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Codes used to identify provision of most or moderately effective contraceptive methods. Contraceptive Type Code Set Code Description Female Sterilization ICD10CM Z30.2 Encounter for sterilization Female Sterilization ICD10PCS 0U574ZZ Destruction of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach Female Sterilization ICD10PCS 0U578ZZ Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic Female Sterilization ICD10PCS 0UL74CZ Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Endo- scopic Approach Female Sterilization ICD10PCS 0UL74DZ Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Endo- scopic Approach Female Sterilization ICD10PCS 0UL74ZZ Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach Female Sterilization ICD10PCS 0UL78DZ Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Female Sterilization ICD10PCS 0UL78ZZ Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic Female Sterilization CPT 58565 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D &C; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Female Sterilization CPT 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Female Sterilization CPT 58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpar- tum, unilateral or bilateral, during same hospitalization (separate procedure) Female Sterilization CPT 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) Female Sterilization CPT 58615 Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or supra- pubic approach Female Sterilization CPT 58670 Laparoscopy, surgical; with lysis of adhesions, with fulguration of oviducts (with or without transection) Female Sterilization CPT 58671 Laparoscopy, surgical; with lysis of adhesions, with occlusion of oviducts by device (e.g., band, clip or Falope ring) Female Sterilization HCPCS A4264 Permanent implantable contraceptive intratubal occlusion device and delivery system IUD/IUS ICD10CM Z30.014 Encounter for initial prescription of intrauterine contraceptive device IUD/IUS ICD10CM Z30.430 Encounter for insertion of intrauterine contraceptive device IUD/IUS ICD10CM Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device IUD/IUS ICD10CM Z30.431 Encounter for routine checking of intrauterine contraceptive device IUD/IUS ICD10CM T83.39XA Other mechanical complication of intrauterine contraceptive device, initial encounter IUD/IUS ICD10CM T83.39AD Other mechanical complication of intrauterine contraceptive device, subsequent encounter IUD/IUS ICD10CM T83.39XS Other mechanical complication of intrauterine contraceptive device, sequela IUD/IUS ICD10CM T83.31XA Breakdown (mechanical) of intrauterine contraceptive device, initial encounter IUD/IUS ICD10CM T83.31XD Breakdown (mechanical) of intrauterine contraceptive device, subsequent encounter IUD/IUS ICD10CM T83.31XS Breakdown (mechanical) of intrauterine contraceptive device, sequela IUD/IUS ICD10CM T83.32XA Displacement of intrauterine contraceptive device, initial encounter
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description IUD/IUS ICD10CM T83.32XD Displacement of intrauterine contraceptive device, subsequent encounter IUD/IUS ICD10CM T83.32XS Displacement of intrauterine contraceptive device, sequela IUD/IUS ICD10PCS 0UH97HZ Insertion of Contraceptive Device into Uterus, Via Natural or Artificial Opening IUD/IUS ICD10PCS 0UH98HZ Insertion of Contraceptive Device into Uterus, Via Natural or Artificial Opening Endoscopic IUD/IUS ICD10PCS 0UHC7HZ Insertion of Contraceptive Device into Cervix, Via Natural or Artificial Opening IUD/IUS ICD10PCS 0UHC8HZ Insertion of Contraceptive Device into Cervix, Via Natural or Artificial Opening Endoscopic IUD/IUS CPT 58300 Insertion of IUD IUD/IUS HCPCS J7300 Intrauterine copper contraceptive IUD/IUS HCPCS J7301 Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg IUD/IUS HCPCS J7302 Levonorgestrel- releasing intrauterine contraceptive system, 52 mg IUD/IUS HCPCS S4989 Contraceptive intrauterine device (e.g. progestacertiud), including implants and supplies IUD/IUS HCPCS Q0090 Levonorgestrel-releasing intrauterine contraceptive system, (skyla), 13.5 mg IUD/IUS HCPCS S4981 Insertion of levonorgestrel- releasing intrauterine system IUD/IUS HCPCS J7297 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 years duration IUD/IUS HCPCS J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration IUD/IUS ICD10PCS 0UH90HZ Insertion of Contraceptive Device into Uterus, Open Approach IUD/IUS HCPCS J7296 Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg IUD/IUS NDC 50419042308 Mirena; levonorgestrel 52 mg intrauterine device IUD/IUS NDC 50419042201 Skyla; levonorgestrel 13.5 mg intrauterine device IUD/IUS NDC 51285020401 ParaGard; copper intrauterine device IUD/IUS NDC 50419042208 Skyla; levonorgestrel 13.5 mg intrauterine system drug implant IUD/IUS NDC 50419042271 Skyla; levonorgestrel 13.5 mg intrauterine system drug implant IUD/IUS NDC 50419042301 Mirena; levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5-year duration IUD/IUS NDC 51285020402 ParaGard; copper intrauteral device IUD/IUS NDC 52544003554 Liletta; levonorgestrel 52 mg intrauterine device IUD/IUS NDC 00023585801 Liletta; levonorgestrel 52 mg intrauterine device IUD/IUS NDC 50419042401 Kyleena; levonorgestrel 19.5 mg intrauterine device, 5-year device IUD/IUS NDC 50419042408 Kyleena; levonorgestrel 19.5 mg intrauterine device IUD/IUS NDC 50419042471 Kyleena; levonorgestrel 19.5 mg intrauterine device IUD/IUS NDC 59365512801 ParaGard; copper intrauterine device IUD/IUS NDC 50419042101 Mirena; levonorgestrel 52 mg intrauterine device Hormonal Implant ICD10CM Z30.017 Encounter for initial prescription of implantable subdermal contraceptive Hormonal Implant ICD10CM Z30.46 Encounter for surveillance of implantable subdermal contraceptive Hormonal Implant CPT 11981 Insertion, non- biodegradable drug delivery implant, Implanon or Nexplanon
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Contraceptive Type Code Set Code Description Hormonal Implant CPT 11983 Removal with reinsertion, non- biodegradable drug delivery implant, Implanon or Nexplanon Hormonal Implant HCPCS J7306 Levonorgestrel (contraceptive) implant system, including implants and supplies Hormonal Implant HCPCS J7307 Etonogestrel [contraceptive] implant system, including implant and supplies Hormonal Implant NDC 00052027201 Implanon; etonogestrel 68 mg subcutaneous implant Hormonal Implant NDC 00052433001 Nexplanon; etonogestrel 68 mg subcutaneous implant Hormonal Implant NDC 00052027401 Nexplanon; etonogestrel 68 mg subcutaneous implant Injectable ICD10CM Z30.013 Encounter for initial prescription of injectable contraceptive Injectable ICD10CM Z30.42 Encounter for surveillance of injectable contraceptive Injectable HCPCS J1050 Injection, medroxyprogesterone acetate (1-month/3-months) Injectable NDC 00009062601 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Injectable NDC 00009074630 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Injectable NDC 00009074635 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Injectable NDC 00009470913 depo-subQ provera 104; medroxyPROGESTERone 104 mg/0.65 mL subcutaneous (1-month/3-months) suspension Injectable NDC 00009737607 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Injectable NDC 00009737611 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Injectable NDC 00247210801 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Injectable NDC 00703680101 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 00703680104 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 00703681121 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 54569370100 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 54569490400 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 54569552700 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 54868334801 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Injectable NDC 54868525700 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Injectable NDC 55045350501 Depo-Provera Contraceptive; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Injectable NDC 59762453701 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 59762453702 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 59762453802 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 59762453809 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) Injectable NDC 68788923301 MedroxyPROGESTERone Acetate; medroxyPROGESTERone 150 mg/mL intramuscular (1-month/3-months) suspension Oral Contraceptive Pills ICD10CM Z30.011 Encounter for initial prescription of contraceptive pills Oral Contraceptive Pills ICD10CM Z30.41 Encounter for surveillance of contraceptive pills Oral Contraceptive Pills HCPCS S4993 Contraceptive pills for birth control Oral Contraceptive Pills NDC 00008253505 Triphasil-21; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 00008253605 Triphasil-21; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 00023586228 Taytulla; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral capsule Oral Contraceptive Pills NDC 00023586230 Taytulla; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral capsule Oral Contraceptive Pills NDC 00052026106 Desogen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00052026108 Desogen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00052028306 Cyclessa; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 00052028308 Cyclessa; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 00062190120 Ortho-Cyclen; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 00062190320 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 00093209028 Zeosa; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 00093209058 Zeosa; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 00093214062 Tri-Lo-Sprintec; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 00093214028 Tri-Lo-Sprintec; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 00093313482 Camrese; ethinyl estradiol-levonorgestrel biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 00093313491 Camrese; ethinyl estradiol-levonorgestrel biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 00093330416 Reclipsen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00093330428 Reclipsen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00093330516 