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MFPP Contraceptive and Medication Supplies Table

Date: 09-30-2015

Minnesota Family Planning Program (MFPP) covers the following contraceptives, anti-infectives, and antifungals dispensed at a pharmacy:

MFPP Contraceptives

MFPP Anti-Infectives and Antifungals

*generic Kariva (21-5)

*Acyclovir 200mg 400mg 800mg

*generic Loestrin (1.0-0.02) (1.5-0.03)

*Amoxicillin 250mg 500mg

generic LoEstrin FE (1.0-0.02) (1.5-0.03)

*Azithromycin 250mg 500mg

*generic Alesse-28 (0.1-0.2)

Benzoin

*generic Triphasil-28 (6-5-10)

Benzoin Compound

*generic Modicon (0.5-0.035)

Benzoin/Isopropyl Alcohol

*genericNordette-28 (0.15-0.03)

Cefixime 400mg

*generic Ortho Cept (0.15–0.03)

Ceftriaxone (IM) 250mg 500mg 1gm

*generic Ortho Micronor (0.35)

*Ciprofloxacin 250mg 500mg 750mg

*generic Ortho Novum 7/7/7 (7-7-7)

*Clindamycin 150mg

*generic Ortho Tri-Cyclen (7 days x 3)

*Doxycycline hyclate 50mg 75mg 100mg

*generic Ovcon (0.4–0.035)

*Erythromycin 250mg 333mg 500 mg

Ovral-21 (0.5-0.05)

Famciclovir 250mg 500mg

*generic Lo/Ovral-28 (0.3-0.03)

Imiquimod

*generic Demulen 1/35E (1.0-0.035)
1/50E (1.0-0.05)

Levofloxacin 250mg 500mg

*generic Ortho-Novum (1.0-0.035) (1.0-1.05)

*Metronidazole 0.75% 250mg 500mg

*generic Ortho-Cyclen (0.25-0.035)

Nitrofurantoin 25 mg 50 mg 100 mg

*generic Seasonale (0.15-0.03)

Ofloxocin 300mg 400mg

*generic Seasonique (0.15-.0.3)

Podofilox 0.5%

*generic Yasmin (0.03-3)

Podophyllum Resin 0.25%

*generic Yaz (0.2-3)

*Probenecid 500mg

Emergency contraceptive - Plan B generic

*Sulfamethox/Trimethprim 800/160mg

Diaphragm

Trichloroacetic Acid

Cervical Cap

Clotrimazole tablet (Femcare) 100mg

Male or Female Condom

*Clotrimazole cream 21gm 22.2gm 45gm
1% 2%

Nuvaring

*Fluconazole 50mg 100mg 150mg 200mg

Ortho Evra Patch

Miconazole suppository 100mg 200mg

Other Contraceptive Supply – Spermicide

Micolazole cream 45 mg 2% 4%

Miconazole 200mg/2% combo pack

Terconazole 80 mg (Terazol 3)

*Terconazole 0.40% (Terazol 7 cream)

*Terconazole 0.80% (Terazol 3 cream)

Tindamax (for Metronidazole intolerance) 250 mg 500 mg

*MFPP will pay at generic MAC

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