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
02402475 ABATACEPT ORENCIA 125 MG / SYR INJECTION 373.7875
SYR
BMS N/A N/A NO SPECIAL AUTHORIZATION Details
02282097 ABATACEPT ORENCIA 250 MG / VIAL INJECTION 500.3400
VIAL
BMS N/A N/A NO SPECIAL AUTHORIZATION Details
02460203 ABOBOTULINUMTOXINA DYSPORT THERAPEUTIC 300 IU / VIAL INJECTION 385.5600
VIAL
ISP N/A N/A NO REGULAR BENEFIT Details
02456117 ABOBOTULINUMTOXINA DYSPORT THERAPEUTIC 500 IU / VIAL INJECTION 642.6000
VIAL
ISP N/A N/A NO REGULAR BENEFIT Details
02458357 ADALIMUMAB HUMIRA (40 MG/0.4 ML INJ PEN) 40 MG / SYR INJECTION SYRINGE N/A
SYR
ABV N/A N/A NO UNDER REVIEW Details
02458349 ADALIMUMAB HUMIRA (40 MG/0.4 ML INJ SYR) 40 MG / SYR INJECTION SYRINGE N/A
SYR
ABV N/A N/A NO UNDER REVIEW Details
02258595 ADALIMUMAB HUMIRA (40 MG/0.8 ML INJ SYR) 40 MG / SYR INJECTION SYRINGE 762.5700
SYR
ABV N/A N/A NO SPECIAL AUTHORIZATION Details
02381486 ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG ORAL TABLET 0.4986
TAB
AHI 0.4986 N/A YES SPECIAL AUTHORIZATION Details
02248728 ALENDRONATE SODIUM APO-ALENDRONATE 10 MG ORAL TABLET 0.4986
TAB
APX 0.4986 N/A YES SPECIAL AUTHORIZATION Details
02388545 ALENDRONATE SODIUM AURO-ALENDRONATE 10 MG ORAL TABLET 0.4986
TAB
AUR 0.4986 N/A YES SPECIAL AUTHORIZATION Details
02288087 ALENDRONATE SODIUM SANDOZ ALENDRONATE 10 MG ORAL TABLET 0.4986
TAB
SDZ 0.4986 N/A YES SPECIAL AUTHORIZATION Details
02258102 ALENDRONATE SODIUM ACT ALENDRONATE 40 MG ORAL TABLET 3.0832
TAB
APH N/A N/A NO SPECIAL AUTHORIZATION Details
02352966 ALENDRONATE SODIUM ALENDRONATE 70 MG ORAL TABLET 2.1014
TAB
SNS 2.1014 N/A YES REGULAR BENEFIT Details
02299712 ALENDRONATE SODIUM ALENDRONATE 70 MG ORAL TABLET 2.1014
TAB
SIV 2.1014 N/A YES REGULAR BENEFIT Details
02381494 ALENDRONATE SODIUM ALENDRONATE SODIUM 70 MG ORAL TABLET 2.1014
TAB
AHI 2.1014 N/A YES REGULAR BENEFIT Details
02248730 ALENDRONATE SODIUM APO-ALENDRONATE 70 MG ORAL TABLET 2.1014
TAB
APX 2.1014 N/A YES REGULAR BENEFIT Details
02388553 ALENDRONATE SODIUM AURO-ALENDRONATE 70 MG ORAL TABLET 2.1014
TAB
AUR 2.1014 N/A YES REGULAR BENEFIT Details
02245329 ALENDRONATE SODIUM FOSAMAX 70 MG ORAL TABLET 11.0114
TAB
MFC 2.1014 N/A YES REGULAR BENEFIT Details
02385031 ALENDRONATE SODIUM JAMP-ALENDRONATE 70 MG ORAL TABLET 2.1014
TAB
JPC 2.1014 N/A YES REGULAR BENEFIT Details
02394871 ALENDRONATE SODIUM MINT-ALENDRONATE 70 MG ORAL TABLET 2.1014
TAB
MPI 2.1014 N/A YES REGULAR BENEFIT Details
02284006 ALENDRONATE SODIUM PMS-ALENDRONATE-FC 70 MG ORAL TABLET 2.1014
TAB
PMS 2.1014 N/A YES REGULAR BENEFIT Details
02288109 ALENDRONATE SODIUM SANDOZ ALENDRONATE 70 MG ORAL TABLET 2.1014
TAB
SDZ 2.1014 N/A YES REGULAR BENEFIT Details
02261715 ALENDRONATE SODIUM TEVA-ALENDRONATE 70 MG ORAL TABLET 2.1014
TAB
TEV 2.1014 N/A YES REGULAR BENEFIT Details
02276429 ALENDRONATE SODIUM/ VITAMIN D3 FOSAVANCE 70 MG * 2,800 UNIT ORAL TABLET N/A
TAB
MFC N/A N/A NO NOT A BENEFIT Details
02454475 ALENDRONATE SODIUM/ VITAMIN D3 APO-ALENDRONATE/VITAMIN D3 70 MG * 5,600 UNIT ORAL TABLET 1.2174
TAB
APX 1.2174 N/A YES REGULAR BENEFIT Details
02314940 ALENDRONATE SODIUM/ VITAMIN D3 FOSAVANCE 70 MG * 5,600 UNIT ORAL TABLET 4.8970
TAB
MFC 1.2174 N/A YES REGULAR BENEFIT Details
02429160 ALENDRONATE SODIUM/ VITAMIN D3 SANDOZ ALENDRONATE/CHOLECALCIFEROL 70 MG * 5,600 UNIT ORAL TABLET 1.2174
TAB
SDZ 1.2174 N/A YES REGULAR BENEFIT Details
02403641 ALENDRONATE SODIUM/ VITAMIN D3 TEVA-ALENDRONATE/CHOLECALCIFEROL 70 MG * 5,600 UNIT ORAL TABLET 1.2174
TAB
TEV 1.2174 N/A YES REGULAR BENEFIT Details
02447576 ALFUZOSIN HCL ALFUZOSIN 10 MG ORAL SUSTAINED-RELEASE TABLET 0.2601
TAB
SIV 0.2601 N/A YES STEP THERAPY/ SPECIAL AUTHORIZATION Details
02315866 ALFUZOSIN HCL APO-ALFUZOSIN 10 MG ORAL SUSTAINED-RELEASE TABLET 0.2601
TAB
APX 0.2601 N/A YES STEP THERAPY/ SPECIAL AUTHORIZATION Details
02443201 ALFUZOSIN HCL AURO-ALFUZOSIN 10 MG ORAL SUSTAINED-RELEASE TABLET 0.2601
TAB
AUR 0.2601 N/A YES STEP THERAPY/ SPECIAL AUTHORIZATION Details
02304678 ALFUZOSIN HCL SANDOZ ALFUZOSIN 10 MG ORAL SUSTAINED-RELEASE TABLET 0.2601
TAB
SDZ 0.2601 N/A YES STEP THERAPY/ SPECIAL AUTHORIZATION Details
02245565 ALFUZOSIN HCL XATRAL 10 MG ORAL SUSTAINED-RELEASE TABLET 1.0404
TAB
SAV 0.2601 N/A YES STEP THERAPY/ SPECIAL AUTHORIZATION Details
02402769 ALLOPURINOL APO-ALLOPURINOL 100 MG ORAL TABLET 0.0780
TAB
APX 0.0780 N/A YES REGULAR BENEFIT Details
02396327 ALLOPURINOL MAR-ALLOPURINOL 100 MG ORAL TABLET 0.0780
TAB
MAR 0.0780 N/A YES REGULAR BENEFIT Details
00402818 ALLOPURINOL ZYLOPRIM 100 MG ORAL TABLET 0.0780
TAB
AAP 0.0780 N/A YES REGULAR BENEFIT Details
02402777 ALLOPURINOL APO-ALLOPURINOL 200 MG ORAL TABLET 0.1300
TAB
APX 0.1300 N/A YES REGULAR BENEFIT Details
02396335 ALLOPURINOL MAR-ALLOPURINOL 200 MG ORAL TABLET 0.1300
TAB
MAR 0.1300 N/A YES REGULAR BENEFIT Details
00479799 ALLOPURINOL ZYLOPRIM 200 MG ORAL TABLET 0.1300
TAB
AAP 0.1300 N/A YES REGULAR BENEFIT Details
02402785 ALLOPURINOL APO-ALLOPURINOL 300 MG ORAL TABLET 0.2125
TAB
APX 0.2125 N/A YES REGULAR BENEFIT Details
02396343 ALLOPURINOL MAR-ALLOPURINOL 300 MG ORAL TABLET 0.2125
TAB
MAR 0.2125 N/A YES REGULAR BENEFIT Details
00402796 ALLOPURINOL ZYLOPRIM 300 MG ORAL TABLET 0.2125
TAB
AAP 0.2125 N/A YES REGULAR BENEFIT Details
02245913 ANAKINRA KINERET 100 MG / SYR INJECTION SYRINGE 50.0700
SYR
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02434334 APREMILAST OTEZLA 30 MG ORAL TABLET N/A
TAB
CLG N/A N/A NO NOT A BENEFIT Details
02434318 APREMILAST/ APREMILAST/ APREMILAST OTEZLA (STARTER PACK) 10 MG * 20 MG * 30 MG ORAL TABLET N/A
TAB
CLG N/A N/A NO NOT A BENEFIT Details
02242907 AZATHIOPRINE APO-AZATHIOPRINE 50 MG ORAL TABLET 0.2405
TAB
APX 0.2405 N/A YES REGULAR BENEFIT Details
00004596 AZATHIOPRINE IMURAN 50 MG ORAL TABLET 1.0927
TAB
APC 0.2405 N/A YES REGULAR BENEFIT Details
02236819 AZATHIOPRINE TEVA-AZATHIOPRINE 50 MG ORAL TABLET 0.2405
TAB
TEV 0.2405 N/A YES REGULAR BENEFIT Details
02370050 BELIMUMAB BENLYSTA 120 MG / VIAL INJECTION N/A
VIAL
GSK N/A N/A NO NOT A BENEFIT Details
02370069 BELIMUMAB BENLYSTA 400 MG / VIAL INJECTION N/A
VIAL
GSK N/A N/A NO NOT A BENEFIT Details
02449153 BETAHISTINE DIHYDROCHLORIDE AURO-BETAHISTINE 16 MG ORAL TABLET 0.1106
TAB
AUR 0.1106 N/A YES REGULAR BENEFIT Details
02466449 BETAHISTINE DIHYDROCHLORIDE BETAHISTINE 16 MG ORAL TABLET 0.1106
TAB
SNS 0.1106 N/A YES REGULAR BENEFIT Details
02330210 BETAHISTINE DIHYDROCHLORIDE PMS-BETAHISTINE 16 MG ORAL TABLET 0.1106
TAB
PMS 0.1106 N/A YES REGULAR BENEFIT Details
02243878 BETAHISTINE DIHYDROCHLORIDE SERC 16 MG ORAL TABLET 0.4864
TAB
BGP 0.1106 N/A YES REGULAR BENEFIT Details
02280191 BETAHISTINE DIHYDROCHLORIDE TEVA-BETAHISTINE 16 MG ORAL TABLET 0.1106
TAB
TEV 0.1106 N/A YES REGULAR BENEFIT Details
02247998 BETAHISTINE DIHYDROCHLORIDE SERC 24 MG ORAL TABLET N/A
TAB
BGP N/A N/A NO NOT A BENEFIT Details
02449145 BETAHISTINE DIHYDROCHLORIDE AURO-BETAHISTINE 8 MG ORAL TABLET 0.1273
TAB
AUR N/A N/A NO REGULAR BENEFIT Details
02244982 BOSENTAN TRACLEER 125 MG ORAL TABLET N/A
TAB
JAI N/A N/A NO NOT A BENEFIT Details
02244981 BOSENTAN TRACLEER 62.5 MG ORAL TABLET N/A
TAB
JAI N/A N/A NO NOT A BENEFIT Details
02324032 BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN XEOMIN 100 UNIT / VIAL INJECTION 330.0000
VIAL
MPC N/A N/A NO REGULAR BENEFIT Details
02371081 BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN XEOMIN 50 UNIT / VIAL INJECTION 165.0000
VIAL
MPC N/A N/A NO REGULAR BENEFIT Details
02225166 BUSERELIN ACETATE SUPREFACT 1 MG / ML INJECTION 12.1873
ML
SAV N/A N/A NO SPECIAL AUTHORIZATION Details
02225158 BUSERELIN ACETATE SUPREFACT INTRANASAL 1 MG / ML NASAL SOLUTION 8.5530
ML
SAV N/A N/A NO SPECIAL AUTHORIZATION Details
02228955 BUSERELIN ACETATE SUPREFACT DEPOT 6.3 MG INJECTION IMPLANT 827.8500
SYS
SAV N/A N/A NO SPECIAL AUTHORIZATION Details
02455897 CABERGOLINE APO-CABERGOLINE 0.5 MG ORAL TABLET 12.3941
TAB
APX 0.0000 0.0000 YES STEP THERAPY/ SPECIAL AUTHORIZATION Details
02242471 CABERGOLINE DOSTINEX 0.5 MG ORAL TABLET 15.1156
TAB
PAL 0.0000 0.0000 YES STEP THERAPY/ SPECIAL AUTHORIZATION Details
02344939 CANAKINUMAB ILARIS 150 MG / VIAL INJECTION N/A
VIAL
NOV N/A N/A NO NOT A BENEFIT Details
02331675 CERTOLIZUMAB PEGOL CIMZIA 200 MG / SYR INJECTION SYRINGE 664.5100
SYR
UCB N/A N/A NO SPECIAL AUTHORIZATION Details
02465574 CERTOLIZUMAB PEGOL CIMZIA AUTO-INJECTOR 200 MG / SYR INJECTION SYRINGE 664.5100
SYR
UCB N/A N/A NO SPECIAL AUTHORIZATION Details
02257130 CINACALCET HYDROCHLORIDE SENSIPAR 30 MG ORAL TABLET N/A
TAB
AMG N/A N/A NO NOT A BENEFIT Details
02257149 CINACALCET HYDROCHLORIDE SENSIPAR 60 MG ORAL TABLET N/A
TAB
AMG N/A N/A NO NOT A BENEFIT Details
02257157 CINACALCET HYDROCHLORIDE SENSIPAR 90 MG ORAL TABLET N/A
TAB
AMG N/A N/A NO NOT A BENEFIT Details
02245828 CLODRONATE DISODIUM CLASTEON 400 MG ORAL CAPSULE 1.2374
CAP
SUN N/A N/A NO REGULAR BENEFIT Details
