Focus on long-acting reversible contraception 2015

Transcription

1 Focus on long-acting reversible contraception 2015

2 Anita Sheetz, CNM, is an employee at the Mesa County Health Department working in the family planning and STD clinic. She has no financial disclosures. Dr. Betsy Longenecker is associate medical director for Rocky Mountain Health Plans. She also works for the St. Mary s Family Medicine residency and often precepts residents at the Mesa County Health Department family planning and STD clinic. Dr. Brittney Beeler is a clinical pharmacist at Rocky Mountain Health Plans. None of the presenters have any financial relationship with the makers of any contraceptive device or medication.

3 Typical use* Perfect use No method 85% 85% Spermicides** 29% 18% Withdrawal 27% 4% Fertility awareness--based methods 25% Combined pill and progestin-only pill 8% 0.3% Evra patch(r) 8% 0.3% NuvaRing(r) 8% 0.3% Depo-Provera(r) 3% 0.3% Intrauterine device ParaGard(r) (copper T) 0.8% 0.6% Mirena(r) (LNG-IUS) 0.2% 0.2% Implanon(r) 0.05% 0.05% CDC

4 Colorado Dept. of Health Perspectives on Sexual and Reproductive Health, 2014, 46, (3):

5 Nexplanon: etonorgestrel subdermal implant 3 years Paragard: Copper containing IUD- 10 years Mirena: levonorgestrel containing IUD, (LNG IUS) 5 years Skyla: LNG IUS 3 years Liletta: LNG IUS 3 years

6 Copper IUD LNG IUS Contraceptive implant spermicidal spermicidal Inhibition of ovulation Inhibition of sperm and ovum migration Inhibition of sperm and ovum migration Thickening of cervical mucus Thickening of cervical mucus Thinning of endometrium Thinning of endometrium Ob Gyn, vol 117, (3), Mar 2011

7 The following patients are rated WHO and CDC category 4 (risks outweigh the benefits) for LNG- IUDs year old smoker year old G4P4 with menorrhagia x 1 year, Hgb 11.2, negative pap but no other work-up year old G0 with 5 sexual partners in last 12 months year old with breast cancer Answers A. 1, 2, and 3 B. 1 and 3 C. 2 and 4

8 Contraindications to IUD Breast cancer Cervical or endometrial cancer Current PID Pregnancy Distorted uterine cavity Unexplained uterine bleeding Severe liver disease SLE with + Antiphospholipid antibodies CDC MEC criteria

9 Mirena greater than 1 year 20-33% Mirena greater than 2 years 70% Skyla greater than 3 years 12% Liletta greater than 3 years 38% Nexplanon greater than 1 year..? 45%

10 LARC Satisfaction rate Continuation rate 12 and 24 mos Failure rate Common reasons for DC Copper IUD 80% 84%/77%.6-.8% Pain cramping 34% LNG IUS Mirena Subdermal implant, (Nexplanon) 86% 88%/79%.2% Pain/crampi ng 28% 79% 83%/69%.05% Irregular bleeding 53% OCPs 54% 55-59%/43% 9% Injectable DMPA 54% 56-58%/38% 6% patch 44% 49%/40% 9% Vaginal ring 53% 54-56%/41% 9% Data from CHOICE project

11 Removal rates within 1 year Age Age Age implant LNG IUS Implant LNG IUS Implant LNG IUS 12.4% 11.7% 15.1 % 12.8% 16.6% 11.8% AJOG June 2015

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14 There is no risk of infertility from use of currently available long-acting reversible contraceptives such as IUDs or Nexplanon.

15 Baseline fertility is restored, and rapidly For example: After Nexplanon removal, etonorgestrel drops to 0 within 1 week= rapid return of fertiltiy

16 A 32-year-old gravida 2 now para 2 female, 10 weeks postpartum, breast-feeding, desires an IUD for contraception. The following statements are true about the advisability of an IUD placement in this situation

17 1. The CDC US medical eligibility criteria consider all LARCs to be category 1(benefits outweigh risks) in this clinical situation 2. IUDs should never be placed until greater than 12 weeks postpartum 3. Insertion of IUDs within 4 weeks of birth is associated with an increased risk of expulsion and insertion less than 36 weeks postpartum is associated with an increased risk of perforation 4. Levonorgestrel-containing IUDs and Nexplanon are contraindicated in breast feeding women ANSWERS A. All of the above B. None of the above C. 2 and 4 D. 1 and 3

