norelgestromin/ethinyl estradiol

150 mcg-35 mcg/24 hour — Patch

Also known as: ZAFEMY NORELGESTROMIN-ETH ESTRADIOL XULANE

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: Excel (XLSX) · Formulary date: Jun 24, 2026 · Checked: 3 hours, 50 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Basic Core Formulary	—	—	—	None