DIN/NPN/ PIN | Generic Name | Product Name, Strength & Dosage Form | Unit Price, Unit of Issue | Manufacturer | LCA Price | MAC Price | Interchangeable Products | Coverage Status | |
---|---|---|---|---|---|---|---|---|---|
02293269 | ACAMPROSATE CALCIUM | CAMPRAL 333 MG ORAL DELAYED-RELEASE TABLET |
0.8996 TAB |
MYP | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02503034 | AMIFAMPRIDINE | RUZURGI 10 MG ORAL TABLET |
20.0000 TAB |
MDK | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02318024 | ATOMOXETINE HCL | APO-ATOMOXETINE 10 MG ORAL CAPSULE |
0.5106 CAP |
APX | 0.5106 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02445883 | ATOMOXETINE HCL | ATOMOXETINE 10 MG ORAL CAPSULE |
0.5106 CAP |
SIV | 0.5106 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02467747 | ATOMOXETINE HCL | ATOMOXETINE 10 MG ORAL CAPSULE |
0.5106 CAP |
SNS | 0.5106 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02471485 | ATOMOXETINE HCL | AURO-ATOMOXETINE 10 MG ORAL CAPSULE |
N/A CAP |
AUR | N/A | N/A | YES | UNDER REVIEW | |
02506807 | ATOMOXETINE HCL | JAMP ATOMOXETINE 10 MG ORAL CAPSULE |
0.5106 CAP |
JPC | 0.5106 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02381028 | ATOMOXETINE HCL | PMS-ATOMOXETINE 10 MG ORAL CAPSULE |
0.5106 CAP |
PMS | 0.5106 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02386410 | ATOMOXETINE HCL | SANDOZ ATOMOXETINE 10 MG ORAL CAPSULE |
0.5106 CAP |
SDZ | 0.5106 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02262800 | ATOMOXETINE HCL | STRATTERA 10 MG ORAL CAPSULE |
N/A CAP |
LIL | N/A | N/A | YES | NOT A BENEFIT | |
02314541 | ATOMOXETINE HCL | TEVA-ATOMOXETINE 10 MG ORAL CAPSULE |
0.5106 CAP |
TEV | 0.5106 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02318083 | ATOMOXETINE HCL | APO-ATOMOXETINE 100 MG ORAL CAPSULE |
1.3382 CAP |
APX | 1.3382 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02467828 | ATOMOXETINE HCL | ATOMOXETINE 100 MG ORAL CAPSULE |
1.3382 CAP |
SNS | 1.3382 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02471558 | ATOMOXETINE HCL | AURO-ATOMOXETINE 100 MG ORAL CAPSULE |
N/A CAP |
AUR | N/A | N/A | YES | UNDER REVIEW | |
02506874 | ATOMOXETINE HCL | JAMP ATOMOXETINE 100 MG ORAL CAPSULE |
1.3382 CAP |
JPC | 1.3382 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02386488 | ATOMOXETINE HCL | SANDOZ ATOMOXETINE 100 MG ORAL CAPSULE |
1.3382 CAP |
SDZ | 1.3382 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02318032 | ATOMOXETINE HCL | APO-ATOMOXETINE 18 MG ORAL CAPSULE |
0.5748 CAP |
APX | 0.5748 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02445905 | ATOMOXETINE HCL | ATOMOXETINE 18 MG ORAL CAPSULE |
0.5748 CAP |
SIV | 0.5748 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02467755 | ATOMOXETINE HCL | ATOMOXETINE 18 MG ORAL CAPSULE |
0.5748 CAP |
SNS | 0.5748 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02471493 | ATOMOXETINE HCL | AURO-ATOMOXETINE 18 MG ORAL CAPSULE |
N/A CAP |
AUR | N/A | N/A | YES | UNDER REVIEW | |
02506815 | ATOMOXETINE HCL | JAMP ATOMOXETINE 18 MG ORAL CAPSULE |
0.5748 CAP |
JPC | 0.5748 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02381036 | ATOMOXETINE HCL | PMS-ATOMOXETINE 18 MG ORAL CAPSULE |
0.5748 CAP |
PMS | 0.5748 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02386429 | ATOMOXETINE HCL | SANDOZ ATOMOXETINE 18 MG ORAL CAPSULE |
0.5748 CAP |
SDZ | 0.5748 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02262819 | ATOMOXETINE HCL | STRATTERA 18 MG ORAL CAPSULE |
N/A CAP |
LIL | N/A | N/A | YES | NOT A BENEFIT | |
02314568 | ATOMOXETINE HCL | TEVA-ATOMOXETINE 18 MG ORAL CAPSULE |
0.5748 CAP |
TEV | 0.5748 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02318040 | ATOMOXETINE HCL | APO-ATOMOXETINE 25 MG ORAL CAPSULE |
0.6420 CAP |
APX | 0.6420 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02445913 | ATOMOXETINE HCL | ATOMOXETINE 25 MG ORAL CAPSULE |
0.6420 CAP |
SIV | 0.6420 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02467763 | ATOMOXETINE HCL | ATOMOXETINE 25 MG ORAL CAPSULE |
0.6420 CAP |
SNS | 0.6420 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02471507 | ATOMOXETINE HCL | AURO-ATOMOXETINE 25 MG ORAL CAPSULE |
N/A CAP |
AUR | N/A | N/A | YES | UNDER REVIEW | |
02506823 | ATOMOXETINE HCL | JAMP ATOMOXETINE 25 MG ORAL CAPSULE |
0.6420 CAP |
JPC | 0.6420 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02381044 | ATOMOXETINE HCL | PMS-ATOMOXETINE 25 MG ORAL CAPSULE |
0.6420 CAP |
PMS | 0.6420 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02386437 | ATOMOXETINE HCL | SANDOZ ATOMOXETINE 25 MG ORAL CAPSULE |
0.6420 CAP |
SDZ | 0.6420 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02262827 | ATOMOXETINE HCL | STRATTERA 25 MG ORAL CAPSULE |
N/A CAP |
LIL | N/A | N/A | YES | NOT A BENEFIT | |
02314576 | ATOMOXETINE HCL | TEVA-ATOMOXETINE 25 MG ORAL CAPSULE |
0.6420 CAP |
