Home Health iDBL
Interactive Drug Benefit List
DIN/NPN/ PIN Generic Name Product Name, Strength & Dosage Form Unit Price, Unit of Issue Manufacturer LCA Price MAC Price Interchangeable Products Coverage Status
02466821 ALMOTRIPTAN MALATE ALMOTRIPTAN 12.5 MG ORAL TABLET 2.3478
TAB 		SNS 2.3478 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02398443 ALMOTRIPTAN MALATE MYLAN-ALMOTRIPTAN 12.5 MG ORAL TABLET 2.3478
TAB 		MYP 2.3478 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02405334 ALMOTRIPTAN MALATE SANDOZ ALMOTRIPTAN 12.5 MG ORAL TABLET 2.3478
TAB 		SDZ 2.3478 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02434849 ALMOTRIPTAN MALATE TEVA-ALMOTRIPTAN 12.5 MG ORAL TABLET 2.3478
TAB 		TEV 2.3478 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02398435 ALMOTRIPTAN MALATE MYLAN-ALMOTRIPTAN 6.25 MG ORAL TABLET 7.0433
TAB 		MYP 0.0000 0.0000 NO RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02314290 NARATRIPTAN HCL TEVA-NARATRIPTAN 1 MG ORAL TABLET 13.1237
TAB 		TEV N/A N/A NO RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02322323 NARATRIPTAN HCL SANDOZ NARATRIPTAN 2.5 MG ORAL TABLET 6.1436
TAB 		SDZ 6.1436 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02314304 NARATRIPTAN HCL TEVA-NARATRIPTAN 2.5 MG ORAL TABLET 6.1436
TAB 		TEV 6.1436 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02483289 RIZATRIPTAN BENZOATE ACCEL-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 2.8150
TAB 		ACP 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02381702 RIZATRIPTAN BENZOATE ACT RIZATRIPTAN 10 MG ORAL TABLET 3.7050
TAB 		TEV 3.7050 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02492490 RIZATRIPTAN BENZOATE AG-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		AGP 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02393476 RIZATRIPTAN BENZOATE APO-RIZATRIPTAN 10 MG ORAL TABLET 3.7050
TAB 		APX 3.7050 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02458772 RIZATRIPTAN BENZOATE CCP-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 2.9633
TAB 		CEL 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02380463 RIZATRIPTAN BENZOATE JAMP-RIZATRIPTAN 10 MG ORAL TABLET 3.7050
TAB 		JPC 3.7050 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02465094 RIZATRIPTAN BENZOATE JAMP-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
WAF 		JPC 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02379678 RIZATRIPTAN BENZOATE MAR-RIZATRIPTAN 10 MG ORAL TABLET 3.7050
TAB 		MAR 3.7050 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02462796 RIZATRIPTAN BENZOATE MAR-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		MAR 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02240521 RIZATRIPTAN BENZOATE MAXALT 10 MG ORAL TABLET 17.3420
TAB 		ORC 3.7050 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02240519 RIZATRIPTAN BENZOATE MAXALT RPD 10 MG ORAL DISINTEGRATING TABLET 17.3420
WAF 		ORC 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02379201 RIZATRIPTAN BENZOATE MYLAN-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		MYP 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02436612 RIZATRIPTAN BENZOATE NAT-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		NTP 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02489384 RIZATRIPTAN BENZOATE NRA-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		NRA 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02393379 RIZATRIPTAN BENZOATE PMS-RIZATRIPTAN RDT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		PMS 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02516756 RIZATRIPTAN BENZOATE RIZATRIPTAN 10 MG ORAL TABLET 3.7050
TAB 		SNS 3.7050 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02442914 RIZATRIPTAN BENZOATE RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		SNS 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02446138 RIZATRIPTAN BENZOATE RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		SIV 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02351889 RIZATRIPTAN BENZOATE SANDOZ RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		SDZ 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02396688 RIZATRIPTAN BENZOATE TEVA-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		TEV 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02483270 RIZATRIPTAN BENZOATE ACCEL-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 2.8150
TAB 		ACP 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02492482 RIZATRIPTAN BENZOATE AG-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET N/A
TAB 		AGP N/A N/A YES UNDER REVIEW Details
02393468 RIZATRIPTAN BENZOATE APO-RIZATRIPTAN 5 MG ORAL TABLET 7.4100
TAB 		APX N/A N/A NO RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02458764 RIZATRIPTAN BENZOATE CCP-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 2.9633
TAB 		CEL 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02465086 RIZATRIPTAN BENZOATE JAMP-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 3.7050
WAF 		JPC 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02462788 RIZATRIPTAN BENZOATE MAR-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		MAR 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02240518 RIZATRIPTAN BENZOATE MAXALT RPD 5 MG ORAL DISINTEGRATING TABLET 17.3420
