Medicare Part D coverage · {84 · RxCUI 2049264
{84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Iclevia 91 Day]
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 [Iclevia 91 Day] is covered by 4,543 Medicare Part D plans (89.9% of enrollable products), averaging Tier 2.3, with prior authorization required on 0% of covering formularies.
- 89.9%
- Plan coverage
- 4,543
- Plans covering
- T2.3
- Avg tier
- 0%
- Prior auth required
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 [Iclevia 91 Day]
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 [Iclevia 91 Day] (RxNorm concept RXCUI 2049264, generic name {84) appears on 282 distinct formulary files spanning 4,543 Medicare Part D plan offerings - 89.9% of enrollable Part D products, near-universal placement. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 2.3.
Real-world access to {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Iclevia 91 Day] depends on utilization management as much as tier placement: 0% of covering formularies require prior authorization. 0% require step therapy. 38.3% 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 [Iclevia 91 Day] today.
Coverage Details
- Formularies covering
- 282
- Plans covering
- 4,543
- Coverage rate
- 89.9%
- 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
- 38.3% 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 [Iclevia 91 Day]
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Florida Complete Care-Duals VIP (HMO-POS D-SNP) | Hpmp OF Florida, Inc. | T1 | No | $0 | FL |
| 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 |
| 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 |
| 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 |
Show the next 30 plans
| 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 |
| CCA One Care (HMO D-SNP) | Commonwealth Care Alliance, Inc. | T1 | No | $0 | MA |
| CCA Senior Care Options (HMO D-SNP) | Commonwealth Care Alliance, Inc. | T1 | No | $0 | MA |
| Elevate Medicare Choice (HMO D-SNP) | Denver Health Medical Plan, Inc. | T1 | No | $0 | CO |
| McLaren Medicare Inspire (HMO) | Mclaren Health Plan, Inc. | T1 | No | $0 | MI |
| McLaren Medicare Inspire Select (HMO) | Mclaren Health Plan, Inc. | T1 | No | $0 | MI |
| AllCare Advantage Redwood Rx (HMO D-SNP) | Allcare Health Plan, Inc. | T1 | No | $0 | OR |
| PrimeWest Senior Health Complete (HMO D-SNP) | Primewest Rural MN Health Care Access Initiative | T1 | No | $0 | MN |
| Prime Health Complete (HMO D-SNP) | Primewest Rural MN Health Care Access Initiative | T1 | No | $0 | MN |
Showing top 50 of 100 plans.
Frequently Asked Questions
Is {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Iclevia 91 Day] 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 [Iclevia 91 Day] is covered by 4,543 Medicare Part D plans (89.9% 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 [Iclevia 91 Day] 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 [Iclevia 91 Day] averages Tier 2.3 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 [Iclevia 91 Day] 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 [Iclevia 91 Day]. Step therapy: 0%. Quantity limits: 38.3%.
Read our methodology - how this data is sourced, computed, and verified.
Nationwide similar Part D drugs
Data-derived peers across the CMS Part D formulary extract: nearest average tier placement and nearest prior-authorization rate. Not therapeutic alternatives or same-generic strengths.
Closest average formulary tier
Similar prior-authorization rate
- metronidazole 10 MG/ML Topical Cream [Noritate] 0% PA
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- diflunisal 375 MG Oral Tablet [Dolobid] 0% PA
- hydrocortisone 1 MG/ML Oral Solution [Khindivi] 0% PA
- indomethacin 50 MG Rectal Suppository [Indocin] 0% PA