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 | |
02398443 | ALMOTRIPTAN MALATE | MYLAN-ALMOTRIPTAN 12.5 MG ORAL TABLET |
2.3478 TAB |
MYP | 2.3478 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02405334 | ALMOTRIPTAN MALATE | SANDOZ ALMOTRIPTAN 12.5 MG ORAL TABLET |
2.3478 TAB |
SDZ | 2.3478 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02434849 | ALMOTRIPTAN MALATE | TEVA-ALMOTRIPTAN 12.5 MG ORAL TABLET |
2.3478 TAB |
TEV | 2.3478 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02398435 | ALMOTRIPTAN MALATE | MYLAN-ALMOTRIPTAN 6.25 MG ORAL TABLET |
7.0433 TAB |
MYP | 0.0000 | 0.0000 | NO | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02314290 | NARATRIPTAN HCL | TEVA-NARATRIPTAN 1 MG ORAL TABLET |
13.1237 TAB |
TEV | N/A | N/A | NO | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02322323 | NARATRIPTAN HCL | SANDOZ NARATRIPTAN 2.5 MG ORAL TABLET |
6.1436 TAB |
SDZ | 6.1436 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02314304 | NARATRIPTAN HCL | TEVA-NARATRIPTAN 2.5 MG ORAL TABLET |
6.1436 TAB |
TEV | 6.1436 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02483289 | RIZATRIPTAN BENZOATE | ACCEL-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
2.8150 TAB |
ACP | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02381702 | RIZATRIPTAN BENZOATE | ACT RIZATRIPTAN 10 MG ORAL TABLET |
3.7050 TAB |
TEV | 3.7050 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02492490 | RIZATRIPTAN BENZOATE | AG-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
AGP | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02393476 | RIZATRIPTAN BENZOATE | APO-RIZATRIPTAN 10 MG ORAL TABLET |
3.7050 TAB |
APX | 3.7050 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02458772 | RIZATRIPTAN BENZOATE | CCP-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
2.9633 TAB |
CEL | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02380463 | RIZATRIPTAN BENZOATE | JAMP-RIZATRIPTAN 10 MG ORAL TABLET |
3.7050 TAB |
JPC | 3.7050 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02465094 | RIZATRIPTAN BENZOATE | JAMP-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 WAF |
JPC | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02379678 | RIZATRIPTAN BENZOATE | MAR-RIZATRIPTAN 10 MG ORAL TABLET |
3.7050 TAB |
MAR | 3.7050 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02462796 | RIZATRIPTAN BENZOATE | MAR-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
MAR | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02240521 | RIZATRIPTAN BENZOATE | MAXALT 10 MG ORAL TABLET |
17.3420 TAB |
ORC | 3.7050 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02240519 | RIZATRIPTAN BENZOATE | MAXALT RPD 10 MG ORAL DISINTEGRATING TABLET |
17.3420 WAF |
ORC | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02379201 | RIZATRIPTAN BENZOATE | MYLAN-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
MYP | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02436612 | RIZATRIPTAN BENZOATE | NAT-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
NTP | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02489384 | RIZATRIPTAN BENZOATE | NRA-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
NRA | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02393379 | RIZATRIPTAN BENZOATE | PMS-RIZATRIPTAN RDT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
PMS | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02516756 | RIZATRIPTAN BENZOATE | RIZATRIPTAN 10 MG ORAL TABLET |
3.7050 TAB |
SNS | 3.7050 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02446138 | RIZATRIPTAN BENZOATE | RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
SIV | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02442914 | RIZATRIPTAN BENZOATE | RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
SNS | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02351889 | RIZATRIPTAN BENZOATE | SANDOZ RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
SDZ | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02396688 | RIZATRIPTAN BENZOATE | TEVA-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
TEV | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02483270 | RIZATRIPTAN BENZOATE | ACCEL-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
2.8150 TAB |
ACP | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02492482 | RIZATRIPTAN BENZOATE | AG-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
N/A TAB |
AGP | N/A | N/A | YES | UNDER REVIEW | |
02393468 | RIZATRIPTAN BENZOATE | APO-RIZATRIPTAN 5 MG ORAL TABLET |
7.4100 TAB |
APX | N/A | N/A | NO | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02458764 | RIZATRIPTAN BENZOATE | CCP-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
2.9633 TAB |
CEL | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02465086 | RIZATRIPTAN BENZOATE | JAMP-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 WAF |
JPC | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02462788 | RIZATRIPTAN BENZOATE | MAR-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
MAR | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02240518 | RIZATRIPTAN BENZOATE | MAXALT RPD 5 MG ORAL DISINTEGRATING TABLET |
17.3420 WAF |
ORC | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02379198 | RIZATRIPTAN BENZOATE | MYLAN-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
MYP | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02436604 | RIZATRIPTAN BENZOATE | NAT-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
NTP | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02393360 | RIZATRIPTAN BENZOATE | PMS-RIZATRIPTAN RDT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
