 years and older.

BREAST CANCER Recommended as a primary prevention of breast cancer in women at increased PREVENTION DRUGS risk for breast cancer. Medications for prevention include tamoxifen, raloxifene, anastrozole, and letrozole.

Coverage is restricted to women at increased risk for breast cancer.

Coverage does not include uses to treat women diagnosed with breast cancer and/or osteoporosis.

CONTRACEPTION Recommended for women with reproductive capacity.

Coverage is provided for OTC methods, oral and injectable contraceptives, patches, intrauterine devices (IUDs), and emergency contraceptives.

Updated March 2021

Coverage may be restricted to formulary contraceptive only.

Coverage does not include abortifacient medications.

Coverage may not be available for group health plans sponsored by religious employers.

FLUORIDE Recommended for preschool children older than 6 months of age whose primary SUPPLEMENTATION water source is deficient in fluoride.

Coverage is restricted to formulary preparations for children up to 16 years of age.

FOLIC ACID Recommended for all women planning or capable of pregnancy to take a daily SUPPLEMENTATION supplement containing 0.4 to 0.8 mg of folic acid to lower the risks of birth defects.

Coverage is restricted to formulary prenatal vitamins with folic acid for women up to 59 years of age.

Coverage does not include prenatal vitamins that contain docosahexaenoic acid (DHA).

HIV PREVENTION DRUGS Recommended for persons who are at high risk of HIV acquisition.

Coverage is restricted to medications denoted as ACA Eligible on the formulary.

Coverage does not include treatment of HIV.

IRON SUPPLEMENTATION Recommended for asymptomatic children ages 6 to 12 months who are at increased risk for iron deficiency anemia.

Coverage is restricted to formulary supplements for children up to 12 months of age.

IMMUNIZATION Recommendations for routine vaccinations are provided by the Advisory VACCINES Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention.

Coverage may be restricted by age and/or gender limitations as recommended by ACIP.

STATINS Recommended that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate- dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater.

Updated March 2021

Coverage is restricted formulary generic statins denoted as ACA Eligible on the formulary.

Coverage is restricted to adults between the ages of 40 to 75 years old.

VITAMIN D Recommended for at risk adults ages 65 years and older.

Coverage is restricted to adults ages 65 years and older.

ADDITIONAL RESOURCES

Bright Futures https://brightfutures.aap.org/Pages/default.aspx

Centers for Disease Control and Prevention http://www.cdc.gov/vaccines/schedules/index.html

Health Resources & Services Administration (HRSA) https://www.hrsa.gov/womens-guidelines/index.html

HealthCare.gov https://www.healthcare.gov/coverage/preventive-care-benefits/

United States Preventive Services Task Force www.uspreventiveservicestaskforce.org

U.S. Department of Health & Human Services http://www.hhs.gov/healthcare/

Updated March 2021

Below is a list of medications that are considered ACA eligible. This list is not a comprehensive list and is subject to change as ACA guidelines are updated or modified, or upon formulary review by our Pharmacy & Therapeutics Committee. Brand name drugs will not be covered in full when the generic becomes available unless medical necessity of the brand name drug is established. Please refer to the formulary for the most complete and up-to-date covered medications available. *Please note: When a generic medication is available on the formulary, the brand form of the drug will only be covered in full when deemed medically necessary.

BRAND NAME GENERIC NAME GEN. THER. CLASS DESCRIPTION

ADULT ASPIRIN REGIMEN ASPIRIN ASPIRIN

ADULT LOW DOSE ASPIRIN EC ASPIRIN ASPIRIN

ASPIR 81 ASPIRIN ASPIRIN

ASPIRIN ASPIRIN ASPIRIN

ASPIRIN EC ASPIRIN ASPIRIN

ASPIR-LOW ASPIRIN ASPIRIN

CHILDREN'S ASPIRIN ASPIRIN ASPIRIN

ECOTRIN ASPIRIN ASPIRIN

LO-DOSE ASPIRIN EC ASPIRIN ASPIRIN

LOW DOSE ASPIRIN EC ASPIRIN ASPIRIN

ST. JOSEPH ASPIRIN ASPIRIN ASPIRIN

ST. JOSEPH ASPIRIN EC ASPIRIN ASPIRIN

GAVILYTE-C PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM CHLORIDE BOWEL PREPARATION PRODUCTS

GAVILYTE-G PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM CHLORIDE BOWEL PREPARATION PRODUCTS

GAVILYTE-N SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG BOWEL PREPARATION PRODUCTS

