junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 junel fe 24 1/20 kaitlib fe kalliga kariva 28 kelnor 1/35 kelnor 1/50 kimidess kurvelo 0.15/30 larin 1.5/30 larin 1/20 larin 24 fe 1/20 larin fe 1.5/30 larin fe 1/20 larissia layolis fe leena lessina levo-eth est 90-20mcg levonest levonor/ethi levonor/ethi 0.1-0.02 levonor/ethi estradio levora-28 0.15/30 lillow 0.15/30 lojaimiess loryna 3-0.02mg low-ogestrel lo-zumandimi 3-0.02mg lutera lyza 0.35mg marlissa 0.15/30 melodetta 24 fe mibelas 24 fe microgestin 1.5/30 microgestin 1/20 microgestin fe 1/20 microgestin fe1.5/30 mili 0.25/35 mircette 28 day mono-linyah 0.25-35 mononessa myzilra necon 0.5/35 necon 7/7/7 nikki 3-0.02mg nor/est/ff 1.5/30 nora-be 0.35mg nore/eth/fer 0.4mg-35 noreth/ethin fe noreth/ethin fe 1/20 noreth/ethin 1.5/30 noreth/ethin 1/20 noreth/ethin fe 1/20 norethindron 0.35mg norgest/ethi 0.25/35 norgest/ethi/estradio norlyroc 0.35mg nortrel 0.5/35 nortrel 1/35 nortrel 7/7/7 ocella 3-0.03mg ogestrel orsythia philith 0.4-35 pimtrea pirmella 1/35 pirmella 7/7/7 portia-28 previfem quasense rajani reclipsen rivelsa setlakin sharobel 0.35mg simliya 28 simpesse sprintec 28 sronyx syeda 3-0.03mg tarina 24 fe tarina fe 1/20 tarina fe 1/20 eq tilia fe tri femynor tri-estaryll tri-legest fe tri-linyah tri-lo estaryll tri-lo marzia tri-lo- sprintec tri-lo-mili tri-mili trinessa trinessa lo tri-previfem tri-sprintec trivora-28 tri-vylibra tri-vylibra lo tulana 0.35mg tydemy velivet vestura 3-0.02mg vienva 0.1-20 viorele volnea vyfemla 0.4-35 vylibra 0.25-35 wera 0.5/35 wymzya fe chw 0.4mg- 35 zarah 3-0.03mg zenchent zovia 1/35e zumandimine 3-0.03mg Cervical Caps (Rx) Femcap mis 22-30mm Diaphragms Caya dpr Omniflex Wide-seal dpr kit 60-95 Emergency Contraception (Rx or OTC) aftera tab 1.5mg econtra ez tab 1.5mg Ella tab 30mg levonorgestr tab 1.5mg my choice tab 1.5mg my way tab 1.5mg new day tab 1.5mg next choice tab 1.5mg opcicon 1.5mg preventeza tab 1.5mg react tab 1.5mg take action tab 1.5mg Female Condoms (OTC) Fc2 female mis condom Injectables (Rx) depo-sq prov inj medroxypr ac inj 150mg/ml Intrauterine Devices and Vaginal Rings eluryng mis etonogestere mis ethy est Spermicides (OTC) conceptrol gel 4% encare sup 100mg gynol ii gel 3% Shur-Seal gel 2% VCF vaginal aer gel,mis contracp Transdermal xulane dis 150-35 Vaginal Sponge Today sponge mis FLUORIDE (GENERIC ONLY) Coverage for children age 6 months to 16 years. sodium fluoride chew 0.25mg, 0.5mg, 1mg, 2.2mg sodium fluoride tab 0.5mg, 1mg sodium fluoride soln 0.25mg 0.5mg 0.125mg pediatric multivitamin/ fluoride chew, tab, soln 0.25mg, 0.5mg, 1mg,0.125mg, 1.1mg, 2.2mg FOLIC ACID Coverage for generic only, prescription and over-the-counter included for women ages 55 or younger who are planning and able to get pregnant. folic acid tab,cap 400mcg, 800mcg Prenatal and multivitamins w/ folic acid (generic OTC only) HIV PRE-EXPOSURE PROPHYLAXIS Effective 7/1/2020 for group benefits and 1/1/ 2021 for individual benefits. emtricitabine 200mg tenofovir 300mg emtricitabine-tenofovir 200-300mg SMOKING CESSATION Coverage includes prescription and over- the-counter, brand and generic for members greater than 18 years old. OTC (Brand and Generic) Nicotine Replacement Gum, Lozenge and Patch (Prescription) Nicotrol Inhaler Nicotrol Nasal Spray varenicline VACCINES BCG Diphtheria, Tetanus, Pertussis Haemophilus B Polysac Conj Hepatitis A Hepatitis B Human Papillomavirus (HPV) Influenza Virus Measles, Mumps & Rubella Virus Meningococcal Pneumococcal Poliovirus, IPV Rotavirus , Oral Varicella Virus Zoster (shingles) This list may change without notice which may affect your benefit coverage. To be sure your medication is covered under the PreventiveRx benefit, call the member services number located on your ID card. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE ® Managed Care, Inc. (RIT), Healthy Alliance ® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 61088MUMENABS Rev. 1/1/2022 ACA Preventive Care Drug List