INDIANA MEDICAID UPDATE

Transcription

1 INDIANA MEDICAID UPDATE August 28, 1998 TO: All Indiana Medicaid Pharmacy Providers SUBJECT: Updated and Revised "FUL" List Accompanying this bulletin are COMPREHENSIVE updated and revised "FUL" (Attachment A) list. Please incorporate the list into the appropriate section in Chapter 11P (Pharmacy Specific Billing Procedures) of the Indiana Medical Assistance Programs Provider Manual. For products, that have an updated FUL pricing, the new pricing will be effective on September 1, If you have any questions regarding the attached lists or the text of this bulletin, please contact EDS Provider Assistance at E98-28 EDS P. O. Box Indianapolis, IN

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3 ATTACHMENT A HCFA MAXIMUM ALLOWABLE COST MAC pricing indicators include the following: + increase in MAC unit price - decrease in MAC unit price NEW an addition to the MAC listing Please note that drugs deleted from MAC are not included on this listing. 3

4 Acebutolol Hydrochloride Eq. 200 mg base, Capsule, Oral /01/98 NEW Eq. 400 mg base, Capsule, Oral /01/97 Acetaminophen: Butalbital: Caffeine 325mg; 50mg; 40mg; Capsule, Oral /01/97 325mg; 50mg; 40mg; Tablet, Oral /01/97 Acetaminophen: Codeine Phosphate 300mg; 15mg; Tablet, Oral /01/94 300mg; 30mg; Tablet, Oral /01/95 300mg; 60mg; Tablet, Oral /01/98 + Acetaminophen: Hydrocodone Bitartrate 500mg; 5mg; Capsule, Oral /01/ mg; 2.5mg, Tablet, Oral /01/97 500mg; 5mg, Tablet, Oral /01/97 500mg; 7.5mg; Tablet, Oral /01/ mg; 7.5mg; Tablet, Oral /01/98-650mg; 10mg; Tablet, Oral /01/98-750mg; 7.5mg; Tablet, Oral /01/98 - Acetaminophen: Oxycodone Hydrochloride 325mg; 5mg; Tablet, Oral /01/98-500mg; 5mg; Capsule, Oral /01/98 - Acetaminophen: Propoxyphene Hydrochloride 650mg; 65mg; Tablet, Oral /01/97 Acetaminophen: Propoxyphene Napsylate 650mg; 100mg; Tablet, Oral /01/97 Acetic Acid, Glacial 2%, Solution/Drops, Otic, 15ml /01/96 Acetic Acid, Glacial; Hydrocortisone 2%; 1%, solutions/drops, Otic 10ml /01/97 Acetylcysteine 10%, Solution, Inhalation 4 ml /01/97 10%, Solution, Inhalation 10 ml /01/98-10%, Solution, Inhalation 30 ml /01/ %, Solution, Inhalation 4 ml /01/ %, Solution, Inhalation 10 ml /01/98-20%, Solution, Inhalation 30 ml /01/98 + 4

5 Acyclovir 200 mg. Capsule, Oral /01/98 NEW 400 mg. Tablet, Oral /01/98 NEW 800 mg, Tablet, Oral /01/98 NEW Albuterol Eq. 90 mcg. Solution, Aerosol Inhalation Refill 17 gm /01/98 NEW Eq. 90 mcg. Solution, Aerosol Inhalation 17 gm /01/98 NEW Albuterol Sulfate Eq % base, Solution, Inhalation 3 ml /01/97 Eq 2 mg base/5ml, Syrup, Oral 480 ml /01/98 NEW Eq 2mg base; Tablet, 100 EA, Oral /01/97 Eq 4mg base; Tablet, 100 EA, Oral /01/97 Allopurinol 100mg; Tablet, Oral /01/94 300mg; Tablet, Oral /01/97 Alprazolam 0.25mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + 1mg; Tablet, Oral /01/98 + 2mg; Tablet, Oral /01/97 Amantadine Hydrochloride 100mg; Capsule, Oral /01/ mg/5ml; Syrup, Oral 480 ml /01/97 Amiloride Hydrochloride 5 mg, Tablet, Oral /01/98 NEW Amiloride Hydrochloride; Hydrochlorothiazide Eq 5mg Anhydrous; 50mg; Tablet, Oral /01/97 Aminophylline 100mg; Tablet, Oral /01/98 - Amitriptyline Hydrochloride 10mg; Tablet, Oral /01/ mg; Tablet, Oral /01/97 50mg; Tablet, Oral /01/97 75mg; Tablet, Oral /01/97 100mg; Tablet, Oral /01/97 150mg; Tablet, Oral /01/97 5

