Njsul.com

New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
ACEBUTOLOL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 200 MG ACEBUTOLOL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 400 MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-30MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-60MG ACETIC ACID/ALUMINUM ACETATE OTIC DROPS 2 % ACYCLOVIR ORAL CAPSULE (HARD, SOFT, ETC.) 200 MG ACYCLOVIR ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200 MG/5ML ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (EA) 2.5 MG/0.5 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 2.5 MG/3ML ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 4 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
ALUMINUM CHLORIDE TOPICAL SOLUTION, NON-ORAL 20 % AMANTADINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 10MG-20MGAMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 10MG-40MGAMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 2.5MG-10MGAMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5 MG-10 MGAMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5MG-40MGAMMONIUM LACTATE TOPICAL LOTION (GRAM) 12% AMOXICILLIN TRIHYDRATE ORAL CAPSULE (HARD, SOFT, ETC.) 500 MG AMOXICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5MLAMOXICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/5MLAMOXICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5MLAMOXICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 400 MG/5MLAMOXICILLIN TRIHYDRATE ORAL TABLET 875MG AMOXICILLIN TRIHYDRATE ORAL TABLET, CHEWABLE 250 MG AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250-62.5/5AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 400-57MG/5AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 600-42.9/5AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE ORAL TABLET 500-125 MG AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE ORAL TABLET 875-125 MG AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 10 MGAMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 12.5 MGAMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 15 MGAMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 20 MGAMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 30 MGAMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 5 MGAMPICILLIN TRIHYDRATE ORAL CAPSULE (HARD, SOFT, ETC.) 250 MG AMPICILLIN TRIHYDRATE ORAL CAPSULE (HARD, SOFT, ETC.) 500 MG ANAGRELIDE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 0.5 MG ANTIPYRINE/BENZOCAINE/GLYCERIN OTIC DROPS 5.4%-1.4% New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
ASCORBIC ACID INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 500MG/ML ATENOLOL/CHLORTHALIDONE ORAL TABLET 100MG-25MG ATENOLOL/CHLORTHALIDONE ORAL TABLET 50 MG-25MG AZELASTINE HCL NASAL AEROSOL, SPRAY WITH PUMP (ML) 137 MCG AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 MG/5ML AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/5ML BACITRACIN TOPICAL OINTMENT (GRAM) 500 UNIT/G BACITRACIN/POLYMYXIN B SULFATE OPHTHALMIC OINTMENT (GRAM) 500-10K/G BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-25MG BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5-6.25MG BENZONATATE ORAL CAPSULE (HARD, SOFT, ETC.) 200 MG BENZOYL PEROXIDE TOPICAL GEL, ALCOHOL BASED 10 % New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL CREAM (GRAM) 0.05%BETHANECHOL CHLORIDE ORAL TABLET 5 MG BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 10-6.25MG BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 2.5-6.25MG BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 5-6.25MG BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/CARBETAPENTANE CIT ORAL LIQUID (ML) 6-10-30/5BUMETANIDE ORAL TABLET 0.5 MG BUPIVACAINE HCL INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 5 MG/ML BUPRENORPHINE HCL SUBLINGUAL TABLET, SUBLINGUAL 2 MG BUPRENORPHINE HCL SUBLINGUAL TABLET, SUBLINGUAL 8 MG BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 100 MG BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 150 MG BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 200 MG BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL TABLET 50-325-40 BUTALBITAL/ASPIRIN/CAFFEINE ORAL CAPSULE (HARD, SOFT, ETC.) 50-325-40 CALCITRIOL ORAL CAPSULE (HARD, SOFT, ETC.) 0.25MCG CALCIUM ACETATE ORAL CAPSULE (HARD, SOFT, ETC.) 667 MG CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-25MG CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 25MG-15MG CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-15MG CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-25MG CARBAMAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/5ML CARBAMAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200MG/10ML CARBAMAZEPINE ORAL TABLET, CHEWABLE 100 MG CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 200 MG CARBIDOPA/LEVODOPA ORAL TABLET 10MG-100MG CARBIDOPA/LEVODOPA ORAL TABLET 25MG-100MG CARBIDOPA/LEVODOPA ORAL TABLET 25MG-250MG CARBIDOPA/LEVODOPA ORAL TABLET, EXTENDED RELEASE 25MG-100MG CARBIDOPA/LEVODOPA ORAL TABLET, EXTENDED RELEASE 50MG-200MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
