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DIALYVITE 800 TABLET

Drug Details

General

Brand Name: DIALYVITE 800 TABLET
Generic Name: folic acid/vit B complex and C
Manufacturer: HILLESTAD PHARM
NDC: 10542007010
Package size: 100EA
Family Planning drug: No
Diabetic Supply Drug: No
HTW drug: No
HTWPlus drug: No
Long-acting reversible contraception product: No
Refill-to-soon Utilization*: 75%

Drug Pricing

340B Cost: .03474
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

PDL PA Required: No
FFS Clinical PA Required‡: No
Compound-only use: No

CHIP

Compound-only use: No
Compound-only use: No

KHC

Effective date: 09/15/2004

‡ 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.