General Information

Generic Name: 
levonorgestrel-ethin estradiol
NDC code: 
00781558315
Package Size: 
28
EA
Prescription/OTC: 
Prescription required
Family Planning drug: 
Yes
Diabetic Supply: 
No
Refill-to-soon Utilization*: 
75%

Drug Pricing

Retail Pharmacy Cost: 
.33609
Retail Pharmacy Eff Date: 
08/28/2018
Specialty Pharmacy Cost: 
.3302
Specialty Pharmacy Eff Date: 
08/28/2018
Long-term Care Pharmacy Cost: 
.32802
Long-term Care Pharmacy Eff Date: 
08/28/2018
340B Cost: 
.35597
Premium Preferred Generic Incentive†: 
No

 

* Impacts only claims paid by the Vendor Drug Program: traditional Medicaid, CSHCN, HTW, and KHC Programs.

† To learn about traditional Medicaid claim pricing and PPG pricing incentives please refer to the Drug Pricing & Reimbursement (PDF) chapter of the VDP Pharmacy Provider Procedure Manual.

‡ Please review the lists of DUR board-approved clinical prior authorizations that apply to traditional Medicaid and those that health plans may use. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each health plan uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. Refer to the MCO Resources for links to each health plan's active clinical prior authorizations.

Program Coverage

Medicaid

Med Effective Date: 
04/11/2012
FFS Clinical PA Required ‡: 
No

CHIP

CHIP Effective Date: 
04/11/2012

CSHCN

CSHCN Effective date: 
04/11/2012

Compound-only Use by Program

Medicaid: 
No
CHIP: 
No
CSHCN: 
No
KHC: 
No