3.0 FORMULARY LIST FOR USE IN FAMILY PLANNING
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1 3.0 FORMULARY LIST FOR USE IN FAMILY PLANNING
2 2018 Provider Agreement Pharmacy Formulary NMDOH Family Planning Program Order questions: Joshua Rodriguez (505) , Julie Roybal (505) , or Vandora Montoya (505) Description Unit Azithromycin 500 mg Each -- A699UD 1 Betadine Swab Stick 3/Pack -- M356N 1 Ceftriaxone Inj 250 mg (Rocephin) -- A678D 1 Chlorhexidine Gluconate Soap 4% 8 oz btl -- M324S 1 Condom Female FC2 -- M301E 1 Condom Male Lube/Extra Lube #1 box -- A614D or A612B 1 Contraceptive Foam W/App Single Can Only --M304S 1 Cycle Beads -- M32CB 1 Exam Gown Paper Case 50/box --M316S 1 Exam Half Gown Paper Case 50/box -- M317S 1 Exam Sheets 40x48 100/box #1 box -- M312E 1 Exam Table Sheeting 18x225 ft 12/case -- M318S 1 Forceps Curved 10 M321S 1 Forceps Forester Sponge M309D 1 Gloves, Exam Pwd Free Latex Large 100/box -- M334L 1 Gloves, Exam Pwd Free Latex Medium 100/box -- M334M 1 Gloves, Exam Pwd Free Latex Small 100/box -- M334Y 1 IUD Levonorgestrel 52mg -- M398DD 1 IUD Paragard -- M397D 1 Levonorgestrel 1.5 mg #1 (emergency contraceptive pill) -- M388PB 1 Lubricating Jelly 113 gm btl -- M M-Progesterone Inj. 150 mg/1 ml (Generic Depo) -- M38ST 1 Metronidazole Vaginal Gel 0.75% w 5 appl 70 gm tube -- M334V 1 Nuvaring 3/Box (Needs to be refrigerated) -- M361A 1 OCP Class I 20 mcg (ORDER multiples of 6) 1 OCP Class II 28 DAY cycle 30 mcg EE (ORDER multiples of 6) 1 OCP Class II 91 DAY cycle (ORDER multiples of 2) 1 OCP Class III 35 mcg (Norethindrone) (ORDER multiples of 6) 1 OCP Class IV 35 mcg (Norgestimate) (ORDER multiples of 6) 1 OCP Class V Progesterone Only Pill (ORDER multiples of 6) 1 OCP Class VI Phasic Pills (ORDER multiples of 6) 1 OCP Compact Veridate Dispenser each -- M354S 1 Ovulation Thermometer #1 1 Family Planning Program Protocol/FPP - 7/18 Section 3 Page 1 of 4
3 Pipelle, Biopsy Uterine #1 1 Pregnancy Test Controls (CONSULT) #1 M3106C 1 Pregnancy Test KIT CONSULT 25/box #1 Box M3106K 1 Prenatal Vitamins 100/btl M320D 1 Speculum Graves 35 x 150mm M344X 1 Speculum Graves Large M344S 1 Speculum Graves Medium M343S 1 Speculum Graves Small M342S 1 Speculum Pederson Large M347S 1 Speculum Pederson Medium M346S 1 Speculum Pederson Small M345S 1 TCA 80% in Alcohol 70% 15 ml -- A691R 1 Uterine Forceps 9.5 Tenaculum M351S 1 Uterine Scissors 9 curved M352C 1 Uterine Sound Ungraduated M361S 1 Uterine Sound M353S 1 Vacutainer Eclipse Needle 21g 1¼" each -- A685O 1 Vacutainer Eclipse Needle 22g 1¼" each -- A682O 1 Vacutainer Holder each -- A665O 1 Vacutainer Tiger Top 10 ml -- A669T 25, 50 Vaginal Contraceptive Film (VCF) 12's -- M389P 1 SITES WITH NEXPLANON TRAINED CLINICIAN ONLY FORCEPS MOSQUITO 5 INCH CURVED EACH -- M378N 1 FORCEPS MOSQUITO 5 INCH STRAIGHT EACH -- M377N 1 GLOVES Surgical Latex SIZE 8 1/2 PAIR (sterile) -- M386N 1 GLOVES Surgical Latex SIZE 6 1/2 PAIR (sterile) -- M379N 1 NEXPLANON M32NE ORDER AT TOP OF PAGE 1 NEXPLANON INSERTION KIT -- M348N 1 NEXPLANON REMOVAL KIT -- M348NR 1 LIDOCAINE w EPI 1% 20ml #1 -- M365F 1 SKIN CLOSURES 1/4" X 3" #3/BOX -- M364N 1 Family Planning Program Protocol/FPP - 7/18 Section 3 Page 2 of 4