Zenchent; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 00093330528 Zenchent; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 00093532828 Junel Fe 24; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00093532862 Junel Fe 24; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00093542328 Gianvi; drospirenone-ethinyl estradiol 3 mg- 0.02 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 00093542358 Gianvi; drospirenone-ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 00093542362 Gianvi; drospirenone-ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 00093603182 Rivelsa; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 00093603191 Rivelsa; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 00093614882 Camrese Lo; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 00093614891 Camrese Lo; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 00093807316 KELNOR 1/50; ethynodiol diacetate and ethinyl estradiol Oral Contraceptive Pills NDC 00093807328 KELNOR 1/50; ethynodiol diacetate and ethinyl estradiol Oral Contraceptive Pills NDC 00247052028 Tri-Norinyl ; ethinyl estradiol-norethindrone triphasic 0.5 mg-1mg-0.5 mg oral tablet Oral Contraceptive Pills NDC 00247069028 Ortho-Cyclen; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 00247069128 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 00247069228 Triphasil-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 00247151328 Ovcon 35; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 00247151728 Desogen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00247176404 Loestrin 21 1/20; ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00247176421 Loestrin 21 1/20; ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00247176521 Loestrin 21 1.5/30; ethinyl estradiol-norethindrone 20 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 00247198621 Yasmin; drospirenone-ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 00247198628 Yasmin; drospirenone-ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00247200828 Loestrin 21 1/20; ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00247201228 Ortho-Cyclen; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 00247201328 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 00247214728 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 00247216928 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 00247217028 Trivora-28 ; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 00247223028 Mircette; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00247223528 Kariva; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00247226028 Ortho-Novum 1/35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00247226828 Yasmin; drospirenone-ethinyl estradiol 3 mg-0.03 oral tablet Oral Contraceptive Pills NDC 00378728153 LEVONORGESTREL AND ETHINYL ESTRADIOL; ethinyl estradiol-levonorgestrel extended cycle 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 00378655053 Ethinyl-Estradiol Levonorgestrel; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 00378655056 LEVONORGESTREL AND ETHINYL ESTRADIOL; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 00378655085 LEVONORGESTREL AND ETHINYL ESTRADIOL; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 00378727253 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00378727256 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00378727285 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00378727753 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 00378727785 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 00378728053 Ethinyl Estradiol-Norethindrone; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378728098 Ethinyl Estradiol-Norethindrone; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378728085 Ethinyl Estradiol-Norethindrone; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378728253 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00378728285 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00378728353 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol- norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378728398 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol-norethin- drone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378728485 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378728490 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 00378728590 Ethinyl- Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 00378728753 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00378728756 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00378728785 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00378729253 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00378729256 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00378729285 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00378729653 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00378729656 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00378729685 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol biphasic oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 00378729753 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol- norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 00378729785 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol- norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 00378729853 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00378729885 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00378729953 Drospirenone and Ethinyl Estradiol; drospirenone and ethinyl estradiol Oral Contraceptive Pills NDC 00378729985 Drospirenone and Ethinyl Estradiol; drospirenone and ethinyl estradiol Oral Contraceptive Pills NDC 00378730053 Drospirenone-Ethinyl Estradiol; drosprenone- ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00378730085 Drospirenone-Ethinyl Estradiol; drosprenone-ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00378730153 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol- norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378730185 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol- norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378730653 Ethinyl Estradiol-Ethynodiol; ethinyl estradiol-ethynodiol 50 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378730685 Ethinyl Estradiol-Ethynodiol; ethinyl estradiol-ethynodiol 50 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00378730753 Ethynodiol Diacetate and Ethinyl Estradiol; ethynodiol diacetate and ethinyl estradiol Oral Contraceptive Pills NDC 00378730785 Ethynodiol Diacetate and Ethinyl Estradiol; ethynodiol diacetate and ethinyl estradiol Oral Contraceptive Pills NDC 00378730853 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol-norethin- drone with iron 25 mcg-0.8 mg oral tablet, chewable Oral Contraceptive Pills NDC 00378730885 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol- norethindrone with iron 25 mcg-0.8 mg oral tablet, chewable Oral Contraceptive Pills NDC 00378731553 Norethindrone Acetate and Ethinyl Estradiol and Ferrous Fumarate; norethindrone acetetate and ethinyl estradiol and ferrous fumarate Oral Contraceptive Pills NDC 00378731585 Norethindrone Acetate and Ethinyl Estradiol and Ferrous Fumarate; norethindrone acetate and ethinyl estradiol and ferrous fumarate Oral Contraceptive Pills NDC 00378731685 LEVONORGESTREL AND ETHINYL ESTRADIOL; levonorgestrel and ethinyl estradiol and ethinyl estradiol Oral Contraceptive Pills NDC 00430000531 Estrostep Fe; ethinyl estradiol-norethindrone with iron triphasic 20 mcg-30 mcg- 35 mcg oral tablet Oral Contraceptive Pills NDC 00430001005 Femcon FE; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 00430042014 Lo Loestrin Fe; ethinyl estradiol-norethindrone with iron biphasic 10 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00430042060 Lo Loestrin Fe; ethinyl estradiol-norethindrone with iron biphasic 10 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00430042095 Lo Loestrin Fe; ethinyl estradiol-norethindrone with iron biphasic 10 mcg-1 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 00430048214 Femcon FE; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 00430053014 Loestrin 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00430053060 Loestrin 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00430053514 Minastrin 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00430053550 Minastrin 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00430053714 Lo Minastrin Fe; ethinyl estradiol-norethindrone with iron biphasic 10 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00430053750 Lo Minastrin Fe; ethinyl estradiol-norethindrone with iron biphasic 10 mcg-1 mg oral tablet, chewable Oral Contraceptive Pills NDC 00430053795 Lo Minastrin Fe; ethinyl estradiol-norethindrone with iron biphasic 10 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00430054050 Minastrin 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet, chewable Oral Contraceptive Pills NDC 00430057045 Estrostep Fe; ethinyl estradiol-norethindrone with iron triphasic 20 mcg-30 mcg- 35 mcg oral tablet Oral Contraceptive Pills NDC 00430058014 Ovcon 35; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 00430058045 Ovcon 35; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 00430058114 Ovcon 35 Fe; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 00555034458 Errin; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00555034479 Errin; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00555071558 Camila; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 00555900867 Nortrel 0.5/35; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 00555900879 Nortrel 0.5/35; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 00555900942 Nortrel 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555900980 Nortrel 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555901058 Nortrel 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555901079 Nortrel 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555901258 Nortrel 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg- 0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555901279 Nortrel 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg- 