1/21/16
Guidance to help you understand when your member cost share will be waived for preventive
medications and devices.
The Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered group and individual health plans to waive cost
share for in-network preventive services, including certain preventive medications and devices. This requirement does not apply to
grandfathered plans. If you do not know whether your plan is subject to this requirement, please contact BCBSAZ.
There are two important things to remember about this mandate. First, the cost share waiver does not apply if you use an out of
network or non-contracted pharmacy provider, so make sure to check your pharmacy provider’s network status. Second, there are
some medications and devices that can be used for both preventive care and to treat a medical condition. Cost share is waived only
when the medication or device is prescribed for preventive care.
The United States Preventive Services Task Force has identified the medications listed below as the recommended preventive
medications. The medication must be prescribed for a preventive care purpose.
The medications followed by “PL” have Prescription Limitations or Precertification requirements. To learn more about Prescription
Limitations and Precertification, please click here.
ASPIRIN
Aspirin (PL)
chew tablet: 75mg, 81mg
tablet: 81mg, 162mg, 325mg
COLONOSCOPY PREP KITS
Generic Bowel Evacuation combinations
Ella (PL)
tablet: 30mg
CONTRACEPTIVES, NON-ORAL
Nuvaring (PL)
ring: 0.120-0.015 mg/24hr
Xulane (PL)
(generic for Ortho Evra)
patch: 6/0.75/wk
CONTRACEPTIVES*
DIAPHRAGMS
CERVICAL CAPS (PL)
FEMALE CONDOMS (PL)
CONTRACEPTIVES, INJECTABLE
Medroxyprogesterone Acetate (PL)
(generic for Depo Provera)
injection: 150mg/ml
Depo Provera
injection: 104mg/ml
CONTRACEPTIVES, EMERGENCY
Levonorgestrol , Next Choice (PL)
(generic for Plan B)
tablet: 0.75mg,
Levonorgestrol ,Next Choice, My Way,
Take Action, Opcicon (PL)
(generic for Plan B One Step)
tablet: 1.5mg
Plan B , Plan B One Step (PL)
tablet: 0.75mg, 1.5mg
ORAL CONTRACEPTIVE, MONOPHASIC
Amethia, Ashlyna, Camrese, Daysee (91day),
(generic for Seasonique) (PL)
tablet 0.15-0.03mg- 0.01mg
Amethia Lo, Comrese Lo,
Levonorgestrel/Ethinyl (91-day),
(generic for LoSeasonique) (PL)
tablet 0.1-0.02mg- 0.01mg
Apri, Emoquette, Enskyce, Reclipsen,
Solia, Desogestrel/ethinyl estradiol, Juleber
(generic for Desogen, Ortho-Cept) (PL)
tablet 0.15mg/30mcg
Jolessa, Quasense, Introvale, Setlakin
Levonorgestrel/Ethinyl estradiol (91-day)
(generic for Seasonale) (PL)
tablet: 0.15-0.03mg
Aviane, Aubra, Lessina, Lutera, Orsythia,
Sronyx, Falmina, Levonorgestrel/Ethinyl
estradiol. Delyla, Vienva
(generic for Alesse, Levlite) (PL)
tablet: 0.1mg/20mcg
Altavera, Levora, Marlissa, Portia, Kurvelo ,
Levonorgestrel-Ethinyl Estradiol, Chateal
(generic for Nordette) (PL)
tablet: 0.15mg/30mcg
Alaycen, Necon, Nortrel, Cyclafem,
Dasetta, Wera, Pirmella
(generic for Brevicon, Modicon, Norinyl,
Ortho Novum) (PL)
tablet: 0.5/35, 1/35
Microgestin, Junel , Gildess , Larin,
Noreth/Ethin, Tarina Fe, Noreth/Ethin FE,
Blisovi
(generic for Loestrin) (PL)
tablet: 1mg/20mcg, 1.5mg/30mcg
Ocella, Syeda, Zarah, DrospirenoneEthinyl Estradiol
(generic for Yasmin) (PL)
tablet: 3-0.03mg
Sprintec, Mononessa, Mono-Linyah,
Norgestimate/Ethinyl, Previfem, Estarylla
(generic for Ortho-Cyclen) (PL)
tablet: 0.25-35mcg
Zovia, Kelnor
(generic for Demulen) (PL)
tablet: 1mg-35 mcg
Page 1 * For plans that have a waiver of cost share for preventive care, PPACA’s requirement to waive cost share for contraceptive
medications and devices will apply on plan or policy years on and after August 1, 2012. If you have a question about if or when this
change is effective for your plan, please contact BCBSAZ.
1/21/16
Guidance to help you understand when your member cost share will be waived for preventive
medications and devices.