6 Amitriptyline Hydrochloride; Perphenazine 10mg; 2mg; Tablet, Oral /01/97 10mg; 4mg; Tablet, Oral /01/97 25mg; 2mg; Tablet, Oral /01/97 25mg;4mg Tablet, Oral /01/98 NEW Amoxapine 25mg; Tablet, Oral /01/97 50mg; Tablet, Oral /01/97 100mg; Tablet, Oral /01/97 150mg; Tablet, Oral /01/97 Amoxicillin 250mg; Capsule, Oral /01/97 500mg; Capsule, Oral /01/ mg/5ml; Powder for reconstitution, Oral 80ml /01/93 125mg/5ml; Powder for reconstitution, Oral 100ml /01/97-125mg/5ml; Powder for reconstitution, Oral 150ml /01/96 250mg/5ml; Powder for reconstitution, Oral 80ml /01/96 250mg/5ml; Powder for reconstitution, Oral 100ml /01/92 250mg/5ml; Powder for reconstitution, Oral 150ml /01/96 Ampicillin/Ampicillin Trihydrate Eq 250mg base; Capsule, Oral /01/98 + Eq 500mg base; Capsule, Oral /01/92 Eq 125mg base/5ml; Powder for reconstitution, /01/ ML, Oral Eq 125mg base/5ml; Powder for reconstitution, /01/ ML, Oral Eq 250mg base/5ml; Powder for reconstitution, /01/ ML, Oral Eq 250mg base/5ml; Powder for reconstitution, /01/ ML, Oral Aspirin: Butalbital: Caffeine 325mg; 50mg; 40mg; Tablet, Oral /01/ mg; 50mg; 40mg; Capsule, Oral /01/98 NEW Aspirin: Caffeine: Propoxyphene Hydrochloride 389mg; 32.4mg; 65mg; Capsule, 100 EA, Oral /01/96 Aspirin: Carisoprodol 325mg; 200mg; Tablet, 100 EA, Oral /01/97 Aspirin: Methocarbamol 325mg; 400mg; Tablet, 100 EA, Oral /01/97 Aspirin, Oxycodone Hydrochloride: Oxycodone Terephthalate 6

7 325mg; 4.5mg, 0.38mg, Tablet, Oral /01/98 + Atenolol 25mg; Tablet, Oral /01/98-50mg; Tablet, Oral /01/97 100mg; Tablet, Oral /01/97 Atenolol: Chlorthalidone 50mg; 25mg; Tablet, Oral /01/98-100mg; 25mg; Tablet, Oral /01/98 - Bacitracin Zinc: Neomycin Sulfate: Polymyxin B Sulfate 400 units/gm; Eq 3.5mg base/gm; 10,000 units/gm; /01/97 Ointment, 3.5 Gm, Ophthalmic Baclofen 10mg; Tablet, 100 EA, Oral /01/97 20mg; Tablet, 100 EA, Oral /01/97 Benzonate 100mg, Capsule, Oral /01/98 NEW Benztropine Mesylate 0.5mg; Tablet, Oral /01/97 1mg; Tablet, Oral /01/98 + 2mg; Tablet, Oral /01/98 + Betamethasone Dipropionate Eq 0.05% base; Cream, 15 GM, Topical /01/95 Eq 0.05% base; Cream, 45 GM, Topical /01/97 Eq 0.05% base; Lotion, 20 ML, Topical /01/95 Eq 0.05% base; Lotion, 60 ML, Topical /01/95 Betamethasone Valerate Eq 0.1% base; Cream, 15GM, Topical /01/97 Eq 0.1% base;cream, 45 GM, Topical /01/96 Eq 0.1% base; Lotion, 60 ML, Topical /01/96 Bethanechol Chloride 10mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Bromodiphenhydramine Hydrochloride: Codeine Phosphate 12.5mg/5ml; 10mg/5ml; Syrup, Oral 480ml /01/98 - Brompheniramine Maleate: Codeine Phosphate: Phenylpropanolamine Hydrochloride 2mg/5ml; 10mg/5ml; 12.5mg/5ml; Syrup, Oral 480ml /01/98 + 7

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9 Brompheniramine Maleate; Dextromethorphan Hydrobromide: Pseudoephedrine Hydrochloride 2mg/5ml; 10mg/5ml; 30mg/5ml; Syrup, Oral 480ml /01/98 + Bumetanide 0.5mg, Tablet, Oral /01/97 1mg, Tablet, Oral /01/98-2mg, Tablet, Oral /01/98 + Captopril 12.5 mg, Tablet, Oral /01/97 25 mg, Tablet, Oral /01/98-50 mg, Tablet, Oral /01/ mg, Tablet, Oral /01/97 Carbamazepine 100mg; Tablet, chewable, 100 EA, Oral /01/96 200mg; Tablet, 100 EA, Oral /01/97 Carbidopa; Levodopa 10mg; 100mg, Tablet, 100 EA, Oral /01/97 25mg; 100mg, Tablet, 100 EA, Oral /01/97 25mg; 250mg, Tablet, 100 EA, Oral /01/97 Carisoprodol 350mg; Tablet, 100 EA, Oral /01/97 Cefaclor Eq. 250mg base, Capsule, Oral /01/98 NEW Eq. 500mg base, Capsule, Oral /01/98 NEW Eq. 125mg base/5ml, Powder for reconstitution, Oral 75ML /01/97 Eq. 125mg base/5ml, Powder for reconstitution, Oral 150ML /01/97 Eq. 187mg base/5ml, Powder for reconstitution, Oral 50ML /01/97 Eq. 187mg base, 5ML, Powder for reconstitution, Oral 100ML /01/97 Eq. 250mg base/5ml, Powder for reconstitution, Oral 75ML /01/98 - Eq. 250mg base/5ml, Powder for reconstitution, Oral 150ML /01/98 - Eq. 375mg base/5ml, Powder for reconstitution, Oral 50ML /01/98 - Eq. 375mg base/5ml, Powder for reconstitution, Oral 100ML /01/98 - Cephalexin Eq 250mg base; Capsule, Oral /01/97 - Eq 500mg base; Capsule, Oral /01/98 - Eq 250mg base; Tablet, Oral /01/98 + Eq 125mg base/5ml; Powder for Reconstitution, Oral 100 ml /01/97-9

