Drug Name Tier Notes vienva oral tablet 1 or 1a* $0 vyfemla oral tablet 1 or 1a* $0 vylibra oral tablet 1 or 1a* $0 wera oral tablet 1 or 1a* $0 wymzya fe oral tablet chewable 1 or 1b* $0 XELRIA FE ORAL TABLET CHEWABLE 1 or 1b* $0 zovia 1/35 (28) oral tablet 1 or 1a* $0 zumandimine oral tablet 1 or 1b* $0 *COMBINATION CONTRACEPTIVES - TRANSDERMAL*** norelgestromin-eth estradiol transdermal patch weekly 1 or 1b* $0 xulane transdermal patch weekly 1 or 1b* $0 zafemy transdermal patch weekly 1 or 1b* $0 *COMBINATION CONTRACEPTIVES - VAGINAL*** eluryng vaginal ring 1 or 1b* $0 ENILLORING VAGINAL RING 1 or 1b* $0 etonogestrel-ethinyl estradiol vaginal ring 1 or 1b* $0 HALOETTE VAGINAL RING 1 or 1b* $0 *CONTINUOUS CONTRACEPTIVES - ORAL*** amethyst oral tablet 1 or 1b* $0 dolishale oral tablet 1 or 1b* $0 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg 1 or 1b* $0 *EMERGENCY CONTRACEPTIVES*** aftera oral tablet 1 or 1b* $0 afterpill oral tablet 1 or 1b* $0 econtra one-step oral tablet 1 or 1b* $0 ELLA ORAL TABLET 2 $0 HER STYLE ORAL TABLET 1 or 1b* $0 levonorgestrel oral tablet 1.5 mg 1 or 1b* $0 my choice oral tablet 1 or 1b* $0 Drug Name Tier Notes my way oral tablet 1 or 1b* $0 new day oral tablet 1 or 1b* $0 opcicon one-step oral tablet 1 or 1b* $0 option 2 oral tablet 1 or 1b* $0 react oral tablet 1 or 1b* $0 take action oral tablet 1 or 1b* $0 *EXTENDED-CYCLE CONTRACEPTIVES - ORAL*** ashlyna oral tablet 1 or 1b* $0 camrese lo oral tablet 1 or 1b* $0 camrese oral tablet 1 or 1b* $0 daysee oral tablet 1 or 1b* $0 iclevia oral tablet 1 or 1b* $0 introvale oral tablet 1 or 1b* $0 jaimiess oral tablet 1 or 1b* $0 jolessa oral tablet 1 or 1b* $0 levonorgest-eth est & eth est oral tablet 1 or 1b* $0 levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg 1 or 1b* $0 lojaimiess oral tablet 1 or 1b* $0 rivelsa oral tablet 1 or 1b* $0 ROSYRAH ORAL TABLET 1 or 1b* $0 setlakin oral tablet 1 or 1b* $0 simpesse oral tablet 1 or 1b* $0 *PROGESTIN CONTRACEPTIVES - INJECTABLE*** DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 2 $0 medroxyprogesterone acetate intramuscular suspension 1 or 1b* $0 medroxyprogesterone acetate intramuscular suspension prefilled syringe 1 or 1b* $0 *PROGESTIN CONTRACEPTIVES - ORAL*** camila oral tablet 1 or 1b* $0 deblitane oral tablet 1 or 1b* $0 EMZAHH ORAL TABLET 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 44