Rebatable Drug List for Iowa Medicaid Effective Date December 01 ...

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00573016530 ADVIL TAB 200MG 12/31/9999 2012300573016540 ADVIL TAB 200MG 12/31/9999 2012300573016651 ADVIL TAB 200MG 12/31/9999 2012300573019610 ADVIL ALLERG TAB CONGEST 12/31/9999 2012300573019620 ADVIL ALLERG TAB CONGEST 12/31/9999 2012300573018810 ADVIL ALLERG TAB SINUS 12/31/9999 2012300573017030 ADVIL CHILD SUS 100/5ML 12/31/9999 2012300573017130 ADVIL CHILD SUS 100/5ML 12/31/9999 2012300573017430 ADVIL CHILD SUS 100/5ML 12/31/9999 2012300573029001 ADVIL CHILD SUS 100/5ML 12/31/9999 2012300573029030 ADVIL CHILD SUS 100/5ML 12/31/9999 2012300573018416 ADVIL COLD/ CAP SINUS 12/31/9999 2012300573018432 ADVIL COLD/ CAP SINUS 12/31/9999 2012300573018010 ADVIL COLD/ TAB SINUS 12/31/9999 2012300573018021 ADVIL COLD/ TAB SINUS 12/31/9999 2012300573019510 ADVIL CONGST TAB RELIEF 12/31/9999 2012300573019520 ADVIL CONGST TAB RELIEF 12/31/9999 2012300573019541 ADVIL CONGST TAB RELIEF 12/31/9999 2012300573017511 ADVIL JR ST TAB 100MG 12/31/9999 2012300573017920 ADVIL JR STR CHW 100MG 12/31/9999 2012300573016820 ADVIL MIGRAI CAP 200MG 12/31/9999 2012300573016830 ADVIL MIGRAI CAP 200MG 12/31/9999 2012300573016840 ADVIL MIGRAI CAP 200MG 12/31/9999 2012300573016710 ADVIL PM CAP 200-25MG 12/31/9999 2012300573016720 ADVIL PM CAP 200-25MG 12/31/9999 2012300573016404 ADVIL PM TAB 200-38MG 12/31/9999 2012300573016405 ADVIL PM TAB 200-38MG 12/31/9999 2012300573016420 ADVIL PM TAB 200-38MG 12/31/9999 2012300573016430 ADVIL PM TAB 200-38MG 12/31/9999 2012300573016440 ADVIL PM TAB 200-38MG 12/31/9999 2012300573016443 ADVIL PM TAB 200-38MG 12/31/9999 2012300573016455 ADVIL PM TAB 200-38MG 12/31/9999 2012300591319301 AFEDITAB TAB 30MG CR 12/31/9999 2012300591319305 AFEDITAB TAB 30MG CR 12/31/9999 2012300591319401 AFEDITAB TAB 60MG CR 12/31/9999 2012300591319405 AFEDITAB TAB 60MG CR 12/31/9999 2012300078056751 AFINITOR TAB 10MG 12/31/9999 2012300078056761 AFINITOR TAB 10MG 12/31/9999 2012300078059451 AFINITOR TAB 2.5MG 12/31/9999 2012300078059461 AFINITOR TAB 2.5MG 12/31/9999 2012300078056651 AFINITOR TAB 5MG 12/31/9999 2012300078056661 AFINITOR TAB 5MG 12/31/9999 2012300078062051 AFINITOR TAB 7.5MG 12/31/9999 2012300078062061 AFINITOR TAB 7.5MG 12/31/9999 2012325208000201 AGGRASTAT INJ 25MG/500 12/31/9999 2012325208000202 AGGRASTAT INJ 25MG/500 12/31/9999 