FillMapCapital Blue Cross Value (HMO)

Does Capital Blue Cross Value (HMO) cover ethinyl estradiol / levonorgestrel / inert ingredients?

Capital Blue Cross Value (HMO)
H3962-004-0 · MA_LOCAL · Medicare Part D
ethinyl estradiol / levonorgestrel / inert ingredients
Do you get help with your Medicare drug costs?None of these

Optional. Some plans charge less at a preferred pharmacy. Enter your ZIP to see which pharmacies near you take this plan — pick yours and the price above is re-worked for it. Until you do, we show what a standard pharmacy costs. Nothing here is saved.

ethinyl estradiol / levonorgestrel / inert ingredientsunder Capital Blue Cross Value (HMO)
Covered — just walk in
Nothing to clear first — take the prescription to an in-network pharmacy.
What you'd pay
$47per 30-day fill

Part D caps what you pay out of pocket at $2,100 for 2026. Before that, you pay the full price until you have paid $100 this year.

This plan charges the same at every pharmacy in its network — where you fill it will not change this figure.

Tier
Tier 3
Approval first
Not needed
Try another first
No
Amount limit
None
Talk to your pharmacist or doctor before acting on anything here. They can see your full history and this page cannot. Never start, stop, or switch a medication based on it. Coverage rules change and plans make exceptions — your pharmacy can check your exact benefit in seconds.As of Sep 16, 2026 · CMS Part D monthly PUF. Reference information, not medical advice and not a price.

Covered forms and strengths (16)

  • {21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } PackTier 3
  • {21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Aubra 28 Day]Tier 3
  • {21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Aviane 28]Tier 3
  • {21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Falmina 28 Day]Tier 3
  • {21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Lessina 28 Day]Tier 3
  • {21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Vienva 28 Day]Tier 3
  • {21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Altavera 28 Day]Tier 3
  • {21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Kurvelo]Tier 3
  • {21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Marlissa 28 Day]Tier 3
  • {21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Portia 28 Day]Tier 3
  • {6 (ethinyl estradiol 0.03 MG / levonorgestrel 0.05 MG Oral Tablet) / 10 (ethinyl estradiol 0.03 MG / levonorgestrel 0.125 MG Oral Tablet) / 5 (ethinyl estradiol 0.04 MG / levonorgestrel 0.075 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } PackTier 3
  • {6 (ethinyl estradiol 0.03 MG / levonorgestrel 0.05 MG Oral Tablet) / 10 (ethinyl estradiol 0.03 MG / levonorgestrel 0.125 MG Oral Tablet) / 5 (ethinyl estradiol 0.04 MG / levonorgestrel 0.075 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Levonest 28 Day]Tier 3
  • {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } PackTier 3
  • {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Iclevia 91 Day]Tier 3
  • {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Introvale 91 Day]Tier 3
  • {84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Setlakin 91 Day]Tier 3

← All coverage for ethinyl estradiol / levonorgestrel / inert ingredients