{84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack
ethinyl estradiol
RxCUI: 751901
What the CMS Formulary Data Shows for {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack
Per the CMS 2026 Part D formulary file, {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack (RxNorm concept RXCUI 751901, generic name ethinyl estradiol) appears on 314 distinct formulary files spanning 4,789 Medicare Part D plan offerings - 94.5% of enrollable Part D products, near-universal placement. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 2.2.
Real-world access to {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack depends on utilization management as much as tier placement: 0% of covering formularies require prior authorization. 0% require step therapy. 35.7% apply quantity limits.
Medicare Part D spending dashboard figures are not published for this drug. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack today.
Coverage Details
- Formularies covering
- 314
- Plans covering
- 4,789
- Coverage rate
- 94.5%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 2, Generic
Restrictions
- Prior authorization required
- 0% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 35.7% of formularies
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Sentara Community Complete Select (HMO D-SNP) | SENTARA HEALTH PLANS | T1 | No | $0 | VA |
| Sentara Community Complete (HMO D-SNP) | SENTARA HEALTH PLANS | T1 | No | $0 | VA |
| Florida Complete Care-Duals VIP (HMO-POS D-SNP) | HPMP OF FLORIDA, INC. | T1 | No | $0 | FL |
| ElderServe MAP (HMO D-SNP) | ELDERSERVE HEALTH, INC. | T1 | No | $0 | NY |
| Cooperative Advantage (HMO D-SNP) | GROUP HEALTH COOPERATIVE OF EAU CLAIRE | T1 | No | $0 | WI |
| Longevity Health Plan (PPO I-SNP) | LONGEVITY HEALTH PLAN OF NEW JERSEY INSURANCE COMP | T1 | No | $0 | NJ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | No | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | No | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | No | $0 | AZ |
| Elderplan Plus Long-Term Care (HMO-POS D-SNP) | ELDERPLAN, INC. | T1 | No | $0 | NY |
| Health Choice Pathway (HMO D-SNP) | HEALTH CHOICE ARIZONA, INC. | T1 | No | $0 | AZ |
| Healthfirst CompleteCare (HMO D-SNP) | HEALTHFIRST HEALTH PLAN, INC. | T1 | No | $0 | NY |
| IMCare Classic (HMO D-SNP) | ITASCA MEDICAL CARE | T1 | No | $0 | MN |
| Johns Hopkins Advantage MD D-SNP (HMO D-SNP) | HOPKINS HEALTH ADVANTAGE, INC. | T1 | No | $0 | MD |
| MetroPlus UltraCare (HMO D-SNP) | METROPLUS HEALTH PLAN, INC. | T1 | No | $0 | NY |
| Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) | UPPER PENINSULA HEALTH PLAN, LLC | T1 | No | $0 | MI |
| CareSource Dual Advantage (HMO D-SNP) | CARESOURCE GEORGIA CO. | T1 | No | $0 | GA |
| Senior Whole Health SCO (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | No | $0 | MA |
| Senior Whole Health SCO NHC (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | No | $0 | MA |
| Molina One Care (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | No | $0 | MA |
| HAP CareSource MI Coordinated Health (HMO D-SNP) | HAP CARESOURCE | T1 | No | $0 | MI |
| PruittHealth Premier D-SNP (HMO D-SNP) | PRUITTHEALTH PREMIER, INC. | T1 | No | $0 | GA |
| Simpra Advantage Dual Care (PPO D-SNP) | SIMPRA ADVANTAGE, INC. | T1 | No | $0 | AL |
| CareAdvantage (HMO D-SNP) | SAN MATEO HEALTH COMMISSION | T1 | No | $0 | CA |
| Gold Coast Health Plan Total Care Advantage (HMO D-SNP) | Ventura County Medi-Cal Managed Care Commission | T1 | No | $0 | CA |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | Health Care Service Corporation | T1 | No | $0 | NM |
| Blue Cross MA Dual Care Plus Preferred (PPO D-SNP) | Health Care Service Corporation | T1 | No | $0 | NM |
| Horizon NJ TotalCare (HMO D-SNP) | HORIZON HEALTHCARE OF NEW JERSEY, INC. | T1 | No | $0 | NJ |
| SecureBlue (HMO D-SNP) | HMO Minnesota | T1 | No | $0 | MN |
| NaviCare (HMO D-SNP) | FALLON COMMUNITY HEALTH PLAN | T1 | No | $0 | MA |
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | No | $0 | NY |
| SeniorCare Complete (HMO D-SNP) | SOUTH COUNTRY HEALTH ALLIANCE | T1 | No | $0 | MN |
| AbilityCare (HMO D-SNP) | SOUTH COUNTRY HEALTH ALLIANCE | T1 | No | $0 | MN |
| Alameda Alliance Wellness (HMO D-SNP) | ALAMEDA ALLIANCE FOR HEALTH | T1 | No | $0 | CA |
| PHP (HMO C-SNP) | AIDS HEALTHCARE FOUNDATION | T1 | No | $0 | CA |
| Astiva Health Savings Plan (HMO) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| Astiva Health C-SNP Deluxe (HMO C-SNP) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| Astiva Health Savings Plan - NorCal (HMO) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| Astiva Health Premier Plan - NorCal (HMO) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| Astiva Health Premier Plan (HMO) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| ATRIO Prime Rx (HMO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Choice Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Choice Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Prime Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Prime Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Prime Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Choice Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Choice Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Support Rx (PPO C-SNP) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| TotalCare (HMO D-SNP) | SANTA CRUZ MONTEREY MERCED SAN BENITO MARIPOSA MANAGED MEDIC | T1 | No | $0 | CA |
Frequently Asked Questions
Is {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack covered by Medicare Part D?
Yes, {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack is covered by 4,789 Medicare Part D plans (94.5% of all Part D formularies).
What tier is {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack on Medicare Part D plans?
{84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack averages Tier 2.2 across Part D plans, ranging from Tier 1 to Tier 4.
Does {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack require prior authorization?
0% of Part D formularies require prior authorization for {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack. Step therapy: 0%. Quantity limits: 35.7%.
Read our methodology - how this data is sourced, computed, and verified.