General Information

Generic Name: 
benzoyl peroxide
Manufacturer: 
PERRIGO CO.
NDC code: 
45802021696
Package Size: 
60
GM
Prescription/OTC: 
Over the counter
Family Planning drug: 
No
Diabetic Supply: 
No
HTW drug: 
No
HTWPlus drug: 
No
Long-acting reversible contraception product: 
No
Refill-to-soon Utilization*: 
75%

Drug Pricing

Retail Pharmacy Cost: 
.22739
Retail Pharmacy Eff Date: 
12/29/2020
Specialty Pharmacy Cost: 
.22341
Specialty Pharmacy Eff Date: 
12/29/2020
Long-term Care Pharmacy Cost: 
.22193
Long-term Care Pharmacy Eff Date: 
12/29/2020
340B Cost: 
.09868
Premium Preferred Generic Incentive†: 
No

Pharmacist Administered

Injection: 
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

Effective date: 
03/16/2012
Compound-only use: 
No
Compound-only use: 
No

CSHCN

Effective date: 
03/16/2012
Compound-only use: 
No
Compound-only use: 
No