0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555901458 Lessina; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00555901467 Lessina; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00555901479 Lessina; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00555901658 Sprintec; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 00555901858 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 00555902058 Portia; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 00555902079 Portia; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 00555902542 Junel 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555902658 Junel Fe 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555902742 Junel 1.5/30; ethinyl estradiol-norethindrone 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 00555902858 Junel Fe 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 00555903270 Tri-Legest Fe; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 00555903400 Balziva; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 00555903458 Balziva; ethinyl estradiol-norethindrone 35 mcg- 0.4 mg oral tablet Oral Contraceptive Pills NDC 00555903479 Balziva; ethinyl estradiol-norethindrone 35 mcg- 0.4 mg oral tablet Oral Contraceptive Pills NDC 00555904358 Apri; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00555904379 Apri; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00555904558 Aviane; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00555904579 Aviane; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00555904758 Enpresse; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 00555904958 Cryselle 28; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 00555904979 Cryselle 28; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 00555905058 Kariva; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00555905079 Kariva; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00555905167 Velivet; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 00555905179 Velivet; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 00555906458 Kelnor; ethinyl estradiol-ethynodiol 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555906479 Kelnor; ethinyl estradiol-ethynodiol 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555906467 Kelnor; ethinyl estradiol-ethynodiol 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00555906658 Aranelle; ethinyl estraidol-norethindrone triphasic 0.5 mg-1 mg-0.5 mg oral tablet Oral Contraceptive Pills NDC 00555906667 Aranelle; ethinyl estradiol-norethindrone triphasic 0.5 mg- 1 mg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 00555906679 Aranelle; ethinyl estradiol-norethindrone triphasic 0.5 mg- 1 mg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 00555912366 Jolessa; ethinyl estradiol-levonorgestrel extrended cycle 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 00555913167 Ocella; drospirenone-ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 00555913179 Ocella; drospirenone-ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 00603359001 Gildagia; ethinyl estradiol-norethindron 35 mcg- 0.4 mg oral tablet Oral Contraceptive Pills NDC 00603359017 Gildagia; ethinyl estradiol-norethindrone 35 mcg- 0.4 mg oral tablet Oral Contraceptive Pills NDC 00603359049 Gildagia; ethinyl estradiol-norethindrone 35 mcg- 0.4 mg oral tablet Oral Contraceptive Pills NDC 00603751201 Kimidess; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00603751217 Kimidess; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00603751249 Kimidess; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 00603752101 Cyclafem 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00603752117 Cyclafem 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 00603752149 Cyclafem 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 00603752501 Cyclafem 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 00603752517 Cyclafem 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 00603752549 Cyclafem 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 00603754001 Emoquette; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00603754017 Emoquette; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00603754049 Emoquette; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00603760602 Gildess; ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 00603760615 Gildess; ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 00603760648 Gildess; ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 00603760715 Gildess; ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00603760748 Gildess; ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00603760801 Gildess FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 00603760817 Gildess FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 00603760917 Gildess FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00603761017 Gildess 24 FE; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00603761049 Gildess 24 FE; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 00603762501 Myzilra; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 00603762517 Myzilra; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 00603762549 Myzilra; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 00603763401 Orsythia; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00603763417 Orsythia; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00603763449 Orsythia; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00603764201 Previfem; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 00603764217 Previfem; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 00603766301 Tri-Previfem; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 00603766317 Tri-Previfem; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 00781405815 Estarylla; ethinyl estradiol-norgestimate triphasic 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 00781406015 Tri-Estarylla; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 00781406215 Tri-Lo-Estarylla; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 00781406615 Isibloom; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 00781407515 Drospirenone/Ethinyl Estradiol/Levomefolate; drosprenone/ethinyl estradiol/ levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 00781407552 Drospirenone/Ethinyl Estradiol/Levomefolate; drosprenone/ethinyl estradiol/ levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 00781410315 Drospirenone/Ethinyl Estradiol/Levomefolate; drosprenone/ethinyl estradiol/ levomefolate 3 mg- 0.03 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 00781410352 Drospirenone/Ethinyl Estradiol/Levomefolate; drosprenone/ethinyl estradiol/ levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 00781411015 Estradiol Valerate and Estradiol Valerate/Dienogest; estradiol valerate and estradiol valerate/dienogest Oral Contraceptive Pills NDC 00781411052 Estradiol Valerate and Estradiol Valerate/Dienogest; estradiol valerate and estradiol valerate/dienogest Oral Contraceptive Pills NDC 00781557515 Vienva; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 00781558315 Altavera; ethinyl estradiol- levonorgestrel 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 00781558436 Introvale; ethinyl estradiol-levonorgestrel extrended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 00781565615 Loryna; drospirenone- ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 00781565815 Syeda; drospirenone- ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 16714007301 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714007302 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714007303 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714007304 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714034001 Levonest-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 16714034002 Levonest-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 16714034003 Levonest-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 16714034004 Levonest-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 16714034601 Dasetta 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg- 0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714034602 Dasetta 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg- 0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714034603 Dasetta 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg- 0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714034604 Dasetta 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg- 0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714034701 Philith; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 16714034702 Philith; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 16714034703 Philith; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 16714034704 Philith; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 16714034801 Dasetta 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714034802 Dasetta 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714034803 Dasetta 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 16714034804 Dasetta 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714035901 Falmina; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 16714035902 Falmina; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 16714035903 Falmina; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 16714035904 Falmina; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 16714036001 Mono-Linyah; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 16714036002 Mono-Linyah; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 16714036003 Mono-Linyah; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 16714036004 Mono-Linyah; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 16714036301 Tri-Linyah; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 16714036302 Tri-Linyah; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 16714036303 Tri-Linyah; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 16714036304 Tri-Linyah; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 16714036501 Elinest; ethinyl estradiol-norgestrel 30 mcg- 0.3 mg oral tablet Oral Contraceptive Pills NDC 16714036502 Elinest; ethinyl estradiol-norgestrel 30 mcg- 0.3 mg oral tablet Oral Contraceptive Pills NDC 16714036503 Elinest; ethinyl estradiol-norgestrel 30 mcg- 0.3 mg