DIN/NPN/ PIN | Generic Name | Product Name, Strength & Dosage Form | Unit Price, Unit of Issue | Manufacturer | LCA Price | MAC Price | Interchangeable Products | Coverage Status | |
---|---|---|---|---|---|---|---|---|---|
02460203 | ABOBOTULINUMTOXINA | DYSPORT THERAPEUTIC 300 IU / VIAL INJECTION |
385.5600 VIAL |
ISP | N/A | N/A | NO | REGULAR BENEFIT | |
02456117 | ABOBOTULINUMTOXINA | DYSPORT THERAPEUTIC 500 IU / VIAL INJECTION |
642.6000 VIAL |
ISP | N/A | N/A | NO | REGULAR BENEFIT | |
02502984 | AMIFAMPRIDINE PHOSPHATE | FIRDAPSE 10 MG ORAL TABLET |
18.0000 TAB |
KYE | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02324032 | BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN | XEOMIN 100 UNIT / VIAL INJECTION |
330.0000 VIAL |
MPC | N/A | N/A | NO | REGULAR BENEFIT | |
02371081 | BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN | XEOMIN 50 UNIT / VIAL INJECTION |
165.0000 VIAL |
MPC | N/A | N/A | NO | REGULAR BENEFIT | |
02464705 | CYSTEAMINE BITARTRATE | PROCYSBI 25 MG ORAL DELAYED-RELEASE CAPSULE |
5.9537 CAP |
RAP | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02464713 | CYSTEAMINE BITARTRATE | PROCYSBI 75 MG ORAL DELAYED-RELEASE CAPSULE |
17.8610 CAP |
RAP | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02379910 | FAMPRIDINE | FAMPYRA 10 MG ORAL SUSTAINED-RELEASE TABLET |
N/A TAB |
BIO | N/A | N/A | NO | NOT A BENEFIT | |
02506343 | GIVOSIRAN SODIUM | GIVLAARI 189 MG / ML INJECTION |
64,454.2979 ML |
ANT | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02468042 | MIGALASTAT HYDROCHLORIDE | GALAFOLD 123 MG ORAL CAPSULE |
1,700.0000 CAP |
AMI | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02457733 | NITISINONE | MDK-NITISINONE 10 MG ORAL CAPSULE |
47.4000 CAP |
MEN | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02458632 | NITISINONE | NITISINONE 10 MG ORAL TABLET |
47.4000 TAB |
CYC | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02459728 | NITISINONE | ORFADIN 10 MG ORAL CAPSULE |
47.4000 CAP |
BVM | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02457717 | NITISINONE | MDK-NITISINONE 2 MG ORAL CAPSULE |
12.9500 CAP |
MEN | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02458616 | NITISINONE | NITISINONE 2 MG ORAL TABLET |
12.9500 TAB |
CYC | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02459698 | NITISINONE | ORFADIN 2 MG ORAL CAPSULE |
12.9500 CAP |
BVM | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02470055 | NITISINONE | MDK-NITISINONE 20 MG ORAL CAPSULE |
128.1000 CAP |
MEN | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02459736 | NITISINONE | ORFADIN 20 MG ORAL CAPSULE |
128.1000 CAP |
BVM | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02457725 | NITISINONE | MDK-NITISINONE 5 MG ORAL CAPSULE |
25.0600 CAP |
MEN | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02458624 | NITISINONE | NITISINONE 5 MG ORAL TABLET |
25.0600 TAB |
CYC | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02459701 | NITISINONE | ORFADIN 5 MG ORAL CAPSULE |
25.0600 CAP |
BVM | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02465663 | NUSINERSEN SODIUM | SPINRAZA 2.4 MG / ML INJECTION |
23,600.0000 ML |
BIO | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
01981501 | ONABOTULINUMTOXINA | BOTOX (100 UNIT/VIAL) 100 UNIT INJECTION |
3.7485 UNIT |
ABV | N/A | N/A | NO | REGULAR BENEFIT | |
02531585 | ONABOTULINUMTOXINA | BOTOX (200 UNIT/VIAL) 200 UNIT INJECTION |
3.7485 UNIT |
ABV | N/A | N/A | NO | REGULAR BENEFIT | |
02531577 | ONABOTULINUMTOXINA | BOTOX (50 UNIT/VIAL) 50 UNIT INJECTION |
3.7485 UNIT |
ABV | N/A | N/A | NO | REGULAR BENEFIT | |
02489252 | PATISIRAN SODIUM | ONPATTRO 2 MG / ML INJECTION |
2,100.4813 ML |
ANT | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02514931 | RISDIPLAM | EVRYSDI 0.75 MG / ML ORAL SOLUTION |
145.4794 ML |
HLR | N/A | N/A | NO | SPECIAL AUTHORIZATION | |