NULYTELY WITH FLAVOR PACKS SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG BOWEL PREPARATION PRODUCTS

PEG 3350-ELECTROLYTE PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM CHLORIDE BOWEL PREPARATION PRODUCTS

PEG-3350 AND ELECTROLYTES PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM CHLORIDE BOWEL PREPARATION PRODUCTS

TRILYTE WITH FLAVOR PACKETS SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG BOWEL PREPARATION PRODUCTS

ANASTROZOLE ANASTROZOLE BREAST CANCER PREVENTION DRUGS

LETROZOLE LETROZOLE BREAST CANCER PREVENTION DRUGS

RALOXIFENE HCL RALOXIFENE HCL BREAST CANCER PREVENTION DRUGS

TAMOXIFEN CITRATE TAMOXIFEN CITRATE BREAST CANCER PREVENTION DRUGS

AFIRMELLE LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

AFTERA LEVONORGESTREL CONTRACEPTIVES

ALTAVERA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

ALYACEN NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

Updated March 2021

AMETHIA LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

AMETHIA LO LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

AMETHYST LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

APRI DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

ARANELLE NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

ASHLYNA LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

AUBRA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

AUBRA EQ LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

AUROVELA NORETHINDRONE ACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

AUROVELA 24 FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

AUROVELA FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

AVIANE LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

AYUNA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

AZURETTE DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL CONTRACEPTIVES

BALZIVA NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

BEKYREE DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL CONTRACEPTIVES

BLISOVI 24 FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

BLISOVI FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

BRIELLYN NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

CAMILA NORETHINDRONE CONTRACEPTIVES

CAMRESE LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

CAMRESE LO LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

CAZIANT DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

CHATEAL LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

CHATEAL EQ LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

CRYSELLE NORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

CYCLAFEM NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

CYRED DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

CYRED EQ DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

DASETTA NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

DAYSEE LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

DEBLITANE NORETHINDRONE CONTRACEPTIVES

DELYLA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

DESOGESTREL-ETHINYL DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES ESTRADIOL

DESOGESTR-ETH ESTRAD ETH DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL CONTRACEPTIVES

Updated March 2021

ESTRA

DROSPIRENONE-ETH ESTRA- DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM CONTRACEPTIVES LEVOMEF

DROSPIRENONE-ETHINYL ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES ESTRADIOL

ECONTRA EZ LEVONORGESTREL CONTRACEPTIVES

ECONTRA ONE-STEP LEVONORGESTREL CONTRACEPTIVES

ELINEST NORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

ELLA ULIPRISTAL ACETATE CONTRACEPTIVES

EMOQUETTE DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

ENPRESSE LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

ENSKYCE DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

ERRIN NORETHINDRONE CONTRACEPTIVES

ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

ETHYNODIOL-ETHINYL ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES ESTRADIOL

FALMINA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

FAYOSIM LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

FEMYNOR NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

GIANVI ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

GILDESS NORETHINDRONE ACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

GILDESS 24 FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

HAILEY NORETHINDRONE ACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

HAILEY 24 FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

HEATHER NORETHINDRONE CONTRACEPTIVES

INCASSIA NORETHINDRONE CONTRACEPTIVES

INTROVALE LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

ISIBLOOM DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

JASMIEL ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

JENCYCLA NORETHINDRONE CONTRACEPTIVES

JOLESSA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

JOLIVETTE NORETHINDRONE CONTRACEPTIVES

JULEBER DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

JUNEL NORETHINDRONE ACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

JUNEL FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

JUNEL FE 24 NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

KAITLIB FE NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

Updated March 2021

KALLIGA DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

KARIVA DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL CONTRACEPTIVES

KELNOR 1-35 ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

KELNOR 1-50 ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

KURVELO LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

LARIN NORETHINDRONE ACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

LARIN 24 FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

LARIN FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

LARISSIA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

LEENA NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

LESSINA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

LEVONEST LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

LEVONORGESTREL LEVONORGESTREL CONTRACEPTIVES

LEVONORGESTREL-ETH LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES ESTRADIOL

LEVONORG-ETH ESTRAD ETH LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES ESTRAD

