EmblemHealth’s Affordable Care Act Preventive Medication Coverage Guidelines for GHI City of New York Members

Date Issued: 11/16/2016

As a result of the Affordable Care Act (ACA) and program changes to the City of New York GHI CBP plan, effective July 1, 2016, the following items and medications are covered for City of New York members with GHI Comprehensive Benefits Plan (CBP) through EmblemHealth at a $0 copay when received in-network. All products, including those designated as over the counter (OTC), will require a physician’s prescription for members to receive the applicable coverage, including the $0 in-network copay. The listed OTC items can be purchased without a prescription, but the member will be responsible for the full cost.

  • Aspirin: 325mg or less for men 45-79 years of age and women 55-79 years of age for the prevention of cardiovascular events. New in 2016 per guidance: 81mg dose for women < 55 years of age for preeclampsia prevention. Generic OTC products only.
  • Fluoride: children ages 6 months–5 years. Generic only. Prescription and OTC products.
  • Iron Supplements: Children ages 6-12 months. Generic only prescription and OTC.
  • Folic Acid: Women through age 50. Generic only. Prescription and OTC.
  • Immunizations: Covers all Advisory Committee on Immunization Practices (ACIP) recommendations.
  • Contraceptives: Persons through age 50. All approved prescription and OTC products; single source brands and generics; and Multisource brands with a Dispense as Written (DAW) request by the physician.
  • Smoking Cessation: Ages 18 and older. All approved prescription and OTC products, brands and generics. Limit: 180 days of therapy per 365 days at $0 copay, then full prescription copay is applied.
  • Vitamin D: Ages 65 and older. Generic only. Prescription and OTC.
  • Bowel Prep Products: Ages 50-75. Generic only. Prescription and OTC. Limit two prescriptions per 365 days at $0 copay.
  • Primary Prevention of Breast Cancer:
    1. Roloxiphene (generic only version of brand name Evista) is only covered for Primary Prevention of Breast Cancer in women age 35 and older. Prescribing physician needs to provide diagnosis to receive coverage and copay allowance.
    2. All other drugs from Primary Prevention of Breast Cancer are covered through New York City PICA Program, not through EmblemHealth.

For more information, review the alphabetical listing of ACA covered drugs.

Note that the third party clinical guidelines used by the ACA to define the items and conditions of coverage for the preventive care services that are covered may change over time. Our listings of ACA covered medications, drugs and items are periodically updated in accordance with ACA requirements to reflect the updated guidelines.