10 Cephalexin (continued) Eq 125mg base/5ml; Powder for Reconstitution, Oral 200 ml /01/97 Eq 250mg base/5ml; Powder for Reconstitution, Oral 100 ml /01/98 + Eq 250mg base/5ml; Powder for Reconstitution, /01/98 + Oral 200 ml Cephradine 250mg; Capsule, Oral /01/98 + Chlordiazepoxide Hydrochloride 5mg; Capsule, Oral /01/ mg; Capsule, Oral /01/96 25mg; Capsule, Oral /01/96 Chlorhexidine Gluconate 0.12%, Solution, Dental 480 ML /01/97 Chlorothiazide 250mg; Tablet, Oral /01/ mg; Tablet, Oral /01/95 Chlorpheniramine Maleate 4mg; Tablet, Oral /01/93 Chlorpropamide 100mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Chlorthalidone 25mg; Tablet, Oral /01/97 50mg; Tablet, Oral /01/97 Chlorzoxazone 500mg; Tablet, Oral /01/97 Cholestyramine Eq. 4gm Resin/Packet, Powder, Oral 60 pk /01/98 - Eq. 4gm Resin/Scoopful, Powder, Oral 239.4gm /01/97 Cimetidine 200mg; Tablet, Oral /01/97 300mg; Tablet, Oral /01/97 400mg; Tablet, Oral /01/97 800mg; Tablet, Oral /01/97 Clemastine Fumarate 2.68mg; Tablet, Oral /01/97 10

11 Clindamycin Phosphate Eq. 1% base, Solution, Topical 30ml /01/98 + Eq. 1% base, Solution, Topical 60ml /01/98 + Clomipramine Hydrochloride 25mg, Capsule, Oral /01/98-50mg, Capsule, Oral /01/98-75mg, Capsule, Oral /01/98 - Clonazepam 0.5mg, Tablet, Oral /01/98 - Clonidine Hydrochloride 0.1mg; Tablet, Oral /01/96 0.2mg; Tablet, Oral /01/96 0.3mg; Tablet, Oral /01/96 Clorazepate Dipotassium 3.75mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Clotrimazole 1%, Solution, 10ml, Topical /01/97 Cloxacillin Sodium Eq 250mg base; Capsule, Oral /01/97 Eq 500mg base; Capsule, Oral /01/98 + Codeine Phosphate: Phenylephrine Hydrochloride: Promethazine Hydrochloride 10mg/5ml; 5mg/5ml; 6.25mg/5ml; Syrup, Oral 480ml /01/97 Codeine Phosphate: Promethazine Hydrochloride 10mg/5ml; 6.25mg/5ml; Syrup, Oral 480ml /01/93 Codeine Phosphate; Pseudoephedrine Hydrochloride: Triprolidine Hydrochloride 10mg/5ml; 30mg/5ml; 1.25mg/5ml; Syrup, /01/95 Oral 480ml Cyclobenzaprine Hydrochloride 10mg; Tablet, Oral /01/97 Cyproheptadine Hydrochloride 2mg/5ml, Syrup, Oral 480ml /01/98 NEW 4mg; Tablet, Oral /01/97 11

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13 Danazol 200mg, Capsule, Oral /01/98 NEW Desipramine Hydrochloride 10mg; Tablet, Oral /01/97 25mg; Tablet, Oral /01/97 50mg; Tablet, Oral /01/97 Desipramine Hydrochloride (continued) 75mg; Tablet, Oral /01/97 100mg; Tablet, Oral /01/96 Desoximetasone 0.25% Cream, Topical 15gm /01/98 NEW 0.25% Cream, Topical 60gm /01/98 NEW Dexamethasone 0.5mg/5ml; Elixir, Oral 100ml /01/96 Dexamethasone: Neomycin Sulfate: Polymyxin B Sulfate 0.1%; Eq 3.5mg base/gm; 10,000 units/gm; Ointment, 3.5 GM, ophthalmic /01/97 Dexamethasone Sodium Phosphate Eq. 0.05% Phosphte, Ointment, Opthalmic 3.5gm /01/98 NEW Eq 0.1% Phosphate, Solution/Drops, Opthalmic 5ml /01/98 - Dexamethasone Sodium Phosphate: Neomycin Sulfate Eq 0.1% Phosphate; Eq 3.5mg base/ml Solution/Drops, 5 ML, Ophthalmic /01/97 Dextromethorphan Hydrobromide: Promethazine Hydrochloride 15mg/5ml; 6.25mg/5ml; Syrup, 480 ML, Oral /01/97 Diazepam 2mg; Tablet, Oral /01/96 5mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Diclofenac Sodium 50mg, Tablet, Delayed release, Oral /01/98-75mg, Tablet, Delayed release, Oral /01/97 Dicloxacillin Sodium Eq 250mg base; Capsule, Oral /01/98 + Eq 500mg base, Capsule, Oral /01/