oral tablet Oral Contraceptive Pills NDC 16714036504 Elinest; ethinyl estradiol-norgestrel 30 mcg- 0.3 mg oral tablet Oral Contraceptive Pills NDC 16714036603 Setlakin; ethinyl estradiol-levonorgestrel extrended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 16714036701 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 16714036702 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 16714036703 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 16714036704 Desogestrel-Ethinyl Estradiol; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 16714037001 Wera; ethinyl estradiol-norethindrone 35 mcg-0.5 mg oral tablet Oral Contraceptive Pills NDC 16714037002 Wera; ethinyl estradiol-norethindrone 35 mcg-0.5 mg oral tablet Oral Contraceptive Pills NDC 16714037003 Wera; ethinyl estradiol-norethindrone 35 mcg-0.5 mg oral tablet Oral Contraceptive Pills NDC 16714037004 Wera; ethinyl estradiol-norethindrone 35 mcg-0.5 mg oral tablet Oral Contraceptive Pills NDC 16714040401 Pimtrea; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 16714040402 Pimtrea; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 16714040403 Pimtrea; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 16714040404 Pimtrea; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 16714040501 Larin FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 16714040502 Larin FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 16714040503 Larin FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 16714040504 Larin FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 16714040601 Larin FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714040602 Larin FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714040603 Larin FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714040604 Larin FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714040701 Larin 1.5/30; ethinyl estradiol-norethindrone 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 16714040702 Larin 1.5/30; ethinyl estradiol-norethindrone 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 16714040703 Larin 1.5/30; ethinyl estradiol-norethindrone 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 16714040704 Larin 1.5/30; ethinyl estradiol-norethindrone 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 16714040801 Larin 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714040802 Larin 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714040803 Larin 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714040804 Larin 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714041301 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714041302 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714041303 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714041304 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714041601 Larin 24 FE; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714041602 Larin 24 FE; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714041603 Larin 24 FE; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714041604 Larin 24 FE; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 16714044001 Deblitane; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714044002 Deblitane; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714044003 Deblitane; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714044004 Deblitane; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714044101 Sharobel; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714044102 Sharobel; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714044103 Sharobel; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714044104 Sharobel; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 16714046401 Juleber; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 16714046402 Juleber; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 16714046403 Juleber; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 16714046404 Juleber; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 17478026006 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 17478026028 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 17478026106 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 17478026128 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 21695040701 TriNessa; norgestimate and ethinyl estradiol Oral Contraceptive Pills NDC 21695068528 Tilia Fe; norethindrone acetate and ethinyl estradiol Oral Contraceptive Pills NDC 21695076928 Sprintec; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 21695077001 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 21695077028 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 21695085501 Enpresse; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 21695085701 Necon 0.5/35; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 21695099528 Aviane; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 23490765301 Desogen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 23490767001 Mircette; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 24090080184 Lo/Ovral-28; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 34908062051 Levonest-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 34908062053 Levonest-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 34908062056 Levonest-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 35356001468 Nortrel 1/35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 35356001568 Tri-Previfem; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 35356002168 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 35356025528 Yaz; drospirenone-ethinyl estradiol 3 mg-0.02 mg oral tablet Oral Contraceptive Pills NDC 35356037028 Cryselle 28; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 50102010000 Lyza; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50102010001 Lyza; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50102010003 Lyza; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50102010010 Lyza; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50102010048 Lyza; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50102012000 Aubra; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 50102012001 Aubra; ethinyl estradiol-levonogestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 50102012003 Aubra; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 50102012010 Aubra; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 50102012048 Aubra; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 50102012801 Tarina Fe 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 50102012803 Tarina Fe 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 50102013000 Chateal; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 50102013001 Chateal; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 50102013003 Chateal; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 50102013010 Chateal; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 50102013048 Chateal; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 50102013090 Chateal ; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 50102015400 Cyred; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 50102015401 Cyred; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 50102015403 Cyred; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 50419040201 Yasmin; drospirenone-ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 50419040203 Yasmin; drospirenone-ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 50419040300 Safyral; drospirenone/ethinyl estradiol/levomefolate 3 mg-0.03 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040301 Safyral; drospirenone/ethinyl estradiol/levomefolate 3 mg-0.03 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040303 Safyral; drospirenone/ethinyl estradiol/levomefolate 3 mg-0.03 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040370 Safyral; drospirenone/ethinyl estradiol/levomefolate 3 mg-0.03 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040371 Safyral; drospirenone/ethinyl estradiol/levomefolate 3 mg-0.03 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040375 Safyral; drospirenone/ethinyl estradiol/levomefolate 3 mg-0.03 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040501 Yaz; drospirenone-ethinyl estradiol 3 mg-0.02 mg oral tablet Oral Contraceptive Pills NDC 50419040503 Yaz; drospirenone-ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 50419040700 Beyaz; drospirenone/ethinyl estradiol/levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040701 Beyaz; drospirenone/ethinyl estradiol/levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040703 Beyaz; drospirenone/ethinyl estradiol/levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040770 Beyaz; drospirenone/ethinyl estradiol/levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040771 Beyaz; drospirenone/ethinyl estradiol/levomefolate 3 mg-0.03 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040775 Beyaz; drospirenone/ethinyl estradiol/levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 50419040900 Natazia; dienogest-estradiol multiphasic oral tablet Oral Contraceptive Pills NDC 50419040901 Natazia; dienogest-estradiol multiphasic oral tablet Oral Contraceptive Pills NDC 50419040903 Natazia; dienogest-estradiol multiphasic oral tablet Oral Contraceptive Pills NDC 50419040970 Natazia; dienogest-estradiol multiphasic oral tablet Oral Contraceptive Pills NDC 50419040973 Natazia; dienogest-estradiol multiphasic oral tablet Oral Contraceptive Pills NDC 50419040976 Natazia; dienogest-estradiol multiphasic oral tablet Oral Contraceptive Pills NDC 50419041112 Levlen; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 50419048201 Angeliq ; drospirenone and estradiol tablet, film coated Oral Contraceptive Pills NDC 50419048203 Angeliq ; drospirenone and estradiol tablet, film coated Oral Contraceptive Pills NDC 50419048271 Angeliq ; drospirenone and estradiol tablet, film coated Oral Contraceptive Pills NDC 50419048272 Angeliq ; drospirenone and estradiol tablet, film coated Oral Contraceptive Pills NDC 50419048301 Angeliq ; drospirenone and estradiol tablet, film coated Oral Contraceptive Pills NDC 50419048303 Angeliq ; drospirenone and estradiol tablet, film coated Oral Contraceptive Pills NDC 50419048371 Angeliq ; drospirenone and estradiol tablet, film coated Oral