Standard Health Pals Formulary
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