14 Dicyclomine Hydrochloride 10mg, Capsule, Oral /01/97 20mg, Tablet, Oral /01/98 - Diethylpropion Hydrochloride 25mg; Tablet, Oral /01/98 + Diltiazem Hydrochloride 30mg; Tablet, Oral /01/97 60mg; Tablet, Oral /01/97 90mg; Tablet, Oral /01/97 120mg; Tablet, Oral /01/97 Diphenhydramine Hydrochloride 25mg; Capsule, Oral /01/98 50mg; Capsule, Oral /01/ mg/5ml; Elixir, Oral 480ml /01/93 Dipivefrin Hydrochloride 0.1%, Solution/Drops, Ophthalmic 5ml /01/97 0.1%, Solution/Drops, Ophthalmic 10ml /01/97 0.1%, Solution/Drops, Ophthalmic 15ml /01/97 Dipyridamole 25mg; Tablet, Oral /01/97 50mg; Tablet, Oral /01/95 75mg; Tablet, Oral /01/95 Disopyramide Phosphate Eq 100mg base; Capsule, Oral /01/98 + Eq 150mg base; Capsule, Oral /01/98 + Doxepin Hydrochloride Eq 10mg base; Capsule, Oral /01/96 Eq 25mg base, Capsule, Oral /01/96 Eq 50mg base; Capsule, Oral /01/97 Eq 75mg base; Capsule, Oral /01/98 - Eq 100mg base; Capsule, Oral /01/97 Eq 150mg base, Capsule, Oral /01/97 Eq 10mg base/ml; Concentrate, Oral /01/93 Doxycycline Hyclate Eq 100mg base; Capsule, Oral /01/98 + Eq 100mg base; Tablet, Oral /01/97 14

15 Erythromycin 250mg; Capsule, delayed release pellets, Oral /01/97 2%; Gel, Topical 30gm /01/ % Ointment, Opthalmic 3,5gm /01/98 + 2%; Solution, Topical 60ml /01/98-2%; Swab, Topical /01/97 Erythromycin Estolate Eq 250mg base; Capsule, Oral /01/98 + Eq 125mg base/5ml, Suspension, Oral 480ml /01/98 NEW Erythromycin Ethylsuccinate Eq 200mg base/5ml; Suspension, Oral 480ml /01/97 Eq 400mg base/5ml; Suspension, Oral 480ml /01/96 Erythromycin Ethylsuccinate; Sulfisoxazole Acetyl Eq. 200mg base/5ml, Eq. 600mg base/5ml, Granule, Oral 100ml /01/97 Eq. 200mg base/5ml, Eq. 600mg base/5ml, Granule, Oral 150ml /01/97 Eq. 200mg base/5ml, Eq. 600mg base/5ml, Granule, Oral 200ml /01/97 Estradiol 0.5mg, Tablet, Oral /01/98 NEW 1mg, Tablet, Oral /01/98 NEW 2mg, Tablet, Oral /01/98 NEW Estropipate 0.75mg; Tablet, Oral /01/ mg, Tablet, Oral /01/98 + 3mg; Tablet, Oral /01/98 - Ethinyl Estradiol; Levonorgestrel 0.03mg;0.15mg, Tablet, Oral /01/98 NEW Ethinyl Estradiol: Norethindrone 0.035mg; 0.5mg; Tablet, 21 EA, Oral /01/ mg; 0.5mg; Tablet, 28 EA, Oral /01/ mg; 1mg; Tablet, 21 EA, Oral /01/ mg; 1mg; Tablet, 28 EA, Oral /01/95 Etodolac 300mg, Capsule, Oral /01/98 NEW 400mg, Tablet, Oral /01/98 NEW Fenoprofen Calcium Eq 600mg base; Tablet, Oral /01/

16 Fluocinolone Acetonide 0.01%; Cream, Topical 15gm /01/ %; Cream, Topical 60gm /01/ %; Cream, Topical 15gm /01/ %; Cream, Topical 60gm /01/ %; Ointment, Topical 60gm /01/ %, Solution, Topical 20ml /01/98 NEW 0.01%, Solution, Topical 60ml /01/98 NEW Fluocinonide 0.05%; Cream, Topical 15gm /01/ %; Cream, Topical 30gm /01/ %; Cream, Topical 60gm /01/ %; Cream, Topical 120gm /01/ %; Gel, Topical 60gm /01/ %, Ointment, Topical 15gm /01/98 NEW 0.05%, Ointment, Topical 30gm /01/98 NEW 0.05%, Ointment, Topical 60gm /01/98 NEW 0.05%; Solution, Topical 60ml /01/97 Fluorometholone 0.1%, Suspension/Drops, Opthalmic 5ml /01/98 NEW 0.1%, Suspension/Drops, Opthalmic 10ml /01/98 NEW 0.1%, Suspension/Drops, Opthalmic 15ml /01/98 NEW Fluphenazine Hydrochloride 1mg; Tablet, Oral /01/97 2.5mg; Tablet, Oral /01/97 5mg; Tablet, Oral /01/97 10mg; Tablet, Oral /01/97 Flurazepam Hydrochloride 15mg; Capsule, 100 EA, Oral /01/94 30mg; Capsule, 100 EA, Oral /01/94 Flurbiprofen 50mg, Tablet, Oral /01/97 100mg, Tablet, Oral /01/98 - Folic Acid 1mg; Tablet, Oral /01/98-1mg; Tablet, Oral /01/98 - Furosemide 10mg/ml; Solution, Oral 60ml /01/97 20mg; Tablet, Oral /01/97 40mg; Tablet, Oral /01/97 16