Contraceptive Pills NDC 50419048372 Angeliq ; drospirenone and estradiol tablet, film coated Oral Contraceptive Pills NDC 50458017115 Modicon; ethinyl estradiol-norethindrone 35 mcg-0.5 mg oral tablet Oral Contraceptive Pills NDC 50458017600 Ortho-Novum 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458017606 Ortho-Novum 1/35; ethinyl estradiol-norehindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458017615 Ortho-Novum 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458017628 Ortho-Novum 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458017800 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458017806 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458017812 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458017815 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 50458017820 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458017828 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 50458019100 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 50458019106 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 50458019112 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 50458019115 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 50458019120 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 50458019128 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 50458019615 Ortho-Cept; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 50458019700 Ortho-Cyclen; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 50458019706 Ortho-Cyclen; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 50458019712 Ortho-Cyclen; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 50458019715 Ortho-Cyclen; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 50458019720 Ortho-Cyclen ; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 50458019728 Ortho-Cyclen ; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 50458019400 Ortho Micronor; norethindrone 0.35 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 50458019406 Ortho Micronor; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50458019411 Ortho Micronor; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50458019412 Ortho Micronor; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50458019416 Ortho Micronor; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50458019423 Ortho Micronor; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50458019428 Ortho Micronor; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 50458025100 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 50458025106 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 50458025112 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 50458025115 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 50458025120 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 50458025128 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 51285005866 Seasonale; ethinyl estradiol-levonorgestrel extended cycle 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 51285007997 Loestrin 21 1/20; ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 51285008070 Loestrin Fe 1/20 (obsolete); ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 51285008198 Loestrin Fe 1/20 (obsolete); ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 51285008297 Loestrin 21 1.5/30; ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 51285008370 Loestrin Fe 1.5/30 (obsolete); ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 51285008498 Loestrin Fe 1.5/30 (obsolete); ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 51285008782 Seasonique; ethinyl estradiol-levonorgestrel biphasic extrended cycle oral tablet Oral Contraceptive Pills NDC 51285008787 Seasonique; ethinyl estradiol-levonorgestrel biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51285009158 Nordette; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 51285009282 LoSeasonique; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51285009287 LoSeasonique; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51285011458 Mircette; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 51285012058 Mircette; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 51285012079 Mircette; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 51285012570 Loestrin Fe 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 51285012698 Loestrin Fe 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 51285012797 Loestrin 21 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 51285012870 Loestrin Fe 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 51285012998 Loestrin Fe 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 51285013197 Loestrin 1/20 ; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 51285043165 Quartette; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51285043182 Quartette; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51285043187 Quartette; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51285054628 Cryselle 28; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 51660012786 Norlyroc; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 51660057286 Delyla; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 51862000706 Microgestin 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 51862001206 Microgestin Fe 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 51862002801 Lutera; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 51862002806 Lutera; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 51862003601 Zarah; drospirenone- ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 51862003603 Zarah; drospirenone- ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 51862004501 Amethia Lo; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51862004591 Amethia Lo; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51862004701 Amethia; ethinyl estradiol-levonorgestrel biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51862004791 Amethia; ethinyl estradiol-levonorgestrel biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 51862007201 Azurette; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 51862007206 Azurette; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 51862009701 Levora; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 51862009706 Levora; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 51862010001 Errin; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 51862010006 Errin; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 51862010201 Camila; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 51862010206 Camila; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 51862023801 Caziant; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 51862023803 Caziant; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 51862026001 Zovia 1/35; ethinyl estradiol-ethynodiol 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 51862026006 Zovia 1/35; ethinyl estradiol- ethynodiol 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 51862027906 Microgestin 1.5/30; ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 51862028401 Tilia Fe; ethinyl estradiol-norethindrone with iron triphasic 20 mcg-30 mcg-35 mcg oral tablet Oral Contraceptive Pills NDC 51862028403 Tilia Fe; ethinyl estradiol-norethindrone with iron triphasic 20 mcg-30 mcg-35 mcg oral tablet Oral Contraceptive Pills NDC 51862029206 Microgestin FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 51862031801 Necon 28; norethindrone and ethinyl estradiol Oral Contraceptive Pills NDC 51862031803 Necon 0.5/35; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 51862047001 Tri-Norinyl; ethinyl estradiol-norethindrone biphasic 0.15 mg-1 mg-0.5 mg oral tablet Oral Contraceptive Pills NDC 51862047006 Tri-Norinyl; ethinyl estradiol-norethindrone biphasic 0.5 mg-1 mg-0.5 mg oral tablet Oral Contraceptive Pills NDC 51862047101 Leena; ethinyl estraidol-norethindrone biphasic 0.5 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 51862047106 Leena; ethinyl estraidol-norethindrone biphasic 0.5 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 51862048965 Levonorgestrel and Ethinyl Estradiol; levonorgestrel and ethinyl estradiol Oral Contraceptive Pills NDC 51862051001 Trivora-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 51862051006 Trivora-28; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 51862054501 Sronyx; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 51862054506 Sronyx; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 51862056401 Low-Ogestrel; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 51862056406 Low-Ogestrel; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 51862088401 Camila; norethindrone tablet Oral Contraceptive Pills NDC 51862088403 Camile; norethindrone tablet Oral Contraceptive Pills NDC 51862088601 Errin; norethindrone tablet Oral Contraceptive Pills NDC 51862088603 Errin; norethindrone tablet Oral Contraceptive Pills NDC 52544005431 Tilia Fe; ethinyl estradiol-norethindrone with iron triphasic 20 mcg-30 mcg-35 mcg oral tablet Oral Contraceptive Pills NDC 52544005841 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol-norethin- drone with iron 20 mcg- 1 mg oral tablet, chewable Oral Contraceptive Pills NDC 52544005872 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol-norethin- drone with iron 20 mcg- 1 mg oral tablet, chewable Oral Contraceptive Pills NDC 52544006431 Layolis FE; ethinyl estradiol-norethindrone with iron 25 mcg- 0.8 mg oral tablet, chewable Oral Contraceptive Pills NDC 52544008728 TriNessa Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 52544008741 TriNessa Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 52544014331 Tilia Fe; ethinyl estradiol-norethindrone with iron triphasic 20 mcg-30 mcg-35 mcg oral tablet Oral Contraceptive Pills NDC 52544016528 Necon 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 52544016731 Microgestin 24 FE; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 52544020431 Generess Fe; ethinyl estradiol-norethindrone with iron 25 mcg- 0.7 mg oral tablet, chewable Oral Contraceptive Pills NDC 52544021928 Leena; ethinyl estradiol-norethindrone biphasic 0.5 mg-1 mg oral tablet Oral Contraceptive Pills NDC 52544022829 Amethia Lo; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 52544023328 Microgestin FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 