Birth Control: medications and paying cash

Overview

Hormonal birth control prevents pregnancy mainly by stopping ovulation and thickening cervical mucus. Combined pills pair an estrogen, usually ethinyl estradiol, with a progestin such as levonorgestrel, norgestimate or drospirenone; most come in 28-day packs, and some in 91-day extended-cycle packs. Progestin-only pills contain no estrogen: norethindrone 0.35 mg and drospirenone 4 mg (Slynd) by prescription, and norgestrel 0.075 mg (Opill), which the FDA approved in 2023 as the first daily birth control pill sold without a prescription. Norethindrone 0.35 mg and Opill are taken at the same time every day with no break between packs; a pill taken more than 3 hours late counts as missed, and a backup method is used for the next 48 hours. Slynd comes in a 28-tablet pack with 24 active and 4 inactive tablets and has its own missed-pill rules, so follow the leaflet for the pill you take. Opill is not for emergency use, and people who have or have had breast cancer should not take it.

Every combined pill carries a boxed warning: cigarette smoking increases the risk of serious cardiovascular events, the risk rises with age and with the number of cigarettes smoked, and women over 35 who smoke must not use them. They are also ruled out for women with a current or past blood clot, stroke or coronary artery disease, migraine with aura or any migraine over 35, uncontrolled high blood pressure, breast cancer, or liver tumors or liver disease, and the labels say pills with drospirenone may carry a higher risk of blood clots than pills with levonorgestrel. Leg pain or swelling, chest pain, sudden shortness of breath or a sudden severe headache needs urgent care.

The injection is medroxyprogesterone, 150 mg into a muscle every 13 weeks or 104 mg under the skin every 12 to 14 weeks. Its boxed warning says it can cause significant bone loss that grows with longer use and may not fully reverse, so it is not recommended for more than 2 years unless other methods are inadequate; the labels also warn of meningioma, mainly with long-term use, and fertility can take months to return. Emergency contraception is for occasional use, not a regular method. Levonorgestrel 1.5 mg is sold without a prescription or an age limit, Plan B One-Step since 2013 and its generics with the same nonprescription status, and is labeled for use within 72 hours; ulipristal (ella) needs a prescription and is labeled for use within 120 hours, and hormonal birth control is started or resumed no sooner than 5 days after taking it. Some states let pharmacists prescribe birth control, under rules that differ by state.

Choosing between the options when you pay cash

The same pill formulation is sold under many generic names, such as Sprintec and Estarylla for norgestimate with ethinyl estradiol, and a pharmacy may fill any product rated equivalent within that formulation. It cannot switch you to a different formulation, dose or pack type, such as a 91-day pack for a 28-day one or the 24-day drospirenone type for the 21-day type. A prescription written generically, with substitution allowed and three packs per fill or a year of refills, means fewer trips and fewer dispensing fees. The generic 150 mg injection comes from several makers, while depo-subQ provera 104 has no generic; ask whether the clinic giving the shot stocks it before choosing where to fill.

Opill and levonorgestrel emergency pills are sold off the shelf without a prescription, but they are different medicines from the prescription pills and from ella, and a pharmacist can say whether one suits you. No generic ulipristal is on the market, ella is stocked as the brand, and not every pharmacy keeps it, so confirm stock before the prescription is sent. Moving between pill types, such as from a combined pill to a progestin-only pill or to a drospirenone pill, is the prescriber’s decision, because the hormones, doses and risks differ.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Drospirenone/Ethinyl Estradiol
  28-day packs, 24 active and 4 inert tablets (Yaz type), 28-day packs, 21 active and 7 inert tablets (Yasmin type)
  Generic: Yes · See the guide
• Ethinylestradiol/Levonorgestrel
  28-day packs (21 active and 7 inert tablets), 91-day extended-cycle packs, Triphasic 28-day packs
  Generic: Yes · See the guide
• Norgestimate/Ethinyl Estradiol
  28-day packs (21 active and 7 inert tablets), Monophasic, triphasic and lower-dose triphasic packs
  Generic: Yes · See the guide
• Norethindrone
  Norethindrone 0.35 mg tablets in 28-day packs (progestin-only contraceptive), Norethindrone acetate 5 mg tablets
  Generic: Yes · Once a day
• Medroxyprogesterone
  Tablets (Provera and generic), Intramuscular injection (Depo-Provera CI in vials and prefilled syringes, and generic), Subcutaneous prefilled syringe (depo-subQ provera 104)
  Generic: Yes · Once a day
• Ulipristal
  Tablet, one per blister package
  Generic: No · See the guide

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• Is a combined pill safe for me, given my age, smoking, blood pressure and any migraines?
• Can you write the pill generically, allow substitution and authorize three packs per fill?
• If I need emergency contraception, should I use levonorgestrel from the shelf or ella?
• How long should I stay on the shot, and what can I do to protect my bones?
• Do any of my medicines, such as seizure medicines or St. John’s wort, make my birth control less effective?

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