2012300597000160 AGGRENOX CAP 25-200MG 12/31/9999 2012354092006301 AGRYLIN CAP 0.5MG 12/31/9999 2012300409485605 A-HYDROCORT INJ 100MG 12/31/9999 2012317478021612 AK-CON SOL 0.1% OP 12/31/9999 2012313548003025 AKNE-MYCIN OIN 2% 12/31/9999 2012317478010020 AK-PENTOLATE SOL 1% OP 07/31/2013 2012317478023835 AK-POLY-BAC OIN OP 12/31/9999 2012317478079210 AKTEN GEL 3.5% 12/31/9999 2012317478006235 AKWA TEARS OIN OP 12/31/9999 2012317478006012 AKWA TEARS SOL OP 12/31/9999 2012317478006112 AKWA TEARS SOL RENEWED 12/31/9999 2012350991051416 ALAGESIC LQ SOL 12/31/9999 2012350991090116 ALAHIST AC LIQ 7.5-10 12/31/9999 2012350991032516 ALAHIST DHC LIQ 7.5-3 12/31/9999 20123
50991081416 ALAHIST DM LIQ 7.5-4-15 12/31/9999 2012350991078360 ALA-HIST IR TAB 2MG 12/31/9999 2012350991078260 ALA-HIST PE TAB 2-10MG 12/31/9999 2012368669071110 ALAMAST DRO 0.1% 06/30/2013 2012300573262006 ALAVERT TAB 10MG 12/31/9999 2012300573262012 ALAVERT TAB 10MG 12/31/9999 2012300573262019 ALAVERT TAB 10MG 12/31/9999 2012300573262024 ALAVERT TAB 10MG 12/31/9999 2012300573262030 ALAVERT TAB 10MG 12/31/9999 2012300573262048 ALAVERT TAB 10MG 12/31/9999 2012300573262065 ALAVERT TAB 10MG 12/31/9999 2012300573262112 ALAVERT TAB 10MG 12/31/9999 2012300573262119 ALAVERT TAB 10MG 12/31/9999 2012300573262148 ALAVERT TAB 10MG 12/31/9999 2012300573262165 ALAVERT TAB 10MG 12/31/9999 2012300573262312 ALAVERT TAB 10MG 12/31/9999 2012300573262412 ALAVERT TAB 10MG 12/31/9999 2012300573266012 ALAVERT ALRG TAB /SINUS 12/31/9999 2012300573266024 ALAVERT ALRG TAB /SINUS 12/31/9999 2012324208060110 ALAWAY DRO 0.025%OP 12/31/9999 2012324208060105 ALAWAY CHILD DRO 0.025%OP 12/31/9999 2012352054055022 ALBENZA TAB 200MG 12/31/9999 2012352054055028 ALBENZA TAB 200MG 12/31/9999 2012376125078410 ALBUKED 25 INJ 25% 12/31/9999 2012376125078425 ALBUKED 25 INJ 25% 12/31/9999 2012376125078505 ALBUKED 5 INJ 5% 12/31/9999 2012376125078525 ALBUKED 5 INJ 5% 12/31/9999 2012344206025105 ALBUMIN HUM INJ 25% 12/31/9999 2012344206025110 ALBUMIN HUM INJ 25% 12/31/9999 2012361953000201 ALBUMIN HUM INJ 25% 12/31/9999 2012361953000202 ALBUMIN HUM INJ 25% 12/31/9999 2012367467064301 ALBUMIN HUM INJ 25% 12/31/9999 2012367467064302 ALBUMIN HUM INJ 25% 12/31/9999 2012368209064301 ALBUMIN HUM INJ 25% 12/31/9999 2012368209064302 ALBUMIN HUM INJ 25% 12/31/9999 2012367467062301 ALBUMIN HUM INJ 5% 12/31/9999 2012367467062302 ALBUMIN HUM INJ 