18 1. The CDC US medical eligibility criteria consider all LARCs to be category 1(benefits outweigh risks) in this clinical situation 3. Insertion of IUDs within 4 weeks of birth is associated with an increased risk of expulsion and insertion less than 36 weeks postpartum is associated with an increased risk of perforation LARCs are OK in breast feeding women per WHO and CDC, but there is limited evidence directed at this subject. Risks of expulsion and perforation from IUDs are higher if done closer to delivery--?12-17% expulsion, overall risk is 2.2/1,000.? Increase in risk <6weeks 10 x higher = 2.2/100 However, IUDs have been used reliably, especially in other countries immediately post partum if access to follow up is difficult. AFP, 89: (6), Mar 15, 2014,

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20 A 22-year-old female with a Mirena IUD in place for 2 years presents with subacute lower abdominal and pelvic pain, and evidence of cervicitis and cervical motion tenderness on exam. Generally recommended treatment includes which of the following: A. Removal of IUD plus ceftriaxone 250 mg IM and doxycycline 100 twice a day 14 days B. Ceftriaxone 250 mg IM and doxycycline 100 twice a day +/- metronidazole x 14 days C. Removal of the IUD and azithromycin 2 g by mouth 1. Recheck in 48 hours D. Ceftriaxone 250 mg IM and doxycycline 100 mg twice a day 7 days

21 PID with IUS in place. Conflicting studies, but no clear evidence that removal of IUD speeds recovery or that leaving it in place is associated with greater long term complications. Ref: CDC

22 23-year-old gravida 1 para 1 female with a Mirena in place for 18 months comes in complaining of more persistent spotting and mild pelvic tenderness. Appropriate initial workup includes Urine pregnancy test Pelvic exam Visualization of strings STI screening

23 Pregnancy test positive Recommended course of treatment is A. Immediate removal of the IUD B. Pelvic ultrasound and IUD removal C. Pelvic ultrasound and careful surveillance during pregnancy without removal of IUD

24 First, rule out ectopic pregnancy IUD removal: benefits outweigh risks ACOG Leaving IUD in place is associated with significant increased risk of preterm labor, chorioamnionitis, SAB-(50%) Balanced with markedly increased risk of spontaneous abortion following removal approximately 25% Shared decision-making

25 Per MCHD protocol, patient needs to have been on a reliable method of contraception, be within a few days of period, and have a urine HCG for all LNG containing methods Back-up required for 7 days for all except Cu containing IUDs per MCHD protocol, and package insert unless inserted within 1 st 7 days of cycle, (but all are likely immediately effective) STI testing (screening) can be done at time of insertion of IUS Insertion of implant does not require pelvic exam

26 No sure fire method or intervention that makes insertion less painful or more successful Oral misoprostol pre-insertion has been tried for cervical dilatation. Statistically it has not shown any benefit The use of topical or injected lidocaine within the cervix or cervical os has not been shown to be effective in reducing pain with insertion Uterine depth has to be sounded to greater than 6 cm Go slow

27 Try not to insert IUDs without an attendant-- because of vasovagal reactions Premedication with NSAIDs helps with post procedure cramps Average pain rating 2-3/10 slightly worse on average in nulliparous women, but their discontinuation rate is same as for all groups Counseling and handling anxiety are key

28 Anita Sheetz, CNM, MS Fellow Duke University/ JNJ Nursing Leadership Program Cohort Mesa County Health Department Family Planning Women s Health Associates of Valley View Hospital, Glenwood Springs Colorado

29 OBJECTIVES Review how long-acting reversible contraceptives led to significant changes in the statistics regarding unplanned pregnancy in Colorado Become aware of how adolescent patients may confidentially access contraceptive advice, contraception, including LARCs in Mesa County

30 WHY DOES THIS MATTER?

31 LARC METHODS Long Activing Reversible Contraceptives Mirena Skyla Liletta Paragard Nexplanon

32 HOW IS COLORADO DOING?

33 Colorado Family Planning Initiative $5 million dollar anonymous grant (Warren Buffet) State Funding $2 million for 2014 Outcomes Teen pregnancy Repeat Teen Birth Abortion 40% 53% 42% Over $5 savings of government money for each $1 spent on LARC *Data from Colorado Department of Public Health and Environment

