August 31, 2012 - Iowa Medicaid Enterprise

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NDC Product Description Termination Date Quarter Covered 00378180301 LEVOTHYROXIN TAB 50MCG 12/31/9999 20121 00378180310 LEVOTHYROXIN TAB 50MCG 12/31/9999 20121 00527134201 LEVOTHYROXIN TAB 50MCG 12/31/9999 20121 00527134210 LEVOTHYROXIN TAB 50MCG 12/31/9999 20121 00781518101 LEVOTHYROXIN TAB 50MCG 06/30/2012 20121 00781518110 LEVOTHYROXIN TAB 50MCG 12/31/9999 20121 00781518192 LEVOTHYROXIN TAB 50MCG 12/31/9999 20121 51079044001 LEVOTHYROXIN TAB 50MCG 12/31/9999 20121 51079044020 LEVOTHYROXIN TAB 50MCG 12/31/9999 20121 00378180501 LEVOTHYROXIN TAB 75MCG 12/31/9999 20121 00378180510 LEVOTHYROXIN TAB 75MCG 12/31/9999 20121 00527134301 LEVOTHYROXIN TAB 75MCG 12/31/9999 20121 00527134310 LEVOTHYROXIN TAB 75MCG 12/31/9999 20121 00781518201 LEVOTHYROXIN TAB 75MCG 09/30/2012 20121 00781518210 LEVOTHYROXIN TAB 75MCG 12/31/9999 20121 00781518292 LEVOTHYROXIN TAB 75MCG 12/31/9999 20121 51079044101 LEVOTHYROXIN TAB 75MCG 12/31/9999 20121 51079044120 LEVOTHYROXIN TAB 75MCG 12/31/9999 20121 00378180701 LEVOTHYROXIN TAB 88MCG 12/31/9999 20121 00378180710 LEVOTHYROXIN TAB 88MCG 12/31/9999 20121 00527134401 LEVOTHYROXIN TAB 88MCG 12/31/9999 20121 00527134410 LEVOTHYROXIN TAB 88MCG 12/31/9999 20121 00781518301 LEVOTHYROXIN TAB 88MCG 12/31/9999 20121 00781518392 LEVOTHYROXIN TAB 88MCG 12/31/9999 20121 60793085401 LEVOXYL TAB 100MCG 12/31/9999 20121 60793085410 LEVOXYL TAB 100MCG 12/31/9999 20121 60793085501 LEVOXYL TAB 112MCG 12/31/9999 20121 60793085510 LEVOXYL TAB 112MCG 12/31/9999 20121 60793085601 LEVOXYL TAB 125MCG 12/31/9999 20121 60793085610 LEVOXYL TAB 125MCG 12/31/9999 20121 60793085701 LEVOXYL TAB 137MCG 12/31/9999 20121 60793085710 LEVOXYL TAB 137MCG 12/31/9999 20121 60793085801 LEVOXYL TAB 150MCG 12/31/9999 20121 60793085810 LEVOXYL TAB 150MCG 12/31/9999 20121 60793085901 LEVOXYL TAB 175MCG 12/31/9999 20121 60793085910 LEVOXYL TAB 175MCG 12/31/9999 20121 60793086001 LEVOXYL TAB 200MCG 12/31/9999 20121 60793086010 LEVOXYL TAB 200MCG 12/31/9999 20121 60793085001 LEVOXYL TAB 25MCG 12/31/9999 20121 60793085010 LEVOXYL TAB 25MCG 12/31/9999 20121 60793085101 LEVOXYL TAB 50MCG 12/31/9999 20121 60793085110 LEVOXYL TAB 50MCG 12/31/9999 20121 60793085201 LEVOXYL TAB 75MCG 12/31/9999 20121 60793085210 LEVOXYL TAB 75MCG 12/31/9999 20121 60793085301 LEVOXYL TAB 88MCG 12/31/9999 20121 60793085310 LEVOXYL TAB 88MCG 12/31/9999 20121 68220011105 LEVSIN INJ 0.5MG/ML 12/31/9999 20121 68220011210 LEVSIN TAB 0.125MG 12/31/9999 20121 68220011250 LEVSIN TAB 0.125MG 12/31/9999 20121 68220011310 LEVSIN/SL SUB 0.125MG 12/31/9999 20121 68220011350 LEVSIN/SL SUB 0.125MG 12/31/9999 20121 00456210108 LEXAPRO SOL 5MG/5ML 12/31/9999 20121 00456201001 LEXAPRO TAB 10MG 12/31/9999 20121 00456201063 LEXAPRO TAB 10MG 12/31/9999 20121 00456202001 LEXAPRO TAB 20MG 12/31/9999 20121 00456202063 LEXAPRO TAB 20MG 12/31/9999 20121 00456200501 LEXAPRO TAB 5MG 12/31/9999 20121 00469650189 LEXISCAN INJ 0.4MG 12/31/9999 20121 00173072700 LEXIVA SUS 50MG/ML 06/30/2013 20121 49702020853 LEXIVA SUS 50MG/ML 12/31/9999 20121 00173072100 LEXIVA TAB 700MG 11/19/2012 20121 49702020718 LEXIVA TAB 700MG 12/31/9999 20121 23359001616 LEXUSS 210 LIQ 12/31/9999 20121 51552044305 L-GLUTAMIC POW 12/31/9999 20121 51552044307 L-GLUTAMIC POW 12/31/9999 20121 54092047612 LIALDA TAB 1.2GM 12/31/9999 20121 00187410010 LIBRAX CAP 5-2.5MG 12/31/9999 20121
