ETHINYL ESTRADIOL/ LEVONORGESTREL TAB,ORAL
Clinical Criteria Summary
Criteria for Combination Hormonal Contraceptive Pills
- Desogestrel/Ethinyl Estradiol (and other Monophasic pills with 20 mcg EE)
- Indication/Use: Highly effective in preventing pregnancy when used as directed.
- Regimen: 21 active pills; 7 inert pills.
- Monophasic pills with 30 mcg EE (includes Drospirenone/Ethinyl Estradiol, Norethindrone/Ethinyl Estradiol)
- Regimen: 21 active pills; 7 inert pills.
- Monophasic pills with 35 mcg EE (includes Norethindrone/Ethinyl Estradiol, Norgestimate/Ethinyl Estradiol)
- Regimen: 21 active pills; 7 inert pills.
- Extended Cycle Pills (Levonorgestrel/Ethinyl Estradiol 30 mcg)
- Regimen: 84 active pills; 7 inert pills.
- Management of nuisance side effects: Adjust estrogen/progestin content or ratio.
Criteria for Progestin-Only Pills
- Indication/Use: Considered in patients with contraindications to estrogen or a desire to avoid estrogen.
- Drug: Norethindrone 0.35 mg (Camila, Errin, Heather, Micronor, Incassia, Jencycla, Nor-QD, Eluryng)
- Regimen: Active pill daily continuously; no inert pills.
Criteria for Non-Oral Hormonal Contraceptives
- Indication/Use: Useful for patients with compliance issues that do not require daily dosing.
- Vaginal Ring (EE 15 mcg/day + Etonogestrel)
- Regimen: 1 ring inserted for 3 wks, 1 wk off.
- Transdermal Patch (EE 35 mcg + Norelgestromin 150 mcg/day)
- Regimen: 1 patch used for 3 wks, 1 wk off.
- Injection (Medroxyprogesterone acetate 150 mg IM or 104 mg SQ)
- Regimen: 1 injection Q3 mos (13 wks or 12 to 14 wks).
- Note: Self-administration of SQ DMPA is a safe and effective alternative; may be offered in the context of shared decision making.
Criteria for Emergency Contraception
- Levonorgestrel 1.5 mg (Aftera, My Choice, My Way, Plan B One-Step, Next Choice, Opcicon, Take Action)
- Regimen: 1 pill x1.
- Ulipristal 30 mg (ella)
- Regimen: 1 pill x1.
Criteria for Long-Acting Reversible Contraceptives (IUDs & Implants)
- Levonorgestrel IUD (52 mg, 19.5 mg, 13.5 mg)
- Duration: Up to 8 yrs, up to 5 yrs, or up to 3 yrs respectively.
- Non-hormonal Copper IUD (Paragard)
- Duration: Up to 10 yrs.
- Etonogestrel Implant (Nexplanon)
- Duration: Up to 5 yrs.
Formulary & Dispensing Criteria
- All contraceptives are listed on the National Formulary as generic components to allow substitution of the least expensive equivalent product.
- 12-month dispensing prerequisites: 1) Stable on product for at least 3 mos; 2) Contraceptive is on CMOP greater than 90-day supply list; and 3) Patient accepts copay burden, if applicable.