5% 12/31/9999 2012367467062303 ALBUMIN HUM INJ 5% 12/31/9999 2012368209062301 ALBUMIN HUM INJ 5% 12/31/9999 2012368209062302 ALBUMIN HUM INJ 5% 12/31/9999 2012368209062303 ALBUMIN HUM INJ 5% 12/31/9999 2012300053768032 ALBUMINAR-25 INJ 25% 12/31/9999 2012300053768033 ALBUMINAR-25 INJ 25% 12/31/9999 2012300053767031 ALBUMINAR-5 INJ 5% 12/31/9999 2012300053767032 ALBUMINAR-5 INJ 5% 12/31/9999 2012344206031025 ALBURX INJ 5% 12/31/9999 2012344206031050 ALBURX INJ 5% 12/31/9999 2012368516521601 ALBUTEIN INJ 25% 12/31/9999 2012368516521602 ALBUTEIN INJ 25% 12/31/9999 2012368516521401 ALBUTEIN INJ 5% 12/31/9999 2012368516521402 ALBUTEIN INJ 5% 12/31/9999 2012300378699052 ALBUTEROL NEB 0.083% 12/31/9999 2012300378699058 ALBUTEROL NEB 0.083% 12/31/9999 2012300378699091 ALBUTEROL NEB 0.083% 12/31/9999 2012300378699093 ALBUTEROL NEB 0.083% 12/31/9999 2012300472083123 ALBUTEROL NEB 0.083% 12/31/9999 2012300487950101 ALBUTEROL NEB 0.083% 12/31/9999 2012300487950102 ALBUTEROL NEB 0.083% 12/31/9999 2012300487950103 ALBUTEROL NEB 0.083% 12/31/9999 2012300487950125 ALBUTEROL NEB 0.083% 12/31/9999 20123
Page 1 and 2: Rebatable Drug List for Iowa Medica
Page 3 and 4: 00713011801 ACEPHEN SUP 120MG 12/31
Page 5 and 6: 37205084462 ACID CONTROL TAB 150MG
Page 7 and 8: 00378220005 ACYCLOVIR CAP 200MG 02/
Page 9: 00173069604 ADVAIR DISKU AER 250/50
Page 13 and 14: 68462029965 ALCLOMETASON OIN 0.05%
Page 15 and 16: 00904582946 ALL DAY ALLG TAB 10MG 1
Page 17 and 18: 49348081812 ALLERGY RELF TAB 10MG 1
Page 19 and 20: 51552012808 ALMOND OIL SWEET 12/31/
Page 21 and 22: 67253090250 ALPRAZOLAM TAB 1MG 12/3
Page 23 and 24: 00168027860 AMCINONIDE CRE 0.1% 12/
Page 25 and 26: 00603221621 AMITRIPTYLIN TAB 100MG
Page 27 and 28: 00781227210 AMLOD/BENAZP CAP 5-10MG
Page 29 and 30: 67877019710 AMLODIPINE TAB 2.5MG 12
Page 31 and 32: 66685101101 AMOX/K CLAV SUS 200/5ML
Page 33 and 34: 65862001705 AMOXICILLIN CAP 500MG 1
Page 35 and 36: 00228306111 AMPHETAMINE CAP 30MG ER
Page 37 and 38: 10019063733 AMP-SULBACTA INJ 2-1GM
Page 39 and 40: 37205031440 ANTACID SUS REG ST 12/3
Page 41 and 42: 00121050416 APAP/CODEINE SOL 120-12
Page 43 and 44: 55513000204 ARANESP INJ 25MCG 12/31
Page 45 and 46: 00085134104 ASMANEX 14 AER 220MCG 1
Page 47 and 48: 63323029280 ASTRAMORPH INJ 2MG/2ML
Page 49 and 50: 60977011601 ATIVAN INJ 2MG/ML 12/31
Page 51 and 52: 00168026550 AUG BETAMET CRE 0.05% 1
