General Information

Generic Name: 
diphenhydramine HCl
Manufacturer: 
EPIC PHARMA LLC
NDC code: 
42806064910
Package Size: 
1000
EA
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: 
.01767
Retail Pharmacy Eff Date: 
02/23/2021
Specialty Pharmacy Cost: 
.01736
Specialty Pharmacy Eff Date: 
02/23/2021
Long-term Care Pharmacy Cost: 
.01724
Long-term Care Pharmacy Eff Date: 
02/23/2021
340B Cost: 
.01243
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: 
08/08/2019
Compound-only use: 
No
Compound-only use: 
No

CSHCN

Effective date: 
08/08/2019
Compound-only use: 
No
Compound-only use: 
No