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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51552049406 SOD IODIDE POW 12/31/9999 2<strong>01</strong>2300409666402 SOD LACTATE INJ 5MEQ/ML 12/31/9999 2<strong>01</strong>2351552026304 SOD LAURYL POW SULFATE 12/31/9999 2<strong>01</strong>2351552026306 SOD LAURYL POW SULFATE 12/31/9999 2<strong>01</strong>2351552026308 SOD LAURYL POW SULFATE 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>6906 SOD NITRITE GRA 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>6909 SOD NITRITE GRA 12/31/9999 2<strong>01</strong>2351552050306 SOD PHOS DIB CRY HEPTAHYD 12/31/9999 2<strong>01</strong>2351552008406 SOD PHOSPHAT CRY TRIBASIC 12/31/9999 2<strong>01</strong>2300409739172 SOD PHOSPHAT INJ 3MM/ML 12/31/9999 2<strong>01</strong>2300517340525 SOD PHOSPHAT INJ 3MM/ML 12/31/9999 2<strong>01</strong>2300517341525 SOD PHOSPHAT INJ 3MM/ML 12/31/9999 2<strong>01</strong>2300517345025 SOD PHOSPHAT INJ 3MM/ML 12/31/9999 2<strong>01</strong>23462870<strong>01</strong>216 SOD POLY SUL POW 12/31/9999 2<strong>01</strong>2300574200302 SOD POLY SUL SUS 15GM/60 12/31/9999 2<strong>01</strong>2300574200316 SOD POLY SUL SUS 15GM/60 12/31/9999 2<strong>01</strong>235155205<strong>01</strong>06 SOD PROPION POW 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>7404 SOD SACCHARI GRA 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>7406 SOD SACCHARI GRA 12/31/9999 2<strong>01</strong>2351552055806 SOD SALICYLA CRY USP 12/31/9999 2<strong>01</strong>2351552055809 SOD SALICYLA CRY USP 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>7206 SOD SILICATE SOL 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>7208 SOD SILICATE SOL 12/31/9999 2<strong>01</strong>2351552118407 SOD STARCH POW GLYCOLAT 12/31/9999 2<strong>01</strong>230<strong>01</strong>68066212 SOD SUL/SULF EMU 10-5% 12/31/9999 2<strong>01</strong>2313925<strong>01</strong>6112 SOD SUL/SULF EMU 10-5% 12/31/9999 2<strong>01</strong>23458020942<strong>01</strong> SOD SUL/SULF EMU 10-5% 02/<strong>01</strong>/2<strong>01</strong>3 2<strong>01</strong>2345802094202 SOD SUL/SULF EMU 10-5% 02/<strong>01</strong>/2<strong>01</strong>3 2<strong>01</strong>2349908<strong>01</strong>7380 SOD SUL/SULF LIQ 9-4.5% 12/31/9999 2<strong>01</strong>2345802094694 SOD SUL/SULF LOT 10-5% 08/<strong>01</strong>/2<strong>01</strong>3 2<strong>01</strong>2345802094696 SOD SUL/SULF LOT 10-5% 12/31/9999 2<strong>01</strong>23458020950<strong>01</strong> SOD SUL/SULF LOT 10-5% 06/<strong>01</strong>/2<strong>01</strong>3 2<strong>01</strong>2342192<strong>01</strong>1360 SOD SUL/SULF PAD 10-4% 12/31/9999 2<strong>01</strong>234580209<strong>01</strong>94 SOD SUL/SULF SUS 10-5% <strong>01</strong>/<strong>01</strong>/2<strong>01</strong>3 2<strong>01</strong>2300904272835 SOD SULFACET SOL 10% OP 12/31/9999 2<strong>01</strong>2324208067004 SOD SULFACET SOL 10% OP 12/31/9999 2<strong>01</strong>2351552030806 SOD SULFATE GRA 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>9305 SOD SULFITE POW ANDHYDR 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>9306 SOD SULFITE POW ANHYDROU 12/31/9999 2<strong>01</strong>2351552<strong>01</strong>9309 SOD SULFITE POW ANHYDROU 12/31/9999 2<strong>01</strong>23005171<strong>01</strong>905 SOD THIOSULF INJ 10% 12/31/9999 2<strong>01</strong>23005175<strong>01</strong>9<strong>01</strong> SOD THIOSULF INJ 25% 12/31/9999 2<strong>01</strong>2351552096704 SOD VALPROAT POW 12/31/9999 2<strong>01</strong>2351552096706 SOD VALPROAT POW 12/31/9999 2<strong>01</strong>2351552008006 SODIUM MIS HYDROXID 12/31/9999 2<strong>01</strong>2364980<strong>01</strong>8210 SODIUM BICAR TAB 10GR 12/31/9999 2<strong>01</strong>2300536454<strong>01</strong>0 SODIUM BICAR TAB 325MG 12/31/9999 2<strong>01</strong>2300536454410 SODIUM BICAR TAB 650MG 12/31/9999 2<strong>01</strong>2300677<strong>01</strong>3110 SODIUM BICAR TAB 650MG 02/28/2<strong>01</strong>5 2<strong>01</strong>23004879<strong>01</strong>060 SODIUM CHLOR NEB 10% 12/31/9999 2<strong>01</strong>2300487900360 SODIUM CHLOR NEB 3% 12/31/9999 2<strong>01</strong>2300487900760 SODIUM CHLOR NEB 7% 12/31/9999 2<strong>01</strong>230026422<strong>01</strong>00 SODIUM CHLOR SOL 0.9% IRR 12/31/9999 2<strong>01</strong>230026422<strong>01</strong>10 SODIUM CHLOR SOL 0.9% IRR 12/31/9999 2<strong>01</strong>230026422<strong>01</strong>50 SODIUM CHLOR SOL 0.9% IRR 12/31/9999 2<strong>01</strong>230026422<strong>01</strong>70 SODIUM CHLOR SOL 0.9% IRR 12/31/9999 2<strong>01</strong>2300338004724 SODIUM CHLOR SOL 0.9% IRR 12/31/2<strong>01</strong>2 2<strong>01</strong>2300338004727 SODIUM CHLOR SOL 0.9% IRR 12/31/9999 2<strong>01</strong>2300338004729 SODIUM CHLOR SOL 0.9% IRR 12/31/9999 2<strong>01</strong>2300338004744 SODIUM CHLOR SOL 0.9% IRR 12/31/9999 2<strong>01</strong>23

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