34 MESA COUNTY,COLORADO AGE AT ONSET OF SEXUAL ACTIVITY

35 CONTRACEPTIVE USE AMOUNG SEXUALLY ACTIVE ADOLECSENTS

36 TEEN PREGNANCY BY ETHNICITY MESA COUNTY,COLORADO

37 COMPARISON OF MESA COUNTY TO REST OF COLORADO

38 ADOLESCENT BARRIERS Access to methods Confidentiality Knowledge Community support Cost Cultural acceptance

39 MESA COUNTY HEALTH DEPARTMENT FAMILY PLANNING AND TITLE X The services provided by Title X grantees include: Family planning with the provision of contraception, education and counseling Breast and pelvic exams for cancer screening Education, screenings and treatment for sexually transmitted diseases (STDs) and Human Immunodeficiency Virus (HIV) Pregnancy diagnosis and pregnancy counseling Referrals to other health care resources

40 ADOLESCENT ACCESS Priority Scheduling for those under 18 Same day appointments Walk in availability Increased the number of providers available Same day implementation

41 CONFIDENTIALITY AND COST Confidential Services (EXCEPTION OF REPORTABLE ABUSE AND CERTAIN STD S) We do not participate in the sharing of information in the local repository. No EOB s will be sent to homes on confidential encounters. Title X funds support the cost of LARC methods.

42 KNOWLEDGE OF LARC METHODS COMMUNITY SUPPORT High School counselors and teachers Riverside Education Afterschool Programs Transitional Teen Programs Get Real B4Babies Access Colorado Nurse Family Partnership Local and National news coverage KKCO, NPR, and Bloomberg Business Weekly Teen Health Web site Teaching teens an intimate exam is NOT necessary for the use of most birth control methods and STD screenings!!

43 LARC IMPLEMENTATION AT MCHD Series1

44 Emergency Contraception when plan A goes wrong Brittney Beeler, Pharm.D.

45 Emergency Contraception Overview EC Options Levonorgestrel (Plan B, Plan B One Step) Ethinyl estradiol + progesterone (multiple brands and generics) Mifepristone (Mifeprex) Ulipristal (Ella) Copper Intrauterine Device (ParaGard) EC efficacy 1. Copper IUD: Failure rate = < 0.1% 2. Ulipristal or mifepristone (25 to 50mg): Failure rate = ~1.4% 3. Levonorgestrel: Failure rate = ~2 to 3%

46 Emergency Contraception When to use it No contraceptive used during sex within the previous 120 hours Contraceptive failure within the previous 120 hours Missing >3 of the 30 to 35 EE mcg pills or >2 of the 20 to 25 EE mcg pills or >1 progestin only pill (POP) > 3 hours late to take a POP > 2 weeks late for depot medroxyprogesterone acetate injection Dislodgement, delay in placing, early removal of ring or patch Dislodgement, breakage, tearing, early removal of diaphragm or cervical cap Condom breakage, slippage or incorrect use Failure of spermicide tablet or film to melt before intercourse Miscalculation of cycle timing Expulsion of IUD or implant

47 2015 ACOG Updates Emergency Contraception Guidelines Educate women on availability of EC before it is needed (Level C) Give info on long acting contraception to women requesting EC (Level C) Make EC available to women up to 5 days after unprotected sex (Level B) Give EC as soon as possible after unprotected sex (Level B) Clinical exam or pregnancy testing not required before providing EC (Level B) Evaluate women who have used EC if menses delayed >1 week or lower abdominal pain or persistent irregular bleeding develops (Level C) Irregular bleeding in the week or month following EC is common and usually resolves on its own Menses usually starts 1 week before or after expected time Oral EC may be used more than once in same menstrual cycle (Level C)

48 2015 ACOG Updates Emergency Copper IUD Contraception Guidelines Most effective EC method (Level A) Appropriate option for women who meet criteria for IUD and desire long acting contraception (Level C) Preferred over oral EC for overweight and obese women as body weight does not affect its efficacy. However, do not withhold oral EC from overweight or obese women (Level B) Ulipristal More effective than levonorgestrel and maintains efficacy up to 5 days (Level A) Levonorgestrel More effective than the combined oral contraceptive (COC) regimen with less side effects (Level A)

49 Emergency Contraception Levonorgestrel Availability: Levonorgestrel 1.5 mg (Plan B One Step) is available OTC as both brand and generic for all women of child bearing age Levonorgestrel 0.75 mg (Plan B) is available as brand and generic but only OTC for those >17 yo Dose: 1.5 mg x 1 dose OR 0.75 mg 12 hours apart Interval can be extended to 24 hours apart (off label) Efficacy of 12 hour regimen decreased when further acts of intercourse occurred after treatment This was not seen in the 24 hour interval group