LEVORA-28 LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

LILLOW LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

LO LOESTRIN FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

LO MINASTRIN FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

LORYNA ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

LOW-OGESTREL NORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

LO-ZUMANDIMINE ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

LUTERA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

LYZA NORETHINDRONE CONTRACEPTIVES

MARLISSA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

MEDROXYPROGESTERONE MEDROXYPROGESTERONE ACETATE CONTRACEPTIVES ACETATE

MELODETTA 24 FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

MIBELAS 24 FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

MICROGESTIN NORETHINDRONE ACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

MICROGESTIN FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

MILI NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

MONO-LINYAH NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

MY CHOICE LEVONORGESTREL CONTRACEPTIVES

Updated March 2021

MY WAY LEVONORGESTREL CONTRACEPTIVES

MYZILRA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

NECON NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

NECON NORETHINDRONE-MESTRANOL CONTRACEPTIVES

NEW DAY LEVONORGESTREL CONTRACEPTIVES

NIKKI ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

NORA-BE NORETHINDRONE CONTRACEPTIVES

NORETHINDRONE NORETHINDRONE CONTRACEPTIVES

NORETHINDRON-ETHINYL NORETHINDRONE ACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES ESTRADIOL

NORETHIN-ETH ESTRA-FERROUS NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES FUM

NORETHIN-ETH ESTRA-FERROUS NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES FUM

NORGESTIMATE-ETHINYL NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES ESTRADIOL

NORLYDA NORETHINDRONE CONTRACEPTIVES

NORLYROC NORETHINDRONE CONTRACEPTIVES

NORTREL NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

NUVARING ETONOGESTREL/ETHINYL ESTRADIOL CONTRACEPTIVES

OCELLA ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

OGESTREL NORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

OPCICON ONE-STEP LEVONORGESTREL CONTRACEPTIVES

OPTION 2 LEVONORGESTREL CONTRACEPTIVES

ORSYTHIA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

PHILITH NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

PIMTREA DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL CONTRACEPTIVES

PIRMELLA NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

PORTIA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

PREVIFEM NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

QUASENSE LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

RECLIPSEN DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

RIVELSA LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

SETLAKIN LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

SHAROBEL NORETHINDRONE CONTRACEPTIVES

SIMLIYA DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL CONTRACEPTIVES

SIMPESSE LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL CONTRACEPTIVES

Updated March 2021

SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

SRONYX LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

SYEDA ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

TAKE ACTION LEVONORGESTREL CONTRACEPTIVES

TARINA 24 FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

TARINA FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

TARINA FE 1-20 EQ NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

TILIA FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

TRI FEMYNOR NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-LEGEST FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

TRI-LINYAH NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-LO-ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-LO-MARZIA NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-LO-MILI NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-LO-SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-MILI NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRINESSA NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRINESSA LO NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-PREVIFEM NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRIVORA-28 LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-VYLIBRA NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TRI-VYLIBRA LO NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

TULANA NORETHINDRONE CONTRACEPTIVES

TYDEMY DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM CONTRACEPTIVES

VELIVET DESOGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

VESTURA ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

VIENVA LEVONORGESTREL-ETHINYL ESTRADIOL CONTRACEPTIVES

VIORELE DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL CONTRACEPTIVES

VYFEMLA NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

VYLIBRA NORGESTIMATE-ETHINYL ESTRADIOL CONTRACEPTIVES

WERA NORETHINDRONE-ETHINYL ESTRADIOL CONTRACEPTIVES

WYMZYA FE NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE CONTRACEPTIVES

XULANE NORELGESTROMIN/ETHINYL ESTRADIOL CONTRACEPTIVES

Updated March 2021

ZARAH ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

ZOVIA 1-35E ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL CONTRACEPTIVES