WAF 		ORC 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02379198 RIZATRIPTAN BENZOATE MYLAN-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		MYP 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02436604 RIZATRIPTAN BENZOATE NAT-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		NTP 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02393360 RIZATRIPTAN BENZOATE PMS-RIZATRIPTAN RDT 5 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		PMS 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02442906 RIZATRIPTAN BENZOATE RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		SNS 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02446111 RIZATRIPTAN BENZOATE RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		SIV 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02351870 RIZATRIPTAN BENZOATE SANDOZ RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		SDZ 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02396661 RIZATRIPTAN BENZOATE TEVA-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET 3.7050
TAB 		TEV 2.8150 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02230420 SUMATRIPTAN HEMISULFATE IMITREX 20 MG / DOSE NASAL UNIT DOSE SPRAY 17.8971
DOSE 		GSK N/A N/A NO RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02230418 SUMATRIPTAN HEMISULFATE IMITREX 5 MG / DOSE NASAL UNIT DOSE SPRAY 17.3952
DOSE 		GSK N/A N/A NO RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02268396 SUMATRIPTAN SUCCINATE APO-SUMATRIPTAN 100 MG ORAL TABLET 3.0549
TAB 		APX 3.0549 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02212161 SUMATRIPTAN SUCCINATE IMITREX DF 100 MG ORAL TABLET 19.4417
TAB 		GSK 3.0549 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02268922 SUMATRIPTAN SUCCINATE MYLAN-SUMATRIPTAN 100 MG ORAL TABLET 3.0549
TAB 		MYP 3.0549 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02256444 SUMATRIPTAN SUCCINATE PMS-SUMATRIPTAN 100 MG ORAL TABLET 3.0549
TAB 		PMS 3.0549 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02286548 SUMATRIPTAN SUCCINATE SUMATRIPTAN 100 MG ORAL TABLET 3.0549
TAB 		SNS 3.0549 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02385589 SUMATRIPTAN SUCCINATE SUMATRIPTAN DF 100 MG ORAL TABLET 3.0549
TAB 		SIV 3.0549 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02239367 SUMATRIPTAN SUCCINATE TEVA-SUMATRIPTAN 100 MG ORAL TABLET 3.0549
TAB 		TEV 3.0549 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02286831 SUMATRIPTAN SUCCINATE TEVA-SUMATRIPTAN DF 100 MG ORAL TABLET 3.0549
TAB 		TEV 3.0549 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02212188 SUMATRIPTAN SUCCINATE IMITREX (0.5 ML) 12 MG / SYR INJECTION SYRINGE 52.5214
SYR 		GSK 41.1185 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02361698 SUMATRIPTAN SUCCINATE TARO-SUMATRIPTAN (0.5 ML) 12 MG / SYR INJECTION SYRINGE 41.1185
SYR 		TAR 41.1185 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02268388 SUMATRIPTAN SUCCINATE APO-SUMATRIPTAN 50 MG ORAL TABLET 2.7732
TAB 		APX 2.7732 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02212153 SUMATRIPTAN SUCCINATE IMITREX DF 50 MG ORAL TABLET 17.6485
TAB 		GSK 2.7732 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02268914 SUMATRIPTAN SUCCINATE MYLAN-SUMATRIPTAN 50 MG ORAL TABLET 2.7732
TAB 		MYP 2.7732 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02256436 SUMATRIPTAN SUCCINATE PMS-SUMATRIPTAN 50 MG ORAL TABLET 2.7732
TAB 		PMS 2.7732 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02286521 SUMATRIPTAN SUCCINATE SUMATRIPTAN 50 MG ORAL TABLET 2.7732
TAB 		SNS 2.7732 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02385570 SUMATRIPTAN SUCCINATE SUMATRIPTAN DF 50 MG ORAL TABLET 2.7732
TAB 		SIV 2.7732 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02286823 SUMATRIPTAN SUCCINATE TEVA-SUMATRIPTAN DF 50 MG ORAL TABLET 2.7732
TAB 		TEV 2.7732 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02481030 ZOLMITRIPTAN AURO-ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		AUR 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02458780 ZOLMITRIPTAN CCP-ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		CEL 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02477106 ZOLMITRIPTAN JAMP ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		JPC 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02421623 ZOLMITRIPTAN JAMP-ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		JPC 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02419521 ZOLMITRIPTAN MINT-ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		MPI 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02421534 ZOLMITRIPTAN NAT-ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		NTP 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02489392 ZOLMITRIPTAN NRA-ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		NRA 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02362988 ZOLMITRIPTAN SANDOZ ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		SDZ 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02428474 ZOLMITRIPTAN SEPTA-ZOLMITRIPTAN-ODT 2.5 MG ORAL DISPERSIBLE TABLET 1.7532
TAB 		SEP 0.0000 0.0000 YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02313960 ZOLMITRIPTAN TEVA-ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		TEV 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02442655 ZOLMITRIPTAN ZOLMITRIPTAN 2.5 MG ORAL TABLET 3.5375
TAB 		SNS 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02238660 ZOLMITRIPTAN ZOMIG 2.5 MG ORAL TABLET 16.3195