50 Emergency Contraception Levonorgestrel EC Timing: Use within 72 hours of unprotected sex. However, there is data to support efficacy up to 120 hours (off label) EC Efficacy: 59 to 94% prevented pregnancies EC MOA: Inhibits or delays ovulation; possible effect on postfertilization if taken at a point when ovulation cannot be inhibited but data is inconclusive Cost: Levonorgestrel Products AWP Next Choice One Dose $37 My Way $37 Opcicon One Step $24 Plan B One Step $41

51 Emergency Contraception EE + Progesterone Dose: mcg EE mcg progesterone BID (12 hours apart). Antiemetic may be taken 1 hour before the first dose to reduce nausea EC Timing: Use within 5 days of unprotected sex EC Efficacy: 47 to 89% prevented pregnancies EC MOA: Inhibits or delays ovulation Advantages/Disadvantages: Easily accessible More private vs options specifically for EC Less effective than levonorgestrel alone More side effects than other EC options No FDA approved indication; no product available specifically for EC

52 Brand Pills per Dose Ethinyl Estradiol per Dose (mcg) Levonorgestrel per Dose (mg) Progestin only pills: Take one dose Plan B a 2 white pills Ovrette b 40 yellow pills Combined progestin and estrogen pills: take two doses 12 hours apart Alesse 5 pink pills Aviane 5 orange pills Cryselle b 4 white pills Enpresse 4 orange pills Lessina 5 pink pills Levlen 4 light orange pills Levlite 5 pink pills Levora 4 white pills Lo/Ovral b 4 white pills Low Ogestrel b 4 white pills Lutera 5 white pills Ogestrel b 2 white pills Ovral b 2 white pills Nordette 4 light orange pills Portia 4 pink pills Seasonale 4 pink pills Seasonique 4 light blue green pills Tri Levlen 4 yellow pills Triphasil 4 yellow pills Trivora 4 pink pills A The above COCs have been declared safe and effective for use as ECs by the FDA B Norgestrel contains two isomers, one of which (levonorgestrel) is bioactive; the amount of norgestrel in each tablet is twice the amount of levonorgestrel

53 Emergency Contraception EE + Progesterone Cost of Commonly Used Monophasic COCs Combined Oral Contraceptive (COC) Cost/28 day Norgestimate/EE (e.g., Sprintec) $35 $50 Drospirenone/EE (e.g., Ocella) $85 $170 Levonorgestrel/EE (e.g., Portia) $35 $45 Norethindrone/EE (e.g., Gildess) $30 $40 Desogestrel/EE (e.g., Apri) $35 $50

54 Emergency Contraception EE + Progesterone Walmart $9/28 days EE Target $9/30days EE Levonorgestrel/EE Multiple Sprintec 35 strengths Kurvelo 30 Tri Sprintec 35 Enskyce 30 Tri Sprintec 35 Pirmella 1/35 and 7/7/7 35 Sprintec 35 Jencycla, norethindrone 0.35 mg 0

55 Emergency Contraception Mifepristone Availability: Mifeprex 200mg (Brand only) Dose: 5 600mg effective for preventing pregnancy, but an optimal dose has not been determined EC Timing: Use within 5 days of unprotected sex EC Efficacy: 99 to 100% prevented pregnancies EC MOA: antiprogestin; primarily delays ovulation; may also have endometrial effects which affect implantation Cost: $90 per tablet

56 Emergency Contraception Mifepristone Advantages/Disadvantages Most effective oral EC Low incidence of side effects RX only Not FDA approved for EC Per Colorado state law: C.R.S (2015): (a) "Emergency contraception" means a drug approved by the federal food and drug administration that prevents pregnancy after sexual intercourse, including but not limited to oral contraceptive pills; except that "emergency contraception" shall not include RU 486, mifepristone, or any other drug or device that induces a medical abortion

57 Emergency Contraception Ulipristal Availability: Ella (Brand only) Dose: 30mg x 1 dose EC Timing: Use within 5 days of unprotected sex EC Efficacy: 98 to 99% prevented pregnancies EC MOA: delays ovulation by up to 5 days; alters endometrium to inhibit implantation; effective in advanced follicular phase, after LH levels have risen but not peaked (when levonorgestrel no longer effective) Cost: $43 per tablet Advantages/Disadvantages More effective than levonorgestrel; similar cost and side effects Controversial for those who believe life starts at fertilization RX only

