General Information

Generic Name: 
fentanyl citrate
NDC code: 
63459050630
Package Size: 
30
EA
Prescription/OTC: 
Prescription required
Family Planning drug: 
No
Diabetic Supply: 
No
Refill-to-soon Utilization*: 
90%

Drug Pricing

Retail Pharmacy Cost: 
87.15466
Retail Pharmacy Eff Date: 
01/10/2017
Specialty Pharmacy Cost: 
81.81866
Specialty Pharmacy Eff Date: 
01/10/2017
Long-term Care Pharmacy Cost: 
85.90959
Long-term Care Pharmacy Eff Date: 
01/10/2017
340B Cost: 
38.24133
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: 
06/29/2007
PA Effective Date: 
11/17/2006
FFS Clinical PA Required ‡: 
Yes

CHIP

CHIP Effective Date: 
06/29/2007

CSHCN

CSHCN Effective date: 
06/29/2007

Compound-only Use by Program

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