02304163 CLONIDINE HCL TEVA-CLONIDINE 0.025 MG ORAL TABLET 0.2713
TAB
TEV N/A N/A NO REGULAR BENEFIT Details
00572349 COLCHICINE COLCHICINE 0.6 MG ORAL TABLET 0.2565
TAB
ODN 0.2565 N/A YES REGULAR BENEFIT Details
00287873 COLCHICINE COLCHICINE 0.6 MG ORAL TABLET N/A
TAB
SDZ N/A N/A YES NOT A BENEFIT Details
02373823 COLCHICINE JAMP-COLCHICINE 0.6 MG ORAL TABLET 0.2565
TAB
JPC 0.2565 N/A YES REGULAR BENEFIT Details
02402181 COLCHICINE PMS-COLCHICINE 0.6 MG ORAL TABLET 0.2565
TAB
PMS 0.2565 N/A YES REGULAR BENEFIT Details
00999999 COMPOUND PRESCRIPTION MISCELLANEOUS COMPOUND 0.0000
MIS
XXX N/A N/A NO RESTRICTED BENEFIT Details
00999216 COMPOUND PRESCRIPTION MISCELLANEOUS COMPOUND 0.0000
MIS
XXX 0.0000 0.0000 NO RESTRICTED BENEFIT Details
00999215 COMPOUND PRESCRIPTION MISCELLANEOUS INJECTABLE COMPOUND INJECTION 0.0000
MIS
XXX 0.0000 0.0000 NO RESTRICTED BENEFIT Details
00999114 COMPOUND PRESCRIPTION MISCELLANEOUS INJECTABLE COMPOUND INJECTION 0.0000
MIS
XXX 0.0000 0.0000 NO RESTRICTED BENEFIT Details
00999113 COMPOUND PRESCRIPTION MISCELLANEOUS ORAL COMPOUND ORAL 0.0000
MIS
XXX 0.0000 0.0000 NO RESTRICTED BENEFIT Details
00999214 COMPOUND PRESCRIPTION MISCELLANEOUS ORAL COMPOUND ORAL 0.0000
MIS
XXX 0.0000 0.0000 NO RESTRICTED BENEFIT Details
02237671 CYCLOSPORINE NEORAL 10 MG ORAL CAPSULE 0.6495
CAP
NOV N/A N/A NO SPECIAL AUTHORIZATION Details
02150670 CYCLOSPORINE NEORAL 100 MG ORAL CAPSULE 5.8920
CAP
NOV 5.0900 N/A YES SPECIAL AUTHORIZATION Details
02242821 CYCLOSPORINE SANDOZ CYCLOSPORINE 100 MG ORAL CAPSULE 5.0900
CAP
SDZ 5.0900 N/A YES SPECIAL AUTHORIZATION Details
02150697 CYCLOSPORINE NEORAL 100 MG / ML ORAL SOLUTION 5.2386
ML
NOV N/A N/A NO SPECIAL AUTHORIZATION Details
02150689 CYCLOSPORINE NEORAL 25 MG ORAL CAPSULE 1.5100
CAP
NOV 1.3050 N/A YES SPECIAL AUTHORIZATION Details
02247073 CYCLOSPORINE SANDOZ CYCLOSPORINE 25 MG ORAL CAPSULE 1.3050
CAP
SDZ 1.3050 N/A YES SPECIAL AUTHORIZATION Details
02150662 CYCLOSPORINE NEORAL 50 MG ORAL CAPSULE 2.9450
CAP
NOV 2.5450 N/A YES SPECIAL AUTHORIZATION Details
02247074 CYCLOSPORINE SANDOZ CYCLOSPORINE 50 MG ORAL CAPSULE 2.5450
CAP
SDZ 2.5450 N/A YES SPECIAL AUTHORIZATION Details
02464705 CYSTEAMINE BITARTRATE PROCYSBI 25 MG ORAL DELAYED-RELEASE CAPSULE 10.3500
CAP
RAP N/A N/A NO SPECIAL AUTHORIZATION Details
02464713 CYSTEAMINE BITARTRATE PROCYSBI 75 MG ORAL DELAYED-RELEASE CAPSULE 31.0500
CAP
RAP N/A N/A NO SPECIAL AUTHORIZATION Details
02368153 DENOSUMAB XGEVA 120 MG / VIAL INJECTION N/A
VIAL
AMG N/A N/A NO NOT A BENEFIT Details
02343541 DENOSUMAB PROLIA 60 MG / SYR INJECTION SYRINGE 370.3600
SYR
AMG N/A N/A NO SPECIAL AUTHORIZATION Details
00493392 DIMETHYL SULFOXIDE RIMSO-50 50 % BLADDER IRRIGATION SOLUTION 1.7000
ML
MYP N/A N/A NO REGULAR BENEFIT Details
02404206 DUTASTERIDE APO-DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
APX 0.3027 N/A YES REGULAR BENEFIT Details
02469308 DUTASTERIDE AURO-DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
AUR 0.3027 N/A YES REGULAR BENEFIT Details
02247813 DUTASTERIDE AVODART 0.5 MG ORAL CAPSULE 1.6819
CAP
GSK 0.3027 N/A YES REGULAR BENEFIT Details
02443058 DUTASTERIDE DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
SNS 0.3027 N/A YES REGULAR BENEFIT Details
02429012 DUTASTERIDE DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
SIV 0.3027 N/A YES REGULAR BENEFIT Details
02416298 DUTASTERIDE MED-DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
GMP 0.3027 N/A YES REGULAR BENEFIT Details
02428873 DUTASTERIDE MINT-DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
MPI 0.3027 N/A YES REGULAR BENEFIT Details
02393220 DUTASTERIDE PMS-DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
PMS 0.3027 N/A YES REGULAR BENEFIT Details
02424444 DUTASTERIDE SANDOZ DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
SDZ 0.3027 N/A YES REGULAR BENEFIT Details
02408287 DUTASTERIDE TEVA-DUTASTERIDE 0.5 MG ORAL CAPSULE 0.3027
CAP
TEV 0.3027 N/A YES REGULAR BENEFIT Details
02322285 ECULIZUMAB SOLIRIS 300 MG / VIAL INJECTION 6,742.0000
VIAL
APG N/A N/A NO SPECIAL AUTHORIZATION Details
02462877 ETANERCEPT ERELZI 25 MG / SYR INJECTION SYRINGE 120.5000
SYR
SDZ N/A N/A NO SPECIAL AUTHORIZATION Details
02242903 ETANERCEPT ENBREL 25 MG / VIAL INJECTION 200.7100
VIAL
AMG N/A N/A NO SPECIAL AUTHORIZATION Details
02455331 ETANERCEPT BRENZYS (AUTO INJECTOR) 50 MG / SYR INJECTION SYRINGE 254.0000
SYR
SSB N/A N/A NO SPECIAL AUTHORIZATION Details
02455323 ETANERCEPT BRENZYS 50 MG / SYR INJECTION SYRINGE 254.0000
SYR
SSB N/A N/A NO SPECIAL AUTHORIZATION Details
02274728 ETANERCEPT ENBREL 50 MG / SYR INJECTION SYRINGE 401.5400
SYR
AMG N/A N/A NO SPECIAL AUTHORIZATION Details
02462850 ETANERCEPT ERELZI (SENSOREADY AUTO INJECTOR) 50 MG / SYR INJECTION SYRINGE 241.0000
SYR
SDZ N/A N/A NO SPECIAL AUTHORIZATION Details
02462869 ETANERCEPT ERELZI 50 MG / SYR INJECTION SYRINGE 241.0000
SYR
SDZ N/A N/A NO SPECIAL AUTHORIZATION Details
02379910 FAMPRIDINE FAMPYRA 10 MG ORAL SUSTAINED-RELEASE TABLET N/A
TAB
BIO N/A N/A NO NOT A BENEFIT Details
02473607 FEBUXOSTAT MAR-FEBUXOSTAT 80 MG ORAL TABLET 1.1925
TAB
MAR 1.1925 N/A YES SPECIAL AUTHORIZATION Details
02357380 FEBUXOSTAT ULORIC 80 MG ORAL TABLET 1.5900
TAB
TAK 1.1925 N/A YES SPECIAL AUTHORIZATION Details
02365383 FINASTERIDE APO-FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
APX 0.4138 N/A YES REGULAR BENEFIT Details
02405814 FINASTERIDE AURO-FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
AUR 0.4138 N/A YES REGULAR BENEFIT Details
02355043 FINASTERIDE FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
AHI 0.4138 N/A YES REGULAR BENEFIT Details
02447541 FINASTERIDE FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
SIV 0.4138 N/A YES REGULAR BENEFIT Details
02445077 FINASTERIDE FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
SNS 0.4138 N/A YES REGULAR BENEFIT Details
02357224 FINASTERIDE JAMP-FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
JPC 0.4138 N/A YES REGULAR BENEFIT Details
02389878 FINASTERIDE MINT-FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
MPI 0.4138 N/A YES REGULAR BENEFIT Details
02310112 FINASTERIDE PMS-FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
PMS 0.4138 N/A YES REGULAR BENEFIT Details
02010909 FINASTERIDE PROSCAR 5 MG ORAL TABLET 2.0816
TAB
MFC 0.4138 N/A YES REGULAR BENEFIT Details
02322579 FINASTERIDE SANDOZ FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
SDZ 0.4138 N/A YES REGULAR BENEFIT Details
02348500 FINASTERIDE TEVA-FINASTERIDE 5 MG ORAL TABLET 0.4138
TAB
TEV 0.4138 N/A YES REGULAR BENEFIT Details
02365480 FINGOLIMOD HYDROCHLORIDE GILENYA 0.5 MG ORAL CAPSULE 86.9525
CAP
NOV N/A N/A NO SPECIAL AUTHORIZATION Details
02246082 FLUNARIZINE HCL FLUNARIZINE 5 MG ORAL CAPSULE 0.7682
CAP
AAP N/A N/A NO REGULAR BENEFIT Details
02245619 GLATIRAMER ACETATE COPAXONE 20 MG / SYR INJECTION SYRINGE 48.0488
SYR
TMP N/A N/A NO SPECIAL AUTHORIZATION Details
02460661 GLATIRAMER ACETATE GLATECT 20 MG / SYR INJECTION SYRINGE 32.4000
SYR
PMS N/A N/A NO SPECIAL AUTHORIZATION Details
02456915 GLATIRAMER ACETATE COPAXONE 40 MG / SYR INJECTION N/A
SYR
TMP N/A N/A NO UNDER REVIEW Details
02413183 GOLIMUMAB SIMPONI 100 MG / SYR INJECTION SYRINGE 1,516.0000
SYR
JAI N/A N/A NO SPECIAL AUTHORIZATION/ UNDER REVIEW Details
02413175 GOLIMUMAB SIMPONI 100 MG / SYR INJECTION SYRINGE 1,516.0000
SYR
JAI N/A N/A NO SPECIAL AUTHORIZATION/ UNDER REVIEW Details
02324784 GOLIMUMAB SIMPONI 50 MG / SYR INJECTION SYRINGE 1,516.0000
SYR
JAI N/A N/A NO SPECIAL AUTHORIZATION Details
02324776 GOLIMUMAB SIMPONI 50 MG / SYR INJECTION SYRINGE 1,516.0000
SYR
JAI N/A N/A NO SPECIAL AUTHORIZATION Details
02225905 GOSERELIN ACETATE ZOLADEX LA 10.8 MG / SYR INJECTION SYRINGE 1,204.7322
SYR
TSA N/A N/A NO SPECIAL AUTHORIZATION Details
02049325 GOSERELIN ACETATE ZOLADEX 3.6 MG / SYR INJECTION SYRINGE 422.6778
SYR
TSA N/A N/A NO SPECIAL AUTHORIZATION Details
02425696 ICATIBANT ACETATE FIRAZYR 30 MG / SYR INJECTION 2,700.0000
SYR
SOT N/A N/A NO SPECIAL AUTHORIZATION Details
02419475 INFLIXIMAB INFLECTRA 100 MG / VIAL INJECTION 525.0000
VIAL
CHH N/A N/A NO SPECIAL AUTHORIZATION Details
02244016 INFLIXIMAB REMICADE 100 MG / VIAL INJECTION 962.6800
VIAL
JAI N/A N/A NO SPECIAL AUTHORIZATION Details
02470373 INFLIXIMAB RENFLEXIS 100 MG / VIAL INJECTION 493.0000
VIAL
SSB N/A N/A NO SPECIAL AUTHORIZATION Details
00999455 INSTANT FOOD THICKENER CONSIST-RITE ORAL POWDER 0.0179
G
DFI N/A N/A NO REGULAR BENEFIT Details
00999561 INSTANT FOOD THICKENER RESOURCE THICKENUP CLEAR ORAL POWDER 0.3065
G
NHN N/A N/A NO REGULAR BENEFIT Details
00999453 INSTANT FOOD THICKENER RESOURCE THICKENUP ORAL POWDER 0.0223
G
NHN N/A N/A NO REGULAR BENEFIT Details
02237319 INTERFERON BETA-1A REBIF (0.5 ML SYRINGE) 22 MCG / SYR INJECTION SYRINGE 129.8174
SYR
SRO N/A N/A NO SPECIAL AUTHORIZATION Details
02318253 INTERFERON BETA-1A REBIF (1.5 ML CARTRIDGE) 44 MCG / ML INJECTION CARTRIDGE 259.6350