58 Emergency Contraception Copper IUD Availability: ParaGard (Brand only) EC Timing: Insert within 5 days of unprotected sex; up to 7 days may be effective due to post fertilization effects but data is limited EC Efficacy: 99% prevented pregnancies EC MOA: Copper interferes with sperm transport and fertilization of egg; also has post fertilization effects to affect implantation Cost: $887 Advantages/Disadvantages: Most effective EC Ongoing contraception (indicated up to 10 years) Requires an office visit for insertion within 5 days for EC use Women at risk of STIs are at high risk for pelvic infection Risk of uterine perforation (1 per 1000 insertions) No FDA approved indication for EC Most effective for obese or overweight women

59 Emergency Contraception Factors Affecting Efficacy BMI Oral EC efficacy declines as BMI increases Obese (BMI > 30) women who use oral EC are 3x more likely to become pregnant compared to non obese women Increasing the dose has not been studied and is not recommended Levonorgestrel Obese and overweight women (BMI 25 to > 30) have an increased risk of becoming pregnant Studies show pregnancy rates are no different for women with BMI >26 who use levonorgestrel EC and those who use no EC Ulipristal Obese women have an increased risk of becoming pregnant; overweight women did not have this same risk in studies Studies have shown efficacy decreases around a BMI of 35

60 Emergency Contraception Factors Affecting Efficacy Drug Interactions Drugs that induce liver enzymes (e.g., anti epileptics) decrease oral EC concentrations. Copper IUD is the best option for women taking these medications. Sex after use of EC Increased risk of pregnancy (pregnancy rate = 6.4 vs 1.5%) Cycle timing Increased risk of pregnancy when conception is the highest (30%) Probability of pregnancy per cycle 3 days before ovulation 15% 1 to 2 days before ovulation 30% Day of ovulation 12% 1 to 2 days after ovulation ~0%

61 Emergency Contraception Starting or Restarting Contraception After levonorgestrel or EE + progesterone EC: Any regular contraceptive method can be started immediately; avoid long acting methods until pregnancy is ruled out Backup barrier methods are required for the first 7 days After ulipristal EC: Progesterone containing contraceptives should not be used for 5 days. Barrier methods are recommended for those 5 days, then hormonal contraception may be started After copper IUD EC: Can be removed after next menstrual period or left in place up to 10 years Menstrual bleeding usually occurs within 1 week of the expected time. If levonorgestrel 1.5 mg is taken within 1 st 3 weeks of cycle, the next period will begin earlier than expected. If taken later in the cycle, the next period will be delayed.

62 References UpToDate (2015, September). Emergency Contraception. Retrieved 10/13/15 from Marions, L., Huttenby, K., Lindell, I., Sun, X., Stabi, B., Gemzell, K. Emergency Contraception with mifepristone and levonorgestrel: mechanism of action. Obstet Gynecol Jul;100(1): Retrieved 10/13/15 from Association of Reproductive Health Professionals.. Update on Emergency Contraception. (2011, March). Association of Reproductive Health Professionals.. Retrieved 10/13/15 from and resources/clinical proceedings/ec/moa Trussell, J., Raymond,E. (2006, September). Emergency Contraception: A cost effective approach to preventing unintended pregnancy. Retrieved 10/13/15 from AIahUKEwi6sM6X 7_IAhUPzGMKHWzUAH0&sig2=T xkocuusx8rjxrn1vqfqw&usg=afqjcngarpkodyk OBEgGV5yl5Y Le05Ng Princeton University. (2015, September). Are emergency contraceptive pills effective or overweight or obese women? Association of Reproductive Health Professionals. Retrieved 10/13/15 from Barclay, L. (2015, August 20). ACOG Updates Emergency Contraception Guidelines. Medscape. Retrieved 10/13/15 from Armstrong, C. Practice Guidelines: ACOG Recommendations on Emergency Contraception. Am Fam Physician Nov 15;82(10):1278. Retried 10/13/15 from World Health Organization. (2012, July). Emergency Contraception. World Health Organization. Retrieved 10/13/2015 from

