General Information

Generic Name: 
acetaminophen/diphenhydramine
NDC code: 
00536100301
Package Size: 
100
EA
Prescription/OTC: 
Over the counter
Family Planning drug: 
No
Diabetic Supply: 
No
Refill-to-soon Utilization*: 
75%

Drug Pricing

Retail Pharmacy Cost: 
.02036
Retail Pharmacy Eff Date: 
12/26/2017
Specialty Pharmacy Cost: 
.02
Specialty Pharmacy Eff Date: 
12/26/2017
Long-term Care Pharmacy Cost: 
.01987
Long-term Care Pharmacy Eff Date: 
12/26/2017
340B Cost: 
.00825
Premium Preferred Generic Incentive†: 
No

 

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

† To learn about traditional Medicaid claim pricing and PPG pricing incentives please refer to the Drug Pricing & Reimbursement (PDF) chapter of the VDP Pharmacy Provider Procedure Manual.

‡ 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.

Program Coverage

Medicaid

Med Effective Date: 
12/02/2014
FFS Clinical PA Required ‡: 
Yes

CSHCN

CSHCN Effective date: 
12/02/2014

Compound-only Use by Program

Medicaid: 
No
CHIP: 
No
CSHCN: 
No
KHC: 
No