Clickable Table

Generic Name Brand Name Strength Dosing 90 Day Cost Coverage Comments Category 1 Category 2
Norethindrone Synphasic QD $60 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
1st Generation Progestins
Levonorgestrel Alesse QD $40 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Levonorgestrel Min-Ovral QD $40 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Levonorgestrel Triquilar QD $70 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Desogestrel Marvelon QD $40 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
3rd Generation Progestins
Norgestimate Tri-Cyclen QD $110 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
3rd Generation Progestins
Norgestimate Tri-Cyclen Lo QD $70 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
3rd Generation Progestins
Drospirenone Yasmin QD $60 BC / IA - Covered

Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days.

Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Anti-Androgenic
Drospirenone YAZ QD $75 BC - NC; IA - Covered

Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days.

Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Anti-Androgenic
Levonorgestrel Mirena IUD As dir $20 BC / IA - Covered

Upfront cost is $396 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $20 every 90 days

Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
IUD
Copper IUD Mona Lisa IUD As dir $5 BC / IA - Covered

Upfront cost is $89 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $4 every 90 days

Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
IUD
Norelgestromin Evra Patch As dir $80 BC - NC; IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Transdermal Vaginal
Etonogestrel Nuvaring Vaginal ring As dir $70 BC - NC; IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Transdermal Vaginal
Legend:
BC = Alberta Blue Cross, IA = Indian Affairs, NC = Not covered, SA = special authorization, SR = sustained release, OTC = over the counter, SQ = subcutaneous injection, SS=Social Services