63 Oral Contraceptive Reference Chart Generic Name Brand Name Estrogen/Progestin Component Cost/30days* Aviane, Orsythia, Falmina, Lessina, Delyla, Aubra, Sronyx, Lutera, levonorgestrel/ee Apri, Solia, Juleber, Reclipsen, Enskyce, Emoquette, Desogestrel/EE Levora, Portia, Altavera, Chateal, Kurvelo, Marlissa, Levonorgestrel/EE Low-Ogestrel, Cryselle, Norgestrel/EE, Elinest Junel 1.5/30, Microgestin 1.5/30, Gildess 1.5/30, Larin 1.5/30 Junel Fe 1.5/30, Microgestin Fe 1.5/30, Gildess Fe 1.5/30, Larin Fe 1.5/30 Junel 1/20, Microgestin 1/20, Gildess 1/20, Larin 1/20, Norethindrone/EE Junel Fe 1/20, Microgestin Fe 1/20, Gildess Fe 1/20, Larin Fe 1/20, Norethindrone/EE/Fe, Tarina Fe Sprintec, Previfem, MonoNessa, Norgestimate/EE, Estarylla, Mono-Linyah Balziva, Zenchent, Briellyn, Philith, Gildagia, Vyfemla Zeosa, Zenchent Fe, Wymzya Fe (chew or swallow) MONOPHASIC Alesse EE 20 mcg/ levonorgestrel 0.1 mg $35 - $50 (not available) Ortho-Cept, Desogen Nordette (not available) Lo/Ovral (not available) EE 30 mcg/ desogestrel 0.15 mg $35 - $50 EE 30 mcg/ levonorgestrel 0.15 mg $35 - $45 EE 30 mcg/ norgestrel 0.3 mg $30 - $40 Loestrin 1.5/30 EE 30 mcg/ norethindrone 1.5 mg $30 - $40 Loestrin Fe 1.5/30 EE 30 mcg/ norethindrone 1.5 mg/ Fe 75 mg $30 - $40 Loestrin 1/20 EE 20 mcg/ norethindrone 1 mg $30 - $40 Loestrin Fe 1/20 EE 20 mcg/ norethindrone 1 mg/fe 75 mg $30 - $40 Ortho-Cyclen EE 35 mcg/ norgestimate 0.25 mg $35 - $50 Ovcon-35 (not available) Femcon Fe (chew or swallow) EE 35 mcg/ norethindrone 0.4 mg $50 - $65 EE 35 mcg/ norethindrone 0.4 mg/fe 75 mg $100 KEY: EE=Ethinyl Estradiol; EV=Estradiol Valerate; Fe=Ferrous Fumarate; SD=subdermal; TD=transdermal; LNG=levonorgestrel

64 Oral Contraceptive Reference Chart Necon 0.5/35, Nortrel 0.5/35, Wera 0.5/35 Necon 1/35, Nortrel 1/35, Cyclafem 1/35, Alyacen 1/35, Dasetta 1/35, Pirmella 1/35 Zovia 1/35E, Kelnor 1/35 None None None Ocella, Syeda, Zarah, drospirenone/ee None Brevicon, Modicon Ortho-Novum 1/35, Norinyl 1+35 EE 35 mcg/ norethindrone 0.5 mg $35 - $40 EE 35 mcg/ norethindrone 1 mg $35 - $45 Demulen 1/35 EE 35 mcg / ethynodiol diacetate 1 mg $35 (not available) Ogestrel EE 50 mcg/ norgestrel 0.5 mg $50 Zovia 1/50E EE 50 mcg/ ethynodiol diacetate 1 mg $30 Norinyl , Mestranol 50 mcg/ norethindrone 1 mg $30 Necon 1/50 Yasmin EE 30 mcg/ drospirenone 3 mg $85 - $170 Safyral *Non-formulary EE 30 mcg/ drospirenone 3 mg/ levomefolate calcium mg $160 (AWP) Kariva, Azurette, Viorele, Pimtrea, desogestrel/ee None Mircette (not available) Necon 10/11 BIPHASIC EE 20, 10 mcg / desogestrel 0.15 mg Extended Cycle Active tablet (EE 20 mcg): 21 days Inactive tablet: 2 days Active EE only (10 mcg): 5 days EE 35 mcg/ norethindrone 0.5, 1 mg Extended Cycle Active tablet (nor 0.5 mg): 10 days Active tablet (nor 1 mg): 11 days Inactive tablet: 7 days $65 - $90 $35 (AWP) Tilia Fe, Tri-Legest Fe Estrostep Fe TRIPHASIC EE 20, 30, 35 mcg/ norethindrone 1 mg/ Fe 75 mg $60 Extended Cycle Active tablet (EE 20 mcg): 5 days Active tablet (EE 30 mcg): 7 days Active tablet (EE 35 mcg): 9 days Inactive tablet (Fe only): 7 days KEY: EE=Ethinyl Estradiol; EV=Estradiol Valerate; Fe=Ferrous Fumarate; SD=subdermal; TD=transdermal; LNG=levonorgestrel

