Preventive Care Coverage at No Cost to You
Eective Jan. 1, 2022
Your health plan may provide certain contraceptive coverage as a benet 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.
Some examples of contraceptive drugs and products that may be covered under your plan are
on this list. They will be reviewed from time-to-time and are subject to change. 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 nd 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 benet 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 benet
• Medical devices such as diaphragms, cervical caps
and contraceptive implants may be covered under the
pharmacy or medical benet
• Female sterilization, including tubal ligation and tubal implant
• Male sterilization
Preventive Care
Services:
Contraception
bcbsil.com
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS † = Covered under medical benet
CERVICAL CAPS
FEMCAP - cervical cap 22 mm,
26 mm, 30 mm
DIAPHRAGMS
CAYA – diaphragm arc-spring
OMNIFLEX DIAPHRAGM – diaphragms
WIDE-SEAL SILICONE DIAPHRAGM
KIT – diaphragm wide seal 60 mm,
65 mm, 70 mm, 75 mm, 80 mm,
85 mm, 90 mm, 95 mm
EMERGENCY CONTRACEPTIVES
Aftera
Econtra Ez
Econtra One-Step
ELLA – ulipristal acetate tab 30 mg
levonorgestrel tab 1.5 mg
(Plan B One-Step)
My Choice
My Way
New Day
Opcicon One-Step
Option 2
Preventeza
React
Take Action
FEMALE CONDOMS
FC FEMALE CONDOM – condoms - female
FC2 FEMALE CONDOM – condoms -
female
IMPLANTABLES
NEXPLANON – etonogestrel subdermal
implant 68 mg
†
INJECTIONS
DEPO-SUBQ PROVERA 104 –
medroxyprogesterone acetate susp
pref syr 104 mg/0.65 mL
†
medroxyprogesterone acetate IM
suspension 150 mg/mL
(Depo-Provera Contraceptive)
medroxyprogesterone acetate IM
suspension prelled syringe 150 mg/
mL (Depo-Provera Contraceptive)
INTRAUTERINES
KYLEENA – levonorgestrel releasing IUD
17.5 mcg/day (19.5 mg total)†
LILETTA – levonorgestrel releasing IUD
19.5 mcg/day (52 mg total)†
MIRENA – levonorgestrel releasing IUD
20 mcg/day (52 mg total)†
PARAGARD INTRAUTERINE COPPER –
copper IUD†
SKYLA – levonorgestrel releasing IUD
14 mcg/day (13.5 mg total)†
ORAL CONTRACEPTIVES
ORAL COMBINED
Armelle
Altavera
Alyacen 1/35, 7/7/7
Apri
Aranelle
Aubra
Aubra EQ
Aurovela 1/20, 1.5/30
Aurovela Fe 1/20, 1.5/30
Aurovela 24 Fe
Aviane
Ayuna
Azurette
Balziva
Bekyree
Blisovi Fe 1/20, 1.5/30
Blisovi 24 Fe
Briellyn
Caziant
Charlotte 24 Fe
Chateal
Chateal EQ
Cryselle-28
Cyclafem 1/35, 7/7/7
Cyred
Cyred EQ
Dasetta 1/35, 7/7/7
Delyla
desogestrel & ethinyl estradiol tab
0.15 mg-30 mcg
desogestrel/ethinyl estradiol &
ethinyl estradiol tab 0.15-0.02/0.01 mg
(21/5) (Mircette)
drospirenone-ethinyl estradiol tab
3-0.02 mg (Yaz)
drospirenone-ethinyl estradiol tab
3-0.03 mg (Yasmin 28)
drospirenone-ethinyl estradi-
ol-levomefolate tab 3-0.02-0.451 mg
(Beyaz)
drospirenone-ethinyl estrad-levome-
folate tab 3-0.03-0.451 mg (Safyral)
Elinest
Emoquette
Enpresse-28
Enskyce
Estarylla
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg, 1 mg-
50 mcg
Falmina
Femynor
Gemmily
Gianvi
Hailey 1.5/30
Hailey Fe 1/20, 1.5/30
Hailey 24 Fe
Isibloom
Jasmiel
Juleber
Junel 1/20, 1.5/30
Junel Fe 1/20, 1.5/30
Junel Fe 24
CONTRACEPTIVE PRODUCT COVERAGE
*
bcbsil.com
Kaitlib Fe
Kalliga
Kariva
Kelnor 1/35, 1/50
Kurvelo
Larin 1/20, 1.5/30
Larin Fe 1/20, 1.5/30
Larin 24 Fe
Larissia
Layolis Fe
Leena
Lessina
Levonest
levonorgestrel & ethinyl estradiol tab
0.1 mg-20 mcg, 0.15 mg-30 mcg
levonorgestrel-ethinyl estradiol tab
0.05-30/0.075-40/0.125-30 mg-mcg
Levora 0.15/30-28
Lillow
Loestrin 1.5/30-21
Loestrin Fe 1/20
Loestrin Fe 1.5/30
LO LOESTRIN FE – norethindrone-ethinyl
estradiol-Fe tab 1 mg-10 mcg (24)/10 mcg
(2)
Loryna
Low-Ogestrel
Lo-Zumandimine
Lutera
Marlissa
Melodetta 24 Fe
Merzee
Mibelas 24 Fe
Microgestin 1/20, 1.5/30
Microgestin Fe 1/20, 1.5/30
Microgestin 24 Fe
Mili
Mono-Linyah
NATAZIA – estradiol valerate-dienogest
tab 3 mg /2-2 mg/2-3 mg/1 mg
Necon 0.5/35-28
