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
02428946 5-FLUOROURACIL/ SALICYLIC ACID ACTIKERALL 0.5 % * 10 % TOPICAL SOLUTION 1.7384
ML 		CIP N/A N/A NO REGULAR BENEFIT Details
02418320 ALEMTUZUMAB LEMTRADA 12 MG / VIAL INJECTION 13,031.1100
VIAL 		GZM N/A N/A NO SPECIAL AUTHORIZATION Details
00704431 CYPROTERONE ACETATE ANDROCUR 50 MG ORAL TABLET 1.4000
TAB 		PMS 1.4000 N/A YES SPECIAL AUTHORIZATION Details
02245898 CYPROTERONE ACETATE CYPROTERONE 50 MG ORAL TABLET 1.4000
TAB 		AAP 1.4000 N/A YES SPECIAL AUTHORIZATION Details
02390760 CYPROTERONE ACETATE MED-CYPROTERONE 50 MG ORAL TABLET 1.4000
TAB 		GMP 1.4000 N/A YES SPECIAL AUTHORIZATION Details
02339528 EVEROLIMUS AFINITOR 10 MG ORAL TABLET N/A
TAB 		NOV N/A N/A NO NOT A BENEFIT Details
02369257 EVEROLIMUS AFINITOR 2.5 MG ORAL TABLET N/A
TAB 		NOV N/A N/A NO NOT A BENEFIT Details
02339501 EVEROLIMUS AFINITOR 5 MG ORAL TABLET N/A
TAB 		NOV N/A N/A NO NOT A BENEFIT Details
02238560 FLUTAMIDE FLUTAMIDE 250 MG ORAL TABLET 1.9858
TAB 		AAP N/A N/A NO SPECIAL AUTHORIZATION Details
02195925 MEGESTROL ACETATE MEGESTROL 160 MG ORAL TABLET 6.9566
TAB 		AAP N/A N/A NO PALLIATIVE COVERAGE/ SPECIAL AUTHORIZATION Details
02195917 MEGESTROL ACETATE MEGESTROL 40 MG ORAL TABLET 1.5958
TAB 		AAP N/A N/A NO PALLIATIVE COVERAGE/ SPECIAL AUTHORIZATION Details
02182750 METHOTREXATE METHOTREXATE 10 MG ORAL TABLET 2.7987
TAB 		PFI N/A N/A NO REGULAR BENEFIT Details
02509067 METHOTREXATE ACH-METHOTREXATE 2.5 MG ORAL TABLET 0.2513
TAB 		AHI 0.2513 N/A YES REGULAR BENEFIT Details
02182963 METHOTREXATE APO-METHOTREXATE 2.5 MG ORAL TABLET 0.2513
TAB 		APX 0.2513 N/A YES REGULAR BENEFIT Details
02524023 METHOTREXATE AURO-METHOTREXATE 2.5 MG ORAL TABLET 0.2513
TAB 		AUR 0.2513 N/A YES REGULAR BENEFIT Details
02170698 METHOTREXATE PMS-METHOTREXATE 2.5 MG ORAL TABLET 0.2513
TAB 		PMS 0.2513 N/A YES REGULAR BENEFIT Details
02422174 METHOTREXATE SODIUM METHOTREXATE INJECTION BP 10 MG / SYR INJECTION SYRINGE 7.0000
SYR 		PMS N/A N/A NO REGULAR BENEFIT Details
02454831 METHOTREXATE SODIUM METOJECT SUBCUTANEOUS 10 MG / SYR INJECTION SYRINGE 29.6400
SYR 		MDX N/A N/A NO REGULAR BENEFIT Details
02539608 METHOTREXATE SODIUM PMS-METHOTREXATE 10 MG / SYR INJECTION SYRINGE N/A
SYR 		PMS N/A N/A NO UNDER REVIEW Details
02454750 METHOTREXATE SODIUM METOJECT SUBCUTANEOUS 12.5 MG / SYR INJECTION SYRINGE 31.2000
SYR 		MDX N/A N/A NO REGULAR BENEFIT Details
02539616 METHOTREXATE SODIUM PMS-METHOTREXATE 12.5 MG / SYR INJECTION SYRINGE N/A
SYR 		PMS N/A N/A NO UNDER REVIEW Details
02422182 METHOTREXATE SODIUM METHOTREXATE (0.6 ML SYRINGE) 15 MG / SYR INJECTION SYRINGE 8.4000
SYR 		PMS 24.5700 N/A NO REGULAR BENEFIT Details
02491311 METHOTREXATE SODIUM METHOTREXATE SUBCUTANEOUS 15 MG / SYR INJECTION SYRINGE 24.5700
SYR 		AHI 24.5700 N/A YES REGULAR BENEFIT Details
02454858 METHOTREXATE SODIUM METOJECT SUBCUTANEOUS 15 MG / SYR INJECTION SYRINGE 24.5700
SYR 		MDX 24.5700 N/A YES REGULAR BENEFIT Details
02539624 METHOTREXATE SODIUM PMS-METHOTREXATE 15 MG / SYR INJECTION SYRINGE N/A
SYR 		PMS N/A N/A YES UNDER REVIEW Details
02491338 METHOTREXATE SODIUM METHOTREXATE SUBCUTANEOUS 17.5 MG / SYR INJECTION SYRINGE 24.0000
SYR 		AHI 24.0000 N/A YES REGULAR BENEFIT Details
02454769 METHOTREXATE SODIUM METOJECT SUBCUTANEOUS 17.5 MG / SYR INJECTION SYRINGE 24.0000
SYR 		MDX 24.0000 N/A YES REGULAR BENEFIT Details
02539632 METHOTREXATE SODIUM PMS-METHOTREXATE 17.5 MG / SYR INJECTION SYRINGE N/A
SYR 		PMS N/A N/A YES UNDER REVIEW Details
02422190 METHOTREXATE SODIUM METHOTREXATE (0.8 ML SYRINGE) 20 MG / SYR INJECTION SYRINGE 11.2000
SYR 		PMS 26.2500 N/A NO REGULAR BENEFIT Details
02491346 METHOTREXATE SODIUM METHOTREXATE SUBCUTANEOUS 20 MG / SYR INJECTION SYRINGE 26.2500
SYR 		AHI 26.2500 N/A YES REGULAR BENEFIT Details
02454866 METHOTREXATE SODIUM METOJECT SUBCUTANEOUS 20 MG / SYR INJECTION SYRINGE 26.2500
SYR 		MDX 26.2500 N/A YES REGULAR BENEFIT Details
02539640 METHOTREXATE SODIUM PMS-METHOTREXATE 20 MG / SYR INJECTION SYRINGE N/A
SYR 		PMS N/A N/A YES UNDER REVIEW Details
02491354 METHOTREXATE SODIUM METHOTREXATE SUBCUTANEOUS 22.5 MG / SYR INJECTION SYRINGE 26.2500
SYR 		AHI 26.2500 N/A YES REGULAR BENEFIT Details
02454777 METHOTREXATE SODIUM METOJECT SUBCUTANEOUS 22.5 MG / SYR INJECTION SYRINGE 26.2500
SYR 		MDX 26.2500 N/A YES REGULAR BENEFIT Details