65 Oral Contraceptive Reference Chart Trivora, Enpresse, Myzilra, Levonest Tri-Levlen (not available) EE 30, 40 mcg/ levonorgestrel 0.05, 0.075, 0.125mg $30 Tri-Sprintec, Trinessa, Tri-Previfem, Tri-Linyah, Tri- Estarylla, Norgestimate/EE None Aranelle, Leena Velivet, Cesia, Caziant Necon 7/7/7, Nortrel 7/7/7, Cyclafem 7/7/7, Alyacen 7/7/7, Dasetta 7/7/7, Pirmella 777 Ortho Tri- Cyclen Ortho Tri- Cyclen LO Tri-Norinyl Cyclessa Ortho-Novum 7/7/7 Extended Cycle Active tablet (EE 30, lev 0.05): 6 days Active tablet (EE 40, lev 0.075): 5 days Active tablet (EE 30, lev 0.125): 10 days Inactive tablet: 7 days EE 35 mcg/ norgestimate 0.18, 0.215, 0.25 mg Extended Cycle Active tablet (nor 0.18): 7 days Active tablet (nor 0.215): 7 days Active tablet (nor 0.25): 7 days Inactive tablet: 7 days EE 25 mcg/ norgestimate 0.18, 0.215, 0.25 mg Extended Cycle Active tablet (nor 0.18): 7 days Active tablet (nor 0.215): 7 days Active tablet (nor 0.25): 7 days Inactive tablet: 7 days EE 35 mcg/ norethindrone 0.5, 1 mg Extended Cycle Active tablet (nor 0.5): 7 days Active tablet (nor 1): 9 days Active tablet (nor 0.5): 5 days Inactive tablet: 7 days EE 25 mcg/ desogestrel 100, 125, 150 mcg Extended Cycle Active tablet (des 100): 7 days Active tablet (des 125): 7 days Active tablet (des 150): 7 days Inactive tablet: 7 days EE 35 mcg/ norethindrone 0.5, 0.75, 1 mg Extended Cycle Active tablet (nor 0.5): 7 days Active tablet (nor 0.75): 7 days Active tablet (nor 1): 7 days Inactive tablet: 7 days $25 - $50 $165 - $175 $45 $35 - $50 $35 FOUR-PHASIC KEY: EE=Ethinyl Estradiol; EV=Estradiol Valerate; Fe=Ferrous Fumarate; SD=subdermal; TD=transdermal; LNG=levonorgestrel

66 Oral Contraceptive Reference Chart None Natazia EV 3, 2, 1 mg/ dienogest 2, 3 mg Extended Cycle Active estrogen only (EV 3 mg): 2 days Active tab (EV 2mg, di 2mg): 5 days Active tab (EV 2mg, di 3mg): 17 days Active estrogen only (EV 1mg): 2 days Inactive tablet: 2 days $160 MONOPHASIC Layolis Fe, norethindrone/ee/fe Lomedia 24 Fe, Norethindrone/EE/Fe None None Generess Fe (chewable only) * Non-formulary Loestrin 24 Fe (not available) Minastrin 24 Fe (chewable) Beyaz *Non-formulary EXTENDED-CYCLE EE 25 mcg/ norethindrone 0.8 mg/ Fe 75mg Extended Cycle: Active tablet: 24 days Inactive tablet: 4 days EE 20 mcg/ norethindrone 1 mg/ Fe 75 mg Extended Cycle: Active tablet: 24 days Inactive tablet: 4 days EE 20 mcg/ norethindrone 1 mg/ Fe 75 mg Extended Cycle: Active tablet: 24 days Inactive tablet: 4 days EE 20 mcg/ drospirenone 3 mg/ levomefolate calcium mg $145 $100 $140 $160 Gianvi, Loryna, Vestura, Nikki MULTIPHASIC None Yaz Lo Loestrin Fe *Non-formulary Extended Cycle Active tablet: 24 days Inactive tablet: 4 days EE 20 mcg/ drospirenone 3 mg Extended Cycle: Active tablet: 24 days Inactive tablet: 4 days EE 10 mcg/ norethindrone 1 mg/ Fe 75mg Extended Cycle: Active tablet: 24 days Active EE only: 2 days Inactive tablet: 2 days KEY: EE=Ethinyl Estradiol; EV=Estradiol Valerate; Fe=Ferrous Fumarate; SD=subdermal; TD=transdermal; LNG=levonorgestrel $70 - $80 $130 (AWP)

