General Information

Generic Name: 
levonorgestrel/ethin.estradiol
Manufacturer: 
MYLAN
NDC code: 
00378728153
Package Size: 
91
EA
Prescription/OTC: 
Prescription required
Family Planning drug: 
Yes
Diabetic Supply: 
No
HTW drug: 
Yes
HTWPlus drug: 
No
Long-acting reversible contraception product: 
No
Refill-to-soon Utilization*: 
75%

Drug Pricing

Retail Pharmacy Cost: 
.26262
Retail Pharmacy Eff Date: 
12/29/2020
Specialty Pharmacy Cost: 
.25802
Specialty Pharmacy Eff Date: 
12/29/2020
Long-term Care Pharmacy Cost: 
.25631
Long-term Care Pharmacy Eff Date: 
12/29/2020
340B Cost: 
.25963
Premium Preferred Generic Incentive†: 
No

Pharmacist Administered

Injection: 
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

Effective date: 
11/09/2015
Compound-only use: 
No

CHIP

Effective date: 
11/09/2015
Compound-only use: 
No

CSHCN

Effective date: 
11/09/2015
Compound-only use: 
No

HTW Program

Effective date: 
11/09/2015
Compound-only use: 
No