Page 53 and 54: 60505057804 AZELASTINE DRO 0.05% 12
Page 55 and 56: 00472110556 BACITR ZINC OIN 500/GM
Page 57 and 58: 11701004814 BAZA CLEAR OIN 12/31/99
Page 59 and 60: 65597010630 BENICAR HCT TAB 40-12.5
Page 61 and 62:
00904105561 BENZTROPINE TAB 0.5MG 1
Page 63 and 64:
10702001401 BETAXOLOL TAB 20MG 12/3
Page 65 and 66:
00135048702 BIOTENE DRY PST MOUTH 1
Page 67 and 68:
51552028104 BORAX GRA 12/31/9999 20
Page 69 and 70:
00378715501 BUDESONIDE CAP 3MG/24HR
Page 71 and 72:
00591354060 BUPROPION TAB 100MG SR
Page 73 and 74:
51079099420 BUSPIRONE TAB 30MG 12/3
Page 75 and 76:
55390035803 CAFCIT SOL 60MG/3ML 12/
Page 77 and 78:
00517271025 CALCIUM CL INJ 10% 12/3
Page 80 and 81:
SNAM RETE GAS SUSTAINABILITY REPORT
Page 82:
44183060430 CARDEC DRO 12/31/9999 2
Page 85 and 86:
00093005101 CARVEDILOL TAB 3.125MG
Page 87 and 88:
00781293801 CEFADROXIL CAP 500MG 12
Page 89:
10019068115 CEFOTAXIME INJ 1GM 12/3
Page 92 and 93:
00409733649 CEFTRIAXONE INJ 2GM 12/
Page 94:
51285044202 CENESTIN TAB 0.625MG 12
Page 97 and 98:
51552056909 CHICKEN LIQ FLAVOR 12/3
Page 99 and 100:
00832030010 CHLORPROMAZ TAB 10MG 12
Page 101 and 102:
00185022305 CILOSTAZOL TAB 100MG 12
Page 103 and 104:
16252051501 CIPROFLOXACN TAB 500MG
Page 105 and 106:
57664050813 CITALOPRAM TAB 20MG 12/
Page 107 and 108:
00085132201 CLARINEX-D TAB 2.5-120
Page 109 and 110:
00009312401 CLEOCIN PHOS INJ 600MG
Page 111 and 112:
00338114703 CLINIMIX E INJ 5%/D15W
Page 113 and 114:
51672401201 CLOMIPRAMINE CAP 50MG 1
Page 115 and 116:
00517073001 CLONIDINE INJ 12/31/999
Page 117 and 118:
51672404301 CLORAZ DIPOT TAB 7.5MG
Page 119 and 120:
60575021216 CODAR AR LIQ 12/31/9999
Page 121 and 122:
62107004113 COMPLETE TAB 12/31/9999
Page 123 and 124:
00904572246 COUGH DROPS LOZ CHERRY
Page 125 and 126:
00603752517 CYCLAFEM TAB 7/7/7 12/3
Page 127 and 128:
00002327004 CYMBALTA CAP 60MG 12/31
Page 129 and 130:
51645074010 DAILY VITAMI TAB FORMUL
Page 131 and 132:
00037502001 DEMADEX TAB 20MG 12/31/
Page 133 and 134:
00067096946 DESENEX SPRY AER LIQUID
Page 135 and 136:
00069454101 DEXAMETH PHO INJ 10MG/M
Page 137 and 138:
00338001703 DEXTROSE INJ 5% 12/31/9
Page 139 and 140:
00941041146 DIANEAL PD-2 SOL 1.5% D
Page 141 and 142:
00781178501 DICLOFENAC TAB 25MG DR
Page 143 and 144:
00049350079 DIFLUCAN TAB 150MG 12/3
Page 145 and 146:
00093511798 DILTIAZEM CAP 180MG ER
Page 147 and 148:
60505021309 DILTZAC CAP 300MG/24 12
Page 149 and 150:
49483006101 DIPHENHYDRAM TAB 25MG 1
Page 151 and 152:
62756079613 DIVALPROEX TAB 125MG DR
Page 153 and 154:
00409020120 DOCETAXEL INJ 160/16ML
Page 155 and 156:
68382034706 DONEPEZIL TAB 10MG ODT
Page 157 and 158:
00093812193 DOXAZOSIN TAB 2MG 12/31
Page 159 and 160:
53489011805 DOXYCYCL HYC CAP 50MG 1
Page 161 and 162:
00310108730 DUTOPROL TAB 25-12.5 12
Page 163 and 164:
00008083721 EFFEXOR XR CAP 37.5MG 1
Page 165 and 166:
60505005107 ENALAPRIL TAB 10MG 12/3
Page 167 and 168:
62037086420 ENOXAPARIN INJ 120/0.8
Page 169 and 170:
55513028301 EPOGEN INJ 10000/ML 12/
Page 171 and 172:
00093585005 ESCITALOPRAM TAB 5MG 12
Page 173 and 174:
00185014001 ETODOLAC TAB 400MG 12/3
Page 175 and 176:
10631010030 EXELDERM SOL 1% 12/31/9
Page 177 and 178:
63323073804 FAMOTIDINE INJ 10MG/ML
Page 179 and 180:
65162073409 FELBAMATE TAB 400MG 12/
Page 181 and 182:
10019003725 FENTANYL CIT INJ 1000MC
Page 183 and 184:
66993010904 FEXOFENADINE TAB 180MG
Page 185 and 186:
00054001121 FLECAINIDE TAB 100MG 12
Page 187 and 188:
00703102030 FLUCONAZOLE/ INJ NACL 4
Page 189 and 190:
60258015520 FLUORIDE CHW 0.25MG F 0
Page 191 and 192:
00555087188 FLUOXETINE CAP 90MG DR
Page 193 and 194:
00378040701 FLUVOXAMINE TAB 25MG 12
Page 195 and 196:
51552020504 FORMALDEHYDE SOL 37% 12
Page 197 and 198:
00409163910 FUROSEMIDE INJ 10MG/ML
Page 199 and 200:
00378542605 GABAPENTIN CAP 100MG 12
Page 201 and 202:
00378542401 GABAPENTIN TAB 600MG 12
Page 203 and 204:
64208823403 GAMMAPLEX INJ 10GM 12/3
Page 205 and 206:
00904598861 GEMFIBROZIL TAB 600MG 1
Page 207 and 208:
58063010001 GLIADEL WAF 7.7MG 10/31
Page 209 and 210:
55390000401 GLUCAGEN INJ 1MG 12/31/
Page 211 and 212:
00781119110 GLYBURIDE TAB 5MG 11/30
Page 213 and 214:
24385026226 GNP CGH RELF LIQ 15MG/5
Page 215 and 216:
10158000103 GOODYS POW EX ST 12/31/
Page 217 and 218:
00168035650 HALOBETASOL OIN 0.05% 1
Page 219 and 220:
51672129006 HC VALERATE CRE 0.2% 12
Page 221 and 222:
25021040001 HEPARIN SOD INJ 1000/ML
Page 223 and 224:
00002879759 HUMALOG MIX INJ 75/25KW
Page 225 and 226:
00143312505 HYDROCHLOROT CAP 12.5MG
Page 227 and 228:
53746011005 HYDROCO/APAP TAB 10-325
Page 229 and 230:
51079077801 HYDROCO/APAP TAB 7.5-32
Page 231 and 232:
00603390021 HYDROCORT TAB 10MG 12/3
Page 233 and 234:
00555088202 HYDROXYUREA CAP 500MG 1
Page 235 and 236:
24486060110 HYOMAX-SL SUB 0.125MG 1
Page 237 and 238:
68094049458 IBUPROFEN SUS 100/5ML 1
Page 239 and 240:
53746046505 IBUPROFEN TAB 600MG 12/
Page 241 and 242:
49884005610 IMIPRAM HCL TAB 50MG 12
Page 243 and 244:
52544093102 INFED INJ 50MG/ML 12/31
Page 245 and 246:
00487980130 IPRATROPIUM SOL 0.02%IN
Page 247 and 248:
00998022515 ISO CARBACHO SOL 3% OP
Page 249 and 250:
62175012841 ISOSORB MONO TAB 30MG E
Page 251 and 252:
00597014760 JENTADUETO TAB 2.5-850
Page 253 and 254:
50474059540 KEPPRA TAB 500MG 12/31/
Page 255 and 256:
00245004115 KLOR-CON 10 TAB 10MEQ E
Page 257 and 258:
00904593061 LABETALOL TAB 300MG 12/
Page 259 and 260:
00067617185 LAMISIL AT CRE 1% 12/31
Page 261 and 262:
13668004505 LAMOTRIGINE TAB 25MG 12
Page 263 and 264:
66758000501 L-CYSTEINE INJ 50MG/ML
Page 265 and 266:
54838054880 LEVETIRACETA SOL 100MG/
Page 267 and 268:
68462054608 LEVETIRACETA TAB 500MG
Page 269 and 270:
50383028604 LEVOFLOXACIN SOL 25MG/M
Page 271 and 272:
00781518710 LEVOTHYROXIN TAB 150MCG
Page 273 and 274:
00409317803 LIDO/EPI 1%- INJ 1:1000
Page 275 and 276:
58281056002 LIORESAL INT INJ 10MG/2
Page 277 and 278:
00172375900 LISINOPRIL TAB 10MG 12/
Page 279 and 280:
24658024345 LISINOPRIL TAB 20MG 12/
Page 281 and 282:
00172375810 LISINOPRIL TAB 5MG 12/3
Page 283 and 284:
00056051168 LODOSYN TAB 25MG 10/31/
Page 285 and 286:
46122010952 LORATADINE-D TAB 5-120M
Page 287 and 288:
00785635001 LORCET TAB 10-650MG 12/
Page 289 and 290:
68084034701 LOSARTAN POT TAB 50MG 1
Page 291 and 292:
00093092619 LOVASTATIN TAB 10MG 12/
Page 293 and 294:
52152019302 LOXAPINE CAP 25MG 12/31
Page 295 and 296:
00067032844 MAALOX REG SUS STRENGTH
Page 297 and 298:
00904198359 MAPAP TAB 500MG 12/31/9
Page 299 and 300:
59746012210 MECLIZINE TAB 12.5MG 12
Page 301 and 302:
54458096405 MELOXICAM TAB 15MG 04/0
Page 303 and 304:
00703480503 MESNA INJ 1GM 12/31/999
Page 305 and 306:
00406202805 METFORMIN TAB 500MG 12/
Page 307 and 308:
43547024950 METFORMIN TAB 850MG 12/
Page 309 and 310:
00591538205 METHOCARBAM TAB 750MG 0
Page 311 and 312:
43386014001 METHYLERGON TAB 0.2MG 1
Page 313 and 314:
00591246810 METOCLOPRAM TAB 10MG 12
Page 315 and 316:
51079080117 METOPROL TAR TAB 50MG 1
Page 317 and 318:
00168038360 METRONIDAZOL LOT 0.75%
Page 319 and 320:
00409230662 MIDAZOLAM INJ 2MG/2ML 1
Page 321 and 322:
00641606701 MILRINONE INJ 1MG/ML 12
Page 323 and 324:
68308050260 MI-OMEGA NF CAP 12/31/9
Page 325 and 326:
60505024901 MIRTAZAPINE TAB 45MG 12
Page 327 and 328:
68462022517 MOMETASONE OIN 0.1% 12/
Page 329 and 330:
00641606801 MORPHINE SUL INJ 10MG/M
Page 331 and 332:
37205011153 MOTION SICK TAB 50MG 12
Page 333 and 334:
00603438121 MULTI-VIT/FL CHW 0.25MG
Page 335 and 336:
61748030113 MYORISAN CAP 10MG 12/31
Page 337 and 338:
00409146301 NALBUPHINE INJ 10MG/ML
Page 339 and 340:
68462019005 NAPROXEN TAB 500MG 12/3
Page 341 and 342:
62011008701 NASAL DECONG TAB 120MG
Page 343 and 344:
00517003425 NEOSTIG METH INJ 0.5MG/
Page 345 and 346:
00074308090 NIASPAN TAB 1000 ER 12/
Page 347 and 348:
00067512507 NICOTINE DIS 14MG/24H 1
Page 349 and 350:
59762669108 NIFEDIPINE TAB 60MG ER
Page 351 and 352:
00378165001 NITROFUR MAC CAP 50MG 1
Page 353 and 354:
63868008910 NON-ASPIRIN TAB 650MG 1
Page 355 and 356:
50458084002 NUCYNTA TAB 100MG 12/31
Page 357 and 358:
68025004830 OB COMPLETE CAP 400 12/
Page 359 and 360:
66993046730 OLANZAPINE TAB 10MG ODT
Page 361 and 362:
66993004905 OLANZAPINE TAB 7.5MG 12
Page 363 and 364:
00407141234 OMNIPAQUE INJ 240MG/ML
Page 365 and 366:
00641608001 ONDANSETRON INJ 4MG/2ML
Page 367 and 368:
63481044070 OPANA ER TAB 40MG 12/31
Page 369 and 370:
00781310195 OXACILLIN INJ 2GM 12/31
Page 371 and 372:
10337035960 OXISTAT LOT 1% 12/31/99
Page 373 and 374:
00603499128 OXYCODONE TAB 15MG 12/3
Page 375 and 376:
00536012297 PAIN & FEVER SOL 160/5M
Page 377 and 378:
00904513559 PAIN RELIEVR TAB PLUS 1
Page 379 and 380:
00378200593 PAROXETIN ER TAB 37.5MG
Page 381 and 382:
00029321113 PAXIL TAB 20MG 08/31/20
Page 383 and 384:
65862017699 PENICILLN VK TAB 500MG
Page 385 and 386:
00781104613 PERPHENAZINE TAB 2MG 12
Page 387 and 388:
58605043301 PHENFLU CD TAB 12/31/99
Page 389 and 390:
61314034201 PHENYLEPHRIN SOL 2.5% O
Page 391 and 392:
00378004893 PIOGLITAZONE TAB 15MG 1
Page 393 and 394:
50991021001 POLY HIST TAB FORTE 12/
Page 395 and 396:
00603153658 POT CHLORIDE LIQ 20% 12
Page 397 and 398:
68382019816 PRAMIPEXOLE TAB 0.5MG 1
Page 399 and 400:
68180048802 PRAVASTATIN TAB 80MG 12
Page 401 and 402:
63739052010 PREDNISONE TAB 20MG 12/
Page 403 and 404:
00186074331 PRILOSEC CAP 40MG 12/31
Page 405 and 406:
59676030301 PROCRIT INJ 3000/ML 12/
Page 407 and 408:
60432060804 PROMETHAZINE SYP 6.25/5
Page 409 and 410:
63323029750 PROPOVEN INJ 10MG/ML 12
Page 411 and 412:
38779051008 PROPYLENE LIQ GLYCOL 12
Page 413 and 414:
67253066010 PYRAZINAMIDE TAB 500MG
Page 415 and 416:
31722037590 QNAPRIL/HCTZ TAB 20-12.
Page 417 and 418:
16729014912 QUETIAPINE TAB 300MG 12
Page 419 and 420:
68180059109 RAMIPRIL CAP 10MG 12/31
Page 421 and 422:
64679074202 RANITIDINE TAB 300MG 12
Page 423 and 424:
53329015713 REMEDY NUTRA CRE 1% 12/
Page 425 and 426:
59572040200 REVLIMID CAP 2.5MG 12/3
Page 427 and 428:
00409614009 RINGERS IRR SOL 12/31/9
Page 429 and 430:
13668003701 RISPERIDONE TAB 1MG 12/
Page 431 and 432:
00603568820 RISPERIDONE TAB 4MG 12/
Page 433 and 434:
00031873612 ROBITUSSIN LIQ CGH/CONG
Page 435 and 436:
64679017402 ROPINIROLE TAB 3MG 12/3
Page 437 and 438:
49908013710 SALICYLIC AC LIQ 26% 12
Page 439 and 440:
15127080313 SB NAT FIBER POW 49% 12
Page 441 and 442:
55513007430 SENSIPAR TAB 60MG 12/31
Page 443 and 444:
60505018203 SERTRALINE TAB 100MG 12
Page 445 and 446:
51552012605 SILICA GEL 12/31/9999 2
Page 447 and 448:
51079045520 SIMVASTATIN TAB 20MG 01
Page 449 and 450:
24658021490 SIMVASTATIN TAB 80MG 12
Page 451 and 452:
49348087934 SM CHILDRENS SUS MS COL
Page 453 and 454:
00603578121 SMZ/TMP DS TAB 800-160
Page 455 and 456:
00409798325 SOD CHLORIDE INJ 0.9% 1
Page 457 and 458:
00338004746 SODIUM CHLOR SOL 0.9% I
Page 459 and 460:
00145213007 SORILUX AER 0.005% 12/3
Page 461 and 462:
53489032801 SPIRONOLACT TAB 50MG 12
Page 463 and 464:
00517301025 STERIL WATER INJ 12/31/
Page 465 and 466:
00591078005 SUCRALFATE TAB 1GM 12/3
Page 467 and 468:
49884048299 SUMATRIPTAN INJ 4MG/0.5
Page 469 and 470:
00085131201 SYLATRON KIT 888MCG 12/
Page 471 and 472:
00409194101 TALWIN INJ 30MG/ML 12/3
Page 473 and 474:
00065041625 TEARS NATURA SOL FREE O
Page 475 and 476:
59746038306 TERAZOSIN CAP 1MG 12/31
Page 477 and 478:
57844071319 TEV-TROPIN INJ 5MG 12/3
Page 479 and 480:
51552048105 THIABENDAZOL POW 12/31/
Page 481 and 482:
60505059702 TIMOLOL MAL SOL 0.25% O
Page 483 and 484:
13811006816 TL-HIST DM LIQ 12/31/99
Page 485 and 486:
13668003360 TOPIRAMATE TAB 100MG 12
Page 487 and 488:
65862012601 TORSEMIDE TAB 10MG 12/3
Page 489 and 490:
00378324201 TRANDOLAPRIL TAB 2MG 11
Page 491 and 492:
43478024445 TRETINOIN GEL 0.025% 12
Page 493 and 494:
00781112301 TRIAMT/HCTZ TAB 37.5-25
Page 495 and 496:
00555903270 TRI-LEGEST TAB FE 12/31
Page 497 and 498:
00135022301 TUMS CALCIUM CHW 750MG
Page 499 and 500:
66302020603 TYVASO SOL 0.6MG/ML 12/
Page 501 and 502:
42192010110 UREA EMU 50% 12/31/9999
Page 503 and 504:
00004003822 VALCYTE TAB 450MG 12/31
Page 505 and 506:
51552129409 VANIBASE CRE 12/31/9999
Page 507 and 508:
00378513205 VENLAFAXINE CAP 75MG ER
Page 509 and 510:
66215030300 VENTAVIS SOL 20MCG/ML 1
Page 511 and 512:
00469357550 VIBATIV INJ 750MG 12/31
Page 513 and 514:
00407222255 VISIPAQUE INJ 270MG/ML
Page 515 and 516:
00078034545 VIVELLE-DOT DIS 0.075MG
Page 517 and 518:
00406205510 WARFARIN TAB 4MG 12/31/
Page 519 and 520:
59630091310 XODOL TAB 7.5-300 12/31
Page 521 and 522:
52152003205 YOHIMBINE TAB 5.4MG 12/
Page 523 and 524:
00310013311 ZESTRIL TAB 30MG 12/31/
Page 525 and 526:
00069417034 ZMAX SUS 2GM 12/31/9999
Page 527 and 528:
00095067416 ZOLVIT SOL 10-300MG 12/
Page 529:
00002411230 ZYPREXA TAB 2.5MG 12/31
show all

Rebatable Drug List for Iowa Medicaid Effective Date December 01 ...

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