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

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60793085910 LEVOXYL TAB 175MCG 12/31/9999 2<strong>01</strong>23607930860<strong>01</strong> LEVOXYL TAB 200MCG 12/31/9999 2<strong>01</strong>2360793086<strong>01</strong>0 LEVOXYL TAB 200MCG 12/31/9999 2<strong>01</strong>23607930850<strong>01</strong> LEVOXYL TAB 25MCG 12/31/9999 2<strong>01</strong>2360793085<strong>01</strong>0 LEVOXYL TAB 25MCG 12/31/9999 2<strong>01</strong>23607930851<strong>01</strong> LEVOXYL TAB 50MCG 12/31/9999 2<strong>01</strong>2360793085110 LEVOXYL TAB 50MCG 12/31/9999 2<strong>01</strong>23607930852<strong>01</strong> LEVOXYL TAB 75MCG 12/31/9999 2<strong>01</strong>2360793085210 LEVOXYL TAB 75MCG 12/31/9999 2<strong>01</strong>23607930853<strong>01</strong> LEVOXYL TAB 88MCG 12/31/9999 2<strong>01</strong>2360793085310 LEVOXYL TAB 88MCG 12/31/9999 2<strong>01</strong>2368220<strong>01</strong>1105 LEVSIN INJ 0.5MG/ML 12/31/9999 2<strong>01</strong>2368220<strong>01</strong>1210 LEVSIN TAB 0.125MG 12/31/9999 2<strong>01</strong>2368220<strong>01</strong>1250 LEVSIN TAB 0.125MG 12/31/9999 2<strong>01</strong>2368220<strong>01</strong>1310 LEVSIN/SL SUB 0.125MG 12/31/9999 2<strong>01</strong>2368220<strong>01</strong>1350 LEVSIN/SL SUB 0.125MG 12/31/9999 2<strong>01</strong>230045621<strong>01</strong>08 LEXAPRO SOL 5MG/5ML 12/31/9999 2<strong>01</strong>23004562<strong>01</strong>0<strong>01</strong> LEXAPRO TAB 10MG 12/31/9999 2<strong>01</strong>23004562<strong>01</strong>063 LEXAPRO TAB 10MG 12/31/9999 2<strong>01</strong>23004562020<strong>01</strong> LEXAPRO TAB 20MG 12/31/9999 2<strong>01</strong>2300456202063 LEXAPRO TAB 20MG 12/31/9999 2<strong>01</strong>23004562005<strong>01</strong> LEXAPRO TAB 5MG 12/31/9999 2<strong>01</strong>230046965<strong>01</strong>89 LEXISCAN INJ 0.4MG 12/31/9999 2<strong>01</strong>230<strong>01</strong>73072700 LEXIVA SUS 50MG/ML 06/30/2<strong>01</strong>3 2<strong>01</strong>2349702020853 LEXIVA SUS 50MG/ML 12/31/9999 2<strong>01</strong>230<strong>01</strong>73072100 LEXIVA TAB 700MG 11/19/2<strong>01</strong>2 2<strong>01</strong>2349702020718 LEXIVA TAB 700MG 12/31/9999 2<strong>01</strong>23233590<strong>01</strong>616 LEXUSS 210 LIQ 12/31/9999 2<strong>01</strong>2351552044305 L-GLUTAMIC POW 12/31/9999 2<strong>01</strong>2351552044307 L-GLUTAMIC POW 12/31/9999 2<strong>01</strong>2351552055404 L-GLUTATHION CRY 12/31/9999 2<strong>01</strong>2351552055405 L-GLUTATHION CRY 12/31/9999 2<strong>01</strong>2351552055406 L-GLUTATHION CRY 12/31/9999 2<strong>01</strong>2354092047612 LIALDA TAB 1.2GM 12/31/9999 2<strong>01</strong>230<strong>01</strong>87410<strong>01</strong>0 LIBRAX CAP 5-2.5MG 12/31/9999 2<strong>01</strong>2324385063325 LICE BEDDING AER 0.5% 12/31/9999 2<strong>01</strong>2337205<strong>01</strong>6628 LICE CONTROL AER 0.5% 12/31/9999 2<strong>01</strong>230<strong>01</strong>13086626 LICE KILLING SHA 0.33-4% 12/31/9999 2<strong>01</strong>2300904252820 LICE KILLING SHA 0.33-4% 12/31/9999 2<strong>01</strong>2337205<strong>01</strong>6526 LICE KILLING SHA 0.33-4% 12/31/9999 2<strong>01</strong>2349348044334 LICE KILLING SHA 0.33-4% 12/31/9999 2<strong>01</strong>2362<strong>01</strong>1<strong>01</strong>1902 LICE KILLING SHA 0.33-4% 12/31/9999 2<strong>01</strong>2324385<strong>01</strong>1603 LICE TREATMT SHA 0.33-4% 12/31/9999 2<strong>01</strong>2337205028516 LICE TRTMNT LIQ CRM RNSE 12/31/9999 2<strong>01</strong>2351879<strong>01</strong>2004 LICEFREEE GEL 12/31/9999 2<strong>01</strong>2351879<strong>01</strong>2008 LICEFREEE GEL 12/31/9999 2<strong>01</strong>2351879<strong>01</strong>8006 LICEFREEE SPR 12/31/9999 2<strong>01</strong>2310337071<strong>01</strong>9 LIDAMANTLE CRE HC3-0.5% 12/31/9999 2<strong>01</strong>23004094712<strong>01</strong> LIDO/DEXTROS INJ 5-7.5% 12/31/9999 2<strong>01</strong>23004093177<strong>01</strong> LIDO/EPI INJ 0.5% 12/31/9999 2<strong>01</strong>23004091209<strong>01</strong> LIDO/EPI INJ 1.5% 12/31/9999 2<strong>01</strong>23004093181<strong>01</strong> LIDO/EPI INJ 1.5% 12/31/9999 2<strong>01</strong>23004090996<strong>01</strong> LIDO/EPI INJ 2% 12/31/9999 2<strong>01</strong>23004093182<strong>01</strong> LIDO/EPI INJ 2% 12/31/9999 2<strong>01</strong>2300409318202 LIDO/EPI INJ 2% 12/31/9999 2<strong>01</strong>2300409318203 LIDO/EPI INJ 2% 12/31/9999 2<strong>01</strong>23004093183<strong>01</strong> LIDO/EPI INJ 2% 12/31/9999 2<strong>01</strong>23004097263<strong>01</strong> LIDO/EPI INJ 2% 12/31/9999 2<strong>01</strong>23004093178<strong>01</strong> LIDO/EPI 1%- INJ 1:100000 12/31/9999 2<strong>01</strong>2300409317802 LIDO/EPI 1%- INJ 1:100000 12/31/9999 2<strong>01</strong>23

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