02482207 | SAPROPTERIN DIHYDROCHLORIDE | KUVAN 100 MG ORAL POWDER PACKET |
N/A PCKT |
BMI | N/A | N/A | NO | NOT A BENEFIT | |
02350580 | SAPROPTERIN DIHYDROCHLORIDE | KUVAN 100 MG ORAL TABLET |
N/A TAB |
BMI | N/A | N/A | NO | NOT A BENEFIT | |
02482215 | SAPROPTERIN DIHYDROCHLORIDE | KUVAN 500 MG ORAL POWDER PACKET |
N/A PCKT |
BMI | N/A | N/A | NO | NOT A BENEFIT |
DIN/NPN/ PIN | 02460203 |
Generic Name | ABOBOTULINUMTOXINA |
Product Name, Strength & Dosage Form | DYSPORT THERAPEUTIC 300 IU / VIAL INJECTION |
Unit Price, Unit of Issue | 385.5600 |
Manufacturer | ISP |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | REGULAR BENEFIT |
Details |
DIN/NPN/ PIN | 02456117 |
Generic Name | ABOBOTULINUMTOXINA |
Product Name, Strength & Dosage Form | DYSPORT THERAPEUTIC 500 IU / VIAL INJECTION |
Unit Price, Unit of Issue | 642.6000 |
Manufacturer | ISP |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | REGULAR BENEFIT |
Details |
DIN/NPN/ PIN | 02502984 |
Generic Name | AMIFAMPRIDINE PHOSPHATE |
Product Name, Strength & Dosage Form | FIRDAPSE 10 MG ORAL TABLET |
Unit Price, Unit of Issue | 18.0000 |
Manufacturer | KYE |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02324032 |
Generic Name | BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN |
Product Name, Strength & Dosage Form | XEOMIN 100 UNIT / VIAL INJECTION |
Unit Price, Unit of Issue | 330.0000 |
Manufacturer | MPC |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | REGULAR BENEFIT |
Details |
DIN/NPN/ PIN | 02371081 |
Generic Name | BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN |
Product Name, Strength & Dosage Form | XEOMIN 50 UNIT / VIAL INJECTION |
Unit Price, Unit of Issue | 165.0000 |
Manufacturer | MPC |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | REGULAR BENEFIT |
Details |
DIN/NPN/ PIN | 02464705 |
Generic Name | CYSTEAMINE BITARTRATE |
Product Name, Strength & Dosage Form | PROCYSBI 25 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 5.9537 |
Manufacturer | RAP |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02464713 |
Generic Name | CYSTEAMINE BITARTRATE |
Product Name, Strength & Dosage Form | PROCYSBI 75 MG ORAL DELAYED-RELEASE CAPSULE |
Unit Price, Unit of Issue | 17.8610 |
Manufacturer | RAP |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02379910 |
Generic Name | FAMPRIDINE |
Product Name, Strength & Dosage Form | FAMPYRA 10 MG ORAL SUSTAINED-RELEASE TABLET |
Unit Price, Unit of Issue | N/A |
Manufacturer | BIO |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02506343 |
Generic Name | GIVOSIRAN SODIUM |
Product Name, Strength & Dosage Form | GIVLAARI 189 MG / ML INJECTION |
Unit Price, Unit of Issue | 64,454.2979 |
Manufacturer | ANT |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02468042 |
Generic Name | MIGALASTAT HYDROCHLORIDE |
Product Name, Strength & Dosage Form | GALAFOLD 123 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 1,700.0000 |
Manufacturer | AMI |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02457733 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | MDK-NITISINONE 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 47.4000 |
Manufacturer | MEN |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02458632 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | NITISINONE 10 MG ORAL TABLET |
Unit Price, Unit of Issue | 47.4000 |
Manufacturer | CYC |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02459728 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | ORFADIN 10 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 47.4000 |
Manufacturer | BVM |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02457717 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | MDK-NITISINONE 2 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 12.9500 |