17 80mg; Tablet, Oral /01/97 Gemfibrozil 600mg; Tablet, Oral /01/97 Glipizide 5mg, Tablet, Oral /01/97 10mg, Tablet, Oral /01/98 - Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate 0.025mg/ml;Eq mg base/ml; 10,000 units/ml /01/96 Solution/Drops, Opthalmic 10ml Griseofulvin, Ultramicrocrystalline 250mg, Tablet, Oral /01/97 330mg, Tablet, Oral /01/98 + Guanabenz Acetate Eq. 4mg base, Tablet, Oral /01/97 Eq. 8 mg base, Tablet, Oral /01/97 Guanfacine Hydrochloride Eq. 1mg base, Tablet, Oral /01/98 NEW Eq. 2mg base, Tablet, Oral /01/98 NEW Haloperidol 0.5mg; Tablet, Oral /01/94 1mg; Tablet, Oral /01/98 + 2mg; Tablet, Oral /01/98 + 5mg; Tablet, Oral /01/94 10mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Homatropine Methylbromide; Hydrocodone Bitartrate 1.5mg/5ml;5mg/5ml, Syrup, Oral 480ml /01/98 NEW Hydralazine Hydrochloride 10mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Hydralazine Hydrochloride: Hydrochlorothiazide 25mg; 25mg; Capsule, Oral /01/97 50mg; 50mg; Capsule, Oral /01/97 Hydrochlorothiazide 25mg; Tablet, Oral /01/97 17

18 50mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Hydrochlorothiazide: Propranolol Hydrochloride 25mg; 40mg; Tablet, Oral /01/97 25mg; 80mg; Tablet, Oral /01/97 Hydrochlorothiazide: Spironolactone 25mg; 25mg; Tablet, Oral /01/98 + Hydrochlorothiazide: Triamterene 25mg; 50mg, Capsule, Oral /01/98 NEW 25mg; 37.5mg; Tablet, Oral /01/97 50mg; 75mg; Tablet, Oral /01/97 Hydrocortisone 0.5%, Cream, Topical 30gm /01/ %, Cream, Topical 20gm /01/ %, Cream, Topical 30gm /01/ %, Cream, Topical 454gm /01/98 NEW 1%; Lotion, Topical 60ml /01/97 1%; Lotion, Topical 120ml /01/95 1%, Ointment, Topical 30gm /01/98 NEW 2.5%; Ointment, Topical 20gm /01/98 - Hydroxychloroquine Sulfate 200mg, Tablet, Oral /01/97 Hydroxyzine Hydrochloride 10mg/5ml; Syrup, Oral 480ml /01/97 10mg; Tablet, Oral /01/97 25mg; Tablet, Oral /01/97 50mg; Tablet, Oral /01/97 Hydroxyzine Pamoate Eq 25mg hcl; Capsule, Oral /01/97 Eq 50mg hcl; Capsule, Oral /01/97 Eq 100mg hcl; Capsule, Oral /01/96 Ibuprofen 400mg; Tablet, Oral /01/96 600mg; Tablet, Oral /01/97 800mg; Tablet, Oral /01/97 Indapamide 1.25mg; Tablet, Oral /01/ mg; Tablet, Oral /01/97 Indomethacin 18

19 25mg; Capsule, Oral /01/97 50mg; Capsule, Oral /01/97 75mg, Capsule, Extended Release, Oral /01/98 NEW Isoniazid 100mg; Tablet, Oral /01/98-300mg; Tablet, Oral /01/98 - Isosorbide Dinitrate 2.5mg; Tablet, 100 EA, sublingual /01/97 5mg; Tablet, 100 EA, Oral /01/97 5mg; Tablet, 100 EA, Sublingual /01/97 10mg; Tablet, 100 EA, Oral /01/97 20mg; Tablet, 100 EA, Oral /01/94 30mg; Tablet, 100 EA, Oral /01/97 Lactulose 10gm/15ml, Solution, Oral 480ml /01/97 Leucovorin Calcium Eq 5mg base; Tablet, Oral /01/95 Eq 25mg base; Tablet, Oral /01/97 Levobunolol Hydrochloride 0.5%, Solution/Drops, Ophthalmic 5ml /01/98 NEW 0.5%; Solution/Drops, Ophthalmic 10 ML /01/97 0.5%; Solution/Drops, Ophthalmic 15 ML /01/97 Lidocaine Hydrochloride 2%; Solution, Oral 100ml /01/97 Lindane 1%; Lotion, Topical 60ml /01/98 + 1%; Lotion, Topical 480ml /01/98 + 1%; Shampoo, Topical 60ml /01/98 + 1%; Shampoo, Topical 480ml /01/98 + Lithium Carbonate 300mg; Capsule, Oral /01/96 300mg; Capsule, Oral /01/97 Lithium Citrate Eq. 300mg Carbonate/5ml, Syrup, Oral 480ml /01/98 NEW Loperamide Hydrochloride 2mg; Capsule, 100 EA, Oral /01/97 Lorazepam 0.5mg; Tablet, Oral /01/