Zenchent, Balziva, Briellyn , Philith,
Gildagia, Vyfemla
((generic for Ovcon 35) (PL)
tablet: 0.4mg-35mcg
Zeosa , Zenchent FE, Wymzya FE
(generic for Femcon Fe) (PL)
tablet: 0.4 mg-35 mcg
norgestrel & ethinyl estradiol, Low-Ogestrel,
Elinest, Cryselle (PL)
Microgestin FE, Junel FE, Gildess FE, Larin
FE, Noreth/Ethin, Noreth/Ethin FE, Blisovi
FE
(generic for Loestrin FE) (PL)
tablet: 1.5mg/30mcg
(generic for Lo/Ovral-28) (PL)
tablet: 0.3mg-30mcg
Norethindrone/Ethinyl estradiol FE, Layolis
FE Kaitlib FE (PL)
(generic for Generess FE)
tablet: 0.8 mg/25 mcg CHW
Generess FE (PL)
tablet: 0.8 mg/25 mcg CHW
Necon (PL)
tablet: 1 mg/50 mcg
Norinyl (PL)
tablet: 1 mg/50 mcg
Ogestrel (PL)
tablet: 0.5 mg/50 mcg
Ortho Cyclen (PL)
tablet: 0.25 mg/35 mcg
Ovcon (PL)
tablet: 1 mg/50 mcg
Quartette 91-day (PL)
tablet: 0.15-0.02/0.025/0.03 mg &eth est
0.01mg
Zovia (PL)
tablet: 1mg-50mcg
Yaz (PL)
tablet: 3-0.02 mg
ORAL CONTRACEPTIVE, BIPHASIC
Amethyst, Levonogestrel-Ethinyl (PL)
(generic for Lybrel)
tablet: 90-20mcg)
Necon (PL)
tablet: 10/11
ORAL CONTRACEPTIVE,
TRIPHASIC
Velivet, Cesia, Caziant (PL)
(generic for Cyclessa)
tablet: 0.1-0.025/0.125-0.025/0.15.025mg
Alaycen, Necon, Nortrel, Cyclafem,
Dasetta, Pirmella (PL)
(generic for Ortho-Novum 7/7/7)
tablet: 0.5-35/0.75-35/1-35
Trivora, Enpresse, Myzilra,
Levonorgestrel/Ethinyl Estradiol (PL)
(generic for Triphasil, Tri-Levlen)
tablet:0.05-30/0.075-40/0.125-30
Aranelle, Leena (PL)
(generic for Tri-Norinyl)
tablet: 0.5-35/1-35/0.5-35mg
Tilia FE, Tri-Legest FE (PL)
(generic for Estrostep FE)
tablet: 1-20/1-30/1-35mg-mcg
Norgest/Ethinyl estradiol, Tri-sprintec,
Trinessa, Tri-Previfem , Tri-Linyah, TriEstarylla (PL)
(generic for Ortho Tri-Cyclen)
Norgest/Ethinyl estradiol, Trinessa Lo, TriLo-Estarylla, Tri-Lo-Sprintec, Tri-Lo Marzia
(generic for Ortho Tri-Cyclen Lo) (PL)
tablet: 0.18-25/0.215-25/0.25-25 mg-mcg
ORAL CONTRACEPTIVE, FOUR-PHASIC
Natazia (PL)
tablet: 3 mg /2-2 mg/2-3 mg/1 mg
ORAL CONTRACEPTIVE, PROGESTINS
Camila, Errin, Heather, Jencycla, Jolivette,
Lyza, Nora BE, Norethindrone , Norlyroc,
Sharobel, Deblitane (PL)
(generic for Ortho-Micronor, Nor-Q-D)
tablet: 0.35mg
ORAL CONTRACEPTIVE, OTHER
Kariva, Azurette , Viorele, Pimtrea,
Deso/Ethinyl, Kimidess, Bekyree (PL)
(generic for Mircette)
tablet: 0.15-0.02-0.02/0.01mg
SPERMACIDES (PL)
(e.g., vaginal gel/foam/film/suppositories)
SPONGES (PL)
FLUORIDE
Sodium fluoride (PL)
chew tablet: 0.2mg, 0.5mg, 1mg
cream: 1%
drops: 0.125mg, 0.25mg, 0.5mg
gel: 1.1%
lozenge: 1mg
paste: 1.1%
rinse 0.05%
solution: 0.05%, 0.2%, .5%, 1mg
tablet: 0.5mg, 1mg
FOLIC ACID
Folic Acid (PL)
tablet: 1mg
HORMONAL ONCOLOGICS
Tamoxifen
tablet: 10mg, 20mg
Raloxifene (PL)
tablet: 60mg
IRON
Ferrous sulfate (PL)
drops: 75mg/ml, 75mg/0.6ml
oral liquid: 5mg/20ml
SMOKING CESSATION
Bupropion HCL Smoking Deterrent (PL)
tablet: 150mg
Chantix (PL)
tablet: 0.5mg, 1mg
Commit (PL)
lozenge: 2mg, 4mg
Nicoderm CQ(PL)
patch: 7mg, 14mg, 21mg
Nicorette(PL)
gum: 2mg, 4mg
Nicotine (multiple generic names) (PL)
gum: 2mg, 4mg
lozenge: 2mg, 4mg
patch: 7mg, 14mg, 24mg
Nicotine System Kit (PL)
patch: 7mg/14mg/21mg
Nicotrol inhaler (PL)
inhaler: 10mg
Nicotrol NS (PL)
nasal Spray: 10mg/ml
Zyban (PL)
tablet: 150mg
Page 2 * For plans that have a waiver of cost share for preventive care, PPACA’s requirement to waive cost share for contraceptive
medications and devices will apply on plan or policy years on and after August 1, 2012. If you have a question about if or when this
change is effective for your plan, please contact BCBSAZ.
1/21/16
Guidance to help you understand when your member cost share will be waived for preventive
medications and devices.
VITAMIN D (PL)
Page 3 * For plans that have a waiver of cost share for preventive care, PPACA’s requirement to waive cost share for contraceptive
medications and devices will apply on plan or policy years on and after August 1, 2012. If you have a question about if or when this
change is effective for your plan, please contact BCBSAZ.