TEV | 0.6420 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02318059 | ATOMOXETINE HCL | APO-ATOMOXETINE 40 MG ORAL CAPSULE |
0.7369 CAP |
APX | 0.7369 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02445948 | ATOMOXETINE HCL | ATOMOXETINE 40 MG ORAL CAPSULE |
0.7369 CAP |
SIV | 0.7369 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02467771 | ATOMOXETINE HCL | ATOMOXETINE 40 MG ORAL CAPSULE |
0.7369 CAP |
SNS | 0.7369 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02471515 | ATOMOXETINE HCL | AURO-ATOMOXETINE 40 MG ORAL CAPSULE |
N/A CAP |
AUR | N/A | N/A | YES | UNDER REVIEW | |
02506831 | ATOMOXETINE HCL | JAMP ATOMOXETINE 40 MG ORAL CAPSULE |
0.7369 CAP |
JPC | 0.7369 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02381052 | ATOMOXETINE HCL | PMS-ATOMOXETINE 40 MG ORAL CAPSULE |
0.7369 CAP |
PMS | 0.7369 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02386445 | ATOMOXETINE HCL | SANDOZ ATOMOXETINE 40 MG ORAL CAPSULE |
0.7369 CAP |
SDZ | 0.7369 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02262835 | ATOMOXETINE HCL | STRATTERA 40 MG ORAL CAPSULE |
N/A CAP |
LIL | N/A | N/A | YES | NOT A BENEFIT | |
02314584 | ATOMOXETINE HCL | TEVA-ATOMOXETINE 40 MG ORAL CAPSULE |
0.7369 CAP |
TEV | 0.7369 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02318067 | ATOMOXETINE HCL | APO-ATOMOXETINE 60 MG ORAL CAPSULE |
0.8092 CAP |
APX | 0.8092 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02445956 | ATOMOXETINE HCL | ATOMOXETINE 60 MG ORAL CAPSULE |
0.8092 CAP |
SIV | 0.8092 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02467798 | ATOMOXETINE HCL | ATOMOXETINE 60 MG ORAL CAPSULE |
0.8092 CAP |
SNS | 0.8092 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02471523 | ATOMOXETINE HCL | AURO-ATOMOXETINE 60 MG ORAL CAPSULE |
N/A CAP |
AUR | N/A | N/A | YES | UNDER REVIEW | |
02506858 | ATOMOXETINE HCL | JAMP ATOMOXETINE 60 MG ORAL CAPSULE |
0.8092 CAP |
JPC | 0.8092 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02381060 | ATOMOXETINE HCL | PMS-ATOMOXETINE 60 MG ORAL CAPSULE |
0.8092 CAP |
PMS | 0.8092 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02386453 | ATOMOXETINE HCL | SANDOZ ATOMOXETINE 60 MG ORAL CAPSULE |
0.8092 CAP |
SDZ | 0.8092 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02262843 | ATOMOXETINE HCL | STRATTERA 60 MG ORAL CAPSULE |
N/A CAP |
LIL | N/A | N/A | YES | NOT A BENEFIT | |
02314592 | ATOMOXETINE HCL | TEVA-ATOMOXETINE 60 MG ORAL CAPSULE |
0.8092 CAP |
TEV | 0.8092 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02318075 | ATOMOXETINE HCL | APO-ATOMOXETINE 80 MG ORAL CAPSULE |
1.2193 CAP |
APX | 1.2193 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02467801 | ATOMOXETINE HCL | ATOMOXETINE 80 MG ORAL CAPSULE |
1.2193 CAP |
SNS | 1.2193 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02471531 | ATOMOXETINE HCL | AURO-ATOMOXETINE 80 MG ORAL CAPSULE |
N/A CAP |
AUR | N/A | N/A | YES | UNDER REVIEW | |
02506866 | ATOMOXETINE HCL | JAMP ATOMOXETINE 80 MG ORAL CAPSULE |
1.2193 CAP |
JPC | 1.2193 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02386461 | ATOMOXETINE HCL | SANDOZ ATOMOXETINE 80 MG ORAL CAPSULE |
1.2193 CAP |
SDZ | 1.2193 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02362511 | ATOMOXETINE HCL | TEVA-ATOMOXETINE 80 MG ORAL CAPSULE |
1.2193 CAP |
TEV | 1.2193 | N/A | YES | STEP THERAPY/ SPECIAL AUTHORIZATION | |
02495341 | DIMETHYL FUMARATE | ACH-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
4.4266 CAP |
AHI | 4.4266 | N/A | YES | SPECIAL AUTHORIZATION | |
02505762 | DIMETHYL FUMARATE | APO-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
4.4266 CAP |
APX | 4.4266 | N/A | YES | SPECIAL AUTHORIZATION | |
02494809 | DIMETHYL FUMARATE | GLN-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
4.4266 CAP |
GLM | 4.4266 | N/A | YES | SPECIAL AUTHORIZATION | |
02516047 | DIMETHYL FUMARATE | JAMP DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
4.4266 CAP |
JPC | 4.4266 | N/A | YES | SPECIAL AUTHORIZATION | |
02502690 | DIMETHYL FUMARATE | MAR-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
4.4266 CAP |
MAR | 4.4266 | N/A | YES | SPECIAL AUTHORIZATION | |
02497026 | DIMETHYL FUMARATE | PMS-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
4.4266 CAP |
PMS | 4.4266 | N/A | YES | SPECIAL AUTHORIZATION | |
02513781 | DIMETHYL FUMARATE | SANDOZ DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
4.4266 CAP |
SDZ | 4.4266 | N/A | YES | SPECIAL AUTHORIZATION | |
02404508 | DIMETHYL FUMARATE | TECFIDERA 120 MG ORAL DELAYED-RELEASE CAPSULE |
17.7064 CAP |
BIO | 4.4266 | N/A | YES | SPECIAL AUTHORIZATION | |
02505770 | DIMETHYL FUMARATE | APO-DIMETHYL FUMARATE 240 MG ORAL DELAYED-RELEASE CAPSULE |
8.6888 CAP |
APX | 8.6888 | N/A | YES | SPECIAL AUTHORIZATION | |
02516055 | DIMETHYL FUMARATE | JAMP DIMETHYL FUMARATE 240 MG ORAL DELAYED-RELEASE CAPSULE |
8.6888 CAP |
JPC | 8.6888 | N/A | YES | SPECIAL AUTHORIZATION | |