02539659 METHOTREXATE SODIUM PMS-METHOTREXATE 22.5 MG / SYR INJECTION SYRINGE N/A
SYR 		PMS N/A N/A YES UNDER REVIEW Details
02419173 METHOTREXATE SODIUM JAMP-METHOTREXATE (UNPRESERVED) 25 MG / ML INJECTION N/A
ML 		JPC N/A N/A NO NOT A BENEFIT Details
02464365 METHOTREXATE SODIUM METHOTREXATE (PRESERVED) 25 MG / ML INJECTION 4.4600
ML 		AHI 4.4600 N/A YES REGULAR BENEFIT Details
02417626 METHOTREXATE SODIUM METHOTREXATE INJECTION (UNPRESERVED) 25 MG / ML INJECTION N/A
ML 		MYP N/A N/A NO NOT A BENEFIT Details
02182777 METHOTREXATE SODIUM METHOTREXATE SOD. (PRESERVED) 25 MG / ML INJECTION 4.4600
ML 		PFI 4.4600 N/A YES REGULAR BENEFIT Details
02099705 METHOTREXATE SODIUM METHOTREXATE SOD.(UNPRESERVED) 25 MG / ML INJECTION 3.5101
ML 		TEV 0.0000 0.0000 YES REGULAR BENEFIT Details
02182955 METHOTREXATE SODIUM METHOTREXATE SOD.(UNPRESERVED) 25 MG / ML INJECTION 5.6250
ML 		PFI 0.0000 0.0000 YES REGULAR BENEFIT Details
02422204 METHOTREXATE SODIUM METHOTREXATE INJECTION BP 25 MG / SYR INJECTION SYRINGE 12.2000
SYR 		PMS 29.2500 N/A NO REGULAR BENEFIT Details
02491362 METHOTREXATE SODIUM METHOTREXATE SUBCUTANEOUS 25 MG / SYR INJECTION SYRINGE 29.2500
SYR 		AHI 29.2500 N/A YES REGULAR BENEFIT Details
02454874 METHOTREXATE SODIUM METOJECT SUBCUTANEOUS 25 MG / SYR INJECTION SYRINGE 29.2500
SYR 		MDX 29.2500 N/A YES REGULAR BENEFIT Details
02539667 METHOTREXATE SODIUM PMS-METHOTREXATE 25 MG / SYR INJECTION SYRINGE N/A
SYR 		PMS N/A N/A YES UNDER REVIEW Details
02422166 METHOTREXATE SODIUM METHOTREXATE INJECTION BP 7.5 MG / SYR INJECTION SYRINGE 5.6000
SYR 		PMS N/A N/A NO REGULAR BENEFIT Details
02241927 RITUXIMAB RITUXAN 10 MG / ML INJECTION N/A
ML 		HLR N/A N/A NO NOT A BENEFIT Details
02498316 RITUXIMAB RIXIMYO 10 MG / ML INJECTION 29.7000
ML 		SDZ N/A N/A NO SPECIAL AUTHORIZATION Details
02495724 RITUXIMAB RUXIENCE 10 MG / ML INJECTION 29.7000
ML 		PFI N/A N/A NO SPECIAL AUTHORIZATION Details
02478382 RITUXIMAB TRUXIMA (10 ML) 10 MG / ML INJECTION 29.7000
ML 		CTC N/A N/A NO SPECIAL AUTHORIZATION Details
02478390 RITUXIMAB TRUXIMA (50 ML) 10 MG / ML INJECTION 29.7000
ML 		CTC N/A N/A NO SPECIAL AUTHORIZATION Details
DIN/NPN/ PIN 02428946
Generic Name 5-FLUOROURACIL/ SALICYLIC ACID
Product Name, Strength & Dosage Form ACTIKERALL 0.5 % * 10 % TOPICAL SOLUTION
Unit Price, Unit of Issue 1.7384
Manufacturer CIP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02418320
Generic Name ALEMTUZUMAB
Product Name, Strength & Dosage Form LEMTRADA 12 MG / VIAL INJECTION
Unit Price, Unit of Issue 13,031.1100
Manufacturer GZM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 00704431
Generic Name CYPROTERONE ACETATE
Product Name, Strength & Dosage Form ANDROCUR 50 MG ORAL TABLET
Unit Price, Unit of Issue 1.4000
Manufacturer PMS
LCA Price 1.4000
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02245898
Generic Name CYPROTERONE ACETATE
Product Name, Strength & Dosage Form CYPROTERONE 50 MG ORAL TABLET
Unit Price, Unit of Issue 1.4000
Manufacturer AAP
LCA Price 1.4000
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02390760
Generic Name CYPROTERONE ACETATE
Product Name, Strength & Dosage Form MED-CYPROTERONE 50 MG ORAL TABLET
Unit Price, Unit of Issue 1.4000
Manufacturer GMP
LCA Price 1.4000
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02339528
Generic Name EVEROLIMUS
Product Name, Strength & Dosage Form AFINITOR 10 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer NOV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02369257
Generic Name EVEROLIMUS
Product Name, Strength & Dosage Form AFINITOR 2.5 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer NOV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02339501
Generic Name EVEROLIMUS
Product Name, Strength & Dosage Form AFINITOR 5 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer NOV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02238560
Generic Name FLUTAMIDE
Product Name, Strength & Dosage Form FLUTAMIDE 250 MG ORAL TABLET
Unit Price, Unit of Issue 1.9858
Manufacturer AAP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02195925
Generic Name MEGESTROL ACETATE
Product Name, Strength & Dosage Form MEGESTROL 160 MG ORAL TABLET
Unit Price, Unit of Issue 6.9566
Manufacturer AAP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status PALLIATIVE COVERAGE/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02195917
