POLY-HIST DM LIQUID

Drug Details

General

Brand Name: POLY-HIST DM LIQUID
Generic Name: thonzylamine/phenylephrine/DM
Manufacturer: POLY PHARMACEUT
NDC: 50991022016
Package size: 473ML

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*: 75%
Specialty Drug†: No

Drug Pricing

Retail Pharmacy Cost: .15876
Retail Pharmacy Eff Date: 04/27/2021
Specialty Pharmacy Cost: .14904
Specialty Pharmacy Eff Date: 04/27/2021
Long-term Care Pharmacy Cost: .15649
Long-term Care Pharmacy Eff Date: 04/27/2021
340B Rate: .06966
Premium Preferred Generic Incentive‡: No

* Impacts only claims paid by HHSC: traditional Medicaid, CSHCN, HTW, and KHC Programs.

† Refer to the Specialty Drug Handbook for more information..

‡ Refer to the Premium Preferred Generic Drugs section for information about traditional Medicaid claim pricing and PPG pricing incentives.