Generic Drug CPI Initiative
Drug List
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| GCN | Generic Name | Original SMAC Unit Price | Current SMAC Unit Price | Current SMAC Effective Date | Calculated Penalty |
|---|---|---|---|---|---|
| 00416 | THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H | 0.74353 | 3.4789 | 10/16/2016 | 0.50478 |
| 00962 | ENALAPRIL MALEATE 20 MG TABLET | 0.16401 | 4.38018 | 3/16/2016 | 3.72414 |
| 00963 | ENALAPRIL MALEATE 2.5 MG TABLET | 0.0473 | 0.2565 | 6/16/2016 | 0.0673 |
| 01130 | DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE | 0.25983 | 1.288 | 2/16/2016 | 0.24868 |
| 02390 | NICARDIPINE HCL 20 MG CAPSULE | 0.3375 | 1.64492 | 7/16/2016 | 0.29492 |
| 02391 | NICARDIPINE HCL 30 MG CAPSULE | 0.405 | 2.16297 | 8/16/2016 | 0.54297 |
| 13880 | OFLOXACIN 0.3 % DROPS | 2.115 | 21.274 | 11/16/2015 | 12.814 |
| 14008 | NYSTATIN/TRIAMCIN 100,000 UN OINT. (G) | 0.0975 | 3.516 | 12/16/2015 | 3.126 |
| 14023 | NEOMYCIN/POLYMYXIN B SULF/HC 3.5 MG/ML- SOLUTION | 1.90658 | 8.39 | 2/16/2016 | 0.76368 |
| 14025 | NEOMYCIN/POLYMYXIN B SULF/HC 3.5 MG/ML- DROPS SUSP | 1.88652 | 8.39 | 11/16/2015 | 0.84392 |
| 14090 | CLORAZEPATE DIPOTASSIUM 15 MG TABLET | 0.2754 | 2.1748 | 5/16/2016 | 1.0732 |
| 14092 | CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET | 0.2618 | 2.53647 | 11/16/2016 | 1.48927 |
| 14093 | CLORAZEPATE DIPOTASSIUM 7.5 MG TABLET | 0.1947 | 1.40733 | 6/16/2016 | 0.62853 |
| 15001 | PROMETHAZINE HCL 25 MG SUPP.RECT | 1.0362 | 9.36512 | 4/16/2016 | 5.22032 |
| 15003 | PROMETHAZINE HCL 12.5 MG SUPP.RECT | 0.9612 | 8.03275 | 12/16/2015 | 4.18795 |
| 16285 | OXYCODONE HCL 5 MG CAPSULE | 0.2138 | 1.2015 | 8/16/2016 | 0.3463 |
| 17280 | VALPROIC ACID (AS SODIUM SALT) 250 MG/5 M SOLUTION | 0.01472 | 0.11037 | 8/16/2015 | 0.05149 |
| 18352 | BETHANECHOL CHLORIDE 25 MG TABLET | 0.0801 | 0.5782 | 3/16/2016 | 0.2578 |
| 19880 | DEXTROAMPHETAMINE SULFATE 10 MG TABLET | 0.3435 | 1.56127 | 12/16/2015 | 0.18727 |
| 20072 | TERBUTALINE SULFATE 2.5 MG TABLET | 0.247 | 1.2954 | 8/16/2016 | 0.3074 |
| 26101 | MODAFINIL 100 MG TABLET | 2.95731 | 11.8433 | 8/16/2015 | 0.01406 |
| 26130 | LEVOTHYROXINE SODIUM 500 MCG VIAL | 19.2 | 633.09125 | 8/16/2016 | 556.29125 |
| 28663 | DOCETAXEL 20 MG/ML (VIAL) | 41.6765 | 208.335 | 3/16/2016 | 41.629 |
| 31211 | HALOBETASOL PROPIONATE 0.05 % OINT. (G) | 0.5325 | 3.036 | 8/16/2016 | 0.906 |
| 31430 | DESONIDE 0.05 % OINT. (G) | 0.4077 | 3.20533 | 12/16/2015 | 1.57453 |
| 34741 | METHAZOLAMIDE 25 MG TABLET | 0.315 | 3.72344 | 5/16/2016 | 2.46344 |
| 35820 | PIROXICAM 10 MG CAPSULE | 0.0891 | 0.9883 | 5/16/2016 | 0.6319 |
| 40073 | TETRACYCLINE HCL 500 MG CAPSULE | 1.24 | 9.83776 | 2/16/2016 | 4.87776 |
| 40333 | DOXYCYCLINE HYCLATE 50 MG CAPSULE | 0.1317 | 1.0125 | 9/16/2016 | 0.4857 |
| 42121 | PHENAZOPYRIDINE HCL 100 MG TABLET | 0.122 | 1.1908 | 8/16/2015 | 0.7028 |
| 46753 | CIMETIDINE 800 MG TABLET | 0.2775 | 1.13082 | 8/16/2016 | 0.02082 |
| 47130 | NAPROXEN SODIUM 275 MG TABLET | 0.08141 | 1.43 | 7/16/2015 | 1.10436 |
| 48811 | HYDROCORTISONE BUTYRATE 0.1 % SOLUTION | 0.3788 | 2.35575 | 8/16/2016 | 0.84055 |
| 53143 | DIPYRIDAMOLE 75 MG TABLET | 0.16767 | 0.79359 | 8/16/2015 | 0.12291 |
| 54650 | FLUOCINONIDE/EMOLLIENT BASE 0.05 % CREAM (G) | 0.2453 | 2.2206 | 7/16/2015 | 1.2394 |
| 64269 | LANSOPRAZOLE/AMOXICILN/CLARITH 30 MG-500 COMBO. PKG | 0.9581 | 4.2662 | 12/16/2015 | 0.4338 |
| 68101 | NORETHINDRONE-E.ESTRADIOL-IRON 1.5 MG-30 TABLET | 0.67358 | 3.2266 | 3/16/2016 | 0.53228 |
| 94594 | CYANOCOBALAMIN (VITAMIN B-12) 1,000 MCG/ VIAL | 2.308 | 9.98 | 11/16/2015 | 0.748 |
| 99371 | HYDROCODONE/IBUPROFEN 10 MG-200 TABLET | 0.6959 | 4.1055 | 12/16/2015 | 1.3219 |
Notes:
Source, Medicaid Data Warehouse
Data through November 30, 2016
