General Information

Generic Name: 
acetaminophen with codeine
NDC code: 
00187000301
Package Size: 
473
ML
Prescription/OTC: 
Prescription required
Family Planning drug: 
No
Diabetic Supply: 
No
Refill-to-soon Utilization*: 
90%

Drug Pricing

Retail Pharmacy Cost: 
4.10391
Retail Pharmacy Eff Date: 
06/01/2016
Specialty Pharmacy Cost: 
3.85265
Specialty Pharmacy Eff Date: 
06/01/2016
Long-term Care Pharmacy Cost: 
4.04528
Long-term Care Pharmacy Eff Date: 
06/01/2016
340B Cost: 
1.80069
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: 
11/24/2004
PA Effective Date: 
07/22/2008
FFS Clinical PA Required ‡: 
Yes

CHIP

CHIP Effective Date: 
11/24/2004

Compound-only Use by Program

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