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Preventive Care Coverage
at No Cost to You
Eective Jan. 1, 2022
Your health plan may provide certain contraceptive coverage as
a benet of membership, at no cost to you when you use a
pharmacy or doctor in your health plan's network. There is no
co-pay, 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 co-payments, coinsurance or
deductible may apply.
Screening Test
• Hepatitis B screenings
• HIV screening
• Screenings for sexually transmitted infections (STIs)
including chlamydia, gonorrhea, and syphilis
Preventive Care
Services for
Women's WellBeing
Contraception*
The following contraceptive items and services may be covered
under the medical or pharmacy benet 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 DEPO-PROVERA and DEPO-SUBQ
PROVERA 104 may be covered under the medical
benet
• Medical devices such as diaphragm, cervical cap
and contraceptive implants may be covered
under the pharmacy or medical benet
• Female sterilization, including tubal ligation and
tubal implant
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Generic Drugs = bold Brand Drugs = CAPITAL LETTERS † = Covered under medical benet
CONTRACEPTIVE PRODUCT COVERAGE
*
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 prelled
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 – copper IUD
†
SKYLA – levonorgestrel releasing IUD 14 mcg/day
(13.5 mg total)
†
ORAL CONTRACEPTIVES
ORAL COMBINED
Aurovela Fe 1/20
Azurette
Bekyree
Blisovi Fe 1/20
desogestrel/ethinyl estradiol & ethinyl estradiol tab
0.15-0.02/0.01 mg (21/5) (Mircette)
Hailey Fe 1/20
Junel Fe 1/20
Kariva
Larin Fe 1/20
Loestrin Fe 1/20
Microgestin Fe 1/20
norethindrone & ethinyl estradiol-Fe chew tab
0.4 mg-35 mcg
norethindrone acetate & ethinyl estradiol-Fe tab
1 mg-20 mcg (Loestrin Fe 1/20)
norgestimate-ethinyl estradiol tab
0.18-35/0.215-35/0.25-35 mg-mcg
Pimtrea
Simliya
Tarina Fe 1/20
Tarina Fe 1/20 EQ
Tri-Estarylla
Tri Femynor
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* Some of these products may be covered under your medical benet 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 benet. 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 benets 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 BCBSTX (unless you have a benet 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 benets.
This information is for informational purposes only, does not constitute legal or other advice and should not be relied upon to determine coverage. Aordable 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 aliated 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 Texas, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
746289.0921
CONTRACEPTIVE PRODUCT COVERAGE
*
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS † = Covered under medical benet
Tri-Linyah
Tri-Mili
Tri-Nymyo
Tri-Previfem
Tri-Sprintec
Tri-Vylibra
Viorele
Volnea
Wymzya Fe
ORAL EXTENDED - CONTINUOUS
Amethia Lo
Camrese Lo
Iclevia
Introvale (91 day)
Jolessa (91 day)
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg
levonorgestrel-ethinyl estradiol tab 0.1-0.02 mg (84)
& ethinyl estradiol tab 0.01 mg (7) (LoSeasonique)
Lojaimiess
Setlakin (91 day)
ORAL PROGESTIN
Camila
Deblitane
Errin
Heather
Incassia
Jencycla
Lyleq
Lyza
Nora-BE
norethindrone tab 0.35 mg (Ortho Micronor)
Norlyda
Norlyroc
Sharobel
Tulana
PATCHES
XULANE – norelgestromin-ethinyl estradiol transdermal
150-35 mcg/24hr
Zafemy
RINGS
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