UNIFIED IPA CONTRACEPTIVE AND INFERTILITY …

1 AFTERAGILDESS FE 1/20 MICROGESTIN 1/20 PREVIFEMALTAVERAHEATHERMICROGESTIN 24 FEQUASENSEALYACEN 1/35 HIDE TILIA FEMICROGESTIN FERECLIPSENALYACEN 7/7/7 INTROVALEMICROGESTIN FE LOJENCYCLAMONO LINYAHSHAROBELAMETHYSTJOLESSAMONONESSASP RINTEC 28 APRIJOLIVETTEMY WAYSRONYXARANELLEJULEBERMYZILRATAKE ACTIONAUBRAJUNEL FE 1/20 AVIANEJUNEL 1/20 NECON 1/35TG CAMRESEAZURETTEJUNEL FE 1/50 28TG CYCLAFEM 7/7/7 BALZIVAJUNEL FE 1/20 NECON 7/7/7TG EMOQUETTEBRIELLYNKARIVANEXT CHOICE ONE DOSETG KIMIDESSCAMILAKELNOR 1/35 NORA BETG MICROGESTIN FECAMRESE LOKIMIDESSNORETHINDRONETG MICROGESTIN FE /ETHINYL ESTRATG MYZILRACHORIONIC GONADOTROPINLARIN ACETATE/ETH TG ORSYTHIACRYSELLE 28 LARIN 1/20 NORGESTIMATE/ETHINYL ESTRTILIA FECYCLAFEM 1/35 LARIN FE ESTRTRI ESTARYLLADASETTA 1/35 LARIN FE 1/20 NORTREL (28)TRI LEGEST FEDASETTA 7/7/7 LESSINANORTREL 1/35 TRI LINYAHDEBLITANELEVONESTNORTREL 7/7/7 TRI LO ESTARYLLADESOGESTREL/ETHINYL ESTRALEVONORGESTREL AND ETHINYNUVARINGTRINESSADESOGESTREL/ETHINY L ESTRALEVONORGESTREL/ ETH ESTRADIO OGESTRELTRINESSA LOELINESTLEVONORGESTREL/ETH ESTRADIOLORSYTHIATRI PREVIFEMELLALEVONORGESTREL/ETHINYL ES ORTHO MICRONORTRI SPRINTECEMOQUETTELEVONORGESTREL/ETHINYL ES ORTHO TRI CYCLENTRIVORA 28 ENPRESSE 28 LEVORAORTHO CYCLENVELIVETENSKYCELO LOESTRIN FEOVCON 35 VIENVAERRINLOW OGESTRELPHILITHVIORELEESTARYLLALUTERAPIM TREAWERAFALMINAMARLISSAPIRMELLA 1/35 WYMZYA FEGILDAGIAMEDROXYPROGESTERONE ACETAPIRMELLA 7/7/7 XULANEGILDESS B ONE STEPZENCHENTGILDESS 1/20 MICROGESTIN 1/20 PORTIA 28 ZENCHENT FEGILDESS FE IPACONTRACEPTIVE AND INFERTILITY MEDICATION FORMULARY2018 NOVAREL PLAN DEDUCTIBLE AND CO PAY RESPOSIBILITYCONTRACEPTIVES COVERED WITHOUT MEMBER CO

2 PAY(ALSO AVAILABLE AT NETWORK PHARMACIES ARE PRESCRIBED CERVICAL CAP WITH SPERMICIDE, DIAPHRAGM WITH SPERMICIDE, SPERMICIDE ALONE, SPONGE WITH SPERMICIDE, FEMALE CONDOM AND MALE CONDOM) INFERTILITY MEDICATIONS ARE SUBJECT TO PLAN CO PAYCLOMID PLAN DEDUCTIBLE AND CO PAY RESPOSIBILITY