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

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00378220005 ACYCLOVIR CAP 200MG 02/28/2<strong>01</strong>3 2<strong>01</strong>2323155<strong>01</strong>46<strong>01</strong> ACYCLOVIR CAP 200MG 12/31/9999 2<strong>01</strong>23510790447<strong>01</strong> ACYCLOVIR CAP 200MG 11/30/2<strong>01</strong>2 2<strong>01</strong>2351079044720 ACYCLOVIR CAP 200MG 11/30/2<strong>01</strong>2 2<strong>01</strong>2360505004206 ACYCLOVIR CAP 200MG 12/31/9999 2<strong>01</strong>2361442<strong>01</strong>11<strong>01</strong> ACYCLOVIR CAP 200MG 12/31/9999 2<strong>01</strong>23633040652<strong>01</strong> ACYCLOVIR CAP 200MG 12/31/9999 2<strong>01</strong>2363304065205 ACYCLOVIR CAP 200MG 12/31/9999 2<strong>01</strong>2367253<strong>01</strong>0<strong>01</strong>0 ACYCLOVIR CAP 200MG 12/31/9999 2<strong>01</strong>2367253<strong>01</strong>0<strong>01</strong>1 ACYCLOVIR CAP 200MG 12/31/9999 2<strong>01</strong>2300472008216 ACYCLOVIR SUS 200/5ML 12/31/9999 2<strong>01</strong>2350383081<strong>01</strong>6 ACYCLOVIR SUS 200/5ML 12/31/9999 2<strong>01</strong>23000938943<strong>01</strong> ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2300093894305 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2300093894319 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2300093894393 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>23003780253<strong>01</strong> ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2300378025305 ACYCLOVIR TAB 400MG 07/31/2<strong>01</strong>3 2<strong>01</strong>2300904612161 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2350268006115 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>23605055306<strong>01</strong> ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2360505530608 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2361442<strong>01</strong>12<strong>01</strong> ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2361442<strong>01</strong>1205 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>23633040504<strong>01</strong> ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2367253<strong>01</strong><strong>01</strong>10 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>2367253<strong>01</strong><strong>01</strong>11 ACYCLOVIR TAB 400MG 12/31/9999 2<strong>01</strong>23000938947<strong>01</strong> ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>2300093894705 ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>2300093894719 ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>2300093894793 ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>23003780302<strong>01</strong> ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>23605055307<strong>01</strong> ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>2360505530705 ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>2361442<strong>01</strong>13<strong>01</strong> ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>2361442<strong>01</strong>1305 ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>23633040505<strong>01</strong> ACYCLOVIR TAB 800MG 12/31/9999 2<strong>01</strong>2355390061320 ACYCLOVIR NA INJ 1000MG 12/31/9999 2<strong>01</strong>2355390061210 ACYCLOVIR NA INJ 500MG 12/31/9999 2<strong>01</strong>2363323<strong>01</strong>0510 ACYCLOVIR NA INJ 500MG 12/31/9999 2<strong>01</strong>2363323032510 ACYCLOVIR NA INJ 50MG/ML 12/31/9999 2<strong>01</strong>2363323032520 ACYCLOVIR NA INJ 50MG/ML 12/31/9999 2<strong>01</strong>2300023367030 ACZONE GEL 5% 12/31/9999 2<strong>01</strong>2300023367060 ACZONE GEL 5% 12/31/9999 2<strong>01</strong>235766500<strong>01</strong><strong>01</strong> ADAGEN INJ 250/ML 12/31/9999 2<strong>01</strong>230008517<strong>01</strong><strong>01</strong> ADALAT CC TAB 30MG ER 12/31/9999 2<strong>01</strong>230008517<strong>01</strong>02 ADALAT CC TAB 30MG ER 12/31/9999 2<strong>01</strong>230008517<strong>01</strong>03 ADALAT CC TAB 30MG ER 12/31/9999 2<strong>01</strong>235041907<strong>01</strong>05 ADALAT CC TAB 30MG ER 12/31/9999 2<strong>01</strong>235041907<strong>01</strong>10 ADALAT CC TAB 30MG ER 12/31/9999 2<strong>01</strong>23000851716<strong>01</strong> ADALAT CC TAB 60MG ER 12/31/9999 2<strong>01</strong>2300085171602 ADALAT CC TAB 60MG ER 12/31/9999 2<strong>01</strong>2300085171603 ADALAT CC TAB 60MG ER 12/31/9999 2<strong>01</strong>2350419070205 ADALAT CC TAB 60MG ER 12/31/9999 2<strong>01</strong>2350419070210 ADALAT CC TAB 60MG ER 12/31/9999 2<strong>01</strong>23000851722<strong>01</strong> ADALAT CC TAB 90MG ER 12/31/9999 2<strong>01</strong>2300085172202 ADALAT CC TAB 90MG ER 12/31/9999 2<strong>01</strong>2350419070305 ADALAT CC TAB 90MG ER 12/31/9999 2<strong>01</strong>230<strong>01</strong>68042446 ADAPALENE CRE 0.1% 12/31/9999 2<strong>01</strong>2345802045384 ADAPALENE CRE 0.1% 12/31/9999 2<strong>01</strong>23

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