General Information

Generic Name: 
PNV 19/iron ps,heme/folic/dha
NDC code: 
69543024030
Package Size: 
30
EA
Prescription/OTC: 
Prescription required
Family Planning drug: 
No
Diabetic Supply: 
No
Refill-to-soon Utilization*: 
75%

Drug Pricing

Retail Pharmacy Cost: 
2.28144
Retail Pharmacy Eff Date: 
11/22/2016
Specialty Pharmacy Cost: 
2.14176
Specialty Pharmacy Eff Date: 
11/22/2016
Long-term Care Pharmacy Cost: 
2.24884
Long-term Care Pharmacy Eff Date: 
11/22/2016
340B Cost: 
1.00104
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: 
11/22/2016
PA Effective Date: 
01/22/2015
FFS Clinical PA Required ‡: 
No

CHIP

CHIP Effective Date: 
11/22/2016

CSHCN

CSHCN Effective date: 
11/22/2016

Compound-only Use by Program

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