20 1mg; Tablet, Oral /01/98 + 2mg; Tablet, Oral /01/

21 Loxapine Succinate Eq. 5mg base, Capsule, Oral /01/98 NEW Eq. 10mg base, Capsule, Oral /01/98 NEW Eq. 25mg base, Capsule, Oral /01/98 NEW Eq. 50mg base, Capsule, Oral /01/98 NEW Maprotiline Hydrochloride 25mg; Tablet, Oral /01/98-50mg; Tablet, Oral /01/98-75mg; Tablet, Oral /01/98 - Meclizine Hydrochloride 12.5mg; Tablet, Oral /01/ mg; Tablet, 100 EA, Oral /01/97 Meclofenamate Sodium Eq 50mg base; Capsule, Oral /01/98 + Eq 100 mg base; Capsule, Oral /01/97 Medroxyprogesterone Acetate 10mg, Tablet, Oral /01/98 NEW Megestrol Acetate 20mg; Tablet, Oral /01/97 40mg; Tablet, Oral /01/97 Meprobamate 200mg; Tablet, Oral /01/94 400mg; Tablet, Oral /01/96 Mestranol: Norethindrone 0.05mg; 1mg; Tablet, 21 EA, Oral /01/ mg; 1mg; Tablet, 28 EA, Oral /01/95 Metaproterenol Sulfate 10mg/5ml; Syrup, 480 ML, Oral /01/97 10mg; Tablet, 100 EA, Oral /01/94 20mg; Tablet, 100 EA, Oral /01/95 Methadone Hydrochloride 10mg/ml; Concentrate, 946 ML, Oral /01/97 Methazolamide 25mg; Tablet, 100 EA, Oral /01/97 50mg; Tablet, 100 EA, Oral /01/97 Methocarbamol 500mg; Tablet, 100 EA, Oral /01/97 21

22 750mg; Tablet, 100 EA, Oral /01/97 Methotrexate Sodium Eq. 2.5mg base, Tablet, Oral /01/97 Methyclothiazide 5mg; Tablet, 100 EA, Oral /01/98 + Methyldopa 125mg; Tablet, Oral /01/96 250mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Methylphenidate Hydrochloride 5mg, Tablet, Oral /01/98 NEW 10mg, Tablet, Oral /01/98 NEW 20mg, Tablet, Oral /01/98 NEW Methylprednisolone 4mg, Tablet, Oral /01/98 NEW Metoclopramide Hydrochloride Eq 5mg base; Tablet, Oral /01/97 Eq 10mg base; Tablet, Oral /01/96 Metoprolol Tartrate 50mg; Tablet, Oral /01/98-100mg; Tablet, Oral /01/98 - Metronidazole 250mg; Tablet, Oral /01/98-500mg; Tablet, Oral /01/98 - Mexiletine Hydrochloride 150mg; Capsule, Oral /01/ mg; Capsule, Oral /01/ mg; Capsule, Oral /01/98 + Minocycline Hydrochloride Eq 50mg base; Capsule, 100 EA, Oral /01/97 Eq 100mg base; Capsule, 50 EA, Oral /01/97 Minoxidil 2.5mg; Tablet, Oral /01/ mg, Tablet, Oral /01/97 Nadolol 20mg, Tablet, Oral /01/97 40mg, Tablet, Oral /01/97 22

23 80mg, Tablet, Oral /01/97 Naphazoline Hydrochloride 0.1%; Solution/Drops, Ophthalmic 15ml /01/96 Naproxen 250mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/96 Naproxen Sodium Eq 250mg base; Tablet, Oral /01/97 Eq 500mg base; Tablet, Oral /01/97 Niacin 500mg; Tablet, Oral /01/94 Nifedipine 10mg; Capsule, Oral /01/ mg, Capsule, Oral /01/98 NEW Nitrofurantoin, Macrocrystalline 50mg, Capsule, Oral /01/97-100mg, Capsule, Oral /01/98 NEW Nortriptyline Hydrochloride Eq 10mg base; Capsule, Oral /01/98 - Eq 25mg base; Capsule, Oral /01/98 - Eq 50mg base; Capsule, Oral /01/97 Eq 75mg base; Capsule, Oral /01/97 Nystatin 100,000 units/gm; Cream, Topical 15gm /01/93 100,000 units/gm; Cream, Topical 30gm /01/94 100,000 units/gm; Ointment, Topical 15gm /01/92 100,000 units/gm; Ointment, Topical 30gm /01/95 100,000 units/ml; Suspension, Oral 60ml /01/96 100,000 units/ml; Suspension, Oral 480ml /01/97 500,000 units; Tablet, Oral /01/92 Nystatin: Triamcinolone Acetonide 100,000 units/gm; 0.1%; Cream, Topical 15gm /01/97 100,000 units/gm; 0.1%; Cream, Topical 30gm /01/97 100,000 units/gm; 0.1%; Cream, Topical 60gm /01/97 100,000 units/gm; 0.1%; Ointment, Topical 15gm /01/97 100,000 units/gm; 0.1%; Ointment, Topical 30gm /01/96 100,000 units/gm; 0.1%; Ointment, Topical 60gm /01/95 23