02497034 | DIMETHYL FUMARATE | PMS-DIMETHYL FUMARATE 240 MG ORAL DELAYED-RELEASE CAPSULE |
8.6888 CAP |
PMS | 8.6888 | N/A | YES | SPECIAL AUTHORIZATION | |
02513803 | DIMETHYL FUMARATE | SANDOZ DIMETHYL FUMARATE 240 MG ORAL DELAYED-RELEASE CAPSULE |
8.6888 CAP |
SDZ | 8.6888 | N/A | YES | SPECIAL AUTHORIZATION | |
02420201 | DIMETHYL FUMARATE | TECFIDERA 240 MG ORAL DELAYED-RELEASE CAPSULE |
N/A CAP |
BIO | N/A | N/A | YES | NOT A BENEFIT | |
02475472 | EDARAVONE | RADICAVA 0.3 MG / ML INJECTION |
4.7380 ML |
MIT | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02532611 | EDARAVONE | RADICAVA 21 MG / ML ORAL SUSPENSION |
189.5200 ML |
MIT | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02481383 | INOTERSEN SODIUM | TEGSEDI 284 MG / SYR INJECTION SYRINGE |
8,043.4874 SYR |
AKC | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02260638 | MEMANTINE HYDROCHLORIDE | EBIXA 10 MG ORAL TABLET |
N/A TAB |
LBC | N/A | N/A | NO | NOT A BENEFIT | |
02352583 | RILUZOLE | APO-RILUZOLE 50 MG ORAL TABLET |
3.4361 TAB |
APX | 3.4361 | N/A | YES | SPECIAL AUTHORIZATION | |
02390299 | RILUZOLE | MYLAN-RILUZOLE 50 MG ORAL TABLET |
3.4361 TAB |
MYP | 3.4361 | N/A | YES | SPECIAL AUTHORIZATION | |
02242763 | RILUZOLE | RILUTEK 50 MG ORAL TABLET |
10.5500 TAB |
SAV | 3.4361 | N/A | YES | SPECIAL AUTHORIZATION | |
02268272 | SODIUM OXYBATE | XYREM 500 MG / ML ORAL SOLUTION |
N/A ML |
JAZ | N/A | N/A | NO | NOT A BENEFIT | |
02527707 | SODIUM PHENYLBUTYRATE/ URSODOXICOLTAURINE | ALBRIOZA 3 G * 1 G ORAL POWDER PACKET |
306.7123 PCKT |
AYX | N/A | N/A | NO | SPECIAL AUTHORIZATION |
DIN/NPN/ PIN | 02293269 |
Generic Name | ACAMPROSATE CALCIUM |
Product Name, Strength & Dosage Form | CAMPRAL 333 MG ORAL DELAYED-RELEASE TABLET |
Unit Price, Unit of Issue | 0.8996 |
Manufacturer | MYP |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02503034 |
Generic Name | AMIFAMPRIDINE |
Product Name, Strength & Dosage Form | RUZURGI 10 MG ORAL TABLET |
Unit Price, Unit of Issue | 20.0000 |
Manufacturer | MDK |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02318024 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | APO-ATOMOXETINE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5106 |
Manufacturer | APX |
LCA Price | 0.5106 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02445883 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5106 |
Manufacturer | SIV |
LCA Price | 0.5106 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02467747 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5106 |
Manufacturer | SNS |
LCA Price | 0.5106 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02471485 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | AURO-ATOMOXETINE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | AUR |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | UNDER REVIEW |
Details |
DIN/NPN/ PIN | 02506807 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | JAMP ATOMOXETINE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5106 |
Manufacturer | JPC |
LCA Price | 0.5106 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02381028 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | PMS-ATOMOXETINE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5106 |
Manufacturer | PMS |
LCA Price | 0.5106 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02386410 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | SANDOZ ATOMOXETINE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5106 |
Manufacturer | SDZ |
LCA Price | 0.5106 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02262800 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | STRATTERA 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | LIL |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02314541 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | TEVA-ATOMOXETINE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5106 |
Manufacturer | TEV |
LCA Price | 0.5106 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02318083 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | APO-ATOMOXETINE 100 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.3382 |
Manufacturer | APX |
LCA Price | 1.3382 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02467828 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 100 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.3382 |
Manufacturer | SNS |
LCA Price | 1.3382 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02471558 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | AURO-ATOMOXETINE 100 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | AUR |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | UNDER REVIEW |
Details |
DIN/NPN/ PIN | 02506874 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | JAMP ATOMOXETINE 100 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.3382 |
Manufacturer | JPC |