CEFACLOR ORAL CAPSULE (HARD, SOFT, ETC.) 250 MG CEFACLOR ORAL CAPSULE (HARD, SOFT, ETC.) 500 MG CEFADROXIL HYDRATE ORAL CAPSULE (HARD, SOFT, ETC.) 500 MG CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML CEFPODOXIME PROXETIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 MG/5MLCEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML CEPHALEXIN MONOHYDRATE ORAL CAPSULE (HARD, SOFT, ETC.) 500 MG CEPHALEXIN MONOHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5MLCETIRIZINE HCL ORAL SOLUTION, ORAL 1 MG/ML CHOLESTYRAMINE/SUCROSE ORAL POWDER (GRAM) 4 G CHOLINE SALICYLATE/MAGNESIUM SALICYLATE ORAL TABLET 500 MG CHOLINE SALICYLATE/MAGNESIUM SALICYLATE ORAL TABLET 750 MG CICLOPIROX OLAMINE TOPICAL CREAM (GRAM) 0.77% New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
CICLOPIROX OLAMINE TOPICAL SUSPENSION, TOPICAL (ML) 0.77% CIMETIDINE HCL ORAL SOLUTION, ORAL 300MG/5ML CITALOPRAM HYDROBROMIDE ORAL SOLUTION, ORAL 10 MG/5 ML CITALOPRAM HYDROBROMIDE ORAL TABLET 10 MG CITALOPRAM HYDROBROMIDE ORAL TABLET 20 MG CITALOPRAM HYDROBROMIDE ORAL TABLET 40 MG CLARITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 CLARITHROMYCIN ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG CLEMASTINE FUMARATE ORAL SYRUP 0.67MG/5ML CLINDAMYCIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 150 MG CLINDAMYCIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 300 MG CLINDAMYCIN PHOSPHATE TOPICAL GEL (GRAM) 1 % New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
CLINDAMYCIN PHOSPHATE TOPICAL LOTION (ML) 1 % CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION, NON-ORAL 1 % CLINDAMYCIN PHOSPHATE TOPICAL SWAB, MEDICATED 1 % CLINDAMYCIN PHOSPHATE VAGINAL CREAM WITH APPLICATOR 2 % CLOBETASOL PROPIONATE TOPICAL CREAM (GRAM) 0.05% CLOBETASOL PROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % CLOBETASOL PROPIONATE TOPICAL SOLUTION, NON-ORAL 0.05 % CLOBETASOL PROPIONATE/EMOLLIENT TOPICAL CREAM (GRAM) 0.05 % CLOMIPRAMINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 25 MG CLOMIPRAMINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG CLONAZEPAM ORAL TABLET, RAPID DISSOLVE 0.125 MG CLONAZEPAM ORAL TABLET, RAPID DISSOLVE 0.25 MG CLONAZEPAM ORAL TABLET, RAPID DISSOLVE 0.5 MG CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.1MG/24HR CLORAZEPATE DIPOTASSIUM ORAL TABLET 15 MG CLORAZEPATE DIPOTASSIUM ORAL TABLET 3.75 MG CLORAZEPATE DIPOTASSIUM ORAL TABLET 7.5 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
CODEINE/PROMETHAZINE HCL ORAL SYRUP 10-6.25/5 CYCLOSPORINE, MODIFIED ORAL SOLUTION, ORAL 100 MG/ML DANTROLENE SODIUM ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG DESMOPRESSIN ACETATE NASAL AEROSOL, SPRAY WITH PUMP (ML) 10/SPRAY DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.15-0.03 DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 7 DAYS X 3 DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL ORAL TABLET 21-5 DESOXIMETASONE TOPICAL CREAM (GRAM) 0.25 % DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 10 MG DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 5 MG DEXTROAMPHETAMINE SULFATE ORAL TABLET 10 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
DEXTROAMPHETAMINE SULFATE ORAL TABLET 5 MG DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 50 MGDICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 75 MGDICLOXACILLIN SODIUM ORAL CAPSULE (HARD, SOFT, ETC.) 250 MG DICLOXACILLIN SODIUM ORAL CAPSULE (HARD, SOFT, ETC.) 500 MG DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 120 MG DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 180 MG DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 240 MG DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 300 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 120 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 60 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 120 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 180 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 240 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 300 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 360 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED-RELEASE DEGRADABLE 240 MG DIPHENHYDRAMINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
