Standard Health Pals Formulary
Spermicide
Coverage Level – 100%
Copay – $0
Limitations – One of the following: may be dispensed in a 30-day time period. No 90 days dispensing is available.
- 10 spermicide applicators
- 9 spermicide films
- One (1) spermicide bottle
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – N/A