LCA Price | 1.3382 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02386488 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | SANDOZ ATOMOXETINE 100 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.3382 |
Manufacturer | SDZ |
LCA Price | 1.3382 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02318032 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | APO-ATOMOXETINE 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5748 |
Manufacturer | APX |
LCA Price | 0.5748 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02445905 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5748 |
Manufacturer | SIV |
LCA Price | 0.5748 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02467755 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5748 |
Manufacturer | SNS |
LCA Price | 0.5748 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02471493 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | AURO-ATOMOXETINE 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | AUR |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | UNDER REVIEW |
Details |
DIN/NPN/ PIN | 02506815 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | JAMP ATOMOXETINE 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5748 |
Manufacturer | JPC |
LCA Price | 0.5748 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02381036 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | PMS-ATOMOXETINE 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5748 |
Manufacturer | PMS |
LCA Price | 0.5748 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02386429 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | SANDOZ ATOMOXETINE 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5748 |
Manufacturer | SDZ |
LCA Price | 0.5748 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02262819 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | STRATTERA 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | LIL |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02314568 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | TEVA-ATOMOXETINE 18 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.5748 |
Manufacturer | TEV |
LCA Price | 0.5748 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02318040 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | APO-ATOMOXETINE 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.6420 |
Manufacturer | APX |
LCA Price | 0.6420 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02445913 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.6420 |
Manufacturer | SIV |
LCA Price | 0.6420 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02467763 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.6420 |
Manufacturer | SNS |
LCA Price | 0.6420 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02471507 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | AURO-ATOMOXETINE 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | AUR |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | UNDER REVIEW |
Details |
DIN/NPN/ PIN | 02506823 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | JAMP ATOMOXETINE 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.6420 |
Manufacturer | JPC |
LCA Price | 0.6420 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02381044 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | PMS-ATOMOXETINE 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.6420 |
Manufacturer | PMS |
LCA Price | 0.6420 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02386437 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | SANDOZ ATOMOXETINE 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.6420 |
Manufacturer | SDZ |
LCA Price | 0.6420 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02262827 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | STRATTERA 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | LIL |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02314576 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | TEVA-ATOMOXETINE 25 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.6420 |
Manufacturer | TEV |
LCA Price | 0.6420 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02318059 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | APO-ATOMOXETINE 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.7369 |
Manufacturer | APX |
LCA Price | 0.7369 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02445948 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.7369 |
Manufacturer | SIV |
LCA Price | 0.7369 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02467771 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.7369 |
Manufacturer | SNS |
LCA Price | 0.7369 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02471515 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | AURO-ATOMOXETINE 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | AUR |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | UNDER REVIEW |
Details |