ML
SRO N/A N/A NO SPECIAL AUTHORIZATION Details
02237320 INTERFERON BETA-1A REBIF (0.5 ML SYRINGE) 44 MCG / SYR INJECTION SYRINGE 158.0386
SYR
SRO N/A N/A NO SPECIAL AUTHORIZATION Details
02269201 INTERFERON BETA-1A AVONEX PS/PEN (30 MCG/0.5 ML) 6 MIU / SYR INJECTION SYRINGE 412.6003
SYR
BIO N/A N/A NO SPECIAL AUTHORIZATION Details
02318261 INTERFERON BETA-1A REBIF (1.5 ML CARTRIDGE) 88 MCG / ML INJECTION CARTRIDGE 316.0775
ML
SRO N/A N/A NO SPECIAL AUTHORIZATION Details
02169649 INTERFERON BETA-1B BETASERON (0.3 MG) 9.6 MIU / VIAL INJECTION 99.3593
VIAL
BAI 99.3593 N/A YES SPECIAL AUTHORIZATION Details
02337819 INTERFERON BETA-1B EXTAVIA (0.3 MG) 9.6 MIU / VIAL INJECTION 99.3593
VIAL
NOV 99.3593 N/A YES SPECIAL AUTHORIZATION Details
02283417 LANREOTIDE ACETATE SOMATULINE AUTOGEL (0.5 ML SYRINGE) 120 MG / SYR INJECTION SYRINGE 1,996.7757
SYR
ISP N/A N/A NO SPECIAL AUTHORIZATION Details
02283395 LANREOTIDE ACETATE SOMATULINE AUTOGEL (0.3 ML SYRINGE) 60 MG / SYR INJECTION SYRINGE 1,195.8951
SYR
ISP N/A N/A NO SPECIAL AUTHORIZATION Details
02283409 LANREOTIDE ACETATE SOMATULINE AUTOGEL (0.3 ML SYRINGE) 90 MG / SYR INJECTION SYRINGE 1,595.2501
SYR
ISP N/A N/A NO SPECIAL AUTHORIZATION Details
02478862 LEFLUNOMIDE ACCEL-LEFLUNOMIDE 10 MG ORAL TABLET N/A
TAB
ACP N/A N/A YES UNDER REVIEW Details
02256495 LEFLUNOMIDE APO-LEFLUNOMIDE 10 MG ORAL TABLET 2.6433
TAB
APX 2.6433 N/A YES RESTRICTED BENEFIT Details
02241888 LEFLUNOMIDE ARAVA 10 MG ORAL TABLET 11.0677
TAB
SAV 2.6433 N/A YES RESTRICTED BENEFIT Details
02351668 LEFLUNOMIDE LEFLUNOMIDE 10 MG ORAL TABLET 2.6433
TAB
SNS 2.6433 N/A YES RESTRICTED BENEFIT Details
02288265 LEFLUNOMIDE PMS-LEFLUNOMIDE 10 MG ORAL TABLET N/A
TAB
PMS N/A N/A YES NOT A BENEFIT Details
02283964 LEFLUNOMIDE SANDOZ LEFLUNOMIDE 10 MG ORAL TABLET 2.6433
TAB
SDZ 2.6433 N/A YES RESTRICTED BENEFIT Details
02261251 LEFLUNOMIDE TEVA-LEFLUNOMIDE 10 MG ORAL TABLET 2.6433
TAB
TEV 2.6433 N/A YES RESTRICTED BENEFIT Details
02478870 LEFLUNOMIDE ACCEL-LEFLUNOMIDE 20 MG ORAL TABLET N/A
TAB
ACP N/A N/A YES UNDER REVIEW Details
02256509 LEFLUNOMIDE APO-LEFLUNOMIDE 20 MG ORAL TABLET 2.6433
TAB
APX 2.6433 N/A YES RESTRICTED BENEFIT Details
02241889 LEFLUNOMIDE ARAVA 20 MG ORAL TABLET 11.0680
TAB
SAV 2.6433 N/A YES RESTRICTED BENEFIT Details
02351676 LEFLUNOMIDE LEFLUNOMIDE 20 MG ORAL TABLET 2.6433
TAB
SNS 2.6433 N/A YES RESTRICTED BENEFIT Details
02288273 LEFLUNOMIDE PMS-LEFLUNOMIDE 20 MG ORAL TABLET N/A
TAB
PMS N/A N/A YES NOT A BENEFIT Details
02283972 LEFLUNOMIDE SANDOZ LEFLUNOMIDE 20 MG ORAL TABLET 2.6433
TAB
SDZ 2.6433 N/A YES RESTRICTED BENEFIT Details
02261278 LEFLUNOMIDE TEVA-LEFLUNOMIDE 20 MG ORAL TABLET 2.6433
TAB
TEV 2.6433 N/A YES RESTRICTED BENEFIT Details
02087316 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 10 MG / ML INJECTION 13.7886
ML
TEV N/A N/A NO REGULAR BENEFIT Details
02170493 LEUCOVORIN CALCIUM LEDERLE LEUCOVORIN CALCIUM 5 MG ORAL TABLET 7.2466
TAB
PFI N/A N/A NO REGULAR BENEFIT Details
02239834 LEUPROLIDE ACETATE LUPRON DEPOT 11.25 MG / VIAL INJECTION 1,065.4400
VIAL
ABV N/A N/A NO SPECIAL AUTHORIZATION Details
02230248 LEUPROLIDE ACETATE LUPRON DEPOT 22.5 MG / VIAL INJECTION 1,071.0000
VIAL
ABV N/A N/A NO SPECIAL AUTHORIZATION Details
00884502 LEUPROLIDE ACETATE LUPRON DEPOT 3.75 MG / VIAL INJECTION 357.6000
VIAL
ABV N/A N/A NO SPECIAL AUTHORIZATION Details
00727695 LEUPROLIDE ACETATE LUPRON 5 MG / ML INJECTION 67.6464
ML
ABV N/A N/A NO SPECIAL AUTHORIZATION Details
00836273 LEUPROLIDE ACETATE LUPRON DEPOT 7.5 MG / VIAL INJECTION 387.9700
VIAL
ABV N/A N/A NO SPECIAL AUTHORIZATION Details
02144336 LEVOCARNITINE CARNITOR 100 MG / ML ORAL SOLUTION 0.5711
ML
SGM N/A N/A NO SPECIAL AUTHORIZATION Details
02144344 LEVOCARNITINE CARNITOR 200 MG / ML INJECTION 13.2000
ML
SGM N/A N/A NO SPECIAL AUTHORIZATION Details
02144328 LEVOCARNITINE CARNITOR 330 MG ORAL TABLET 1.8858
TAB
SGM N/A N/A NO SPECIAL AUTHORIZATION Details
02449781 MEPOLIZUMAB NUCALA 144 MG / VIAL INJECTION 1,938.4600
VIAL
GSK N/A N/A NO SPECIAL AUTHORIZATION Details
02468042 MIGALASTAT HYDROCHLORIDE GALAFOLD 123 MG ORAL CAPSULE 1,700.0000
CAP
AMI N/A N/A NO SPECIAL AUTHORIZATION Details
02250519 MIGLUSTAT ZAVESCA 100 MG ORAL CAPSULE N/A
CAP
JAI N/A N/A NO NOT A BENEFIT Details
02188783 NAFARELIN ACETATE SYNAREL 2 MG / ML NASAL SOLUTION 48.8851
ML
PFI N/A N/A NO REGULAR BENEFIT Details
02286386 NATALIZUMAB TYSABRI 20 MG / ML INJECTION 176.9525
ML
BIO N/A N/A NO SPECIAL AUTHORIZATION Details
02457733 NITISINONE MDK-NITISINONE 10 MG ORAL CAPSULE 47.4000
CAP
MEN N/A N/A NO SPECIAL AUTHORIZATION Details
02458632 NITISINONE NITISINONE 10 MG ORAL TABLET 47.4000
TAB
CYC N/A N/A NO SPECIAL AUTHORIZATION Details
02459728 NITISINONE ORFADIN 10 MG ORAL CAPSULE 47.4000
CAP
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02457717 NITISINONE MDK-NITISINONE 2 MG ORAL CAPSULE 12.9500
CAP
MEN N/A N/A NO SPECIAL AUTHORIZATION Details
02458616 NITISINONE NITISINONE 2 MG ORAL TABLET 12.9500
TAB
CYC N/A N/A NO SPECIAL AUTHORIZATION Details
02459698 NITISINONE ORFADIN 2 MG ORAL CAPSULE 12.9500
CAP
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02470055 NITISINONE MDK-NITISINONE 20 MG ORAL CAPSULE 128.1000
CAP
MEN N/A N/A NO SPECIAL AUTHORIZATION Details
02459736 NITISINONE ORFADIN 20 MG ORAL CAPSULE 128.1000
CAP
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02457725 NITISINONE MDK-NITISINONE 5 MG ORAL CAPSULE 25.0600
CAP
MEN N/A N/A NO SPECIAL AUTHORIZATION Details
02458624 NITISINONE NITISINONE 5 MG ORAL TABLET 25.0600
TAB
CYC N/A N/A NO SPECIAL AUTHORIZATION Details
02459701 NITISINONE ORFADIN 5 MG ORAL CAPSULE 25.0600
CAP
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02465663 NUSINERSEN SODIUM SPINRAZA 2.4 MG / ML INJECTION 23,600.0000
ML
BIO N/A N/A NO SPECIAL AUTHORIZATION Details
02467224 OCRELIZUMAB OCREVUS 30 MG / ML INJECTION 815.0000
ML
HLR N/A N/A NO SPECIAL AUTHORIZATION Details
02239323 OCTREOTIDE ACETATE SANDOSTATIN LAR 10 MG / VIAL INJECTION 1,315.7400
VIAL
NOV N/A N/A NO SPECIAL AUTHORIZATION Details
02248640 OCTREOTIDE ACETATE OCTREOTIDE ACETATE OMEGA 100 MCG / ML INJECTION 3.2970
ML
OMG 3.2970 N/A YES SPECIAL AUTHORIZATION Details
00839205 OCTREOTIDE ACETATE SANDOSTATIN 100 MCG / ML INJECTION 9.7135
ML
NOV 3.2970 N/A YES SPECIAL AUTHORIZATION Details
02239324 OCTREOTIDE ACETATE SANDOSTATIN LAR 20 MG / VIAL INJECTION 1,699.8900
VIAL
NOV N/A N/A NO SPECIAL AUTHORIZATION Details
02248642 OCTREOTIDE ACETATE OCTREOTIDE ACETATE OMEGA 200 MCG / ML INJECTION 6.3420
ML
OMG 6.3420 N/A YES SPECIAL AUTHORIZATION Details
02049392 OCTREOTIDE ACETATE SANDOSTATIN 200 MCG / ML INJECTION 18.6861
ML
NOV 6.3420 N/A YES SPECIAL AUTHORIZATION Details
02239325 OCTREOTIDE ACETATE SANDOSTATIN LAR 30 MG / VIAL INJECTION 2,180.9400
VIAL
NOV N/A N/A NO SPECIAL AUTHORIZATION Details
02248639 OCTREOTIDE ACETATE OCTREOTIDE ACETATE OMEGA 50 MCG / ML INJECTION 1.7465
ML
OMG 1.7465 N/A YES SPECIAL AUTHORIZATION Details
00839191 OCTREOTIDE ACETATE SANDOSTATIN 50 MCG / ML INJECTION 5.1460
ML
NOV 1.7465 N/A YES SPECIAL AUTHORIZATION Details
02248641 OCTREOTIDE ACETATE OCTREOTIDE ACETATE OMEGA 500 MCG / ML INJECTION 15.4945
ML
OMG N/A N/A NO SPECIAL AUTHORIZATION Details
01981501 ONABOTULINUMTOXINA BOTOX (50/100/200 UNITS/VIAL) INJECTION 3.5700
UNIT
ALL N/A N/A NO REGULAR BENEFIT Details
02244550 PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM 3 MG / ML INJECTION 3.0317
ML
PFI N/A N/A NO REGULAR BENEFIT Details
02244551 PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM 6 MG / ML INJECTION 9.0366
ML
PFI N/A N/A NO REGULAR BENEFIT Details
02244552 PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM 9 MG / ML INJECTION 9.0953
ML
PFI N/A N/A NO REGULAR BENEFIT Details
02029448 PENTOSAN POLYSULFATE SODIUM ELMIRON 100 MG ORAL CAPSULE 2.1600
CAP
JAI N/A N/A NO REGULAR BENEFIT Details
02393751 PIRFENIDONE ESBRIET 267 MG ORAL CAPSULE 13.6251
CAP
HLR N/A N/A NO SPECIAL AUTHORIZATION Details
02223767 QUINAGOLIDE NORPROLAC 0.075 MG ORAL TABLET 1.1485
TAB
FEI N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
02223775 QUINAGOLIDE NORPROLAC 0.15 MG ORAL TABLET 1.7177
TAB
FEI N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
02316838 RISEDRONATE SODIUM ACTONEL 150 MG ORAL TABLET N/A
TAB
ASC N/A N/A NO NOT A BENEFIT Details
02298384 RISEDRONATE SODIUM TEVA-RISEDRONATE 30 MG ORAL TABLET 10.8388
TAB
TEV N/A N/A NO SPECIAL AUTHORIZATION Details
02246896 RISEDRONATE SODIUM ACTONEL 35 MG ORAL TABLET 11.4233
TAB
ASC 1.9787 N/A YES REGULAR BENEFIT Details
02370417 RISEDRONATE SODIUM ACTONEL DR 35 MG ORAL DELAYED-RELEASE TABLET N/A
TAB
ASC N/A N/A NO NOT A BENEFIT Details
02353687 RISEDRONATE SODIUM APO-RISEDRONATE 35 MG ORAL TABLET 1.9787
TAB
APX 1.9787 N/A YES REGULAR BENEFIT Details
02406306 RISEDRONATE SODIUM AURO-RISEDRONATE 35 MG ORAL TABLET 1.9787
TAB
AUR 1.9787 N/A YES REGULAR BENEFIT Details
02368552 RISEDRONATE SODIUM JAMP-RISEDRONATE 35 MG ORAL TABLET 1.9787
TAB
JPC 1.9787 N/A YES REGULAR BENEFIT Details
02302209 RISEDRONATE SODIUM PMS-RISEDRONATE 35 MG ORAL TABLET 1.9787
TAB
PMS 1.9787 N/A YES REGULAR BENEFIT Details
02370255 RISEDRONATE SODIUM RISEDRONATE 35 MG ORAL TABLET 1.9787
TAB
SNS 1.9787 N/A YES REGULAR BENEFIT Details
02411407 RISEDRONATE SODIUM RISEDRONATE-35 35 MG ORAL TABLET 1.9787
TAB
SIV 1.9787 N/A YES REGULAR BENEFIT Details
02327295 RISEDRONATE SODIUM SANDOZ RISEDRONATE 35 MG ORAL TABLET 1.9787
TAB
SDZ 1.9787 N/A YES REGULAR BENEFIT Details
02298392 RISEDRONATE SODIUM TEVA-RISEDRONATE 35 MG ORAL TABLET 1.9787
TAB
TEV 1.9787 N/A YES REGULAR BENEFIT Details
02298376 RISEDRONATE SODIUM TEVA-RISEDRONATE 5 MG ORAL TABLET 1.6729
TAB
TEV N/A N/A NO SPECIAL AUTHORIZATION Details
02350580 SAPROPTERIN DIHYDROCHLORIDE KUVAN 100 MG ORAL TABLET N/A
TAB
BMI N/A N/A NO NOT A BENEFIT Details
02472961 SARILUMAB KEVZARA (PREFILLED PEN) 150 MG / SYR INJECTION 721.0000
SYR
SAV N/A N/A NO SPECIAL AUTHORIZATION Details
02460521 SARILUMAB KEVZARA 150 MG / SYR INJECTION SYRINGE 721.0000
SYR
SAV N/A N/A NO SPECIAL AUTHORIZATION Details
02472988 SARILUMAB KEVZARA (PREFILLED PEN) 200 MG / SYR INJECTION 721.0000
SYR
SAV N/A N/A NO SPECIAL AUTHORIZATION Details
02460548 SARILUMAB KEVZARA 200 MG / SYR INJECTION SYRINGE 721.0000
SYR
SAV N/A N/A NO SPECIAL AUTHORIZATION Details
02438070 SECUKINUMAB COSENTYX 150 MG / ML INJECTION SYRINGE 831.1100
ML
NOV N/A N/A NO SPECIAL AUTHORIZATION Details
02435128 SILTUXIMAB SYLVANT 100 MG / VIAL INJECTION 697.7000
VIAL
JAI N/A N/A NO SPECIAL AUTHORIZATION Details
02435136 SILTUXIMAB SYLVANT 400 MG / VIAL INJECTION 2,790.8000
VIAL
JAI N/A N/A NO SPECIAL AUTHORIZATION Details
02418304 STANDARDIZED TIMOTHY GRASS POLLEN GRASTEK 2,800 UNIT SUBLINGUAL DISINTEGRATING TABLET N/A
TAB
ALK N/A N/A NO NOT A BENEFIT Details
02416328 TERIFLUNOMIDE AUBAGIO 14 MG ORAL TABLET 57.7432
TAB
GZM N/A N/A NO SPECIAL AUTHORIZATION Details
02407590 TETRABENAZINE APO-TETRABENAZINE 25 MG ORAL TABLET 3.3746
TAB
APX 3.3746 N/A YES SPECIAL AUTHORIZATION Details
02199270 TETRABENAZINE NITOMAN 25 MG ORAL TABLET 7.3649
TAB
VCL 3.3746 N/A YES SPECIAL AUTHORIZATION Details
02402424 TETRABENAZINE PMS-TETRABENAZINE 25 MG ORAL TABLET 3.3746
TAB
PMS 3.3746 N/A YES SPECIAL AUTHORIZATION Details
02410338 TETRABENAZINE TETRABENAZINE 25 MG ORAL TABLET 3.3746
TAB
STM 3.3746 N/A YES SPECIAL AUTHORIZATION Details
02483327 TOCILIZUMAB ACTEMRA (0.9 ML AUTO INJECTOR) 162 MG / SYR INJECTION SYRINGE N/A
SYR
HLR N/A N/A NO UNDER REVIEW Details
02424770 TOCILIZUMAB ACTEMRA (0.9 ML SYRINGE) 162 MG / SYR INJECTION SYRINGE 358.9050
SYR
HLR N/A N/A NO SPECIAL AUTHORIZATION/ UNDER REVIEW Details
02350106 TOCILIZUMAB ACTEMRA (10 ML) 200 MG / VIAL INJECTION 457.0000
VIAL
HLR N/A N/A NO SPECIAL AUTHORIZATION Details
02350114 TOCILIZUMAB ACTEMRA (20 ML) 400 MG / VIAL INJECTION 914.0000
VIAL
HLR N/A N/A NO SPECIAL AUTHORIZATION Details
02350092 TOCILIZUMAB ACTEMRA (4 ML) 80 MG / VIAL INJECTION 182.8000
VIAL
HLR N/A N/A NO SPECIAL AUTHORIZATION Details
02470608 TOFACITINIB CITRATE XELJANZ XR 11 MG ORAL EXTENDED-RELEASE TABLET 47.9178
TAB
PFI N/A N/A NO SPECIAL AUTHORIZATION Details
02423898 TOFACITINIB CITRATE XELJANZ 5 MG ORAL TABLET 23.9589
TAB
PFI N/A N/A NO SPECIAL AUTHORIZATION Details
02408163 ULIPRISTAL ACETATE FIBRISTAL 5 MG ORAL TABLET 11.4600
TAB
ASC N/A N/A NO RESTRICTED BENEFIT Details
02320673 USTEKINUMAB STELARA (0.5 ML VIAL OR SYRINGE) 45 MG INJECTION VIAL OR SYRINGE 4,465.5800
VL/SYR
JAI N/A N/A NO SPECIAL AUTHORIZATION Details
02320681 USTEKINUMAB STELARA (1.0 ML SYRINGE) 90 MG / SYR INJECTION SYRINGE 4,465.5800
SYR
JAI N/A N/A NO SPECIAL AUTHORIZATION Details
02436841 VEDOLIZUMAB ENTYVIO 300 MG / VIAL INJECTION 3,290.0000
VIAL
TAK N/A N/A NO SPECIAL AUTHORIZATION Details
02269198 ZOLEDRONIC ACID ACLASTA 0.05 MG / ML INJECTION 7.0850
ML
NOV 3.3540 N/A YES SPECIAL AUTHORIZATION Details
02415100 ZOLEDRONIC ACID TARO-ZOLEDRONIC ACID 0.05 MG / ML INJECTION 3.3540
ML
TAR 3.3540 N/A YES SPECIAL AUTHORIZATION Details
02422433 ZOLEDRONIC ACID ZOLEDRONIC ACID 0.05 MG / ML INJECTION 3.3540
ML
DRL 3.3540 N/A YES SPECIAL AUTHORIZATION Details
02482525 ZOLEDRONIC ACID JAMP-ZOLEDRONIC ACID 0.8 MG / ML INJECTION 38.7856
ML
JPC 38.7856 N/A YES SPECIAL AUTHORIZATION Details
02415186 ZOLEDRONIC ACID TARO-ZOLEDRONIC ACID CONCENTRATE 0.8 MG / ML INJECTION 38.7856
ML
TAR 38.7856 N/A YES SPECIAL AUTHORIZATION Details
02401606 ZOLEDRONIC ACID ZOLEDRONIC ACID - Z 0.8 MG / ML INJECTION 38.7856
ML
SDZ 38.7856 N/A YES SPECIAL AUTHORIZATION Details
02444739 ZOLEDRONIC ACID ZOLEDRONIC ACID 0.8 MG / ML INJECTION 38.7856
ML
MDA 38.7856 N/A YES SPECIAL AUTHORIZATION Details
02407639 ZOLEDRONIC ACID ZOLEDRONIC ACID 0.8 MG / ML INJECTION 38.7856
ML
TEV 38.7856 N/A YES SPECIAL AUTHORIZATION Details
02422425 ZOLEDRONIC ACID ZOLEDRONIC ACID CONCENTRATE 0.8 MG / ML INJECTION 38.7856
ML
DRL 38.7856 N/A YES SPECIAL AUTHORIZATION Details
02472805 ZOLEDRONIC ACID ZOLEDRONIC ACID FOR INJECTION 0.8 MG / ML INJECTION 38.7856
ML
MAR 38.7856 N/A YES SPECIAL AUTHORIZATION Details
02248296 ZOLEDRONIC ACID ZOMETA CONCENTRATE 0.8 MG / ML INJECTION 115.7940
ML
NOV 38.7856 N/A YES SPECIAL AUTHORIZATION Details
DIN/NPN/ PIN 02402475
Generic Name ABATACEPT
Product Name, Strength & Dosage Form ORENCIA 125 MG / SYR INJECTION
Unit Price, Unit of Issue 373.7875
Manufacturer BMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02282097
Generic Name ABATACEPT
Product Name, Strength & Dosage Form ORENCIA 250 MG / VIAL INJECTION
Unit Price, Unit of Issue 500.3400
Manufacturer BMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
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 02458357
Generic Name ADALIMUMAB
Product Name, Strength & Dosage Form HUMIRA (40 MG/0.4 ML INJ PEN) 40 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer ABV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02458349
Generic Name ADALIMUMAB
Product Name, Strength & Dosage Form HUMIRA (40 MG/0.4 ML INJ SYR) 40 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue N/A
Manufacturer ABV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02258595
Generic Name ADALIMUMAB
Product Name, Strength & Dosage Form HUMIRA (40 MG/0.8 ML INJ SYR) 40 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 762.5700
Manufacturer ABV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02381486
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form ALENDRONATE SODIUM 10 MG ORAL TABLET
Unit Price, Unit of Issue 0.4986
Manufacturer AHI
LCA Price 0.4986
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02248728
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form APO-ALENDRONATE 10 MG ORAL TABLET
Unit Price, Unit of Issue 0.4986
Manufacturer APX
LCA Price 0.4986
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02388545
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form AURO-ALENDRONATE 10 MG ORAL TABLET
Unit Price, Unit of Issue 0.4986
Manufacturer AUR
LCA Price 0.4986
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02288087
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form SANDOZ ALENDRONATE 10 MG ORAL TABLET
Unit Price, Unit of Issue 0.4986
Manufacturer SDZ
LCA Price 0.4986
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02258102
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form ACT ALENDRONATE 40 MG ORAL TABLET
Unit Price, Unit of Issue 3.0832
Manufacturer APH
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02352966
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form ALENDRONATE 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer SNS
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02299712
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form ALENDRONATE 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer SIV
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02381494
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form ALENDRONATE SODIUM 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer AHI
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02248730
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form APO-ALENDRONATE 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer APX
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02388553
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form AURO-ALENDRONATE 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer AUR
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02245329
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form FOSAMAX 70 MG ORAL TABLET
Unit Price, Unit of Issue 11.0114
Manufacturer MFC
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02385031
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form JAMP-ALENDRONATE 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer JPC
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02394871
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form MINT-ALENDRONATE 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer MPI
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02284006
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form PMS-ALENDRONATE-FC 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer PMS
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02288109
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form SANDOZ ALENDRONATE 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer SDZ
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02261715
Generic Name ALENDRONATE SODIUM
Product Name, Strength & Dosage Form TEVA-ALENDRONATE 70 MG ORAL TABLET
Unit Price, Unit of Issue 2.1014
Manufacturer TEV
LCA Price 2.1014
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02276429
Generic Name ALENDRONATE SODIUM/ VITAMIN D3
Product Name, Strength & Dosage Form FOSAVANCE 70 MG * 2,800 UNIT ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer MFC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02454475
Generic Name ALENDRONATE SODIUM/ VITAMIN D3
Product Name, Strength & Dosage Form APO-ALENDRONATE/VITAMIN D3 70 MG * 5,600 UNIT ORAL TABLET
Unit Price, Unit of Issue 1.2174
Manufacturer APX
LCA Price 1.2174
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02314940
Generic Name ALENDRONATE SODIUM/ VITAMIN D3
Product Name, Strength & Dosage Form FOSAVANCE 70 MG * 5,600 UNIT ORAL TABLET
Unit Price, Unit of Issue 4.8970
Manufacturer MFC
LCA Price 1.2174
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02429160
Generic Name ALENDRONATE SODIUM/ VITAMIN D3
Product Name, Strength & Dosage Form SANDOZ ALENDRONATE/CHOLECALCIFEROL 70 MG * 5,600 UNIT ORAL TABLET
Unit Price, Unit of Issue 1.2174
Manufacturer SDZ
LCA Price 1.2174
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02403641
Generic Name ALENDRONATE SODIUM/ VITAMIN D3
Product Name, Strength & Dosage Form TEVA-ALENDRONATE/CHOLECALCIFEROL 70 MG * 5,600 UNIT ORAL TABLET
Unit Price, Unit of Issue 1.2174
Manufacturer TEV
LCA Price 1.2174
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02447576
Generic Name ALFUZOSIN HCL
Product Name, Strength & Dosage Form ALFUZOSIN 10 MG ORAL SUSTAINED-RELEASE TABLET
Unit Price, Unit of Issue 0.2601
Manufacturer SIV
LCA Price 0.2601
MAC Price N/A
Interchangeable Products YES
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02315866
Generic Name ALFUZOSIN HCL
Product Name, Strength & Dosage Form APO-ALFUZOSIN 10 MG ORAL SUSTAINED-RELEASE TABLET
Unit Price, Unit of Issue 0.2601
Manufacturer APX
LCA Price 0.2601
MAC Price N/A
Interchangeable Products YES
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02443201
Generic Name ALFUZOSIN HCL
Product Name, Strength & Dosage Form AURO-ALFUZOSIN 10 MG ORAL SUSTAINED-RELEASE TABLET
Unit Price, Unit of Issue 0.2601
Manufacturer AUR
LCA Price 0.2601
MAC Price N/A
Interchangeable Products YES
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02304678
Generic Name ALFUZOSIN HCL
Product Name, Strength & Dosage Form SANDOZ ALFUZOSIN 10 MG ORAL SUSTAINED-RELEASE TABLET
Unit Price, Unit of Issue 0.2601
Manufacturer SDZ
LCA Price 0.2601
MAC Price N/A
Interchangeable Products YES
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02245565
Generic Name ALFUZOSIN HCL
Product Name, Strength & Dosage Form XATRAL 10 MG ORAL SUSTAINED-RELEASE TABLET
Unit Price, Unit of Issue 1.0404
Manufacturer SAV
LCA Price 0.2601
MAC Price N/A
Interchangeable Products YES
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02402769
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form APO-ALLOPURINOL 100 MG ORAL TABLET
Unit Price, Unit of Issue 0.0780
Manufacturer APX
LCA Price 0.0780
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02396327
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form MAR-ALLOPURINOL 100 MG ORAL TABLET
Unit Price, Unit of Issue 0.0780
Manufacturer MAR
LCA Price 0.0780
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00402818
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form ZYLOPRIM 100 MG ORAL TABLET
Unit Price, Unit of Issue 0.0780
Manufacturer AAP
LCA Price 0.0780
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02402777
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form APO-ALLOPURINOL 200 MG ORAL TABLET
Unit Price, Unit of Issue 0.1300
Manufacturer APX
LCA Price 0.1300
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02396335
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form MAR-ALLOPURINOL 200 MG ORAL TABLET
Unit Price, Unit of Issue 0.1300
Manufacturer MAR
LCA Price 0.1300
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00479799
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form ZYLOPRIM 200 MG ORAL TABLET
Unit Price, Unit of Issue 0.1300
Manufacturer AAP
LCA Price 0.1300
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02402785
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form APO-ALLOPURINOL 300 MG ORAL TABLET
Unit Price, Unit of Issue 0.2125
Manufacturer APX
LCA Price 0.2125
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02396343
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form MAR-ALLOPURINOL 300 MG ORAL TABLET
Unit Price, Unit of Issue 0.2125
Manufacturer MAR
LCA Price 0.2125
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00402796
Generic Name ALLOPURINOL
Product Name, Strength & Dosage Form ZYLOPRIM 300 MG ORAL TABLET
Unit Price, Unit of Issue 0.2125
Manufacturer AAP
LCA Price 0.2125
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02245913
Generic Name ANAKINRA
Product Name, Strength & Dosage Form KINERET 100 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 50.0700
Manufacturer BVM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02434334
Generic Name APREMILAST
Product Name, Strength & Dosage Form OTEZLA 30 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer CLG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02434318
Generic Name APREMILAST/ APREMILAST/ APREMILAST
Product Name, Strength & Dosage Form OTEZLA (STARTER PACK) 10 MG * 20 MG * 30 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer CLG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02242907
Generic Name AZATHIOPRINE
Product Name, Strength & Dosage Form APO-AZATHIOPRINE 50 MG ORAL TABLET
Unit Price, Unit of Issue 0.2405
Manufacturer APX
LCA Price 0.2405
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00004596
Generic Name AZATHIOPRINE
Product Name, Strength & Dosage Form IMURAN 50 MG ORAL TABLET
Unit Price, Unit of Issue 1.0927
Manufacturer APC
LCA Price 0.2405
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02236819
Generic Name AZATHIOPRINE
Product Name, Strength & Dosage Form TEVA-AZATHIOPRINE 50 MG ORAL TABLET
Unit Price, Unit of Issue 0.2405
Manufacturer TEV
LCA Price 0.2405
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02370050
Generic Name BELIMUMAB
Product Name, Strength & Dosage Form BENLYSTA 120 MG / VIAL INJECTION
Unit Price, Unit of Issue N/A
Manufacturer GSK
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02370069
Generic Name BELIMUMAB
Product Name, Strength & Dosage Form BENLYSTA 400 MG / VIAL INJECTION
Unit Price, Unit of Issue N/A
Manufacturer GSK
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02449153
Generic Name BETAHISTINE DIHYDROCHLORIDE
Product Name, Strength & Dosage Form AURO-BETAHISTINE 16 MG ORAL TABLET
Unit Price, Unit of Issue 0.1106
Manufacturer AUR
LCA Price 0.1106
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02466449
Generic Name BETAHISTINE DIHYDROCHLORIDE
Product Name, Strength & Dosage Form BETAHISTINE 16 MG ORAL TABLET
Unit Price, Unit of Issue 0.1106
Manufacturer SNS
LCA Price 0.1106
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02330210
Generic Name BETAHISTINE DIHYDROCHLORIDE
Product Name, Strength & Dosage Form PMS-BETAHISTINE 16 MG ORAL TABLET
Unit Price, Unit of Issue 0.1106
Manufacturer PMS
LCA Price 0.1106
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02243878
Generic Name BETAHISTINE DIHYDROCHLORIDE
Product Name, Strength & Dosage Form SERC 16 MG ORAL TABLET
Unit Price, Unit of Issue 0.4864
Manufacturer BGP
LCA Price 0.1106
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02280191
Generic Name BETAHISTINE DIHYDROCHLORIDE
Product Name, Strength & Dosage Form TEVA-BETAHISTINE 16 MG ORAL TABLET
Unit Price, Unit of Issue 0.1106
Manufacturer TEV
LCA Price 0.1106
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02247998
Generic Name BETAHISTINE DIHYDROCHLORIDE
Product Name, Strength & Dosage Form SERC 24 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer BGP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02449145
Generic Name BETAHISTINE DIHYDROCHLORIDE
Product Name, Strength & Dosage Form AURO-BETAHISTINE 8 MG ORAL TABLET
Unit Price, Unit of Issue 0.1273
Manufacturer AUR