Nextstellis
Nikki
norethindrone acetate & ethinyl
estradiol tab 1.5 mg-30 mcg
norethindrone & ethinyl estradiol-Fe
chew tab 0.4 mg-35 mcg, 0.8 mg-25
mcg (Generess Fe)
norethindrone acetate ethinyl
estradioal-fe cap 1 mg-20 mcg (24)
norethindrone acetate/ethinyl
estradiol
norethindrone acetate & ethinyl
estradiol tab 1 mg-20 mcg (Loestrin
1/20-21)
norethindrone acetate & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin Fe 1.5/30)
norethindrone acetate-ethinyl
estradiol-Fe chew tab 1 mg-20 mcg
(24) (Minastrin 24 Fe)
norethindrone acetate & ethinyl
estradiol-Fe tab 1 mg-20 mcg (Loestrin
Fe 1/20)
norethindrone acetate-ethinyl
estradiol-Fe tab 1 mg-20 mcg (24)
norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg
norgestimate-ethinyl estradiol tab
0.18-25/0.215-25/0.25-25 mg-mcg
norgestimate-ethinyl estradiol tab
0.18-35/0.215-35/0.25-35 mg-mcg
Nortrel 0.5/35 (28), 1/35, 7/7/7
Nylia 7/7/7
Nymyo
Ocella
Orsythia
Philith
Pimtrea
Pirmella 1/35, 7/7/7
Portia-28
Previfem
Reclipsen
Simliya
Sprintec 28
Sronyx
Syeda
Tarina Fe 1/20
Tarina Fe 1/20 EQ
Tarina 24 Fe
Tilia Fe
Tri-Estarylla
Tri Femynor
Tri-Legest Fe
Tri-Linyah
Tri-Lo-Estarylla
Tri-Lo-Marzia
Tri-Lo-Mili
Tri-Lo-Sprintec
Tri-Mili
Tri-Nymyo
Tri-Previfem
Tri-Sprintec
Trivora-28
Tri-Vylibra
Tri-Vylibra Lo
TYBLUME - levonorgestrel & ethinyl
estradiol tab 0.1 mg-20 mcg
Tydemy
Velivet
Vestura
Vienva
Viorele
Volnea
Vyfemla
CONTRACEPTIVE PRODUCT COVERAGE
*
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS † = Covered under medical benet
bcbsil.com
Vylibra
Wera
Wymzya Fe
Zarah
Zovia 1/35, 1/35E
Zumandimine
ORAL EXTENDED - CONTINUOUS
Amethia
Amethia Lo
Amethyst
Ashlyna
Camrese
Camrese Lo
Daysee
Dolishale
Fayosim
Iclevia
Introvale (91 day)
Jaimiess
Jolessa (91 day)
levonorgestrel-ethinyl estradiol
(continuous) tab 90-20 mcg
levonorgestrel & ethinyl estradiol
(91 day) tab 0.15-0.03 mg
levonorgestrel-ethinyl estradiol tab
0.15-0.03 mg (84) & ethinyl estradiol
tab 0.01 mg (7) (Seasonique)
levonorgestrel-ethinyl estradiol tab
0.1-0.02 mg (84) & ethinyl estradiol tab
0.01 mg (7) (LoSeasonique)
levonorgestrel-ethinyl estradiol tab
0.15-0.02/0.025/0.03 mg & ethinyl
estradiol 0.01 mg (Quartette)
Lojaimiess
Rivelsa
Setlakin (91 day)
Simpesse
ORAL PROGESTIN
Camila
Deblitane
Errin
Heather
Incassia
Jencycla
Lyleq
Lyza
Nora-BE
norethindrone tab 0.35 mg
(Ortho Micronor)
Norlyda
Norlyroc
Sharobel
SLYND – drospirenone tab 4 mg
Tulana
PATCHES
TWIRLA - levonorgestrel-ethinyl estradiol
transdermal ptwk 120-30 mcg/24hr
XULANE – norelgestromin-ethinyl
estradiol transdermal 150-35 mcg/24hr
Zafemy
RINGS
ANNOVERA - segesterone acetate-ethinyl
estradiol vaginal ring 0.15-
0.013 mg/24hr
NUVARING – etonogestrel-ethinyl
estradiol vaginal ring 0.120-0.015
mg/24hr
SPERMICIDES
ENCARE – nonoxynol-9 vaginal
suppository 100 mg
OPTIONS CONCEPTROL VAGINAL –
nonoxynol-9 gel 4%
OPTIONS GYNOL II VAGINAL –
nonoxynol-9 gel 3%
SHUR-SEAL – nonoxynol-9 gel 2%
VCF VAGINAL CONTRACEPTIVE –
nonoxynol-9 lm 28%, foam 12.5%
VCF Vaginal Contraceptive Gel-
nonoxynol-9-gel 4%
SPONGES
TODAY SPONGE – nonoxynol-9 vaginal
sponge 1000 mg
VAGINAL GEL
PHEXXI - lactic acid-citric acid-potassium
bitartrate gel 1.8-1-0.4%
CONTRACEPTIVE PRODUCT COVERAGE*
* Some of these products may be covered under your medical benet 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 benet. 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 benets 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 benet 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 benets.
This information is for informational purposes only, does not constitute legal or other advice and should not be relied upon to determine coverage.
Aordable 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 aliated 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
bcbsil.com
233345.0921
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS † = Covered under medical benet
