General Information

Generic Name: 
antihem.FVIII,sin-chn,B-dm tru
NDC code: 
69911047602
Package Size: 
1
EA
Prescription/OTC: 
Prescription required
Family Planning drug: 
No
Diabetic Supply: 
No
Refill-to-soon Utilization*: 
75%

Drug Pricing

Retail Pharmacy Cost: 
1.617
Retail Pharmacy Eff Date: 
02/08/2017
Specialty Pharmacy Cost: 
1.518
Specialty Pharmacy Eff Date: 
02/08/2017
Long-term Care Pharmacy Cost: 
1.5939
Long-term Care Pharmacy Eff Date: 
02/14/2017
340B Cost: 
1.122
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: 
02/08/2017
Class: 
NOT ASSIGNED
FFS Clinical PA Required ‡: 
No

CHIP

CHIP Effective Date: 
02/08/2017

CSHCN

CSHCN Effective date: 
02/08/2017

Compound-only Use by Program

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