Generic Name MEGESTROL ACETATE
Product Name, Strength & Dosage Form MEGESTROL 40 MG ORAL TABLET
Unit Price, Unit of Issue 1.5958
Manufacturer AAP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status PALLIATIVE COVERAGE/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02182750
Generic Name METHOTREXATE
Product Name, Strength & Dosage Form METHOTREXATE 10 MG ORAL TABLET
Unit Price, Unit of Issue 2.7987
Manufacturer PFI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02509067
Generic Name METHOTREXATE
Product Name, Strength & Dosage Form ACH-METHOTREXATE 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 0.2513
Manufacturer AHI
LCA Price 0.2513
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02182963
Generic Name METHOTREXATE
Product Name, Strength & Dosage Form APO-METHOTREXATE 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 0.2513
Manufacturer APX
LCA Price 0.2513
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02524023
Generic Name METHOTREXATE
Product Name, Strength & Dosage Form AURO-METHOTREXATE 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 0.2513
Manufacturer AUR
LCA Price 0.2513
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02170698
Generic Name METHOTREXATE
Product Name, Strength & Dosage Form PMS-METHOTREXATE 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 0.2513
Manufacturer PMS
LCA Price 0.2513
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02422174
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE INJECTION BP 10 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 7.0000
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02454831
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METOJECT SUBCUTANEOUS 10 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 29.6400
Manufacturer MDX
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02539608
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form PMS-METHOTREXATE 10 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02454750
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METOJECT SUBCUTANEOUS 12.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 31.2000
Manufacturer MDX
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02539616
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form PMS-METHOTREXATE 12.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02422182
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE (0.6 ML SYRINGE) 15 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 8.4000
Manufacturer PMS
LCA Price 24.5700
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02491311
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE SUBCUTANEOUS 15 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 24.5700
Manufacturer AHI
LCA Price 24.5700
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02454858
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METOJECT SUBCUTANEOUS 15 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 24.5700
Manufacturer MDX
LCA Price 24.5700
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02539624
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form PMS-METHOTREXATE 15 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02491338
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE SUBCUTANEOUS 17.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 24.0000
Manufacturer AHI
LCA Price 24.0000
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02454769
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METOJECT SUBCUTANEOUS 17.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 24.0000
Manufacturer MDX
LCA Price 24.0000
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02539632
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form PMS-METHOTREXATE 17.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02422190
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE (0.8 ML SYRINGE) 20 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 11.2000
Manufacturer PMS
LCA Price 26.2500
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02491346
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE SUBCUTANEOUS 20 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 26.2500
Manufacturer AHI
LCA Price 26.2500
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02454866