52544023528 Nor-QD; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 52544024531 Necon 1/50; mestranol-norethindrone 0.05 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 52544024728 Mononessa; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 52544024828 TriNessa; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 52544024928 Microgestin FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 52544025428 Brevicon; ethinyl estradiol-norethindrone 35 mcg- 0.5 mg oral tablet Oral Contraceptive Pills NDC 52544025928 Norinyl 1+35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 52544025988 Norinyl 1+35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 52544026531 Norinyl 1+50; mestranol-norethindrone 0.05 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 52544026829 Amethia; ethinyl estradiol-levonorgestrel biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 52544027428 Tri-Norinyl; ethinyl estradiol-norethindrone triphasic 0.5 mg-1 mg-0.5 mg oral tablet Oral Contraceptive Pills NDC 52544027621 Microgestin 1/20; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 52544027928 Levora; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 52544029021 Microgestin 1.5/30; ethinyl estradiol-norethindrone 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 52544029128 Trivora- 28; ethinyl estrdiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 52544029231 Zenchent Fe; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 52544029241 Zenchent Fe; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 52544029528 Amethyst; ethinyl estradiol-levonorgestrel 20 mcg-90 mcg oral tablet Oral Contraceptive Pills NDC 52544029831 Rajani; drospirenon/ethinyl estradiol/levomefolate 3 mg- 0.02 mg- 0.451 mg oral tablet Oral Contraceptive Pills NDC 52544038328 Zovia 1/35; ethinyl estraidol-ethynodiol 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 52544038428 Zovia 1/50; ethinyl estradiol- ethynodiol 50 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 52544038431 Zovia 1/50E-28; ethynodiol diacetate and ethinyl estradiol Oral Contraceptive Pills NDC 52544055028 Necon 0.5/35; ethinyl estradiol-norethindrone 35 mcg-0.5 mg oral tablet Oral Contraceptive Pills NDC 52544055228 Necon 1/35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 52544055428 Necon 10/11; ethinyl estradiol-norethindrone biphasic 0.5 mg-1 mg oral tablet Oral Contraceptive Pills NDC 52544062928 Nora-Be; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 52544063028 Microgestin FE 1/20; ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 52544063128 Microgestin FE 1.5/30; ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 52544084728 Low-Ogestrel; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 52544084828 Ogestrel- 28; ethinyl estradiol-norgestrel 50 mcg-0.5 mg oral tablet Oral Contraceptive Pills NDC 52544089228 Jolivette; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 52544093628 Necon 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 52544094028 Azurette; desogestrel-ethinyl estradiol biphasic oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 52544094928 Lutera; ethinyl estradiol-levonorgestrel 20 mcg-100 mcg oral tablet Oral Contraceptive Pills NDC 52544095021 Microgestin 1/20; ethinyl estradiol-norethindrone 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 52544095121 Microgestin 1.5/30; ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 52544095328 Zenchant; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 52544095428 Reclipsen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 52544095931 Caziant; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 52544096691 Quasense; ethinyl estraidol-levonorgestrel extended cycle 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 52544096728 Sronyx; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 52544098131 Zarah; drospirenone- ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 52544098228 Vestura; drospirenon- ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 52544098231 Vestura; drospirenon- ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 54569067900 Lo/Ovral-28; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 54569068900 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 54569068901 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 54569384400 Levlen; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 54569422200 Desogen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 54569427301 Ortho-Cyclen; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 54569481700 Zovia 1/35; ethinyl estradiol-ethynodiol 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 54569487801 Apri; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 54569499700 Levora; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 54569499800 Low-Ogestrel; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 54569534900 Yasmin; drospirenon-ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 54569549300 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 54569549302 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 54569579600 TriNessa; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 54569579700 Microgestin FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 54569579800 Lutera; ethinyl estradiol-levonorgestrel 20 mcg-100 mcg oral tablet Oral Contraceptive Pills NDC 54569581600 Mononessa; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 54569582600 Kariva; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 54569068500 Ortho-Novum 1/35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 54569068501 Ortho-Novum 1/35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 54569603200 Reclipsen; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 54569612800 Ocella; drospirenone-ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 54569614400 Yaz; drospirenone-ethinyl estradiol 3 mg-0.02 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 54569627200 Gianvi; drospirenone-ethinyl estradiol 3 mg-0.02 mg oral tablet Oral Contraceptive Pills NDC 54569628000 Previfem; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 54569628100 Tri-Previfem; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 54868044300 Ortho-Norvum 1/35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 54868050700 Nordette; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 54868050801 Ortho-Novum 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 54868050901 Ovcon 35; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 54868051600 Tri-Norinyl ; ethinyl estradio-norethindrone triphasic 0.5 mg-1 mg-0.5 mg oral tablet Oral Contraceptive Pills NDC 54868156400 Levlen; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 54868231600 Seasonale; ethinyl estradiol-levonorgestrel extended cycle 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 54868270100 Ortho-Cept; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 54868404500 Necon 1/35; ethinyl estradiol- norethinrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 54868409300 Ortho Tri-Cyclen; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 54868423900 Trivora- 28; ethinyl estrdiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 54868436900 Ortho Micronor; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 54868424000 Zovia 1/35E-28; ethynodiol diacetate and ethinyl estradiol Oral Contraceptive Pills NDC 54868453800 Necon 0.5/35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 54868459000 Yasmin; drospirenone-ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 54868460700 Levora; ethinyl estradiol-levonorgestrel 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 54868473000 Ortho Tri-Cyclen Lo; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 54868473100 Mircette; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 54868474200 Kariva; desogestrel-ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 54868474500 Microgestin FE 1.5/30; ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 54868475400 Apri; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 54868477600 Nortel 1/35; ethinyl estradiol-norethindrone 35 mcg-1 mg oral tablet Oral Contraceptive Pills NDC 54868477800 Zovia 1/50E-28; ethynodiol diacetate and ethinyl estradiol Oral Contraceptive Pills NDC 54868481400 Camila; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 54868482800 Sprintec; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 54868485000 Low-Ogestrel; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 54868485100 Cryselle 28; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 54868486000 Enpresse; ethinyl estradiol-levonorgestrel triphasic oral tablet Oral Contraceptive Pills NDC 54868502800 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 54868503100 Velivet; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 54868528600 Nortrel 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg- 0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 54868532600 Junel Fe 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 54868535600 Aviane; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 54868582600 TriNessa; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 54868582800 Yaz; drospirenone-ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 54868592200 Ocella; drospirenone-ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 54868593500 Junel Fe 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 54868594200 Kelnor; ethinyl estradiol-ethynodiol 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 54868604400 Microgestin Fe; levonorgestrel and ethinyl estradiol Oral Contraceptive Pills NDC 54868610000 Loestrin 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 54868616100 Femcon FE; ethinyl estradiol-norethindrone with iron 35 mcg- 0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 54868616200 Gianvi; drospirenone-ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 54868621000 Lutera; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 54868627200 Junel 1.5/30; norethindrone acetate and ethinyl estradiol tablet Oral Contraceptive Pills NDC 54868627300 Zenchent; norethindrone and ethinyl estradiol Oral Contraceptive Pills NDC 54868627400 Tilia Fe; norethindrone acetate and ethinyl estradiol Oral Contraceptive Pills NDC 54868627500 LoSeasonique; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 