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02244982
Generic Name BOSENTAN
Product Name, Strength & Dosage Form TRACLEER 125 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer JAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02244981
Generic Name BOSENTAN
Product Name, Strength & Dosage Form TRACLEER 62.5 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer JAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
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 02225166
Generic Name BUSERELIN ACETATE
Product Name, Strength & Dosage Form SUPREFACT 1 MG / ML INJECTION
Unit Price, Unit of Issue 12.1873
Manufacturer SAV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02225158
Generic Name BUSERELIN ACETATE
Product Name, Strength & Dosage Form SUPREFACT INTRANASAL 1 MG / ML NASAL SOLUTION
Unit Price, Unit of Issue 8.5530
Manufacturer SAV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02228955
Generic Name BUSERELIN ACETATE
Product Name, Strength & Dosage Form SUPREFACT DEPOT 6.3 MG INJECTION IMPLANT
Unit Price, Unit of Issue 827.8500
Manufacturer SAV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02455897
Generic Name CABERGOLINE
Product Name, Strength & Dosage Form APO-CABERGOLINE 0.5 MG ORAL TABLET
Unit Price, Unit of Issue 12.3941
Manufacturer APX
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products YES
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02242471
Generic Name CABERGOLINE
Product Name, Strength & Dosage Form DOSTINEX 0.5 MG ORAL TABLET
Unit Price, Unit of Issue 15.1156
Manufacturer PAL
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products YES
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02344939
Generic Name CANAKINUMAB
Product Name, Strength & Dosage Form ILARIS 150 MG / VIAL INJECTION
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 02331675
Generic Name CERTOLIZUMAB PEGOL
Product Name, Strength & Dosage Form CIMZIA 200 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 664.5100
Manufacturer UCB
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02465574
Generic Name CERTOLIZUMAB PEGOL
Product Name, Strength & Dosage Form CIMZIA AUTO-INJECTOR 200 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 664.5100
Manufacturer UCB
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02257130
Generic Name CINACALCET HYDROCHLORIDE
Product Name, Strength & Dosage Form SENSIPAR 30 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer AMG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02257149
Generic Name CINACALCET HYDROCHLORIDE
Product Name, Strength & Dosage Form SENSIPAR 60 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer AMG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02257157
Generic Name CINACALCET HYDROCHLORIDE
Product Name, Strength & Dosage Form SENSIPAR 90 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer AMG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02245828
Generic Name CLODRONATE DISODIUM
Product Name, Strength & Dosage Form CLASTEON 400 MG ORAL CAPSULE
Unit Price, Unit of Issue 1.2374
Manufacturer SUN
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02304163
Generic Name CLONIDINE HCL
Product Name, Strength & Dosage Form TEVA-CLONIDINE 0.025 MG ORAL TABLET
Unit Price, Unit of Issue 0.2713
Manufacturer TEV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00572349
Generic Name COLCHICINE
Product Name, Strength & Dosage Form COLCHICINE 0.6 MG ORAL TABLET
Unit Price, Unit of Issue 0.2565
Manufacturer ODN
LCA Price 0.2565
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00287873
Generic Name COLCHICINE
Product Name, Strength & Dosage Form COLCHICINE 0.6 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer SDZ
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02373823
Generic Name COLCHICINE
Product Name, Strength & Dosage Form JAMP-COLCHICINE 0.6 MG ORAL TABLET
Unit Price, Unit of Issue 0.2565
Manufacturer JPC
LCA Price 0.2565
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02402181
Generic Name COLCHICINE
Product Name, Strength & Dosage Form PMS-COLCHICINE 0.6 MG ORAL TABLET
Unit Price, Unit of Issue 0.2565
Manufacturer PMS
LCA Price 0.2565
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00999999
Generic Name COMPOUND PRESCRIPTION
Product Name, Strength & Dosage Form MISCELLANEOUS COMPOUND
Unit Price, Unit of Issue 0.0000
Manufacturer XXX
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 00999216
Generic Name COMPOUND PRESCRIPTION
Product Name, Strength & Dosage Form MISCELLANEOUS COMPOUND
Unit Price, Unit of Issue 0.0000
Manufacturer XXX
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 00999215
Generic Name COMPOUND PRESCRIPTION
Product Name, Strength & Dosage Form MISCELLANEOUS INJECTABLE COMPOUND INJECTION
Unit Price, Unit of Issue 0.0000
Manufacturer XXX
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 00999114
Generic Name COMPOUND PRESCRIPTION
Product Name, Strength & Dosage Form MISCELLANEOUS INJECTABLE COMPOUND INJECTION
Unit Price, Unit of Issue 0.0000
Manufacturer XXX
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 00999113
Generic Name COMPOUND PRESCRIPTION
Product Name, Strength & Dosage Form MISCELLANEOUS ORAL COMPOUND ORAL
Unit Price, Unit of Issue 0.0000
Manufacturer XXX
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 00999214
Generic Name COMPOUND PRESCRIPTION
Product Name, Strength & Dosage Form MISCELLANEOUS ORAL COMPOUND ORAL
Unit Price, Unit of Issue 0.0000
Manufacturer XXX
LCA Price 0.0000
MAC Price 0.0000
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02237671
Generic Name CYCLOSPORINE
Product Name, Strength & Dosage Form NEORAL 10 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.6495
Manufacturer NOV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02150670
Generic Name CYCLOSPORINE
Product Name, Strength & Dosage Form NEORAL 100 MG ORAL CAPSULE
Unit Price, Unit of Issue 5.8920
Manufacturer NOV
LCA Price 5.0900
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02242821
Generic Name CYCLOSPORINE
Product Name, Strength & Dosage Form SANDOZ CYCLOSPORINE 100 MG ORAL CAPSULE
Unit Price, Unit of Issue 5.0900
Manufacturer SDZ
LCA Price 5.0900
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02150697
Generic Name CYCLOSPORINE
Product Name, Strength & Dosage Form NEORAL 100 MG / ML ORAL SOLUTION
Unit Price, Unit of Issue 5.2386
Manufacturer NOV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02150689
Generic Name CYCLOSPORINE
Product Name, Strength & Dosage Form NEORAL 25 MG ORAL CAPSULE
Unit Price, Unit of Issue 1.5100
Manufacturer NOV
LCA Price 1.3050
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02247073
Generic Name CYCLOSPORINE
Product Name, Strength & Dosage Form SANDOZ CYCLOSPORINE 25 MG ORAL CAPSULE
Unit Price, Unit of Issue 1.3050
Manufacturer SDZ
LCA Price 1.3050
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02150662
Generic Name CYCLOSPORINE
Product Name, Strength & Dosage Form NEORAL 50 MG ORAL CAPSULE
Unit Price, Unit of Issue 2.9450
Manufacturer NOV
LCA Price 2.5450
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02247074
Generic Name CYCLOSPORINE
Product Name, Strength & Dosage Form SANDOZ CYCLOSPORINE 50 MG ORAL CAPSULE
Unit Price, Unit of Issue 2.5450
Manufacturer SDZ
LCA Price 2.5450
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
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 10.3500
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 31.0500
Manufacturer RAP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02368153
Generic Name DENOSUMAB
Product Name, Strength & Dosage Form XGEVA 120 MG / VIAL INJECTION
Unit Price, Unit of Issue N/A
Manufacturer AMG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02343541
Generic Name DENOSUMAB
Product Name, Strength & Dosage Form PROLIA 60 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 370.3600
Manufacturer AMG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 00493392
Generic Name DIMETHYL SULFOXIDE
Product Name, Strength & Dosage Form RIMSO-50 50 % BLADDER IRRIGATION SOLUTION
Unit Price, Unit of Issue 1.7000
Manufacturer MYP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02404206
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form APO-DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer APX
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02469308
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form AURO-DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer AUR
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02247813
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form AVODART 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 1.6819
Manufacturer GSK
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02443058
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer SNS
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02429012
