Clickable Table
| Generic Name | Brand Name | Strength | Dosing | 90 Day Cost | Coverage | Comments | Category 1 | Category 2 |
|---|---|---|---|---|---|---|---|---|
| Norethindrone AcetateLolo | Lolo | QD | $85 | BC - NC / NIHB - Covered |
H
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 | ||
| Norethindrone | Synphasic | QD | $60 | BC / NIHB - Covered |
H
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 | $30 | BC / NIHB - Covered |
H
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 / NIHB - Covered |
H
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 | Seasonique | QD | $95 | BC - NC / NIHB - Covered |
H
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 / NIHB - Covered |
H
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 / NIHB - Covered |
H
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 | $65 | BC / NIHB - Covered |
H
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 / NIHB - Covered |
Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days. |
H
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 / NIHB - Covered |
Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days. |
H
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 | Kyleena | IUD | As dir | $20 | BC / NIHB - Covered |
Upfront cost is $396 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $20 every 90 days |
H
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.
|
Intrauterine Devices (IUDs) |
| Levonorgestrel | Mirena | IUD | As dir | $25 | BC / NIHB - Covered |
Upfront cost is $422 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $21 every 90 days |
H
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.
|
Intrauterine Devices (IUDs) |
| Norelgestromin | Evra | Patch | As dir | $100 | BC - NC / NIHB - Covered |
H
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 | $65 | BC - NC / NIHB - Covered |
H
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 |