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Levonorgestrel 90 mcg / Ethinyl Estradiol 20 mcg Tablet Pack (Generic for Lybrel and Amethyst)

Coverage Level – 100%

Copay – $0

Limitations – No more than 90 days’ supply

Restrictions – Health Pals Mail Order Pharmacy Network

Comments – Generic for Lybrel 90 mcg / 20 mcg and Amethyst 90 mcg / 20 mcg