DIPHENOXYLATE HCL/ATROPINE SULFATE ORAL TABLET 2.5-.025MG DISOPYRAMIDE PHOSPHATE ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG DISOPYRAMIDE PHOSPHATE ORAL CAPSULE (HARD, SOFT, ETC.) 150 MG DIVALPROEX SODIUM ORAL CAPSULE, SPRINKLE 125 MG DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 125 MGDIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 250 MGDIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 500 MGDIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 250 MG DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG DORZOLAMIDE HCL/TIMOLOL MALEATE OPHTHALMIC DROPS 2%-0.5% DOXEPIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG DOXEPIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG DOXEPIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 75 MG ECONAZOLE NITRATE TOPICAL CREAM (GRAM) 1 % New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ORAL TABLET 10MG-25MG ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ORAL TABLET 5MG-12.5MG ERYTHROMYCIN BASE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 3-5% ERYTHROMYCIN BASE/ETHYL ALCOHOL TOPICAL SOLUTION, NON-ORAL 2 % ETHOSUXIMIDE ORAL CAPSULE (HARD, SOFT, ETC.) 250 MG ETHYNODIOL D-ETHINYL ESTRADIOL ORAL TABLET 1 MG-35MCG ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 400 MG FENOFIBRATE,MICRONIZED ORAL CAPSULE (HARD, SOFT, ETC.) 200 MG FENOFIBRATE,MICRONIZED ORAL CAPSULE (HARD, SOFT, ETC.) 67 MG FENTANYL CITRATE/PF INJECTION AMPUL (ML) 50 MCG/ML FENTANYL CITRATE/PF INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 50 MCG/ML FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 100MCG/HR New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 25MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 50MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 75MCG/HR FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FOLIC ACID ORAL CAPSULE (HARD, SOFT, ETC.) 110-0.5MGFEXOFENADINE HCL ORAL TABLET 180 MG FLUCONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 10 MG/ML FLUDROCORTISONE ACETATE ORAL TABLET 0.1 MG FLUOCINONIDE TOPICAL OINTMENT (GRAM) 0.05% FLUOXETINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG FLUOXETINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 20 MG FLUOXETINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 40 MG FLUOXETINE HCL ORAL SOLUTION, ORAL 20 MG/5 ML New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
FLUTICASONE PROPIONATE NASAL SPRAY, SUSPENSION 50 MCG FOLIC ACID/VITAMIN B COMP W-C ORAL CAPSULE (HARD, SOFT, ETC.) 1 MG FUROSEMIDE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 10 MG/ML GABAPENTIN ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG GABAPENTIN ORAL CAPSULE (HARD, SOFT, ETC.) 300 MG GABAPENTIN ORAL CAPSULE (HARD, SOFT, ETC.) 400 MG GENTAMICIN SULFATE IN SALINE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 120MG/0.1LGLIMEPIRIDE ORAL TABLET 1 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 2.5 MG GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG GLIPIZIDE/METFORMIN HCL ORAL TABLET 2.5-500MG GLIPIZIDE/METFORMIN HCL ORAL TABLET 5 MG-500MG GLYBURIDE/METFORMIN HCL ORAL TABLET 2.5-500MG GLYBURIDE/METFORMIN HCL ORAL TABLET 5 MG-500MG GRISEOFULVIN,MICROSIZE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 HYDROCHLOROTHIAZIDE ORAL CAPSULE (HARD, SOFT, ETC.) 12.5 MG HYDROCODONE BIT/ACETAMINOPHEN ORAL CAPSULE (HARD, SOFT, ETC.) 5 New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
HYDROCODONE BIT/ACETAMINOPHEN ORAL SOLUTION, ORAL 7.5-500/15 HYDROCODONE BIT/ACETAMINOPHEN ORAL SOLUTION, ORAL 7.5-500/CP HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 10-660MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 10-750MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 10MG-325MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 10MG-500MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 10MG-650MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 2.5-500MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 5 MG-500MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 5MG-325MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 7.5-325MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 7.5-500MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 7.5-650 MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 7.5-750MG HYDROCODONE BIT/HOMATROPINE ORAL SYRUP 5-1.5MG/5 HYDROCODONE POLISTRX/CHLORPHENIRAMINE POLISTIREX ORAL SUSPENSION, EXTENDED RELEASE 12 HR 10-8MG/5MLHYDROCODONE/IBUPROFEN ORAL TABLET 7.5-200 MG HYDROCORTISONE RECTAL ENEMA (ML) 100MG/60ML HYDROCORTISONE TOPICAL CREAM (GRAM) 2.5 % HYDROCORTISONE TOPICAL OINTMENT (GRAM) 2.5 % HYDROCORTISONE VALERATE TOPICAL CREAM (GRAM) 0.2 % New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