TAB 		XPI 3.5375 N/A YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02243045 ZOLMITRIPTAN ZOMIG RAPIMELT 2.5 MG ORAL DISPERSIBLE TABLET 16.3195
TAB 		XPI 0.0000 0.0000 YES RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
02248993 ZOLMITRIPTAN ZOMIG 5 MG / DOSE NASAL UNIT DOSE SPRAY 16.3195
DOSE 		XPI N/A N/A NO RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION Details
DIN/NPN/ PIN 02466821
Generic Name ALMOTRIPTAN MALATE
Product Name, Strength & Dosage Form ALMOTRIPTAN 12.5 MG ORAL TABLET
Unit Price, Unit of Issue 2.3478
Manufacturer SNS
LCA Price 2.3478
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02398443
Generic Name ALMOTRIPTAN MALATE
Product Name, Strength & Dosage Form MYLAN-ALMOTRIPTAN 12.5 MG ORAL TABLET
Unit Price, Unit of Issue 2.3478
Manufacturer MYP
LCA Price 2.3478
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02405334
Generic Name ALMOTRIPTAN MALATE
Product Name, Strength & Dosage Form SANDOZ ALMOTRIPTAN 12.5 MG ORAL TABLET
Unit Price, Unit of Issue 2.3478
Manufacturer SDZ
LCA Price 2.3478
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02434849
Generic Name ALMOTRIPTAN MALATE
Product Name, Strength & Dosage Form TEVA-ALMOTRIPTAN 12.5 MG ORAL TABLET
Unit Price, Unit of Issue 2.3478
Manufacturer TEV
LCA Price 2.3478
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02398435
Generic Name ALMOTRIPTAN MALATE
Product Name, Strength & Dosage Form MYLAN-ALMOTRIPTAN 6.25 MG ORAL TABLET
Unit Price, Unit of Issue 7.0433
Manufacturer MYP
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02314290
Generic Name NARATRIPTAN HCL
Product Name, Strength & Dosage Form TEVA-NARATRIPTAN 1 MG ORAL TABLET
Unit Price, Unit of Issue 13.1237
Manufacturer TEV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02322323
Generic Name NARATRIPTAN HCL
Product Name, Strength & Dosage Form SANDOZ NARATRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 6.1436
Manufacturer SDZ
LCA Price 6.1436
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02314304
Generic Name NARATRIPTAN HCL
Product Name, Strength & Dosage Form TEVA-NARATRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 6.1436
Manufacturer TEV
LCA Price 6.1436
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02483289
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form ACCEL-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 2.8150
Manufacturer ACP
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02381702
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form ACT RIZATRIPTAN 10 MG ORAL TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer TEV
LCA Price 3.7050
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02492490
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form AG-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer AGP
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02393476
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form APO-RIZATRIPTAN 10 MG ORAL TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer APX
LCA Price 3.7050
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458772
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form CCP-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 2.9633
Manufacturer CEL
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02380463
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form JAMP-RIZATRIPTAN 10 MG ORAL TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer JPC
LCA Price 3.7050
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02465094
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form JAMP-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer JPC
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02379678
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form MAR-RIZATRIPTAN 10 MG ORAL TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer MAR
LCA Price 3.7050
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02462796
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form MAR-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer MAR
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02240521
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form MAXALT 10 MG ORAL TABLET
Unit Price, Unit of Issue 17.3420
Manufacturer ORC
LCA Price 3.7050
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02240519
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form MAXALT RPD 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 17.3420
Manufacturer ORC
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02379201
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form MYLAN-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer MYP
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02436612
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form NAT-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer NTP
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02489384
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form NRA-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer NRA
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02393379
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form PMS-RIZATRIPTAN RDT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer PMS
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02516756
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form RIZATRIPTAN 10 MG ORAL TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer SNS
