Drug List – Contraceptives – Expanded Offering – 2021 ESI Standard Offering – Contraceptives

Preventive Items and Services

Following is a list of contraceptives that are currently included in the Express Scripts’ standard contraceptive expanded offering for the Preventive Items and Services Program. Contraceptives are provided at a zero cost share. Please note that Multi Source Brand contraceptives** are only available at a zero cost share when specific plan requirements are met. The list is subject to change.

Please note: coverage of medications at $0 cost share is dependent on the list of medications covered by your drug formulary. Please refer to your drug formulary first before making an assumption that coverage of a medication is $0.

* Indicates Single Source Brand product **Indicates Multi Source Brand product

Cervical Cap Emergency FEMCAP* AFTERA** ECONTRA EZ Diaphragm FALLBACK SOLO CAYA CONTOURED* MY WAY WIDE SEAL DIAPHRAGM* NEW DAY NEXT CHOICE OPCICON ONE-STEP Emergency/progestin blocker OPTION 2 PLAN B ONE-STEP** ELLA* TAKE ACTION**

Female Condom Implantable Rod FC2 FEMALE CONDOM* NEXPLANON*

Injection IUD Copper DEPO-PROVERA** PARAGARD T 380-A* DEPO-SUBQ PROVERA 104* MEDROXYPROGESTERONE IUD/progestin LILETTA* MIRENA* SKYLA* KYLEENA*

Preventive Items and Services – Drug List - Contraceptives

Oral Contraceptives-Combined

AFIRMELLE JULEBER PIMTREA ALTAVERA JUNEL/FE /FE 24 PIRMELLA ALYACEN KAITLIB FE PORTIA AMETHYST KALLIGA PREVIFEM APRI KARIVA RECLIPSEN ARANELLE KELNOR SAFYRAL** AUBRA/EQ KURVELO SIMLIYA AUROVELA /FE /24 FE LARIN/FE 24 FE SPRINTEC AVIANE LARISSIA SRONYX AYUNA LAYOLIS FE SYEDA AZURETTE LEENA TARINA FE /24 FE / EQ BALCOLTRA* LESSINA TAYTULLA* BALZIVA LEVONEST TILIA FE BEKYREE LEVONORGESTREL-E.E. TRI FEMYNOR BEYAZ** LEVORA TRI-ESTARYLLA BLISOVI FE /24 FE LILLOW TRI-LEGEST FE BRIELLYN LO LOESTRIN FE* TRI-LINYAH CAZIANT LOESTRIN/FE** TRI-LO-ESTARYLLA CHARLOTTE LORYNA TRI-LO-MARZIA CHATEAL/EQ LOW-OGESTREL TRI-LO-MILI CRYSELLE LO-ZUMANDIMINE TRI-LO-SPRINTEC CYCLAFEM LUTERA TRI-MILI CYRED/EQ MARLISSA TRI-PREVIFEM DASETTA MELODETTA 24 FE TRI-SPRINTEC DESOGESTREL-E.E. MIBELAS 24 FE TRIVORA DROSPIRENONE-E.E. MICROGESTIN/FE TRI-VYLIBRA ELINEST MILI TYBLUME** EMOQUETTE MINASTRIN 24 FE** TYDEMY ENPRESSE MIRCETTE** VELIVET ENSKYCE MONO-LINYAH VIENVA ESTARYLLA NATAZIA* VIORELE ESTROSTEP FE** NECON VOLNEA ETHYNODIOL-E.E. NIKKI VYFEMLA FALMINA NORETHINDRONE-E.E./FE VYLIBRA FEMYNOR NORGESTIMATE-E.E. WERA GEMMILY NORGESTREL-E.E. WYMZYA FE GENERESS FE** NORTREL YASMIN** GIANVI OCELLA YAZ** HAILEY /24 FE OGESTREL ZARAH ISIBLOOM ORSYTHIA ZOVIA JASMIEL PHILITH ZUMANDIMINE

Preventive Items and Services

Oral Contraceptive-Continuous Patch AMETHIA / LO XULANE ASHLYNA TWIRLA* CAMRESE / LO DAYSEE Spermicide FAYOSIM GYNOL II INTROVALE PHEXXI* JAIMIESS / LOJAIMIESS VCF FILM* JOLESSA VCF FOAM LEVONORGESTREL-E.E. VCF GEL* LOSEASONIQUE** QUARTETTE** RIVELSA Sponge SEASONIQUE** TODAY CONTRACEPTIVE SPONGE* SETLAKIN SIMPESSE

Vaginal Ring Oral Contraceptive-Progestin ONLY ANNOVERA* CAMILA ELURYNG DEBLITANE ETONOGESTREL-E.E. HEATHER NUVARING** INCASSIA JENCYCLA LYZA NORA-BE NORETHINDRONE NORLYDA NORLYROC SHAROBEL SLYND TULANA