HYDROXYCHLOROQUINE SULFATE ORAL TABLET 200 MG HYDROXYUREA ORAL CAPSULE (HARD, SOFT, ETC.) 500 MG HYDROXYZINE PAMOATE ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG HYDROXYZINE PAMOATE ORAL CAPSULE (HARD, SOFT, ETC.) 25 MG HYDROXYZINE PAMOATE ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG HYOSCYAMINE SULFATE ORAL ELIXIR 125MCG/5ML HYOSCYAMINE SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 0.375 MG IBUPROFEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/5ML INDOMETHACIN ORAL CAPSULE (HARD, SOFT, ETC.) 25 MG INDOMETHACIN ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG INDOMETHACIN ORAL CAPSULE, EXTENDED RELEASE 75 MG IPRATROPIUM BROMIDE NASAL AEROSOL, SPRAY (ML) 21 MCG IPRATROPIUM BROMIDE NASAL AEROSOL, SPRAY (ML) 42MCG IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION AMPUL FOR NEBULIZATION (ML) 0.5-3MG/3IRON,CARBONYL/ASCORBIC ACID/CYANOCOBALAMIN/FOLIC ACID ORAL TABLET New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 120 MG ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 60 MG ISOTRETINOIN ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG ITRACONAZOLE ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG KETOROLAC TROMETHAMINE OPHTHALMIC DROPS 0.4 % KETOROLAC TROMETHAMINE OPHTHALMIC DROPS 0.5 % LAMOTRIGINE ORAL TABLET, DISPERSIBLE 25 MG LAMOTRIGINE ORAL TABLET, DISPERSIBLE 5 MG LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 15 MG LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 30 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
LEVETIRACETAM ORAL SOLUTION, ORAL 100 MG/ML LEVOCETIRIZINE DIHYDROCHLORIDE ORAL TABLET 5 MG LEVONORGESTREL-ETH ESTRA ORAL TABLET 0.15-0.03 LEVONORGESTREL-ETH ESTRA ORAL TABLET 6-5-10 LIDOCAINE HCL MUCOUS MEMBRANE JEL (ML) 2 % LIDOCAINE HCL MUCOUS MEMBRANE SOLUTION, NON-ORAL 40 MG/ML LIDOCAINE/PRILOCAINE TOPICAL CREAM (GRAM) 2.5%-2.5% New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-25MG LITHIUM CARBONATE ORAL CAPSULE (HARD, SOFT, ETC.) 150 MG LITHIUM CARBONATE ORAL CAPSULE (HARD, SOFT, ETC.) 300 MG LOPERAMIDE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 2 MG LOPERAMIDE HCL ORAL LIQUID (ML) 1 MG/5 ML LORATADINE/PSEUDOEPHEDRINE SULFATE ORAL TABLET, EXTENDED RELEASE 24 HR 10MG-240MGLORAZEPAM ORAL CONCENTRATE, ORAL 2 MG/ML LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 100-12.5MG LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 100MG-25MG LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 50-12.5MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
LOXAPINE SUCCINATE ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG MEDROXYPROGESTERONE ACET INTRAMUSCULAR DISPOSABLE SYRINGE (ML) 150 MG/MLMEDROXYPROGESTERONE ACET INTRAMUSCULAR VIAL (SDV,MDV OR ADDITIVE) (ML) 150 MG/MLMEDROXYPROGESTERONE ACET ORAL TABLET 10 MG MEDROXYPROGESTERONE ACET ORAL TABLET 2.5 MG MEDROXYPROGESTERONE ACET ORAL TABLET 5 MG MEGESTROL ACETATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 400MG/10MLMEGESTROL ACETATE ORAL TABLET 20 MG METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 750 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
METHOTREXATE SODIUM/PF INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 25 METHYLPREDNISOLONE ORAL TABLET, DOSE PACK 4 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 50 MG METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 100MG-25MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
METRONIDAZOLE VAGINAL GEL WITH APPLICATOR (GRAM) 0.75% MINOCYCLINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG MINOCYCLINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 15-25MG MOMETASONE FUROATE TOPICAL CREAM (GRAM) 0.1% MOMETASONE FUROATE TOPICAL OINTMENT (GRAM) 0.1% MOMETASONE FUROATE TOPICAL SOLUTION, NON-ORAL 0.1% MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 100 MG MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 15 MG MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 200 MG MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 30 MG MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 60 MG MYCOPHENOLATE MOFETIL ORAL CAPSULE (HARD, SOFT, ETC.) 250 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE OTIC SOLUTION, NON-ORAL 3.5-10K-1NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE OTIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 3.5-10K-1NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.1%NIACIN ORAL TABLET 500 MG NICARDIPINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 20 MG NICARDIPINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 30 MG NIFEDIPINE ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 60 MG NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 90 MG NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 30 MG NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 60 MG NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.1MG/HR NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.2MG/HR NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.4MG/HR New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.6MG/HR NIZATIDINE ORAL CAPSULE (HARD, SOFT, ETC.) 150 MG NIZATIDINE ORAL CAPSULE (HARD, SOFT, ETC.) 300 MG NORETHINDRONE A-E ESTRADIOL ORAL TABLET 1.5-0.03MG NORETHINDRONE A-E ESTRADIOL ORAL TABLET 1MG-20MCG NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE ORAL TABLET 1.5-0.03MGNORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE ORAL TABLET 1MG-20MCGNORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE ORAL TABLET 5-7-9-7 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.4-0.035 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.5-0.035 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 1 MG-35MCG NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 7 DAYS X 3 NORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.3-0.03MG NORTRIPTYLINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 25 MG NORTRIPTYLINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG NORTRIPTYLINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 75 MG NORTRIPTYLINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML NYSTATIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100000/ML NYSTATIN/TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 100000-0.1 New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 10 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 20 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 40 MG ONDANSETRON ORAL TABLET, RAPID DISSOLVE 4 MG ONDANSETRON ORAL TABLET, RAPID DISSOLVE 8 MG OXAZEPAM ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG OXAZEPAM ORAL CAPSULE (HARD, SOFT, ETC.) 15 MG OXAZEPAM ORAL CAPSULE (HARD, SOFT, ETC.) 30 MG OXCARBAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 300MG/5ML OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 10MG-325MG OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 10MG-650MG OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 2.5-325MG OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 5MG-325MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 7.5-325MG OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 7.5-500MG OXYCODONE HCL/OXYCODONE TEREPHTHALATE/ASPIRIN ORAL TABLET 4.5-325MGPANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 20 MGPANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) PEDIATRIC MULTIVITAMINS COMBINATION NO.12/SODIUM FLUORIDE ORAL TABLET, CHEWABLE 0.5 MGPENICILLIN V POTASSIUM ORAL TABLET 250 MG PENICILLIN V POTASSIUM ORAL TABLET 500 MG PENTOXIFYLLINE ORAL TABLET, EXTENDED RELEASE 400 MG PHENYLEPHRINE HCL/PYRILAMINE MALEATE/CHLORPHENIRAMINE ORAL LIQUID (ML) 7.5-12.5-2PHENYTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/4ML New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
PHENYTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 MG/5ML PHENYTOIN SODIUM EXTENDED ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG POLYETHYLENE GLYCOL 3350 ORAL POWDER (GRAM) 17G/DOSE POLYMYXIN B SULFATE/TRIMETHOPRIM OPHTHALMIC DROPS 10K/ML-0.1 POTASSIUM CHLORIDE ORAL CAPSULE, EXTENDED RELEASE 10 MEQ POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 10 MEQ POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 5 MEQ PRAZOSIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 2 MG PRAZOSIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5 MG PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 1 %PREDNISOLONE ORAL SOLUTION, ORAL 15 MG/5 ML PREDNISOLONE SOD PHOSPHATE ORAL SOLUTION, ORAL 15 MG/5 ML PREDNISOLONE SOD PHOSPHATE ORAL SOLUTION, ORAL 5 MG/5 ML PRENATAL VITAMIN NO.15/IRON,CARBONYL/FOLIC ACID/DOCUSATE SOD ORAL New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
