General Information

Generic Name: 
factor IX
NDC code: 
68516360302
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: 
1.3132
Retail Pharmacy Eff Date: 
01/03/2017
Specialty Pharmacy Cost: 
1.2328
Specialty Pharmacy Eff Date: 
01/03/2017
Long-term Care Pharmacy Cost: 
1.29444
Long-term Care Pharmacy Eff Date: 
01/03/2017
340B Cost: 
.9112
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: 
05/10/2010
Class: 
NOT ASSIGNED
FFS Clinical PA Required ‡: 
No

CHIP

CHIP Effective Date: 
05/10/2010

Compound-only Use by Program

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