ACETAMINOP-CODEINE 120-12 MG/5

Drug Details

General

Brand Name: ACETAMINOP-CODEINE 120-12 MG/5

Generic Name: acetaminophen with codeine

Manufacturer: PHARM ASSOC INC

NDC: 00121050404

Package size: 118ML

Drug Information

Family Planning drug: No

Diabetic Supply Drug: No

HTW drug: No

HTWPlus drug: No

Long-acting reversible contraception product: No

Refill-to-soon Utilization*: 90%

Specialty Drug†: No

Drug Pricing

Retail Pharmacy Cost: .02324

Retail Pharmacy Eff Date: 02/27/2024

Specialty Pharmacy Cost: .02182

Specialty Pharmacy Eff Date: 02/27/2024

Long-term Care Pharmacy Cost: .02291

Long-term Care Pharmacy Eff Date: 02/27/2024

340B Rate: .01019

Premium Preferred Generic Incentive‡: No

Program Coverage

Medicaid

Effective date: 03/01/2002

End date: 09/01/2024

End reason: Discontinued by Manufacturer

Compound-only use: No

PDL PA Required: No

PDL Class: ANALGESICS: NARCOTICS SHORT

FFS Clinical PA Required‡: Yes

Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
Eff. Date: 03/26/2017
End Date: 09/01/2024

Opioid Clinical Policy (MME and days supply limits) (PDF)
Eff. Date: 09/01/2020
End Date: 09/01/2024

Part B Cost-share Drug**: No

Part D Wrap-around Drug***: No

CHIP

Effective date: 03/01/2002

End date: 09/01/2024

End reason: Discontinued by Manufacturer

CSHCN

Effective date: 03/01/2002

End date: 09/01/2024

End reason: Discontinued by Manufacturer

Compound-only use: No

KHC

Effective date: 03/01/2002

End date: 09/01/2024

End reason: Discontinued by Manufacturer

09/01/2024