Medications not yet evaluated by P&T are considered NON-FORMULARY . . . . . Always check 2 unique patient identifiers - NAME and DATE OF BIRTH - at every step! . . . . . Please be sure to document all clinical activities daily.
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levonorgestrel
  • Formulary Miscellaneous Programs
  • Restricted Mirena --> Restricted to OB/GYN for treatment of dysfunctional uterine bleeding and menorrhagia.
Drug Name Form Strength Formulary Unrestricted Formulary Restricted Non-Formulary Interchange
Mirena DEVICE, INTRAUTERAL 52 mg      
Plan B One-Step, Opcicon One-Step, Next Choice, My Way, Fallback Solo TABLET, ORAL 1.5 mg      
Comments:

PLAN B is discontinued, PLAN B-1 STEP is classified as formulary. Generally limit use to inpatients (ex. rape victims admitted for medical reasons). ER patients should usually receive a prescription to obtain as an outpatient. Rare exception cases possible - use your professional judgement. May be obtained from an outside pharmacy for a specific patient as needed. PLAN B should be given within 72 hours of unprotected intercourse.

 

MIRENA is classified as formulary status, restricted to OB/GYN for treatment of dysfunctional uterine bleeding and menorrhagia.

MIRENA is supplied by surgery and not stocked by pharmacy.

 

 

 

Reviewed: March 27, 2007 (PLAN B), July 28, 2009 (MIRENA), November 17, 2009 (PLAN B-1STEP)

Last updated: Jun. 28, 2022






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