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METOJECT SUBCUTANEOUS 20 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 26.2500
Manufacturer MDX
LCA Price 26.2500
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02539640
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form PMS-METHOTREXATE 20 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02491354
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE SUBCUTANEOUS 22.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 26.2500
Manufacturer AHI
LCA Price 26.2500
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02454777
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METOJECT SUBCUTANEOUS 22.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 26.2500
Manufacturer MDX
LCA Price 26.2500
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02539659
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form PMS-METHOTREXATE 22.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02419173
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form JAMP-METHOTREXATE (UNPRESERVED) 25 MG / ML INJECTION
Unit Price, Unit of Issue N/A
Manufacturer JPC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02464365
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE (PRESERVED) 25 MG / ML INJECTION
Unit Price, Unit of Issue 4.4600
Manufacturer AHI
LCA Price 4.4600
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02417626
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE INJECTION (UNPRESERVED) 25 MG / ML INJECTION
Unit Price, Unit of Issue N/A
Manufacturer MYP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02182777
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE SOD. (PRESERVED) 25 MG / ML INJECTION
Unit Price, Unit of Issue 4.4600
Manufacturer PFI
LCA Price 4.4600
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02099705
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE SOD.(UNPRESERVED) 25 MG / ML INJECTION
Unit Price, Unit of Issue 3.5101
Manufacturer TEV
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02182955
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE SOD.(UNPRESERVED) 25 MG / ML INJECTION
Unit Price, Unit of Issue 5.6250
Manufacturer PFI
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02422204
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE INJECTION BP 25 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 12.2000
Manufacturer PMS
LCA Price 29.2500
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02491362
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE SUBCUTANEOUS 25 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 29.2500
Manufacturer AHI
LCA Price 29.2500
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02454874
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METOJECT SUBCUTANEOUS 25 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 29.2500
Manufacturer MDX
LCA Price 29.2500
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02539667
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form PMS-METHOTREXATE 25 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02422166
Generic Name METHOTREXATE SODIUM
Product Name, Strength & Dosage Form METHOTREXATE INJECTION BP 7.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 5.6000
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02241927
Generic Name RITUXIMAB
Product Name, Strength & Dosage Form RITUXAN 10 MG / ML INJECTION
Unit Price, Unit of Issue N/A
Manufacturer HLR
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02498316
Generic Name RITUXIMAB
Product Name, Strength & Dosage Form RIXIMYO 10 MG / ML INJECTION
Unit Price, Unit of Issue 29.7000
Manufacturer SDZ
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02495724
Generic Name RITUXIMAB
Product Name, Strength & Dosage Form RUXIENCE 10 MG / ML INJECTION
Unit Price, Unit of Issue 29.7000
Manufacturer PFI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02478382
Generic Name RITUXIMAB
Product Name, Strength & Dosage Form TRUXIMA (10 ML) 10 MG / ML INJECTION
Unit Price, Unit of Issue 29.7000
Manufacturer CTC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02478390
Generic Name RITUXIMAB
Product Name, Strength & Dosage Form TRUXIMA (50 ML) 10 MG / ML INJECTION
Unit Price, Unit of Issue 29.7000
Manufacturer CTC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
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