DIN/NPN/ PIN | 02506831 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | JAMP ATOMOXETINE 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.7369 |
Manufacturer | JPC |
LCA Price | 0.7369 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02381052 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | PMS-ATOMOXETINE 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.7369 |
Manufacturer | PMS |
LCA Price | 0.7369 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02386445 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | SANDOZ ATOMOXETINE 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.7369 |
Manufacturer | SDZ |
LCA Price | 0.7369 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02262835 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | STRATTERA 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | LIL |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02314584 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | TEVA-ATOMOXETINE 40 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.7369 |
Manufacturer | TEV |
LCA Price | 0.7369 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02318067 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | APO-ATOMOXETINE 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.8092 |
Manufacturer | APX |
LCA Price | 0.8092 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02445956 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.8092 |
Manufacturer | SIV |
LCA Price | 0.8092 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02467798 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.8092 |
Manufacturer | SNS |
LCA Price | 0.8092 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02471523 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | AURO-ATOMOXETINE 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | AUR |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | UNDER REVIEW |
Details |
DIN/NPN/ PIN | 02506858 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | JAMP ATOMOXETINE 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.8092 |
Manufacturer | JPC |
LCA Price | 0.8092 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02381060 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | PMS-ATOMOXETINE 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.8092 |
Manufacturer | PMS |
LCA Price | 0.8092 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02386453 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | SANDOZ ATOMOXETINE 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.8092 |
Manufacturer | SDZ |
LCA Price | 0.8092 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02262843 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | STRATTERA 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | LIL |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02314592 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | TEVA-ATOMOXETINE 60 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 0.8092 |
Manufacturer | TEV |
LCA Price | 0.8092 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02318075 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | APO-ATOMOXETINE 80 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.2193 |
Manufacturer | APX |
LCA Price | 1.2193 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02467801 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | ATOMOXETINE 80 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.2193 |
Manufacturer | SNS |
LCA Price | 1.2193 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02471531 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | AURO-ATOMOXETINE 80 MG ORAL CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | AUR |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | UNDER REVIEW |
Details |
DIN/NPN/ PIN | 02506866 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | JAMP ATOMOXETINE 80 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.2193 |
Manufacturer | JPC |
LCA Price | 1.2193 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02386461 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | SANDOZ ATOMOXETINE 80 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.2193 |
Manufacturer | SDZ |
LCA Price | 1.2193 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02362511 |
Generic Name | ATOMOXETINE HCL |
Product Name, Strength & Dosage Form | TEVA-ATOMOXETINE 80 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1.2193 |
Manufacturer | TEV |
LCA Price | 1.2193 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | STEP THERAPY/ SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02495341 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | ACH-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 4.4266 |
Manufacturer | AHI |
LCA Price | 4.4266 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02505762 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | APO-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 4.4266 |