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25 Oxacillin Sodium Eq 250mg base/5ml; Powder for Reconstitution, Oral 100ml /01/94 Oxazepam 10mg; Capsule, Oral /01/ mg; Capsule, Oral /01/98-30mg; Capsule, Oral /01/98 + Oxybutynin Chloride 5mg; Tablet, 100 EA, Oral /01/98 - Penicillin V Potassium Eq 125mg base/5ml; Powder for Reconstitution, /01/98 + Oral 100ml Eq 125mg base/5ml; Powder for Reconstitution, /01/98 + Oral 200ml Eq 250mg base/5ml; Powder for Reconstitution, /01/98 + Oral 100ml Eq 250mg base/5ml; Powder for Reconstitution, /01/98 + Oral 200ml Eq 250mg base; Tablet, Oral /01/98 + Eq 500mg base; Tablet, Oral /01/95 Perphenazine 2mg; Tablet, Oral /01/98-4mg; Tablet, Oral /01/98-8mg; Tablet, Oral /01/98-16mg; Tablet, Oral /01/97 Phendimetrazine Tartrate* 35mg; Tablet, Oral /01/96 Phentermine Hydrochloride* 30mg; Capsule, Oral /01/ mg; Capsule, Oral /01/ mg; Tablet, Oral /01/98 + Phenylephrine Hydrochloride: Promethazine Hydrochloride 5mg/5ml; 6.25mg/5ml; Syrup, Oral 480ml /01/98 + Pindolol 5mg; Tablet, Oral /01/98-10mg; Tablet, Oral /01/98 - * These items are non-covered under Indiana Medicaid. The FUL rates are for informational purposes only. 25

26 Piroxicam 10mg; Capsule, Oral /01/97 20mg; Capsule, Oral /01/97 Potassium Chloride 8meq; Tablet, extended release, Oral /01/97 Prazosin Hydrochloride Eq 1mg base; Capsule, Oral /01/98 + Eq 2mg base; Capsule, Oral /01/97 Eq 5mg base; Capsule, Oral /01/98 + Prednisolone Acetate 1% Suspension/Drops, Ophthalmic 5ml /01/98 NEW 1% Suspension/Drops, Ophthalmic 10ml /01/98 NEW Prednisolone Sodium Phosphate Eq 1% Phosphate; Solution/Drops, Ophthalmic 5ml /01/97 Eq 1% Phosphate; Solution/Drops, Opthalmic 15ml /01/97 Prednisolone Sodium Phosphate: Sulfacetamide Sodium Eq.25% Phosphate; 10% Solution/Drops, Ophthalmic 5ml /01/97 Eq.25% Phosphate; 10% Solution/Drops, Ophthalmic 10ml /01/98 + Prednisone 5mg; Tablet, Oral /01/97 10mg; Tablet, Oral /01/97 20mg; Tablet, Oral /01/97 50mg; Tablet, Oral /01/98 + Primidone 250mg; Tablet, Oral /01/97 Probenecid 500mg; Tablet, Oral /01/98 + Procainamide Hydrochloride 500mg; Tablet, extended release, Oral /01/97 750mg; Tablet, extended release, Oral /01/97 Prochlorperazine Maleate Eq 5mg base, Tablet, Oral /01/98 - Eq 10mg base, Tablet, Oral /01/98 - Promethazine Hydrochloride 6.25mg/5ml; Syrup, Oral 480ml /01/98 + Proparacaine Hydrochloride 26

27 0.5%, Solution/Drops, Ophthalmic 15ml /01/97 Propoxyphene Hydrochloride 65mg; Capsule, Oral /01/95 Propranolol Hydrochloride 60mg, Capsule, Extended Release, Oral /01/98 NEW 80mg, Capsule, Extended Release, Oral /01/98 NEW 120mg, Capsule, Extended Release, Oral /01/98 NEW 160mg, Capsule, Extended Release, Oral /01/98 NEW 10mg; Tablet, Oral /01/97 20mg; Tablet, Oral /01/97 40mg; Tablet, Oral /01/97 60mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Pseudoephedrine Hydrochloride: Triprolidine Hydrochloride 60mg; 2.5mg; Tablet, 100 EA, Oral /01/97 Quinidine Gluconate 324mg; Tablet, extended release, 100 EA, Oral /01/98 + Quinidine Sulfate 200mg; Tablet, 100 EA, Oral /01/96 300mg; Tablet, 100 EA, Oral /01/93 Ranitidine Hydrochloride Eq. 300mg base, Tablet, Oral /01/98 NEW Selegiline Hydrochloride 5mg, Tablet, Oral /01/98-5mg, Tablet, Oral /01/98 - Selenium Sulfide 2.5%; Lotion/Shampoo, Topical 120ml /01/98 - Silver Sulfadiazine 1%; Cream, Topical 20gm /01/96 1%; Cream, Topical 50gm /01/95 1%; Cream, Topical 85gm /01/96 1%; Cream, Topical 400gm /01/96 Spironolactone 25mg; Tablet, Oral /01/98 + Sulfacetamide Sodium 10%; Ointment, Ophthalmic 3.5gm /01/ %; Solution/Drops, Ophthalmic 2ml /01/98-10%; Solution/Drops, Ophthalmic 5ml /01/98-27