4 OCP Substitute Table Listed by class and alphabetical order in each choice. OCP brands may vary due to manufacturer availability and cost. Class First Choice Second Choice Third Choice Combined Oral Contraceptive (COC) Class I: 0.1 mg levonorgestrel/ 20 mcg ethinyl estradiol (ee) Aviane Orsythia (CI-20) Lessina Sronyx Lutera Class II: 0.3 mg norgestrel/ 1 mg. norethindrone/ Gildess Fe 1/20* Junel Fe 1/20 Loestrin Fe 1/20 Microgestin Fe 1/ mg levonorgestrel/ 1.5 mg norethindrone/ (CII-30) Class III: / Norethindrone (CIII-35) Class IV: 35 mcg. ee/ Norgestimate (CIV-35) Cryselle Low-Ogestrel Lo/Ovral* 1 mg norethindrone/ Alyacen 1/35 Cyclafem 1/35 Necon 1/35 Norinyl 1+35 Nortrel 1/35 ON 1/ mg norgestimate/ MonoNessa Ortho Cyclen Previfem Sprintec Altavera 0.15/30 Levora Nordette* Portia Seasonale* Seaonique 0.5 mg norethindrone/ Aranelle Brevicon 0.5/35* Modicon* Necon 0.5/35 Nortrel 0.5/35 Gildess Fe 1.5/30* Junel Fe 1.5/30 Loestrin Fe 1.5/30 Microgestin Fe 1.5/ norethindrone/ Balziva Briellyn Ovcon 35 Zenchent Family Planning Program Protocol/FPP - 7/18 Section 3 Page 3 of 4
5 Class First Choice Second Choice Third Choice Progestin Only Pill (POP) Class V: 0.35 mg norethindrone Progestin Only Pill Camila Errin Heather Nor-QD (CV-POP) Jolivette Nora-BE Micronor Class VI: Phasic Pills (CVI-Triphasic) Norgestimate Levonorgestrel 7 D 0.18 mg norgestimate/ 7 D mg nor./ 7 D 0.25 mg nor./ Ortho Tri-Cyclen Lo 6 D 0.05 mg levonorgestrel/ 5 D lev./ 40 mcg ee 10 D mg lev./ 7 D 0.18 mg norgestimate/ 7 D mg nor./ 7 D 0.25 mg nor./ Ortho Tri-Cyclen TriNessa Tri-Previfem Tri-Sprintec Norethindrone Enpresse Trivora 7 D 0.5 mg norethindrone/ 7 D 0.75 mg nor./ 7 D 1 mg nor./ Alyacen 7/7/7 Cyclafem 7/7/7 Necon 7/7/7 Nortrel 7/7/7 ON 7/7/7 7 D 0.5 mg norethindrone/ 9 D 1 mg nor./ 5 D 0.5 mg nor./ Leena Tri-Norinyl 5 D 1 mg norethindrone/ 7 D 1 mg nor./ 9 D 1 mg nor./ Estrostep Fe Tilia Fe Tri-Legest Fe *These OCPs are included for reference purposes only, they are currently not available. Reference: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20 th revised edition. New York: Ardent Media; Family Planning Program Protocol/FPP - 7/18 Section 3 Page 4 of 4
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See Monograph for Details Alesse, Aviane, Lessina, Levlite, Lutera, Sronyx Monophasic Ethinyl estradiol 20 mcg Levonorgestrel 0.1 mg Angeliq Monophasic Estradiol 1 mg Drospirenone 0.5 mg Approved in Europe
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