54868627600 Seasonique; ethinyl estradiol-levonorgestrel biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 55289024708 Nordette; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 55289088704 Ogestrel- 28; ethinyl estradiol-norgestrel 50 mcg-0.5 mg oral tablet Oral Contraceptive Pills NDC 55045349701 Low-Ogestrel; ethinyl estradiol-norgestrel 30 mcg-0.3 mg oral tablet Oral Contraceptive Pills NDC 55045349801 Errin; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 55887005228 Microgestin FE 1.5/30 (obsolete); ethinyl estradiol-norethindrone 30 mcg-1.5 mg oral tablet Oral Contraceptive Pills NDC 63187005428 Mononessa; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 63187045828 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 63187074828 NORETHINDRONE TAB 0.35 MG; norethindrone tablet Oral Contraceptive Pills NDC 63187075428 Tri-Lo-Marzia; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 63187088928 Aviane; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 63187089028 Junel Fe 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 65162031658 Lomedia 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 65162031684 Lomedia 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 65162034784 Zenchent Fe; ethinyl estradiol-norethindrone with iron 35 mcg- 0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 66116043628 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 66116047028 Gianvi; drospirenone-ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 66993061528 Cesia; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 68180083711 Tri-Lo-Marzia; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 68180083713 Tri-Lo-Marzia; ethinyl estradiol-norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 68180083811 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 68180083813 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 68180084011 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 68180084013 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel extended cycle 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 68180084311 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel extended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68180084313 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel extended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68180084411 Kurvelo; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 68180084413 Kurvelo; ethinyl estradiol-levonorgestrel 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 68180084611 Daysee; ethinyl estradiol-levonorgestrel extended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68180084613 Daysee; ethinyl estradiol-levonorgestrel extended cycle 30 mcg-0.15 mg oral tablet Oral Contraceptive Pills NDC 68180084811 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 68180084813 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel low dose biphasic extended cycle oral tablet Oral Contraceptive Pills NDC 68180085411 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 68180085413 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 68180085711 Levonorgestrel and Ethinyl Estradiol; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 68180085713 Levonorgestrel and Ethinyl Estradiol; Oral Contraceptive Pills NDC 68180086011 Fayosim; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 68180086012 Fayosim; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 68180086013 Fayosim; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 68180086411 Blisovi 24 FE; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 68180086413 Blisovi 24 FE; ethinyl estradiol-levonorgestrel quadriphasic extended cycle oral tablet Oral Contraceptive Pills NDC 68180086511 Blisovi FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68180086513 Blisovi FE 1/20; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68180086611 Blisovi FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 68180086613 Blisovi FE 1.5/30; ethinyl estradiol-norethindrone with iron 30 mcg- 1.5 mg oral tablet Oral Contraceptive Pills NDC 68180087311 Wymzya Fe; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 68180087313 Wymzya Fe; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 68180087511 Vyfemla; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68180087513 Vyfemla; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 68180087611 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 68180087613 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 68180087711 Jencycla; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 68180087713 Jencycla; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 68180087911 Bekyree; desogestrel and ethinyl estradiol and ethinyl estradiol Oral Contraceptive Pills NDC 68180087913 Bekyree; desogestrel and ethinyl estradiol and ethinyl estradiol Oral Contraceptive Pills NDC 68180088011 Bekyree; desogestrel and ethinyl estradiol and ethinyl estradiol Oral Contraceptive Pills NDC 68180088013 Bekyree; desogestrel and ethinyl estradiol and ethinyl estradiol Oral Contraceptive Pills NDC 68180088211 Enskyce; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 68180088213 Enskyce; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 68180089111 Enskyce; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 68180089113 Enskyce; desogestrel-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 68180088611 Nikki; drospirenone-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 68180088613 Nikki; drospirenone-ethinyl estradiol 0.15 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 68180089211 Pirmella 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75-1 mg oral tablet Oral Contraceptive Pills NDC 68180089213 Pirmella 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75-1 mg oral tablet Oral Contraceptive Pills NDC 68180089311 Pirmella 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68180089313 Pirmella 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68180089713 Ethinyl Estradiol-Norethindrone and Ferrous Fumarate; ethinyl estradiol-norethin- drone with iron 35 mcg- 0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 68180089813 Wymzya Fe; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 68180089913 Wymzya Fe; ethinyl estradiol-norethindrone with iron 35 mcg-0.4 mg oral tablet, chewable Oral Contraceptive Pills NDC 68180090211 Drospirenone-Ethinyl Estradiol; drosprenone-ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 68180090213 Drospirenone-Ethinyl Estradiol; drosprenone-ethinyl estradiol 3 mg-0.03 mg oral tablet Oral Contraceptive Pills NDC 68180090311 Kaitlib FE; ethinyl estradiol-norethindrone with iron 25 mcg-0.8 mg oral tablet, chewable Oral Contraceptive Pills NDC 68180090313 Kaitlib FE; ethinyl estradiol-norethindrone with iron 25 mcg- 0.8 mg oral tablet, chewable Oral Contraceptive Pills NDC 68180090411 Tydemy; drospirenone, ethinyl estradiol and levomefolate calcium and levomefolate calcium Oral Contraceptive Pills NDC 68180090413 Tydemy; drospirenone, ethinyl estradiol and levomefolate calcium and levomefolate calcium
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 68180091111 Mibelas 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet, chewable Oral Contraceptive Pills NDC 68180091113 Mibelas 24 Fe; ethinyl estradiol-norethindrone with iron 20 mcg- 1 mg oral tablet, chewable Oral Contraceptive Pills NDC 68258500502 Necon 7/7/7; ethinyl estradio-norethindrone triphasic 0.5 mg-0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 68462013279 Ethinyl Estradiol-Norethindrone; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68462013281 Ethinyl Estradiol-Norethindrone; ethinyl estradiol-norethindrone 20 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68462030329 Heather; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 68462030384 Heather; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 68462030529 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 68462030584 Norethindrone; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 68462030929 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 68462030984 Ethinyl Estradiol-Norgestimate; ethinyl estradiol-norgestimate 35 mcg-0.25 mg oral tablet Oral Contraceptive Pills NDC 68462031629 Briellyn; ethinyl estradiol- norethindrone 35 mcg- 0.4 mg oral tablet Oral Contraceptive Pills NDC 68462031684 Briellyn; ethinyl estradiol-norethindrone 35 mcg-0.4 mg oral tablet Oral Contraceptive Pills NDC 68462031829 Viorele; desogestrel- ethinyl estradiol biphasic oral tablet Oral Contraceptive Pills NDC 68462931884 Viorele; desogestrel-ethinyl estradio biphasic oral tablet Oral Contraceptive Pills NDC 68462038829 Marlissa; ethinyl estradiol-levonorgestrel 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68462038884 Marlissa; ethinyl estradiol-levonorgestrel 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68462039429 Alyacen 1/35; ethinyl estradiol- norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68462039484 Alyacen 1/35; ethinyl estradiol- norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 68462055629 Alyacen 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 68462055684 Alyacen 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg-0.75 mg-1 mg oral tablet Oral Contraceptive Pills NDC 68462056529 Ethinyl Estradiol-Norgestimate; ethinyl estradiol- norgestimate 35 mcg oral tablet Oral Contraceptive Pills NDC 68462063729 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg-90 mcg oral tablet Oral Contraceptive Pills NDC 68462063784 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel 20 mcg-90 mcg oral tablet Oral Contraceptive Pills NDC 68462064691 Ashlyna; ethinyl estradiol-levonorgestrel extended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68462064693 Ashlyna; ethinyl estradiol-levonorgestrel extended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68462065629 Norethindrone and Acetate and Ethinyl Estradiol; norethindrone acetate and ethinyl estradiol tablet