PMS | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02442906 | RIZATRIPTAN BENZOATE | RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
SNS | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02446111 | RIZATRIPTAN BENZOATE | RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
SIV | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02351870 | RIZATRIPTAN BENZOATE | SANDOZ RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
SDZ | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02396661 | RIZATRIPTAN BENZOATE | TEVA-RIZATRIPTAN ODT 5 MG ORAL DISINTEGRATING TABLET |
3.7050 TAB |
TEV | 2.8150 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02230420 | SUMATRIPTAN HEMISULFATE | IMITREX 20 MG / DOSE NASAL UNIT DOSE SPRAY |
17.8971 DOSE |
GSK | N/A | N/A | NO | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02230418 | SUMATRIPTAN HEMISULFATE | IMITREX 5 MG / DOSE NASAL UNIT DOSE SPRAY |
17.3952 DOSE |
GSK | N/A | N/A | NO | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02268396 | SUMATRIPTAN SUCCINATE | APO-SUMATRIPTAN 100 MG ORAL TABLET |
3.0549 TAB |
APX | 3.0549 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02212161 | SUMATRIPTAN SUCCINATE | IMITREX DF 100 MG ORAL TABLET |
19.4417 TAB |
GSK | 3.0549 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02268922 | SUMATRIPTAN SUCCINATE | MYLAN-SUMATRIPTAN 100 MG ORAL TABLET |
3.0549 TAB |
MYP | 3.0549 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02256444 | SUMATRIPTAN SUCCINATE | PMS-SUMATRIPTAN 100 MG ORAL TABLET |
3.0549 TAB |
PMS | 3.0549 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02286548 | SUMATRIPTAN SUCCINATE | SUMATRIPTAN 100 MG ORAL TABLET |
3.0549 TAB |
SNS | 3.0549 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02385589 | SUMATRIPTAN SUCCINATE | SUMATRIPTAN DF 100 MG ORAL TABLET |
3.0549 TAB |
SIV | 3.0549 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02239367 | SUMATRIPTAN SUCCINATE | TEVA-SUMATRIPTAN 100 MG ORAL TABLET |
3.0549 TAB |
TEV | 3.0549 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02286831 | SUMATRIPTAN SUCCINATE | TEVA-SUMATRIPTAN DF 100 MG ORAL TABLET |
3.0549 TAB |
TEV | 3.0549 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
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 | |
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 | |
02268388 | SUMATRIPTAN SUCCINATE | APO-SUMATRIPTAN 50 MG ORAL TABLET |
2.7732 TAB |
APX | 2.7732 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02212153 | SUMATRIPTAN SUCCINATE | IMITREX DF 50 MG ORAL TABLET |
17.6485 TAB |
GSK | 2.7732 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02268914 | SUMATRIPTAN SUCCINATE | MYLAN-SUMATRIPTAN 50 MG ORAL TABLET |
2.7732 TAB |
MYP | 2.7732 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02256436 | SUMATRIPTAN SUCCINATE | PMS-SUMATRIPTAN 50 MG ORAL TABLET |
2.7732 TAB |
PMS | 2.7732 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02286521 | SUMATRIPTAN SUCCINATE | SUMATRIPTAN 50 MG ORAL TABLET |
2.7732 TAB |
SNS | 2.7732 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02385570 | SUMATRIPTAN SUCCINATE | SUMATRIPTAN DF 50 MG ORAL TABLET |
2.7732 TAB |
SIV | 2.7732 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02286823 | SUMATRIPTAN SUCCINATE | TEVA-SUMATRIPTAN DF 50 MG ORAL TABLET |
2.7732 TAB |
TEV | 2.7732 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02481030 | ZOLMITRIPTAN | AURO-ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
AUR | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02458780 | ZOLMITRIPTAN | CCP-ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
CEL | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02477106 | ZOLMITRIPTAN | JAMP ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
JPC | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02421623 | ZOLMITRIPTAN | JAMP-ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
JPC | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02419521 | ZOLMITRIPTAN | MINT-ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
MPI | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02421534 | ZOLMITRIPTAN | NAT-ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
NTP | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02489392 | ZOLMITRIPTAN | NRA-ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
NRA | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02362988 | ZOLMITRIPTAN | SANDOZ ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
SDZ | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02428474 | ZOLMITRIPTAN | SEPTA-ZOLMITRIPTAN-ODT 2.5 MG ORAL DISPERSIBLE TABLET |
1.7532 TAB |
SEP | 0.0000 | 0.0000 | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02313960 | ZOLMITRIPTAN | TEVA-ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
TEV | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02442655 | ZOLMITRIPTAN | ZOLMITRIPTAN 2.5 MG ORAL TABLET |
3.5375 TAB |
SNS | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02238660 | ZOLMITRIPTAN | ZOMIG 2.5 MG ORAL TABLET |
16.3195 TAB |
XPI | 3.5375 | N/A | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02243045 | ZOLMITRIPTAN | ZOMIG RAPIMELT 2.5 MG ORAL DISPERSIBLE TABLET |
16.3195 TAB |
XPI | 0.0000 | 0.0000 | YES | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION | |
02248993 | ZOLMITRIPTAN | ZOMIG 5 MG / DOSE NASAL UNIT DOSE SPRAY |
16.3195 DOSE |
XPI | N/A | N/A | NO | RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION |
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 | 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 | 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 | 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 |