PRENATAL VITAMIN NO.18/IRON,CARBONYL/FOLIC ACID/DOCUSATE SOD ORAL TABLET 90-1-50 MGPROBENECID ORAL TABLET 500 MG PROCHLORPERAZINE MALEATE ORAL TABLET 10 MG PROCHLORPERAZINE MALEATE ORAL TABLET 5 MG PROMETHAZINE HCL INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 25 MG/ML PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 80 MG RAMIPRIL ORAL CAPSULE (HARD, SOFT, ETC.) 1.25 MG RAMIPRIL ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG RAMIPRIL ORAL CAPSULE (HARD, SOFT, ETC.) 5 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
RISPERIDONE ORAL TABLET, RAPID DISSOLVE 1 MG RISPERIDONE ORAL TABLET, RAPID DISSOLVE 2 MG SALICYLIC ACID/CERAMIDES 1,3,6-11 TOPICAL COMBINATION PACKAGE (ML) 6 % SELEGILINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5 MG SELENIUM SULFIDE TOPICAL SUSPENSION, TOPICAL (ML) 2.5 % New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
SODIUM BICARBONATE INTRAVENOUS DISPOSABLE SYRINGE (ML) 1MEQ/ML SODIUM FLUORIDE DENTAL CREAM (GRAM) 1.1 % SODIUM FLUORIDE ORAL TABLET, CHEWABLE 0.25(0.55) SODIUM FLUORIDE ORAL TABLET, CHEWABLE 1MG(2.2MG) SODIUM POLYSTYRENE SULFONATE ORAL POWDER (GRAM) SPIRONOLACTONE/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-25MG STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 20 MG SULFACETAMIDE SODIUM TOPICAL CLEANSER (ML) 10 % SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (GRAM) 10-5%(W/W) SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200-40MG/5SULFASALAZINE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 500 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
TAMSULOSIN HCL ORAL CAPSULE, EXT RELEASE 24 HR 0.4 MG TEMAZEPAM ORAL CAPSULE (HARD, SOFT, ETC.) 15 MG TEMAZEPAM ORAL CAPSULE (HARD, SOFT, ETC.) 30 MG TERAZOSIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 1 MG TERAZOSIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG TERAZOSIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 2 MG TERAZOSIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5 MG TERCONAZOLE VAGINAL CREAM WITH APPLICATOR 0.4 % THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 100 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 200 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 300 MG THEOPHYLLINE/DEXTROSE 5%-WATER INTRAVENOUS INTRAVENOUS SOLUTION 200MG/50MLTHIORIDAZINE HCL ORAL TABLET 10 MG THIOTHIXENE ORAL CAPSULE (HARD, SOFT, ETC.) 1 MG THIOTHIXENE ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
THIOTHIXENE ORAL CAPSULE (HARD, SOFT, ETC.) 2 MG THIOTHIXENE ORAL CAPSULE (HARD, SOFT, ETC.) 5 MG TOBRAMYCIN SULFATE/DEXAMETHASONE OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.3-0.1%TOPIRAMATE ORAL TABLET 100 MG TRAMADOL HCL/ACETAMINOPHEN ORAL TABLET 37.5-325MG TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.05 % New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL CAPSULE (HARD, SOFT, ETC.) 37.5-25 MGTRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG-25MGTRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL TABLET 37.5-25 MG TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL TABLET 75 MG-50MG URSODIOL ORAL CAPSULE (HARD, SOFT, ETC.) 300 MG VALPROIC ACID ORAL CAPSULE (HARD, SOFT, ETC.) 250 MG VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 150 MG VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 37.5 MG VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 75 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 120 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 180 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 360 MG VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 120 MG New Jersey Department of Human Services
State Upper Limit (SUL) List
as of August 12, 2011
Pharmacy reimbursement for legend and non-legend drugs is based on the lowest of the Average
Wholesale Price (AWP) less 17.5 percent; the Federal Upper Limit (FUL); the State Upper Limit (SUL),
each with a dispensing fee of $3.73 to $3.99; or the pharmacy’s usual and customary charge
Current SUL SUL Effective
Generic Name
VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 180 MG VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 240 MG VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC ACID/BIOTIN ORAL TABLET ZALEPLON ORAL CAPSULE (HARD, SOFT, ETC.) 10 MG ZALEPLON ORAL CAPSULE (HARD, SOFT, ETC.) 5 MG ZINC SULFATE ORAL CAPSULE (HARD, SOFT, ETC.) 220(50)MG ZOLPIDEM TARTRATE ORAL TABLET, EXTENDED RELEASE MULTIPHASE 12.5 MG ZONISAMIDE ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG ZONISAMIDE ORAL CAPSULE (HARD, SOFT, ETC.) 25 MG

Source: http://njsul.com/sites/default/files/State_Upper_Limit%20(SUL)_List_-_Final_Effective_08-12-2011.pdf