LCA Price 3.7050
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02442914
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer SNS
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02446138
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer SIV
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02351889
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form SANDOZ RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer SDZ
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02396688
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form TEVA-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer TEV
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02483270
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form ACCEL-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 2.8150
Manufacturer ACP
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02492482
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form AG-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue N/A
Manufacturer AGP
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02393468
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form APO-RIZATRIPTAN 5 MG ORAL TABLET
Unit Price, Unit of Issue 7.4100
Manufacturer APX
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458764
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form CCP-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 2.9633
Manufacturer CEL
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02465086
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form JAMP-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer JPC
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02462788
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form MAR-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer MAR
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02240518
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form MAXALT RPD 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 17.3420
Manufacturer ORC
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02379198
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form MYLAN-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer MYP
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02436604
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form NAT-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer NTP
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02393360
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form PMS-RIZATRIPTAN RDT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer PMS
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02442906
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer SNS
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02446111
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer SIV
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02351870
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form SANDOZ RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer SDZ
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02396661
Generic Name RIZATRIPTAN BENZOATE
Product Name, Strength & Dosage Form TEVA-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET
Unit Price, Unit of Issue 3.7050
Manufacturer TEV
LCA Price 2.8150
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02230420
Generic Name SUMATRIPTAN HEMISULFATE
Product Name, Strength & Dosage Form IMITREX 20 MG / DOSE NASAL UNIT DOSE SPRAY
Unit Price, Unit of Issue 17.8971
Manufacturer GSK
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02230418
Generic Name SUMATRIPTAN HEMISULFATE
Product Name, Strength & Dosage Form IMITREX 5 MG / DOSE NASAL UNIT DOSE SPRAY
Unit Price, Unit of Issue 17.3952
Manufacturer GSK
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02268396
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form APO-SUMATRIPTAN 100 MG ORAL TABLET
Unit Price, Unit of Issue 3.0549
Manufacturer APX
LCA Price 3.0549
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02212161
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form IMITREX DF 100 MG ORAL TABLET
Unit Price, Unit of Issue 19.4417
Manufacturer GSK
LCA Price 3.0549
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02268922
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form MYLAN-SUMATRIPTAN 100 MG ORAL TABLET
Unit Price, Unit of Issue 3.0549
Manufacturer MYP
LCA Price 3.0549
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02256444
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form PMS-SUMATRIPTAN 100 MG ORAL TABLET
Unit Price, Unit of Issue 3.0549
Manufacturer PMS
LCA Price 3.0549
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02286548
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form SUMATRIPTAN 100 MG ORAL TABLET
Unit Price, Unit of Issue 3.0549
Manufacturer SNS
LCA Price 3.0549
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02385589
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form SUMATRIPTAN DF 100 MG ORAL TABLET
Unit Price, Unit of Issue 3.0549
Manufacturer SIV
LCA Price 3.0549
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02239367
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form TEVA-SUMATRIPTAN 100 MG ORAL TABLET
Unit Price, Unit of Issue 3.0549
Manufacturer TEV
LCA Price 3.0549
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02286831
