Standard Health Pals Formulary
Norgestimate 0.18 mg / Ethinyl Estradiol 0.035 mg Tablet Pack (Generic for Ortho Tri-Cyclen)
Coverage Level – 100%
Copay – $0
Limitations – No more than 90 days’ supply
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – Generic for Ortho Tri-Cyclen