67 Oral Contraceptive Reference Chart None Amethia, Camrese, Daysee Camrese Lo, Amethia Lo, Levonorgestrel/EE Quasense, Jolessa, Introvale, Setlakin, levonorgestrel/ee None Lo Minastrin Fe (chewable) *Non-formulary Seasonique LoSeasonique Seasonale Quartette *Non-formulary EE 10 mcg/ norethindrone 1 mg/ Fe 75mg Extended Cycle: Active tablet: 24 days Active EE only: 2 days Inactive tablet: 2 days EE 30, 10 mcg/ levonorgestrel 0.15 mg Extended Cycle: Active tablet: 84 days Active EE only (10 mcg): 7 days EE 20, 10 mcg/ levonorgestrel 0.1 mg Extended Cycle: Active tablet: 84 days Active EE only (10 mcg): 7 days EE 30 mcg/ levonorgestrel 0.15 mg Extended Cycle: Active tablet: 84 days Inactive tablet: 7 days EE 20, 25, 30, 10 mcg/ levonorgestrel 0.15 mg Extended Cycle Active tablet (EE 20 mcg): 42 days Active tablet (EE 25 mcg): 21 days Active tablet (EE 30 mcg): 21 days Active EE only (10 mcg): 7 days unavailable $90 - $100 $90 $55 - $160 $130 (AWP) None CONTINUOUS CYCLE (no hormone-free interval) Amethyst EE 20 mcg/ levonorgestrel 90 mcg Take daily $65 Jolivette, Errin, Camila, Nora-BE, Heather, Jencycla, Deblitane, Sharobel, Lyza, Norlyroc, norethindrone PROGESTIN-ONLY PILLS Nor-QD norethindrone 0.35 mg $40 EMERGENCY CONTRACEPTIVES Next Choice One Dose, My Way, Plan B One-Step levonorgestrel 1.5 mg (1 pill) $40 levonorgestrel 1.5 mg None Ella ulipristal 30 mg $43 (AWP) KEY: EE=Ethinyl Estradiol; EV=Estradiol Valerate; Fe=Ferrous Fumarate; SD=subdermal; TD=transdermal; LNG=levonorgestrel

68 Oral Contraceptive Reference Chart Non-Oral Contraceptive Alternatives Generic Name Brand Name EE Progestin Route Cost/30 days* Medroxyprogesterone acetate Depo-Provera None medroxyprogesterone acetate 150mg *every 3 months; no > 2 yrs. IM $80 None Depo-SubQ Provera 104 None medroxyprogesterone acetate 104mg *every 3 months; no > 2 yrs. None Nexplanon None etonogestrel 68 mg *remove or replace by 3 rd year None Liletta None levonorgestrel 52 mg Initial release of 18.6 mcg/day then decreases to: Year 1: LNG 16.3 mcg/day Year 2: LNG 14.3 mcg/day Year 3: LNG 12.6 mcg/day *Remove or replace by 3 rd year None Mirena None levonorgestrel 52 mg Initial release of 20 mcg/day *Remove or replace by 5 th year None Skyla None levonorgestrel 13.5 mg Initial release of 14 mcg/day after the 1 st 24 days *Remove or replace by 3 rd year None ParaGard Copper: Non-hormonal T380A *Remove or replace on or before 10 years None NuvaRing 15 mcg/day Xulane Ortho Evra (not available) 35 mcg/day etonogestrel 12 mcg/day *leave in for 3 continuous weeks, then 1-week ring-free interval norelgestromin 200 mcg/day *apply weekly for 3 weeks, then week 4 is patch-free SubQ $275 (AWP) SD implant $926 (AWP) IUD $750 (AWP) IUD $973 IUD $781 IUD $890 (AWP) vaginal ring TD patch $140 $140 *Based on 2015 RMHP claims data and AWP (when claims data not available); average cost range given for generics or brand (when no generics are available) KEY: EE=Ethinyl Estradiol; EV=Estradiol Valerate; Fe=Ferrous Fumarate; SD=subdermal; TD=transdermal; LNG=levonorgestrel

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