General Information

Generic Name: 
etonogestrel
NDC code: 
00052433001
Package Size: 
1
EA
Prescription/OTC: 
Prescription required
Family Planning drug: 
Yes
Diabetic Supply: 
No
HTW Drug: 
Yes
Refill-to-soon Utilization*: 
75%

Drug Pricing

Retail Pharmacy Cost: 
916.1236
Retail Pharmacy Eff Date: 
07/02/2019
Specialty Pharmacy Cost: 
860.0344
Specialty Pharmacy Eff Date: 
07/02/2019
Long-term Care Pharmacy Cost: 
903.03612
Long-term Care Pharmacy Eff Date: 
07/02/2019
340B Cost: 
401.9726
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: 
01/07/2016
FFS Clinical PA Required ‡: 
No

HTW Program

HTW Effective Date: 
01/07/2016

Compound-only Use by Program

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