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer SIV
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02416298
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form MED-DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer GMP
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02428873
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form MINT-DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer MPI
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02393220
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form PMS-DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer PMS
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02424444
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form SANDOZ DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer SDZ
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02408287
Generic Name DUTASTERIDE
Product Name, Strength & Dosage Form TEVA-DUTASTERIDE 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.3027
Manufacturer TEV
LCA Price 0.3027
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02322285
Generic Name ECULIZUMAB
Product Name, Strength & Dosage Form SOLIRIS 300 MG / VIAL INJECTION
Unit Price, Unit of Issue 6,742.0000
Manufacturer APG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02462877
Generic Name ETANERCEPT
Product Name, Strength & Dosage Form ERELZI 25 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 120.5000
Manufacturer SDZ
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02242903
Generic Name ETANERCEPT
Product Name, Strength & Dosage Form ENBREL 25 MG / VIAL INJECTION
Unit Price, Unit of Issue 200.7100
Manufacturer AMG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02455331
Generic Name ETANERCEPT
Product Name, Strength & Dosage Form BRENZYS (AUTO INJECTOR) 50 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 254.0000
Manufacturer SSB
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02455323
Generic Name ETANERCEPT
Product Name, Strength & Dosage Form BRENZYS 50 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 254.0000
Manufacturer SSB
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02274728
Generic Name ETANERCEPT
Product Name, Strength & Dosage Form ENBREL 50 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 401.5400
Manufacturer AMG
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02462850
Generic Name ETANERCEPT
Product Name, Strength & Dosage Form ERELZI (SENSOREADY AUTO INJECTOR) 50 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 241.0000
Manufacturer SDZ
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02462869
Generic Name ETANERCEPT
Product Name, Strength & Dosage Form ERELZI 50 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 241.0000
Manufacturer SDZ
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 02473607
Generic Name FEBUXOSTAT
Product Name, Strength & Dosage Form MAR-FEBUXOSTAT 80 MG ORAL TABLET
Unit Price, Unit of Issue 1.1925
Manufacturer MAR
LCA Price 1.1925
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02357380
Generic Name FEBUXOSTAT
Product Name, Strength & Dosage Form ULORIC 80 MG ORAL TABLET
Unit Price, Unit of Issue 1.5900
Manufacturer TAK
LCA Price 1.1925
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02365383
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form APO-FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer APX
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02405814
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form AURO-FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer AUR
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02355043
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer AHI
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02447541
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer SIV
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02445077
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer SNS
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02357224
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form JAMP-FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer JPC
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02389878
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form MINT-FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer MPI
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02310112
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form PMS-FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer PMS
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02010909
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form PROSCAR 5 MG ORAL TABLET
Unit Price, Unit of Issue 2.0816
Manufacturer MFC
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02322579
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form SANDOZ FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer SDZ
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02348500
Generic Name FINASTERIDE
Product Name, Strength & Dosage Form TEVA-FINASTERIDE 5 MG ORAL TABLET
Unit Price, Unit of Issue 0.4138
Manufacturer TEV
LCA Price 0.4138
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02365480
Generic Name FINGOLIMOD HYDROCHLORIDE
Product Name, Strength & Dosage Form GILENYA 0.5 MG ORAL CAPSULE
Unit Price, Unit of Issue 86.9525
Manufacturer NOV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02246082
Generic Name FLUNARIZINE HCL
Product Name, Strength & Dosage Form FLUNARIZINE 5 MG ORAL CAPSULE
Unit Price, Unit of Issue 0.7682
Manufacturer AAP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02245619
Generic Name GLATIRAMER ACETATE
Product Name, Strength & Dosage Form COPAXONE 20 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 48.0488
Manufacturer TMP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02460661
Generic Name GLATIRAMER ACETATE
Product Name, Strength & Dosage Form GLATECT 20 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 32.4000
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02456915
Generic Name GLATIRAMER ACETATE
Product Name, Strength & Dosage Form COPAXONE 40 MG / SYR INJECTION
Unit Price, Unit of Issue N/A
Manufacturer TMP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02413183
Generic Name GOLIMUMAB
Product Name, Strength & Dosage Form SIMPONI 100 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 1,516.0000
Manufacturer JAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION/ UNDER REVIEW
Details
DIN/NPN/ PIN 02413175
Generic Name GOLIMUMAB
Product Name, Strength & Dosage Form SIMPONI 100 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 1,516.0000
Manufacturer JAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION/ UNDER REVIEW
Details
DIN/NPN/ PIN 02324784
Generic Name GOLIMUMAB
Product Name, Strength & Dosage Form SIMPONI 50 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 1,516.0000
Manufacturer JAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02324776
Generic Name GOLIMUMAB
Product Name, Strength & Dosage Form SIMPONI 50 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 1,516.0000
Manufacturer JAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02225905
Generic Name GOSERELIN ACETATE
Product Name, Strength & Dosage Form ZOLADEX LA 10.8 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 1,204.7322
Manufacturer TSA
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02049325
Generic Name GOSERELIN ACETATE
Product Name, Strength & Dosage Form ZOLADEX 3.6 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 422.6778
Manufacturer TSA
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02425696
Generic Name ICATIBANT ACETATE
Product Name, Strength & Dosage Form FIRAZYR 30 MG / SYR INJECTION
Unit Price, Unit of Issue 2,700.0000
Manufacturer SOT
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02419475
Generic Name INFLIXIMAB
Product Name, Strength & Dosage Form INFLECTRA 100 MG / VIAL INJECTION
Unit Price, Unit of Issue 525.0000
Manufacturer CHH
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02244016
Generic Name INFLIXIMAB
Product Name, Strength & Dosage Form REMICADE 100 MG / VIAL INJECTION
Unit Price, Unit of Issue 962.6800
Manufacturer JAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02470373
Generic Name INFLIXIMAB
Product Name, Strength & Dosage Form RENFLEXIS 100 MG / VIAL INJECTION
Unit Price, Unit of Issue 493.0000
Manufacturer SSB
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 00999455
Generic Name INSTANT FOOD THICKENER
Product Name, Strength & Dosage Form CONSIST-RITE ORAL POWDER
Unit Price, Unit of Issue 0.0179
Manufacturer DFI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00999561
Generic Name INSTANT FOOD THICKENER
Product Name, Strength & Dosage Form RESOURCE THICKENUP CLEAR ORAL POWDER
Unit Price, Unit of Issue 0.3065
Manufacturer NHN