NDC Product Description Termination Date Quarter Covered 24385063325 LICE BEDDING AER 0.5% 12/31/9999 20121 37205016628 LICE CONTROL AER 0.5% 12/31/9999 20121 00113086626 LICE KILLING SHA 0.33-4% 12/31/9999 20121 37205016526 LICE KILLING SHA 0.33-4% 12/31/9999 20121 49348044330 LICE KILLING SHA 0.33-4% 12/31/9999 20121 49348044334 LICE KILLING SHA 0.33-4% 12/31/9999 20121 62011011902 LICE KILLING SHA 0.33-4% 12/31/9999 20121 24385011603 LICE TREATMT SHA 0.33-4% 12/31/9999 20121 15127020608 LICE TRTMNT LIQ 12/31/9999 20121 37205028516 LICE TRTMNT LIQ CRM RNSE 12/31/9999 20121 00904252820 LICE-AID SHA 12/31/9999 20121 51879012004 LICEFREEE GEL 12/31/9999 20121 51879012008 LICEFREEE GEL 12/31/9999 20121 51879018006 LICEFREEE SPR 12/31/9999 20121 10337070019 LIDAMANTLE CRE 3% 12/31/9999 20121 10337071019 LIDAMANTLE CRE HC3-0.5% 12/31/9999 20121 00409471201 LIDO/DEXTROS INJ 5-7.5% 12/31/9999 20121 00409317701 LIDO/EPI INJ 0.5% 12/31/9999 20121 00409120901 LIDO/EPI INJ 1.5% 12/31/9999 20121 00409318101 LIDO/EPI INJ 1.5% 12/31/9999 20121 00409099601 LIDO/EPI INJ 2% 12/31/9999 20121 00409318201 LIDO/EPI INJ 2% 12/31/9999 20121 00409318202 LIDO/EPI INJ 2% 12/31/9999 20121 00409318203 LIDO/EPI INJ 2% 12/31/9999 20121 00409318301 LIDO/EPI INJ 2% 12/31/9999 20121 00409726301 LIDO/EPI INJ 2% 12/31/9999 20121 00409317801 LIDO/EPI 1%- INJ 1:100000 12/31/9999 20121 00409317802 LIDO/EPI 1%- INJ 1:100000 12/31/9999 20121 00409317803 LIDO/EPI 1%- INJ 1:100000 12/31/9999 20121 00168035730 LIDO/PRILOCN CRE 2.5-2.5% 12/31/9999 20121 00168035755 LIDO/PRILOCN CRE 2.5-2.5% 12/31/9999 20121 00781705803 LIDO/PRILOCN CRE 2.5-2.5% 12/31/9999 20121 00781705805 LIDO/PRILOCN CRE 2.5-2.5% 12/31/9999 20121 00781705839 LIDO/PRILOCN CRE 2.5-2.5% 12/31/9999 20121 50383066730 LIDO/PRILOCN CRE 2.5-2.5% 12/31/9999 20121 00168035756 LIDO/PRILOCN KIT 2.5-2.5% 12/31/9999 20121 00264959410 LIDOCAIN/D5W INJ 4MG/ML 12/31/9999 20121 00264959420 LIDOCAIN/D5W INJ 4MG/ML 12/31/9999 20121 00338040902 LIDOCAIN/D5W INJ 4MG/ML 05/31/2012 20121 00338040903 LIDOCAIN/D5W INJ 4MG/ML 12/31/9999 20121 00409793124 LIDOCAIN/D5W INJ 4MG/ML 12/31/9999 20121 00409793132 LIDOCAIN/D5W INJ 4MG/ML 12/31/9999 20121 00264959820 LIDOCAIN/D5W INJ 8MG/ML 12/31/9999 20121 00338041102 LIDOCAIN/D5W INJ 8MG/ML 12/31/9999 20121 00409793932 LIDOCAIN/D5W INJ 8MG/ML 12/31/9999 20121 13925015901 LIDOCAINE CRE 3% 12/31/9999 20121 13925015903 LIDOCAINE CRE 3% 12/31/9999 20121 59088099703 LIDOCAINE CRE 3% 12/31/9999 20121 59088099707 LIDOCAINE CRE 3% 12/31/9999 20121 00093920031 LIDOCAINE GEL 2% JELLY 12/31/9999 20121 17478071110 LIDOCAINE GEL 2% JELLY 12/31/9999 20121 17478071130 LIDOCAINE GEL 2% JELLY 12/31/9999 20121 17478081110 LIDOCAINE GEL 2% JELLY 12/31/9999 20121 17478081130 LIDOCAINE GEL 2% JELLY 12/31/9999 20121 50383078105 LIDOCAINE GEL 2% JELLY 12/31/9999 20121 50383078130 LIDOCAINE GEL 2% JELLY 12/31/9999 20121 00409427501 LIDOCAINE INJ 0.5% 09/01/2012 20121 00409427801 LIDOCAINE INJ 0.5% 12/31/9999 20121 00409427001 LIDOCAINE INJ 1% 12/31/9999 20121 00409427601 LIDOCAINE INJ 1% 12/31/9999 20121 00409427602 LIDOCAINE INJ 1% 12/31/9999 20121 00409427902 LIDOCAINE INJ 1% 12/31/9999 20121 00409471302 LIDOCAINE INJ 1% 12/31/9999 20121 00409471332 LIDOCAINE INJ 1% 12/31/9999 20121 00517062525 LIDOCAINE INJ 1% 12/31/9999 20121 63323020102 LIDOCAINE INJ 1% 12/31/9999 20121 63323020110 LIDOCAINE INJ 1% 12/31/9999 20121
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Rebatable Drug List for Iowa Medica
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August 31, 2012 - Iowa Medicaid Enterprise

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