Manufacturer | MEN |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02458616 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | NITISINONE 2 MG ORAL TABLET |
Unit Price, Unit of Issue | 12.9500 |
Manufacturer | CYC |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02459698 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | ORFADIN 2 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 12.9500 |
Manufacturer | BVM |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02470055 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | MDK-NITISINONE 20 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 128.1000 |
Manufacturer | MEN |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02459736 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | ORFADIN 20 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 128.1000 |
Manufacturer | BVM |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02457725 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | MDK-NITISINONE 5 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 25.0600 |
Manufacturer | MEN |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02458624 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | NITISINONE 5 MG ORAL TABLET |
Unit Price, Unit of Issue | 25.0600 |
Manufacturer | CYC |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02459701 |
Generic Name | NITISINONE |
Product Name, Strength & Dosage Form | ORFADIN 5 MG ORAL CAPSULE |
Unit Price, Unit of Issue | 25.0600 |
Manufacturer | BVM |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02465663 |
Generic Name | NUSINERSEN SODIUM |
Product Name, Strength & Dosage Form | SPINRAZA 2.4 MG / ML INJECTION |
Unit Price, Unit of Issue | 23,600.0000 |
Manufacturer | BIO |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 01981501 |
Generic Name | ONABOTULINUMTOXINA |
Product Name, Strength & Dosage Form | BOTOX (100 UNIT/VIAL) 100 UNIT INJECTION |
Unit Price, Unit of Issue | 3.7485 |
Manufacturer | ABV |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | REGULAR BENEFIT |
Details |
DIN/NPN/ PIN | 02531585 |
Generic Name | ONABOTULINUMTOXINA |
Product Name, Strength & Dosage Form | BOTOX (200 UNIT/VIAL) 200 UNIT INJECTION |
Unit Price, Unit of Issue | 3.7485 |
Manufacturer | ABV |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | REGULAR BENEFIT |
Details |
DIN/NPN/ PIN | 02531577 |
Generic Name | ONABOTULINUMTOXINA |
Product Name, Strength & Dosage Form | BOTOX (50 UNIT/VIAL) 50 UNIT INJECTION |
Unit Price, Unit of Issue | 3.7485 |
Manufacturer | ABV |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | REGULAR BENEFIT |
Details |
DIN/NPN/ PIN | 02489252 |
Generic Name | PATISIRAN SODIUM |
Product Name, Strength & Dosage Form | ONPATTRO 2 MG / ML INJECTION |
Unit Price, Unit of Issue | 2,100.4813 |
Manufacturer | ANT |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02514931 |
Generic Name | RISDIPLAM |
Product Name, Strength & Dosage Form | EVRYSDI 0.75 MG / ML ORAL SOLUTION |
Unit Price, Unit of Issue | 145.4794 |
Manufacturer | HLR |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | SPECIAL AUTHORIZATION |
Details |
DIN/NPN/ PIN | 02482207 |
Generic Name | SAPROPTERIN DIHYDROCHLORIDE |
Product Name, Strength & Dosage Form | KUVAN 100 MG ORAL POWDER PACKET |
Unit Price, Unit of Issue | N/A |
Manufacturer | BMI |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02350580 |
Generic Name | SAPROPTERIN DIHYDROCHLORIDE |
Product Name, Strength & Dosage Form | KUVAN 100 MG ORAL TABLET |
Unit Price, Unit of Issue | N/A |
Manufacturer | BMI |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | NOT A BENEFIT |
Details |
DIN/NPN/ PIN | 02482215 |
Generic Name | SAPROPTERIN DIHYDROCHLORIDE |
Product Name, Strength & Dosage Form | KUVAN 500 MG ORAL POWDER PACKET |
Unit Price, Unit of Issue | N/A |
Manufacturer | BMI |
LCA Price | N/A |
MAC Price | N/A |
Interchangeable Products | NO |
Coverage Status | NOT A BENEFIT |
Details |