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 00999453
Generic Name INSTANT FOOD THICKENER
Product Name, Strength & Dosage Form RESOURCE THICKENUP ORAL POWDER
Unit Price, Unit of Issue 0.0223
Manufacturer NHN
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02237319
Generic Name INTERFERON BETA-1A
Product Name, Strength & Dosage Form REBIF (0.5 ML SYRINGE) 22 MCG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 129.8174
Manufacturer SRO
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02318253
Generic Name INTERFERON BETA-1A
Product Name, Strength & Dosage Form REBIF (1.5 ML CARTRIDGE) 44 MCG / ML INJECTION CARTRIDGE
Unit Price, Unit of Issue 259.6350
Manufacturer SRO
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02237320
Generic Name INTERFERON BETA-1A
Product Name, Strength & Dosage Form REBIF (0.5 ML SYRINGE) 44 MCG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 158.0386
Manufacturer SRO
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02269201
Generic Name INTERFERON BETA-1A
Product Name, Strength & Dosage Form AVONEX PS/PEN (30 MCG/0.5 ML) 6 MIU / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 412.6003
Manufacturer BIO
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02318261
Generic Name INTERFERON BETA-1A
Product Name, Strength & Dosage Form REBIF (1.5 ML CARTRIDGE) 88 MCG / ML INJECTION CARTRIDGE
Unit Price, Unit of Issue 316.0775
Manufacturer SRO
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02169649
Generic Name INTERFERON BETA-1B
Product Name, Strength & Dosage Form BETASERON (0.3 MG) 9.6 MIU / VIAL INJECTION
Unit Price, Unit of Issue 99.3593
Manufacturer BAI
LCA Price 99.3593
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02337819
Generic Name INTERFERON BETA-1B
Product Name, Strength & Dosage Form EXTAVIA (0.3 MG) 9.6 MIU / VIAL INJECTION
Unit Price, Unit of Issue 99.3593
Manufacturer NOV
LCA Price 99.3593
MAC Price N/A
Interchangeable Products YES
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02283417
Generic Name LANREOTIDE ACETATE
Product Name, Strength & Dosage Form SOMATULINE AUTOGEL (0.5 ML SYRINGE) 120 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 1,996.7757
Manufacturer ISP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02283395
Generic Name LANREOTIDE ACETATE
Product Name, Strength & Dosage Form SOMATULINE AUTOGEL (0.3 ML SYRINGE) 60 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 1,195.8951
Manufacturer ISP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02283409
Generic Name LANREOTIDE ACETATE
Product Name, Strength & Dosage Form SOMATULINE AUTOGEL (0.3 ML SYRINGE) 90 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 1,595.2501
Manufacturer ISP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02478862
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form ACCEL-LEFLUNOMIDE 10 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer ACP
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02256495
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form APO-LEFLUNOMIDE 10 MG ORAL TABLET
Unit Price, Unit of Issue 2.6433
Manufacturer APX
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02241888
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form ARAVA 10 MG ORAL TABLET
Unit Price, Unit of Issue 11.0677
Manufacturer SAV
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02351668
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form LEFLUNOMIDE 10 MG ORAL TABLET
Unit Price, Unit of Issue 2.6433
Manufacturer SNS
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02288265
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form PMS-LEFLUNOMIDE 10 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02283964
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form SANDOZ LEFLUNOMIDE 10 MG ORAL TABLET
Unit Price, Unit of Issue 2.6433
Manufacturer SDZ
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02261251
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form TEVA-LEFLUNOMIDE 10 MG ORAL TABLET
Unit Price, Unit of Issue 2.6433
Manufacturer TEV
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02478870
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form ACCEL-LEFLUNOMIDE 20 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer ACP
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status UNDER REVIEW
Details
DIN/NPN/ PIN 02256509
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form APO-LEFLUNOMIDE 20 MG ORAL TABLET
Unit Price, Unit of Issue 2.6433
Manufacturer APX
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02241889
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form ARAVA 20 MG ORAL TABLET
Unit Price, Unit of Issue 11.0680
Manufacturer SAV
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02351676
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form LEFLUNOMIDE 20 MG ORAL TABLET
Unit Price, Unit of Issue 2.6433
Manufacturer SNS
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02288273
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form PMS-LEFLUNOMIDE 20 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer PMS
LCA Price N/A
MAC Price N/A
Interchangeable Products YES
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02283972
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form SANDOZ LEFLUNOMIDE 20 MG ORAL TABLET
Unit Price, Unit of Issue 2.6433
Manufacturer SDZ
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02261278
Generic Name LEFLUNOMIDE
Product Name, Strength & Dosage Form TEVA-LEFLUNOMIDE 20 MG ORAL TABLET
Unit Price, Unit of Issue 2.6433
Manufacturer TEV
LCA Price 2.6433
MAC Price N/A
Interchangeable Products YES
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02087316
Generic Name LEUCOVORIN CALCIUM
Product Name, Strength & Dosage Form LEUCOVORIN CALCIUM 10 MG / ML INJECTION
Unit Price, Unit of Issue 13.7886
Manufacturer TEV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02170493
Generic Name LEUCOVORIN CALCIUM
Product Name, Strength & Dosage Form LEDERLE LEUCOVORIN CALCIUM 5 MG ORAL TABLET
Unit Price, Unit of Issue 7.2466
Manufacturer PFI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02239834
Generic Name LEUPROLIDE ACETATE
Product Name, Strength & Dosage Form LUPRON DEPOT 11.25 MG / VIAL INJECTION
Unit Price, Unit of Issue 1,065.4400
Manufacturer ABV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02230248
Generic Name LEUPROLIDE ACETATE
Product Name, Strength & Dosage Form LUPRON DEPOT 22.5 MG / VIAL INJECTION
Unit Price, Unit of Issue 1,071.0000
Manufacturer ABV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 00884502
Generic Name LEUPROLIDE ACETATE
Product Name, Strength & Dosage Form LUPRON DEPOT 3.75 MG / VIAL INJECTION
Unit Price, Unit of Issue 357.6000
Manufacturer ABV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 00727695
Generic Name LEUPROLIDE ACETATE
Product Name, Strength & Dosage Form LUPRON 5 MG / ML INJECTION
Unit Price, Unit of Issue 67.6464
Manufacturer ABV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 00836273
Generic Name LEUPROLIDE ACETATE
Product Name, Strength & Dosage Form LUPRON DEPOT 7.5 MG / VIAL INJECTION
Unit Price, Unit of Issue 387.9700
Manufacturer ABV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02144336
Generic Name LEVOCARNITINE
Product Name, Strength & Dosage Form CARNITOR 100 MG / ML ORAL SOLUTION
Unit Price, Unit of Issue 0.5711
Manufacturer SGM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02144344
Generic Name LEVOCARNITINE
Product Name, Strength & Dosage Form CARNITOR 200 MG / ML INJECTION
Unit Price, Unit of Issue 13.2000
Manufacturer SGM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02144328
Generic Name LEVOCARNITINE
Product Name, Strength & Dosage Form CARNITOR 330 MG ORAL TABLET
Unit Price, Unit of Issue 1.8858
Manufacturer SGM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02449781
Generic Name MEPOLIZUMAB
Product Name, Strength & Dosage Form NUCALA 144 MG / VIAL INJECTION
Unit Price, Unit of Issue 1,938.4600
Manufacturer GSK
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 02250519
Generic Name MIGLUSTAT
Product Name, Strength & Dosage Form ZAVESCA 100 MG ORAL CAPSULE
Unit Price, Unit of Issue N/A
Manufacturer JAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02188783
Generic Name NAFARELIN ACETATE
Product Name, Strength & Dosage Form SYNAREL 2 MG / ML NASAL SOLUTION
Unit Price, Unit of Issue 48.8851
Manufacturer PFI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02286386
Generic Name NATALIZUMAB
Product Name, Strength & Dosage Form TYSABRI 20 MG / ML INJECTION
Unit Price, Unit of Issue 176.9525
Manufacturer BIO
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 02467224
Generic Name OCRELIZUMAB
Product Name, Strength & Dosage Form OCREVUS 30 MG / ML INJECTION
Unit Price, Unit of Issue 815.0000
Manufacturer HLR
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION