Drug Name Tier Notes GALBRIELA ORAL TABLET CHEWABLE 1 or 1b* $0 gemmily oral capsule 1 or 1b* $0 hailey 1.5/30 oral tablet 1 or 1a* $0 hailey 24 fe oral tablet 1 or 1a* $0 hailey fe 1.5/30 oral tablet 1 or 1a* $0 hailey fe 1/20 oral tablet 1 or 1a* $0 isibloom oral tablet 1 or 1a* $0 jasmiel oral tablet 1 or 1b* $0 JOYEAUX ORAL TABLET 1 or 1b* $0 juleber oral tablet 1 or 1a* $0 junel 1.5/30 oral tablet 1 or 1a* $0 junel 1/20 oral tablet 1 or 1a* $0 junel fe 1.5/30 oral tablet 1 or 1a* $0 junel fe 1/20 oral tablet 1 or 1a* $0 junel fe 24 oral tablet 1 or 1a* $0 kaitlib fe oral tablet chewable 1 or 1b* $0 kalliga oral tablet 1 or 1a* $0 kelnor 1/35 oral tablet 1 or 1a* $0 kelnor 1/50 oral tablet 1 or 1a* $0 kurvelo oral tablet 1 or 1a* $0 larin 1.5/30 oral tablet 1 or 1a* $0 larin 1/20 oral tablet 1 or 1a* $0 larin 24 fe oral tablet 1 or 1a* $0 larin fe 1.5/30 oral tablet 1 or 1a* $0 larin fe 1/20 oral tablet 1 or 1a* $0 lessina oral tablet 1 or 1a* $0 levonorgest-eth estradiol-iron oral tablet 1 or 1b* $0 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1 or 1a* $0 levora 0.15/30 (28) oral tablet 1 or 1a* $0 loestrin 1.5/30 (21) oral tablet 1 or 1a* $0 loestrin 1/20 (21) oral tablet 1 or 1a* $0 loestrin fe 1.5/30 oral tablet 1 or 1a* $0 loestrin fe 1/20 oral tablet 1 or 1a* $0 loryna oral tablet 1 or 1b* $0 low-ogestrel oral tablet 1 or 1a* $0 lo-zumandimine oral tablet 1 or 1b* $0 lutera oral tablet 1 or 1a* $0 Drug Name Tier Notes marlissa oral tablet 1 or 1a* $0 merzee oral capsule 1 or 1b* $0 MIBELAS 24 FE ORAL TABLET CHEWABLE 1 or 1a* $0 microgestin 1.5/30 oral tablet 1 or 1a* $0 microgestin 1/20 oral tablet 1 or 1a* $0 microgestin fe 1.5/30 oral tablet 1 or 1a* $0 microgestin fe 1/20 oral tablet 1 or 1a* $0 mili oral tablet 1 or 1a* $0 MINZOYA ORAL TABLET 1 or 1b* $0 mono-linyah oral tablet 1 or 1a* $0 necon 0.5/35 (28) oral tablet 1 or 1a* $0 nikki oral tablet 1 or 1b* $0 norethin ace-eth estrad-fe oral capsule 1 or 1b* $0 norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5- 30 mg-mcg 1 or 1a* $0 norethin ace-eth estrad-fe oral tablet chewable 1 or 1a* $0 norethindrone acet-ethinyl est oral tablet 1 or 1a* $0 norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 or 1a* $0 nortrel 0.5/35 (28) oral tablet 1 or 1a* $0 nortrel 1/35 (21) oral tablet 1 or 1a* $0 nortrel 1/35 (28) oral tablet 1 or 1a* $0 nylia 1/35 oral tablet 1 or 1a* $0 ocella oral tablet 1 or 1b* $0 philith oral tablet 1 or 1a* $0 portia-28 oral tablet 1 or 1a* $0 reclipsen oral tablet 1 or 1a* $0 sprintec 28 oral tablet 1 or 1a* $0 sronyx oral tablet 1 or 1a* $0 syeda oral tablet 1 or 1b* $0 tarina 24 fe oral tablet 1 or 1a* $0 tarina fe 1/20 eq oral tablet 1 or 1a* $0 taysofy oral capsule 1 or 1b* $0 TURQOZ ORAL TABLET 1 or 1a* $0 VALTYA 1/50 ORAL TABLET 1 or 1a* $0 vestura oral tablet 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 43