DEPARTMENT OF HEALTH & HUMAN SERVICES
Center for Medicaid and State Operations
DATE: August 26, 2009
FROM: Director
Pharmacy Division
SUBJECT: Notification of Medicaid Drug Federal Upper Limit (FUL) Changes to Transmittal No. 37, Dated November 20, 2001
TO: Associate Regional Administrators, Division of Medicaid and State Operations
Please inform the States in your region of the following FUL changes as soon as possible. The changes are to be implemented no later than September 25, 2009.
CMS used the following compendia sources in compiling this list:
B – Blue Book, M – Medi-Span, R – Red Book
FUL Deletions
Generic Name
FUL Decreases
Generic Name FUL Price
FUL Decreases – continued
Generic Name FUL Price
FUL Additions
Generic Name FUL Price
FUL Additions - continued
Generic Name FUL Price
http://www.cms.hhs.gov/Reimbursement. If you have any questions, please contact Gail Sexton at gail.sexton@cms.hhs.gov, telephone number (410) 786-4583 or Meagan Khau at meagan.khau@cms.hhs.gov, telephone number (410) 786-1357.
Clobetasol Propionate, Emollient Base
0.05%, Cream, Topical, 30 $ 0.4465 B
These changes will be posted to our website at
/s/
Larry Reed
Director, Division of Pharmacy
cc: Regional Administrators
Amoxicillin; Clavulanic Acid
600 mg/5ml; EQ 42.9 mg Base/5 ml, Suspension, Oral, 75 $ 0.4500 R
500 mg; EQ 125 mg Base, Tablet, Oral, 20 $ 2.1158 B
875 mg; EQ 125 mg Base, Tablet, Oral, 20 $ 2.5320 B FUL Changes - Page 3 of 3
Citalopram Hydrobromide
EQ 10 mg Base/5 ml, Solution, Oral, 240 $ 0.3124 B
EQ 10 mg Base, Tablet, Oral, 100 $ 0.1673 B
EQ 20 mg Base, Tablet, Oral, 100 $ 0.1725 B
EQ 40 mg Base, Tablet, Oral, 100 $ 0.1755 B
Clarithromycin
500 mg, Tablet, Oral, 60 $ 0.8625 B
Clobetasol Propionate
0.05%, Cream, Topical, 30 $ 0.1825 B
Methylphenidate Hydrochloride
5 mg, Tablet, Oral, 100 $ 0.2253 R
10 mg, Tablet, Oral, 100 $ 0.3006 R
20 mg, Tablet, Oral, 100 $ 0.3309 R
Naproxen
250 mg, Tablet, Oral, 100 $ 0.1032 B
375 mg, Tablet, Oral, 100 $ 0.0761 B
500 mg, Tablet, Oral, 100 $ 0.0824 B
Ofloxacin
0.3%, Solution/Drops, Ophthalmic, 5 $ 3.4500 B
Tizanidine Hydrochloride
EQ 2 mg Base, Tablet, Oral, 150 $ 0.2600 R
EQ 4 mg Base, Tablet, Oral, 150 $ 0.3200 R
Amiodarone Hydrochloride
200 mg, Tablet, Oral, 60 $ 0.7375 R
Benzonatate
100 mg, Capsule, Oral, 100 $ 0.1403 B
200 mg, Capsule, Oral, 100 $ 0.2460 B
Betamethasone Dipropionate; Clotrimazole
EQ 0.05% Base/1%, Cream, Topical, 15 $ 0.8230 B FUL Changes - Page 2 of 3
Erythromycin
0.5%, Ointment, Ophthalmic, 3
Metoprolol Succinate
EQ 100 mg, Tartrate, Tablet, Extended Release, Oral, 100
EQ 200 mg, Tartrate, Tablet, Extended Release, Oral, 100
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-15
Baltimore, Maryland 21244-1850