28 10%; Solution/Drops, Ophthalmic 15ml /01/98 - Sulfamethoxazole: Trimethoprim 200mg/5ml; 40mg/5ml; Suspension, Oral 473ml /01/ mg/5ml; 40mg/5ml; Suspension, Oral 480ml /01/97 400mg; 80mg; Tablet, Oral /01/97 800mg; 160mg; Tablet Oral /01/94 Sulfasalazine 500mg, Tablet, Oral /01/97 Sulfinpyrazone 200mg; Capsule, Oral /01/96 Sulfisoxazole 500 mg; Tablet, Oral /01/97 Sulindac 150mg; Tablet, Oral /01/97 200mg; Tablet, Oral /01/97 Temazepam 15mg; Capsule, Oral /01/98-30mg; Capsule, Oral /01/98 - Tetracycline Hydrochloride 250mg; Capsule, Oral /01/98-500mg; Capsule, Oral /01/98 + Theophylline 80mg/15ml; Elixir, Oral 480ml /01/93 100mg, Tablet, Extended Release, Oral /01/98 NEW 200mg, Tablet, Extended Release, Oral /01/98 NEW 300mg, Tablet, Extended Release, Oral /01/98 NEW Thioridazine Hydrochloride 30mg/ml; Concentrate, Oral 120 ml /01/97 10mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Thiothixene 1mg; Capsule, Oral /01/97 2mg; Capsule, Oral /01/97 28

29 5mg; Capsule, Oral /01/97 10mg; Capsule, Oral /01/97 Thiothixene Hydrochloride Eq 5mg base/ml; Concentrate, Oral 120ml /01/94 Timolol Maleate Eq. 0.25% base, Solution/Drops, Ophthalmic 5ml /01/98 NEW Eq. 0.25% base, Solution/Drops, Ophthalmic 10ml /01/98 NEW Eq. 0.25% base, Solution/Drops, Ophthalmic 15ml /01/98 NEW Eq. 0.5% base, Solution/Drops, Ophthalmic 5ml /01/98 NEW Eq. 0.5% base, Solution/Drops, Ophthalmic 10ml /01/98 NEW Eq. 0.5% base, Solution/Drops, Ophthalmic 15ml /01/98 NEW 5mg; Tablet, Oral /01/97 10mg; Tablet, Oral /01/97 20mg; Tablet, Oral /01/97 Tobramycin 0.3%, Solution/Drops, Ophthalmic 5 ml /01/97 Tolazamide 100mg; Tablet, Oral /01/ mg; Tablet, Oral /01/98 + Tolbutamide 500mg; Tablet, Oral /01/98 + Tolmetin Sodium Eq 400mg base; Capsule, Oral /01/96 Eq 600mg base; Tablet, Oral /01/97 Trazodone Hydrochloride 50mg; Tablet, Oral /01/ mg; Tablet, Oral /01/97 150mg, Tablet, Oral /01/98 NEW Triamcinolone Acetonide 0.025%; Cream, Topical 15gm /01/ %; Cream, Topical 80gm /01/98-0.1%; Cream, Topical 15gm /01/97 0.1%; Cream, Topical 80gm /01/97 0.1%; Cream, Topical 454gm /01/97 0.1%; Cream, Topical 2270gm /01/98-0.5%; Cream, Topical 15gm /01/97 0.1%; Lotion, Topical 60ml /01/ %; Ointment, Topical 15gm /01/ %; Ointment, Topical 80gm /01/ %; Ointment, Topical 15gml /01/92 29

30 0.1%; Ointment, Topical 454gm /01/97 0.1%; Paste, Dental 5gm /01/96 30

31 Triazolam 0.125mg, Tablet, 100 EA, Oral /01/ mg, Tablet, 100 EA, Oral /01/97 Trifluoperazine Hydrochloride Eq 1mg base, Tablet, 100 EA, Oral /01/97 Eq 2mg base, Tablet, 100 EA, Oral /01/97 Eq 5mg base, Tablet, 100 EA, Oral /01/97 Eq 10mg base, Tablet, 100 EA, Oral /01/97 Trihexyphenidyl Hydrochloride 2mg, Tablet, Oral /01/98 NEW Trimethoprim 100mg, Tablet, 100 EA, Oral /01/97 200mg; Tablet, 100 EA, Oral /01/97 Triple Sulfa (Sulfabenzamide; Sulfacetamide; Sulfathiazole) 3.7%; 2.86%; 3.42%, Cream, Vaginal 78gm /01/98 + Tropicamide 0.5%; Solution/Drops, Ophthalmic15ml /01/97 1% Solution/Drops, Ophthalmic 15ml /01/98 NEW Valproic Acid 250mg; Capsule, 100 EA, Oral /01/97 250mg/5ml; Syrup, 480 ML, Oral /01/97 Verapamil Hydrochloride 40mg; Tablet, Oral /01/97 80mg; Tablet, Oral /01/97 120mg, Tablet, Extended Release, Oral /01/98 NEW 180mg, Tablet, Extended Release, Oral /01/98 NEW 120mg; Tablet, Oral /01/97 240mg; Tablet, Extended Release, Oral /01/97 31