8/1/20

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

CONTRACEPTIVES* CERVICAL CAPS (PL)

CONTRACEPTIVES, INJECTABLE Medroxyprogesterone Acetate (PL) (generic for Depo Provera) injection: 150mg/ml CONTRACEPTIVES, EMERGENCY Aftera, Econtra EZ, Econtra OS, Levonorgestrol, My Choice, My Way, New Day, Next Choice, Opcicon, Option 2, Preventeza, React, Take Action (PL) (generic for Plan B One Step) tablet: 1.5mg CONTRACEPTIVES, NON-ORAL Eluryng (generic for Nuvaring) (PL) ring: 0.120-0.015 mg/24hr Nuvaring (PL) ring: 0.120-0.015 mg/24hr Xulane (PL) transdermal patch: 150-35mcg/24hr DIAPHRAGMS FEMALE CONDOMS (PL)

ORAL CONTRACEPTIVE, MONOPHASIC Afirmelle, Aubra, Aubra EQ, Aviane, Delyla, Falmina, Larissia, Lessina, Levonorgestrel/Ethinyl Estradiol, Lutera, Orsythia, Sronyx, Vienva (generic for Alesse, Levlite) (PL) tablet: 0.1mg/20mcg Necon, Nortrel, Wera (generic for Brevicon) (PL) tablet: 0.5mg/35mcg Ethynodiol Diacetate/Ethinyl Estradiol 1-35, Kelnor 1/35, Zovia 1/35 (generic for Demulen 1/35) (PL) tablet: 1mg-35 mcg Ethynodiol Diacetate/Ethinyl Estradiol 1-50, Kelnor 1/50, Zovia 1/50E (generic for Demulen 1/50) (PL) tablet: 1mg-50 mcg Apri, Cyred, Cyred EQ, Desogestrel/Ethinyl Estradiol, Emoquette, Enskyce, Isibloom, Juleber, Kalliga, Reclipsen, Solia (generic for Desogen-28) (PL) tablet: 0.15mg/30mcg Norethindrone/Ethinyl Estradiol FE, Wymzya FE (generic for Femcon FE) (PL) chewable tablet: 0.4mg-35mcg Aurovela 21 1.5/30, Hailey 21 1.5/30, Junel 21 1.5/30, Larin 21 1.5/30, Microgestin 21 1.5/30, Norethindrone Acetate/Ethinyl Estradiol 21 1.5/30 (generic for Loestrin 21 1.5/30) (PL) tablet: 21 1.5mg/30mcg Aurovela 21 1/20, Junel 21 1/20, Larin 21 1/20, Microgestin 21 1/20, Norethindrone

Acetate/Ethinyl Estradiol 21 1/20 (generic for Loestrin 21 1/20) (PL) tablet: 21 1mg/20mcg Aurovela FE 1.5/30, Blisovi FE 1.5/30, Gildess FE 1.5/30, Hailey FE 1.5/30, Junel FE 1.5/30, Larin FE 1.5/30, Microgestin FE 1.5/30 (generic for Loestrin FE 1.5/30) (PL) tablet: 1.5mg/30mcg Aurovela FE 1/20, Blisovi FE 1/20, Gildess , Hailey FE 1.20, FE 1/20, Junel FE 1/20, Larin FE 1/20, Microgestin FE 1/20, Norethindrone Acetate/Ethinyl Estradiol FE 1/20 (generic for Loestrin FE 1/20) (PL) tablet: 1mg/20mcg Cryselle-28, Elinest, Low-Ogestrel, (generic for Lo/Ovral-28) (PL) tablet: 0.3mg-30mcg Amethia Lo, Comrese Lo, Levonorgestrel/Ethinyl Estradiol (generic for LoSeasonique) (PL) tablet: 0.1-0.02mg (84) & 0.01mg (7) Lojaimiess (generic for LoSeasonique) (PL) tablet: 0.1-0.02mg (84) & 0.01mg (7) Jaimess (generic for Seasonique) (PL) tablet:0.15-0.03mg (84) & 0.01mg (7) Altavera, Ayuna, Chateal, Chateal EQ, Kurvelo, Levonorgestrel-Ethinyl Estradiol, Levora-28, Lillow, Marlissa, Portia-28 (generic for Nordette) (PL) tablet: 0.15mg/30mcg Alyacen, Cyclafem, Dasetta, Necon, Nortrel, Pirmella (generic for Ortho Novum) (PL) tablet: 1mg/35mcg

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* 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.

8/1/20

Guidance to help you understand when your member cost share will be waived for preventive

medications and devices.

Balziva, Briellyn, Gildagia, Philith, Vyfemla Zenchent (generic for Ovcon 35) (PL) tablet: 0.4mg-35mcg Estarylla, Mono-Linyah, Mononessa, Norgestimate/Ethinyl Estradiol, Previfem, Sprintec-28, Vylibra, Mili (generic for Ortho-Cyclen) (PL) tablet: 0.25-35mcg Introvale, Jolessa, Levonorgestrel/Ethinyl Estradiol, Quasense, Setlakin (generic for Seasonale) (PL) tablet: 0.15-0.03mg Amethia, Ashlyna, Camrese, Daysee, Levonorgestrel/Ethinyl Estradiol, Simpesse (generic for Seasonique) (PL) tablet: 0.15-0.03mg- 0.01mg Drospirenone-Ethinyl Estradiol, Ocella, Syeda, Zarah, Zumandimine (PL) (generic for Yasmin 28) tablet 3-0.03mg ORAL CONTRACEPTIVE, BIPHASIC Amethyst, Levonogestrel-Ethinyl Estradiol (PL) (generic for Lybrel) tablet: 90-20mcg ORAL CONTRACEPTIVE, TRIPHASIC Caziant Pak, Cesia Pak, Velivet Pak (PL) (generic for Cyclessa Pak) tablet: 0.1-0.025/0.125-0.025/

0.15-0.025mg Tilia FE, Tri-Legest FE (PL) (generic for Estrostep FE) tablet: 1-20/1-30/1-35mg-mcg Norgestimate/Ethinyl Estradiol, Tri Femynor, Tri-Estarylla, Tri-Linyah, Tri-Mili, Trinessa, Tri-Previfem, Tri-Sprintec, Tri-Vylibra (PL) (generic for Ortho Tri-Cyclen) tablet: 0.18-35/0.215-35/0.25-35 mg-mcg Norgestimate/Ethinyl Estradiol, Tri-Lo Estarylla, Tri-Lo Marzia, Tri-Lo-Mili, Tri-Lo Sprintec, Tri-Vylibra Lo, Trinessa Lo (generic for Ortho Tri-Cyclen Lo) (PL) tablet: 0.18-25/0.215-25/0.25-25mg-mcg

Alyacen 7/7/7, Cyclafem 7/7/7, Dasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Pirmella 7/7/7 (PL) (generic for Ortho-Novum 7/7/7) tablet: 0.5-35/0.75-35/1-35mg-mcg Aranelle, Leena (PL) (generic for Tri-Norinyl 28) tablet: 0.5-35/1-35/0.5-35mg-mcg Enpresse 28, Levonorgestrel/Ethinyl Estradiol, Myzilra, Trivora 28 (PL) (generic for Triphasil 28) tablet: 0.05-30/0.075-40/0.125-30mg-mcg ORAL CONTRACEPTIVE, PROGESTINS Camila, Deblitane, Errin, Heather, Incassia, Jencycla, Jolivette, Lyza, Nora-BE, Norethindrone, Norlyda, Norlyroc, Sharobel, Tulana (PL) (generic for Ortho Micronor) tablet: 0.35mg Slynd (PL) tablet: 4mg ORAL CONTRACEPTIVE, OTHER Azurette, Bekyree, Desogestrel/Ethinyl Estradiol, Kariva, Kimidess, Pimtrea, Simliya, Viorele, Volnea (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: 0.25mg, 0.5mg,1mg cream: 1% drops: 0.125mg, 0.25mg, 0.5mg gel: 1.1% paste: 1.1% rinse 0.05% solution: 0.05%, 0.2%, 0.5%, 1mg tablet: 0.5mg, 1mg

FOLIC ACID Folic Acid (PL) tablet: 1mg HORMONAL ONCOLOGICS Anastrozole (PL) tablet: 1mg Exemestane (PL) tablet:25mg Letrozole (PL) tablet:2.5mg Tamoxifen (PL) tablet: 10mg, 20mg Raloxifene (PL) tablet: 60mg ANTI-VIRALS, HIV Truvada (PL)

tablet: 200-300mg, 100-150mg, 133-200mg, 167-250mg

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 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 VITAMIN D (PL)

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.

Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call 602-864-4884 for Spanish and 877-475-4799 for all other languages and other aids and services.

If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ’s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, 602-864-2288, TTY/TDD 602-864-4823, crc@azblue.com. You can file a grievance in person or by mail or email. If you need help filing a grievance BCBSAZ’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800- 368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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