ZUMANDIMINE ETHINYL ESTRADIOL/DROSPIRENONE CONTRACEPTIVES

TENOFOVIR DISOPROXIL TENOFOVIR DISOPROXIL FUMARATE HIV PREVENTION FUMARATE

TRUVADA EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE HIV PREVENTION

BUPROBAN BUPROPION HCL SMOKING DETERRENTS

BUPROPION HCL SR BUPROPION HCL SMOKING DETERRENTS

CHANTIX VARENICLINE TARTRATE SMOKING DETERRENTS

NICODERM CQ NICOTINE SMOKING DETERRENTS

NICORELIEF NICOTINE POLACRILEX SMOKING DETERRENTS

NICORETTE NICOTINE POLACRILEX SMOKING DETERRENTS

NICOTINE GUM NICOTINE POLACRILEX SMOKING DETERRENTS

NICOTINE LOZENGE NICOTINE POLACRILEX SMOKING DETERRENTS

NICOTINE PATCH NICOTINE SMOKING DETERRENTS

NICOTROL NICOTINE SMOKING DETERRENTS

NICOTROL NS NICOTINE SMOKING DETERRENTS

QUIT 2 NICOTINE POLACRILEX SMOKING DETERRENTS

QUIT 4 NICOTINE POLACRILEX SMOKING DETERRENTS

STOP SMOKING AID NICOTINE POLACRILEX SMOKING DETERRENTS

ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM STATINS

LOVASTATIN LOVASTATIN STATINS

PRAVASTATIN SODIUM PRAVASTATIN SODIUM STATINS

ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM STATINS

SIMVASTATIN SIMVASTATIN STATINS

ACTHIB HAEMOPHILUS B CONJUGATE VACCINE(TETANUS TOXOID VACCINE CONJUGATE)/PF

ADACEL TDAP DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS VACCINE/PF VACCINE

AFLURIA QUAD 2019-20 (3YR UP) INFLUENZA VIRUS VACCINE QUADRIVALENT 2019-20 (36 MOS UP)/PF VACCINE

AFLURIA QUAD 2019-20 (6- INFLUENZA VIRUS VACCINE QUADRIVAL 2019-20 (6 MOS-35 MOS)/PF VACCINE 35MO)

AFLURIA QUAD 2019-2020 INFLUENZA VIRUS VACCINE QUADRIVALENT 2019-20 (6 MOS AND UP) VACCINE

BEXSERO MENINGOCOCCAL GROUP B VACCINE, 4-COMPONENT VACCINE

BOOSTRIX TDAP DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS VACCINE VACCINE