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 68462065690 Norethindrone and Acetate and Ethinyl Estradiol; norethindrone acetate and ethinyl estradiol tablet Oral Contraceptive Pills NDC 68462065729 Norethindrone and Acetate and Ethinyl Estradiol; norethindrone acetate and ethinyl estradiol tablet Oral Contraceptive Pills NDC 68462065790 Norethindrone and Acetate and Ethinyl Estradiol; norethindrone acetate and ethinyl estradiol tablet Oral Contraceptive Pills NDC 68462067291 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel extended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68462067295 Ethinyl Estradiol-Levonorgestrel; ethinyl estradiol-levonorgestrel extended cycle 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 68462071929 Ethinyl Estradiol-Norgestimate; ethinyl estradiol- norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 68462071984 Ethinyl Estradiol-Norgestimate; ethinyl estradiol- norgestimate triphasic 25 mcg oral tablet Oral Contraceptive Pills NDC 68462072029 Drospirenone-Ethinyl Estradiol; drospirenone- ethinyl estradiol 3 mg-0.02 mg oral tablet Oral Contraceptive Pills NDC 68462072084 Drospirenone-Ethinyl Estradiol; drospirenone- ethinyl estradiol 3 mg- 0.02 mg oral tablet Oral Contraceptive Pills NDC 68462073329 Drospirenone-Ethinyl Estradiol; drospirenone- ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 68462073384 Drospirenone-Ethinyl Estradiol; drospirenone- ethinyl estradiol 3 mg- 0.03 mg oral tablet Oral Contraceptive Pills NDC 68788632502 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 68788633902 Marlissa; ethinyl estradiol-levonorgestrel 30 mcg- 0.15 mg oral tablet Oral Contraceptive Pills NDC 69238103106 Melodetta 24 Fe; norethindrone acetate and ethinyl estradiol and ferrous fumarate Oral Contraceptive Pills NDC 69238103107 Melodetta 24 Fe; norethindrone acetate and ethinyl estradiol and ferrous fumarate Oral Contraceptive Pills NDC 69238153106 Larissia; ethinyl estradiol-levonorgestrel 20 mcg- 100 mcg oral tablet Oral Contraceptive Pills NDC 69238155106 Femynor; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 69238155406 Lillow; levonorgestrel and ethinyl estradiol Oral Contraceptive Pills NDC 69238158306 Norlyda; norethindrone 0.35 mg oral tablet Oral Contraceptive Pills NDC 69238160706 Tri Femynor; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 70700011484 Loryna; drospirenone and ethinyl estradiol tablets Oral Contraceptive Pills NDC 70700011485 Loryna; drospirenone and ethinyl estradiol tablets Oral Contraceptive Pills NDC 70700011584 Syeda; drospirenone and ethinyl estradiol Oral Contraceptive Pills NDC 70700011585 Syeda; drospirenone and ethinyl estradiol Oral Contraceptive Pills NDC 70700011787 Introvale; levonorgestrel and ethinyl estradiol Oral Contraceptive Pills NDC 70700012084 Tri-Lo-Estarylla; norgestimate and ethinyl estradiol Oral Contraceptive Pills NDC 70700012085 Tri-Lo-Estarylla; norgestimate and ethinyl estradiol Oral Contraceptive Pills NDC 75834011529 Drospirenone-Ethinyl Estradiol; drospirenone and ethinyl estradiol Oral Contraceptive Pills NDC 75834011584 Drospirenone-Ethinyl Estradiol; drospirenone and ethinyl estradiol
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Oral Contraceptive Pills NDC 75834011629 Drospirenone-Ethinyl Estradiol; drospirenone and ethinyl estradiol Oral Contraceptive Pills NDC 75834011684 Drospirenone-Ethinyl Estradiol; drospirenone and ethinyl estradiol Oral Contraceptive Pills NDC 75854060101 FaLessa Kit; ethinyl estradiol/folic acid/levonorgestrel 0.02 mg- 1 mg- 0.1 mg oral kit Oral Contraceptive Pills NDC 76388028301 Cyclessa; desogestrel-ethinyl estradiol triphasic oral tablet Oral Contraceptive Pills NDC 76413010428 Cyclafem 7/7/7; ethinyl estradiol-norethindrone triphasic 0.5 mg- 0.75 mg- 1 mg oral tablet Oral Contraceptive Pills NDC 76413010528 Cyclafem 1/35; ethinyl estradiol-norethindrone 35 mcg- 1 mg oral tablet Oral Contraceptive Pills NDC 76413011128 Levonorgestrel and Ethinyl Estradiol; levonorgestrel and ethinyl estradiol Oral Contraceptive Pills NDC 76413011628 Myzilra; levonorgestrel and ethinyl estradiol Oral Contraceptive Pills NDC 76413011828 Norethindrone; norethindrone tablet Oral Contraceptive Pills NDC 76413012128 Previfem; ethinyl estradiol-norgestimate 35 mcg- 0.25 mg oral tablet Oral Contraceptive Pills NDC 76413012828 Tri-Sprintec; ethinyl estradiol-norgestimate triphasic 35 mcg oral tablet Oral Contraceptive Pills NDC 76413013028 Yasmin; drospirenone-ethinyl estradiol 3 mg- 0.03 mg oral tablet Patch ICD10CM Z30.016 Encounter for initial prescription of transdermal patch hormonal contraceptive device Patch ICD10CM Z30.45 Encounter for surveillance of transdermal patch hormonal contraceptive device Patch HCPCS J7304 Contraceptive supply, hormone containing patch, each Patch NDC 00378334053 Xulane; NORELGESTROMIN/ETHIN.ESTRADIOL Patch NDC 00378334016 Xulane; NORELGESTROMIN/ETHIN.ESTRADIOL Patch NDC 00378334017 Xulane; NORELGESTROMIN/ETHIN.ESTRADIOL Patch NDC 00378334032 Xulane; NORELGESTROMIN/ETHIN.ESTRADIOL Patch NDC 50458019201 Ortho Evra; ethinyl estradiol-norelgestromin 35 mcg-150 mcg/24 hr transdermal film, extended release Patch NDC 50458019215 Ortho Evra; ethinyl estradiol-norelgestromin 35 mcg-150 mcg/24 hr transdermal film, extended release Vaginal Ring ICD10CM Z30.015 Encounter for initial prescription of vaginal ring hormonal contraceptive Vaginal Ring ICD10CM Z30.44 Encounter for surveillance of vaginal ring hormonal contraceptive device Vaginal Ring HCPCS J7303 Contraceptive supply, hormone containing vaginal ring, each Vaginal Ring NDC 00052027301 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 00052027303 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 54868483201 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 00052027385 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 76413013103 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 00052027304 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 00052027305 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 00052027381 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 50090100800 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Vaginal Ring NDC 54569586500 NuvaRing; ethinyl estradiol-etonogestrel 0.015 mg-0.120 mg vaginal ring Diaphragm CPT 57170 Diaphragm or cervical cap fitting with instructions
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Diaphragm HCPCS A4266 Diaphragm for contraceptive use Diaphragm HCPCS A4261 Cervical cap for contraceptive device Diaphragm NDC 00027013160 Koromex Diaphragm Coil 60 mm Diaphragm NDC 00027013180 Koromex Coil Diaphragm 80 mm Diaphragm NDC 00062330100 Ortho Flexible Diaphragm Kit 55 mm Diaphragm NDC 00062330200 Ortho Diaphragm Kit All-Flex 60mm Diaphragm NDC 00062330300 Ortho Diaphragm Kit All-Flex 65mm Diaphragm NDC 00062330400 Ortho Diaphragm Kit All-Flex 70mm Diaphragm NDC 00062330500 Ortho Diaphragm Kit All-Flex 75mm Diaphragm NDC 00062330600 Ortho Diaphragm Kit All-Flex 80mm Diaphragm NDC 00062330700 Ortho Diaphragm Kit All-Flex 85mm Diaphragm NDC 00062330800 Ortho Diaphragm Kit All-Flex 90mm Diaphragm NDC 00062330900 Ortho Flexible Diaphragm 95mm Diaphragm NDC 00062334100 Ortho Coiled Spring Diaphragm Kit 55 mm Diaphragm NDC 00062334200 Ortho Coiled Spring Diaphragm Kit 60 mm Diaphragm NDC 00062334300 Ortho Diaphragm Kit Coil Spring 65mm Diaphragm NDC 00062334400 Ortho Diaphragm Kit Coil Spring 70mm Diaphragm NDC 00062334500 Ortho Diaphragm Kit Coil Spring 75mm Diaphragm NDC 00062334600 Ortho Diaphragm Kit Coil Spring 80mm Diaphragm NDC 00062334700 Ortho Diaphragm Kit Coil Spring 85mm Diaphragm NDC 00062334800 Ortho Coiled Spring Diaphragm Kit 90 mm Diaphragm NDC 00062334900 Ortho Coiled Spring Diaphragm Kit 95 mm Diaphragm NDC 00062335000 Ortho Coiled Spring Diaphragm Kit 50 mm Diaphragm NDC 00062335100 Ortho Coiled Spring Diaphragm Kit 100 mm Diaphragm NDC 00062335200 Ortho Coiled Spring Diaphragm Kit 105 mm Diaphragm NDC 00062338100 Ortho Flat Spring Diaphragm Kit 55 mm Diaphragm NDC 00062338200 Ortho Flat Spring Diaphragm Kit 60 mm Diaphragm NDC 00062338300 Ortho Flat Spring Diaphragm Kit 65 mm Diaphragm NDC 00062338400 Ortho Flat Spring Diaphragm Kit 70 mm Diaphragm NDC 00062338500 Ortho Flat Spring Diaphragm Kit 75 mm Diaphragm NDC 00062338600 Ortho Flat Spring Diaphragm Kit 80 mm Diaphragm NDC 00062338700 Ortho Diaphragm Kit Flat Spring 85mm Diaphragm NDC 00062338800 Ortho Flat Spring Diaphragm Kit 90 mm Diaphragm NDC 00062338900 Ortho Flat Spring Diaphragm Kit 95 mm Diaphragm NDC 00062364103 Ortho All-Flex Fitting Diaphragm Set Diaphragm NDC 00062364300 Ortho Coil Spring Fitting Diaphragm Set Diaphragm NDC 00234005100 Koromex Diaphragm
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org Integrity • Accountability • Collaboration • Trust • Respect
Contraceptive Type Code Set Code Description Diaphragm NDC 00234013100 Koromex Diaphragm Diaphragm NDC 00234013150 Koromex Diaphragm Diaphragm NDC 00234013155 Koromex Diaphragm Diaphragm NDC 00234013160 Koromex Diaphragm Diaphragm NDC 00234013165 Koromex Diaphragm Diaphragm NDC 00234013170 Koromex Diaphragm Diaphragm NDC 00234013175 Koromex Diaphragm Diaphragm NDC 00234013180 Koromex Diaphragm Diaphragm NDC 00234013185 Koromex Diaphragm Diaphragm NDC 00234013190 Koromex Diaphragm Diaphragm NDC 00234013195 Koromex Diaphragm Diaphragm NDC 00234013600 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00234013660 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00234013665 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00234013670 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00234013675 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00234013680 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00234013685 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00234013690 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00234013695 Koro-Flex Arcing Spring Diaphragm Diaphragm NDC 00396401065 Omniflex Diaphragm Silicone 65mm Diaphragm NDC 00396401070 Arcing Diaphragm Silicone 70mm Diaphragm NDC 00396401075 Arcing Diaphragm Silicone 75mm Diaphragm NDC 00396401080 Omniflex Diaphragm Silicone 80mm Diaphragm NDC 63704002001 Caya Contoured Diaphragm Diaphragm NDC 00062331000 Ortho All-Flex Diaphragm, 65 mm Exp. 5/31/17 Diaphragm NDC 00062331100 Ortho All-Flex Diaphragm, 70 mm Exp. 6/30/17 Diaphragm NDC 00062331200 Ortho All-Flex Diaphragm, 75 mm (obsolete) Diaphragm NDC 00062331300 Ortho All-Flex Diaphragm, 80 mm Exp. 11/30/16
711 East Daily Drive, Suite 106, Camarillo, CA 93010 | 1-888-301-1228 | www.goldcoasthealthplan.org