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Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol Medicare Part D Coverage

Brand name: Rivelsa
Dosage form
KIT
31%
of Medicare Part D plans
cover Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol
1,702 of 5,530 plans
2.7
Avg. formulary tier
$8.00
Median 30-day copay
$0.00–$16.00
Copay range

Formulary Tier Distribution

How Medicare Part D plans classify Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol. Lower tiers = lower copays.

Tier 1 - Preferred Generic 3%
46 plans • avg $0.00/mo
Tier 2 - Generic 35%
589 plans • avg $5.40/mo
Tier 3 - Preferred Brand 55%
933 plans • avg $0.08/mo
Tier 4 - Non-Preferred Drug 8%
134 plans • avg $0.00/mo

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Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol Medicare Coverage by State

Coverage rates and average costs vary significantly by state. Click a state to see the specific plans available there.

Alabama 100% avg $4.46 Arizona 100% avg $2.00 Arkansas 100% avg $14.95 California 100% Colorado 100% avg $2.38 Connecticut 100% avg $10.00 Delaware 100% avg $9.00 District of Columbia 100% avg $8.00 Florida 100% avg $2.57 Georgia 100% avg $4.26 Hawaii 100% Idaho 100% avg $6.67 Illinois 100% avg $2.18 Indiana 100% Iowa 100% Kansas 100% avg $8.00 Kentucky 100% avg $4.00 Louisiana 100% Maine 100% avg $1.56 Maryland 100% avg $2.00 Massachusetts 100% Michigan 100% Minnesota 100% Mississippi 100% avg $8.80 Missouri 100% avg $8.00 Montana 100% Nebraska 100% Nevada 100% avg $8.00 New Hampshire 100% New Jersey 100% avg $3.15 New Mexico 100% avg $8.00 New York 100% avg $1.62 North Carolina 100% avg $6.66 North Dakota 100% Ohio 100% avg $0.34 Oklahoma 100% avg $5.00 Oregon 100% avg $3.60 Pennsylvania 100% avg $6.48 Rhode Island 100% South Carolina 100% avg $2.67 South Dakota 100% Tennessee 100% avg $6.19 Texas 100% avg $2.02 Utah 100% avg $8.00 Virginia 100% avg $12.00 Washington 100% avg $1.00 West Virginia 100% Wisconsin 100% Wyoming 100%

Related Versions of Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol

camrese Lo Brand

Frequently Asked Questions about Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol

31% of Medicare Part D plans cover Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol. It is most commonly placed on Tier 3. Coverage varies by plan and geographic area.

The median 30-day copay for Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol on Medicare Part D is $8.00 at a preferred pharmacy. Costs range from $0.00 to $16.00 depending on the plan.

Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol is placed on Tier 3 by most Medicare Part D plans. Lower tier numbers generally mean lower copays.

0% of plans require prior authorization for Levonorgestrel/Ethinyl Estradiol and Ethinyl Estradiol. Prior authorization means your doctor must confirm the drug is medically necessary before the plan will cover it.

Coverage statistics based on CMS formulary data for plan year 2026. Data updated regularly. Methodology →