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form TEVA-SUMATRIPTAN DF 100 MG ORAL TABLET
Unit Price, Unit of Issue 3.0549
Manufacturer TEV
LCA Price 3.0549
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02212188
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form IMITREX (0.5 ML) 12 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 52.5214
Manufacturer GSK
LCA Price 41.1185
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02361698
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form TARO-SUMATRIPTAN (0.5 ML) 12 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 41.1185
Manufacturer TAR
LCA Price 41.1185
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02268388
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form APO-SUMATRIPTAN 50 MG ORAL TABLET
Unit Price, Unit of Issue 2.7732
Manufacturer APX
LCA Price 2.7732
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02212153
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form IMITREX DF 50 MG ORAL TABLET
Unit Price, Unit of Issue 17.6485
Manufacturer GSK
LCA Price 2.7732
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02268914
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form MYLAN-SUMATRIPTAN 50 MG ORAL TABLET
Unit Price, Unit of Issue 2.7732
Manufacturer MYP
LCA Price 2.7732
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02256436
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form PMS-SUMATRIPTAN 50 MG ORAL TABLET
Unit Price, Unit of Issue 2.7732
Manufacturer PMS
LCA Price 2.7732
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02286521
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form SUMATRIPTAN 50 MG ORAL TABLET
Unit Price, Unit of Issue 2.7732
Manufacturer SNS
LCA Price 2.7732
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02385570
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form SUMATRIPTAN DF 50 MG ORAL TABLET
Unit Price, Unit of Issue 2.7732
Manufacturer SIV
LCA Price 2.7732
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02286823
Generic Name SUMATRIPTAN SUCCINATE
Product Name, Strength & Dosage Form TEVA-SUMATRIPTAN DF 50 MG ORAL TABLET
Unit Price, Unit of Issue 2.7732
Manufacturer TEV
LCA Price 2.7732
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02481030
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form AURO-ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer AUR
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458780
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form CCP-ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer CEL
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02477106
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form JAMP ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer JPC
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02421623
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form JAMP-ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer JPC
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02419521
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form MINT-ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer MPI
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02421534
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form NAT-ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer NTP
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02489392
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form NRA-ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer NRA
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02362988
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form SANDOZ ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer SDZ
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02428474
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form SEPTA-ZOLMITRIPTAN-ODT 2.5 MG ORAL DISPERSIBLE TABLET
Unit Price, Unit of Issue 1.7532
Manufacturer SEP
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02313960
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form TEVA-ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer TEV
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02442655
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form ZOLMITRIPTAN 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 3.5375
Manufacturer SNS
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02238660
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form ZOMIG 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 16.3195
Manufacturer XPI
LCA Price 3.5375
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02243045
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form ZOMIG RAPIMELT 2.5 MG ORAL DISPERSIBLE TABLET
Unit Price, Unit of Issue 16.3195
Manufacturer XPI
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02248993
Generic Name ZOLMITRIPTAN
Product Name, Strength & Dosage Form ZOMIG 5 MG / DOSE NASAL UNIT DOSE SPRAY
Unit Price, Unit of Issue 16.3195
Manufacturer XPI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Details
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The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.
Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.
Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL(iDBL), and any such changes to the Interactive DBL(iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.