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CIPROFLOXACIN HCL 250 MG TAB

Drug Details

General

Brand Name: CIPROFLOXACIN HCL 250 MG TAB
Generic Name: ciprofloxacin HCl
Manufacturer: YILING PHARMACE
NDC: 69117000801
Package size: 100EA
Family Planning drug: No
Diabetic Supply Drug: No
HTW drug: Yes
HTWPlus drug: No
Long-acting reversible contraception product: No
Refill-to-soon Utilization*: 75%

Drug Pricing

Retail Pharmacy Cost: .09846
Retail Pharmacy Eff Date: 03/23/2021
Specialty Pharmacy Cost: .09673
Specialty Pharmacy Eff Date: 03/23/2021
Long-term Care Pharmacy Cost: .09609
Long-term Care Pharmacy Eff Date: 03/23/2021
Premium Preferred Generic Incentive†: Yes

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

† Refer to the Pricing and Reimbursement chapter of the Pharmacy Provider Procedure Manual for information about traditional Medicaid claim pricing and PPG pricing incentives.

‡ Refer to the Clinical Prior Authorization Assistance Chart (PDF) for the list of clinical prior authorization each MCO uses and how those authorizations relate to those used in traditional Medicaid. Refer to the MCO Resources page for links to each MCO’s clinical prior authorizations.

Program Coverage

Medicaid

Effective date: 03/12/2020
End date: 01/01/2040
End reason: No Longer Rebatable
PDL PA Required: No
PDL Class: FLUOROQUINOLONES: ORAL
FFS Clinical PA Required‡: No
Compound-only use: No

CHIP

Effective date: 03/12/2020
End date: 01/01/2040
End reason: No Longer Rebatable
Compound-only use: No

CSHCN

Effective date: 03/12/2020
End date: 01/01/2040
End reason: No Longer Rebatable
Compound-only use: No

HTW

Effective date: 06/19/2020
End date: 01/01/2040

‡ 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.