Contraceptive Drug List
Effective July 1, 2015
Eligible benefit plans include coverage under the Affordable Care Act for the following contraceptives to be covered at $0 member cost share. This list will be reviewed periodically and is subject to change. To determine cost share for medications not listed below, log onto your account at MyPrime.com.
Some of these products may be covered under your medical benefit.
*Prescription coverage for contraception may vary according to the terms and conditions of the plan
**A prescription is required for emergency contraceptives to be covered without cost-sharing under the pharmacy benefit for non-grandfathered plans
This information is for informational purposes only, does not constitute legal or other advice, and should not be relied upon to determine coverage. Affordable 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 affiliated eligible organizations, in which case separate payment may be available for certain contraceptive services. Formore information about the religious employer exemption or eligible organization accommodation, please contact us at the phone number on your member ID card.
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS
PRENTIF CAVITY-RIM CERVICAL CAP PRENTIF FITTING SET
OMNIFLEX DIAPHRAGM ORTHO ALL-FLEX
ORTHO COIL SPRING KIT ORTHO FLAT SPRING KIT WIDE-SEAL SILICONE INJECTIONS
DEPO-PROVERA CONTRACEPTIVE (generic available)
DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate IMPLANTABLE