ACTIQ 200 MCG LOZENGE

Drug Details

General

Brand Name: ACTIQ 200 MCG LOZENGE

Generic Name: fentanyl citrate

Manufacturer: TEVA USA

NDC: 63459050230

Package size: 30EA

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: 85.63892

Retail Pharmacy Eff Date: 01/11/2022

Specialty Pharmacy Cost: 80.39572

Specialty Pharmacy Eff Date: 01/11/2022

Long-term Care Pharmacy Cost: 84.41551

Long-term Care Pharmacy Eff Date: 01/11/2022

340B Rate: 37.57626

Premium Preferred Generic Incentive‡: No

Program Coverage

Medicaid

Effective date: 07/17/2003

End date: 05/31/2024

End reason: No Longer Rebatable

Compound-only use: No

PDL PA Required: Yes

PDL Class: ANALGESICS: NARCOTICS SHORT

FFS Clinical PA Required‡: Yes

Fentanyl Agents (PDF)
Eff. Date: 01/31/2011
End Date: 05/31/2024

Opiate Overutilization (PDF)
Eff. Date: 11/05/2013
End Date: 05/31/2024

Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
Eff. Date: 03/26/2017
End Date: 05/31/2024

Part B Cost-share Drug**: No

Part D Wrap-around Drug***: No

Opioid Clinical Policy (MME and days supply limits) (PDF)
Eff. Date: 09/01/2020
End Date: 05/31/2024

CHIP

Effective date: 07/17/2003

End date: 05/31/2024

End reason: No Longer Rebatable

CSHCN

Effective date: 07/17/2003

End date: 05/31/2024

End reason: No Longer Rebatable

Compound-only use: No

05/31/2024