Standard Health Pals Formulary
Levonorgestrel 1.5 mg Tablet (Generic for Plan B One Step)
Coverage Level – 100%
Copay – $0
Limitations – No more than 90 days’ supply; Maximum of 1 box in 30 days; Maximum of 3 boxes in 90 days.
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – Generic for Plan B One Step