DAPTACEL DTAP DIPHTHERIA, PERTUSSIS (ACELL), TETANUS PEDIATRIC VACCINE/PF VACCINE

DIPHTHERIA-TETANUS TOXOIDS- TETANUS,DIPHTHERIA TOXOID PED/PF VACCINE PED

Updated March 2021

ENGERIX-B ADULT HEPATITIS B VIRUS VACCINE RECOMBINANT/PF VACCINE

ENGERIX-B PEDIATRIC- HEPATITIS B VIRUS VACCINE RECOMBINANT/PF VACCINE ADOLESCENT

FLUAD 2019-2020 INFLUENZA VACCINE TVS 2019-20 (65 YR UP)/ADJUVANT MF59C.1/PF VACCINE

FLUCELVAX QUAD 2019-2020 FLU VACCINE QUAD 2019-2020(4 YEARS AND OLDER)CELL DERIVED/PF VACCINE

FLUCELVAX QUAD 2019-2020 FLU VACCINE QUADRIV 2019-2020(4 YEARS AND OLDER)CELL DERIVED VACCINE

GARDASIL 9 HUMAN PAPILLOMAVIRUS VACCINE, 9-VALENT/PF VACCINE

HAVRIX HEPATITIS A VIRUS VACCINE/PF VACCINE

HEPLISAV-B HEPATITIS B VACCINE RECOMBINANT/VACCINE ADJUVANT CPG 1018/PF VACCINE

HIBERIX HAEMOPHILUS B CONJUGATE VACCINE(TETANUS TOXOID VACCINE CONJUGATE)/PF

INFANRIX DTAP DIPHTHERIA, PERTUSSIS (ACELL), TETANUS PEDIATRIC VACCINE/PF VACCINE

IPOL POLIOMYELITIS VACCINE, KILLED VACCINE

KINRIX DIPHTHERIA, PERTUSSIS(ACELL),TETANUS,POLIO VACCINE/PF VACCINE

MENACTRA MENINGOCOCCALVACCINE A,C,Y,W-135,DIPHTHERIA TOXOID CONJ/PF VACCINE

MENOMUNE-A-C-Y-W-135 MENINGOCOCCAL VAC A,C,Y,W-135 VACCINE

MENVEO A-C-Y-W-135-DIP MENINGOCOCCALVACCINE A,C,Y,W-135,DIPHTHERIA TOXOID CONJ/PF VACCINE

M-M-R II VACCINE MEASLES, MUMPS, AND RUBELLA VACCINE LIVE/PF VACCINE

PEDIARIX HEP B VIRUS,RCMB/DIPTH,PERTUS(ACELL),TET,POLIO VACCINE/PF VACCINE

PEDVAXHIB HAEMOPHILUS B CONJUGATE VACCINE (MENINGOCOCCAL VACCINE PROT.CONJ)/PF

PENTACEL DIPHTHERIA,PERTUSSIS(ACELL),TETANUS,POLIO/HAEMOPHILUS B/PF VACCINE

PENTACEL ACTHIB COMPONENT HAEMOPHILUS B POLYSACC CONJ-TETANUS TOX,COMPONENT 2 OF 2/PF VACCINE

PENTACEL DTAP-IPV DIPHTHER,PERTUS(ACEL),TETANUS,POLIO VACC,COMPONENT 1 OF 2/PF VACCINE COMPONENT

PNEUMOVAX 23 PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE VACCINE VACCINE

PREVNAR 13 PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE (DIPHTHERIA CRM)/PF VACCINE

PROQUAD MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE LIVE/PF VACCINE

QUADRACEL DTAP-IPV DIPHTHERIA, PERTUSSIS(ACELL),TETANUS,POLIO VACCINE/PF VACCINE

RECOMBIVAX HB HEPATITIS B VIRUS VACCINE RECOMBINANT/PF VACCINE

ROTARIX ROTAVIRUS VACCINE, LIVE ORAL ATTENUATED,89-12 STRAIN, G1P(8) VACCINE

ROTATEQ ROTAVIRUS VACCINE, LIVE ORAL PENTAVALENT VACCINE

SHINGRIX VARICELLA-ZOSTER VIRUS GLYCOPROTEIN E,REC/AS01B ADJUVANT/PF VACCINE

TDVAX TETANUS AND DIPHTHERIA TOXOIDS, ADULT VACCINE

TENIVAC TETANUS AND DIPHTHERIA TOXOIDS, ADSORBED, ADULT/PF VACCINE

TRUMENBA NEISSERIA MENINGITIDIS GROUP B, LIPIDATED FHBP RECOMBINANT VACCINE

TWINRIX HEPATITIS A VIRUS AND HEPATITIS B VIRUS VACCINE/PF VACCINE

Updated March 2021

VAQTA HEPATITIS A VIRUS VACCINE/PF VACCINE

VARIVAX VACCINE VARICELLA VIRUS VACCINE LIVE/PF VACCINE

ZOSTAVAX ZOSTER VACCINE LIVE/PF VACCINE

BABY DDROPS CHOLECALCIFEROL (VITAMIN D3) VITAMINS

BABY VITAMIN D3 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

CHILDREN'S FERROUS SULFATE FERROUS SULFATE VITAMINS

CHILDREN'S IRON FERROUS SULFATE VITAMINS

CHILDREN'S VITAMIN D3 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

CLASSIC PRENATAL PRENATAL VIT WITH CALCIUM NO.126/FERROUS FUMARATE/FOLIC ACID VITAMINS

D3 DOTS CHOLECALCIFEROL (VITAMIN D3) VITAMINS

D3-2000 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

D3-50 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

DECARA CHOLECALCIFEROL (VITAMIN D3) VITAMINS

DELTA D3 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

DIALYVITE VITAMIN D CHOLECALCIFEROL (VITAMIN D3) VITAMINS

DIALYVITE VITAMIN D3 MAX CHOLECALCIFEROL (VITAMIN D3) VITAMINS

D-VI-SOL CHOLECALCIFEROL (VITAMIN D3) VITAMINS

FERROUS SULFATE FERROUS SULFATE VITAMINS

FLUORABON FLUORIDE (SODIUM) VITAMINS

FLUORIDE FLUORIDE (SODIUM) VITAMINS

FLUORITAB FLUORIDE (SODIUM) VITAMINS

FLURA-DROPS FLUORIDE (SODIUM) VITAMINS

FOLIC ACID FOLIC ACID VITAMINS

JUST D CHOLECALCIFEROL (VITAMIN D3) VITAMINS

KIDS VITAMIN D3 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

KPN PRENATAL VITS WITH CALCIUM NO.98/FERROUS FUMARATE/FOLIC ACID VITAMINS

KPN PRENATAL VITAMIN CALCIUM,IRON,FOLIC ACID (LESS THAN 1 MG) VITAMINS

LUDENT FLUORIDE FLUORIDE (SODIUM) VITAMINS

M-NATAL PLUS PRENATAL VITS WITH CALCIUM NO.72/FERROUS FUMARATE/FOLIC ACID VITAMINS

NIVA-PLUS MULTIVITAMIN-MINERALS NO.60/FERROUS FUMARATE/FOLIC ACID VITAMINS

OPTIMAL D3 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

PEDIA D-VITE CHOLECALCIFEROL (VITAMIN D3) VITAMINS

PEDIA IRON FERROUS SULFATE VITAMINS

PERRY PRENATAL PRENATAL VITS WITH CALCIUM 36/FERROUS FUMARATE/FOLIC ACID VITAMINS

PNV-VP-U PRENATAL VITAMINS NO.5/FERROUS FUMARATE/FOLIC ACID VITAMINS

Updated March 2021

PRENATAL PRENATAL VITS WITH CALCIUM 95/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL PRENATAL VITS WITH CALCIUM NO.96/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL PRENATAL VIT WITH CALCIUM NO.130/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL 19 PRENATAL VITS WITH CALCIUM NO.115/IRON FUMARATE/FOLIC ACID VITAMINS

PRENATAL 19 PRENATAL VITS NO.115/IRON FUMARATE/FOLIC ACID/DOCUSATE SOD. VITAMINS

PRENATAL COMPLETE PRENATAL VITS WITH CALCIUM NO.21/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL FORMULA PRENATAL VITS WITH CALCIUM 95/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL LOW IRON PRENATAL VITS WITH CALCIUM NO.74/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL MULTI PRENATAL VIT WITH CALCIUM NO.122/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL MULTIVITAMIN PRENATAL VITAMINS NO.121/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL MULTIVITAMIN PRENATAL VITS WITH CALCIUM 95/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL ONE DAILY PRENATAL VIT WITH CALCIUM NO.129/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL PLUS PRENATAL VITS WITH CALCIUM NO.72/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL PLUS PRENATAL VITS WITH CALCIUM NO.72/IRON,CARBONYL/FOLIC ACID VITAMINS

PRENATAL VITAMIN PRENATAL VITS WITH CALCIUM 137/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL VITAMIN PRENATAL VITS WITH CALCIUM NO.124/FERROUS FUMARAT/FOLIC ACID VITAMINS

PRENATAL VITAMIN PLUS LOW PRENATAL VITS WITH CALCIUM NO.72/FERROUS FUMARATE/FOLIC ACID VITAMINS IRON

PRENATAL VITAMINS PRENATAL VITAMIN CALCIUM,IRON,FOLIC ACID (LESS THAN 1 MG) VITAMINS

PRENATAL VITAMINS PRENATAL VITS WITH CALCIUM 95/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL VITAMINS PRENATAL VIT WITH CALCIUM NO.130/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL VITAMINS PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID VITAMINS

PRENATAL-U PRENATAL VITAMINS NO.5/FERROUS FUMARATE/FOLIC ACID VITAMINS

PREPLUS PRENATAL VITS WITH CALCIUM NO.72/FERROUS FUMARATE/FOLIC ACID VITAMINS

RIGHT STEP PRENATAL VITAMINS PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID VITAMINS

SODIUM FLUORIDE FLUORIDE (SODIUM) VITAMINS

THERA-D CHOLECALCIFEROL (VITAMIN D3) VITAMINS

VINATE-M PRENATAL VITS WITH CALCIUM 136/FERROUS FUMARATE/FOLIC ACID VITAMINS

VITAJOY DAILY D CHOLECALCIFEROL (VITAMIN D3) VITAMINS

VITAMIN D2 ERGOCALCIFEROL (VITAMIN D2) VITAMINS

VITAMIN D3 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

VITAMIN D-400 CHOLECALCIFEROL (VITAMIN D3) VITAMINS

VOL-NATE MULTIVITAMIN WITH MINERALS NO.64/FERROUS FUMARATE/FOLIC ACID VITAMINS

WEE CARE IRON,CARBONYL VITAMINS

Updated March 2021

Ready to start preventive care? Register for and log into your myProvidence account to: + Review your prescription drug formulary + Review your medical plan benefit summaries and handbooks + Have more questions about where to start? Call Providence Health Plan customer service at: 503-574-7400 or 877-216-3644 (TTY: 711)

Updated March 2021