Manufacturer | APX |
LCA Price | 4.4266 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02494809 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | GLN-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 4.4266 |
Manufacturer | GLM |
LCA Price | 4.4266 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02516047 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | JAMP DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 4.4266 |
Manufacturer | JPC |
LCA Price | 4.4266 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02502690 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | MAR-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 4.4266 |
Manufacturer | MAR |
LCA Price | 4.4266 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02497026 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | PMS-DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 4.4266 |
Manufacturer | PMS |
LCA Price | 4.4266 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02513781 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | SANDOZ DIMETHYL FUMARATE 120 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 4.4266 |
Manufacturer | SDZ |
LCA Price | 4.4266 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02404508 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | TECFIDERA 120 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 17.7064 |
Manufacturer | BIO |
LCA Price | 4.4266 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02505770 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | APO-DIMETHYL FUMARATE 240 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 8.6888 |
Manufacturer | APX |
LCA Price | 8.6888 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02516055 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | JAMP DIMETHYL FUMARATE 240 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 8.6888 |
Manufacturer | JPC |
LCA Price | 8.6888 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02497034 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | PMS-DIMETHYL FUMARATE 240 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 8.6888 |
Manufacturer | PMS |
LCA Price | 8.6888 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02513803 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | SANDOZ DIMETHYL FUMARATE 240 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 8.6888 |
Manufacturer | SDZ |
LCA Price | 8.6888 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02420201 |
Generic Name | DIMETHYL FUMARATE |
Product Name, Strength & Dosage Form | TECFIDERA 240 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | N/A |
Manufacturer | BIO |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02475472 |
Generic Name | EDARAVONE |
Product Name, Strength & Dosage Form | RADICAVA 0.3 MG / ML INJECTION |
Unit Price, Unit of Issue | 4.7380 |
Manufacturer | MIT |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02532611 |
Generic Name | EDARAVONE |
Product Name, Strength & Dosage Form | RADICAVA 21 MG / ML ORAL SUSPENSION |
Unit Price, Unit of Issue | 189.5200 |
Manufacturer | MIT |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02481383 |
Generic Name | INOTERSEN SODIUM |
Product Name, Strength & Dosage Form | TEGSEDI 284 MG / SYR INJECTION SYRINGE |
Unit Price, Unit of Issue | 8,043.4874 |
Manufacturer | AKC |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02260638 |
Generic Name | MEMANTINE HYDROCHLORIDE |
Product Name, Strength & Dosage Form | EBIXA 10 MG ORAL TABLET |
Unit Price, Unit of Issue | N/A |
Manufacturer | LBC |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02352583 |
Generic Name | RILUZOLE |
Product Name, Strength & Dosage Form | APO-RILUZOLE 50 MG ORAL TABLET |
Unit Price, Unit of Issue | 3.4361 |
Manufacturer | APX |
LCA Price | 3.4361 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02390299 |
Generic Name | RILUZOLE |
Product Name, Strength & Dosage Form | MYLAN-RILUZOLE 50 MG ORAL TABLET |
Unit Price, Unit of Issue | 3.4361 |
Manufacturer | MYP |
LCA Price | 3.4361 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02242763 |
Generic Name | RILUZOLE |
Product Name, Strength & Dosage Form | RILUTEK 50 MG ORAL TABLET |
Unit Price, Unit of Issue | 10.5500 |
Manufacturer | SAV |
LCA Price | 3.4361 |
MAC Price | N/A |
Interchangeable Products | YES |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02268272 |
Generic Name | SODIUM OXYBATE |
Product Name, Strength & Dosage Form | XYREM 500 MG / ML ORAL SOLUTION |
Unit Price, Unit of Issue | N/A |
Manufacturer | JAZ |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02527707 |
Generic Name | SODIUM PHENYLBUTYRATE/ URSODOXICOLTAURINE |
Product Name, Strength & Dosage Form | ALBRIOZA 3 G * 1 G ORAL POWDER PACKET |
Unit Price, Unit of Issue | 306.7123 |
Manufacturer | AYX |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |