Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or...

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Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name NDC NAME STR UOM NDC NAME STR UOM B 08290309628 1 CC LUER-LOK SYRINGE .000 08290305535 1/2CC ALLERGIST TRAY REGU .000 08290309695 10CC CONTROL SYRINGE LUER .000 08290305462 10CC LAB SYRINGE ECCENTRI .000 08290305482 10CC SYRINGE ECCENTRIC TI .000 08290309604 10CC SYRINGE LUER-LOK TIP .000 08290309605 10CC SYRINGE LUER-LOK TIP .000 08290301604 10CC SYRINGE SLIP TIP .000 08290301605 10CC SYRINGE SLIP TIP .000 08290303404 10CC SYRINGE/INTERLINK SY .000 08290303405 10CC SYRINGE/INTERLINK VI .000 08290309638 10CC SYRINGE/NEEDLE LUER- .000 08290309639 10CC SYRINGE/NEEDLE LUER- .000 08290305520 1CC ALLERGIST SYRINGE DET .000 08290005520 1CC ALLERGIST SYRINGE DET .000 08290309623 1CC TUBERCULIN SYRINGE .000 08290309625 1CC TUBERCULIN SYRINGE DE .000 08290309626 1CC TUBERCULIN SYRINGE DE .000 08290309602 1CC TUBERCULIN SYRINGE SL .000 08290305617 20CC SYRINGE LUER-LOK TIP .000 08290305618 30CC SYRINGE LUER-LOK TIP .000 08290309650 30CC SYRINGE LUER-LOK TIP .000 08290309571 3CC LUER-LOK .000 08290309572 3CC LUER-LOK SYRINGE .000 08290309570 3CC LUER-LOK SYRINGE .000 08290309575 3CC LUER-LOK SYRINGE .000 08290309577 3CC LUER-LOK SYRINGE .000 08290309637 3CC LUER-LOK SYRINGE 20G .000 08290309574 3CC LUER-LOK SYRINGE 22G .000 08290309582 3CC LUER-LOK TIP SYRINGE .000 08290309584 3CC LUER-LOK TIP SYRINGE .000 08290309591 3CC LUER-LOK TIP SYRINGE .000 08290305591 3CC MEDSAVER SYRINGE/PERM .000 08290305592 3CC MEDSAVER SYRINGE/PERM .000 08290305593 3CC MEDSAVER SYRINGE/PERM .000 08290305595 3CC MEDSAVER SYRINGE/PERM .000 08290305600 3CC MEDSAVER SYRINGE/PERM .000 08290309585 3CC SYRINGE .000 08290303400 3CC SYRINGE/INTERLINK SYR .000 08290303401 3CC SYRINGE/INTERLINK VIA .000 08290309543 3CC SYRINGE/NEEDLE LUER-L .000 08290309541 3CC SYRINGE/NEEDLE REGULA .000 08290309542 3CC SYRINGE/NEEDLE THIN W .000 19810005751 4-WAY NASAL LONG LASTING .050 % 19810000561 4-WAY NASAL SPRAY .050 % 19810000581 4-WAY NASAL SPRAY .050 % 19810000582 4-WAY NASAL SPRAY .050 % 19810000265 4-WAY SALINE .000 08290309663 50-60CC SYRINGE .000 08290309603 5CC SYRINGE .000 08290303402 5CC SYRINGE/INTERLINK SYR .000 08290303403 5CC SYRINGE/INTERLINK VIA .000 08290309660 60CC SYRINGE ECCENTRIC TI .000 08290309680 60CC SYRINGE LUER-LOK TIP .000 00904421472 A & D .000 00085113002 A + D PERSONAL CARE LOTIO .000 00074567102 A-HYDROCORT 100.00 MG 00074567202 A-HYDROCORT 250.00 MG 00074567304 A-HYDROCORT 500.00 MG 00074568401 A-METHAPRED 40.000 MG 00074568502 A-METHAPRED 125.00 MG 00074563004 A-METHAPRED 500.00 MG 00074563108 A-METHAPRED 1000.0 MG 00603702073 A/B OTIC .000 45802031156 A/B OTIC .000 99207001830 A/T/S 2.000 % 99207001960 A/T/S 2.000 % 53265024810 ABLETEX PSE .000 53265024850 ABLETEX PSE .000 00766080100 ABREVA 10.000 % 46287050704 ABSORBASE .000 46287050716 ABSORBASE .000 51552006504 ACACIA .000 00310040160 ACCOLATE 10.000 MG 00310040239 ACCOLATE 20.000 MG 00310040260 ACCOLATE 20.000 MG 00071052723 ACCUPRIL 5.000 MG 00071052740 ACCUPRIL 5.000 MG 00071053023 ACCUPRIL 10.000 MG 00071053040 ACCUPRIL 10.000 MG 00071053223 ACCUPRIL 20.000 MG 00071053240 ACCUPRIL 20.000 MG 00071053523 ACCUPRIL 40.000 MG 00603699721 ACCUSURE .000 00603699821 ACCUSURE .000 00004015549 ACCUTANE 10.000 MG 00004015649 ACCUTANE 40.000 MG 00004016949 ACCUTANE 20.000 MG 49884058701 ACEBUTOLOL HCL 200.00 MG 49884058801 ACEBUTOLOL HCL 400.00 MG 00378120001 ACEBUTOLOL HCL 200.00 MG 00378140001 ACEBUTOLOL HCL 400.00 MG 00032110101 ACEON 2.000 MG 00032110201 ACEON 4.000 MG 00032110301 ACEON 8.000 MG 00713011801 ACEPHEN 120.00 MG 00713011811 ACEPHEN 120.00 MG 00713011812 ACEPHEN 120.00 MG 00713011850 ACEPHEN 120.00 MG 00713011866 ACEPHEN 120.00 MG 00713016401 ACEPHEN 325.00 MG 00713016411 ACEPHEN 325.00 MG 00713016412 ACEPHEN 325.00 MG 00713016450 ACEPHEN 325.00 MG 00713016466 ACEPHEN 325.00 MG 00713016501 ACEPHEN 650.00 MG 00713016505 ACEPHEN 650.00 MG 00713016512 ACEPHEN 650.00 MG 00713016550 ACEPHEN 650.00 MG 00536301401 ACETA-GESIC .000 00536301435 ACETA-GESIC .000 00536321801 ACETAMINOPHEN 500.00 MG Page 1 of 125

Transcript of Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or...

Page 1: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

Low Cost Drugs for the Elderly or Disabled Benefit

Catastrophic Cap "Qualifying" NDC numbers.

Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

B

08290309628 1 CC LUER-LOK SYRINGE.000

08290305535 1/2CC ALLERGIST TRAY REGU.000

08290309695 10CC CONTROL SYRINGE LUER.000

08290305462 10CC LAB SYRINGE ECCENTRI.000

08290305482 10CC SYRINGE ECCENTRIC TI.000

08290309604 10CC SYRINGE LUER-LOK TIP.000

08290309605 10CC SYRINGE LUER-LOK TIP.000

08290301604 10CC SYRINGE SLIP TIP.000

08290301605 10CC SYRINGE SLIP TIP.000

08290303404 10CC SYRINGE/INTERLINK SY.000

08290303405 10CC SYRINGE/INTERLINK VI.000

08290309638 10CC SYRINGE/NEEDLE LUER-.000

08290309639 10CC SYRINGE/NEEDLE LUER-.000

08290305520 1CC ALLERGIST SYRINGE DET.000

08290005520 1CC ALLERGIST SYRINGE DET.000

08290309623 1CC TUBERCULIN SYRINGE.000

08290309625 1CC TUBERCULIN SYRINGE DE.000

08290309626 1CC TUBERCULIN SYRINGE DE.000

08290309602 1CC TUBERCULIN SYRINGE SL.000

08290305617 20CC SYRINGE LUER-LOK TIP.000

08290305618 30CC SYRINGE LUER-LOK TIP.000

08290309650 30CC SYRINGE LUER-LOK TIP.000

08290309571 3CC LUER-LOK.000

08290309572 3CC LUER-LOK SYRINGE.000

08290309570 3CC LUER-LOK SYRINGE.000

08290309575 3CC LUER-LOK SYRINGE.000

08290309577 3CC LUER-LOK SYRINGE.000

08290309637 3CC LUER-LOK SYRINGE 20G.000

08290309574 3CC LUER-LOK SYRINGE 22G.000

08290309582 3CC LUER-LOK TIP SYRINGE.000

08290309584 3CC LUER-LOK TIP SYRINGE.000

08290309591 3CC LUER-LOK TIP SYRINGE.000

08290305591 3CC MEDSAVER SYRINGE/PERM.000

08290305592 3CC MEDSAVER SYRINGE/PERM.000

08290305593 3CC MEDSAVER SYRINGE/PERM.000

08290305595 3CC MEDSAVER SYRINGE/PERM.000

08290305600 3CC MEDSAVER SYRINGE/PERM.000

08290309585 3CC SYRINGE.000

08290303400 3CC SYRINGE/INTERLINK SYR.000

08290303401 3CC SYRINGE/INTERLINK VIA.000

08290309543 3CC SYRINGE/NEEDLE LUER-L.000

08290309541 3CC SYRINGE/NEEDLE REGULA.000

08290309542 3CC SYRINGE/NEEDLE THIN W.000

19810005751 4-WAY NASAL LONG LASTING.050 %

19810000561 4-WAY NASAL SPRAY.050 %

19810000581 4-WAY NASAL SPRAY.050 %

19810000582 4-WAY NASAL SPRAY.050 %

19810000265 4-WAY SALINE.000

08290309663 50-60CC SYRINGE.000

08290309603 5CC SYRINGE.000

08290303402 5CC SYRINGE/INTERLINK SYR.000

08290303403 5CC SYRINGE/INTERLINK VIA.000

08290309660 60CC SYRINGE ECCENTRIC TI.000

08290309680 60CC SYRINGE LUER-LOK TIP.000

00904421472 A & D.000

00085113002 A + D PERSONAL CARE LOTIO.000

00074567102 A-HYDROCORT100.00 MG

00074567202 A-HYDROCORT250.00 MG

00074567304 A-HYDROCORT500.00 MG

00074568401 A-METHAPRED40.000 MG

00074568502 A-METHAPRED125.00 MG

00074563004 A-METHAPRED500.00 MG

00074563108 A-METHAPRED1000.0 MG

00603702073 A/B OTIC.000

45802031156 A/B OTIC.000

99207001830 A/T/S2.000 %

99207001960 A/T/S2.000 %

53265024810 ABLETEX PSE.000

53265024850 ABLETEX PSE.000

00766080100 ABREVA10.000 %

46287050704 ABSORBASE.000

46287050716 ABSORBASE.000

51552006504 ACACIA.000

00310040160 ACCOLATE10.000 MG

00310040239 ACCOLATE20.000 MG

00310040260 ACCOLATE20.000 MG

00071052723 ACCUPRIL5.000 MG

00071052740 ACCUPRIL5.000 MG

00071053023 ACCUPRIL10.000 MG

00071053040 ACCUPRIL10.000 MG

00071053223 ACCUPRIL20.000 MG

00071053240 ACCUPRIL20.000 MG

00071053523 ACCUPRIL40.000 MG

00603699721 ACCUSURE.000

00603699821 ACCUSURE.000

00004015549 ACCUTANE10.000 MG

00004015649 ACCUTANE40.000 MG

00004016949 ACCUTANE20.000 MG

49884058701 ACEBUTOLOL HCL200.00 MG

49884058801 ACEBUTOLOL HCL400.00 MG

00378120001 ACEBUTOLOL HCL200.00 MG

00378140001 ACEBUTOLOL HCL400.00 MG

00032110101 ACEON2.000 MG

00032110201 ACEON4.000 MG

00032110301 ACEON8.000 MG

00713011801 ACEPHEN120.00 MG

00713011811 ACEPHEN120.00 MG

00713011812 ACEPHEN120.00 MG

00713011850 ACEPHEN120.00 MG

00713011866 ACEPHEN120.00 MG

00713016401 ACEPHEN325.00 MG

00713016411 ACEPHEN325.00 MG

00713016412 ACEPHEN325.00 MG

00713016450 ACEPHEN325.00 MG

00713016466 ACEPHEN325.00 MG

00713016501 ACEPHEN650.00 MG

00713016505 ACEPHEN650.00 MG

00713016512 ACEPHEN650.00 MG

00713016550 ACEPHEN650.00 MG

00536301401 ACETA-GESIC.000

00536301435 ACETA-GESIC.000

00536321801 ACETAMINOPHEN500.00 MG

Page 1 of 125

Page 2: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00536321810 ACETAMINOPHEN500.00 MG

00536322201 ACETAMINOPHEN325.00 MG

00536322210 ACETAMINOPHEN325.00 MG

00536323101 ACETAMINOPHEN500.00 MG

00536323110 ACETAMINOPHEN500.00 MG

00536323307 ACETAMINOPHEN80.000 MG

00536323407 ACETAMINOPHEN80.000 MG

00536132012 ACETAMINOPHEN325.00 MG

00536125512 ACETAMINOPHEN120.00 MG

00536126012 ACETAMINOPHEN650.00 MG

00536012285 ACETAMINOPHEN160.00 MG/5ML

00536012297 ACETAMINOPHEN160.00 MG/5ML

00182700111 ACETAMINOPHEN325.00 MG

00182844789 ACETAMINOPHEN325.00 MG

00182845389 ACETAMINOPHEN500.00 MG

00182100010 ACETAMINOPHEN325.00 MG

00182100019 ACETAMINOPHEN325.00 MG

00182109511 ACETAMINOPHEN650.00 MG

00182147337 ACETAMINOPHEN160.00 MG/5ML

00182147340 ACETAMINOPHEN160.00 MG/5ML

00182166211 ACETAMINOPHEN120.00 MG

00054301050 ACETAMINOPHEN160.00 MG/5ML

00054301063 ACETAMINOPHEN160.00 MG/5ML

00054401625 ACETAMINOPHEN500.00 MG

00677178210 ACETAMINOPHEN500.00 MG

00677178401 ACETAMINOPHEN500.00 MG

00904260612 ACETAMINOPHEN120.00 MG

00615059138 ACETAMINOPHEN325.00 MG

00615059143 ACETAMINOPHEN325.00 MG

00615451043 ACETAMINOPHEN500.00 MG

00677067801 ACETAMINOPHEN500.00 MG

00677067810 ACETAMINOPHEN500.00 MG

00904785860 ACETAMINOPHEN500.00 MG

00904785960 ACETAMINOPHEN500.00 MG

00904786060 ACETAMINOPHEN500.00 MG

17714001301 ACETAMINOPHEN500.00 MG

17714001310 ACETAMINOPHEN500.00 MG

17714001401 ACETAMINOPHEN500.00 MG

17714001410 ACETAMINOPHEN500.00 MG

17236060201 ACETAMINOPHEN500.00 MG

17236060210 ACETAMINOPHEN500.00 MG

17236060301 ACETAMINOPHEN80.000 MG

17236060303 ACETAMINOPHEN80.000 MG

17236035001 ACETAMINOPHEN325.00 MG

17236035010 ACETAMINOPHEN325.00 MG

17236035050 ACETAMINOPHEN325.00 MG

17236035055 ACETAMINOPHEN325.00 MG

45802073030 ACETAMINOPHEN650.00 MG

45802073032 ACETAMINOPHEN650.00 MG

45802073033 ACETAMINOPHEN650.00 MG

45802073034 ACETAMINOPHEN650.00 MG

45802073230 ACETAMINOPHEN120.00 MG

45802073232 ACETAMINOPHEN120.00 MG

45802073233 ACETAMINOPHEN120.00 MG

50383010115 ACETAMINOPHEN100.00 MG/ML

51079000219 ACETAMINOPHEN325.00 MG

51079000220 ACETAMINOPHEN325.00 MG

51079000222 ACETAMINOPHEN325.00 MG

51079000240 ACETAMINOPHEN325.00 MG

51079000260 ACETAMINOPHEN325.00 MG

51079039619 ACETAMINOPHEN500.00 MG

51079039620 ACETAMINOPHEN500.00 MG

53746001101 ACETAMINOPHEN325.00 MG

53746001110 ACETAMINOPHEN325.00 MG

60432061008 ACETAMINOPHEN160.00 MG/5ML

00615451053 ACETAMINOPHEN500.00 MG

00615451063 ACETAMINOPHEN500.00 MG

60793000504 ACETAMINOPHEN CHILDRENS160.00 MG/5ML

51079010620 ACETAMINOPHEN/CODEINE.000

51079010621 ACETAMINOPHEN/CODEINE.000

50383007916 ACETAMINOPHEN/CODEINE.000

51285030202 ACETAMINOPHEN/CODEINE.000

00904777516 ACETAMINOPHEN/CODEINE.000

00677099633 ACETAMINOPHEN/CODEINE.000

00054801304 ACETAMINOPHEN/CODEINE.000

00054801704 ACETAMINOPHEN/CODEINE.000

00054800204 ACETAMINOPHEN/CODEINE.000

00054300550 ACETAMINOPHEN/CODEINE.000

00054300563 ACETAMINOPHEN/CODEINE.000

00093005001 ACETAMINOPHEN/CODEINE.000

00093005010 ACETAMINOPHEN/CODEINE.000

00093035001 ACETAMINOPHEN/CODEINE.000

00093035005 ACETAMINOPHEN/CODEINE.000

00093035010 ACETAMINOPHEN/CODEINE.000

00182107840 ACETAMINOPHEN/CODEINE.000

00603102058 ACETAMINOPHEN/CODEINE.000

00603233921 ACETAMINOPHEN/CODEINE.000

00603233928 ACETAMINOPHEN/CODEINE.000

00603233721 ACETAMINOPHEN/CODEINE.000

00472141904 ACETAMINOPHEN/CODEINE.000

00472141916 ACETAMINOPHEN/CODEINE.000

60432024504 ACETAMINOPHEN/CODEINE.000

60432024516 ACETAMINOPHEN/CODEINE.000

51285030305 ACETAMINOPHEN/CODEINE #3.000

51079016120 ACETAMINOPHEN/CODEINE #3.000

51079016121 ACETAMINOPHEN/CODEINE #3.000

51079016124 ACETAMINOPHEN/CODEINE #3.000

51079016199 ACETAMINOPHEN/CODEINE #3.000

00603233802 ACETAMINOPHEN/CODEINE #3.000

00603233816 ACETAMINOPHEN/CODEINE #3.000

00603233819 ACETAMINOPHEN/CODEINE #3.000

00603233820 ACETAMINOPHEN/CODEINE #3.000

00603233821 ACETAMINOPHEN/CODEINE #3.000

00603233822 ACETAMINOPHEN/CODEINE #3.000

00603233832 ACETAMINOPHEN/CODEINE #3.000

00093015001 ACETAMINOPHEN/CODEINE #3.000

00093015010 ACETAMINOPHEN/CODEINE #3.000

00054802224 ACETAMINOPHEN/CODEINE #3.000

60429050030 ACETAMINOPHEN/CODEINE #3.000

51079016123 ACETAMINOPHEN/CODEINE #3.000

51285030402 ACETAMINOPHEN/CODEINE #4.000

51285030404 ACETAMINOPHEN/CODEINE #4.000

00472088282 ACETASOL HC.000

00527105001 ACETAZOLAMIDE250.00 MG

00527105005 ACETAZOLAMIDE250.00 MG

00527105010 ACETAZOLAMIDE250.00 MG

53489016601 ACETAZOLAMIDE125.00 MG

00677124801 ACETAZOLAMIDE125.00 MG

51079026215 ACETIC ACID2.000 %

60432074115 ACETIC ACID2.000 %

00074614309 ACETIC ACID 0.25%.250 %

00074614322 ACETIC ACID 0.25%.250 %

24208061577 ACETIC ACID/ALUMINUM ACET.000

00904199160 ACETOHEXAMIDE500.00 MG

00555044202 ACETOHEXAMIDE250.00 MG

00555044302 ACETOHEXAMIDE500.00 MG

51552007004 ACETONE.000

51552023804 ACETONE.000

00074330703 ACETYLCYSTEINE10.000 %

00074330801 ACETYLCYSTEINE20.000 %

00074330803 ACETYLCYSTEINE20.000 %

00054302502 ACETYLCYSTEINE10.000 %

Page 2 of 125

Page 3: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00054302602 ACETYLCYSTEINE20.000 %

00054302702 ACETYLCYSTEINE10.000 %

00054302802 ACETYLCYSTEINE20.000 %

50383072608 ACHE-EZE MINERAL ICE2.000 %

50383072808 ACHE-EZE MINERAL ICE2.000 %

00904017813 ACID GONE.000

00904536560 ACID GONE.000

00904772714 ACID GONE ANTACID.000

60267012585 ACID JELLY.000

00904533646 ACID REDUCER 200200.00 MG

00603770192 ACIDIC VAGINAL JELLY.921 %

00536718101 ACIDOPHILUS.000

00536718001 ACIDOPHILUS/CITRUS PECTIN.000

00182001301 ACIDOPHILUS/PECTIN.000

00904421360 ACIDOPHILUS/PECTIN.000

45802041349 ACNE 1010.000 %

45802003704 ACNE CLEANSING MAXIMUM ST.000

45802019503 ACNE TREATMENT VANISHING10.000 %

17714001501 ACTEDRIL.000

17714001510 ACTEDRIL.000

62794013106 ACTICIN5.000 %

00574012104 ACTIDOSE-AQUA25.000 GM/120M

00574012108 ACTIDOSE-AQUA50.000 GM/240M

00574012125 ACTIDOSE-AQUA15.000 GM/72ML

00574012174 ACTIDOSE-AQUA25.000 GM/120M

00574012176 ACTIDOSE-AQUA50.000 GM/240M

00574012004 ACTIDOSE/SORBITOL25.000 GM/120M

00574012008 ACTIDOSE/SORBITOL50.000 GM/240M

00574012074 ACTIDOSE/SORBITOL25.000 GM/120M

00574012076 ACTIDOSE/SORBITOL50.000 GM/240M

00081001812 ACTIFED.000

00081001824 ACTIFED.000

51079063944 ACTIVATED CHARCOAL/SORBIT50.000 GM/240M

50383011504 ACTIVE SYRUP.000

50383011516 ACTIVE SYRUP.000

00009517401 ACTIVELLA.000

00009517402 ACTIVELLA.000

00149047001 ACTONEL30.000 MG

00149047101 ACTONEL5.000 MG

64764015104 ACTOS15.000 MG

64764015105 ACTOS15.000 MG

64764015106 ACTOS15.000 MG

64764030114 ACTOS30.000 MG

64764030115 ACTOS30.000 MG

64764030116 ACTOS30.000 MG

64764045124 ACTOS45.000 MG

64764045125 ACTOS45.000 MG

64764045126 ACTOS45.000 MG

00172426870 ACYCLOVIR800.00 MG

00172426660 ACYCLOVIR200.00 MG

00172426670 ACYCLOVIR200.00 MG

00172426760 ACYCLOVIR400.00 MG

00172426770 ACYCLOVIR400.00 MG

00172426860 ACYCLOVIR800.00 MG

00182266689 ACYCLOVIR200.00 MG

00182266789 ACYCLOVIR800.00 MG

00228260511 ACYCLOVIR200.00 MG

00228260550 ACYCLOVIR200.00 MG

00228260611 ACYCLOVIR400.00 MG

00228260650 ACYCLOVIR400.00 MG

00228260711 ACYCLOVIR800.00 MG

00228260750 ACYCLOVIR800.00 MG

00182820089 ACYCLOVIR400.00 MG

00472008216 ACYCLOVIR200.00 MG/5ML

00378220005 ACYCLOVIR200.00 MG

00378025301 ACYCLOVIR400.00 MG

00378030201 ACYCLOVIR800.00 MG

00093894001 ACYCLOVIR200.00 MG

00093894005 ACYCLOVIR200.00 MG

00093894301 ACYCLOVIR400.00 MG

00093894305 ACYCLOVIR400.00 MG

00093894701 ACYCLOVIR800.00 MG

00093894705 ACYCLOVIR800.00 MG

51079087620 ACYCLOVIR200.00 MG

51079087720 ACYCLOVIR400.00 MG

51079087820 ACYCLOVIR800.00 MG

49884056501 ACYCLOVIR200.00 MG

49884056601 ACYCLOVIR400.00 MG

49884056701 ACYCLOVIR800.00 MG

55370055507 ACYCLOVIR400.00 MG

55370055509 ACYCLOVIR400.00 MG

55370055607 ACYCLOVIR800.00 MG

55370055608 ACYCLOVIR800.00 MG

55370055707 ACYCLOVIR200.00 MG

55370055709 ACYCLOVIR200.00 MG

17236085401 ACYCLOVIR400.00 MG

63304050401 ACYCLOVIR400.00 MG

63304050501 ACYCLOVIR800.00 MG

63304065201 ACYCLOVIR200.00 MG

63304065205 ACYCLOVIR200.00 MG

60429071150 ACYCLOVIR200.00 MG

60429071350 ACYCLOVIR800.00 MG

59911316305 ACYCLOVIR400.00 MG

00074199010 ACYCLOVIR SODIUM500.00 MG

00026884148 ADALAT CC30.000 MG

00026884151 ADALAT CC30.000 MG

00026884154 ADALAT CC30.000 MG

00026885148 ADALAT CC60.000 MG

00026885151 ADALAT CC60.000 MG

00026885154 ADALAT CC60.000 MG

00026886148 ADALAT CC90.000 MG

00026886151 ADALAT CC90.000 MG

00904261160 ADC/FLUORIDE.000

00482011501 ADEFLOR M.000

57844000901 ADIPEX-P37.500 MG

57844001901 ADIPEX-P37.500 MG

61570040111 ADRENALIN1.000 MG/ML

61570041881 ADRENALIN1.000 MG/ML

61570030031 ADRENALIN.100 %

00013113601 ADRIAMYCIN PFS2.000 MG/ML

00013114601 ADRIAMYCIN PFS2.000 MG/ML

00013116601 ADRIAMYCIN PFS2.000 MG/ML

00013117601 ADRIAMYCIN PFS2.000 MG/ML

00013109601 ADRIAMYCIN RDF20.000 MG

00013110601 ADRIAMYCIN RDF50.000 MG

00013105602 ADRUCIL50.000 MG/ML

00998050515 ADSORBONAC5.000 %

00173069500 ADVAIR DISKUS.000

00173069502 ADVAIR DISKUS.000

00173069600 ADVAIR DISKUS.000

00173069602 ADVAIR DISKUS.000

00173069700 ADVAIR DISKUS.000

00173069702 ADVAIR DISKUS.000

58177035020 ADVANCED NATALCARE.000

00456067299 AEROBID250.00 MCG/ACT

00456067099 AEROBID-M250.00 MCG/ACT

00256015001 AEROLATE III TD65.000 MG

00256011401 AEROLATE JR130.00 MG

00256011501 AEROLATE SENIOR260.00 MG

00085098802 AFRIN.050 %

00085124701 AFRIN CHILDRENS.250 %

00085302002 AFRIN EXTRA MOISTURIZING.050 %

Page 3 of 125

Page 4: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00085400401 AFRIN NASAL SPRAY.050 %

00085075605 AFRIN NASAL SPRAY.050 %

00085075606 AFRIN NASAL SPRAY.050 %

00085075608 AFRIN NASAL SPRAY.050 %

00085075612 AFRIN NASAL SPRAY.050 %

00085068301 AFRIN SALINE NASAL MIST.000

00085113801 AFRIN SALINE NASAL MIST.650 %

00085411201 AFRIN SINUS.050 %

00085411202 AFRIN SINUS.050 %

00597000160 AGGRENOX.000

54092006301 AGRYLIN.500 MG

54092006401 AGRYLIN1.000 MG

53014007525 AIRET.083 %

53014007560 AIRET.083 %

49884069301 AKINETON2.000 MG

00677051032 ALAMAG.000

00182080939 ALAMAG.000

00182600439 ALAMAG PLUS.000

00053768001 ALBUMINAR-2525.000 %

00053767003 ALBUMINAR-55.000 %

00053767006 ALBUMINAR-55.000 %

00172439018 ALBUTEROL90.000 MCG/ACT

50111080131 ALBUTEROL90.000 MCG/ACT

50111080132 ALBUTEROL90.000 MCG/ACT

59930156001 ALBUTEROL90.000 MCG/ACT

62037079444 ALBUTEROL90.000 MCG/ACT

53489017601 ALBUTEROL SULFATE2.000 MG

53489017605 ALBUTEROL SULFATE2.000 MG

53489017701 ALBUTEROL SULFATE4.000 MG

53489017705 ALBUTEROL SULFATE4.000 MG

51079065720 ALBUTEROL SULFATE2.000 MG

51079065820 ALBUTEROL SULFATE4.000 MG

50383074016 ALBUTEROL SULFATE2.000 MG/5ML

50383074120 ALBUTEROL SULFATE.500 %

50383074225 ALBUTEROL SULFATE.083 %

00904287640 ALBUTEROL SULFATE2.000 MG

00904287661 ALBUTEROL SULFATE2.000 MG

00904287761 ALBUTEROL SULFATE4.000 MG

00904765855 ALBUTEROL SULFATE.500 %

24208034720 ALBUTEROL SULFATE.500 %

00677135901 ALBUTEROL SULFATE2.000 MG

00677135905 ALBUTEROL SULFATE2.000 MG

00677136001 ALBUTEROL SULFATE4.000 MG

00677136005 ALBUTEROL SULFATE4.000 MG

00172640544 ALBUTEROL SULFATE.083 %

00172640549 ALBUTEROL SULFATE.083 %

00182601465 ALBUTEROL SULFATE.500 %

00603100540 ALBUTEROL SULFATE.083 %

00603100643 ALBUTEROL SULFATE.500 %

00603100758 ALBUTEROL SULFATE2.000 MG/5ML

00378025501 ALBUTEROL SULFATE2.000 MG

00378025505 ALBUTEROL SULFATE2.000 MG

00378057201 ALBUTEROL SULFATE4.000 MG

00378057205 ALBUTEROL SULFATE4.000 MG

00472083123 ALBUTEROL SULFATE.083 %

00472083130 ALBUTEROL SULFATE.083 %

00472083160 ALBUTEROL SULFATE.083 %

00472082516 ALBUTEROL SULFATE2.000 MG/5ML

00054806311 ALBUTEROL SULFATE.083 %

00054806321 ALBUTEROL SULFATE.083 %

00093222605 ALBUTEROL SULFATE2.000 MG

00093066501 ALBUTEROL SULFATE2.000 MG

00093066505 ALBUTEROL SULFATE2.000 MG

00093066601 ALBUTEROL SULFATE4.000 MG

00093066605 ALBUTEROL SULFATE4.000 MG

00093066116 ALBUTEROL SULFATE2.000 MG/5ML

59930150006 ALBUTEROL SULFATE.083 %

59930151504 ALBUTEROL SULFATE.500 %

60432009406 ALBUTEROL SULFATE.083 %

00998001615 ALCAINE.500 %

00074150005 ALCOHOL 5%/DEXTROSE 5%.000

00074377204 ALCOHOL ABSOLUTE95.000 %

00065011612 ALCON SALINE SENSITIVE EY.000

00025101131 ALDACTAZIDE.000

00025101155 ALDACTAZIDE.000

00025102131 ALDACTAZIDE.000

00025103131 ALDACTONE100.00 MG

00025103134 ALDACTONE100.00 MG

00025104131 ALDACTONE50.000 MG

00025104134 ALDACTONE50.000 MG

00025100131 ALDACTONE25.000 MG

00025100151 ALDACTONE25.000 MG

00025100155 ALDACTONE25.000 MG

00006063468 ALDOCLOR.000

00006069468 ALDORIL D30.000

00006093568 ALDORIL D50.000

00006042368 ALDORIL-15.000

00006045668 ALDORIL-25.000

00006045682 ALDORIL-25.000

00536011183 ALENIC ALKA.000

00536301301 ALENIC ALKA.000

00008257601 ALESSE-28.000

00008257602 ALESSE-28.000

00904318840 ALFALFA OIL500.00 MG

00074226602 ALFENTANIL500.00 MCG/ML

00074226605 ALFENTANIL500.00 MCG/ML

00074226649 ALFENTANIL500.00 MCG/ML

00074226651 ALFENTANIL500.00 MCG/ML

00904523051 ALL DAY RELIEF220.00 MG

00904523059 ALL DAY RELIEF220.00 MG

00904405760 ALL-IN-ONE.000

00904132221 ALL-NITE COLD FORMULA.000

00904132263 ALL-NITE COLD FORMULA.000

00904132321 ALL-NITE COLD FORMULA.000

00904132363 ALL-NITE COLD FORMULA.000

00536346701 ALLER-CHLOR4.000 MG

00536346710 ALLER-CHLOR4.000 MG

00536346735 ALLER-CHLOR4.000 MG

00536037097 ALLER-CHLOR2.000 MG/5ML

00536342101 ALLERFRIM.000

00536051085 ALLERFRIM.000

00536051097 ALLERFRIM.000

00182117533 ALLERGEN.000

00904001224 ALLERGY4.000 MG

00904001259 ALLERGY4.000 MG

00904001280 ALLERGY4.000 MG

00713029531 ALLERGY CREAM2.000 %

00904261360 ALLOPURINOL100.00 MG

00904261361 ALLOPURINOL100.00 MG

00904261380 ALLOPURINOL100.00 MG

00904261440 ALLOPURINOL300.00 MG

00904261460 ALLOPURINOL300.00 MG

00904261461 ALLOPURINOL300.00 MG

00677087001 ALLOPURINOL100.00 MG

00677087010 ALLOPURINOL100.00 MG

00677087101 ALLOPURINOL300.00 MG

00677087105 ALLOPURINOL300.00 MG

00677087110 ALLOPURINOL300.00 MG

51079020519 ALLOPURINOL100.00 MG

51079020520 ALLOPURINOL100.00 MG

51079020619 ALLOPURINOL300.00 MG

51079020620 ALLOPURINOL300.00 MG

Page 4 of 125

Page 5: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

49884060201 ALLOPURINOL100.00 MG

49884060210 ALLOPURINOL100.00 MG

49884060301 ALLOPURINOL300.00 MG

49884060305 ALLOPURINOL300.00 MG

49884060310 ALLOPURINOL300.00 MG

49884010401 ALLOPURINOL100.00 MG

49884010410 ALLOPURINOL100.00 MG

49884010501 ALLOPURINOL300.00 MG

49884010505 ALLOPURINOL300.00 MG

49884010510 ALLOPURINOL300.00 MG

53489015601 ALLOPURINOL100.00 MG

53489015605 ALLOPURINOL100.00 MG

53489015610 ALLOPURINOL100.00 MG

53489015701 ALLOPURINOL300.00 MG

53489015705 ALLOPURINOL300.00 MG

53489015710 ALLOPURINOL300.00 MG

00378013701 ALLOPURINOL100.00 MG

00378013710 ALLOPURINOL100.00 MG

00378018101 ALLOPURINOL300.00 MG

00378018105 ALLOPURINOL300.00 MG

60429001430 ALLOPURINOL300.00 MG

60429001490 ALLOPURINOL300.00 MG

00536002583 ALMACONE.000

00536303501 ALMACONE MLT.000

00536001583 ALMACONE-II DOUBLE STRENG.000

51552012804 ALMOND OIL SWEET.000

00456016410 ALMORA500.00 MG

00904405684 ALOE VERA.000

00182405726 ALOE VERA EXTRACT100.00 MG

00003401891 ALOE VESTA 2-N-1 ANTIFUNG2.000 %

00003325102 ALOE VESTA 2-N-1 ANTIFUNG2.000 %

00003325105 ALOE VESTA 2-N-1 ANTIFUNG2.000 %

00003401868 ALOE VESTA 2-N-1 PERINEAL.000

00003401869 ALOE VESTA 2-N-1 PERINEAL.000

00003401870 ALOE VESTA 2-N-1 PERINEAL.000

00003324908 ALOE VESTA 2-N-1 PROTECTI.000

00003324913 ALOE VESTA 2-N-1 PROTECTI.000

00003401872 ALOE VESTA 2-N-1 SKIN CON.000

00003401873 ALOE VESTA 2-N-1 SKIN CON.000

00003401874 ALOE VESTA 2-N-1 SKIN CON.000

00003401871 ALOE VESTA 3-N-1 CLEANSIN.000

00003698400 ALOE VESTA PROTECTIVE.000

00003698421 ALOE VESTA PROTECTIVE.000

52544047108 ALORA.050 MG/24HR

52544047208 ALORA.075 MG/24HR

52544047308 ALORA.100 MG/24HR

00281005515 ALPHATREX.050 %

00281005546 ALPHATREX.050 %

00228202910 ALPRAZOLAM.500 MG

00228202950 ALPRAZOLAM.500 MG

00228202996 ALPRAZOLAM.500 MG

00228203110 ALPRAZOLAM1.000 MG

00228203150 ALPRAZOLAM1.000 MG

00228203196 ALPRAZOLAM1.000 MG

00228203910 ALPRAZOLAM2.000 MG

00228203950 ALPRAZOLAM2.000 MG

00228202710 ALPRAZOLAM.250 MG

00228202750 ALPRAZOLAM.250 MG

00228202796 ALPRAZOLAM.250 MG

00378400101 ALPRAZOLAM.250 MG

00378400105 ALPRAZOLAM.250 MG

00378400301 ALPRAZOLAM.500 MG

00378400305 ALPRAZOLAM.500 MG

00378400501 ALPRAZOLAM1.000 MG

00378400505 ALPRAZOLAM1.000 MG

00378400701 ALPRAZOLAM2.000 MG

51079078820 ALPRAZOLAM.250 MG

51079078821 ALPRAZOLAM.250 MG

51079078920 ALPRAZOLAM.500 MG

51079078921 ALPRAZOLAM.500 MG

51079079020 ALPRAZOLAM1.000 MG

51079079021 ALPRAZOLAM1.000 MG

00904779140 ALPRAZOLAM.250 MG

00904779160 ALPRAZOLAM.250 MG

00904779340 ALPRAZOLAM1.000 MG

00904779360 ALPRAZOLAM1.000 MG

00781106101 ALPRAZOLAM.250 MG

00781106105 ALPRAZOLAM.250 MG

00781107701 ALPRAZOLAM.500 MG

00781107705 ALPRAZOLAM.500 MG

00781107901 ALPRAZOLAM1.000 MG

00781107905 ALPRAZOLAM1.000 MG

00781108901 ALPRAZOLAM2.000 MG

00781108905 ALPRAZOLAM2.000 MG

59762371901 ALPRAZOLAM.250 MG

59762371903 ALPRAZOLAM.250 MG

59762371904 ALPRAZOLAM.250 MG

59762372001 ALPRAZOLAM.500 MG

59762372003 ALPRAZOLAM.500 MG

59762372004 ALPRAZOLAM.500 MG

59762372101 ALPRAZOLAM1.000 MG

59762372103 ALPRAZOLAM1.000 MG

59762372104 ALPRAZOLAM1.000 MG

59762372201 ALPRAZOLAM2.000 MG

59762372203 ALPRAZOLAM2.000 MG

61570011001 ALTACE1.250 MG

61570011056 ALTACE1.250 MG

61570011101 ALTACE2.500 MG

61570011105 ALTACE2.500 MG

61570011156 ALTACE2.500 MG

61570011201 ALTACE5.000 MG

61570011205 ALTACE5.000 MG

61570011256 ALTACE5.000 MG

61570012001 ALTACE10.000 MG

61570012005 ALTACE10.000 MG

51552021804 ALUM AMMONIUM.000

00574100616 ALUMINUM.000

00536009185 ALUMINUM HYDROXIDE320.00 MG/5ML

00904783216 ALUMINUM HYDROXIDE320.00 MG/5ML

00597007017 ALUPENT.650 MG/ACT

00603101058 AMANTADINE HCL50.000 MG/5ML

00832101500 AMANTADINE HCL100.00 MG

00832101550 AMANTADINE HCL100.00 MG

00904343216 AMANTADINE HCL50.000 MG/5ML

51079048120 AMANTADINE HCL100.00 MG

50383080716 AMANTADINE HCL50.000 MG/5ML

60432009316 AMANTADINE HCL50.000 MG/5ML

53706100303 AMBERDERM.000

00904787235 AMBOCAINE.000

00074669501 AMIDATE2.000 MG/ML

00074669502 AMIDATE2.000 MG/ML

00074806019 AMIDATE2.000 MG/ML

00074806029 AMIDATE2.000 MG/ML

00074806101 AMIDATE2.000 MG/ML

00074806201 AMIDATE2.000 MG/ML

00074195501 AMIKACIN SULFATE50.000 MG/ML

00074195601 AMIKACIN SULFATE250.00 MG/ML

00074195701 AMIKACIN SULFATE250.00 MG/ML

00074195801 AMIKACIN SULFATE250.00 MG/ML

00074102702 AMIKACIN SULFATE250.00 MG/ML

00074102704 AMIKACIN SULFATE250.00 MG/ML

00015301597 AMIKIN50.000 MG/ML

Page 5 of 125

Page 6: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00015301520 AMIKIN50.000 MG/ML

00015302020 AMIKIN250.00 MG/ML

00015302097 AMIKIN250.00 MG/ML

00015302320 AMIKIN250.00 MG/ML

00015302397 AMIKIN250.00 MG/ML

49884011701 AMILORIDE HCL5.000 MG

49884011705 AMILORIDE HCL5.000 MG

49884011710 AMILORIDE HCL5.000 MG

52544068501 AMILORIDE/HYDROCHLOROTHIA.000

00677122301 AMILORIDE/HYDROCHLOROTHIA.000

00904211360 AMILORIDE/HYDROCHLOROTHIA.000

00904211361 AMILORIDE/HYDROCHLOROTHIA.000

00904211380 AMILORIDE/HYDROCHLOROTHIA.000

00555048302 AMILORIDE/HYDROCHLOROTHIA.000

00555048305 AMILORIDE/HYDROCHLOROTHIA.000

00378057701 AMILORIDE/HYDROCHLOROTHIA.000

00378057705 AMILORIDE/HYDROCHLOROTHIA.000

60951076470 AMILORIDE/HYDROCHLOROTHIA.000

60267023414 AMINO ACID CERVICAL.000

00904318146 AMINO ACID MEGA.000

00904318152 AMINO ACID MEGA.000

00904318260 AMINO ACIDS.000

00115701103 AMINOBENZOATE POTASSIUM500.00 MG

00074434673 AMINOCAPROIC ACID250.00 MG/ML

00006339511 AMINOHIPPURATE SODIUM20.000 %

00074592101 AMINOPHYLLINE25.000 MG/ML

00074592201 AMINOPHYLLINE25.000 MG/ML

00074490619 AMINOPHYLLINE25.000 MG/ML

00074490918 AMINOPHYLLINE25.000 MG/ML

00074738501 AMINOPHYLLINE25.000 MG/ML

00074738601 AMINOPHYLLINE25.000 MG/ML

00054402625 AMINOPHYLLINE200.00 MG

00054804916 AMINOPHYLLINE105.00 MG/5ML

00054304563 AMINOPHYLLINE105.00 MG/5ML

00143102001 AMINOPHYLLINE100.00 MG

00143102010 AMINOPHYLLINE100.00 MG

00143102501 AMINOPHYLLINE200.00 MG

00143102510 AMINOPHYLLINE200.00 MG

00677000301 AMINOPHYLLINE100.00 MG

00677000701 AMINOPHYLLINE200.00 MG

51552031316 AMINOPHYLLINE ANHYDROUS.000

51552031399 AMINOPHYLLINE ANHYDROUS.000

00074585503 AMINOSYN.000

00074585505 AMINOSYN.000

00074585603 AMINOSYN 8.5%/ELECTROLYTE.000

00074585605 AMINOSYN 8.5%/ELECTROLYTE.000

00074712207 AMINOSYN II.000

00074108803 AMINOSYN II.000

00074108805 AMINOSYN II.000

00074770229 AMINOSYN II 4.25/DEXTROSE.000

00074775129 AMINOSYN II 4.25/DEXTROSE.000

00074775229 AMINOSYN II 4.25/DEXTROSE.000

00074775729 AMINOSYN II 4.25/DEXTROSE.000

00074108903 AMINOSYN II 8.5%/ELECTROL.000

00074721703 AMINOSYN-HF.000

00074415405 AMINOSYN-M.000

00093913306 AMIODARONE HCL200.00 MG

00093913352 AMIODARONE HCL200.00 MG

00093913393 AMIODARONE HCL200.00 MG

00185014405 AMIODARONE HCL200.00 MG

00185014460 AMIODARONE HCL200.00 MG

00555091704 AMIODARONE HCL200.00 MG

00555091709 AMIODARONE HCL200.00 MG

51079090620 AMIODARONE HCL200.00 MG

49884045802 AMIODARONE HCL200.00 MG

49884045804 AMIODARONE HCL200.00 MG

49884045805 AMIODARONE HCL200.00 MG

00781120305 AMIODARONE HCL200.00 MG

00781120360 AMIODARONE HCL200.00 MG

00781120392 AMIODARONE HCL200.00 MG

38245013325 AMIODARONE HCL200.00 MG

38245013355 AMIODARONE HCL200.00 MG

00781148601 AMITRIPTYLINE HCL10.000 MG

00781148610 AMITRIPTYLINE HCL10.000 MG

00781148701 AMITRIPTYLINE HCL25.000 MG

00781148710 AMITRIPTYLINE HCL25.000 MG

00781148801 AMITRIPTYLINE HCL50.000 MG

00781148810 AMITRIPTYLINE HCL50.000 MG

00781148901 AMITRIPTYLINE HCL75.000 MG

00781149001 AMITRIPTYLINE HCL100.00 MG

00781149101 AMITRIPTYLINE HCL150.00 MG

00904020060 AMITRIPTYLINE HCL10.000 MG

00904020061 AMITRIPTYLINE HCL10.000 MG

00904020080 AMITRIPTYLINE HCL10.000 MG

00904020160 AMITRIPTYLINE HCL25.000 MG

00904020180 AMITRIPTYLINE HCL25.000 MG

00904020260 AMITRIPTYLINE HCL50.000 MG

00904020280 AMITRIPTYLINE HCL50.000 MG

00904020360 AMITRIPTYLINE HCL75.000 MG

00904020361 AMITRIPTYLINE HCL75.000 MG

00904020460 AMITRIPTYLINE HCL100.00 MG

00677047501 AMITRIPTYLINE HCL10.000 MG

00677047510 AMITRIPTYLINE HCL10.000 MG

00677047601 AMITRIPTYLINE HCL25.000 MG

00677047610 AMITRIPTYLINE HCL25.000 MG

00677047701 AMITRIPTYLINE HCL50.000 MG

00677047710 AMITRIPTYLINE HCL50.000 MG

00677047801 AMITRIPTYLINE HCL75.000 MG

00677056801 AMITRIPTYLINE HCL100.00 MG

00677064501 AMITRIPTYLINE HCL150.00 MG

50111036603 AMITRIPTYLINE HCL10.000 MG

50111036801 AMITRIPTYLINE HCL50.000 MG

50111036803 AMITRIPTYLINE HCL50.000 MG

50111037001 AMITRIPTYLINE HCL100.00 MG

50111037101 AMITRIPTYLINE HCL150.00 MG

51079056320 AMITRIPTYLINE HCL100.00 MG

51079056420 AMITRIPTYLINE HCL150.00 MG

51079014720 AMITRIPTYLINE HCL75.000 MG

51079010719 AMITRIPTYLINE HCL25.000 MG

51079010720 AMITRIPTYLINE HCL25.000 MG

51079013120 AMITRIPTYLINE HCL10.000 MG

51079013320 AMITRIPTYLINE HCL50.000 MG

53489010401 AMITRIPTYLINE HCL10.000 MG

53489010410 AMITRIPTYLINE HCL10.000 MG

53489010501 AMITRIPTYLINE HCL25.000 MG

53489010510 AMITRIPTYLINE HCL25.000 MG

53489010601 AMITRIPTYLINE HCL50.000 MG

53489010610 AMITRIPTYLINE HCL50.000 MG

53489010701 AMITRIPTYLINE HCL75.000 MG

53489010705 AMITRIPTYLINE HCL75.000 MG

53489010801 AMITRIPTYLINE HCL100.00 MG

53489010901 AMITRIPTYLINE HCL150.00 MG

00603221221 AMITRIPTYLINE HCL10.000 MG

00603221232 AMITRIPTYLINE HCL10.000 MG

00603221321 AMITRIPTYLINE HCL25.000 MG

00603221332 AMITRIPTYLINE HCL25.000 MG

00603221421 AMITRIPTYLINE HCL50.000 MG

00603221432 AMITRIPTYLINE HCL50.000 MG

00603221521 AMITRIPTYLINE HCL75.000 MG

00603221621 AMITRIPTYLINE HCL100.00 MG

00603221721 AMITRIPTYLINE HCL150.00 MG

00378261001 AMITRIPTYLINE HCL10.000 MG

Page 6 of 125

Page 7: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00378261010 AMITRIPTYLINE HCL10.000 MG

00378262501 AMITRIPTYLINE HCL25.000 MG

00378262510 AMITRIPTYLINE HCL25.000 MG

00378265001 AMITRIPTYLINE HCL50.000 MG

00378265010 AMITRIPTYLINE HCL50.000 MG

00378267501 AMITRIPTYLINE HCL75.000 MG

00378268501 AMITRIPTYLINE HCL100.00 MG

00378269501 AMITRIPTYLINE HCL150.00 MG

00245002322 AMLACTIN12.000 %

00245002340 AMLACTIN12.000 %

00245002414 AMLACTIN12.000 %

45802051377 AMMONIUM LACTATE12.000 %

45802052526 AMMONIUM LACTATE12.000 %

45802052555 AMMONIUM LACTATE12.000 %

00677137801 AMOXAPINE50.000 MG

00677137901 AMOXAPINE100.00 MG

00904399746 AMOXAPINE150.00 MG

00332226804 AMOXICILLIN250.00 MG

00332310705 AMOXICILLIN250.00 MG

00228264025 AMOXICILLIN250.00 MG

00093415073 AMOXICILLIN125.00 MG/5ML

00093415079 AMOXICILLIN125.00 MG/5ML

00093415080 AMOXICILLIN125.00 MG/5ML

00093415573 AMOXICILLIN250.00 MG/5ML

00093415579 AMOXICILLIN250.00 MG/5ML

00093415580 AMOXICILLIN250.00 MG/5ML

00093226301 AMOXICILLIN500.00 MG

00093226401 AMOXICILLIN875.00 MG

00093226701 AMOXICILLIN125.00 MG

00093226801 AMOXICILLIN250.00 MG

00093226805 AMOXICILLIN250.00 MG

00093310701 AMOXICILLIN250.00 MG

00093310705 AMOXICILLIN250.00 MG

00093310756 AMOXICILLIN250.00 MG

00093310905 AMOXICILLIN500.00 MG

00093310953 AMOXICILLIN500.00 MG

00047250020 AMOXICILLIN125.00 MG/5ML

00047073024 AMOXICILLIN250.00 MG

00904261760 AMOXICILLIN250.00 MG

00904261761 AMOXICILLIN250.00 MG

00904261904 AMOXICILLIN125.00 MG/5ML

00904261907 AMOXICILLIN125.00 MG/5ML

00904262004 AMOXICILLIN250.00 MG/5ML

00904262007 AMOXICILLIN250.00 MG/5ML

51079060020 AMOXICILLIN250.00 MG

51079060120 AMOXICILLIN500.00 MG

60429002130 AMOXICILLIN250.00 MG

60429002230 AMOXICILLIN500.00 MG

63304065401 AMOXICILLIN250.00 MG

63304065405 AMOXICILLIN250.00 MG

63304065501 AMOXICILLIN500.00 MG

63304065505 AMOXICILLIN500.00 MG

63304051401 AMOXICILLIN125.00 MG

63304051501 AMOXICILLIN250.00 MG

63304051504 AMOXICILLIN250.00 MG

63304076020 AMOXICILLIN200.00 MG

63304076101 AMOXICILLIN400.00 MG

63304076120 AMOXICILLIN400.00 MG

63304076220 AMOXICILLIN500.00 MG

63304076301 AMOXICILLIN875.00 MG

63304076305 AMOXICILLIN875.00 MG

63304076320 AMOXICILLIN875.00 MG

59930157301 AMOXICILLIN125.00 MG

59930157302 AMOXICILLIN125.00 MG

59930157303 AMOXICILLIN125.00 MG

59930161101 AMOXICILLIN250.00 MG

59930161103 AMOXICILLIN250.00 MG

55370088407 AMOXICILLIN250.00 MG

55370088408 AMOXICILLIN250.00 MG

55370088507 AMOXICILLIN500.00 MG

55370088508 AMOXICILLIN500.00 MG

55370088613 AMOXICILLIN125.00 MG/5ML

55370088614 AMOXICILLIN125.00 MG/5ML

55370088680 AMOXICILLIN125.00 MG/5ML

55370088713 AMOXICILLIN250.00 MG/5ML

55370088714 AMOXICILLIN250.00 MG/5ML

55370088780 AMOXICILLIN250.00 MG/5ML

55370089207 AMOXICILLIN250.00 MG

55370089208 AMOXICILLIN250.00 MG

00029600632 AMOXIL250.00 MG

00029600730 AMOXIL500.00 MG

00029600732 AMOXIL500.00 MG

00029600818 AMOXIL125.00 MG/5ML

00029600822 AMOXIL125.00 MG/5ML

00029600918 AMOXIL250.00 MG/5ML

00029600922 AMOXIL250.00 MG/5ML

00029600923 AMOXIL250.00 MG/5ML

00029603520 AMOXIL50.000 MG/ML

00029603839 AMOXIL50.000 MG/ML

00029604412 AMOXIL200.00 MG

00029604420 AMOXIL200.00 MG

00029604512 AMOXIL400.00 MG

00029604520 AMOXIL400.00 MG

00029604612 AMOXIL500.00 MG

00029604620 AMOXIL500.00 MG

00029604625 AMOXIL500.00 MG

00029604712 AMOXIL875.00 MG

00029604720 AMOXIL875.00 MG

00029604725 AMOXIL875.00 MG

00029604818 AMOXIL200.00 MG/5ML

00029604854 AMOXIL200.00 MG/5ML

00029604855 AMOXIL200.00 MG/5ML

00029604859 AMOXIL200.00 MG/5ML

00029604918 AMOXIL400.00 MG/5ML

00029604954 AMOXIL400.00 MG/5ML

00029604955 AMOXIL400.00 MG/5ML

00029604959 AMOXIL400.00 MG/5ML

00185008401 AMPHETAMINE SALT COMBO.000

00185011101 AMPHETAMINE SALT COMBO.000

00013140544 AMPHOCIN50.000 MG

51552030401 AMPHOTERICIN B905.00 U/MG

51552030405 AMPHOTERICIN B905.00 U/MG

55370088007 AMPICILLIN250.00 MG

55370088008 AMPICILLIN250.00 MG

00904201740 AMPICILLIN250.00 MG

00904201760 AMPICILLIN250.00 MG

00904401004 AMPICILLIN125.00 MG/5ML

00904401008 AMPICILLIN125.00 MG/5ML

00904401404 AMPICILLIN250.00 MG/5ML

00904401408 AMPICILLIN250.00 MG/5ML

00093311110 AMPICILLIN250.00 MG

00093514501 AMPICILLIN250.00 MG

00093514505 AMPICILLIN250.00 MG

00093514601 AMPICILLIN500.00 MG

00093514605 AMPICILLIN500.00 MG

00332311105 AMPICILLIN250.00 MG

00332311106 AMPICILLIN250.00 MG

00332311303 AMPICILLIN500.00 MG

00332311306 AMPICILLIN500.00 MG

55370088107 AMPICILLIN500.00 MG

55370088108 AMPICILLIN500.00 MG

55370088213 AMPICILLIN125.00 MG/5ML

Page 7 of 125

Page 8: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

55370088240 AMPICILLIN125.00 MG/5ML

55370088313 AMPICILLIN250.00 MG/5ML

55370088340 AMPICILLIN250.00 MG/5ML

00015740220 AMPICILLIN SODIUM250.00 MG

00015740299 AMPICILLIN SODIUM250.00 MG

00015740320 AMPICILLIN SODIUM500.00 MG

00015740399 AMPICILLIN SODIUM500.00 MG

00015740420 AMPICILLIN SODIUM1.000 GM

00015740499 AMPICILLIN SODIUM1.000 GM

00015740518 AMPICILLIN SODIUM2.000 GM

00015740520 AMPICILLIN SODIUM2.000 GM

00015740589 AMPICILLIN SODIUM2.000 GM

00015740120 AMPICILLIN SODIUM125.00 MG

00015740199 AMPICILLIN SODIUM125.00 MG

00015740418 AMPICILLIN SODIUM1.000 GM

00015740489 AMPICILLIN SODIUM1.000 GM

00015740599 AMPICILLIN SODIUM2.000 GM

00015710028 AMPICILLIN SODIUM10.000 GM

00015710098 AMPICILLIN SODIUM10.000 GM

17236060501 ANALGESIC.000

17236060510 ANALGESIC.000

45802007503 ANALGESIC BALM.000

45802007505 ANALGESIC BALM.000

45802035603 ANALGESIC BALM10.000 %

45802035653 ANALGESIC BALM10.000 %

00168003631 ANALGESIC BALM.000

00168021916 ANALGESIC BALM.000

00168021931 ANALGESIC BALM.000

00496077804 ANALPRAM-HC.000

00007313001 ANCEF1.000 GM

00007313016 ANCEF1.000 GM

00007313076 ANCEF1.000 GM

00007313116 ANCEF500.00 MG

00007313505 ANCEF10.000 GM

00007313705 ANCEF1.000 GM

00007313576 ANCEF10.000 GM

60258043616 ANDEHIST.000

60258043730 ANDEHIST.000

60258044216 ANDEHIST DM.000

00173007195 ANECTINE20.000 MG/ML

58177004211 ANEMAGEN.000

58177004311 ANEMAGEN FA.000

45802004703 ANESTHETIC HEMORRH1.000 %

45802018501 ANESTHETIC ORAL20.000 %

58768030205 ANGISCEIN10.000 %

00009030503 ANSAID100.00 MG

00009030530 ANSAID100.00 MG

00182616039 ANTACID.000

00603089957 ANTACID.000

00182616139 ANTACID DOUBLE STRENGTH.000

00603071257 ANTACID M.000

00603071557 ANTACID M MAXIMUM STRENGT.000

00603001121 ANTACID PLUS.000

00904772512 ANTI-DIARRHEAL2.000 MG

00904536624 ANTI-DIARRHEAL2.000 MG

00713041812 ANTI-DIARRHEAL2.000 MG

00713041821 ANTI-DIARRHEAL2.000 MG

00713041866 ANTI-DIARRHEAL2.000 MG

00182108211 ANTI-DIARRHEAL2.000 MG

00182506434 ANTI-FUNGAL CREAM2.000 %

45802035803 ANTI-ITCH.000

00182512134 ANTI-ITCH MAXIMUM STRENGT2.000 %

50383076715 ANTIBEN.000

45802007301 ANTIBIOTIC.000

45802007303 ANTIBIOTIC.000

00677167621 ANTIBIOTIC EAR.000

00677167721 ANTIBIOTIC EAR.000

00074196703 ANTICOAGULANT CITRATE PHO.000

00074196704 ANTICOAGULANT CITRATE PHO.000

45802029903 ANTIFUNGAL.000

53303005050 ANTIFUNGAL2.000 %

45802010803 ANTIFUNGAL OINTMENT.000

00904504452 ANTIOXIDANT.000

00536558806 ANTIOXIDANT FORMULA.000

00182446619 ANTIOXIDANT FORMULA SG.000

00536558908 ANTIOXIDANT ULTRA FORMULA.000

24208056162 ANTIPYRINE/BENZOCAINE.000

45802017365 ANTISEPTIC CLEANSER10.000 %

45802020033 ANTISEPTIC CLEANSING PADS.000

45802020096 ANTISEPTIC CLEANSING PADS.000

45802017851 ANTISEPTIC SKIN CLEANSER.000

45802017883 ANTISEPTIC SKIN CLEANSER.000

60432000904 ANTISPASMODIC.000

60432000916 ANTISPASMODIC.000

60432000928 ANTISPASMODIC.000

00904775716 ANTITUSSIVE/DECONGESTANT.000

00049210066 ANTIVERT12.500 MG

00049211066 ANTIVERT25.000 MG

00049214066 ANTIVERT50.000 MG

00904768812 ANU-MED.000

00904768822 ANU-MED.000

00713050301 ANUCORT-HC25.000 MG

00713050312 ANUCORT-HC25.000 MG

00713050324 ANUCORT-HC25.000 MG

00071307513 ANUSOL1.000 %

61570030361 ANUSOL-HC25.000 MG

61570030362 ANUSOL-HC25.000 MG

61570031311 ANUSOL-HC2.500 %

00472141004 APAP160.00 MG/5ML

00472141016 APAP160.00 MG/5ML

17236060701 APAP500.00 MG

17236060707 APAP500.00 MG

17236060710 APAP500.00 MG

17714001201 APAP325.00 MG

17714001210 APAP325.00 MG

50383009904 APAP160.00 MG/5ML

50383009916 APAP160.00 MG/5ML

60258005008 APAP 500500.00 MG/5ML

00472141799 APAP DROPS100.00 MG/ML

53746000101 APAP EXTRA STRENGTH500.00 MG

53746000110 APAP EXTRA STRENGTH500.00 MG

53746000150 APAP EXTRA STRENGTH500.00 MG

53746001801 APAP EXTRA STRENGTH500.00 MG

53746001810 APAP EXTRA STRENGTH500.00 MG

17714002601 APAPGESIC.000

17714002610 APAPGESIC.000

00482001608 APATATE FORTE.000

00076040103 APHRODYNE5.400 MG

00076040104 APHRODYNE5.400 MG

00083007330 APRESOLINE50.000 MG

51285057628 APRI.000

00904025024 APRODINE.000

00904025059 APRODINE.000

00006778064 AQUA-MEPHYTON10.000 MG/ML

00006778066 AQUA-MEPHYTON10.000 MG/ML

00006778433 AQUA-MEPHYTON2.000 MG/ML

00574003016 AQUABASE.000

00574003035 AQUABASE.000

59743005401 AQUABID-DM.000

59743005405 AQUABID-DM.000

59743005425 AQUABID-DM.000

00003177901 AQUACEL HYDROFIBER WOUND.000

Page 8 of 125

Page 9: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00003177902 AQUACEL HYDROFIBER WOUND.000

00003177903 AQUACEL HYDROFIBER WOUND.000

00003177904 AQUACEL HYDROFIBER WOUND.000

58768010415 AQUASITE.000

58768010124 AQUASITE.000

00037015392 AQUATENSEN5.000 MG

60258011130 AQUAVIT-E15.000 IU/0.3ML

54838000530 AQUEOUS VITAMIN E15.000 IU/0.3ML

00024007401 ARALEN50.000 MG/ML

00024008401 ARALEN500.00 MG

00006322210 ARAMINE10.000 MG/ML

00083260104 AREDIA30.000 MG

00083260901 AREDIA90.000 MG

00904421551 ARGININE500.00 MG

00469512430 ARISTOCORT4.000 MG

00469512471 ARISTOCORT4.000 MG

00469510115 ARISTOCORT A.025 %

00469510160 ARISTOCORT A.025 %

00469510215 ARISTOCORT A.100 %

00469510260 ARISTOCORT A.100 %

00469510415 ARISTOCORT A.500 %

00469510515 ARISTOCORT A.100 %

00469510560 ARISTOCORT A.100 %

00469511601 ARISTOCORT FORTE40.000 MG/ML

00469511605 ARISTOCORT FORTE40.000 MG/ML

00456045701 ARMOUR THYROID15.000 MG

00456045800 ARMOUR THYROID30.000 MG

00456045801 ARMOUR THYROID30.000 MG

00456045863 ARMOUR THYROID30.000 MG

00456045869 ARMOUR THYROID30.000 MG

00456045900 ARMOUR THYROID60.000 MG

00456045901 ARMOUR THYROID60.000 MG

00456045951 ARMOUR THYROID60.000 MG

00456045963 ARMOUR THYROID60.000 MG

00456045969 ARMOUR THYROID60.000 MG

00456046001 ARMOUR THYROID90.000 MG

00456046100 ARMOUR THYROID120.00 MG

00456046101 ARMOUR THYROID120.00 MG

00456046163 ARMOUR THYROID120.00 MG

00456046169 ARMOUR THYROID120.00 MG

00456046200 ARMOUR THYROID180.00 MG

00456046201 ARMOUR THYROID180.00 MG

00456046301 ARMOUR THYROID240.00 MG

00456046401 ARMOUR THYROID300.00 MG

50383076816 AROMATIC CASCARA SAGRADA325.00 MG/5ML

45802022882 ARTHRI-LOTION10.000 %

00904519556 ARTHRICREAM10.000 %

45802022653 ARTHRICREAM HEAT.000

00182505882 ARTHRITIS PAIN MEDICINE10.000 %

00025141134 ARTHROTEC 50.000

00025141160 ARTHROTEC 50.000

00025141190 ARTHROTEC 50.000

00025142134 ARTHROTEC 75.000

00025142160 ARTHROTEC 75.000

59879060906 ARTHX DS.000

59879060912 ARTHX DS.000

59879071906 ARTHX SS.000

00536197072 ARTIFICIAL TEARS1.400 %

00536655091 ARTIFICIAL TEARS.000

50383002615 ARTIFICIAL TEARS.000

00904166335 ARTIFICIAL TEARS1.400 %

00677098530 ARTIFICIAL TEARS1.400 %

00536329401 ASCORBIC ACID1000.0 MG

00904770418 ASPIR-LOW81.000 MG

00904770470 ASPIR-LOW81.000 MG

00904770480 ASPIR-LOW81.000 MG

00904034640 ASPIR-MOX.000

00904034659 ASPIR-MOX.000

00904034740 ASPIR-MOX IB.000

00904034759 ASPIR-MOX IB.000

00904510159 ASPIRCAF.000

00904521260 ASPIRIN975.00 MG

00904404073 ASPIRIN81.000 MG

17714001001 ASPIRIN325.00 MG

17714001010 ASPIRIN325.00 MG

17714001101 ASPIRIN325.00 MG

17714001110 ASPIRIN325.00 MG

17236001436 ASPIRIN81.000 MG

17236037810 ASPIRIN325.00 MG

17236038201 ASPIRIN325.00 MG

17236038210 ASPIRIN325.00 MG

00904058560 ASPIRIN800.00 MG

00904201959 ASPIRIN325.00 MG

00904201980 ASPIRIN325.00 MG

00904200940 ASPIRIN325.00 MG

00904200960 ASPIRIN325.00 MG

00904200970 ASPIRIN325.00 MG

00904201159 ASPIRIN325.00 MG

00904201160 ASPIRIN325.00 MG

00904201360 ASPIRIN325.00 MG

00904201380 ASPIRIN325.00 MG

00904201452 ASPIRIN500.00 MG

00904201492 ASPIRIN500.00 MG

00677134701 ASPIRIN975.00 MG

00677117201 ASPIRIN800.00 MG

00677077201 ASPIRIN650.00 MG

00677077210 ASPIRIN650.00 MG

00615052243 ASPIRIN325.00 MG

00615350843 ASPIRIN75.000 MG

45802070114 ASPIRIN60.000 MG

45802070130 ASPIRIN60.000 MG

45802070133 ASPIRIN60.000 MG

45802070214 ASPIRIN120.00 MG

45802070230 ASPIRIN120.00 MG

45802070233 ASPIRIN120.00 MG

45802070314 ASPIRIN200.00 MG

45802070330 ASPIRIN200.00 MG

45802070333 ASPIRIN200.00 MG

45802070414 ASPIRIN300.00 MG

45802070430 ASPIRIN300.00 MG

45802070433 ASPIRIN300.00 MG

45802070514 ASPIRIN600.00 MG

45802070530 ASPIRIN600.00 MG

45802070533 ASPIRIN600.00 MG

00536329736 ASPIRIN81.000 MG

00536330501 ASPIRIN325.00 MG

00536330510 ASPIRIN325.00 MG

00574000201 ASPIRIN325.00 MG

00574000211 ASPIRIN325.00 MG

00603003121 ASPIRIN325.00 MG

00603003125 ASPIRIN325.00 MG

00603016621 ASPIRIN325.00 MG

00574703412 ASPIRIN300.00 MG

00574703612 ASPIRIN600.00 MG

00182044401 ASPIRIN325.00 MG

00182044410 ASPIRIN325.00 MG

00182044801 ASPIRIN325.00 MG

00182044810 ASPIRIN325.00 MG

00182044817 ASPIRIN325.00 MG

00182044889 ASPIRIN325.00 MG

00182044901 ASPIRIN650.00 MG

00904201372 ASPIRIN325.00 MG

Page 9 of 125

Page 10: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00182106001 ASPIRIN AD WITH ANTACID.000

17236038001 ASPIRIN BUFFERED.000

17236038010 ASPIRIN BUFFERED.000

49483022401 ASPIRIN EC975.00 MG

17236070510 ASPIRIN EC81.000 MG

17236070566 ASPIRIN EC81.000 MG

00904517518 ASPIRIN EC81.000 MG

00615056443 ASPIRIN EC325.00 MG

00677077101 ASPIRIN EC325.00 MG

00677077110 ASPIRIN EC325.00 MG

49483022410 ASPIRIN EC975.00 MG

00182106105 ASPIRIN EC81.000 MG

00182106107 ASPIRIN EC81.000 MG

00536331810 ASPIRIN EC325.00 MG

00536331301 ASPIRIN EC325.00 MG

00536331310 ASPIRIN EC325.00 MG

00536308610 ASPIRIN EC81.000 MG

00536308641 ASPIRIN EC81.000 MG

00904790460 ASPIRIN LOW DOSE81.000 MG

00603236121 ASPIRIN/CODEINE.000

00603236221 ASPIRIN/CODEINE.000

00172398460 ASPIRIN/CODEINE.000

00172398560 ASPIRIN/CODEINE.000

00904390740 ASPIRIN/CODEINE.000

00677064701 ASPIRIN/CODEINE.000

00677067601 ASPIRIN/CODEINE.000

00186115002 ASTRAMORPH.500 MG/ML

00186115102 ASTRAMORPH1.000 MG/ML

00186115212 ASTRAMORPH.500 MG/ML

00186115312 ASTRAMORPH1.000 MG/ML

00186115903 ASTRAMORPH.500 MG/ML

00186116003 ASTRAMORPH1.000 MG/ML

00186000431 ATACAND4.000 MG

00186000831 ATACAND8.000 MG

00186001628 ATACAND16.000 MG

00186001631 ATACAND16.000 MG

00186001654 ATACAND16.000 MG

00186003228 ATACAND32.000 MG

00186003231 ATACAND32.000 MG

00186003254 ATACAND32.000 MG

00186016228 ATACAND HCT.000

00186016254 ATACAND HCT.000

00186032228 ATACAND HCT.000

00186032254 ATACAND HCT.000

59075058510 ATAMET.000

59075058710 ATAMET.000

00049559093 ATARAX10.000 MG/5ML

00049560066 ATARAX10.000 MG

00049561066 ATARAX25.000 MG

00049562066 ATARAX50.000 MG

00049563066 ATARAX100.00 MG

00093075201 ATENOLOL50.000 MG

00093075210 ATENOLOL50.000 MG

00093075301 ATENOLOL100.00 MG

00378075701 ATENOLOL100.00 MG

00378021801 ATENOLOL25.000 MG

00378021810 ATENOLOL25.000 MG

00378023101 ATENOLOL50.000 MG

00378023110 ATENOLOL50.000 MG

00677147801 ATENOLOL50.000 MG

00677147810 ATENOLOL50.000 MG

00677147901 ATENOLOL100.00 MG

00677147910 ATENOLOL100.00 MG

00677163301 ATENOLOL25.000 MG

00677163310 ATENOLOL25.000 MG

00781150601 ATENOLOL50.000 MG

00781150610 ATENOLOL50.000 MG

00781150701 ATENOLOL100.00 MG

00781150710 ATENOLOL100.00 MG

00781107801 ATENOLOL25.000 MG

00781107810 ATENOLOL25.000 MG

00904539260 ATENOLOL25.000 MG

00904539280 ATENOLOL25.000 MG

00904763560 ATENOLOL100.00 MG

49884045601 ATENOLOL50.000 MG

49884045610 ATENOLOL50.000 MG

49884045701 ATENOLOL100.00 MG

49884045710 ATENOLOL100.00 MG

51079075919 ATENOLOL25.000 MG

51079075920 ATENOLOL25.000 MG

51079068419 ATENOLOL50.000 MG

51079068420 ATENOLOL50.000 MG

51079068520 ATENOLOL100.00 MG

53489053601 ATENOLOL25.000 MG

53489053610 ATENOLOL25.000 MG

53489052901 ATENOLOL50.000 MG

53489052910 ATENOLOL50.000 MG

53489053001 ATENOLOL100.00 MG

53489053010 ATENOLOL100.00 MG

60429002530 ATENOLOL50.000 MG

60429002590 ATENOLOL50.000 MG

60429002630 ATENOLOL100.00 MG

60429021190 ATENOLOL25.000 MG

53489053101 ATENOLOL/CHLORTHALIDONE.000

53489053201 ATENOLOL/CHLORTHALIDONE.000

00904788160 ATENOLOL/CHLORTHALIDONE.000

00904788260 ATENOLOL/CHLORTHALIDONE.000

00677148001 ATENOLOL/CHLORTHALIDONE.000

00677148101 ATENOLOL/CHLORTHALIDONE.000

00378206301 ATENOLOL/CHLORTHALIDONE.000

00378206401 ATENOLOL/CHLORTHALIDONE.000

00008006402 ATIVAN1.000 MG

00008006407 ATIVAN1.000 MG

00008006502 ATIVAN2.000 MG

00008006507 ATIVAN2.000 MG

00008058105 ATIVAN2.000 MG/ML

00008058107 ATIVAN2.000 MG/ML

00008008102 ATIVAN.500 MG

00008008105 ATIVAN.500 MG

00008006405 ATIVAN1.000 MG

00074737601 ATRACURIUM BESYLATE10.000 MG/ML

00074737701 ATRACURIUM BESYLATE10.000 MG/ML

00074737901 ATRACURIUM BESYLATE10.000 MG/ML

00904082435 ATROPINE SULFATE1.000 %

24208082555 ATROPINE SULFATE1.000 %

24208075006 ATROPINE SULFATE1.000 %

24208075060 ATROPINE SULFATE1.000 %

00074491118 ATROPINE SULFATE.100 MG/ML

00074491134 ATROPINE SULFATE.100 MG/ML

00065070212 ATROPINE SULFATE1.000 %

00548103900 ATROPINE SULFATE.100 MG/ML

00548203900 ATROPINE SULFATE.100 MG/ML

00548333800 ATROPINE SULFATE.100 MG/ML

00548333900 ATROPINE SULFATE.100 MG/ML

00168006538 ATROPINE SULFATE1.000 %

00168017215 ATROPINE SULFATE1.000 %

61314030301 ATROPINE SULFATE1.000 %

61314030302 ATROPINE SULFATE1.000 %

00074491015 ATROPINE SULFATE ABBOJECT.100 MG/ML

00074491034 ATROPINE SULFATE ABBOJECT.100 MG/ML

00597008062 ATROVENT.020 %

00597008130 ATROVENT.030 %

Page 10 of 125

Page 11: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00597008214 ATROVENT18.000 MCG/ACT

00597008676 ATROVENT.060 %

00472038215 AUGMENTED BETAMETHASONE D.050 %

00472038245 AUGMENTED BETAMETHASONE D.050 %

00168026815 AUGMENTED BETAMETHASONE D.050 %

00168026850 AUGMENTED BETAMETHASONE D.050 %

00904510936 AUGMENTED BETAMETHASONE D.050 %

00904510945 AUGMENTED BETAMETHASONE D.050 %

59930157501 AUGMENTED BETAMETHASONE D.050 %

59930157503 AUGMENTED BETAMETHASONE D.050 %

00029607112 AUGMENTIN.000

00029607212 AUGMENTIN.000

00029608612 AUGMENTIN.000

00029608621 AUGMENTIN.000

00029608729 AUGMENTIN.000

00029608739 AUGMENTIN.000

00029608751 AUGMENTIN.000

00029609229 AUGMENTIN.000

00029609239 AUGMENTIN.000

00029609251 AUGMENTIN.000

00029608012 AUGMENTIN.000

00029608031 AUGMENTIN.000

00904079335 AURODEX.000

00472001699 AUROTO.000

00087277531 AVALIDE.000

00087277532 AVALIDE.000

00087277631 AVALIDE.000

00087277632 AVALIDE.000

00904785599 AVALON OATMEAL BATH/OILAT.000

00904785699 AVALON OATMEAL BATH/REGUL.000

00029315818 AVANDIA2.000 MG

00029315913 AVANDIA4.000 MG

00029315918 AVANDIA4.000 MG

00029315920 AVANDIA4.000 MG

00029316013 AVANDIA8.000 MG

00029316020 AVANDIA8.000 MG

00087277131 AVAPRO75.000 MG

00087277132 AVAPRO75.000 MG

00087277215 AVAPRO150.00 MG

00087277231 AVAPRO150.00 MG

00087277232 AVAPRO150.00 MG

00087277235 AVAPRO150.00 MG

00087277315 AVAPRO300.00 MG

00087277331 AVAPRO300.00 MG

00087277332 AVAPRO300.00 MG

00002246805 AVENTYL10.000 MG/5ML

00002081702 AVENTYL10.000 MG

00002081703 AVENTYL10.000 MG

00002081902 AVENTYL25.000 MG

00002081903 AVENTYL25.000 MG

51285001728 AVIANE.000

62794014002 AVITA.025 %

62794014003 AVITA.025 %

62794014102 AVITA.025 %

62794014103 AVITA.025 %

00002314530 AXID300.00 MG

08290409440 AXILLARY BLOCK NEEDLE BLO.000

08290009440 AXILLARY BLOCK NEEDLE BLO.000

00378100501 AZATHIOPRINE50.000 MG

00054408425 AZATHIOPRINE50.000 MG

00054808425 AZATHIOPRINE50.000 MG

00075006037 AZMACORT100.00 MCG/ACT

00677164630 AZO-GESIC95.000 MG

00904502546 AZO-GESIC95.000 MG

59743011530 AZO-GESIC95.000 MG

00603004816 AZO-SEPTIC95.000 MG

00065027505 AZOPT1.000 %

00065027510 AZOPT1.000 %

00065027515 AZOPT1.000 %

00013010101 AZULFIDINE500.00 MG

00013010120 AZULFIDINE500.00 MG

00013010201 AZULFIDINE EN-TABS500.00 MG

00013010220 AZULFIDINE EN-TABS500.00 MG

61451501507 B & O 15-A SUPPRETTE.000

61451501508 B & O 15-A SUPPRETTE.000

61451501607 B & O 16-A SUPPRETTE.000

61451501608 B & O 16-A SUPPRETTE.000

00904418360 B-COMPLEX.000

00904418160 B-COMPLEX B-12.000

00677160401 B-COMPLEX PLUS VITAMIN C.000

00093915201 B-COMPLEX VITAMIN PLUS.000

00093915205 B-COMPLEX VITAMIN PLUS.000

17236063201 B-COMPLEX W/C.000

17236063210 B-COMPLEX W/C.000

00904422060 B-COMPLEX/B-12 TR.000

00182405901 B-COMPLEX/VITAMIN B-12.000

08290305620 B-D 1/2CC TUBERCULIN SYRI.000

08290309645 B-D 10CC LUER-LOK SYRINGE.000

08290309640 B-D 10CC LUER-LOK SYRINGE.000

08290309641 B-D 10CC LUER-LOK SYRINGE.000

08290309642 B-D 10CC LUER-LOK SYRINGE.000

08290309643 B-D 10CC LUER-LOK SYRINGE.000

08290301029 B-D 10CC SYRINGE LUER-LOK.000

08290301030 B-D 10CC SYRINGE SLIP TIP.000

08290301025 B-D 1CC SYRINGE SLIP TIP.000

08290309664 B-D 2 OZ SYRINGE CATHETER.000

08290309694 B-D 20CC SYRINGE ECCENTRI.000

08290301625 B-D 20CC SYRINGE LUER SLI.000

08290301031 B-D 20CC SYRINGE LUER-LOK.000

08290301032 B-D 20CC SYRINGE SLIP TIP.000

08290309484 B-D 30CC SYRINGE ECCENTRI.000

08290301033 B-D 30CC SYRINGE LUER-LOK.000

08290301034 B-D 30CC SYRINGE SLIP TIP.000

08290309576 B-D 3CC LUER-LOK SYRINGE.000

08290309579 B-D 3CC LUER-LOK SYRINGE.000

08290309580 B-D 3CC LUER-LOK SYRINGE.000

08290309581 B-D 3CC LUER-LOK SYRINGE/.000

08290309578 B-D 3CC LUER-LOK SYRINGE/.000

08290309573 B-D 3CC LUER-LOK SYRINGE/.000

08290309598 B-D 3CC LUER-LOK SYRINGE/.000

08290309587 B-D 3CC LUER-LOK SYRINGE/.000

08290309588 B-D 3CC LUER-LOK SYRINGE/.000

08290309589 B-D 3CC LUER-LOK SYRINGE/.000

08290309599 B-D 3CC LUER-LOK SYRINGE/.000

08290309586 B-D 3CC SYRINGE LUER SLIP.000

08290301026 B-D 3CC SYRINGE LUER-LOK.000

08290301112 B-D 3CC SYRINGE SLIP TIP.000

08290305904 B-D 3CC SYRINGE/SAFETYGLI.000

08290305906 B-D 3CC SYRINGE/SAFETYGLI.000

08290301627 B-D 50-60CC SYRINGE LUER.000

08290309630 B-D 5CC LUER-LOK SYRINGE/.000

08290309631 B-D 5CC LUER-LOK SYRINGE/.000

08290309632 B-D 5CC LUER-LOK SYRINGE/.000

08290309634 B-D 5CC LUER-LOK SYRINGE/.000

08290309635 B-D 5CC LUER-LOK SYRINGE/.000

08290309633 B-D 5CC LUER-LOK SYRINGE/.000

08290309698 B-D 5CC SYRINGE LUER-LOK.000

08290309699 B-D 5CC SYRINGE LUER-LOK.000

08290301027 B-D 5CC SYRINGE LUER-LOK.000

08290301028 B-D 5CC SYRINGE SLIP TIP.000

08290301603 B-D 5CC SYRINGE/LUER SLIP.000

08290301037 B-D 60CC SYRINGE CATHETER.000

Page 11 of 125

Page 12: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

08290301035 B-D 60CC SYRINGE LUER-LOK.000

08290301036 B-D 60CC SYRINGE SLIP TIP.000

08290305140 B-D DISPOSABLE NEEDLE REG.000

08290305128 B-D DISPOSABLE NEEDLE/30G.000

08290305200 B-D FILTER NEEDLE/5 MICRO.000

08290328230 B-D GLUCOSE5.000 GM

08290305190 B-D HYPODERMIC NEEDLE REG.000

08290305193 B-D HYPODERMIC NEEDLE REG.000

08290305102 B-D HYPODERMIC NEEDLE REG.000

08290305103 B-D HYPODERMIC NEEDLE REG.000

08290305177 B-D HYPODERMIC NEEDLE REG.000

08290305185 B-D HYPODERMIC NEEDLE REG.000

08290303005 B-D HYPODERMIC NEEDLE REG.000

08290303006 B-D HYPODERMIC NEEDLE REG.000

08290303007 B-D HYPODERMIC NEEDLE REG.000

08290303008 B-D HYPODERMIC NEEDLE REG.000

08290303009 B-D HYPODERMIC NEEDLE REG.000

08290303011 B-D HYPODERMIC NEEDLE REG.000

08290303013 B-D HYPODERMIC NEEDLE SHO.000

08290303014 B-D HYPODERMIC NEEDLE SHO.000

08290303015 B-D HYPODERMIC NEEDLE SHO.000

08290309311 B-D INSULIN SYRINGE.000

08290309301 B-D INSULIN SYRINGE.000

08290309306 B-D INSULIN SYRINGE.000

08290320096 B-D INSULIN SYRINGE.000

08290328282 B-D INSULIN SYRINGE.000

08290328410 B-D INSULIN SYRINGE.000

08290328465 B-D INSULIN SYRINGE.000

08290329650 B-D INSULIN SYRINGE.000

08290841103 B-D INSULIN SYRINGE.000

08290843103 B-D INSULIN SYRINGE.000

08290846603 B-D INSULIN SYRINGE.000

08290846601 B-D INSULIN SYRINGE.000

08290329651 B-D INSULIN SYRINGE DETAC.000

08290329652 B-D INSULIN SYRINGE DETAC.000

08290329653 B-D INSULIN SYRINGE DETAC.000

08290329622 B-D INSULIN SYRINGE DETAC.000

08290328430 B-D INSULIN SYRINGE MICRO.000

08290329430 B-D INSULIN SYRINGE MICRO.000

08290328283 B-D INSULIN SYRINGE MICRO.000

08290309300 B-D INSULIN SYRINGE MICRO.000

08290328290 B-D INSULIN SYRINGE ULTRA.000

08290328278 B-D INSULIN SYRINGE ULTRA.000

08290328279 B-D INSULIN SYRINGE ULTRA.000

08290329431 B-D INSULIN SYRINGE ULTRA.000

08290329411 B-D INSULIN SYRINGE ULTRA.000

08290328411 B-D INSULIN SYRINGE ULTRA.000

08290328418 B-D INSULIN SYRINGE ULTRA.000

08290329466 B-D INSULIN SYRINGE ULTRA.000

08290843803 B-D INSULIN SYRINGE ULTRA.000

08290841203 B-D INSULIN SYRINGE/MICRO.000

08290841003 B-D INSULIN SYRINGE/MICRO.000

08290329410 B-D INSULIN SYRINGE/MICRO.000

08290329465 B-D INSULIN SYRINGE/MICRO.000

08290328412 B-D INSULIN SYRINGE/MICRO.000

08290329412 B-D INSULIN SYRINGE/MICRO.000

08290329420 B-D INSULIN SYRINGE/MICRO.000

08290329424 B-D INSULIN SYRINGE/MICRO.000

08290329461 B-D INSULIN SYRINGE/MICRO.000

08290328281 B-D INSULIN SYRINGE/MICRO.000

08290309305 B-D INSULIN SYRINGE/MICRO.000

08290846502 B-D INSULIN SYRINGE/MICRO.000

08290309309 B-D INSULIN SYRINGE/U-100.000

08290309310 B-D INSULIN SYRINGE/U-100.000

08290329485 B-D INSULIN SYRINGE/U-100.000

08290328204 B-D PEN.000

08290321951 B-D PEN MINI.000

08290309661 B-D SYRINGE.000

08290309644 B-D SYRINGE.000

08290841803 B-D ULTRA-FINE II SHORT.000

08290846803 B-D ULTRA-FINE II SHORT N.000

08290320109 B-D ULTRAFINE III SHORT P.000

08290328203 B-D ULTRAFINE ORIGINAL PE.000

10267102501 B-PLEX.000

10267102505 B-PLEX.000

00182406201 B-PLEX.000

10267102701 B-PLEX PLUS.000

10267102705 B-PLEX PLUS.000

00182074767 BABY VITAMIN.000

00182609567 BABY VITAMIN/IRON.000

00168002938 BAC/POLY/NEOMY/HC.000

00009023301 BACITRACIN50000. U

00168002638 BACITRACIN500.00 U/GM

00182020830 BACITRACIN500.00 U/GM

00182020833 BACITRACIN500.00 U/GM

00182020834 BACITRACIN500.00 U/GM

00574020001 BACITRACIN50000. U

00603044150 BACITRACIN500.00 U/GM

45802006001 BACITRACIN500.00 U/GM

45802006003 BACITRACIN500.00 U/GM

45802006005 BACITRACIN500.00 U/GM

45802006070 BACITRACIN500.00 U/GM

00713028031 BACITRACIN500.00 U/GM

00904072936 BACITRACIN500.00 U/GM

00168001104 BACITRACIN ZINC500.00 U/GM

00168001116 BACITRACIN ZINC500.00 U/GM

00168001131 BACITRACIN ZINC500.00 U/GM

00168001135 BACITRACIN ZINC500.00 U/GM

00168011109 BACITRACIN ZINC500.00 U/GM

00472110516 BACITRACIN ZINC500.00 U/GM

00472110534 BACITRACIN ZINC500.00 U/GM

00472110556 BACITRACIN ZINC500.00 U/GM

00168001209 BACITRACIN/NEOMYCIN/POLYM.000

00168001231 BACITRACIN/NEOMYCIN/POLYM.000

00168001235 BACITRACIN/NEOMYCIN/POLYM.000

00168002738 BACITRACIN/NEOMYCIN/POLYM.000

00168002109 BACITRACIN/POLYMYXIN.000

00168002131 BACITRACIN/POLYMYXIN.000

00168002135 BACITRACIN/POLYMYXIN.000

24208055555 BACITRACIN/POLYMYXIN B.000

19810005791 BACKACHE MAXIMUM STRENGTH580.00 MG

00904336540 BACLOFEN10.000 MG

00904336560 BACLOFEN10.000 MG

00904336561 BACLOFEN10.000 MG

00904336640 BACLOFEN20.000 MG

00904336660 BACLOFEN20.000 MG

00904521640 BACLOFEN10.000 MG

00904521660 BACLOFEN10.000 MG

00832102400 BACLOFEN10.000 MG

00832102410 BACLOFEN10.000 MG

00832102450 BACLOFEN10.000 MG

00832102500 BACLOFEN20.000 MG

00832102550 BACLOFEN20.000 MG

00677126001 BACLOFEN20.000 MG

51552061305 BACLOFEN.000

00591573005 BACLOFEN10.000 MG

00591573105 BACLOFEN20.000 MG

00172409660 BACLOFEN10.000 MG

00172409680 BACLOFEN10.000 MG

00172409760 BACLOFEN20.000 MG

00172409765 BACLOFEN20.000 MG

00182129589 BACLOFEN10.000 MG

Page 12 of 125

Page 13: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00182129689 BACLOFEN20.000 MG

00074397703 BACTERIOSTATIC WATER FOR.000

00029602540 BACTOCILL1.000 GM

00029602840 BACTOCILL2.000 GM

00004195501 BACTRIM.000

00004195801 BACTRIM.000

00029152544 BACTROBAN2.000 %

00904767660 BALANCE PMS FORMULA.000

00904319251 BALANCED B-100.000

00904418452 BALANCED B-50.000

00904317760 BALANCED B-50.000

00074391103 BALANCED SALT.000

00032196071 BALNEOL.000

00072420008 BALNETAR LIQUIM2.500 %

00904367822 BALSA-DERM.000

00456052316 BANALG.000

00456052321 BANALG.000

00456052521 BANALG-HS LINIMENT.000

00456060101 BANCAP-HC.000

00904517416 BANOPHEN12.500 MG/5ML

00904517428 BANOPHEN12.500 MG/5ML

00904535431 BANOPHEN.000

00904203059 BANOPHEN25.000 MG

00904203060 BANOPHEN25.000 MG

00904122800 BANOPHEN12.500 MG/5ML

00904122820 BANOPHEN12.500 MG/5ML

00904786331 BANOPHEN MAXIMUM STRENGTH2.000 %

00037030192 BARBIDONNA.000

00026063504 BAYGAM.000

00026063512 BAYGAM.000

00026063601 BAYHEP B.000

00026063605 BAYHEP B.000

00026061802 BAYRAB150.00 IU/ML

00026061810 BAYRAB150.00 IU/ML

00182611672 BEDDING SPRAY.500 %

00904315560 BEE POLLEN500.00 MG

00536335708 BEE-ZEE.000

00486113201 BEELITH.000

51991007512 BELCOMP-PB.000

00574704512 BELLADONNA & OPIUM.000

00254903558 BELLADONNA ALKA/PB.000

00574704012 BELLADONNA ALKALOIDS & OP.000

00603241821 BELLADONNA ALKALOIDS/PHEN.000

00603241832 BELLADONNA ALKALOIDS/PHEN.000

00603103058 BELLADONNA ALKALOIDS/PHEN.000

00254232028 BELLADONNA ALKALOIDS/PHEN.000

00143114010 BELLADONNA ALKALOIDS/PHEN.000

00143114051 BELLADONNA ALKALOIDS/PHEN.000

00904374161 BELLADONNA ALKALOIDS/PHEN.000

00904254860 BELLAMINE.000

00071425903 BENADRYL50.000 MG/ML

00071425913 BENADRYL50.000 MG/ML

00071425945 BENADRYL50.000 MG/ML

00071440210 BENADRYL50.000 MG/ML

00071084013 BENADRYL25.000 MG

00071084018 BENADRYL25.000 MG

00071233317 BENADRYL ALLERGY12.500 MG/5ML

00904203624 BENAPHEN PLUS.000

51552013504 BENTONITE.000

00071219517 BENYLIN15.000 MG/5ML

00071240117 BENYLIN PEDIATRIC7.500 MG/5ML

00066044160 BENZAGEL WASH10.000 %

00066043115 BENZAGEL-1010.000 %

00066043015 BENZAGEL-55.000 %

00066051046 BENZAMYCIN.000

45802007703 BENZOCAINE5.000 %

51552022804 BENZOIN COMPOUND TINCTURE.000

00574911902 BENZOIN COMPOUND TINCTURE.000

51552017704 BENZOIN TINCTURE PLAIN.000

50111085101 BENZONATATE100.00 MG

00904773760 BENZONATATE100.00 MG

00677147201 BENZONATATE100.00 MG

00603242621 BENZONATATE100.00 MG

00603242628 BENZONATATE100.00 MG

00258367801 BENZONATATE200.00 MG

00258365401 BENZONATATE100.00 MG

00258365405 BENZONATATE100.00 MG

00182108001 BENZONATATE100.00 MG

00603770982 BENZOYL PEROXIDE5.000 %

00603771082 BENZOYL PEROXIDE10.000 %

00603771482 BENZOYL PEROXIDE5.000 %

00603771487 BENZOYL PEROXIDE5.000 %

00603771582 BENZOYL PEROXIDE10.000 %

00603771587 BENZOYL PEROXIDE10.000 %

00536408956 BENZOYL PEROXIDE5.000 %

00536409256 BENZOYL PEROXIDE10.000 %

00536081095 BENZOYL PEROXIDE5.000 %

00536081595 BENZOYL PEROXIDE10.000 %

45802025342 BENZOYL PEROXIDE10.000 %

45802015449 BENZOYL PEROXIDE5.000 %

50111039301 BENZTROPINE MESYLATE.500 MG

50111039401 BENZTROPINE MESYLATE1.000 MG

50111039403 BENZTROPINE MESYLATE1.000 MG

50111039501 BENZTROPINE MESYLATE2.000 MG

50111039503 BENZTROPINE MESYLATE2.000 MG

49884016401 BENZTROPINE MESYLATE.500 MG

49884016501 BENZTROPINE MESYLATE1.000 MG

49884016510 BENZTROPINE MESYLATE1.000 MG

49884016601 BENZTROPINE MESYLATE2.000 MG

49884016610 BENZTROPINE MESYLATE2.000 MG

51079022020 BENZTROPINE MESYLATE.500 MG

51079022119 BENZTROPINE MESYLATE1.000 MG

51079022120 BENZTROPINE MESYLATE1.000 MG

51079022220 BENZTROPINE MESYLATE2.000 MG

00904105560 BENZTROPINE MESYLATE.500 MG

00904105561 BENZTROPINE MESYLATE.500 MG

00904105661 BENZTROPINE MESYLATE1.000 MG

00904105680 BENZTROPINE MESYLATE1.000 MG

00904105760 BENZTROPINE MESYLATE2.000 MG

00904105761 BENZTROPINE MESYLATE2.000 MG

00904105780 BENZTROPINE MESYLATE2.000 MG

00832108000 BENZTROPINE MESYLATE.500 MG

00832108010 BENZTROPINE MESYLATE.500 MG

00832108100 BENZTROPINE MESYLATE1.000 MG

00832108110 BENZTROPINE MESYLATE1.000 MG

00832108200 BENZTROPINE MESYLATE2.000 MG

00832108210 BENZTROPINE MESYLATE2.000 MG

17236084701 BENZTROPINE MESYLATE1.000 MG

17236084710 BENZTROPINE MESYLATE1.000 MG

17236084801 BENZTROPINE MESYLATE2.000 MG

17236084810 BENZTROPINE MESYLATE2.000 MG

00182129989 BENZTROPINE MESYLATE.500 MG

00182170089 BENZTROPINE MESYLATE1.000 MG

00182170189 BENZTROPINE MESYLATE2.000 MG

00004002001 BEROCCA.000

00004015201 BEROCCA PLUS.000

00536490201 BETA CAROTENE25000. IU

00904431560 BETA CAROTENE25000. IU

00904422260 BETA CAROTENE10000. IU

00093067139 BETA-VAL.100 %

00093067315 BETA-VAL.100 %

00093067395 BETA-VAL.100 %

Page 13 of 125

Page 14: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00034236040 BETADINE7.500 %

00034210001 BETADINE10.000 %

00034210002 BETADINE10.000 %

00034210040 BETADINE10.000 %

00034210080 BETADINE10.000 %

00034210087 BETADINE10.000 %

00034210088 BETADINE10.000 %

00034210089 BETADINE10.000 %

00034210090 BETADINE10.000 %

00034231033 BETADINE5.000 %

00034234001 BETADINE10.000 %

00034234003 BETADINE10.000 %

00034234010 BETADINE10.000 %

00034234019 BETADINE10.000 %

00034200005 BETADINE ANTIBIOTIC/MOIST.000

00034235040 BETADINE SKIN CLEANSER7.500 %

00034220001 BETADINE SURGICAL SCRUB7.500 %

00034220004 BETADINE SURGICAL SCRUB7.500 %

00034220088 BETADINE SURGICAL SCRUB7.500 %

00034220089 BETADINE SURGICAL SCRUB7.500 %

00034220090 BETADINE SURGICAL SCRUB7.500 %

00034213580 BETADINE SWAB AID10.000 %

00034213001 BETADINE SWABSTICKS10.000 %

00034213003 BETADINE SWABSTICKS10.000 %

00093030239 BETAMETHASONE DIPROPIONAT.050 %

00093030260 BETAMETHASONE DIPROPIONAT.050 %

00472038015 BETAMETHASONE DIPROPIONAT.050 %

00472038045 BETAMETHASONE DIPROPIONAT.050 %

00472038115 BETAMETHASONE DIPROPIONAT.050 %

00472038145 BETAMETHASONE DIPROPIONAT.050 %

00168005515 BETAMETHASONE DIPROPIONAT.050 %

00168005546 BETAMETHASONE DIPROPIONAT.050 %

00168005615 BETAMETHASONE DIPROPIONAT.050 %

00168005646 BETAMETHASONE DIPROPIONAT.050 %

00168005760 BETAMETHASONE DIPROPIONAT.050 %

45802001935 BETAMETHASONE DIPROPIONAT.050 %

45802001942 BETAMETHASONE DIPROPIONAT.050 %

45802002146 BETAMETHASONE DIPROPIONAT.050 %

45802002197 BETAMETHASONE DIPROPIONAT.050 %

00904076736 BETAMETHASONE DIPROPIONAT.050 %

00904076745 BETAMETHASONE DIPROPIONAT.050 %

00904076803 BETAMETHASONE DIPROPIONAT.050 %

00904077645 BETAMETHASONE VALERATE.100 %

00904077803 BETAMETHASONE VALERATE.100 %

00168003315 BETAMETHASONE VALERATE.100 %

00168003346 BETAMETHASONE VALERATE.100 %

00168004015 BETAMETHASONE VALERATE.100 %

00168004046 BETAMETHASONE VALERATE.100 %

00168004160 BETAMETHASONE VALERATE.100 %

00472037015 BETAMETHASONE VALERATE.100 %

00472037045 BETAMETHASONE VALERATE.100 %

00472037115 BETAMETHASONE VALERATE.100 %

00472037145 BETAMETHASONE VALERATE.100 %

50419010510 BETAPACE80.000 MG

50419010511 BETAPACE80.000 MG

50419010610 BETAPACE160.00 MG

50419010611 BETAPACE160.00 MG

50419010710 BETAPACE240.00 MG

50419010711 BETAPACE240.00 MG

50419010910 BETAPACE120.00 MG

50419010911 BETAPACE120.00 MG

50419011506 BETAPACE AF80.000 MG

50419011511 BETAPACE AF80.000 MG

50419011606 BETAPACE AF160.00 MG

50419011611 BETAPACE AF160.00 MG

50419011906 BETAPACE AF120.00 MG

50419011911 BETAPACE AF120.00 MG

00034340401 BETASEPT SURGICAL SCRUB4.000 %

00034340440 BETASEPT SURGICAL SCRUB4.000 %

00034340487 BETASEPT SURGICAL SCRUB4.000 %

00034340489 BETASEPT SURGICAL SCRUB4.000 %

00034340490 BETASEPT SURGICAL SCRUB4.000 %

00034340498 BETASEPT SURGICAL SCRUB4.000 %

61314024501 BETAXOLOL HCL.500 %

61314024502 BETAXOLOL HCL.500 %

61314024503 BETAXOLOL HCL.500 %

60505055602 BETAXOLOL HCL.500 %

60505055603 BETAXOLOL HCL.500 %

60505055604 BETAXOLOL HCL.500 %

50111032301 BETHANECHOL CHLORIDE5.000 MG

50111032401 BETHANECHOL CHLORIDE10.000 MG

50111032501 BETHANECHOL CHLORIDE25.000 MG

50111032601 BETHANECHOL CHLORIDE50.000 MG

65086052205 BETIMOL.250 %

65086052210 BETIMOL.250 %

65086052215 BETIMOL.250 %

65086052505 BETIMOL.500 %

65086052510 BETIMOL.500 %

65086052515 BETIMOL.500 %

00065024605 BETOPTIC-S.250 %

00065024610 BETOPTIC-S.250 %

00065024615 BETOPTIC-S.250 %

00065024620 BETOPTIC-S.250 %

00575022501 BICITRA.000

00575022530 BICITRA.000

17314933001 BICITRA.000

00904508160 BILBERRY FRUIT375.00 MG

62794009965 BIOBRANE GLOVES.000

62794009966 BIOBRANE GLOVES.000

62794009967 BIOBRANE GLOVES.000

62794009968 BIOBRANE GLOVES.000

62794009677 BIOBRANE II /THIN LARGE P.000

62794009525 BIOBRANE II/LARGE PORE.000

62794009576 BIOBRANE II/LARGE PORE SH.000

62794009577 BIOBRANE II/LARGE PORE SH.000

62794009676 BIOBRANE II/THIN LARGE PO.000

00065041928 BION TEARS.000

00536665901 BIOTIN300.00 MCG

00182406001 BIOTIN300.00 MCG

00904543360 BIOTIN300.00 MCG

00713041625 BISAC-EVAC5.000 MG

00713010901 BISAC-EVAC10.000 MG

00713010905 BISAC-EVAC10.000 MG

00713010908 BISAC-EVAC10.000 MG

00713010910 BISAC-EVAC10.000 MG

00713010912 BISAC-EVAC10.000 MG

00713010950 BISAC-EVAC10.000 MG

00603808611 BISACODYL10.000 MG

00677078001 BISACODYL10.000 MG

00677078012 BISACODYL10.000 MG

45802071014 BISACODYL10.000 MG

45802071030 BISACODYL10.000 MG

45802071032 BISACODYL10.000 MG

45802071033 BISACODYL10.000 MG

45802071034 BISACODYL10.000 MG

45802071047 BISACODYL10.000 MG

53265076012 BISACODYL10.000 MG

53265076050 BISACODYL10.000 MG

00245010405 BISACODYL10.000 MG

00245010412 BISACODYL10.000 MG

00245010450 BISACODYL10.000 MG

00574705005 BISACODYL10.000 MG

Page 14 of 125

Page 15: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00574705012 BISACODYL10.000 MG

00574705050 BISACODYL10.000 MG

00536135501 BISACODYL10.000 MG

00536135512 BISACODYL10.000 MG

00536338101 BISACODYL EC5.000 MG

00536338110 BISACODYL EC5.000 MG

00603248121 BISACODYL EC5.000 MG

00603248132 BISACODYL EC5.000 MG

00603005435 BISACODYL EC5.000 MG

00574000401 BISACODYL EC5.000 MG

00574000410 BISACODYL EC5.000 MG

00574000411 BISACODYL EC5.000 MG

00182853489 BISACODYL EC5.000 MG

00254006028 BISACODYL EC5.000 MG

53265012210 BISACODYL EC5.000 MG

53265012211 BISACODYL EC5.000 MG

00677057801 BISACODYL EC5.000 MG

00677057810 BISACODYL EC5.000 MG

00615059843 BISACODYL EC5.000 MG

00904792717 BISACODYL EC5.000 MG

00904792760 BISACODYL EC5.000 MG

00904792761 BISACODYL EC5.000 MG

00904792780 BISACODYL EC5.000 MG

17236012101 BISACODYL EC5.000 MG

17236012110 BISACODYL EC5.000 MG

00904505812 BISCOLAX10.000 MG

00904505860 BISCOLAX10.000 MG

00904131309 BISMATROL524.00 MG/30ML

00904131409 BISMATROL690.00 MG/30ML

00904131546 BISMATROL262.00 MG

00185077101 BISOPROLOL FUMARATE5.000 MG

00185077130 BISOPROLOL FUMARATE5.000 MG

00185077401 BISOPROLOL FUMARATE10.000 MG

00185077430 BISOPROLOL FUMARATE10.000 MG

51079095520 BISOPROLOL FUMARATE & HYD.000

51079095620 BISOPROLOL FUMARATE & HYD.000

51079095420 BISOPROLOL FUMARATE/HCTZ.000

00781183301 BISOPROLOL FUMARATE/HCTZ.000

00781182401 BISOPROLOL FUMARATE/HCTZ.000

00781184101 BISOPROLOL FUMARATE/HCTZ.000

00185070101 BISOPROLOL FUMARATE/HCTZ.000

00185070105 BISOPROLOL FUMARATE/HCTZ.000

00185070130 BISOPROLOL FUMARATE/HCTZ.000

00185070401 BISOPROLOL FUMARATE/HCTZ.000

00185070405 BISOPROLOL FUMARATE/HCTZ.000

00185070430 BISOPROLOL FUMARATE/HCTZ.000

00185070701 BISOPROLOL FUMARATE/HCTZ.000

00185070705 BISOPROLOL FUMARATE/HCTZ.000

00185070730 BISOPROLOL FUMARATE/HCTZ.000

00172573060 BISOPROLOL FUMARATE/HCTZ.000

00378050101 BISOPROLOL FUMARATE/HCTZ.000

00378050301 BISOPROLOL FUMARATE/HCTZ.000

00378050501 BISOPROLOL FUMARATE/HCTZ.000

00015306301 BLENOXANE30.000 U

00015301020 BLENOXANE15.000 U

00074163601 BLEOMYCIN SULFATE15.000 U

00006043768 BLOCADREN20.000 MG

00006013668 BLOCADREN10.000 MG

00006005968 BLOCADREN5.000 MG

00536230259 BLUE GEL MUSCULAR RELIEF.000

00904317140 BONE MEAL/VITAMIN D.000

00904317170 BONE MEAL/VITAMIN D.000

00087098703 BOOST.000

00087098743 BOOST.000

00087067004 BOOST.000

00087067044 BOOST.000

00087067417 BOOST.000

00087067445 BOOST.000

00087067457 BOOST.000

00087067517 BOOST.000

00087067545 BOOST.000

00087067557 BOOST.000

00087067617 BOOST.000

00087067645 BOOST.000

00087067657 BOOST.000

00087067711 BOOST.000

00087067745 BOOST.000

00087067751 BOOST.000

00087094145 BOOST HIGH PROTEIN.000

00087094146 BOOST HIGH PROTEIN.000

00087094147 BOOST HIGH PROTEIN.000

00087094405 BOOST HIGH PROTEIN.000

00087094407 BOOST HIGH PROTEIN.000

00087094445 BOOST HIGH PROTEIN.000

00087094447 BOOST HIGH PROTEIN.000

00087094005 BOOST HIGH PROTEIN.000

00087094006 BOOST HIGH PROTEIN.000

00087094007 BOOST HIGH PROTEIN.000

00087094045 BOOST HIGH PROTEIN.000

00087094047 BOOST HIGH PROTEIN.000

00087094105 BOOST HIGH PROTEIN.000

00087094106 BOOST HIGH PROTEIN.000

00087094107 BOOST HIGH PROTEIN.000

00087035101 BOOST HIGH PROTEIN.000

00087093111 BOOST PLUS.000

00087093145 BOOST PLUS.000

00087093151 BOOST PLUS.000

00087093211 BOOST PLUS.000

00087093245 BOOST PLUS.000

00087093251 BOOST PLUS.000

00087093304 BOOST PLUS.000

00087093344 BOOST PLUS.000

00087093345 BOOST PLUS.000

00087095104 BOOST/FIBER.000

00087095144 BOOST/FIBER.000

00087095202 BOOST/FIBER.000

00087095242 BOOST/FIBER.000

00168004231 BORIC ACID10.000 %

51552004604 BORIC ACID.000

51552034304 BORIC ACID.000

00904352403 BOROFAIR.000

00904316825 BRAN500.00 MG

00024105010 BREONESIN200.00 MG

00028750701 BRETHINE1.000 MG/ML

00028007201 BRETHINE2.500 MG

00028007210 BRETHINE2.500 MG

00028010501 BRETHINE5.000 MG

00028010510 BRETHINE5.000 MG

00074169810 BRETYLIUM TOSYLATE50.000 MG/ML

00074926301 BRETYLIUM TOSYLATE50.000 MG/ML

00074926718 BRETYLIUM TOSYLATE50.000 MG/ML

00074926801 BRETYLIUM TOSYLATE50.000 MG/ML

00641221141 BRETYLIUM TOSYLATE50.000 MG/ML

00074763862 BRETYLIUM TOSYLATE/D5W.000

00074763962 BRETYLIUM TOSYLATE/D5W.000

52544025428 BREVICON-28.000

00904317570 BREWERS YEAST500.00 MG

00904422327 BREWERS YEAST.000

00182602240 BROMATANE DX.000

50383059316 BROMETANE DX.000

50383059328 BROMETANE DX.000

00451420104 BROMFED.000

Page 15 of 125

Page 16: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00451420116 BROMFED.000

00451406050 BROMFED.000

00451410116 BROMFED DM.000

58177001904 BROMFENEX.000

58177002004 BROMFENEX PD.000

00781181701 BROMOCRIPTINE MESYLATE2.500 MG

00781181731 BROMOCRIPTINE MESYLATE2.500 MG

00603104458 BROMOPHED DX.000

00603250521 BROMPHENIRAMINE/PSEUDOEPH.000

00603250621 BROMPHENIRAMINE/PSEUDOEPH.000

00482044001 BRONTEX.000

00482044116 BRONTEX.000

00536344801 BRONTO-VITES.000

54838012540 BROTAPP.000

54838012570 BROTAPP.000

54838012580 BROTAPP.000

54838013640 BROTAPP DM.000

54838013670 BROTAPP DM.000

00065079515 BSS.000

00065079525 BSS.000

00065079530 BSS.000

00065079550 BSS.000

00065080050 BSS PLUS.000

00182190901 BUFFERED ASPIRIN.000

00182190910 BUFFERED ASPIRIN.000

19810000525 BUFFERIN.000

19810000526 BUFFERIN.000

19810000527 BUFFERIN.000

19810000731 BUFFERIN.000

19810000532 BUFFERIN ARTHRITIS STRENG.000

19810007171 BUFFERIN EXTRA STRENGTH.000

19810007172 BUFFERIN EXTRA STRENGTH.000

19810007173 BUFFERIN EXTRA STRENGTH.000

19810000903 BUFFERIN LOW DOSE81.000 MG

00615454153 BUMETANIDE.500 MG

00615454163 BUMETANIDE.500 MG

51079089120 BUMETANIDE.500 MG

51079089219 BUMETANIDE1.000 MG

51079089220 BUMETANIDE1.000 MG

51079089320 BUMETANIDE2.000 MG

00172423260 BUMETANIDE.500 MG

00172423360 BUMETANIDE1.000 MG

00172423380 BUMETANIDE1.000 MG

00172423460 BUMETANIDE2.000 MG

00172423480 BUMETANIDE2.000 MG

00185012801 BUMETANIDE.500 MG

00185012805 BUMETANIDE.500 MG

00185012901 BUMETANIDE1.000 MG

00185012905 BUMETANIDE1.000 MG

00185013001 BUMETANIDE2.000 MG

00185013005 BUMETANIDE2.000 MG

00378041701 BUMETANIDE2.000 MG

00378024501 BUMETANIDE.500 MG

00378037001 BUMETANIDE1.000 MG

00074141204 BUMETANIDE.250 MG/ML

00074141210 BUMETANIDE.250 MG/ML

00004012101 BUMEX1.000 MG

00004012501 BUMEX.500 MG

00004016201 BUMEX2.000 MG

00004194406 BUMEX.250 MG/ML

00004012111 BUMEX1.000 MG

00004012114 BUMEX1.000 MG

00004012511 BUMEX.500 MG

00004016211 BUMEX2.000 MG

00074115801 BUPIVACAINE HCL.250 %

00074115802 BUPIVACAINE HCL.250 %

00074115901 BUPIVACAINE HCL.250 %

00074115902 BUPIVACAINE HCL.250 %

00074116001 BUPIVACAINE HCL.250 %

00074116101 BUPIVACAINE HCL.500 %

00074116201 BUPIVACAINE HCL.500 %

00074116202 BUPIVACAINE HCL.500 %

00074116301 BUPIVACAINE HCL.500 %

00074116401 BUPIVACAINE HCL.750 %

00074116501 BUPIVACAINE HCL.750 %

00074116502 BUPIVACAINE HCL.750 %

00074427201 BUPIVACAINE HCL.250 %

00074427301 BUPIVACAINE HCL.500 %

00074427401 BUPIVACAINE HCL.750 %

00074574922 BUPIVACAINE HCL.250 %

00074361301 BUPIVACAINE/DEXTROSE SPIN.000

00074904101 BUPIVACAINE/EPINEPHRINE.000

00074904201 BUPIVACAINE/EPINEPHRINE.000

00074904202 BUPIVACAINE/EPINEPHRINE.000

00074904301 BUPIVACAINE/EPINEPHRINE.000

00074904401 BUPIVACAINE/EPINEPHRINE.000

00074904501 BUPIVACAINE/EPINEPHRINE.000

00074904502 BUPIVACAINE/EPINEPHRINE.000

00074904601 BUPIVACAINE/EPINEPHRINE.000

00074904701 BUPIVACAINE/EPINEPHRINE.000

00074201201 BUPRENORPHINE HCL.324 MG/ML

00093028001 BUPROPION HCL75.000 MG

00093029001 BUPROPION HCL100.00 MG

00378043301 BUPROPION HCL75.000 MG

00378043501 BUPROPION HCL100.00 MG

51079094320 BUPROPION HCL75.000 MG

51079094420 BUPROPION HCL100.00 MG

00781106401 BUPROPION HCL100.00 MG

00781105301 BUPROPION HCL75.000 MG

45802007903 BURN OINTMENT.000

45802007905 BURN OINTMENT.000

00087081841 BUSPAR5.000 MG

00087081844 BUSPAR5.000 MG

00087081941 BUSPAR10.000 MG

00087081944 BUSPAR10.000 MG

00087082232 BUSPAR15.000 MG

00087082233 BUSPAR15.000 MG

00087082481 BUSPAR30.000 MG

00378116580 BUSPIRONE HCL15.000 MG

00378116591 BUSPIRONE HCL15.000 MG

51079096020 BUSPIRONE HCL15.000 MG

49884072501 BUSPIRONE HCL7.500 MG

49884072505 BUSPIRONE HCL7.500 MG

00677143901 BUTAL/ASA/CAFF.000

00527155201 BUTAL/ASA/CAFF.000

00228202310 BUTAL/ASA/CAFF.000

00228202396 BUTAL/ASA/CAFF.000

00143178501 BUTAL/ASA/CAFF.000

00143178510 BUTAL/ASA/CAFF.000

00904514060 BUTAL/ASA/CAFF/COD.000

00904393460 BUTALBITAL COMPOUND.000

00904389260 BUTALBITAL COMPOUND.000

00904389280 BUTALBITAL COMPOUND.000

00603254821 BUTALBITAL COMPOUND.000

00603254832 BUTALBITAL COMPOUND.000

00603255021 BUTALBITAL COMPOUND.000

00603254021 BUTALBITAL/ACETAMINOPHEN.000

00143111501 BUTALBITAL/ACETAMINOPHEN/.000

00143111505 BUTALBITAL/ACETAMINOPHEN/.000

00258365701 BUTALBITAL/ACETAMINOPHEN/.000

00143178701 BUTALBITAL/APAP/CAFFEINE.000

00143178705 BUTALBITAL/APAP/CAFFEINE.000

Page 16 of 125

Page 17: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00182265905 BUTALBITAL/APAP/CAFFEINE.000

00603254621 BUTALBITAL/APAP/CAFFEINE.000

00603254721 BUTALBITAL/APAP/CAFFEINE.000

00603254728 BUTALBITAL/APAP/CAFFEINE.000

00093085401 BUTALBITAL/APAP/CAFFEINE.000

00904328040 BUTALBITAL/APAP/CAFFEINE.000

00904328060 BUTALBITAL/APAP/CAFFEINE.000

00904549060 BUTALBITAL/APAP/CAFFEINE.000

17236045901 BUTALBITAL/APAP/CAFFEINE.000

17236045905 BUTALBITAL/APAP/CAFFEINE.000

00677173801 BUTALBITAL/APAP/CAFFEINE.000

00677174801 BUTALBITAL/APAP/CAFFEINE.000

52544048505 BUTALBITAL/APAP/CAFFEINE.000

00143300001 BUTALBITAL/APAP/CAFFEINE/.000

00182163101 BUTALBITAL/ASPIRIN/CAFFEI.000

60951067570 BUTALBITAL/ASPIRIN/CAFFEI.000

00037011016 BUTISOL SODIUM30.000 MG/5ML

00037011360 BUTISOL SODIUM30.000 MG

00037011380 BUTISOL SODIUM30.000 MG

00074162301 BUTORPHANOL TARTRATE1.000 MG/ML

00074162401 BUTORPHANOL TARTRATE1.000 MG/ML

00074162601 BUTORPHANOL TARTRATE2.000 MG/ML

00074162602 BUTORPHANOL TARTRATE2.000 MG/ML

00074162701 BUTORPHANOL TARTRATE2.000 MG/ML

00074230101 BUTORPHANOL TARTRATE1.000 MG/ML

00074230201 BUTORPHANOL TARTRATE2.000 MG/ML

00074486701 BUTTERFLY.000

00074456501 BUTTERFLY.000

00074487102 BUTTERFLY INT.000

00904123000 BYDRAMINE12.500 MG/5ML

00904123009 BYDRAMINE12.500 MG/5ML

00904123020 BYDRAMINE12.500 MG/5ML

00904317260 C-BIOFLAVANOIDS.000

60258078016 C-COF HC.000

60258078116 C-COF XP.000

59743005701 C-HIST SR.000

17714001601 C.P.M.4.000 MG

17714001610 C.P.M.4.000 MG

00904424960 C/ROSE HIPS500.00 MG

00904425060 C/ROSE HIPS1000.0 MG

00904175089 CAFATINE PB.000

00078003302 CAFERGOT.000

00078034905 CAFERGOT.000

00904775339 CAFFEINE200.00 MG

00904775344 CAFFEINE200.00 MG

00536474297 CAL-GEST ANTACID500.00 MG

00071318119 CALADRYL.000

00182603037 CALAMINE.000

00904253300 CALAMINE.000

45802013082 CALAMINE.000

51552022304 CALAMINE.000

45802023482 CALAMINE PHENOLATED.000

00025177131 CALAN40.000 MG

00025185131 CALAN80.000 MG

00025185151 CALAN80.000 MG

00025185152 CALAN80.000 MG

00025186131 CALAN120.00 MG

00025186152 CALAN120.00 MG

00025189131 CALAN SR240.00 MG

00025189134 CALAN SR240.00 MG

00025189151 CALAN SR240.00 MG

00025190131 CALAN SR120.00 MG

00025190134 CALAN SR120.00 MG

00025191131 CALAN SR180.00 MG

00025191134 CALAN SR180.00 MG

00182414005 CALCARB 6001500.0 MG

00182414026 CALCARB 6001500.0 MG

00182414126 CALCARB/D 600.000

54391002502 CALCI-CHEW1250.0 MG

54391022502 CALCI-CHEW1250.0 MG

54391032502 CALCI-CHEW1250.0 MG

00091115005 CALCIFEROL500000 IU/ML

00091415060 CALCIFEROL8000.0 IU/ML

00074811031 CALCIJEX1.000 MCG/ML

00074120001 CALCIJEX1.000 MCG/ML

00536277085 CALCIONATE1.800 GM/5ML

51991040516 CALCIQUID1.800 GM/5ML

00904527260 CALCITRATE/VITAMIN D.000

00536342608 CALCIUM 6001500.0 MG

00536342408 CALCIUM 600-D.000

00603009526 CALCIUM ANTACID500.00 MG

00904125792 CALCIUM ANTACID500.00 MG

00904125892 CALCIUM ANTACID500.00 MG

00904769591 CALCIUM ANTACID EXTRA STR750.00 MG

00603009627 CALCIUM ANTACID EXTRA STR750.00 MG

00603009727 CALCIUM ANTACID EXTRA STR750.00 MG

00536688908 CALCIUM CARBONATE500.00 MG

00536341410 CALCIUM CARBONATE650.00 MG

00054811616 CALCIUM CARBONATE1250.0 MG/5ML

00054812025 CALCIUM CARBONATE1250.0 MG

00054412025 CALCIUM CARBONATE1250.0 MG

00054311763 CALCIUM CARBONATE1250.0 MG/5ML

00904323252 CALCIUM CARBONATE600.00 MG

00904323261 CALCIUM CARBONATE600.00 MG

00904323292 CALCIUM CARBONATE600.00 MG

17714002501 CALCIUM CARBONATE648.00 MG

17714002510 CALCIUM CARBONATE648.00 MG

00002203502 CALCIUM CARBONATE650.00 MG

00074163110 CALCIUM CHLORIDE10.000 %

00548330400 CALCIUM CHLORIDE10.000 %

00548200400 CALCIUM CHLORIDE10.000 %

00548100400 CALCIUM CHLORIDE10.000 %

00074492818 CALCIUM CHLORIDE ABBOJECT10.000 %

00074492834 CALCIUM CHLORIDE ABBOJECT10.000 %

00074490818 CALCIUM CHLORIDE ABBOJECT10.000 %

00182415101 CALCIUM CITRATE950.00 MG

00904506260 CALCIUM CITRATE950.00 MG

00074389405 CALCIUM GLUCEPTATE1.100 GM/5ML

00074118401 CALCIUM GLUCONATE10.000 %

00054412125 CALCIUM GLUCONATE500.00 MG

00054812125 CALCIUM GLUCONATE500.00 MG

00536341610 CALCIUM GLUCONATE650.00 MG

00536341710 CALCIUM GLUCONATE975.00 MG

17236038810 CALCIUM GLUCONATE650.00 MG

00904263660 CALCIUM LACTATE650.00 MG

00904263680 CALCIUM LACTATE650.00 MG

00536342201 CALCIUM LACTATE650.00 MG

00536342210 CALCIUM LACTATE650.00 MG

00182036201 CALCIUM LACTATE650.00 MG

00904529418 CALCIUM PYRUVATE600.00 MG

00904543760 CALCIUM-MAGNESIUM-ZINC.000

00182415601 CALCIUM/MAGNESIUM.000

00904323352 CALCIUM/VITAMIN D.000

00904323392 CALCIUM/VITAMIN D.000

45802007282 CALDYPHEN.000

45802034182 CALDYPHEN.000

45802034282 CALDYPHEN.000

00904263321 CALLERGY.000

00904776021 CALLERGY CLEAR.000

00005551019 CALTRATE 6001500.0 MG

00005550919 CALTRATE 600 PLUS/VIT D.000

00005550924 CALTRATE 600 PLUS/VIT D.000

Page 17 of 125

Page 18: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00005555619 CALTRATE PLUS.000

00005556719 CALTRATE PLUS.000

00024201505 CAMPHO-PHENIQUE.000

00024515006 CAMPHO-PHENIQUE.000

00024021201 CAMPHO-PHENIQUE.000

00024021202 CAMPHO-PHENIQUE.000

00904785175 CAMPHOR & PHENOL.000

00003045051 CAPOTEN12.500 MG

00003048550 CAPOTEN100.00 MG

00003033850 CAPOZIDE.000

00003038450 CAPOZIDE.000

00003039050 CAPOZIDE.000

00496081002 CAPSAICIN.025 %

45802033010 CAPSAICIN.025 %

45802033023 CAPSAICIN.025 %

00182507652 CAPSAICIN.025 %

00536252525 CAPSAICIN.025 %

00182512852 CAPSICUM OLEORESIN.025 %

00182512952 CAPSICUM OLEORESIN.075 %

60976002501 CAPSIN.025 %

60976007501 CAPSIN.075 %

00364262801 CAPTOPRIL12.500 MG

00378300701 CAPTOPRIL12.500 MG

00378300710 CAPTOPRIL12.500 MG

00378301201 CAPTOPRIL25.000 MG

00378301210 CAPTOPRIL25.000 MG

00378301701 CAPTOPRIL50.000 MG

00378301710 CAPTOPRIL50.000 MG

00378302201 CAPTOPRIL100.00 MG

00143117101 CAPTOPRIL12.500 MG

00143117110 CAPTOPRIL12.500 MG

00143117125 CAPTOPRIL12.500 MG

00143117201 CAPTOPRIL25.000 MG

00143117210 CAPTOPRIL25.000 MG

00143117225 CAPTOPRIL25.000 MG

00143117301 CAPTOPRIL50.000 MG

00143117310 CAPTOPRIL50.000 MG

00143117325 CAPTOPRIL50.000 MG

00143117401 CAPTOPRIL100.00 MG

00143117425 CAPTOPRIL100.00 MG

51079086320 CAPTOPRIL12.500 MG

51079086420 CAPTOPRIL25.000 MG

55370014207 CAPTOPRIL25.000 MG

55370014209 CAPTOPRIL25.000 MG

55370014407 CAPTOPRIL50.000 MG

55370014409 CAPTOPRIL50.000 MG

55370014507 CAPTOPRIL100.00 MG

55370016407 CAPTOPRIL12.500 MG

55370016409 CAPTOPRIL12.500 MG

00904504560 CAPTOPRIL12.500 MG

00904504580 CAPTOPRIL12.500 MG

00904504660 CAPTOPRIL25.000 MG

00904504680 CAPTOPRIL25.000 MG

00904504760 CAPTOPRIL50.000 MG

00904504780 CAPTOPRIL50.000 MG

00904504860 CAPTOPRIL100.00 MG

59930165501 CAPTOPRIL12.500 MG

59930165502 CAPTOPRIL12.500 MG

59930165503 CAPTOPRIL12.500 MG

59930165601 CAPTOPRIL25.000 MG

59930165602 CAPTOPRIL25.000 MG

59930165603 CAPTOPRIL25.000 MG

59930165701 CAPTOPRIL50.000 MG

59930165702 CAPTOPRIL50.000 MG

59930165703 CAPTOPRIL50.000 MG

59930165801 CAPTOPRIL100.00 MG

59772704501 CAPTOPRIL12.500 MG

59772704503 CAPTOPRIL12.500 MG

59772704601 CAPTOPRIL25.000 MG

59772704603 CAPTOPRIL25.000 MG

59772704701 CAPTOPRIL50.000 MG

59772704703 CAPTOPRIL50.000 MG

59772704801 CAPTOPRIL100.00 MG

60429003060 CAPTOPRIL25.000 MG

60429003130 CAPTOPRIL50.000 MG

00093017601 CAPTOPRIL/HYDROCHLOROTHIA.000

00093017701 CAPTOPRIL/HYDROCHLOROTHIA.000

00093018101 CAPTOPRIL/HYDROCHLOROTHIA.000

00093018201 CAPTOPRIL/HYDROCHLOROTHIA.000

00378008101 CAPTOPRIL/HYDROCHLOROTHIA.000

00378008301 CAPTOPRIL/HYDROCHLOROTHIA.000

00378008401 CAPTOPRIL/HYDROCHLOROTHIA.000

00378008601 CAPTOPRIL/HYDROCHLOROTHIA.000

59772516005 CAPTOPRIL/HYDROCHLOROTHIA.000

59772516105 CAPTOPRIL/HYDROCHLOROTHIA.000

59772516205 CAPTOPRIL/HYDROCHLOROTHIA.000

59772516305 CAPTOPRIL/HYDROCHLOROTHIA.000

60951073170 CAPTOPRIL/HYDROCHLOROTHIA.000

60951073370 CAPTOPRIL/HYDROCHLOROTHIA.000

60951073970 CAPTOPRIL/HYDROCHLOROTHIA.000

60951074170 CAPTOPRIL/HYDROCHLOROTHIA.000

53303002016 CARA-KLENZ.000

53303002060 CARA-KLENZ.000

53303002062 CARA-KLENZ.000

51079087019 CARBAMAZEPINE100.00 MG

51079087020 CARBAMAZEPINE100.00 MG

51079038519 CARBAMAZEPINE200.00 MG

51079038520 CARBAMAZEPINE200.00 MG

00615451543 CARBAMAZEPINE100.00 MG

00904385560 CARBAMAZEPINE200.00 MG

00904385561 CARBAMAZEPINE200.00 MG

00904385580 CARBAMAZEPINE200.00 MG

17236035201 CARBAMAZEPINE200.00 MG

17236035205 CARBAMAZEPINE200.00 MG

17236035210 CARBAMAZEPINE200.00 MG

00182133189 CARBAMAZEPINE100.00 MG

00182123389 CARBAMAZEPINE200.00 MG

00258358701 CARBAMAZEPINE200.00 MG

00258358710 CARBAMAZEPINE200.00 MG

00228214310 CARBAMAZEPINE200.00 MG

00228214350 CARBAMAZEPINE200.00 MG

00228214396 CARBAMAZEPINE200.00 MG

00093010901 CARBAMAZEPINE200.00 MG

00093010910 CARBAMAZEPINE200.00 MG

00093077801 CARBAMAZEPINE100.00 MG

00904322035 CARBAMIDE PEROXIDE6.500 %

58768073512 CARBASTAT.010 %

60258027816 CARBIC-D.000

00904771861 CARBIDOPA/LEVODOPA.000

00904771961 CARBIDOPA/LEVODOPA.000

00904772061 CARBIDOPA/LEVODOPA.000

00615356143 CARBIDOPA/LEVODOPA.000

51079078320 CARBIDOPA/LEVODOPA.000

51079075520 CARBIDOPA/LEVODOPA.000

51079075619 CARBIDOPA/LEVODOPA.000

51079075620 CARBIDOPA/LEVODOPA.000

00093029201 CARBIDOPA/LEVODOPA.000

00093029205 CARBIDOPA/LEVODOPA.000

00093029301 CARBIDOPA/LEVODOPA.000

00093029305 CARBIDOPA/LEVODOPA.000

00093029310 CARBIDOPA/LEVODOPA.000

00093029401 CARBIDOPA/LEVODOPA.000

Page 18 of 125

Page 19: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00093029405 CARBIDOPA/LEVODOPA.000

00093029410 CARBIDOPA/LEVODOPA.000

00228234010 CARBIDOPA/LEVODOPA.000

00228234050 CARBIDOPA/LEVODOPA.000

00228234096 CARBIDOPA/LEVODOPA.000

00228253810 CARBIDOPA/LEVODOPA.000

00228253850 CARBIDOPA/LEVODOPA.000

00228253910 CARBIDOPA/LEVODOPA.000

00228253950 CARBIDOPA/LEVODOPA.000

00228253996 CARBIDOPA/LEVODOPA.000

00228254010 CARBIDOPA/LEVODOPA.000

00228254050 CARBIDOPA/LEVODOPA.000

00228254096 CARBIDOPA/LEVODOPA.000

00182194989 CARBIDOPA/LEVODOPA.000

60951060368 CARBIDOPA/LEVODOPA.000

60951060568 CARBIDOPA/LEVODOPA.000

60951060585 CARBIDOPA/LEVODOPA.000

60951060768 CARBIDOPA/LEVODOPA.000

60951060785 CARBIDOPA/LEVODOPA.000

00378008801 CARBIDOPA/LEVODOPA ER.000

00378009401 CARBIDOPA/LEVODOPA ER.000

51079092319 CARBIDOPA/LEVODOPA ER.000

51079092320 CARBIDOPA/LEVODOPA ER.000

60432010130 CARBINOXAMINE.000

60432020204 CARBINOXAMINE COMPOUND.000

60432020216 CARBINOXAMINE COMPOUND.000

60432095130 CARBINOXAMINE COMPOUND.000

60432010204 CARBINOXAMINE SYRUP.000

60432010208 CARBINOXAMINE SYRUP.000

60432010216 CARBINOXAMINE SYRUP.000

00074103630 CARBOCAINE1.000 %

00074103850 CARBOCAINE1.000 %

00074106720 CARBOCAINE2.000 %

00074204750 CARBOCAINE2.000 %

00003403202 CARBOFLEX ODOR CONTROL DR.000

00003403203 CARBOFLEX ODOR CONTROL DR.000

00003403204 CARBOFLEX ODOR CONTROL DR.000

00004018301 CARDENE20.000 MG

00004018401 CARDENE30.000 MG

00004018022 CARDENE SR30.000 MG

00004018091 CARDENE SR30.000 MG

00004018122 CARDENE SR45.000 MG

00004018222 CARDENE SR60.000 MG

00004018191 CARDENE SR45.000 MG

00049275066 CARDURA1.000 MG

00049276066 CARDURA2.000 MG

00049277066 CARDURA4.000 MG

00049278066 CARDURA8.000 MG

00143117601 CARISOPRODOL350.00 MG

00143117605 CARISOPRODOL350.00 MG

00143117610 CARISOPRODOL350.00 MG

00603258221 CARISOPRODOL350.00 MG

00603258228 CARISOPRODOL350.00 MG

00603258232 CARISOPRODOL350.00 MG

51079005520 CARISOPRODOL350.00 MG

51285087404 CARISOPRODOL350.00 MG

51285087405 CARISOPRODOL350.00 MG

53489011001 CARISOPRODOL350.00 MG

53489011005 CARISOPRODOL350.00 MG

53489011010 CARISOPRODOL350.00 MG

00677058901 CARISOPRODOL350.00 MG

00677058905 CARISOPRODOL350.00 MG

00677058906 CARISOPRODOL350.00 MG

00677058907 CARISOPRODOL350.00 MG

00677058910 CARISOPRODOL350.00 MG

00904035560 CARISOPRODOL350.00 MG

00904035580 CARISOPRODOL350.00 MG

49884024601 CARISOPRODOL/ASPIRIN.000

49884024605 CARISOPRODOL/ASPIRIN.000

00185072401 CARISOPRODOL/ASPIRIN.000

00185072405 CARISOPRODOL/ASPIRIN.000

00603258321 CARISOPRODOL/ASPIRIN.000

00603258421 CARISOPRODOL/ASPIRIN/CODE.000

00185074901 CARISOPRODOL/ASPIRIN/CODE.000

53303014140 CARRADRES.000

53303000018 CARRAFILM TRANSPARENT FIL.000

53303000019 CARRAFILM TRANSPARENT FIL.000

53303000020 CARRAFILM TRANSPARENT FIL.000

53303000021 CARRAFILM TRANSPARENT FIL.000

53303013140 CARRAFOAM.000

53303013180 CARRAFOAM.000

53303014414 CARRAGINATE.000

53303014420 CARRAGINATE.000

53303014440 CARRAGINATE.000

53303014480 CARRAGINATE.000

53303014040 CARRASMART FILM.000

53303014060 CARRASMART FILM.000

53303014220 CARRASMART FOAM.000

53303014240 CARRASMART FOAM.000

53303014260 CARRASMART FOAM.000

53303000008 CARRASORB H.000

53303000009 CARRASORB H.000

53303000010 CARRASORB H.000

53303000016 CARRASORB M DRIGEL.000

53303001205 CARRASYN V HYDROGEL WOUND.000

53303001230 CARRASYN V HYDROGEL WOUND.000

53303017260 CARRAVITE.000

53303001101 CARRINGTON.000

53303004004 CARRINGTON MOISTURE BARRI.000

53303004040 CARRINGTON MOISTURE BARRI.000

53303004104 CARRINGTON MOISTURE BARRI.000

53303004135 CARRINGTON MOISTURE BARRI.000

53303011108 CARRINGTON SHAMPOO & BODY.000

53303006040 CARRINGTON SKIN BALM.000

24208036705 CARTEOLOL HCL1.000 %

24208036710 CARTEOLOL HCL1.000 %

24208036715 CARTEOLOL HCL1.000 %

61314023805 CARTEOLOL HCL1.000 %

61314023810 CARTEOLOL HCL1.000 %

62037059705 CARTIA XT120.00 MG

62037059790 CARTIA XT120.00 MG

62037059805 CARTIA XT180.00 MG

62037059890 CARTIA XT180.00 MG

62037059905 CARTIA XT240.00 MG

62037059990 CARTIA XT240.00 MG

62037060005 CARTIA XT300.00 MG

62037060090 CARTIA XT300.00 MG

00074166413 CARTROL2.500 MG

00074166513 CARTROL5.000 MG

00054804816 CASCARA SAGRADA325.00 MG/5ML

00574331202 CASTOR OIL95.000 %

00028015101 CATAFLAM50.000 MG

00597000601 CATAPRES.100 MG

00597000701 CATAPRES.200 MG

00597001101 CATAPRES.300 MG

00597003112 CATAPRES-TTS-1.100 MG/24HR

00597003212 CATAPRES-TTS-2.200 MG/24HR

00597003334 CATAPRES-TTS-3.300 MG/24HR

00281018737 CATRIX CORRECTION.000

00904527360 CATS CLAW350.00 MG

00904508260 CAYENNE PEPPER450.00 MG

00456070701 CEBO #1 BLUE.000

Page 19 of 125

Page 20: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00456070801 CEBO #2 GREEN.000

00456070901 CEBO #3 ORANGE.000

00002306102 CECLOR250.00 MG

00002306115 CECLOR250.00 MG

00002306215 CECLOR500.00 MG

00002505768 CECLOR125.00 MG/5ML

00002505818 CECLOR250.00 MG/5ML

00002505868 CECLOR250.00 MG/5ML

00002513048 CECLOR187.00 MG/5ML

00002513248 CECLOR375.00 MG/5ML

00904793260 CEFACLOR250.00 MG

00904793407 CEFACLOR125.00 MG/5ML

00904793471 CEFACLOR125.00 MG/5ML

00904793550 CEFACLOR187.00 MG/5ML

00904793607 CEFACLOR250.00 MG/5ML

00904793671 CEFACLOR250.00 MG/5ML

00904793704 CEFACLOR375.00 MG/5ML

00904793750 CEFACLOR375.00 MG/5ML

00172477060 CEFACLOR250.00 MG

00172477160 CEFACLOR500.00 MG

00172477222 CEFACLOR125.00 MG/5ML

00172477223 CEFACLOR125.00 MG/5ML

00172477321 CEFACLOR187.00 MG/5ML

00172477422 CEFACLOR250.00 MG/5ML

00172477423 CEFACLOR250.00 MG/5ML

00172477520 CEFACLOR375.00 MG/5ML

00172477521 CEFACLOR375.00 MG/5ML

63304095401 CEFACLOR125.00 MG/5ML

63304095402 CEFACLOR125.00 MG/5ML

63304095503 CEFACLOR187.00 MG/5ML

63304095504 CEFACLOR187.00 MG/5ML

63304095601 CEFACLOR250.00 MG/5ML

63304095602 CEFACLOR250.00 MG/5ML

63304095703 CEFACLOR375.00 MG/5ML

63304095704 CEFACLOR375.00 MG/5ML

63304065801 CEFACLOR250.00 MG

63304065901 CEFACLOR500.00 MG

55370089407 CEFACLOR250.00 MG

55370089507 CEFACLOR500.00 MG

55370089614 CEFACLOR250.00 MG/5ML

55370089675 CEFACLOR250.00 MG/5ML

55370089714 CEFACLOR125.00 MG/5ML

55370089775 CEFACLOR125.00 MG/5ML

55370089813 CEFACLOR375.00 MG/5ML

55370089821 CEFACLOR375.00 MG/5ML

55370089913 CEFACLOR187.00 MG/5ML

55370089921 CEFACLOR187.00 MG/5ML

00172419460 CEFACLOR ER500.00 MG

63304051250 CEFADROXIL HEMIHYDRATE1.000 GM

63304058201 CEFADROXIL HEMIHYDRATE500.00 MG

63304058250 CEFADROXIL HEMIHYDRATE500.00 MG

00172405843 CEFADROXIL MONOHYDRATE500.00 MG

00172405848 CEFADROXIL MONOHYDRATE500.00 MG

00172405860 CEFADROXIL MONOHYDRATE500.00 MG

00172405870 CEFADROXIL MONOHYDRATE500.00 MG

00172405948 CEFADROXIL MONOHYDRATE1.000 GM

00904787860 CEFADROXIL MONOHYDRATE500.00 MG

59772727103 CEFADROXIL MONOHYDRATE500.00 MG

00015762898 CEFADYL1.000 GM

00015733899 CEFAZOLIN SODIUM500.00 MG

00015733912 CEFAZOLIN SODIUM1.000 GM

00015733999 CEFAZOLIN SODIUM1.000 GM

00015734639 CEFAZOLIN SODIUM10.000 GM

00015734697 CEFAZOLIN SODIUM10.000 GM

00093070407 CEFAZOLIN SODIUM500.00 MG

00093070507 CEFAZOLIN SODIUM1.000 GM

00093070603 CEFAZOLIN SODIUM500.00 MG

00093070703 CEFAZOLIN SODIUM1.000 GM

00093070903 CEFAZOLIN SODIUM10.000 GM

00074473203 CEFAZOLIN SODIUM1.000 GM

00015733812 CEFAZOLIN SODIUM500.00 MG

00074608913 CEFOL.000

00173038700 CEFTIN250.00 MG

00173038701 CEFTIN250.00 MG

00173038742 CEFTIN250.00 MG

00173039400 CEFTIN500.00 MG

00173039401 CEFTIN500.00 MG

00173039442 CEFTIN500.00 MG

00002950001 CEFUROXIME SODIUM7.500 GM

00002899510 CEFUROXIME SODIUM1.500 GM

00781391870 CEFUROXIME SODIUM750.00 MG

00781392646 CEFUROXIME SODIUM7.500 GM

00002536225 CEFUROXIME SODIUM750.00 MG

00002536310 CEFUROXIME SODIUM1.500 GM

00002535725 CEFUROXIME SODIUM750.00 MG

00781392280 CEFUROXIME SODIUM1.500 GM

00025152031 CELEBREX100.00 MG

00025152034 CELEBREX100.00 MG

00025152051 CELEBREX100.00 MG

00025152531 CELEBREX200.00 MG

00025152534 CELEBREX200.00 MG

00025152551 CELEBREX200.00 MG

00085056605 CELESTONE-SOLUSPAN.000

51285044202 CENESTIN.625 MG

51285044205 CENESTIN.625 MG

51285044302 CENESTIN.900 MG

51285044305 CENESTIN.900 MG

51285044402 CENESTIN1.250 MG

51285044405 CENESTIN1.250 MG

00074339732 CENOLATE500.00 MG/ML

00074311831 CENOLATE500.00 MG/ML

54838001070 CENTAMIN.000

54838001080 CENTAMIN.000

00005423930 CENTRUM.000

00005434361 CENTRUM.000

00005497502 CENTRUM HERBALS GARLIC300.00 MG

00005424919 CENTRUM JR/EXTRA C.000

00005422219 CENTRUM JR/EXTRA CALCIUM.000

00005423419 CENTRUM JR/IRON.000

00005417719 CENTRUM SILVER.000

00005417723 CENTRUM SILVER.000

51079060420 CEPHALEXIN MONOHYDRATE250.00 MG

51079060520 CEPHALEXIN MONOHYDRATE500.00 MG

00093314501 CEPHALEXIN MONOHYDRATE250.00 MG

00093314505 CEPHALEXIN MONOHYDRATE250.00 MG

00093314701 CEPHALEXIN MONOHYDRATE500.00 MG

00093314705 CEPHALEXIN MONOHYDRATE500.00 MG

00093417573 CEPHALEXIN MONOHYDRATE125.00 MG/5ML

00093417574 CEPHALEXIN MONOHYDRATE125.00 MG/5ML

00093417773 CEPHALEXIN MONOHYDRATE250.00 MG/5ML

00093417774 CEPHALEXIN MONOHYDRATE250.00 MG/5ML

00093223801 CEPHALEXIN MONOHYDRATE250.00 MG

00093224001 CEPHALEXIN MONOHYDRATE500.00 MG

00182127989 CEPHALEXIN MONOHYDRATE500.00 MG

00172407360 CEPHALEXIN MONOHYDRATE250.00 MG

00172407370 CEPHALEXIN MONOHYDRATE250.00 MG

00172407460 CEPHALEXIN MONOHYDRATE500.00 MG

00172407470 CEPHALEXIN MONOHYDRATE500.00 MG

00332314705 CEPHALEXIN MONOHYDRATE500.00 MG

60429003740 CEPHALEXIN MONOHYDRATE500.00 MG

63304065601 CEPHALEXIN MONOHYDRATE250.00 MG

63304065605 CEPHALEXIN MONOHYDRATE250.00 MG

Page 20 of 125

Page 21: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

63304065701 CEPHALEXIN MONOHYDRATE500.00 MG

63304065705 CEPHALEXIN MONOHYDRATE500.00 MG

63304095801 CEPHALEXIN MONOHYDRATE125.00 MG/5ML

63304095802 CEPHALEXIN MONOHYDRATE125.00 MG/5ML

63304095901 CEPHALEXIN MONOHYDRATE250.00 MG/5ML

63304095902 CEPHALEXIN MONOHYDRATE250.00 MG/5ML

60429003640 CEPHALEXIN MONOHYDRATE250.00 MG

00536279059 CEROVITE.000

00536344238 CEROVITE ADVANCED FORMULA.000

00536344308 CEROVITE JR.000

00536344508 CEROVITE SILVER.000

00904502309 CERTA-VITE.000

00182614244 CERTAGEN.000

00182416201 CERTAGEN.000

00182416205 CERTAGEN.000

00182416210 CERTAGEN.000

00182415826 CERTAGEN SENIOR.000

00603772986 CERVICAL AMINO ACID.000

00031825001 CHAPSTICK PETROLEUM JELLY.000

00031825401 CHAPSTICK PETROLEUM JELLY.000

00031825801 CHAPSTICK PETROLEUM JELLY.000

00536667101 CHELATED ZINC50.000 MG

54092040216 CHERACOL/CODEINE.000

00603107554 CHERATUSSIN AC.000

00603107556 CHERATUSSIN AC.000

00603107558 CHERATUSSIN AC.000

00603107560 CHERATUSSIN AC.000

00254906558 CHERATUSSIN DAC.000

00603107858 CHERATUSSIN DAC.000

00182113920 CHEWABLE ANTACID500.00 MG

00904323852 CHEWABLE CALCIUM1250.0 MG

00904269860 CHEWABLE MULTIVITAMINS/FL.000

00093915901 CHEWABLE MULTIVITAMINS/FL.000

00904527460 CHEWABLE MULTIVITE W/FL.000

00904527560 CHEWABLE MULTIVITE W/FL.000

00904268360 CHEWABLE VITAMIN/FLUORIDE.000

00904268380 CHEWABLE VITAMIN/FLUORIDE.000

00904422452 CHILDREN MULTI-VIT.000

50383057804 CHILDREN'S ALLERGY MEDICI12.500 MG/5ML

50383057816 CHILDREN'S ALLERGY MEDICI12.500 MG/5ML

17236002201 CHILDREN'S CHEWABLE MULTI.000

17236011301 CHILDREN'S CHEWABLE MULTI.000

54838014440 CHILDREN'S SILAPAP160.00 MG/5ML

54838014470 CHILDREN'S SILAPAP160.00 MG/5ML

54838014480 CHILDREN'S SILAPAP160.00 MG/5ML

54838013740 CHILDREN'S SILFEDRINE30.000 MG/5ML

54838013770 CHILDREN'S SILFEDRINE30.000 MG/5ML

54838010440 CHILDREN'S SILFEDRINE15.000 MG/5ML

54838010470 CHILDREN'S SILFEDRINE15.000 MG/5ML

17714000936 CHILDRENS ASPIRIN81.000 MG

00182142095 CHILDRENS ASPIRIN81.000 MG

00031224201 CHILDRENS DIMETAPP DECONG.000

00904530920 CHILDRENS IBUPROFEN100.00 MG/5ML

00904546335 CHILDRENS IBUPROFEN40.000 MG/ML

00904546420 CHILDRENS IBUPROFEN100.00 MG/5ML

00009500302 CHILDRENS NASALCROM5.200 MG/ACT

00536012372 CHILDRENS PAIN/FEVER100.00 MG/ML

53100021492 CHILDRENS PANADOL80.000 MG

00904768652 CHILDS CHEW COMPLETE.000

00904767060 CHILDS CHEW VITE.000

00904262160 CHILDS CHEW VITE.000

00904262170 CHILDS CHEW VITE.000

00904767160 CHILDS CHEW VITE/IRON.000

00904765460 CHILDS CHEW/C.000

00904053660 CHILDS IRON.000

00904053670 CHILDS IRON.000

00904053680 CHILDS IRON.000

00085083503 CHLOR-TRIMETON2.000 MG/5ML

00085018406 CHLOR-TRIMETON.000

00085018407 CHLOR-TRIMETON.000

00085090103 CHLOR-TRIMETON.000

00085008001 CHLOR-TRIMETON4.000 MG

00085008002 CHLOR-TRIMETON4.000 MG

00085000902 CHLOR-TRIMETON REPETABS12.000 MG

00085000903 CHLOR-TRIMETON REPETABS12.000 MG

00085000909 CHLOR-TRIMETON REPETABS12.000 MG

00085037402 CHLOR-TRIMETON REPETABS8.000 MG

00085037409 CHLOR-TRIMETON REPETABS8.000 MG

00603108858 CHLORAL HYDRATE500.00 MG/5ML

00904130016 CHLORAL HYDRATE500.00 MG/5ML

60432053316 CHLORAL HYDRATE500.00 MG/5ML

60793040571 CHLORAMPHENICOL SODIUM SU1.000 GM

51079014120 CHLORDIAZEPOXIDE HCL25.000 MG

51079014121 CHLORDIAZEPOXIDE HCL25.000 MG

51079037420 CHLORDIAZEPOXIDE HCL5.000 MG

51079037421 CHLORDIAZEPOXIDE HCL5.000 MG

51079037520 CHLORDIAZEPOXIDE HCL10.000 MG

51079037521 CHLORDIAZEPOXIDE HCL10.000 MG

00555003302 CHLORDIAZEPOXIDE HCL10.000 MG

00555003305 CHLORDIAZEPOXIDE HCL10.000 MG

00555015802 CHLORDIAZEPOXIDE HCL5.000 MG

00555015804 CHLORDIAZEPOXIDE HCL5.000 MG

00555015902 CHLORDIAZEPOXIDE HCL25.000 MG

00555015904 CHLORDIAZEPOXIDE HCL25.000 MG

00378027701 CHLORDIAZEPOXIDE/AMITRIPT.000

00378027705 CHLORDIAZEPOXIDE/AMITRIPT.000

00378021101 CHLORDIAZEPOXIDE/AMITRIPT.000

00378021105 CHLORDIAZEPOXIDE/AMITRIPT.000

00603271421 CHLORDIAZEPOXIDE/CLIDINIU.000

00603271432 CHLORDIAZEPOXIDE/CLIDINIU.000

00677124701 CHLORDIAZEPOXIDE/CLIDINIU.000

00677124710 CHLORDIAZEPOXIDE/CLIDINIU.000

00904250360 CHLORDIAZEPOXIDE/CLIDINIU.000

00904250380 CHLORDIAZEPOXIDE/CLIDINIU.000

50383072016 CHLORHEXADINE GLUCONATE.120 %

00472003616 CHLORHEXIDINE GLUCONATE.120 %

00093001416 CHLORHEXIDINE GLUCONATE.120 %

60505035500 CHLORHEXIDINE GLUCONATE.120 %

61570040571 CHLOROMYCETIN1.000 GM

00536345101 CHLOROPHYLL.000

00074416901 CHLOROPROCAINE HCL2.000 %

00074417001 CHLOROPROCAINE HCL3.000 %

00115705606 CHLOROQUINE PHOSPHATE250.00 MG

00143212522 CHLOROQUINE PHOSPHATE500.00 MG

52604808007 CHLOROSTAT2.000 %

52604808009 CHLOROSTAT2.000 %

51079006020 CHLOROTHIAZIDE250.00 MG

51079006120 CHLOROTHIAZIDE500.00 MG

00378015001 CHLOROTHIAZIDE250.00 MG

00378016201 CHLOROTHIAZIDE500.00 MG

00143120901 CHLOROTHIAZIDE250.00 MG

00143121001 CHLOROTHIAZIDE500.00 MG

00182047101 CHLORPHENIRAMINE MALEATE4.000 MG

00182047110 CHLORPHENIRAMINE MALEATE4.000 MG

00603278421 CHLORPHENIRAMINE MALEATE8.000 MG

00603278432 CHLORPHENIRAMINE MALEATE8.000 MG

00603278521 CHLORPHENIRAMINE MALEATE12.000 MG

00603278532 CHLORPHENIRAMINE MALEATE12.000 MG

00677168701 CHLORPHENIRAMINE MALEATE4.000 MG

00677168710 CHLORPHENIRAMINE MALEATE4.000 MG

17236011601 CHLORPHENIRAMINE MALEATE4.000 MG

17236011610 CHLORPHENIRAMINE MALEATE4.000 MG

Page 21 of 125

Page 22: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

17236011624 CHLORPHENIRAMINE MALEATE4.000 MG

51079016320 CHLORPHENIRAMINE MALEATE4.000 MG

53746003701 CHLORPHENIRAMINE MALEATE4.000 MG

53746003730 CHLORPHENIRAMINE MALEATE4.000 MG

53746003750 CHLORPHENIRAMINE MALEATE4.000 MG

53746003779 CHLORPHENIRAMINE MALEATE4.000 MG

00677174701 CHLORPHENIRAMINE/PSEUDOEP.000

00185130401 CHLORPHENIRAMINE/PSEUDOEP.000

00185130410 CHLORPHENIRAMINE/PSEUDOEP.000

00472074298 CHLORPROMAZINE HCL100.00 MG/ML

00054314658 CHLORPROMAZINE HCL100.00 MG/ML

00641139735 CHLORPROMAZINE HCL25.000 MG/ML

00641139835 CHLORPROMAZINE HCL25.000 MG/ML

00832030000 CHLORPROMAZINE HCL10.000 MG

00832030010 CHLORPROMAZINE HCL10.000 MG

00832030100 CHLORPROMAZINE HCL25.000 MG

00832030110 CHLORPROMAZINE HCL25.000 MG

00832030200 CHLORPROMAZINE HCL50.000 MG

00832030210 CHLORPROMAZINE HCL50.000 MG

00832030300 CHLORPROMAZINE HCL100.00 MG

00832030310 CHLORPROMAZINE HCL100.00 MG

00832030400 CHLORPROMAZINE HCL200.00 MG

00832030410 CHLORPROMAZINE HCL200.00 MG

00781171501 CHLORPROMAZINE HCL10.000 MG

00781171513 CHLORPROMAZINE HCL10.000 MG

00781171601 CHLORPROMAZINE HCL25.000 MG

00781171610 CHLORPROMAZINE HCL25.000 MG

00781171613 CHLORPROMAZINE HCL25.000 MG

00781171701 CHLORPROMAZINE HCL50.000 MG

00781171801 CHLORPROMAZINE HCL100.00 MG

00781171810 CHLORPROMAZINE HCL100.00 MG

00781171813 CHLORPROMAZINE HCL100.00 MG

00781171901 CHLORPROMAZINE HCL200.00 MG

51079013020 CHLORPROMAZINE HCL50.000 MG

51079051620 CHLORPROMAZINE HCL100.00 MG

51079051720 CHLORPROMAZINE HCL200.00 MG

51079051820 CHLORPROMAZINE HCL10.000 MG

51079051920 CHLORPROMAZINE HCL25.000 MG

00781171910 CHLORPROMAZINE HCL200.00 MG

51079020220 CHLORPROPAMIDE100.00 MG

51079020320 CHLORPROPAMIDE250.00 MG

50111037201 CHLORPROPAMIDE100.00 MG

50111037301 CHLORPROPAMIDE250.00 MG

50111037303 CHLORPROPAMIDE250.00 MG

00904022560 CHLORPROPAMIDE100.00 MG

00904022660 CHLORPROPAMIDE250.00 MG

00378019701 CHLORPROPAMIDE100.00 MG

00378019705 CHLORPROPAMIDE100.00 MG

00378021001 CHLORPROPAMIDE250.00 MG

00378021010 CHLORPROPAMIDE250.00 MG

00603283521 CHLORPROPAMIDE100.00 MG

00182185189 CHLORPROPAMIDE100.00 MG

00378021301 CHLORTHALIDONE50.000 MG

00378021310 CHLORTHALIDONE50.000 MG

00378022201 CHLORTHALIDONE25.000 MG

00378022210 CHLORTHALIDONE25.000 MG

00904134961 CHLORTHALIDONE25.000 MG

00904134980 CHLORTHALIDONE25.000 MG

00904135080 CHLORTHALIDONE50.000 MG

00904135160 CHLORTHALIDONE100.00 MG

00904766380 CHLORTHALIDONE25.000 MG

00904766560 CHLORTHALIDONE50.000 MG

50111036201 CHLORTHALIDONE25.000 MG

50111036203 CHLORTHALIDONE25.000 MG

50111036301 CHLORTHALIDONE50.000 MG

50111036303 CHLORTHALIDONE50.000 MG

50111036401 CHLORTHALIDONE100.00 MG

51079005820 CHLORTHALIDONE25.000 MG

51079005920 CHLORTHALIDONE50.000 MG

51079047620 CHLORZOXAZONE500.00 MG

00904030240 CHLORZOXAZONE500.00 MG

00904030260 CHLORZOXAZONE500.00 MG

00555058502 CHLORZOXAZONE500.00 MG

00555058504 CHLORZOXAZONE500.00 MG

00093054201 CHLORZOXAZONE500.00 MG

00093054205 CHLORZOXAZONE500.00 MG

00087069502 CHOICE DM.000

00087069506 CHOICE DM.000

00087069542 CHOICE DM.000

00087069546 CHOICE DM.000

00087069602 CHOICE DM.000

00087069641 CHOICE DM.000

00087069642 CHOICE DM.000

00087066002 CHOICE DM.000

00087066005 CHOICE DM.000

00087066006 CHOICE DM.000

00087066045 CHOICE DM.000

00087066046 CHOICE DM.000

00087065302 CHOICE DM TF.000

00087065305 CHOICE DM TF.000

00087065345 CHOICE DM TF.000

00430021424 CHOLEDYL SA400.00 MG

00430022124 CHOLEDYL SA600.00 MG

00904335289 CHOLESTATIN.000

00185094097 CHOLESTYRAMINE4.000 GM/DOSE

00185094098 CHOLESTYRAMINE4.000 GM

59930163801 CHOLESTYRAMINE4.000 GM

59930163802 CHOLESTYRAMINE4.000 GM/DOSE

59772558501 CHOLESTYRAMINE4.000 GM

59772558502 CHOLESTYRAMINE4.000 GM/DOSE

00185093997 CHOLESTYRAMINE LIGHT4.000 GM/DOSE

00185093998 CHOLESTYRAMINE LIGHT4.000 GM

59772558901 CHOLESTYRAMINE LIGHT4.000 GM

59772558902 CHOLESTYRAMINE LIGHT4.000 GM/DOSE

00536343901 CHOLINE BITARTRATE500.00 MG

00182189501 CHOLINE MAGNESIUM TRISALI750.00 MG

00182189901 CHOLINE MAGNESIUM TRISALI500.00 MG

00904339560 CHOLINE MAGNESIUM TRISALI500.00 MG

00904339660 CHOLINE MAGNESIUM TRISALI750.00 MG

00904339760 CHOLINE MAGNESIUM TRISALI1000.0 MG

54838052270 CHOLINE MAGNESIUM TRISALI500.00 MG/5ML

50111052801 CHOLINE MAGNESIUM TRISALI500.00 MG

50111052901 CHOLINE MAGNESIUM TRISALI750.00 MG

50111052902 CHOLINE MAGNESIUM TRISALI750.00 MG

50111053001 CHOLINE MAGNESIUM TRISALI1000.0 MG

57664021908 CHOLINE MAGNESIUM TRISALI500.00 MG

57664022008 CHOLINE MAGNESIUM TRISALI750.00 MG

57664022108 CHOLINE MAGNESIUM TRISALI1000.0 MG

57664022109 CHOLINE MAGNESIUM TRISALI1000.0 MG

57664029108 CHOLINE MAGNESIUM TRISALI500.00 MG

60258009008 CHOLINE MAGNESIUM TRISALI500.00 MG/5ML

00182416601 CHOLINOID.000

00904529252 CHONDROITIN SULFATE250.00 MG

00904419213 CHROMIUM200.00 MCG

00904431460 CHROMIUM200.00 MCG

00536666808 CHROMIUM PICOLINATE200.00 MCG

00074409301 CHROMIUM TRACE METAL4.000 MCG/ML

00093011306 CIMETIDINE400.00 MG

00378031701 CIMETIDINE300.00 MG

00378031705 CIMETIDINE300.00 MG

00378031767 CIMETIDINE300.00 MG

00378037201 CIMETIDINE400.00 MG

Page 22 of 125

Page 23: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00378037205 CIMETIDINE400.00 MG

00378005301 CIMETIDINE200.00 MG

00378054101 CIMETIDINE800.00 MG

00182266017 CIMETIDINE200.00 MG

00182266019 CIMETIDINE200.00 MG

00182198489 CIMETIDINE300.00 MG

00182198589 CIMETIDINE400.00 MG

00182198689 CIMETIDINE800.00 MG

00172711748 CIMETIDINE300.00 MG

00172711760 CIMETIDINE300.00 MG

00172711770 CIMETIDINE300.00 MG

00172717149 CIMETIDINE400.00 MG

00172717160 CIMETIDINE400.00 MG

00172717170 CIMETIDINE400.00 MG

00172717180 CIMETIDINE400.00 MG

00172771146 CIMETIDINE800.00 MG

00172771160 CIMETIDINE800.00 MG

00904544540 CIMETIDINE300.00 MG

00904544560 CIMETIDINE300.00 MG

00904544561 CIMETIDINE300.00 MG

00904544640 CIMETIDINE400.00 MG

00904544660 CIMETIDINE400.00 MG

00904544661 CIMETIDINE400.00 MG

00904544760 CIMETIDINE800.00 MG

00904544761 CIMETIDINE800.00 MG

00904786860 CIMETIDINE400.00 MG

00904786880 CIMETIDINE400.00 MG

17236044701 CIMETIDINE400.00 MG

17236044705 CIMETIDINE400.00 MG

17236044760 CIMETIDINE400.00 MG

17236017101 CIMETIDINE300.00 MG

17236017230 CIMETIDINE800.00 MG

00677152801 CIMETIDINE300.00 MG

00677152901 CIMETIDINE400.00 MG

00677152905 CIMETIDINE400.00 MG

50111055001 CIMETIDINE300.00 MG

50111055002 CIMETIDINE300.00 MG

50111055003 CIMETIDINE300.00 MG

50111055101 CIMETIDINE400.00 MG

50111055102 CIMETIDINE400.00 MG

50111055103 CIMETIDINE400.00 MG

50111055104 CIMETIDINE400.00 MG

50111055201 CIMETIDINE800.00 MG

50111055202 CIMETIDINE800.00 MG

50111055210 CIMETIDINE800.00 MG

51079080720 CIMETIDINE300.00 MG

51079080820 CIMETIDINE400.00 MG

51079080920 CIMETIDINE800.00 MG

55370013507 CIMETIDINE300.00 MG

55370013508 CIMETIDINE300.00 MG

55370013607 CIMETIDINE400.00 MG

55370013608 CIMETIDINE400.00 MG

55370013706 CIMETIDINE800.00 MG

55370013725 CIMETIDINE800.00 MG

60429004718 CIMETIDINE400.00 MG

60429004730 CIMETIDINE400.00 MG

60429004760 CIMETIDINE400.00 MG

60429004790 CIMETIDINE400.00 MG

60505001806 CIMETIDINE200.00 MG

60505001904 CIMETIDINE300.00 MG

60505001906 CIMETIDINE300.00 MG

60505002004 CIMETIDINE400.00 MG

60505002006 CIMETIDINE400.00 MG

60505002008 CIMETIDINE400.00 MG

60505002102 CIMETIDINE800.00 MG

60505002103 CIMETIDINE800.00 MG

60951063070 CIMETIDINE200.00 MG

60951063285 CIMETIDINE400.00 MG

60951063330 CIMETIDINE800.00 MG

55953020470 CIMETIDINE400.00 MG

58437000218 CIMETIDINE400.00 MG

58437000313 CIMETIDINE800.00 MG

58437000321 CIMETIDINE800.00 MG

55370020202 CIMETIDINE HCL150.00 MG/ML

55370020204 CIMETIDINE HCL150.00 MG/ML

50383005008 CIMETIDINE HCL300.00 MG/5ML

00182616444 CIMETIDINE HCL300.00 MG/5ML

00472051408 CIMETIDINE HCL300.00 MG/5ML

00472051416 CIMETIDINE HCL300.00 MG/5ML

00093050687 CIMETIDINE HCL300.00 MG/5ML

00074744401 CIMETIDINE HCL150.00 MG/ML

00074744501 CIMETIDINE HCL150.00 MG/ML

00054322758 CIMETIDINE HCL300.00 MG/5ML

00054822716 CIMETIDINE HCL300.00 MG/5ML

00054823016 CIMETIDINE HCL300.00 MG/5ML

60951063757 CIMETIDINE HCL150.00 MG/ML

60951063769 CIMETIDINE HCL150.00 MG/ML

60505035302 CIMETIDINE HCL300.00 MG/5ML

60432000708 CIMETIDINE HCL300.00 MG/5ML

51552004804 CITRIC ACID ANHYDROUS.000

51552007604 CITRIC ACID MONOHYDRATE.000

00766042520 CITRUCEL500.00 MG

00536322301 CITRUS CALCIUM950.00 MG

00536322408 CITRUS CALCIUM 1500 + D.000

00085045803 CLARITIN10.000 MG

00085045804 CLARITIN10.000 MG

00085045805 CLARITIN10.000 MG

00085045806 CLARITIN10.000 MG

00085112802 CLARITIN10.000 MG

00085122301 CLARITIN10.000 MG/10ML

00085063501 CLARITIN-D 12 HOUR.000

00085063504 CLARITIN-D 12 HOUR.000

00085063505 CLARITIN-D 12 HOUR.000

00085123301 CLARITIN-D 24 HOUR.000

00085123302 CLARITIN-D 24 HOUR.000

00093030801 CLEMASTINE FUMARATE2.680 MG

00093030912 CLEMASTINE FUMARATE.670 MG/5ML

00093926812 CLEMASTINE FUMARATE.670 MG/5ML

00093926816 CLEMASTINE FUMARATE.670 MG/5ML

00603109654 CLEMASTINE FUMARATE.670 MG/5ML

00781135801 CLEMASTINE FUMARATE1.340 MG

00781135901 CLEMASTINE FUMARATE2.680 MG

00904152400 CLEMASTINE FUMARATE.670 MG/5ML

00904152420 CLEMASTINE FUMARATE.670 MG/5ML

00904767960 CLEMASTINE FUMARATE2.680 MG

00904772988 CLEMASTINE FUMARATE1.340 MG

54838051440 CLEMASTINE FUMARATE.670 MG/5ML

60432073204 CLEMASTINE FUMARATE.670 MG/5ML

60505035700 CLEMASTINE FUMARATE.670 MG/5ML

00009344703 CLEOCIN150.00 MG/ML

00009090211 CLEOCIN150.00 MG/ML

00009090218 CLEOCIN150.00 MG/ML

00009312403 CLEOCIN150.00 MG/ML

00009337502 CLEOCIN.000

00009338102 CLEOCIN.000

00009338202 CLEOCIN.000

00009022501 CLEOCIN150.00 MG

00009022502 CLEOCIN150.00 MG

00009022503 CLEOCIN150.00 MG

00009039502 CLEOCIN300.00 MG

00009039513 CLEOCIN300.00 MG

00009039514 CLEOCIN300.00 MG

Page 23 of 125

Page 24: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00009072809 CLEOCIN150.00 MG/ML

00009077526 CLEOCIN150.00 MG/ML

00009087026 CLEOCIN150.00 MG/ML

00009332901 CLEOCIN-T1.000 %

00009333101 CLEOCIN-T1.000 %

00009333102 CLEOCIN-T1.000 %

00009311601 CLEOCIN-T1.000 %

00009311602 CLEOCIN-T1.000 %

00009311614 CLEOCIN-T1.000 %

00058015210 CLERZ 2.000

00058015215 CLERZ 2.000

00058015230 CLERZ 2.000

00065019205 CLERZ PLUS.000

00065019210 CLERZ PLUS.000

50419045104 CLIMARA.050 MG/24HR

50419045204 CLIMARA.100 MG/24HR

50419045304 CLIMARA.075 MG/24HR

50419045404 CLIMARA.025 MG/24HR

00496083645 CLINAC OC.000

00574001602 CLINDA-DERM1.000 %

00093317101 CLINDAMYCIN HCL150.00 MG

51079059819 CLINDAMYCIN HCL150.00 MG

51079059820 CLINDAMYCIN HCL150.00 MG

00591570801 CLINDAMYCIN HCL150.00 MG

59762332801 CLINDAMYCIN HCL150.00 MG

63304069201 CLINDAMYCIN HCL150.00 MG

63304069301 CLINDAMYCIN HCL300.00 MG

63304069316 CLINDAMYCIN HCL300.00 MG

00904773330 CLINDAMYCIN PHOSPHATE1.000 %

45802026337 CLINDAMYCIN PHOSPHATE1.000 %

00074405001 CLINDAMYCIN PHOSPHATE150.00 MG/ML

00074405101 CLINDAMYCIN PHOSPHATE150.00 MG/ML

00074405201 CLINDAMYCIN PHOSPHATE150.00 MG/ML

00074405303 CLINDAMYCIN PHOSPHATE150.00 MG/ML

00074405403 CLINDAMYCIN PHOSPHATE150.00 MG/ML

00074405503 CLINDAMYCIN PHOSPHATE150.00 MG/ML

00074419701 CLINDAMYCIN PHOSPHATE150.00 MG/ML

00168020130 CLINDAMYCIN PHOSPHATE1.000 %

00168020160 CLINDAMYCIN PHOSPHATE1.000 %

00168020230 CLINDAMYCIN PHOSPHATE1.000 %

00168020260 CLINDAMYCIN PHOSPHATE1.000 %

59762372801 CLINDAMYCIN PHOSPHATE1.000 %

59762372802 CLINDAMYCIN PHOSPHATE1.000 %

59762374301 CLINDAMYCIN PHOSPHATE1.000 %

59762374302 CLINDAMYCIN PHOSPHATE1.000 %

60432069330 CLINDAMYCIN PHOSPHATE1.000 %

60432069360 CLINDAMYCIN PHOSPHATE1.000 %

00006094168 CLINORIL150.00 MG

00006094268 CLINORIL200.00 MG

00414000605 CLIOQUINOL3.000 %

00603780176 CLIOQUINOL/HYDROCORTISONE.000

00472040015 CLOBETASOL PROPIONATE.050 %

00472040030 CLOBETASOL PROPIONATE.050 %

00472040045 CLOBETASOL PROPIONATE.050 %

00472040115 CLOBETASOL PROPIONATE.050 %

00472040130 CLOBETASOL PROPIONATE.050 %

00472040145 CLOBETASOL PROPIONATE.050 %

00472040225 CLOBETASOL PROPIONATE.050 %

00472040250 CLOBETASOL PROPIONATE.050 %

00168026925 CLOBETASOL PROPIONATE.050 %

00168026950 CLOBETASOL PROPIONATE.050 %

00168029315 CLOBETASOL PROPIONATE.050 %

00168029330 CLOBETASOL PROPIONATE.050 %

00168029360 CLOBETASOL PROPIONATE.050 %

00168016215 CLOBETASOL PROPIONATE.050 %

00168016230 CLOBETASOL PROPIONATE.050 %

00168016246 CLOBETASOL PROPIONATE.050 %

00168016260 CLOBETASOL PROPIONATE.050 %

00168016315 CLOBETASOL PROPIONATE.050 %

00168016330 CLOBETASOL PROPIONATE.050 %

00168016346 CLOBETASOL PROPIONATE.050 %

00168016360 CLOBETASOL PROPIONATE.050 %

60432013325 CLOBETASOL PROPIONATE.050 %

60432013350 CLOBETASOL PROPIONATE.050 %

00168030115 CLOBETASOL PROPIONATE EMO.050 %

00168030130 CLOBETASOL PROPIONATE EMO.050 %

00168030160 CLOBETASOL PROPIONATE EMO.050 %

00093004103 CLOMIPHENE CITRATE50.000 MG

00093004156 CLOMIPHENE CITRATE50.000 MG

49884070154 CLOMIPHENE CITRATE50.000 MG

49884070155 CLOMIPHENE CITRATE50.000 MG

00781202701 CLOMIPRAMINE HCL25.000 MG

00781203701 CLOMIPRAMINE HCL50.000 MG

00781204701 CLOMIPRAMINE HCL75.000 MG

00093095601 CLOMIPRAMINE HCL25.000 MG

00093095801 CLOMIPRAMINE HCL50.000 MG

00093096001 CLOMIPRAMINE HCL75.000 MG

00378302501 CLOMIPRAMINE HCL25.000 MG

00378305001 CLOMIPRAMINE HCL50.000 MG

00378307501 CLOMIPRAMINE HCL75.000 MG

00378191001 CLONAZEPAM.500 MG

00378191010 CLONAZEPAM.500 MG

00378191201 CLONAZEPAM1.000 MG

00378191210 CLONAZEPAM1.000 MG

00378191401 CLONAZEPAM2.000 MG

00378191405 CLONAZEPAM2.000 MG

00185006301 CLONAZEPAM.500 MG

00185006305 CLONAZEPAM.500 MG

00185006310 CLONAZEPAM.500 MG

00185006401 CLONAZEPAM1.000 MG

00185006405 CLONAZEPAM1.000 MG

00185006410 CLONAZEPAM1.000 MG

00185006501 CLONAZEPAM2.000 MG

00185006505 CLONAZEPAM2.000 MG

00185006510 CLONAZEPAM2.000 MG

00228300311 CLONAZEPAM.500 MG

00228300350 CLONAZEPAM.500 MG

00228300411 CLONAZEPAM1.000 MG

00228300450 CLONAZEPAM1.000 MG

00228300511 CLONAZEPAM2.000 MG

00228300550 CLONAZEPAM2.000 MG

00093083201 CLONAZEPAM.500 MG

00093083205 CLONAZEPAM.500 MG

00093083210 CLONAZEPAM.500 MG

00093083301 CLONAZEPAM1.000 MG

00093083305 CLONAZEPAM1.000 MG

00093083310 CLONAZEPAM1.000 MG

00093083401 CLONAZEPAM2.000 MG

00093083405 CLONAZEPAM2.000 MG

00904534240 CLONAZEPAM.500 MG

00904534260 CLONAZEPAM.500 MG

00904534340 CLONAZEPAM1.000 MG

00904534360 CLONAZEPAM1.000 MG

00904534440 CLONAZEPAM2.000 MG

00904534460 CLONAZEPAM2.000 MG

51079088120 CLONAZEPAM.500 MG

51079088121 CLONAZEPAM.500 MG

51079088220 CLONAZEPAM1.000 MG

51079088221 CLONAZEPAM1.000 MG

51079088320 CLONAZEPAM2.000 MG

51079088321 CLONAZEPAM2.000 MG

60429052490 CLONAZEPAM.500 MG

Page 24 of 125

Page 25: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

60429052590 CLONAZEPAM1.000 MG

51079029919 CLONIDINE HCL.100 MG

51079029920 CLONIDINE HCL.100 MG

51079030019 CLONIDINE HCL.200 MG

51079030020 CLONIDINE HCL.200 MG

51079030120 CLONIDINE HCL.300 MG

51552048001 CLONIDINE HCL.000

51552048005 CLONIDINE HCL.000

00615257243 CLONIDINE HCL.100 MG

00904102740 CLONIDINE HCL.300 MG

00904102761 CLONIDINE HCL.300 MG

00228212710 CLONIDINE HCL.100 MG

00228212750 CLONIDINE HCL.100 MG

00228212810 CLONIDINE HCL.200 MG

00228212850 CLONIDINE HCL.200 MG

00228212910 CLONIDINE HCL.300 MG

00378015201 CLONIDINE HCL.100 MG

00378015210 CLONIDINE HCL.100 MG

00378018601 CLONIDINE HCL.200 MG

00378018610 CLONIDINE HCL.200 MG

00378019901 CLONIDINE HCL.300 MG

52544083605 CLORAZEPATE DIPOTASSIUM7.500 MG

52544083701 CLORAZEPATE DIPOTASSIUM15.000 MG

53265004810 CLORAZEPATE DIPOTASSIUM3.750 MG

53265004850 CLORAZEPATE DIPOTASSIUM3.750 MG

53265004910 CLORAZEPATE DIPOTASSIUM7.500 MG

53265004950 CLORAZEPATE DIPOTASSIUM7.500 MG

53265005010 CLORAZEPATE DIPOTASSIUM15.000 MG

00378007001 CLORAZEPATE DIPOTASSIUM15.000 MG

00378004001 CLORAZEPATE DIPOTASSIUM7.500 MG

00378004005 CLORAZEPATE DIPOTASSIUM7.500 MG

00378003001 CLORAZEPATE DIPOTASSIUM3.750 MG

00378003005 CLORAZEPATE DIPOTASSIUM3.750 MG

62794007201 CLORPRES.000

62794000101 CLORPRES.000

62794002701 CLORPRES.000

00904782231 CLOTRIM ANTIFUNGAL1.000 %

00904782236 CLOTRIM ANTIFUNGAL1.000 %

00904777645 CLOTRIMAZOLE1.000 %

00904784357 CLOTRIMAZOLE100.00 MG

00182509533 CLOTRIMAZOLE1.000 %

00182509534 CLOTRIMAZOLE1.000 %

00182503160 CLOTRIMAZOLE1.000 %

00603773078 CLOTRIMAZOLE1.000 %

00093024831 CLOTRIMAZOLE1.000 %

00093024843 CLOTRIMAZOLE1.000 %

00093311901 CLOXACILLIN SODIUM250.00 MG

00093312101 CLOXACILLIN SODIUM500.00 MG

00093415973 CLOXACILLIN SODIUM125.00 MG/5ML

51079092120 CLOZAPINE25.000 MG

51079092220 CLOZAPINE100.00 MG

00378082501 CLOZAPINE25.000 MG

00378086001 CLOZAPINE100.00 MG

00378086005 CLOZAPINE100.00 MG

00172435910 CLOZAPINE25.000 MG

00172435960 CLOZAPINE25.000 MG

00172435970 CLOZAPINE25.000 MG

00172436010 CLOZAPINE100.00 MG

00172436060 CLOZAPINE100.00 MG

00172436070 CLOZAPINE100.00 MG

00078012605 CLOZARIL25.000 MG

00078012606 CLOZARIL25.000 MG

00078012705 CLOZARIL100.00 MG

00078012706 CLOZARIL100.00 MG

00904501546 CO-ENZYME Q-1030.000 MG

00131210437 CO-GESIC.000

00054816303 COCAINE HCL4.000 %

00054816403 COCAINE HCL10.000 %

00054315440 COCAINE HCL4.000 %

00054315540 COCAINE HCL10.000 %

51552009304 COCONUT OIL.000

00904422560 COD LIVER OIL.000

00536638401 COD LIVER OIL.000

00182002001 COD LIVER OIL.000

00003091450 COD LIVER OIL.000

00003092630 COD LIVER OIL.000

00003092730 COD LIVER OIL.000

00254907358 CODAFED EXPECTORANT.000

00603110758 CODAFED EXPECTORANT.000

00603110658 CODAFED PEDIATRIC EXPECTO.000

60258077016 CODAL-DH.000

60258077116 CODAL-DM.000

00074109712 CODEINE PHOSPHATE15.000 MG/ML

00074109732 CODEINE PHOSPHATE15.000 MG/ML

00074110212 CODEINE PHOSPHATE30.000 MG/ML

00054815624 CODEINE SULFATE30.000 MG

00054815724 CODEINE SULFATE60.000 MG

00054415625 CODEINE SULFATE30.000 MG

00054415725 CODEINE SULFATE60.000 MG

58177022304 CODEINE/GUAIFENESIN.000

00131513464 CODICLEAR DH.000

00131513470 CODICLEAR DH.000

00131512964 CODIMAL DH.000

00131512970 CODIMAL DH.000

00131513164 CODIMAL DM.000

00131513170 CODIMAL DM.000

00131503864 CODIMAL PH.000

00131503870 CODIMAL PH.000

00254907858 CODITUSS DH.000

00603111154 CODITUSS DH.000

00603111158 CODITUSS DH.000

00603111160 CODITUSS DH.000

00603072854 CODITUSS DM.000

00603072858 CODITUSS DM.000

00006327516 COGENTIN1.000 MG/ML

54092041416 COLACE150.00 MG/15ML

54092041508 COLACE60.000 MG/15ML

54092005302 COLACE100.00 MG

54092005310 COLACE100.00 MG

54092005352 COLACE100.00 MG

54092050101 COLACE GLYCERIN ADULT3.000 GM

00904204760 COLCHICINE.600 MG

00677168301 COLCHICINE.600 MG

00677168310 COLCHICINE.600 MG

00603305221 COLCHICINE.600 MG

00603305232 COLCHICINE.600 MG

00143120101 COLCHICINE.600 MG

00143120110 COLCHICINE.600 MG

00143120125 COLCHICINE.600 MG

00074378101 COLCHICINE.600 MG

59743008501 COLCHICINE.600 MG

59743008510 COLCHICINE.600 MG

00168004516 COLD CREAM.000

00168004531 COLD CREAM.000

45802009405 COLD CREAM.000

45802009429 COLD CREAM.000

53746005001 COLD TABLETS.000

53746005010 COLD TABLETS.000

51991005001 COLDEC.000

51991006001 COLDEC-TR.000

00009045003 COLESTID1.000 GM

00009037003 COLESTID5.000 GM/7.5G

Page 25 of 125

Page 26: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00009037005 COLESTID5.000 GM

00009026001 COLESTID5.000 GM

00009026002 COLESTID5.000 GM

00009026004 COLESTID5.000 GM

00009026017 COLESTID5.000 GM

51991014501 COLFED-A.000

45802099049 COLIC DROPS40.000 MG/0.6ML

00008076901 COLLYRIUM.000

00574202001 COLOCORT100.00 MG/60ML

00574202007 COLOCORT100.00 MG/60ML

61570041451 COLY-MYCIN-M150.00 MG

00091703623 COLYTE.000

00091440123 COLYTE.000

00091440149 COLYTE.000

00091440313 COLYTE-FLAVORED.000

00003401848 COMBIDERM ACD.000

00003401849 COMBIDERM ACD.000

00003187725 COMBIDERM ACD.000

00003187774 COMBIDERM ACD.000

00003187775 COMBIDERM ACD.000

00003651027 COMBIDERM ACD.000

00003651029 COMBIDERM ACD.000

00003651031 COMBIDERM ACD.000

00003187773 COMBIDERM ACD NON-ADHESIV.000

00597001314 COMBIVENT.000

00007335216 COMPAZINE5.000 MG/ML

00085415104 COMPLEX 15.000

00085410025 COMPLEX 15.000

00087008904 COMPLY.000

00087008942 COMPLY.000

00087008944 COMPLY.000

00574722612 COMPRO25.000 MG

00078032705 COMTAN200.00 MG

19810002274 COMTREX COLD/COUGH RELIEF.000

19810000411 COMTREX MAXIMUM-STRENGTH.000

17714003001 CONGESTANT.000

17714003010 CONGESTANT.000

58177004423 CONISON.000

00472135808 CONSTULOSE10.000 GM/15ML

00472135832 CONSTULOSE10.000 GM/15ML

45800023520 CONTAC DAY AND NIGHT.000

45800023816 CONTAC SEVERE COLD/FLU NO.000

00074409201 COPPER TRACE METAL.400 MG/ML

00008418804 CORDARONE200.00 MG

00008418806 CORDARONE200.00 MG

00008081401 CORDARONE I.V.50.000 MG/ML

00007413920 COREG3.125 MG

00007414020 COREG6.250 MG

00007414120 COREG12.500 MG

00007414220 COREG25.000 MG

00085052201 CORICIDIN.000

00085052202 CORICIDIN.000

00085052203 CORICIDIN.000

00085052204 CORICIDIN.000

00085052205 CORICIDIN.000

45802023961 CORN AND CALLUS REMOVER17.000 %

08290305224 CORNWALL 10CC FLUID DISPE.000

08290003525 CORNWALL METAL PIPETTING.000

08290003526 CORNWALL METAL PIPETTING.000

08290003527 CORNWALL METAL PIPETTING.000

08290003528 CORNWALL METAL PIPETTING.000

08290003050 CORNWALL SYRINGE PIPETTIN.000

08290003052 CORNWALL SYRINGE PIPETTIN.000

08290003054 CORNWALL SYRINGE PIPETTIN.000

08290003056 CORNWALL SYRINGE PIPETTIN.000

00603012916 CORRECTIVE LAXATIVE5.000 MG

00009399008 CORTAID FASTSTICK MAXIMUM1.000 %

00009399108 CORTAID INTENSIVE THERAPY1.000 %

00009399113 CORTAID MAXIMUM STRENGTH.000

00009399101 CORTAID MAXIMUM STRENGTH.000

00009399102 CORTAID MAXIMUM STRENGTH.000

00009348601 CORTAID MAXIMUM STRENGTH1.000 %

00009348602 CORTAID MAXIMUM STRENGTH1.000 %

00009337301 CORTAID/ALOE.000

00009004401 CORTEF20.000 MG

00009003101 CORTEF10.000 MG

00642001101 CORTIC.000

50474040501 CORTICAINE.500 %

00677004601 CORTISONE ACETATE25.000 MG

00904204360 CORTISONE ACETATE25.000 MG

00603306221 CORTISONE ACETATE25.000 MG

00143120201 CORTISONE ACETATE25.000 MG

61570003150 CORTISPORIN.000

61570003310 CORTISPORIN.000

61570003410 CORTISPORIN.000

61570003535 CORTISPORIN.000

61570003675 CORTISPORIN.000

00904314110 CORTOMYCIN.000

00904299538 CORTOMYCIN.000

00904301710 CORTOMYCIN.000

00006362835 COSOPT.000

00006362836 COSOPT.000

59743002016 COTUSS-V.000

00056016870 COUMADIN4.000 MG

00056016875 COUMADIN4.000 MG

00056016890 COUMADIN4.000 MG

00056016970 COUMADIN1.000 MG

00056016975 COUMADIN1.000 MG

00056016990 COUMADIN1.000 MG

00056017070 COUMADIN2.000 MG

00056017075 COUMADIN2.000 MG

00056017090 COUMADIN2.000 MG

00056017270 COUMADIN5.000 MG

00056017275 COUMADIN5.000 MG

00056017290 COUMADIN5.000 MG

00056017370 COUMADIN7.500 MG

00056017375 COUMADIN7.500 MG

00056017470 COUMADIN10.000 MG

00056017475 COUMADIN10.000 MG

00056017670 COUMADIN2.500 MG

00056017675 COUMADIN2.500 MG

00056017690 COUMADIN2.500 MG

00056018870 COUMADIN3.000 MG

00056018875 COUMADIN3.000 MG

00056018890 COUMADIN3.000 MG

00056018970 COUMADIN6.000 MG

00056018975 COUMADIN6.000 MG

00056018990 COUMADIN6.000 MG

00590032435 COUMADIN5.000 MG

00025201131 COVERA-HS180.00 MG

00025201134 COVERA-HS180.00 MG

00025202131 COVERA-HS240.00 MG

00025202134 COVERA-HS240.00 MG

00006095128 COZAAR25.000 MG

00006095154 COZAAR25.000 MG

00006095158 COZAAR25.000 MG

00006095228 COZAAR50.000 MG

00006095231 COZAAR50.000 MG

00006095254 COZAAR50.000 MG

00006095258 COZAAR50.000 MG

00006095282 COZAAR50.000 MG

00006096028 COZAAR100.00 MG

Page 26 of 125

Page 27: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00006096031 COZAAR100.00 MG

00006096058 COZAAR100.00 MG

00032120501 CREON 5.000

00032120507 CREON 5.000

00032121001 CREON 10.000

00032121007 CREON 10.000

00032122001 CREON 20.000

00032122007 CREON 20.000

00087056341 CRITICARE HN.000

24208030010 CROLOM4.000 %

49502068912 CROMOLYN SODIUM20.000 MG/2ML

00093138943 CROMOLYN SODIUM4.000 %

00054816721 CROMOLYN SODIUM20.000 MG/2ML

00054816723 CROMOLYN SODIUM20.000 MG/2ML

00172640649 CROMOLYN SODIUM20.000 MG/2ML

00172640659 CROMOLYN SODIUM20.000 MG/2ML

61314023710 CROMOLYN SODIUM4.000 %

60432015706 CROMOLYN SODIUM20.000 MG/2ML

60432015721 CROMOLYN SODIUM20.000 MG/2ML

00065912470 CRUCIAL.000

00065912872 CRUCIAL.000

00006067268 CUPRIMINE125.00 MG

00006060268 CUPRIMINE250.00 MG

00052028306 CYCLESSA.000

00378075101 CYCLOBENZAPRINE HCL10.000 MG

00378075110 CYCLOBENZAPRINE HCL10.000 MG

00591565801 CYCLOBENZAPRINE HCL10.000 MG

00591565805 CYCLOBENZAPRINE HCL10.000 MG

00591565810 CYCLOBENZAPRINE HCL10.000 MG

00182191989 CYCLOBENZAPRINE HCL10.000 MG

00677142901 CYCLOBENZAPRINE HCL10.000 MG

00677142905 CYCLOBENZAPRINE HCL10.000 MG

00904758660 CYCLOBENZAPRINE HCL10.000 MG

00904780940 CYCLOBENZAPRINE HCL10.000 MG

00904780960 CYCLOBENZAPRINE HCL10.000 MG

00904780961 CYCLOBENZAPRINE HCL10.000 MG

00904780980 CYCLOBENZAPRINE HCL10.000 MG

51552048305 CYCLOBENZAPRINE HCL.000

50111056301 CYCLOBENZAPRINE HCL10.000 MG

50111056302 CYCLOBENZAPRINE HCL10.000 MG

50111056303 CYCLOBENZAPRINE HCL10.000 MG

51079064419 CYCLOBENZAPRINE HCL10.000 MG

51079064420 CYCLOBENZAPRINE HCL10.000 MG

51079064497 CYCLOBENZAPRINE HCL10.000 MG

60951076770 CYCLOBENZAPRINE HCL10.000 MG

60429005230 CYCLOBENZAPRINE HCL10.000 MG

00469740420 CYCLOCORT.100 %

00469740460 CYCLOCORT.100 %

00469705415 CYCLOCORT.100 %

00469705430 CYCLOCORT.100 %

00469705460 CYCLOCORT.100 %

00469711515 CYCLOCORT.100 %

00469711530 CYCLOCORT.100 %

00469711560 CYCLOCORT.100 %

00065039515 CYCLOGYL.500 %

00065039602 CYCLOGYL1.000 %

00065039605 CYCLOGYL1.000 %

00065039615 CYCLOGYL1.000 %

00065039702 CYCLOGYL2.000 %

00065039705 CYCLOGYL2.000 %

00065039715 CYCLOGYL2.000 %

24208073501 CYCLOPENTOLATE HCL1.000 %

24208073506 CYCLOPENTOLATE HCL1.000 %

00054412925 CYCLOPHOSPHAMIDE25.000 MG

00054413025 CYCLOPHOSPHAMIDE50.000 MG

00054813025 CYCLOPHOSPHAMIDE50.000 MG

00054808925 CYCLOPHOSPHAMIDE25.000 MG

00185093230 CYCLOSPORINE MODIFIED25.000 MG

00185093330 CYCLOSPORINE MODIFIED100.00 MG

50111090943 CYCLOSPORINE MODIFIED25.000 MG

50111092043 CYCLOSPORINE MODIFIED100.00 MG

00074605713 CYLERT37.500 MG

00074607313 CYLERT75.000 MG

00074608813 CYLERT37.500 MG

00074602513 CYLERT18.750 MG

00182113289 CYPROHEPTADINE HCL4.000 MG

00172292960 CYPROHEPTADINE HCL4.000 MG

00172292980 CYPROHEPTADINE HCL4.000 MG

00472075516 CYPROHEPTADINE HCL2.000 MG/5ML

00603309832 CYPROHEPTADINE HCL4.000 MG

50111031401 CYPROHEPTADINE HCL4.000 MG

50111031403 CYPROHEPTADINE HCL4.000 MG

49884004301 CYPROHEPTADINE HCL4.000 MG

49884004310 CYPROHEPTADINE HCL4.000 MG

00904114560 CYPROHEPTADINE HCL4.000 MG

00904114561 CYPROHEPTADINE HCL4.000 MG

00904114580 CYPROHEPTADINE HCL4.000 MG

61451222501 CYSTOSPAZ.150 MG

61451226001 CYSTOSPAZ-M.375 MG

52604341401 CYTOMEL5.000 MCG

52604341601 CYTOMEL25.000 MCG

52604341701 CYTOMEL50.000 MCG

00009037301 CYTOSAR-U100.00 MG

00025145120 CYTOTEC100.00 MCG

00025145134 CYTOTEC100.00 MCG

00025145160 CYTOTEC100.00 MCG

00025146131 CYTOTEC200.00 MCG

00025146134 CYTOTEC200.00 MCG

00025146160 CYTOTEC200.00 MCG

00004026948 CYTOVENE250.00 MG

00004027848 CYTOVENE500.00 MG

00015050301 CYTOXAN50.000 MG

00015050302 CYTOXAN50.000 MG

00015050401 CYTOXAN25.000 MG

60258000501 CYTRA K CRYSTALS.000

60258000116 CYTRA-2.000

60258000216 CYTRA-3.000

60258000316 CYTRA-K.000

60258070416 CYTUSS HC.000

59743005301 D-AMINE-SR.000

59743005305 D-AMINE-SR.000

00182018201 D.O.S.250.00 MG

00182018217 D.O.S.250.00 MG

00182028701 D.O.S.100.00 MG

00182028710 D.O.S.100.00 MG

00074507501 DACARBAZINE200.00 MG

00074507503 DACARBAZINE200.00 MG

58768072715 DACRIOSE.000

58768072720 DACRIOSE.000

00615068753 DAILY MULTIPLE VITAMINS W.000

00615068763 DAILY MULTIPLE VITAMINS W.000

00536041059 DAILY VITAMINS HOMOGENIZE.000

00536041085 DAILY VITAMINS HOMOGENIZE.000

00536354601 DAILY VITE.000

00536354610 DAILY VITE.000

00536354701 DAILY VITE.000

00536354710 DAILY VITE.000

50383062408 DALYVITE.000

50383062428 DALYVITE.000

00555063302 DANAZOL50.000 MG

00555063402 DANAZOL100.00 MG

00555063502 DANAZOL200.00 MG

Page 27 of 125

Page 28: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00555063509 DANAZOL200.00 MG

00024030306 DANOCRINE50.000 MG

00024030406 DANOCRINE100.00 MG

00024030506 DANOCRINE200.00 MG

00024030560 DANOCRINE200.00 MG

00173020155 DARAPRIM25.000 MG

00002036302 DARVOCET-N 100.000

00002036303 DARVOCET-N 100.000

00002036333 DARVOCET-N 100.000

00002035102 DARVOCET-N 50.000

00002080302 DARVON65.000 MG

00002080303 DARVON65.000 MG

00002311102 DARVON COMPOUND-65.000

00904781595 DAY TIME LIQUID CAPS.000

00074392501 DAYALETS.000

00025138131 DAYPRO600.00 MG

00025138134 DAYPRO600.00 MG

00025138151 DAYPRO600.00 MG

00075245001 DDAVP.010 %

00075245101 DDAVP4.000 MCG/ML

00075245153 DDAVP4.000 MCG/ML

00006004168 DECADRON.500 MG

00006006312 DECADRON.750 MG

00006006368 DECADRON.750 MG

00006009750 DECADRON4.000 MG

00006761504 DECADRON.050 %

00482018310 DECONAMINE.000

00482018410 DECONAMINE.000

00482018516 DECONAMINE.000

00482018616 DECONAMINE CX.000

00482018110 DECONAMINE SR.000

00482018150 DECONAMINE SR.000

00603311621 DECONGEST II.000

00904101430 DECONGESTANT NOSE DROPS1.000 %

00603314321 DECONGESTINE TR.000

00603314328 DECONGESTINE TR.000

00496084502 DECUBITENE.000

00496084520 DECUBITENE.000

00904386575 DEEP SEA NASAL SPRAY.650 %

60258022016 DEHISTINE.000

60267020022 DEHYDRATED ALCOHOL98.000 %

60267010011 DEHYDRATED ALCOHOL98.000 %

00087046204 DELIVER 2.0.000

00087046244 DELIVER 2.0.000

00009019302 DELTASONE10.000 MG

00004026201 DEMADEX5.000 MG

00004026301 DEMADEX10.000 MG

00004026349 DEMADEX10.000 MG

00004026401 DEMADEX20.000 MG

00004026449 DEMADEX20.000 MG

00004026501 DEMADEX100.00 MG

00004026549 DEMADEX100.00 MG

53169010260 DEMADEX5.000 MG

00004026249 DEMADEX5.000 MG

00004026706 DEMADEX10.000 MG/ML

00004026806 DEMADEX10.000 MG/ML

00024033206 DEMEROL50.000 MG/5ML

00024033502 DEMEROL50.000 MG

00024033504 DEMEROL50.000 MG

00024033506 DEMEROL50.000 MG

00024033704 DEMEROL100.00 MG

00074120301 DEMEROL50.000 MG/ML

00074117630 DEMEROL25.000 MG/ML

00074117802 DEMEROL50.000 MG/ML

00074117811 DEMEROL50.000 MG/ML

00074117830 DEMEROL50.000 MG/ML

00074117831 DEMEROL50.000 MG/ML

00074117911 DEMEROL75.000 MG/ML

00074117921 DEMEROL75.000 MG/ML

00074117930 DEMEROL75.000 MG/ML

00074117931 DEMEROL75.000 MG/ML

00074118021 DEMEROL100.00 MG/ML

00074118031 DEMEROL100.00 MG/ML

00074118130 DEMEROL50.000 MG/ML

00074120120 DEMEROL100.00 MG/ML

00074125301 DEMEROL50.000 MG/ML

00074125401 DEMEROL75.000 MG/1.5ML

00074125502 DEMEROL50.000 MG/ML

00074125601 DEMEROL100.00 MG/ML

00074126601 DEMEROL50.000 MG/ML

00074126701 DEMEROL50.000 MG/ML

00074127102 DEMEROL50.000 MG/ML

00006069068 DEMSER250.00 MG

00025016109 DEMULEN 1/35-28.000

00025016124 DEMULEN 1/35-28.000

00025016184 DEMULEN 1/35-28.000

00025007124 DEMULEN 1/50-21.000

00025008109 DEMULEN 1/50-28.000

00025008124 DEMULEN 1/50-28.000

00025008184 DEMULEN 1/50-28.000

00074156410 DEPACON100.00 MG/ML

00074568113 DEPAKENE250.00 MG

00074568216 DEPAKENE250.00 MG/5ML

00074621211 DEPAKOTE125.00 MG

00074621213 DEPAKOTE125.00 MG

00074621411 DEPAKOTE250.00 MG

00074621413 DEPAKOTE250.00 MG

00074621453 DEPAKOTE250.00 MG

00074621511 DEPAKOTE500.00 MG

00074621513 DEPAKOTE500.00 MG

00074621553 DEPAKOTE500.00 MG

00037440101 DEPEN TITRATABS250.00 MG

00009027101 DEPO-ESTRADIOL5.000 MG/ML

00009028002 DEPO-MEDROL40.000 MG/ML

00009028003 DEPO-MEDROL40.000 MG/ML

00009028051 DEPO-MEDROL40.000 MG/ML

00009028052 DEPO-MEDROL40.000 MG/ML

00009030602 DEPO-MEDROL80.000 MG/ML

00009030612 DEPO-MEDROL80.000 MG/ML

00009307301 DEPO-MEDROL40.000 MG/ML

00009347501 DEPO-MEDROL80.000 MG/ML

00009347503 DEPO-MEDROL80.000 MG/ML

00009027401 DEPO-MEDROL20.000 MG/ML

00009307303 DEPO-MEDROL40.000 MG/ML

00009034702 DEPO-TESTOSTERONE100.00 MG/ML

00009041701 DEPO-TESTOSTERONE200.00 MG/ML

00009041702 DEPO-TESTOSTERONE200.00 MG/ML

00574007116 DERMABASE.000

00574007140 DERMABASE.000

00904407731 DERMACAINE.000

45802059176 DERMALINE DERMATOLOGICAL.000

45802059177 DERMALINE DERMATOLOGICAL.000

45802059274 DERMALINE DERMATOLOGICAL.000

45802059275 DERMALINE DERMATOLOGICAL.000

45802060317 DERMALUBE.000

59743005001 DESAL-II.000

00078034751 DESFERAL2.000 GM

00083380104 DESFERAL500.00 MG

00093032601 DESIPRAMINE HCL50.000 MG

00093032701 DESIPRAMINE HCL75.000 MG

00185001901 DESIPRAMINE HCL25.000 MG

00185001905 DESIPRAMINE HCL25.000 MG

Page 28 of 125

Page 29: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00185001910 DESIPRAMINE HCL25.000 MG

00185002901 DESIPRAMINE HCL10.000 MG

00185073601 DESIPRAMINE HCL100.00 MG

00185073605 DESIPRAMINE HCL100.00 MG

00185072101 DESIPRAMINE HCL50.000 MG

00185072105 DESIPRAMINE HCL50.000 MG

00185072110 DESIPRAMINE HCL50.000 MG

00185072201 DESIPRAMINE HCL75.000 MG

00185072205 DESIPRAMINE HCL75.000 MG

00185076053 DESIPRAMINE HCL150.00 MG

00904157040 DESIPRAMINE HCL25.000 MG

00904157060 DESIPRAMINE HCL25.000 MG

00904157080 DESIPRAMINE HCL25.000 MG

00904157140 DESIPRAMINE HCL50.000 MG

00904157160 DESIPRAMINE HCL50.000 MG

00904157260 DESIPRAMINE HCL75.000 MG

00904158260 DESIPRAMINE HCL50.000 MG

00904158261 DESIPRAMINE HCL50.000 MG

00781197101 DESIPRAMINE HCL10.000 MG

00781197201 DESIPRAMINE HCL25.000 MG

00781197210 DESIPRAMINE HCL25.000 MG

00781197301 DESIPRAMINE HCL50.000 MG

00781197310 DESIPRAMINE HCL50.000 MG

00781197401 DESIPRAMINE HCL75.000 MG

00781197501 DESIPRAMINE HCL100.00 MG

00781197650 DESIPRAMINE HCL150.00 MG

24208034205 DESMOPRESSIN ACETATE.010 %

00074226501 DESMOPRESSIN ACETATE4.000 MCG/ML

00052026106 DESOGEN.000

00904772402 DESONIDE.050 %

00182506651 DESONIDE.050 %

00182506652 DESONIDE.050 %

00904772436 DESONIDE.050 %

45802042235 DESONIDE.050 %

45802042237 DESONIDE.050 %

45802042335 DESONIDE.050 %

45802042337 DESONIDE.050 %

00677141340 DESOXIMETASONE.250 %

00904076502 DESOXIMETASONE.050 %

00904076536 DESOXIMETASONE.050 %

00168015115 DESOXIMETASONE.250 %

00168015160 DESOXIMETASONE.250 %

00072600345 DESQUAM-E2.500 %

00072610345 DESQUAM-E5.000 %

00072620345 DESQUAM-E10.000 %

00072662101 DESQUAM-X5.000 %

00072662103 DESQUAM-X5.000 %

00072672101 DESQUAM-X10.000 %

00072672103 DESQUAM-X10.000 %

00072690505 DESQUAM-X5.000 %

00072700005 DESQUAM-X10.000 %

00087077541 DESYREL50.000 MG

00087077543 DESYREL50.000 MG

00087077641 DESYREL100.00 MG

00087077643 DESYREL100.00 MG

00087077843 DESYREL150.00 MG

00087077844 DESYREL150.00 MG

00087079641 DESYREL300.00 MG

00496051304 DETACHOL STER TIP.000

00496051306 DETACHOL STER TIP.000

00496051315 DETACHOL STER TIP.000

00496051348 DETACHOL STER TIP.000

00009454101 DETROL1.000 MG

00009454102 DETROL1.000 MG

00009454103 DETROL1.000 MG

00009454401 DETROL2.000 MG

00009454402 DETROL2.000 MG

00009454403 DETROL2.000 MG

00009519001 DETROL LA2.000 MG

00009519002 DETROL LA2.000 MG

00009519004 DETROL LA2.000 MG

00009519101 DETROL LA4.000 MG

00009519102 DETROL LA4.000 MG

00009519104 DETROL LA4.000 MG

00009519003 DETROL LA2.000 MG

00009519103 DETROL LA4.000 MG

00904096716 DETUSSIN.000

58768025005 DEXACIDIN.000

00904024660 DEXAMETHASONE4.000 MG

49884008301 DEXAMETHASONE.250 MG

49884008310 DEXAMETHASONE.250 MG

49884008401 DEXAMETHASONE.500 MG

49884008410 DEXAMETHASONE.500 MG

49884008501 DEXAMETHASONE.750 MG

49884008510 DEXAMETHASONE.750 MG

49884008601 DEXAMETHASONE1.500 MG

49884008610 DEXAMETHASONE1.500 MG

49884008701 DEXAMETHASONE4.000 MG

49884008703 DEXAMETHASONE4.000 MG

49884008710 DEXAMETHASONE4.000 MG

49884012901 DEXAMETHASONE6.000 MG

49884012903 DEXAMETHASONE6.000 MG

00472097208 DEXAMETHASONE.500 MG/5ML

00603319111 DEXAMETHASONE.750 MG

00603319221 DEXAMETHASONE1.500 MG

00054417925 DEXAMETHASONE.500 MG

00054418025 DEXAMETHASONE.750 MG

00054418225 DEXAMETHASONE1.500 MG

00054418425 DEXAMETHASONE4.000 MG

00054418625 DEXAMETHASONE6.000 MG

00054817925 DEXAMETHASONE.500 MG

00054818025 DEXAMETHASONE.750 MG

00054818125 DEXAMETHASONE1.500 MG

00054817525 DEXAMETHASONE4.000 MG

00054818325 DEXAMETHASONE6.000 MG

60432046600 DEXAMETHASONE.500 MG/5ML

60432046608 DEXAMETHASONE.500 MG/5ML

00904090605 DEXAMETHASONE ACETATE8.000 MG/ML

00641036725 DEXAMETHASONE SODIUM PHOS10.000 MG/ML

00904300605 DEXAMETHASONE SODIUM PHOS.100 %

00904300838 DEXAMETHASONE SODIUM PHOS.050 %

24208072002 DEXAMETHASONE SODIUM PHOS.100 %

00904066740 DEXAPHEN SA.000

00904066760 DEXAPHEN SA.000

00904066815 DEXAPHEN SA.000

00904066895 DEXAPHEN SA.000

00677090020 DEXASPORIN.000

00904062416 DEXCHLORPHENIRAMINE MALEA2.000 MG/5ML

00904062428 DEXCHLORPHENIRAMINE MALEA2.000 MG/5ML

00603319821 DEXCHLORPHENIRAMINE MALEA4.000 MG

00603319921 DEXCHLORPHENIRAMINE MALEA6.000 MG

60432053916 DEXCHLORPHENIRAMINE MALEA2.000 MG/5ML

60432053928 DEXCHLORPHENIRAMINE MALEA2.000 MG/5ML

59879050401 DEXCHLORPHENIRAMINE MALEA6.000 MG

00007351220 DEXEDRINE5.000 MG

00007351320 DEXEDRINE10.000 MG

00007351420 DEXEDRINE15.000 MG

00007351920 DEXEDRINE5.000 MG

00074150503 DEXTRAN 75.000

00555095202 DEXTROAMPHETAMINE SULFATE5.000 MG

00555095302 DEXTROAMPHETAMINE SULFATE10.000 MG

00074150805 DEXTROSE 2.5%2.500 %

Page 29 of 125

Page 30: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00074794003 DEXTROSE 2.5%.000

00074794009 DEXTROSE 2.5%.000

00074794102 DEXTROSE 5%.000

00074794103 DEXTROSE 5%.000

00074794109 DEXTROSE 5%.000

00074793303 DEXTROSE 5%.000

00074793309 DEXTROSE 5%.000

00074792202 DEXTROSE 5%5.000 %

00074792203 DEXTROSE 5%5.000 %

00074792209 DEXTROSE 5%5.000 %

00074792253 DEXTROSE 5%5.000 %

00074792255 DEXTROSE 5%5.000 %

00074792261 DEXTROSE 5%5.000 %

00074792320 DEXTROSE 5%5.000 %

00074792336 DEXTROSE 5%5.000 %

00074792337 DEXTROSE 5%5.000 %

00074792402 DEXTROSE 5%.000

00074792403 DEXTROSE 5%.000

00074792409 DEXTROSE 5%.000

00074792502 DEXTROSE 5%.000

00074792503 DEXTROSE 5%.000

00074792509 DEXTROSE 5%.000

00074792602 DEXTROSE 5%.000

00074792603 DEXTROSE 5%.000

00074792609 DEXTROSE 5%.000

00074792903 DEXTROSE 5%.000

00074792909 DEXTROSE 5%.000

00074710002 DEXTROSE 5%5.000 %

00074710013 DEXTROSE 5%5.000 %

00074710066 DEXTROSE 5%5.000 %

00074710067 DEXTROSE 5%5.000 %

00074152201 DEXTROSE 5%5.000 %

00074152202 DEXTROSE 5%5.000 %

00074152203 DEXTROSE 5%5.000 %

00074152301 DEXTROSE 5%5.000 %

00074152311 DEXTROSE 5%5.000 %

00074149501 DEXTROSE 5%5.000 %

00074153405 DEXTROSE 10%.000

00074793002 DEXTROSE 10%10.000 %

00074793003 DEXTROSE 10%10.000 %

00074793009 DEXTROSE 10%10.000 %

00074793819 DEXTROSE 10%10.000 %

00074408902 DEXTROSE 10%10.000 %

00074564125 DEXTROSE 10%10.000 %

00074486202 DEXTROSE 10%/NACL 0.225%.000

00074486203 DEXTROSE 10%/NACL 0.225%.000

00074564225 DEXTROSE 20%20.000 %

00074793519 DEXTROSE 20%20.000 %

00074153503 DEXTROSE 20%20.000 %

00074177510 DEXTROSE 25%250.00 MG/ML

00074789818 DEXTROSE 25%250.00 MG/ML

00548101500 DEXTROSE 25%25.000 %

00548331500 DEXTROSE 25%250.00 MG/ML

00074800415 DEXTROSE 30%30.000 %

00074582325 DEXTROSE 30%30.000 %

00074564425 DEXTROSE 40%40.000 %

00074793719 DEXTROSE 40%40.000 %

00074711907 DEXTROSE 50%50.000 %

00074751715 DEXTROSE 50%50.000 %

00074751716 DEXTROSE 50%50.000 %

00074490222 DEXTROSE 50%50.000 %

00074490234 DEXTROSE 50%50.000 %

00074153603 DEXTROSE 50%50.000 %

00074151805 DEXTROSE 50%50.000 %

00548330100 DEXTROSE 50%50.000 %

00548200100 DEXTROSE 50%50.000 %

00548100100 DEXTROSE 50%50.000 %

00641228541 DEXTROSE 50%50.000 %

00074664802 DEXTROSE 50% FTV50.000 %

00074564525 DEXTROSE 50% PARTIAL FILL50.000 %

00074793619 DEXTROSE 50% PARTIAL FILL50.000 %

00074800515 DEXTROSE 60% PARTIAL FILL60.000 %

00074791819 DEXTROSE 70%70.000 %

00074712007 DEXTROSE 70%70.000 %

00074151905 DEXTROSE 70%70.000 %

00074564725 DEXTROSE 70% PARTIAL FILL70.000 %

51991002206 DHEA25.000 MG

00904527152 DHEA25.000 MG

00054818225 DHT.200 MG

00054817225 DHT.125 MG

00054418925 DHT.200 MG

00054419019 DHT.125 MG

00054419119 DHT.400 MG

00054317044 DHT INTENSOL.200 MG/ML

53303001930 DIAB.000

53303003014 DIAB.000

53303003030 DIAB.000

53303002111 DIAB DAILY CARE.000

53303017360 DIAB EXTRA.000

53303008180 DIAB KLENZ.000

53303017061 DIAB NUTRI.000

00069393066 DIABINESE100.00 MG

00069394066 DIABINESE250.00 MG

00069394082 DIABINESE250.00 MG

00472180204 DIAPER RASH40.000 %

00182508757 DIAPER RASH40.000 %

00713025804 DIAPER RASH40.000 %

45802017944 DIAPER RELIEF40.000 %

00182709539 DIARRHEA/CRAMP RELIEF750.00 MG/15ML

00228205110 DIAZEPAM2.000 MG

00228205150 DIAZEPAM2.000 MG

00228205210 DIAZEPAM5.000 MG

00228205250 DIAZEPAM5.000 MG

00228205310 DIAZEPAM10.000 MG

00228205350 DIAZEPAM10.000 MG

00172392560 DIAZEPAM2.000 MG

00172392570 DIAZEPAM2.000 MG

00172392660 DIAZEPAM5.000 MG

00172392670 DIAZEPAM5.000 MG

00172392760 DIAZEPAM10.000 MG

00172392770 DIAZEPAM10.000 MG

00555016302 DIAZEPAM2.000 MG

00555016305 DIAZEPAM2.000 MG

00555016402 DIAZEPAM10.000 MG

00555016405 DIAZEPAM10.000 MG

00555036302 DIAZEPAM5.000 MG

00555036305 DIAZEPAM5.000 MG

00591562005 DIAZEPAM10.000 MG

00591562010 DIAZEPAM10.000 MG

00378047701 DIAZEPAM10.000 MG

00378047705 DIAZEPAM10.000 MG

00378034501 DIAZEPAM5.000 MG

00378034505 DIAZEPAM5.000 MG

00378027101 DIAZEPAM2.000 MG

00378027105 DIAZEPAM2.000 MG

00074127312 DIAZEPAM5.000 MG/ML

00074127322 DIAZEPAM5.000 MG/ML

00074127332 DIAZEPAM5.000 MG/ML

00074321301 DIAZEPAM5.000 MG/ML

00074321302 DIAZEPAM5.000 MG/ML

51079028420 DIAZEPAM2.000 MG

51079028421 DIAZEPAM2.000 MG

Page 30 of 125

Page 31: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

51079028520 DIAZEPAM5.000 MG

51079028521 DIAZEPAM5.000 MG

51079028523 DIAZEPAM5.000 MG

51079028620 DIAZEPAM10.000 MG

51079028621 DIAZEPAM10.000 MG

00641401486 DIAZEPAM5.000 MG

00641401488 DIAZEPAM5.000 MG

00641401489 DIAZEPAM5.000 MG

00641401586 DIAZEPAM10.000 MG

00641401588 DIAZEPAM10.000 MG

00641401589 DIAZEPAM10.000 MG

00641140833 DIAZEPAM5.000 MG/ML

00904390160 DIAZEPAM5.000 MG

00904390340 DIAZEPAM2.000 MG

00904390380 DIAZEPAM2.000 MG

45802005003 DIBUCAINE1.000 %

45802005005 DIBUCAINE1.000 %

00904264631 DIBUCAINE1.000 %

00168004631 DIBUCAINE1.000 %

00074374113 DICAL-D.000

00093094801 DICLOFENAC POTASSIUM50.000 MG

00093094805 DICLOFENAC POTASSIUM50.000 MG

00378247401 DICLOFENAC POTASSIUM50.000 MG

50111054601 DICLOFENAC SODIUM DR50.000 MG

50111054603 DICLOFENAC SODIUM DR50.000 MG

50111054604 DICLOFENAC SODIUM DR50.000 MG

50111054701 DICLOFENAC SODIUM DR75.000 MG

50111054703 DICLOFENAC SODIUM DR75.000 MG

50111054704 DICLOFENAC SODIUM DR75.000 MG

52555020501 DICLOFENAC SODIUM DR75.000 MG

52555020510 DICLOFENAC SODIUM DR75.000 MG

00781178501 DICLOFENAC SODIUM EC25.000 MG

00781178701 DICLOFENAC SODIUM EC50.000 MG

00781178901 DICLOFENAC SODIUM EC75.000 MG

00228255106 DICLOFENAC SODIUM EC75.000 MG

00228255111 DICLOFENAC SODIUM EC75.000 MG

00228255196 DICLOFENAC SODIUM EC75.000 MG

00054422121 DICLOFENAC SODIUM EC50.000 MG

00054422125 DICLOFENAC SODIUM EC50.000 MG

00054422131 DICLOFENAC SODIUM EC50.000 MG

00054422225 DICLOFENAC SODIUM EC75.000 MG

00054422231 DICLOFENAC SODIUM EC75.000 MG

00054422325 DICLOFENAC SODIUM EC25.000 MG

00054822125 DICLOFENAC SODIUM EC50.000 MG

00054822225 DICLOFENAC SODIUM EC75.000 MG

00054822325 DICLOFENAC SODIUM EC25.000 MG

00093104101 DICLOFENAC SODIUM ER100.00 MG

00781138101 DICLOFENAC SODIUM XR100.00 MG

00904264860 DICLOXACILLIN SODIUM500.00 MG

00093312301 DICLOXACILLIN SODIUM250.00 MG

00093312501 DICLOXACILLIN SODIUM500.00 MG

00332312305 DICLOXACILLIN SODIUM250.00 MG

00332312505 DICLOXACILLIN SODIUM500.00 MG

59772604801 DICLOXACILLIN SODIUM250.00 MG

60429005940 DICLOXACILLIN SODIUM250.00 MG

00143312601 DICYCLOMINE HCL10.000 MG

00143312610 DICYCLOMINE HCL10.000 MG

00182051910 DICYCLOMINE HCL10.000 MG

00378161001 DICYCLOMINE HCL10.000 MG

00378161005 DICYCLOMINE HCL10.000 MG

00378162001 DICYCLOMINE HCL20.000 MG

00378162005 DICYCLOMINE HCL20.000 MG

00527058601 DICYCLOMINE HCL10.000 MG

00527058605 DICYCLOMINE HCL10.000 MG

00527058610 DICYCLOMINE HCL10.000 MG

00527128201 DICYCLOMINE HCL20.000 MG

00527128205 DICYCLOMINE HCL20.000 MG

00527128210 DICYCLOMINE HCL20.000 MG

00603326521 DICYCLOMINE HCL10.000 MG

00603326532 DICYCLOMINE HCL10.000 MG

00603326621 DICYCLOMINE HCL20.000 MG

00143122701 DICYCLOMINE HCL20.000 MG

00143122710 DICYCLOMINE HCL20.000 MG

00904019580 DICYCLOMINE HCL20.000 MG

00677049801 DICYCLOMINE HCL20.000 MG

00677034101 DICYCLOMINE HCL10.000 MG

00904789660 DICYCLOMINE HCL10.000 MG

00904789680 DICYCLOMINE HCL10.000 MG

51079011820 DICYCLOMINE HCL10.000 MG

51079011920 DICYCLOMINE HCL20.000 MG

00149040560 DIDRONEL200.00 MG

00149040660 DIDRONEL400.00 MG

58063045701 DIDRONEL IV50.000 MG/ML

00168024215 DIFLORASONE DIACETATE.050 %

00168024230 DIFLORASONE DIACETATE.050 %

00168024260 DIFLORASONE DIACETATE.050 %

00168024315 DIFLORASONE DIACETATE.050 %

00168024330 DIFLORASONE DIACETATE.050 %

00168024360 DIFLORASONE DIACETATE.050 %

00093075501 DIFLUNISAL500.00 MG

00093075505 DIFLUNISAL500.00 MG

00093075506 DIFLUNISAL500.00 MG

00904776361 DIFLUNISAL250.00 MG

60951076985 DIFLUNISAL500.00 MG

51079094520 DIGITEK.125 MG

51079094524 DIGITEK.125 MG

51079094620 DIGITEK.250 MG

62794014501 DIGITEK.125 MG

62794014510 DIGITEK.125 MG

62794014556 DIGITEK.125 MG

62794014601 DIGITEK.250 MG

62794014610 DIGITEK.250 MG

62794014656 DIGITEK.250 MG

51285091502 DIGOXIN.250 MG

51285091505 DIGOXIN.250 MG

51285091602 DIGOXIN.125 MG

51285091605 DIGOXIN.125 MG

00641141035 DIGOXIN.250 MG/ML

00615054743 DIGOXIN.125 MG

00904794480 DIGOXIN.125 MG

00904794580 DIGOXIN.250 MG

00074216931 DIGOXIN.250 MG/ML

00074216932 DIGOXIN.250 MG/ML

00054819216 DIGOXIN PEDIATRIC.050 MG/ML

00054819316 DIGOXIN PEDIATRIC.050 MG/ML

00054319246 DIGOXIN PEDIATRIC.050 MG/ML

00472163904 DIHISTINE DH.000

00472163916 DIHISTINE DH.000

00182157340 DIHISTINE DH.000

51552023301 DIHYDROERGOTAMINE MESYLAT.000

52544048201 DILACOR XR120.00 MG

52544048301 DILACOR XR180.00 MG

52544048305 DILACOR XR180.00 MG

52544048401 DILACOR XR240.00 MG

52544048405 DILACOR XR240.00 MG

00071221420 DILANTIN125.00 MG/5ML

00071036224 DILANTIN100.00 MG

00071036232 DILANTIN100.00 MG

00071036240 DILANTIN100.00 MG

00091092001 DILATRATE SR40.000 MG

00044102203 DILAUDID2.000 MG

00281111231 DILOR250.00 MG/ML

Page 31 of 125

Page 32: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00281111553 DILOR200.00 MG

00281111653 DILOR400.00 MG

00281112774 DILOR-G.000

62037054801 DILTIA XT120.00 MG

62037054810 DILTIA XT120.00 MG

62037054901 DILTIA XT180.00 MG

62037054910 DILTIA XT180.00 MG

62037055001 DILTIA XT240.00 MG

62037055010 DILTIA XT240.00 MG

00228257703 DILTIAZEM CD180.00 MG

00228257709 DILTIAZEM CD180.00 MG

00228257750 DILTIAZEM CD180.00 MG

00228257803 DILTIAZEM CD240.00 MG

00228257809 DILTIAZEM CD240.00 MG

00228257850 DILTIAZEM CD240.00 MG

00228257903 DILTIAZEM CD300.00 MG

00228257909 DILTIAZEM CD300.00 MG

00228257950 DILTIAZEM CD300.00 MG

00228258803 DILTIAZEM CD120.00 MG

00228258809 DILTIAZEM CD120.00 MG

00228258850 DILTIAZEM CD120.00 MG

00172421970 DILTIAZEM HCL30.000 MG

00172422070 DILTIAZEM HCL60.000 MG

00172422170 DILTIAZEM HCL90.000 MG

00378052501 DILTIAZEM HCL120.00 MG

00378002301 DILTIAZEM HCL30.000 MG

00378002305 DILTIAZEM HCL30.000 MG

00378004501 DILTIAZEM HCL60.000 MG

00378004505 DILTIAZEM HCL60.000 MG

00378013501 DILTIAZEM HCL90.000 MG

00378013505 DILTIAZEM HCL90.000 MG

00074117101 DILTIAZEM HCL5.000 MG/ML

00074117102 DILTIAZEM HCL5.000 MG/ML

00074229111 DILTIAZEM HCL5.000 MG/ML

00093031801 DILTIAZEM HCL30.000 MG

00093031805 DILTIAZEM HCL30.000 MG

00093031901 DILTIAZEM HCL60.000 MG

00093031905 DILTIAZEM HCL60.000 MG

00093032001 DILTIAZEM HCL90.000 MG

00093032101 DILTIAZEM HCL120.00 MG

52544077505 DILTIAZEM HCL30.000 MG

52544077601 DILTIAZEM HCL60.000 MG

51079074519 DILTIAZEM HCL30.000 MG

51079074520 DILTIAZEM HCL30.000 MG

51079074523 DILTIAZEM HCL30.000 MG

51079074524 DILTIAZEM HCL30.000 MG

51079074619 DILTIAZEM HCL60.000 MG

51079074620 DILTIAZEM HCL60.000 MG

51079074623 DILTIAZEM HCL60.000 MG

51079074624 DILTIAZEM HCL60.000 MG

51079074720 DILTIAZEM HCL90.000 MG

00904771440 DILTIAZEM HCL30.000 MG

00904771460 DILTIAZEM HCL30.000 MG

00904771540 DILTIAZEM HCL60.000 MG

00904771660 DILTIAZEM HCL90.000 MG

00904771760 DILTIAZEM HCL120.00 MG

00904771761 DILTIAZEM HCL120.00 MG

60505070401 DILTIAZEM HCL5.000 MG/ML

60505070402 DILTIAZEM HCL5.000 MG/ML

51079092420 DILTIAZEM HCL ER60.000 MG

51079092520 DILTIAZEM HCL ER90.000 MG

51079092620 DILTIAZEM HCL ER120.00 MG

51079094708 DILTIAZEM HCL ER120.00 MG

51079094808 DILTIAZEM HCL ER180.00 MG

51079094908 DILTIAZEM HCL ER240.00 MG

52544086510 DILTIAZEM HCL ER180.00 MG

00093511298 DILTIAZEM HCL ER120.00 MG

00093511798 DILTIAZEM HCL ER180.00 MG

00093511898 DILTIAZEM HCL ER240.00 MG

00093511998 DILTIAZEM HCL ER300.00 MG

00378609001 DILTIAZEM HCL ER90.000 MG

00378612001 DILTIAZEM HCL ER120.00 MG

00378522001 DILTIAZEM HCL ER120.00 MG

00378522005 DILTIAZEM HCL ER120.00 MG

00378528001 DILTIAZEM HCL ER180.00 MG

00378528005 DILTIAZEM HCL ER180.00 MG

00378534001 DILTIAZEM HCL ER240.00 MG

00378534005 DILTIAZEM HCL ER240.00 MG

00378606001 DILTIAZEM HCL ER60.000 MG

60505001606 DILTIAZEM HCL ER240.00 MG

60505001608 DILTIAZEM HCL ER240.00 MG

00904784060 DILTIAZEM HCL SR60.000 MG

00904784160 DILTIAZEM HCL SR90.000 MG

00904538260 DILTIAZEM XR240.00 MG/24HR

00904538261 DILTIAZEM XR240.00 MG/24HR

00677168601 DIMENHYDRINATE50.000 MG

00536374501 DIMENHYDRINATE50.000 MG

00182019501 DIMENHYDRINATE50.000 MG

00031223110 DIMETAPP.000

00031223120 DIMETAPP.000

00031223130 DIMETAPP.000

00031224021 DIMETAPP DM.000

00031224023 DIMETAPP DM.000

00031228378 DIMETAPP PEDIATRIC7.500 MG/0.8ML

00182177440 DIOCTO150.00 MG/15ML

00472093616 DIOCTO150.00 MG/15ML

00472092416 DIOCTO60.000 MG/15ML

00536059085 DIOCTO150.00 MG/15ML

00536060085 DIOCTO60.000 MG/15ML

17236061401 DIOCTYN100.00 MG

17236061410 DIOCTYN100.00 MG

00078031406 DIOVAN HCT.000

00078031506 DIOVAN HCT.000

60432003304 DIPHEN AF12.500 MG/5ML

60432003308 DIPHEN AF12.500 MG/5ML

60432003316 DIPHEN AF12.500 MG/5ML

60432003328 DIPHEN AF12.500 MG/5ML

00536077085 DIPHENHIST12.500 MG/5ML

00536077097 DIPHENHIST12.500 MG/5ML

00536359401 DIPHENHIST25.000 MG

00536359701 DIPHENHIST25.000 MG

00536418095 DIPHENHIST/ZINC ACETATE.000

45802002503 DIPHENHYDRAMINE2.000 %

00904433331 DIPHENHYDRAMINE2.000 %

00904530660 DIPHENHYDRAMINE HCL25.000 MG

00904530680 DIPHENHYDRAMINE HCL25.000 MG

00904530760 DIPHENHYDRAMINE HCL50.000 MG

00904530780 DIPHENHYDRAMINE HCL50.000 MG

17714002001 DIPHENHYDRAMINE HCL25.000 MG

17714002010 DIPHENHYDRAMINE HCL25.000 MG

17714002101 DIPHENHYDRAMINE HCL50.000 MG

17714002110 DIPHENHYDRAMINE HCL50.000 MG

17236051601 DIPHENHYDRAMINE HCL25.000 MG

17236051610 DIPHENHYDRAMINE HCL25.000 MG

17236051801 DIPHENHYDRAMINE HCL50.000 MG

17236051810 DIPHENHYDRAMINE HCL50.000 MG

10267083501 DIPHENHYDRAMINE HCL25.000 MG

10267083504 DIPHENHYDRAMINE HCL25.000 MG

10267083601 DIPHENHYDRAMINE HCL50.000 MG

10267083604 DIPHENHYDRAMINE HCL50.000 MG

00641037625 DIPHENHYDRAMINE HCL50.000 MG/ML

00904203524 DIPHENHYDRAMINE HCL25.000 MG

Page 32 of 125

Page 33: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00904203559 DIPHENHYDRAMINE HCL25.000 MG

00904205661 DIPHENHYDRAMINE HCL50.000 MG

00904123016 DIPHENHYDRAMINE HCL12.500 MG/5ML

51079006619 DIPHENHYDRAMINE HCL50.000 MG

51079006620 DIPHENHYDRAMINE HCL50.000 MG

00555005902 DIPHENHYDRAMINE HCL50.000 MG

00555005905 DIPHENHYDRAMINE HCL50.000 MG

00548139000 DIPHENHYDRAMINE HCL50.000 MG/ML

00603333732 DIPHENHYDRAMINE HCL25.000 MG

00603333832 DIPHENHYDRAMINE HCL50.000 MG

00185064801 DIPHENHYDRAMINE HCL25.000 MG

00185064810 DIPHENHYDRAMINE HCL25.000 MG

00185064901 DIPHENHYDRAMINE HCL50.000 MG

00185064910 DIPHENHYDRAMINE HCL50.000 MG

00182049210 DIPHENHYDRAMINE HCL25.000 MG

00074229031 DIPHENHYDRAMINE HCL50.000 MG/ML

00536377206 DIPHENHYDRAMINE HCL50.000 MG

53265023710 DIPHENOXYLATE HYDROCHLORI.000

53265023711 DIPHENOXYLATE HYDROCHLORI.000

51079006719 DIPHENOXYLATE/ATROPINE.000

51079006720 DIPHENOXYLATE/ATROPINE.000

49884077101 DIPHENOXYLATE/ATROPINE.000

49884077110 DIPHENOXYLATE/ATROPINE.000

00054319446 DIPHENOXYLATE/ATROPINE.000

00054817116 DIPHENOXYLATE/ATROPINE.000

00054819116 DIPHENOXYLATE/ATROPINE.000

00172396660 DIPHENOXYLATE/ATROPINE.000

00172396680 DIPHENOXYLATE/ATROPINE.000

00185002401 DIPHENOXYLATE/ATROPINE.000

00185002405 DIPHENOXYLATE/ATROPINE.000

00185002410 DIPHENOXYLATE/ATROPINE.000

00378041501 DIPHENOXYLATE/ATROPINE.000

00378041510 DIPHENOXYLATE/ATROPINE.000

00603336021 DIPHENOXYLATE/ATROPINE.000

24208054005 DIPIVEFRIN HCL.100 %

24208054010 DIPIVEFRIN HCL.100 %

24208054015 DIPIVEFRIN HCL.100 %

61314023505 DIPIVEFRIN HCL.100 %

61314023510 DIPIVEFRIN HCL.100 %

61314023515 DIPIVEFRIN HCL.100 %

00310030011 DIPRIVAN10.000 MG/ML

00310030022 DIPRIVAN10.000 MG/ML

00310030050 DIPRIVAN10.000 MG/ML

00310030054 DIPRIVAN10.000 MG/ML

00310030064 DIPRIVAN10.000 MG/ML

00038029061 DIPRIVAN10.000 MG/ML

00038029062 DIPRIVAN10.000 MG/ML

00038029065 DIPRIVAN10.000 MG/ML

00085063401 DIPROLENE.050 %

00085063403 DIPROLENE.050 %

00085057502 DIPROLENE.050 %

00085057505 DIPROLENE.050 %

00085051701 DIPROLENE AF.050 %

00085051704 DIPROLENE AF.050 %

00085085302 DIPROSONE.050 %

00085085303 DIPROSONE.050 %

00074204302 DIPYRIDAMOLE5.000 MG/ML

00074204310 DIPYRIDAMOLE5.000 MG/ML

00555025202 DIPYRIDAMOLE25.000 MG

00555025205 DIPYRIDAMOLE25.000 MG

00555028502 DIPYRIDAMOLE50.000 MG

00555028505 DIPYRIDAMOLE50.000 MG

00555028602 DIPYRIDAMOLE75.000 MG

00555028605 DIPYRIDAMOLE75.000 MG

00641113834 DIPYRIDAMOLE5.000 MG/ML

00641113931 DIPYRIDAMOLE5.000 MG/ML

00641256944 DIPYRIDAMOLE5.000 MG/ML

00904108660 DIPYRIDAMOLE25.000 MG

00904108661 DIPYRIDAMOLE25.000 MG

00904108680 DIPYRIDAMOLE25.000 MG

00904108760 DIPYRIDAMOLE50.000 MG

00904108761 DIPYRIDAMOLE50.000 MG

00904108860 DIPYRIDAMOLE75.000 MG

00904108861 DIPYRIDAMOLE75.000 MG

51079006820 DIPYRIDAMOLE25.000 MG

51079006920 DIPYRIDAMOLE50.000 MG

51079007020 DIPYRIDAMOLE75.000 MG

00085055502 DISOPHROL.000

00093312701 DISOPYRAMIDE PHOSPHATE100.00 MG

00093312901 DISOPYRAMIDE PHOSPHATE150.00 MG

58177000204 DISOPYRAMIDE PHOSPHATE ER150.00 MG

00603075291 DISPOSABLE ENEMA.000

00904353578 DISPOSABLE ENEMA.000

00904353588 DISPOSABLE ENEMA.000

17314920001 DITROPAN5.000 MG

17314920104 DITROPAN5.000 MG/5ML

17314850001 DITROPAN XL5.000 MG

17314850101 DITROPAN XL10.000 MG

17314850201 DITROPAN XL15.000 MG

00006021468 DIURIL250.00 MG

00006043268 DIURIL500.00 MG

00006323966 DIURIL250.00 MG/5ML

53746009901 DM.000

53746009902 DM.000

00083023088 DOAN'S PILLS325.00 MG

00083023589 DOANS EXTRA STRENGH500.00 MG

00074234401 DOBUTAMINE HCL12.500 MG/ML

00074234402 DOBUTAMINE HCL12.500 MG/ML

00074472901 DOBUTAMINE HCL12.500 MG/ML

00074202520 DOBUTAMINE HCL12.500 MG/ML

00074202554 DOBUTAMINE HCL12.500 MG/ML

00002749601 DOBUTAMINE HCL/D5W.000

00002749801 DOBUTAMINE HCL/D5W.000

00002750001 DOBUTAMINE HCL/D5W.000

00074372432 DOBUTAMINE/DEXTROSE 5%.000

00074234534 DOBUTAMINE/DEXTROSE 5%.000

00074234632 DOBUTAMINE/DEXTROSE 5%.000

00074234634 DOBUTAMINE/DEXTROSE 5%.000

00074234732 DOBUTAMINE/DEXTROSE 5%.000

00002717510 DOBUTREX12.500 MG/ML

00603074658 DOC-Q-LACE150.00 MG/15ML

00603074758 DOC-Q-LACE60.000 MG/15ML

00603014621 DOC-Q-LACE100.00 MG

00603014632 DOC-Q-LACE100.00 MG

50383077016 DOCU60.000 MG/15ML

50383077116 DOCU150.00 MG/15ML

51079007119 DOCUSATE CALCIUM240.00 MG

51079007120 DOCUSATE CALCIUM240.00 MG

51079007140 DOCUSATE CALCIUM240.00 MG

51079007150 DOCUSATE CALCIUM240.00 MG

17236061301 DOCUSATE CALCIUM240.00 MG

17236061310 DOCUSATE CALCIUM240.00 MG

00904789259 DOCUSATE CALCIUM240.00 MG

00904789260 DOCUSATE CALCIUM240.00 MG

00677094101 DOCUSATE CALCIUM240.00 MG

00677094105 DOCUSATE CALCIUM240.00 MG

00182822189 DOCUSATE CALCIUM240.00 MG

00182130201 DOCUSATE CALCIUM240.00 MG

00182130205 DOCUSATE CALCIUM240.00 MG

00536375505 DOCUSATE CALCIUM240.00 MG

00536375510 DOCUSATE CALCIUM240.00 MG

00536375601 DOCUSATE SODIUM100.00 MG

Page 33 of 125

Page 34: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00536375610 DOCUSATE SODIUM100.00 MG

00536375701 DOCUSATE SODIUM250.00 MG

00536375710 DOCUSATE SODIUM250.00 MG

00574010101 DOCUSATE SODIUM100.00 MG

00574010110 DOCUSATE SODIUM100.00 MG

00574010201 DOCUSATE SODIUM250.00 MG

00574010210 DOCUSATE SODIUM250.00 MG

00182836389 DOCUSATE SODIUM100.00 MG

00054818704 DOCUSATE SODIUM50.000 MG/15ML

00054818804 DOCUSATE SODIUM50.000 MG/15ML

00615058543 DOCUSATE SODIUM100.00 MG

00677019101 DOCUSATE SODIUM100.00 MG

00677019110 DOCUSATE SODIUM100.00 MG

00677019201 DOCUSATE SODIUM250.00 MG

00904093616 DOCUSATE SODIUM60.000 MG/15ML

17714003401 DOCUSATE SODIUM100.00 MG

17714003410 DOCUSATE SODIUM100.00 MG

17714003501 DOCUSATE SODIUM250.00 MG

17714003510 DOCUSATE SODIUM250.00 MG

51079004820 DOCUSATE SODIUM250.00 MG

51079001919 DOCUSATE SODIUM100.00 MG

51079001920 DOCUSATE SODIUM100.00 MG

51079001940 DOCUSATE SODIUM100.00 MG

51079001960 DOCUSATE SODIUM100.00 MG

51079052120 DOCUSATE SODIUM50.000 MG

60258095501 DOCUSATE SODIUM100.00 MG

60258095510 DOCUSATE SODIUM100.00 MG

00904224360 DOCUSATE SODIUM/CASANTHRA.000

00904224380 DOCUSATE SODIUM/CASANTHRA.000

00615058743 DOCUSATE SODIUM/CASANTHRA.000

60258095601 DOCUSATE SODIUM/CASANTHRA.000

60258095610 DOCUSATE SODIUM/CASANTHRA.000

00713040560 DOCUSOFT S100.00 MG

00713040599 DOCUSOFT S100.00 MG

00904224461 DOK100.00 MG

00904789159 DOK250.00 MG

00904788959 DOK100.00 MG

00904788960 DOK100.00 MG

00904788980 DOK100.00 MG

54092013801 DOLACET.000

59743001101 DOLAGESIC.000

00006067561 DOLOBID250.00 MG

00006069761 DOLOBID500.00 MG

00054121842 DOLOPHINE10.000 MG/ML

00026261301 DOME-PASTE BANDAGE.000

00026261401 DOME-PASTE BANDAGE.000

00026431202 DOMEBORO.000

59743002710 DONNAPHEN.000

00074426501 DOPAMINE HCL80.000 MG/ML

00074426618 DOPAMINE HCL80.000 MG/ML

00074414103 DOPAMINE HCL.000

00074581916 DOPAMINE HCL40.000 MG/ML

00074582001 DOPAMINE HCL40.000 MG/ML

00074582010 DOPAMINE HCL40.000 MG/ML

00074910420 DOPAMINE HCL40.000 MG/ML

00074910518 DOPAMINE HCL40.000 MG/ML

00074780822 DOPAMINE HCL-DEXTROSE 5%.000

00074780824 DOPAMINE HCL-DEXTROSE 5%.000

00074780922 DOPAMINE HCL-DEXTROSE 5%.000

00074780924 DOPAMINE HCL-DEXTROSE 5%.000

00074781022 DOPAMINE HCL-DEXTROSE 5%.000

00074414202 DOPAMINE HCL-DEXTROSE 5%.000

00074414203 DOPAMINE HCL-DEXTROSE 5%.000

00074415502 DOPAMINE HCL-DEXTROSE 5%.000

00430083819 DORYX100.00 MG

00378402101 DOXAZOSIN MESYLATE1.000 MG

00378402201 DOXAZOSIN MESYLATE2.000 MG

00378402401 DOXAZOSIN MESYLATE4.000 MG

00378402801 DOXAZOSIN MESYLATE8.000 MG

00172368560 DOXAZOSIN MESYLATE1.000 MG

00172368660 DOXAZOSIN MESYLATE2.000 MG

00172368670 DOXAZOSIN MESYLATE2.000 MG

00172368760 DOXAZOSIN MESYLATE4.000 MG

00172368770 DOXAZOSIN MESYLATE4.000 MG

00172368860 DOXAZOSIN MESYLATE8.000 MG

00172368870 DOXAZOSIN MESYLATE8.000 MG

00228264211 DOXAZOSIN MESYLATE1.000 MG

00228264250 DOXAZOSIN MESYLATE1.000 MG

00228264311 DOXAZOSIN MESYLATE2.000 MG

00228264350 DOXAZOSIN MESYLATE2.000 MG

00228264411 DOXAZOSIN MESYLATE4.000 MG

00228264450 DOXAZOSIN MESYLATE4.000 MG

00228264511 DOXAZOSIN MESYLATE8.000 MG

00228264550 DOXAZOSIN MESYLATE8.000 MG

00093812001 DOXAZOSIN MESYLATE1.000 MG

00093812101 DOXAZOSIN MESYLATE2.000 MG

00093812201 DOXAZOSIN MESYLATE4.000 MG

00093812301 DOXAZOSIN MESYLATE8.000 MG

49884055201 DOXAZOSIN MESYLATE1.000 MG

49884055210 DOXAZOSIN MESYLATE1.000 MG

49884055301 DOXAZOSIN MESYLATE2.000 MG

49884055310 DOXAZOSIN MESYLATE2.000 MG

49884055401 DOXAZOSIN MESYLATE4.000 MG

49884055410 DOXAZOSIN MESYLATE4.000 MG

49884055501 DOXAZOSIN MESYLATE8.000 MG

49884055510 DOXAZOSIN MESYLATE8.000 MG

51079095720 DOXAZOSIN MESYLATE1.000 MG

51079095820 DOXAZOSIN MESYLATE2.000 MG

51079095920 DOXAZOSIN MESYLATE4.000 MG

58177026604 DOXAZOSIN MESYLATE1.000 MG

58177026704 DOXAZOSIN MESYLATE2.000 MG

58177026804 DOXAZOSIN MESYLATE4.000 MG

58177026904 DOXAZOSIN MESYLATE8.000 MG

60505009300 DOXAZOSIN MESYLATE1.000 MG

60505009301 DOXAZOSIN MESYLATE1.000 MG

60505009400 DOXAZOSIN MESYLATE2.000 MG

60505009401 DOXAZOSIN MESYLATE2.000 MG

60505009500 DOXAZOSIN MESYLATE4.000 MG

60505009501 DOXAZOSIN MESYLATE4.000 MG

60505009600 DOXAZOSIN MESYLATE8.000 MG

60505009601 DOXAZOSIN MESYLATE8.000 MG

49884021701 DOXEPIN HCL10.000 MG

49884021710 DOXEPIN HCL10.000 MG

49884021801 DOXEPIN HCL25.000 MG

49884021810 DOXEPIN HCL25.000 MG

49884021901 DOXEPIN HCL50.000 MG

49884021910 DOXEPIN HCL50.000 MG

49884022001 DOXEPIN HCL75.000 MG

49884022010 DOXEPIN HCL75.000 MG

49884022101 DOXEPIN HCL100.00 MG

49884022110 DOXEPIN HCL100.00 MG

49884022201 DOXEPIN HCL150.00 MG

49884022203 DOXEPIN HCL150.00 MG

49884022205 DOXEPIN HCL150.00 MG

51079043620 DOXEPIN HCL10.000 MG

51079043720 DOXEPIN HCL25.000 MG

51079043820 DOXEPIN HCL50.000 MG

51079064520 DOXEPIN HCL75.000 MG

51079065120 DOXEPIN HCL100.00 MG

51079068837 DOXEPIN HCL10.000 MG/ML

54838051240 DOXEPIN HCL10.000 MG/ML

00641451386 DOXEPIN HCL100.00 MG

Page 34 of 125

Page 35: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00641451486 DOXEPIN HCL150.00 MG

00904126161 DOXEPIN HCL25.000 MG

00904126261 DOXEPIN HCL50.000 MG

00904126461 DOXEPIN HCL100.00 MG

00093961212 DOXEPIN HCL10.000 MG/ML

00378425001 DOXEPIN HCL50.000 MG

00378425010 DOXEPIN HCL50.000 MG

00378312501 DOXEPIN HCL25.000 MG

00378312510 DOXEPIN HCL25.000 MG

00378537501 DOXEPIN HCL75.000 MG

00378537510 DOXEPIN HCL75.000 MG

00378641001 DOXEPIN HCL100.00 MG

00378641010 DOXEPIN HCL100.00 MG

00378104901 DOXEPIN HCL10.000 MG

00378104910 DOXEPIN HCL10.000 MG

60432065104 DOXEPIN HCL10.000 MG/ML

00009757201 DOXIDAN.000

00009757202 DOXIDAN.000

00009757203 DOXIDAN.000

00009757204 DOXIDAN.000

00009361101 DOXIDAN.000

00009361102 DOXIDAN.000

00904043061 DOXYCYCLINE HYCLATE100.00 MG

00904042861 DOXYCYCLINE HYCLATE100.00 MG

00603348019 DOXYCYCLINE HYCLATE50.000 MG

00603348119 DOXYCYCLINE HYCLATE100.00 MG

00603348128 DOXYCYCLINE HYCLATE100.00 MG

00603348219 DOXYCYCLINE HYCLATE100.00 MG

00603348228 DOXYCYCLINE HYCLATE100.00 MG

00172362648 DOXYCYCLINE HYCLATE100.00 MG

00172362670 DOXYCYCLINE HYCLATE100.00 MG

00172298448 DOXYCYCLINE HYCLATE50.000 MG

00172298548 DOXYCYCLINE HYCLATE100.00 MG

00172298570 DOXYCYCLINE HYCLATE100.00 MG

00143314205 DOXYCYCLINE HYCLATE100.00 MG

00143314214 DOXYCYCLINE HYCLATE100.00 MG

00143314225 DOXYCYCLINE HYCLATE100.00 MG

00143314250 DOXYCYCLINE HYCLATE100.00 MG

00182153589 DOXYCYCLINE HYCLATE100.00 MG

00182103589 DOXYCYCLINE HYCLATE100.00 MG

00093065305 DOXYCYCLINE HYCLATE100.00 MG

00093075005 DOXYCYCLINE HYCLATE100.00 MG

00093075053 DOXYCYCLINE HYCLATE100.00 MG

00047083030 DOXYCYCLINE HYCLATE100.00 MG

17236052705 DOXYCYCLINE HYCLATE100.00 MG

17236052714 DOXYCYCLINE HYCLATE100.00 MG

17236052728 DOXYCYCLINE HYCLATE100.00 MG

17236052755 DOXYCYCLINE HYCLATE100.00 MG

00904042751 DOXYCYCLINE HYCLATE50.000 MG

00904042840 DOXYCYCLINE HYCLATE100.00 MG

00904042851 DOXYCYCLINE HYCLATE100.00 MG

00904043040 DOXYCYCLINE HYCLATE100.00 MG

00904043051 DOXYCYCLINE HYCLATE100.00 MG

00677079902 DOXYCYCLINE HYCLATE100.00 MG

00677079905 DOXYCYCLINE HYCLATE100.00 MG

00677059802 DOXYCYCLINE HYCLATE50.000 MG

00677056202 DOXYCYCLINE HYCLATE100.00 MG

00677056205 DOXYCYCLINE HYCLATE100.00 MG

53489011802 DOXYCYCLINE HYCLATE50.000 MG

53489011805 DOXYCYCLINE HYCLATE50.000 MG

53489011902 DOXYCYCLINE HYCLATE100.00 MG

53489011905 DOXYCYCLINE HYCLATE100.00 MG

53489012002 DOXYCYCLINE HYCLATE100.00 MG

53489012005 DOXYCYCLINE HYCLATE100.00 MG

00143314150 DOXYCYCLINE HYCLATE50.000 MG

60429006920 DOXYCYCLINE HYCLATE100.00 MG

49884072601 DOXYCYCLINE MONOHYDRATE50.000 MG

49884072703 DOXYCYCLINE MONOHYDRATE100.00 MG

49884072704 DOXYCYCLINE MONOHYDRATE100.00 MG

00185080501 DOXYCYCLINE MONOHYDRATE50.000 MG

00185081001 DOXYCYCLINE MONOHYDRATE100.00 MG

00185081052 DOXYCYCLINE MONOHYDRATE100.00 MG

00185081053 DOXYCYCLINE MONOHYDRATE100.00 MG

00904773834 DOXYLAMINE SUCCINATE25.000 MG

00009364202 DRAMAMINE50.000 MG

00009364203 DRAMAMINE50.000 MG

00009364219 DRAMAMINE50.000 MG

00009364201 DRAMAMINE50.000 MG

00009364801 DRAMAMINE II25.000 MG

00009364804 DRAMAMINE II25.000 MG

00904408031 DRAWING SALVE.000

00603350521 DREXOPHED SR.000

00603350528 DREXOPHED SR.000

00904205112 DRIMINATE50.000 MG

00904205159 DRIMINATE50.000 MG

00904205160 DRIMINATE50.000 MG

00024039102 DRISDOL8000.0 IU/ML

00024039202 DRISDOL50000. IU

00603118158 DRITUSS DM.000

00603118258 DRITUSS HD.000

00085014701 DRIXORAL COLD/ALLERGY.000

00085014703 DRIXORAL COLD/ALLERGY.000

00085014711 DRIXORAL COLD/ALLERGY.000

00085050801 DRIXORAL NON-DROWSY120.00 MG

00085050802 DRIXORAL NON-DROWSY120.00 MG

00085078901 DRIXORAL SINUS.000

00085078902 DRIXORAL SINUS.000

52604040601 DRIZE-R.000

00074118701 DROPERIDOL2.500 MG/ML

00904775127 DRY SKIN.000

00904775216 DRY SKIN MOISTURIZING.000

00026815120 DTIC-DOME200.00 MG

00083610004 DULCOLAX10.000 MG

00083610008 DULCOLAX10.000 MG

00083610050 DULCOLAX10.000 MG

00083610051 DULCOLAX10.000 MG

00083620032 DULCOLAX5.000 MG

00083620048 DULCOLAX5.000 MG

00083620053 DULCOLAX5.000 MG

00083620055 DULCOLAX5.000 MG

00083630033 DULCOLAX BOWEL PREP KIT.000

00003187932 DUODERM EXTRA THIN CGF SP.000

00003187611 DUODERM HYDROACTIVE DRESS.000

51991001616 DURADRYL.000

51991070001 DURADRYL JR.000

51285074257 DURAGANIDIN DM.000

00641111233 DURAMORPH.500 MG/ML

00641111433 DURAMORPH1.000 MG/ML

51285089602 DURASAL II.000

00065041435 DURATEARS.000

50474061201 DURATUSS.000

50474063016 DURATUSS DM.000

50474062001 DURATUSS G1200.0 MG

50474064001 DURATUSS GP.000

50474061016 DURATUSS HD.000

00087078242 DURICEF250.00 MG/5ML

00087078446 DURICEF500.00 MG

00087078641 DURICEF125.00 MG/5ML

60258037116 DY-G.000

00007365021 DYAZIDE.000

00007365022 DYAZIDE.000

00007365030 DYAZIDE.000

Page 35 of 125

Page 36: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

99207049710 DYNACIN50.000 MG

99207049850 DYNACIN100.00 MG

99207049905 DYNACIN75.000 MG

99207049910 DYNACIN75.000 MG

51991021701 DYNAHIST ER.000

00603119058 DYPHYLLINE-GG.000

51991037501 DYPHYLLINE-GG.000

54838051380 DYPHYLLINE-GG.000

50383080616 DYPHYLLINE-GG.000

60258033516 DYPHYLLINE-GG.000

00677178001 DYPHYLLINE/GG.000

00074630613 E.E.S. 200200.00 MG/5ML

00074630616 E.E.S. 200200.00 MG/5ML

00074637313 E.E.S. 400400.00 MG/5ML

00074637316 E.E.S. 400400.00 MG/5ML

00074572913 E.E.S. 400400.00 MG

00074572953 E.E.S. 400400.00 MG

00074636902 E.E.S. GRANULES200.00 MG/5ML

00074636910 E.E.S. GRANULES200.00 MG/5ML

00182602464 EAR DROPS6.500 %

45802049756 EAR DROPS6.500 %

00536300094 EAR WAX DROPS6.500 %

00603724073 EAR-GESIC.000

00603016702 EC ASPIRIN325.00 MG

00603016721 EC ASPIRIN325.00 MG

00004641501 EC-NAPROSYN375.00 MG

00004641601 EC-NAPROSYN500.00 MG

00904508560 ECHINACEA ROOT400.00 MG

00904543460 ECHINACEA-GOLDEN SEAL.000

00998063705 ECONOPRED PLUS1.000 %

00998063710 ECONOPRED PLUS1.000 %

49692090120 ECOTRIN325.00 MG

49692090123 ECOTRIN325.00 MG

49692090236 ECOTRIN LOW STRENGTH81.000 MG

49692091236 ECOTRIN LOW STRENGTH81.000 MG

49692090350 ECOTRIN MAXIMUM STRENGTH500.00 MG

49692090360 ECOTRIN MAXIMUM STRENGTH500.00 MG

00006009068 EDECRIN50.000 MG

00006006568 EDECRIN25.000 MG

00091141044 EDEX10.000 MCG

00091142044 EDEX20.000 MCG

00091102722 EDEX-REFILL PACK10.000 MCG

00091102922 EDEX-REFILL PACK20.000 MCG

00091111011 EDEX-STARTER PACK10.000 MCG

00091112011 EDEX-STARTER PACK20.000 MCG

00904788616 EFASIN HD PLUS.000

00904794873 EFFERVESCENT PAIN RELIEF.000

00603350816 EFFERVESCENT POT CHLORIDE.000

00310004010 ELAVIL10.000 MG

00310004110 ELAVIL50.000 MG

00310004210 ELAVIL75.000 MG

00310004550 ELAVIL25.000 MG

39506002260 ELDEPRYL5.000 MG

51079088703 ELDEPRYL5.000 MG

51079088724 ELDEPRYL5.000 MG

00456064416 ELIXOPHYLLIN80.000 MG/15ML

00456064808 ELIXOPHYLLIN-GG.000

00456064816 ELIXOPHYLLIN-GG.000

00456064508 ELIXOPHYLLIN-KI.000

51991021516 ELLIS TONIC.000

00085037001 ELOCON.100 %

00085037002 ELOCON.100 %

00281029104 EMECHECK.000

00009757301 EMETROL.000

00009757302 EMETROL.000

00009757401 EMETROL.000

00009757402 EMETROL.000

00173044001 EMGEL2.000 %

00173044002 EMGEL2.000 %

00186151601 EMLA.000

00378105101 ENALAPRIL MALEATE2.500 MG

00378105105 ENALAPRIL MALEATE2.500 MG

00378105201 ENALAPRIL MALEATE5.000 MG

00378105210 ENALAPRIL MALEATE5.000 MG

00378105301 ENALAPRIL MALEATE10.000 MG

00378105310 ENALAPRIL MALEATE10.000 MG

00378105401 ENALAPRIL MALEATE20.000 MG

00378105405 ENALAPRIL MALEATE20.000 MG

00185011401 ENALAPRIL MALEATE2.500 MG

00185011410 ENALAPRIL MALEATE2.500 MG

00185011450 ENALAPRIL MALEATE2.500 MG

00185012701 ENALAPRIL MALEATE5.000 MG

00185012710 ENALAPRIL MALEATE5.000 MG

00185012750 ENALAPRIL MALEATE5.000 MG

00185014701 ENALAPRIL MALEATE10.000 MG

00185014710 ENALAPRIL MALEATE10.000 MG

00185014750 ENALAPRIL MALEATE10.000 MG

00185021401 ENALAPRIL MALEATE20.000 MG

00185021410 ENALAPRIL MALEATE20.000 MG

00185021450 ENALAPRIL MALEATE20.000 MG

00172419560 ENALAPRIL MALEATE2.500 MG

00172419580 ENALAPRIL MALEATE2.500 MG

00172419660 ENALAPRIL MALEATE5.000 MG

00172419680 ENALAPRIL MALEATE5.000 MG

00172419760 ENALAPRIL MALEATE10.000 MG

00172419780 ENALAPRIL MALEATE10.000 MG

00172419860 ENALAPRIL MALEATE20.000 MG

00172419880 ENALAPRIL MALEATE20.000 MG

00093002601 ENALAPRIL MALEATE2.500 MG

00093002610 ENALAPRIL MALEATE2.500 MG

00093002701 ENALAPRIL MALEATE5.000 MG

00093002710 ENALAPRIL MALEATE5.000 MG

00093002801 ENALAPRIL MALEATE10.000 MG

00093002810 ENALAPRIL MALEATE10.000 MG

00093002901 ENALAPRIL MALEATE20.000 MG

00093002910 ENALAPRIL MALEATE20.000 MG

49884059101 ENALAPRIL MALEATE2.500 MG

49884059110 ENALAPRIL MALEATE2.500 MG

49884059201 ENALAPRIL MALEATE5.000 MG

49884059210 ENALAPRIL MALEATE5.000 MG

49884059301 ENALAPRIL MALEATE10.000 MG

49884059310 ENALAPRIL MALEATE10.000 MG

49884059401 ENALAPRIL MALEATE20.000 MG

49884059410 ENALAPRIL MALEATE20.000 MG

51079095020 ENALAPRIL MALEATE2.500 MG

51079095120 ENALAPRIL MALEATE5.000 MG

51079095220 ENALAPRIL MALEATE10.000 MG

51079095320 ENALAPRIL MALEATE20.000 MG

63304052201 ENALAPRIL MALEATE2.500 MG

63304052210 ENALAPRIL MALEATE2.500 MG

63304052301 ENALAPRIL MALEATE5.000 MG

63304052310 ENALAPRIL MALEATE5.000 MG

63304052401 ENALAPRIL MALEATE10.000 MG

63304052410 ENALAPRIL MALEATE10.000 MG

63304052501 ENALAPRIL MALEATE20.000 MG

63304052510 ENALAPRIL MALEATE20.000 MG

00074212201 ENALAPRILAT1.250 MG/ML

00074212202 ENALAPRILAT1.250 MG/ML

58406042534 ENBREL25.000 MG

58406042541 ENBREL25.000 MG

52604020006 ENDAGEN-HD.000

60951079670 ENDOCET.000

Page 36 of 125

Page 37: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

60951079770 ENDOCET.000

60951060270 ENDOCET.000

60951060275 ENDOCET.000

60951060285 ENDOCET.000

60951061070 ENDODAN.000

00074694003 ENDRATE150.00 MG/ML

00074683801 ENDURONYL.000

00074685401 ENDURONYL FORTE.000

00536741551 ENEMA DISPOSABLE.000

00087140342 ENFALYTE.000

00087026524 ENFALYTE.000

00087024644 ENFAMIL 20.000

00087002042 ENFAMIL 22.000

00087070249 ENFAMIL NATALINS RX.000

00087140602 ENFAMIL PREMATURE LIPIL N.000

00087201044 ENFAMIL PREMATURE LIPIL N.000

00087140542 ENFAMIL PREMATURE LIPIL N.000

00087140642 ENFAMIL PREMATURE LIPIL N.000

00087026744 ENFAMIL PREMATURE LIPIL N.000

00087030222 ENFAMIL READY-TO-USE.000

00087030240 ENFAMIL READY-TO-USE.000

00087031542 ENFAMIL W/IRON NURSETTE.000

00087024844 ENFAMIL WITH IRON 20.000

00087025924 ENFAMIL WITH IRON 20.000

00087026943 ENFAMIL WITH IRON 24.000

00087030501 ENFAMIL/IRON READY-TO-USE.000

00087030540 ENFAMIL/IRON READY-TO-USE.000

00074940601 ENFLURANE.000

00074940602 ENFLURANE.000

00074940649 ENFLURANE.000

00074940651 ENFLURANE.000

59743000816 ENPLUS-HD.000

00065906072 ENTRITION 0.5.000

00065906272 ENTRITION HN.000

00482310001 ENTSOL HYPERTONIC NASAL I.000

00482310008 ENTSOL HYPERTONIC NASAL W.000

00482310009 ENTSOL HYPERTONIC NASAL W.000

00482311010 ENTSOL NASAL SPRAY.000

00482312008 ENTSOL NASAL WASH.000

54092014101 ENTUSS.000

54092043716 ENTUSS EXPECTORANT.000

59441043904 ENTUSS-D JR.000

59441043916 ENTUSS-D JR.000

00472136016 ENULOSE10.000 GM/15ML

00472136064 ENULOSE10.000 GM/15ML

00785551004 ENZONE.000

00143314501 EPHEDRINE SULFATE25.000 MG

00074307331 EPHEDRINE SULFATE50.000 MG/ML

00091074010 EPIFOAM.000

08290405202 EPILOR LOSS OF RESISTANCE.000

08290405203 EPILOR LOSS OF RESISTANCE.000

08290405206 EPILOR LOSS OF RESISTANCE.000

08290405207 EPILOR LOSS OF RESISTANCE.000

00065026407 EPINAL1.000 %

00065026507 EPINAL.500 %

00904777035 EPINEPHRINE BITRATE.220 MG/ACT

00641142036 EPINEPHRINE HCL1.000 MG/ML

00548101600 EPINEPHRINE HCL1.000 :10000

00548101400 EPINEPHRINE HCL.100 MG/ML

00548201600 EPINEPHRINE HCL.100 MG/ML

00548331600 EPINEPHRINE HCL.100 MG/ML

00548906100 EPINEPHRINE HCL1.000 MG/ML

00074492118 EPINEPHRINE HCL.100 MG/ML

00074492134 EPINEPHRINE HCL.100 MG/ML

00074490118 EPINEPHRINE HCL.100 MG/ML

00074724101 EPINEPHRINE HCL1.000 MG/ML

60793040111 EPINEPHRINE HCL1.000 MG/ML

49502050001 EPIPEN1.000 :1000

49502050002 EPIPEN1.000 :1000

00093009001 EPITOL200.00 MG

00003177908 EPIVIEW.000

00003177910 EPIVIEW.000

00003177911 EPIVIEW.000

00003177912 EPIVIEW.000

51552037604 EPSOM SALT.000

50383078530 EQUALIZER GAS RELIEF40.000 MG/0.6ML

00904033660 ERGOLOID MESYLATES1.000 MG

00677078201 ERGOLOID MESYLATES1.000 MG

00677078205 ERGOLOID MESYLATES1.000 MG

53489028101 ERGOLOID MESYLATES1.000 MG

53489028105 ERGOLOID MESYLATES1.000 MG

53489028110 ERGOLOID MESYLATES1.000 MG

00172295960 ERGOLOID MESYLATES1.000 MG

00074630413 ERY-TAB250.00 MG

00074630453 ERY-TAB250.00 MG

00074632013 ERY-TAB333.00 MG

00074632053 ERY-TAB333.00 MG

00074632113 ERY-TAB500.00 MG

00430069624 ERYC250.00 MG

00074269802 ERYDERM2.000 %

00074630213 ERYPED 200200.00 MG/5ML

00074630253 ERYPED 200200.00 MG/5ML

00074630513 ERYPED 400400.00 MG/5ML

00074630553 ERYPED 400400.00 MG/5ML

00074647844 ERYTHROCIN1000.0 MG

00074631613 ERYTHROCIN STEARATE500.00 MG

00074634620 ERYTHROCIN STEARATE250.00 MG

00074634653 ERYTHROCIN STEARATE250.00 MG

00074630113 ERYTHROMYCIN250.00 MG

00074630153 ERYTHROMYCIN250.00 MG

00168021560 ERYTHROMYCIN2.000 %

00168021630 ERYTHROMYCIN2.000 %

00168021660 ERYTHROMYCIN2.000 %

00168007011 ERYTHROMYCIN5.000 MG/GM

00168007038 ERYTHROMYCIN5.000 MG/GM

00168007039 ERYTHROMYCIN5.000 MG/GM

00603713770 ERYTHROMYCIN5.000 MG/GM

00904774340 ERYTHROMYCIN250.00 MG

00904774360 ERYTHROMYCIN250.00 MG

00904792638 ERYTHROMYCIN5.000 MG/GM

24208091019 ERYTHROMYCIN5.000 MG/GM

24208091055 ERYTHROMYCIN5.000 MG/GM

45802003846 ERYTHROMYCIN2.000 %

24208042160 ERYTHROMYCIN2.000 %

60432067160 ERYTHROMYCIN2.000 %

00074622713 ERYTHROMYCIN BASE500.00 MG

00074632613 ERYTHROMYCIN BASE250.00 MG

00074632653 ERYTHROMYCIN BASE250.00 MG

00472097716 ERYTHROMYCIN ESTOLATE125.00 MG/5ML

00472097916 ERYTHROMYCIN ESTOLATE250.00 MG/5ML

00904247016 ERYTHROMYCIN ESTOLATE125.00 MG/5ML

00472097416 ERYTHROMYCIN ETHYLSUCCINA400.00 MG/5ML

00472097116 ERYTHROMYCIN ETHYLSUCCINA200.00 MG/5ML

00378640005 ERYTHROMYCIN ETHYLSUCCINA400.00 MG

00074258913 ERYTHROMYCIN ETHYLSUCCINA400.00 MG

00074258953 ERYTHROMYCIN ETHYLSUCCINA400.00 MG

00074374716 ERYTHROMYCIN ETHYLSUCCINA200.00 MG/5ML

00074374816 ERYTHROMYCIN ETHYLSUCCINA400.00 MG/5ML

00074647644 ERYTHROMYCIN LACTOBIONATE500.00 MG

00074648201 ERYTHROMYCIN LACTOBIONATE500.00 MG

00378010601 ERYTHROMYCIN STEARATE250.00 MG

00555044521 ERYTHROMYCIN/SULFISOXAZOL.000

Page 37 of 125

Page 38: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00555044522 ERYTHROMYCIN/SULFISOXAZOL.000

00555044523 ERYTHROMYCIN/SULFISOXAZOL.000

00074715613 ERYTHROMYCIN/SULFISOXAZOL.000

00074715643 ERYTHROMYCIN/SULFISOXAZOL.000

00074715653 ERYTHROMYCIN/SULFISOXAZOL.000

00904247504 ERYTHROMYCIN/SULFISOXAZOL.000

00904247507 ERYTHROMYCIN/SULFISOXAZOL.000

00904247508 ERYTHROMYCIN/SULFISOXAZOL.000

00456067801 ESGIC-PLUS.000

00456067802 ESGIC-PLUS.000

00456067901 ESGIC-PLUS.000

00007400720 ESKALITH300.00 MG

00007400725 ESKALITH300.00 MG

00007401020 ESKALITH CR450.00 MG

00766108043 ESOTERICA DRY SKIN TREATM.000

00766110114 ESOTERICA REGULAR2.000 %

00766113114 ESOTERICA SUNSCREEN FORMU.000

00072760303 ESTAR5.000 %

00093012901 ESTAZOLAM1.000 MG

00093013001 ESTAZOLAM2.000 MG

00172403660 ESTAZOLAM1.000 MG

00172403760 ESTAZOLAM2.000 MG

00087075501 ESTRACE1.000 MG

00430375414 ESTRACE.100 MG/GM

00083231062 ESTRADERM.050 MG/24HR

00083232008 ESTRADERM.100 MG/24HR

00083232062 ESTRADERM.100 MG/24HR

00083231008 ESTRADERM.050 MG/24HR

00378335099 ESTRADIOL.050 MG/24HR

00378335299 ESTRADIOL.100 MG/24HR

00378145201 ESTRADIOL.500 MG

00378145205 ESTRADIOL.500 MG

00378145401 ESTRADIOL1.000 MG

00378145405 ESTRADIOL1.000 MG

00378145801 ESTRADIOL2.000 MG

00378145805 ESTRADIOL2.000 MG

00555088602 ESTRADIOL1.000 MG

00555088604 ESTRADIOL1.000 MG

00555088702 ESTRADIOL2.000 MG

00555088704 ESTRADIOL2.000 MG

00555089902 ESTRADIOL.500 MG

51552038401 ESTRADIOL.000

51552038405 ESTRADIOL.000

51285050102 ESTRADIOL.500 MG

51285050202 ESTRADIOL1.000 MG

51285050204 ESTRADIOL1.000 MG

51285050402 ESTRADIOL2.000 MG

51285050404 ESTRADIOL2.000 MG

59772002503 ESTRADIOL.500 MG

59772002603 ESTRADIOL1.000 MG

59772002604 ESTRADIOL1.000 MG

59772002703 ESTRADIOL2.000 MG

59772002704 ESTRADIOL2.000 MG

00032102601 ESTRATEST.000

00032102610 ESTRATEST.000

00032102301 ESTRATEST H.S..000

00013215036 ESTRING2.000 MG

51552038101 ESTRIOL.000

51552044501 ESTRONE.000

00555072702 ESTROPIPATE.750 MG

00555072802 ESTROPIPATE1.500 MG

00555072902 ESTROPIPATE3.000 MG

00378455101 ESTROPIPATE.750 MG

00378455301 ESTROPIPATE1.500 MG

00904221360 ETHAVERINE HCL100.00 MG

58177080402 ETHEZYME.000

54092004601 ETHMOZINE200.00 MG

54092004652 ETHMOZINE200.00 MG

54092004701 ETHMOZINE250.00 MG

54092004752 ETHMOZINE250.00 MG

54092004801 ETHMOZINE300.00 MG

00093966016 ETHOSUXIMIDE250.00 MG/5ML

00093839701 ETODOLAC300.00 MG

00093089201 ETODOLAC400.00 MG

00378720001 ETODOLAC200.00 MG

00378723301 ETODOLAC300.00 MG

00378723305 ETODOLAC300.00 MG

00378124201 ETODOLAC500.00 MG

00378023701 ETODOLAC400.00 MG

00378023705 ETODOLAC400.00 MG

00228259911 ETODOLAC400.00 MG

00228259950 ETODOLAC400.00 MG

00228263211 ETODOLAC500.00 MG

00185013901 ETODOLAC500.00 MG

00185013905 ETODOLAC500.00 MG

00185013910 ETODOLAC500.00 MG

00185014001 ETODOLAC400.00 MG

55370055207 ETODOLAC400.00 MG

55370055208 ETODOLAC400.00 MG

49884059601 ETODOLAC500.00 MG

00677162301 ETODOLAC400.00 MG

00228267111 ETODOLAC CR400.00 MG

00228267150 ETODOLAC CR400.00 MG

00093112201 ETODOLAC ER400.00 MG

00093111801 ETODOLAC EXTENDED-RELEASE600.00 MG

00093717201 ETODOLAC EXTENDED-RELEASE500.00 MG

00074148501 ETOPOSIDE20.000 MG/ML

00074148502 ETOPOSIDE20.000 MG/ML

00074148503 ETOPOSIDE20.000 MG/ML

00785630101 EUDAL-SR.000

00085052505 EULEXIN125.00 MG

00085052506 EULEXIN125.00 MG

00085052503 EULEXIN125.00 MG

00002416502 EVISTA60.000 MG

00002416507 EVISTA60.000 MG

00002416530 EVISTA60.000 MG

00043012740 EX-LAX STOOL SOFTENER100.00 MG

57599754204 EXACTECH R-S-G TEST STRIP.000

57599754305 EXACTECH R-S-G TEST STRIP.000

57599717402 EXACTECH TEST STRIPS.000

19810000021 EXCEDRIN.000

19810000022 EXCEDRIN.000

19810000023 EXCEDRIN.000

19810000161 EXCEDRIN.000

19810000163 EXCEDRIN.000

19810000165 EXCEDRIN.000

19810000166 EXCEDRIN.000

19810007729 EXCEDRIN.000

19810007822 EXCEDRIN.000

19810000911 EXCEDRIN.000

19810000610 EXCEDRIN.000

19810000619 EXCEDRIN.000

19810000296 EXCEDRIN.000

19810000297 EXCEDRIN.000

19810000298 EXCEDRIN.000

19810000291 EXCEDRIN ASPIRIN FREE.000

19810000292 EXCEDRIN ASPIRIN FREE.000

19810000293 EXCEDRIN ASPIRIN FREE.000

19810000891 EXCEDRIN ASPIRIN FREE.000

19810000892 EXCEDRIN ASPIRIN FREE.000

19810000893 EXCEDRIN ASPIRIN FREE.000

19810002903 EXCEDRIN ASPIRIN FREE.000

Page 38 of 125

Page 39: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

19810000790 EXCEDRIN MIGRAINE.000

19810000808 EXCEDRIN MIGRAINE.000

19810000809 EXCEDRIN MIGRAINE.000

19810000863 EXCEDRIN MIGRAINE.000

19810000865 EXCEDRIN MIGRAINE.000

19810000866 EXCEDRIN MIGRAINE.000

19810000240 EXCEDRIN PM.000

19810000322 EXCEDRIN PM.000

19810000323 EXCEDRIN PM.000

19810000326 EXCEDRIN PM.000

19810007641 EXCEDRIN PM.000

19810007067 EXCEDRIN PM.000

19810007068 EXCEDRIN PM.000

19810000181 EXCEDRIN PM.000

19810000182 EXCEDRIN PM.000

19810000183 EXCEDRIN PM.000

19810000184 EXCEDRIN PM.000

50383013204 EXPECTORANT COUGH CONTROL100.00 MG/5ML

50383013208 EXPECTORANT COUGH CONTROL100.00 MG/5ML

50383013216 EXPECTORANT COUGH CONTROL100.00 MG/5ML

50383013228 EXPECTORANT COUGH CONTROL100.00 MG/5ML

00256012701 EXTENDRYL.000

00256013301 EXTENDRYL.000

00256017701 EXTENDRYL JR.000

00256011101 EXTENDRYL SR.000

45802012517 EXTRA CARE.000

17714003701 EXTRA STRENGTH ACETAMINOP500.00 MG

17714003710 EXTRA STRENGTH ACETAMINOP500.00 MG

45802017453 EXTRA STRENGTH MUSCLE RUB.000

00536090197 EYE IRRIGATING SOLUTION.000

00182505631 EYE LUBRICANT.000

00065053001 EYE STREAM.000

00065053004 EYE STREAM.000

00182705137 EYE WASH.000

00904537720 EYE WASH.000

50383001804 EYE WASH.000

00904508760 EYEBRIGHT HERB454.00 MG

58768010314 EYESCRUB.000

00065909270 F.A.A..000

00093089601 FAMOTIDINE20.000 MG

00093089610 FAMOTIDINE20.000 MG

00093089701 FAMOTIDINE40.000 MG

00093089710 FAMOTIDINE40.000 MG

00172572810 FAMOTIDINE20.000 MG

00172572860 FAMOTIDINE20.000 MG

00172572870 FAMOTIDINE20.000 MG

00172572880 FAMOTIDINE20.000 MG

00172572910 FAMOTIDINE40.000 MG

00172572960 FAMOTIDINE40.000 MG

00172572970 FAMOTIDINE40.000 MG

00378304001 FAMOTIDINE40.000 MG

00378302001 FAMOTIDINE20.000 MG

00378302005 FAMOTIDINE20.000 MG

00904555346 FAMOTIDINE20.000 MG

00904555360 FAMOTIDINE20.000 MG

00904555446 FAMOTIDINE40.000 MG

00904555460 FAMOTIDINE40.000 MG

00904555480 FAMOTIDINE40.000 MG

49884060801 FAMOTIDINE20.000 MG

49884060810 FAMOTIDINE20.000 MG

49884060811 FAMOTIDINE20.000 MG

49884060901 FAMOTIDINE40.000 MG

49884060910 FAMOTIDINE40.000 MG

49884060911 FAMOTIDINE40.000 MG

51079096619 FAMOTIDINE20.000 MG

51079096620 FAMOTIDINE20.000 MG

59911595004 FAMOTIDINE10.000 MG/ML

59911595104 FAMOTIDINE10.000 MG/ML

59911595204 FAMOTIDINE10.000 MG/ML

62037095501 FAMOTIDINE20.000 MG

62037095510 FAMOTIDINE20.000 MG

62037095601 FAMOTIDINE40.000 MG

62037095610 FAMOTIDINE40.000 MG

00904555380 FAMOTIDINE20.000 MG

00004016103 FANSIDAR.000

00574030805 FATTIBASE.000

00574030816 FATTIBASE.000

58177002409 FE-TINIC150.00 MG

58177002411 FE-TINIC150.00 MG

58177002511 FE-TINIC 150 FORTE.000

00069322066 FELDENE10.000 MG

00069323066 FELDENE20.000 MG

00904531246 FEMATROL5.000 MG

00713042230 FEMILAX5.000 MG

00713042260 FEMILAX5.000 MG

00904378640 FENOPROFEN CALCIUM600.00 MG

00904378660 FENOPROFEN CALCIUM600.00 MG

00378047101 FENOPROFEN CALCIUM600.00 MG

00172414160 FENOPROFEN CALCIUM600.00 MG

00074127602 FENTANYL CITRATE.050 MG/ML

00074127605 FENTANYL CITRATE.050 MG/ML

00074127612 FENTANYL CITRATE.050 MG/ML

00074127615 FENTANYL CITRATE.050 MG/ML

00074127632 FENTANYL CITRATE.050 MG/ML

00074909332 FENTANYL CITRATE.050 MG/ML

00074909335 FENTANYL CITRATE.050 MG/ML

00074909336 FENTANYL CITRATE.050 MG/ML

00074909338 FENTANYL CITRATE.050 MG/ML

00074909410 FENTANYL CITRATE.050 MG/ML

00074909420 FENTANYL CITRATE.050 MG/ML

00074909422 FENTANYL CITRATE.050 MG/ML

00074909425 FENTANYL CITRATE.050 MG/ML

00074909428 FENTANYL CITRATE.050 MG/ML

00074909431 FENTANYL CITRATE.050 MG/ML

00074909450 FENTANYL CITRATE.050 MG/ML

00074909461 FENTANYL CITRATE.050 MG/ML

00641240241 FENTANYL CITRATE.050 MG/ML

00641240341 FENTANYL CITRATE.050 MG/ML

00641111733 FENTANYL CITRATE PARTIAL.050 MG/ML

00641111834 FENTANYL CITRATE PARTIAL.050 MG/ML

00641111934 FENTANYL CITRATE PARTIAL.050 MG/ML

00074118612 FENTANYL/DROPERIDOL.000

49692094056 FEOSOL220.00 MG/5ML

49692094220 FEOSOL200.00 MG

00182138167 FER-GEN-SOL15.000 MG/0.6ML

00087074002 FER-IN-SOL15.000 MG/0.6ML

00536071080 FER-IRON75.000 MG/0.6ML

00245005301 FERATAB300.00 MG

00024101510 FERGON240.00 MG

00074707930 FERO-FOLIC-500.000

51991063511 FEROCON.000

00904067752 FEROSUL50.000 MG

00904067780 FEROSUL50.000 MG

10267046401 FEROTRINSIC.000

00182158610 FERRA TD250.00 MG

00182430026 FERRA-CAPS50.000 MG

59879011801 FERRAGEN.000

00904539561 FERREX 150150.00 MG

51991020311 FERREX 150150.00 MG

51991019811 FERREX 150 FORTE.000

00372003101 FERRO-BOB325.00 MG

49483003101 FERRO-DSS.000

Page 39 of 125

Page 40: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00574050801 FERROUS GLUCONATE324.00 MG

00574050810 FERROUS GLUCONATE324.00 MG

00574050811 FERROUS GLUCONATE324.00 MG

00245006101 FERROUS GLUCONATE300.00 MG

00182408201 FERROUS GLUCONATE240.00 MG

00904213782 FERROUS GLUCONATE325.00 MG

00677006901 FERROUS GLUCONATE240.00 MG

17236040410 FERROUS GLUCONATE325.00 MG

00182403010 FERROUS SULFATE325.00 MG

00677007001 FERROUS SULFATE325.00 MG

00677007010 FERROUS SULFATE325.00 MG

00677007101 FERROUS SULFATE325.00 MG

00677007110 FERROUS SULFATE325.00 MG

00677052733 FERROUS SULFATE220.00 MG/5ML

00904216390 FERROUS SULFATE325.00 MG

00904216490 FERROUS SULFATE325.00 MG

00904216680 FERROUS SULFATE325.00 MG

00904146516 FERROUS SULFATE220.00 MG/5ML

00904098950 FERROUS SULFATE75.000 MG/0.6ML

00904759082 FERROUS SULFATE325.00 MG

00904759083 FERROUS SULFATE325.00 MG

00904759161 FERROUS SULFATE325.00 MG

00904759182 FERROUS SULFATE325.00 MG

00904759183 FERROUS SULFATE325.00 MG

17714002401 FERROUS SULFATE325.00 MG

17714002410 FERROUS SULFATE325.00 MG

17236040610 FERROUS SULFATE325.00 MG

17236040611 FERROUS SULFATE325.00 MG

54838000180 FERROUS SULFATE220.00 MG/5ML

54838000250 FERROUS SULFATE75.000 MG/0.6ML

49483000804 FERROUS SULFATE325.00 MG

50383063050 FERROUS SULFATE75.000 MG/0.6ML

50383077816 FERROUS SULFATE220.00 MG/5ML

00182402801 FERROUS SULFATE325.00 MG

00182402810 FERROUS SULFATE325.00 MG

00182402889 FERROUS SULFATE325.00 MG

00182402901 FERROUS SULFATE325.00 MG

00182120140 FERROUS SULFATE220.00 MG/5ML

00574060801 FERROUS SULFATE324.00 MG

00574060810 FERROUS SULFATE324.00 MG

00574060811 FERROUS SULFATE324.00 MG

00536589001 FERROUS SULFATE325.00 MG

00603076247 FERROUS SULFATE75.000 MG/0.6ML

00603076358 FERROUS SULFATE220.00 MG/5ML

00536065085 FERROUS SULFATE220.00 MG/5ML

00472146516 FERROUS SULFATE220.00 MG/5ML

00472146995 FERROUS SULFATE75.000 MG/0.6ML

60432005750 FERROUS SULFATE75.000 MG/0.6ML

60432006616 FERROUS SULFATE220.00 MG/5ML

00904531852 FEVERFEW500.00 MG

00182138026 FIBER LAXATIVE625.00 MG

00904250091 FIBER TABS625.00 MG

00904270165 FIBER-EZE48.570 %

00904270166 FIBER-EZE48.570 %

00904270171 FIBER-EZE48.570 %

00904270265 FIBER-EZE30.000 %

00904270266 FIBER-EZE30.000 %

00904270271 FIBER-EZE30.000 %

00904761177 FIBER-EZE58.600 %

00904761277 FIBER-EZE58.600 %

00904761364 FIBER-EZE28.000 %

00904761365 FIBER-EZE28.000 %

00904761366 FIBER-EZE28.000 %

00904761464 FIBER-EZE28.000 %

00536430605 FIBER-LAX500.00 MG

00536430608 FIBER-LAX500.00 MG

00536430611 FIBER-LAX500.00 MG

00005250002 FIBERCON625.00 MG

00005250033 FIBERCON625.00 MG

00005250086 FIBERCON625.00 MG

00603018120 FIBERTAB625.00 MG

00078008405 FIORICET.000

00078008408 FIORICET.000

00078024305 FIORICET/CODEINE.000

00078010305 FIORINAL.000

00078010308 FIORINAL.000

00078010705 FIORINAL/CODEINE #3.000

00904404360 FISH OIL1000.0 MG

00025194234 FLAGYL375.00 MG

00025194250 FLAGYL375.00 MG

00025182131 FLAGYL500.00 MG

00025182150 FLAGYL500.00 MG

00025183131 FLAGYL250.00 MG

00025183150 FLAGYL250.00 MG

00025182151 FLAGYL500.00 MG

00025183155 FLAGYL250.00 MG

00025196130 FLAGYL ER750.00 MG

00065015812 FLEX-CARE.000

00006093128 FLEXERIL10.000 MG

62794008506 FLEXZAN 2 X 3.000

62794008518 FLEXZAN 4 X 4.000

62794008532 FLEXZAN 4 X 8.000

62794008564 FLEXZAN 8 X 8.000

00173049100 FLOVENT44.000 MCG/ACT

00173049400 FLOVENT110.00 MCG/ACT

00173049500 FLOVENT220.00 MCG/ACT

00173049700 FLOVENT44.000 MCG/ACT

00173049800 FLOVENT110.00 MCG/ACT

00173049900 FLOVENT220.00 MCG/ACT

00173050400 FLOVENT ROTADISK250.00 MCG/BLIS

00173050900 FLOVENT ROTADISK100.00 MCG/BLIS

00173051100 FLOVENT ROTADISK50.000 MCG/BLIS

50419051106 FLUDARA50.000 MG

00456052101 FLUMADINE100.00 MG

51552061101 FLUNISOLIDE ANHYDROUS.000

00168005815 FLUOCINOLONE ACETONIDE.010 %

00168005860 FLUOCINOLONE ACETONIDE.010 %

00168005960 FLUOCINOLONE ACETONIDE.010 %

00168006015 FLUOCINOLONE ACETONIDE.025 %

00168006060 FLUOCINOLONE ACETONIDE.025 %

00168006415 FLUOCINOLONE ACETONIDE.025 %

00168006460 FLUOCINOLONE ACETONIDE.025 %

00168013460 FLUOCINONIDE.050 %

00168013515 FLUOCINONIDE.050 %

00168013560 FLUOCINONIDE.050 %

00168013915 FLUOCINONIDE.050 %

00168013930 FLUOCINONIDE.050 %

00168013960 FLUOCINONIDE.050 %

00168014015 FLUOCINONIDE.050 %

00168014030 FLUOCINONIDE.050 %

00168014060 FLUOCINONIDE.050 %

00093026215 FLUOCINONIDE.050 %

00093026230 FLUOCINONIDE.050 %

00093026292 FLUOCINONIDE.050 %

00093026415 FLUOCINONIDE.050 %

00093026430 FLUOCINONIDE.050 %

00093026492 FLUOCINONIDE.050 %

00093026592 FLUOCINONIDE.050 %

00093026639 FLUOCINONIDE.050 %

00904767702 FLUOCINONIDE.050 %

00904767731 FLUOCINONIDE.050 %

00904767736 FLUOCINONIDE.050 %

Page 40 of 125

Page 41: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00677073540 FLUOCINONIDE.050 %

00904077336 FLUOCINONIDE-E.050 %

00093026315 FLUOCINONIDE-E.050 %

00093026330 FLUOCINONIDE-E.050 %

00093026392 FLUOCINONIDE-E.050 %

51817060216 FLUOR-A-DAY.250 MG

51817061116 FLUOR-A-DAY.500 MG

51817062216 FLUOR-A-DAY1.000 MG

51817065661 FLUOR-A-DAY.275 MG/DROP

24208039083 FLUOR-I-STRIPS9.000 MG

24208039183 FLUOR-I-STRIPS A.T.1.000 MG

58768035805 FLUOR-OP.100 %

58768035810 FLUOR-OP.100 %

58768035815 FLUOR-OP.100 %

00065078112 FLUORESCEIN SODIUM2.000 %

00065009205 FLUORESCITE10.000 %

00065009402 FLUORESCITE25.000 %

00093913110 FLUORIDE1.000 MG

00603362232 FLUORIDE.500 MG

00603362332 FLUORIDE1.000 MG

24208028805 FLUOROMETHOLONE.100 %

24208028810 FLUOROMETHOLONE.100 %

24208028815 FLUOROMETHOLONE.100 %

61314032805 FLUOROMETHOLONE.100 %

61314032810 FLUOROMETHOLONE.100 %

61314032815 FLUOROMETHOLONE.100 %

00832008600 FLUOXYMESTERONE10.000 MG

53265064456 FLUPHENAZINE DECANOATE25.000 MG/ML

53265030110 FLUPHENAZINE DECANOATE25.000 MG/ML

51079048520 FLUPHENAZINE HCL1.000 MG

51079048620 FLUPHENAZINE HCL2.500 MG

51079048720 FLUPHENAZINE HCL5.000 MG

51079048820 FLUPHENAZINE HCL10.000 MG

49884006101 FLUPHENAZINE HCL1.000 MG

49884006105 FLUPHENAZINE HCL1.000 MG

49884006201 FLUPHENAZINE HCL2.500 MG

49884006205 FLUPHENAZINE HCL2.500 MG

49884006401 FLUPHENAZINE HCL10.000 MG

49884006405 FLUPHENAZINE HCL10.000 MG

49884007601 FLUPHENAZINE HCL5.000 MG

49884007605 FLUPHENAZINE HCL5.000 MG

00677122001 FLUPHENAZINE HCL10.000 MG

00781143601 FLUPHENAZINE HCL1.000 MG

00781143613 FLUPHENAZINE HCL1.000 MG

00781143701 FLUPHENAZINE HCL2.500 MG

00781143705 FLUPHENAZINE HCL2.500 MG

00781143801 FLUPHENAZINE HCL5.000 MG

00781143805 FLUPHENAZINE HCL5.000 MG

00781143813 FLUPHENAZINE HCL5.000 MG

00781143901 FLUPHENAZINE HCL10.000 MG

00781143905 FLUPHENAZINE HCL10.000 MG

00904367360 FLUPHENAZINE HCL1.000 MG

00904367460 FLUPHENAZINE HCL2.500 MG

00904367560 FLUPHENAZINE HCL5.000 MG

00904367561 FLUPHENAZINE HCL5.000 MG

00378609701 FLUPHENAZINE HCL10.000 MG

00378609705 FLUPHENAZINE HCL10.000 MG

00378607401 FLUPHENAZINE HCL5.000 MG

00378607405 FLUPHENAZINE HCL5.000 MG

00378600401 FLUPHENAZINE HCL1.000 MG

00378600405 FLUPHENAZINE HCL1.000 MG

00378600901 FLUPHENAZINE HCL2.500 MG

00378600905 FLUPHENAZINE HCL2.500 MG

24208073205 FLURATE.000

00904280060 FLURAZEPAM HCL15.000 MG

00904280160 FLURAZEPAM HCL30.000 MG

51079030220 FLURAZEPAM HCL15.000 MG

51079030221 FLURAZEPAM HCL15.000 MG

51079030320 FLURAZEPAM HCL30.000 MG

51079030321 FLURAZEPAM HCL30.000 MG

00378441501 FLURAZEPAM HCL15.000 MG

00378441505 FLURAZEPAM HCL15.000 MG

00378443001 FLURAZEPAM HCL30.000 MG

00378443005 FLURAZEPAM HCL30.000 MG

00143336701 FLURAZEPAM HCL15.000 MG

00143336705 FLURAZEPAM HCL15.000 MG

00143337001 FLURAZEPAM HCL30.000 MG

00143337005 FLURAZEPAM HCL30.000 MG

00378009301 FLURBIPROFEN100.00 MG

00378009305 FLURBIPROFEN100.00 MG

00378007601 FLURBIPROFEN50.000 MG

00093071101 FLURBIPROFEN100.00 MG

00093071105 FLURBIPROFEN100.00 MG

51079081520 FLURBIPROFEN100.00 MG

00904501940 FLURBIPROFEN100.00 MG

00904501960 FLURBIPROFEN100.00 MG

59930177101 FLURBIPROFEN50.000 MG

59930177201 FLURBIPROFEN100.00 MG

59762372401 FLURBIPROFEN100.00 MG

59762372403 FLURBIPROFEN100.00 MG

59762372405 FLURBIPROFEN100.00 MG

24208031425 FLURBIPROFEN SODIUM.030 %

00781504001 FLUVOXAMINE MALEATE25.000 MG

00781504101 FLUVOXAMINE MALEATE50.000 MG

00781504201 FLUVOXAMINE MALEATE100.00 MG

00378040701 FLUVOXAMINE MALEATE25.000 MG

00378041201 FLUVOXAMINE MALEATE50.000 MG

00378041401 FLUVOXAMINE MALEATE100.00 MG

00555096702 FLUVOXAMINE MALEATE25.000 MG

00555096802 FLUVOXAMINE MALEATE50.000 MG

00555096902 FLUVOXAMINE MALEATE100.00 MG

00172439160 FLUVOXAMINE MALEATE50.000 MG

00172439260 FLUVOXAMINE MALEATE100.00 MG

00172438960 FLUVOXAMINE MALEATE25.000 MG

00185001701 FLUVOXAMINE MALEATE25.000 MG

00185002701 FLUVOXAMINE MALEATE50.000 MG

00185002705 FLUVOXAMINE MALEATE50.000 MG

00185015701 FLUVOXAMINE MALEATE100.00 MG

00185015705 FLUVOXAMINE MALEATE100.00 MG

60505016401 FLUVOXAMINE MALEATE25.000 MG

60505016501 FLUVOXAMINE MALEATE50.000 MG

60505016601 FLUVOXAMINE MALEATE100.00 MG

00603018621 FOAMING ANTACID.000

00603018721 FOAMING ANTACID ES.000

00245001611 FOLGARD RX 2.2.000

00182430901 FOLIC ACID400.00 MCG

00182050710 FOLIC ACID1.000 MG

00182050789 FOLIC ACID1.000 MG

00536384301 FOLIC ACID800.00 MCG

00536384401 FOLIC ACID400.00 MCG

00603371432 FOLIC ACID1.000 MG

00143124801 FOLIC ACID1.000 MG

00143124810 FOLIC ACID1.000 MG

00904062580 FOLIC ACID1.000 MG

00615066443 FOLIC ACID1.000 MG

00677044910 FOLIC ACID1.000 MG

17236015810 FOLIC ACID1.000 MG

10267012001 FOLIC ACID1.000 MG

10267012004 FOLIC ACID1.000 MG

00904319760 FOLIC ACID400.00 MCG

51079004119 FOLIC ACID1.000 MG

51079004120 FOLIC ACID1.000 MG

Page 41 of 125

Page 42: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

60429021290 FOLIC ACID1.000 MG

00185538076 FOLTRIN.000

00185538088 FOLTRIN.000

51552020504 FORMALDEHYDE37.000 %

17236039301 FORMULA 21.000

17236039310 FORMULA 21.000

00904263060 FORMULA B.000

00904792960 FORMULA B PLUS.000

00904004920 FORMULA EM.000

00713029831 FORMULATION R.000

00713029832 FORMULATION R.000

00713060435 FORMULATION R.000

00677082701 FORTABS.000

00173043400 FORTAZ1.000 GM

00173043500 FORTAZ2.000 GM

00173038237 FORTAZ6.000 GM

00173037731 FORTAZ500.00 MG

00173037835 FORTAZ1.000 GM

00173037934 FORTAZ2.000 GM

00173038032 FORTAZ INFUSION PACK1.000 GM

00173038132 FORTAZ INFUSION PACK2.000 GM

00006092531 FOSAMAX5.000 MG

00006092558 FOSAMAX5.000 MG

00006093628 FOSAMAX10.000 MG

00006093631 FOSAMAX10.000 MG

00006093658 FOSAMAX10.000 MG

00006093682 FOSAMAX10.000 MG

00006003121 FOSAMAX70.000 MG

00006003144 FOSAMAX70.000 MG

00006007721 FOSAMAX35.000 MG

00006007744 FOSAMAX35.000 MG

00006021231 FOSAMAX40.000 MG

19810005861 FOSTEX BPO10.000 %

19810005841 FOSTEX BPO VANISH10.000 %

19810005821 FOSTEX MEDICATED CLEANSIN2.000 %

00072380001 FOSTRIL2.000 %

00182431401 FRUITY CHEWS NF.000

00182431501 FRUITY CHEWS/IRON NF.000

00003043730 FUNGIZONE50.000 MG

00003043732 FUNGIZONE50.000 MG

00003043760 FUNGIZONE50.000 MG

54092031128 FURACIN.200 %

54092031028 FURACIN SOLUABLE DRESSING.200 %

54092031016 FURACIN SOLUABLE DRESSING.200 %

51079007219 FUROSEMIDE20.000 MG

51079007220 FUROSEMIDE20.000 MG

51079007319 FUROSEMIDE40.000 MG

51079007320 FUROSEMIDE40.000 MG

51079007324 FUROSEMIDE40.000 MG

51079052719 FUROSEMIDE80.000 MG

51079052720 FUROSEMIDE80.000 MG

00615156943 FUROSEMIDE20.000 MG

00615157143 FUROSEMIDE80.000 MG

00781144601 FUROSEMIDE80.000 MG

00781144605 FUROSEMIDE80.000 MG

00781196601 FUROSEMIDE40.000 MG

00781196610 FUROSEMIDE40.000 MG

00781181801 FUROSEMIDE20.000 MG

00781181810 FUROSEMIDE20.000 MG

00904148080 FUROSEMIDE20.000 MG

00904148260 FUROSEMIDE80.000 MG

00904148261 FUROSEMIDE80.000 MG

00074963104 FUROSEMIDE10.000 MG/ML

00074610102 FUROSEMIDE10.000 MG/ML

00074610104 FUROSEMIDE10.000 MG/ML

00074610110 FUROSEMIDE10.000 MG/ML

00074610202 FUROSEMIDE10.000 MG/ML

00074610204 FUROSEMIDE10.000 MG/ML

00074610210 FUROSEMIDE10.000 MG/ML

00074605514 FUROSEMIDE10.000 MG/ML

00074605617 FUROSEMIDE10.000 MG/ML

00074605618 FUROSEMIDE10.000 MG/ML

00074163910 FUROSEMIDE10.000 MG/ML

00054829725 FUROSEMIDE20.000 MG

00054829816 FUROSEMIDE8.000 MG/ML

00054829925 FUROSEMIDE40.000 MG

00054830125 FUROSEMIDE80.000 MG

00054429725 FUROSEMIDE20.000 MG

00054429731 FUROSEMIDE20.000 MG

00054429925 FUROSEMIDE40.000 MG

00054429931 FUROSEMIDE40.000 MG

00054430125 FUROSEMIDE80.000 MG

00054430129 FUROSEMIDE80.000 MG

00054329446 FUROSEMIDE10.000 MG/ML

00054329450 FUROSEMIDE10.000 MG/ML

00054329863 FUROSEMIDE8.000 MG/ML

00182116189 FUROSEMIDE40.000 MG

00182117089 FUROSEMIDE20.000 MG

00172290760 FUROSEMIDE40.000 MG

00172290780 FUROSEMIDE40.000 MG

00172290860 FUROSEMIDE20.000 MG

00172290880 FUROSEMIDE20.000 MG

00378023201 FUROSEMIDE80.000 MG

00378023205 FUROSEMIDE80.000 MG

00378021601 FUROSEMIDE40.000 MG

00378021610 FUROSEMIDE40.000 MG

00378020801 FUROSEMIDE20.000 MG

00378020810 FUROSEMIDE20.000 MG

00548143100 FUROSEMIDE10.000 MG/ML

51079007323 FUROSEMIDE40.000 MG

60429007990 FUROSEMIDE40.000 MG

60432061304 FUROSEMIDE10.000 MG/ML

60432061360 FUROSEMIDE10.000 MG/ML

00074127404 FUROSEMIDE-CARPUJECT10.000 MG/ML

00074127414 FUROSEMIDE-CARPUJECT10.000 MG/ML

00074127424 FUROSEMIDE-CARPUJECT10.000 MG/ML

00074127434 FUROSEMIDE-CARPUJECT10.000 MG/ML

00074127502 FUROSEMIDE-CARPUJECT10.000 MG/ML

00074127522 FUROSEMIDE-CARPUJECT10.000 MG/ML

59743000201 G-PHED.000

59743000301 G-PHED-PD.000

00026064612 GAMIMUNE N5.000 %

00026064620 GAMIMUNE N5.000 %

00026064624 GAMIMUNE N5.000 %

00026064625 GAMIMUNE N5.000 %

00026064671 GAMIMUNE N5.000 %

00026064812 GAMIMUNE N10.000 %

00026064815 GAMIMUNE N10.000 %

00026064820 GAMIMUNE N10.000 %

00026064824 GAMIMUNE N10.000 %

00026064871 GAMIMUNE N10.000 %

00053748601 GAMMAR-P I.V.1.000 GM

00053748602 GAMMAR-P I.V.2.500 GM

00053748605 GAMMAR-P I.V.5.000 GM

00053748610 GAMMAR-P I.V.10.000 GM

60258025616 GANDIDIN NR100.00 MG/5ML

60258026216 GANI-TUSS DM NR.000

60258026116 GANI-TUSS NR.000

00085006904 GARAMYCIN40.000 MG/ML

00904315660 GARLIC OIL500.00 MG

00904315760 GARLIC OIL1000.0 MG

00904316060 GARLIC OIL1500.0 MG

Page 42 of 125

Page 43: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00904317389 GARLIC/PARSLEY.000

00904515260 GARLIN.000

00904780760 GARLIN100.00 MG

00904545846 GAS FREE EXTRA STRENGTH125.00 MG

00043011312 GAS-X80.000 MG

00043011336 GAS-X80.000 MG

00043013410 GAS-X125.00 MG

00043013430 GAS-X125.00 MG

00043013450 GAS-X125.00 MG

00043001312 GAS-X80.000 MG

00043001336 GAS-X80.000 MG

00043001718 GAS-X EXTRA STRENGTH125.00 MG

00043001748 GAS-X EXTRA STRENGTH125.00 MG

00043011718 GAS-X EXTRA STRENGTH125.00 MG

00043011748 GAS-X EXTRA STRENGTH125.00 MG

00043012918 GAS-X EXTRA STRENGTH125.00 MG

00043012948 GAS-X EXTRA STRENGTH125.00 MG

00182038501 GELATIN650.00 MG

00904007860 GELATIN650.00 MG

00071003424 GELUSIL.000

00071203622 GELUSIL.000

00093067005 GEMFIBROZIL600.00 MG

00093067006 GEMFIBROZIL600.00 MG

00182195689 GEMFIBROZIL600.00 MG

00904537940 GEMFIBROZIL600.00 MG

00904537952 GEMFIBROZIL600.00 MG

00904537961 GEMFIBROZIL600.00 MG

51079078719 GEMFIBROZIL600.00 MG

51079078720 GEMFIBROZIL600.00 MG

60505003404 GEMFIBROZIL600.00 MG

60505003408 GEMFIBROZIL600.00 MG

60429008160 GEMFIBROZIL600.00 MG

00002750101 GEMZAR200.00 MG

00002750201 GEMZAR1.000 GM

00182160516 GENAC.000

00182145501 GENACED.000

00182202219 GENACOL MAXIMUM STRENGTH.000

00182141501 GENACOTE325.00 MG

00182209116 GENAHIST25.000 MG

00182209201 GENAHIST25.000 MG

00182209216 GENAHIST25.000 MG

00182200137 GENAHIST12.500 MG/5ML

00182158517 GENAPAP80.000 MG

00182214637 GENAPAP160.00 MG/5ML

00182214717 GENAPAP80.000 MG

00182215401 GENAPAP500.00 MG

00182141001 GENAPAP325.00 MG

00182145701 GENAPAP500.00 MG

00182147764 GENAPAP100.00 MG/ML

00182147237 GENAPAP160.00 MG/5ML

00182215201 GENAPAP EXTRA STRENGTH500.00 MG

00182215219 GENAPAP EXTRA STRENGTH500.00 MG

00182214516 GENAPAP SINUS MAXIMUM STR.000

00182145998 GENAPHED30.000 MG

00182147116 GENAPHED PLUS.000

00182144464 GENASAL.050 %

00182144466 GENASAL.050 %

00182141329 GENASEC.000

00182141726 GENASOFT100.00 MG

00182146001 GENASYME80.000 MG

00182219166 GENASYME40.000 MG/0.6ML

00182222001 GENATON.000

00182223637 GENATUSS DM.000

00182183201 GENEBS500.00 MG

00182183210 GENEBS500.00 MG

00182145301 GENEBS500.00 MG

00182145310 GENEBS500.00 MG

00182014101 GENEBS325.00 MG

00182014110 GENEBS325.00 MG

00182000601 GENERIX T.000

60432003816 GENERLAC10.000 GM/15ML

60432003864 GENERLAC10.000 GM/15ML

00182169233 GENEYES.050 %

00182151376 GENFIBER50.000 %

00182151378 GENFIBER50.000 %

00182151476 GENFIBER50.000 %

00074647932 GENGRAF100.00 MG

00074646332 GENGRAF25.000 MG

00182240101 GENPRIL200.00 MG

00182240119 GENPRIL200.00 MG

58768036505 GENTACIDIN.300 %

00603715837 GENTAFAIR.300 %

00641233143 GENTAMICIN SULFATE40.000 MG/ML

00904190705 GENTAMICIN SULFATE.300 %

00904190735 GENTAMICIN SULFATE.300 %

00904266336 GENTAMICIN SULFATE.100 %

24208058060 GENTAMICIN SULFATE.300 %

24208058064 GENTAMICIN SULFATE.300 %

45802005605 GENTAMICIN SULFATE.100 %

45802005611 GENTAMICIN SULFATE.100 %

45802005635 GENTAMICIN SULFATE.100 %

45802004605 GENTAMICIN SULFATE.100 %

45802004611 GENTAMICIN SULFATE.100 %

45802004635 GENTAMICIN SULFATE.100 %

00168007115 GENTAMICIN SULFATE.100 %

00168007815 GENTAMICIN SULFATE.100 %

00074340001 GENTAMICIN SULFATE10.000 MG/ML

00074340101 GENTAMICIN SULFATE10.000 MG/ML

00074340201 GENTAMICIN SULFATE10.000 MG/ML

00074120703 GENTAMICIN SULFATE40.000 MG/ML

61314063305 GENTAMICIN SULFATE.300 %

00074787913 GENTAMICIN SULFATE/0.9% S.000

00074788313 GENTAMICIN SULFATE/0.9% S.000

00074788423 GENTAMICIN SULFATE/0.9% S.000

00074788923 GENTAMICIN SULFATE/0.9% S.000

58768078815 GENTEAL.300 %

58768078825 GENTEAL.300 %

58768079036 GENTEAL.000

59743000401 GEONE (G-1).000

00904541416 GERAVIM.000

00904098316 GERAVINE.000

50383012016 GERI-TONIC.000

00182605440 GERI-VITE.000

54838000780 GERIATON.000

53100011121 GERITOL.000

53100011131 GERITOL.000

53100011211 GERITOL.000

53100011232 GERITOL.000

53100011266 GERITOL.000

53100011267 GERITOL.000

53100011276 GERITOL.000

53100000291 GERITOL EXTEND.000

53100000296 GERITOL EXTEND.000

00904434651 GERMANIUM10.000 MG

00603125658 GEVRATONIC.000

60258026601 GFN/PSE.000

59743001901 GG 200 NR200.00 MG

00904508851 GINKGO BILOBA60.000 MG

00904519773 GINKGO BILOBA40.000 MG

00482166050 GLANDOSANE.000

00482166150 GLANDOSANE.000

00482166250 GLANDOSANE.000

Page 43 of 125

Page 44: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

08290305294 GLASPAK DISPOSABLE 10CC S.000

08290305292 GLASPAK DISPOSABLE 1CC TU.000

08290305257 GLASPAK DISPOSABLE 2-1/2C.000

08290305291 GLASPAK DISPOSABLE 2-1/2C.000

08290305293 GLASPAK DISPOSABLE 5CC SY.000

00904792440 GLIPIZIDE5.000 MG

00904792460 GLIPIZIDE5.000 MG

00904792480 GLIPIZIDE5.000 MG

00904792540 GLIPIZIDE10.000 MG

00904792560 GLIPIZIDE10.000 MG

00904792580 GLIPIZIDE10.000 MG

00781145201 GLIPIZIDE5.000 MG

00781145210 GLIPIZIDE5.000 MG

00781145301 GLIPIZIDE10.000 MG

00781145310 GLIPIZIDE10.000 MG

00677154501 GLIPIZIDE10.000 MG

52544046010 GLIPIZIDE5.000 MG

51079081019 GLIPIZIDE5.000 MG

51079081020 GLIPIZIDE5.000 MG

51079081023 GLIPIZIDE5.000 MG

51079081024 GLIPIZIDE5.000 MG

51079081119 GLIPIZIDE10.000 MG

51079081120 GLIPIZIDE10.000 MG

00378110501 GLIPIZIDE5.000 MG

00378110505 GLIPIZIDE5.000 MG

00378111001 GLIPIZIDE10.000 MG

00378111005 GLIPIZIDE10.000 MG

00182199489 GLIPIZIDE5.000 MG

00182199589 GLIPIZIDE10.000 MG

00172364960 GLIPIZIDE5.000 MG

00172364970 GLIPIZIDE5.000 MG

00172365060 GLIPIZIDE10.000 MG

00172365070 GLIPIZIDE10.000 MG

60951071470 GLIPIZIDE10.000 MG

60951071485 GLIPIZIDE10.000 MG

00087607005 GLUCOPHAGE850.00 MG

00087607111 GLUCOPHAGE1000.0 MG

00087606005 GLUCOPHAGE500.00 MG

00087606010 GLUCOPHAGE500.00 MG

00087606313 GLUCOPHAGE XR500.00 MG

00182404826 GLUCOSAMINE SULFATE500.00 MG

51991010906 GLUCOSAMINE SULFATE500.00 MG

51991010933 GLUCOSAMINE SULFATE500.00 MG

00904529352 GLUCOSAMINE SULFATE500.00 MG

00677165206 GLUCOSAMINE-CHONDROITIN.000

00677165267 GLUCOSAMINE-CHONDROITIN.000

51991003106 GLUCOSAMINE-CHONDROITIN.000

00904548118 GLUCOSAMINE-CHONDROITIN D.000

00904548152 GLUCOSAMINE-CHONDROITIN D.000

00049411066 GLUCOTROL5.000 MG

00049411073 GLUCOTROL5.000 MG

00049412066 GLUCOTROL10.000 MG

00049412073 GLUCOTROL10.000 MG

00049162030 GLUCOTROL XL2.500 MG

00049155066 GLUCOTROL XL5.000 MG

00049155073 GLUCOTROL XL5.000 MG

00049156066 GLUCOTROL XL10.000 MG

00049156073 GLUCOTROL XL10.000 MG

00087607211 GLUCOVANCE.000

00087607311 GLUCOVANCE.000

00087607411 GLUCOVANCE.000

00904257960 GLUTAMIC ACID HCL340.00 MG

00482015490 GLUTOFAC.000

00574006930 GLUTOSE40.000 %

00574006945 GLUTOSE40.000 %

00093943301 GLYBURIDE2.500 MG

00093943305 GLYBURIDE2.500 MG

00093947753 GLYBURIDE1.250 MG

00093936401 GLYBURIDE5.000 MG

00093936405 GLYBURIDE5.000 MG

00093936410 GLYBURIDE5.000 MG

00093834201 GLYBURIDE1.250 MG

00093834301 GLYBURIDE2.500 MG

00093834305 GLYBURIDE2.500 MG

00093834310 GLYBURIDE2.500 MG

00093834401 GLYBURIDE5.000 MG

00093834405 GLYBURIDE5.000 MG

00093834410 GLYBURIDE5.000 MG

51079087219 GLYBURIDE2.500 MG

51079087220 GLYBURIDE2.500 MG

51079087319 GLYBURIDE5.000 MG

51079087320 GLYBURIDE5.000 MG

60429008512 GLYBURIDE5.000 MG

60429008518 GLYBURIDE5.000 MG

60429008527 GLYBURIDE5.000 MG

60429008530 GLYBURIDE5.000 MG

60429008536 GLYBURIDE5.000 MG

60429008560 GLYBURIDE5.000 MG

60429008590 GLYBURIDE5.000 MG

59762372501 GLYBURIDE1.250 MG

59762372603 GLYBURIDE2.500 MG

59762372704 GLYBURIDE5.000 MG

59762372706 GLYBURIDE5.000 MG

59762372707 GLYBURIDE5.000 MG

55370050607 GLYBURIDE MICRONIZED6.000 MG

55370050608 GLYBURIDE MICRONIZED6.000 MG

55370050609 GLYBURIDE MICRONIZED6.000 MG

55370014607 GLYBURIDE MICRONIZED1.500 MG

55370014608 GLYBURIDE MICRONIZED1.500 MG

55370014609 GLYBURIDE MICRONIZED1.500 MG

55370014707 GLYBURIDE MICRONIZED3.000 MG

55370014708 GLYBURIDE MICRONIZED3.000 MG

55370014709 GLYBURIDE MICRONIZED3.000 MG

00093803401 GLYBURIDE MICRONIZED1.500 MG

00093803501 GLYBURIDE MICRONIZED3.000 MG

00093803505 GLYBURIDE MICRONIZED3.000 MG

00093803510 GLYBURIDE MICRONIZED3.000 MG

00093803601 GLYBURIDE MICRONIZED6.000 MG

00378111301 GLYBURIDE MICRONIZED1.500 MG

00378112501 GLYBURIDE MICRONIZED3.000 MG

00378112510 GLYBURIDE MICRONIZED3.000 MG

00378114201 GLYBURIDE MICRONIZED6.000 MG

59762378101 GLYBURIDE MICRONIZED1.500 MG

59762378201 GLYBURIDE MICRONIZED3.000 MG

59762378203 GLYBURIDE MICRONIZED3.000 MG

59762378301 GLYBURIDE MICRONIZED6.000 MG

59762378302 GLYBURIDE MICRONIZED6.000 MG

59762378303 GLYBURIDE MICRONIZED6.000 MG

00574017810 GLYCERIN.000

51552009404 GLYCERIN99.500 %

45802071514 GLYCERIN ADULT3.000 GM

45802071530 GLYCERIN ADULT3.000 GM

45802071531 GLYCERIN ADULT3.000 GM

45802071533 GLYCERIN ADULT3.000 GM

00713010102 GLYCERIN ADULT3.000 GM

00713010113 GLYCERIN ADULT3.000 GM

00713010126 GLYCERIN ADULT3.000 GM

00713010151 GLYCERIN ADULT3.000 GM

00904266717 GLYCERIN ADULT3.000 GM

00904266757 GLYCERIN ADULT3.000 GM

00904266760 GLYCERIN ADULT3.000 GM

00603051119 GLYCERIN ADULT3.000 GM

Page 44 of 125

Page 45: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00603051121 GLYCERIN ADULT3.000 GM

00603051135 GLYCERIN ADULT3.000 GM

00603051235 GLYCERIN CHILD1.500 GM

00904266612 GLYCERIN CHILD1.500 GM

00904266617 GLYCERIN CHILD1.500 GM

00713010213 GLYCERIN CHILD1.500 GM

00713010226 GLYCERIN CHILD1.500 GM

45802071630 GLYCERIN CHILD1.500 GM

45802071631 GLYCERIN CHILD1.500 GM

45802071633 GLYCERIN CHILD1.500 GM

00074797408 GLYCINE1.500 %

00074614206 GLYCINE1.500 %

00074614236 GLYCINE1.500 %

51552036904 GLYCOLIC ACID70.000 %

00009344901 GLYNASE6.000 MG

00009344903 GLYNASE6.000 MG

00009035201 GLYNASE3.000 MG

00009035204 GLYNASE3.000 MG

00009034101 GLYNASE1.500 MG

00009034102 GLYNASE1.500 MG

00009035202 GLYNASE3.000 MG

00009035203 GLYNASE3.000 MG

00009501201 GLYSET25.000 MG

00009501301 GLYSET50.000 MG

00009501401 GLYSET100.00 MG

00065908570 GLYTROL.000

00065908672 GLYTROL.000

00065908673 GLYTROL.000

50383078608 GOLDEN AGE VITAMIN/MINERA.000

52268010001 GOLYTELY.000

52268010101 GOLYTELY.000

52268070001 GOLYTELY.000

00998025915 GONIOSCOPIC PRISM2.500 %

00065025915 GONIOSCOPIC PRISM.000

58768070115 GONIOSOL2.500 %

00603127054 GRANUL-DERM.000

62794000250 GRANULEX.000

62794000251 GRANULEX.000

00536217090 GREEN SOAP.000

00904266828 GREEN SOAP.000

51552015104 GREEN SOAP.000

59743013116 GUAI-CO.000

59743013216 GUAI-DEX.000

50383020804 GUAIASORB100.00 MG/5ML

50383008704 GUAIATUSSIN AC.000

50383008716 GUAIATUSSIN AC.000

50383009804 GUAIATUSSIN DM.000

50383009828 GUAIATUSSIN DM.000

00451260204 GUAIFED.000

00451260216 GUAIFED.000

00254621128 GUAIFEN PSE.000

00603127658 GUAIFEN-C.000

00536082585 GUAIFENESIN100.00 MG/5ML

00536082597 GUAIFENESIN100.00 MG/5ML

00372004116 GUAIFENESIN100.00 MG/5ML

00182261401 GUAIFENESIN200.00 MG

00054333750 GUAIFENESIN100.00 MG/5ML

00054833704 GUAIFENESIN100.00 MG/5ML

00054833804 GUAIFENESIN100.00 MG/5ML

00677177333 GUAIFENESIN100.00 MG/5ML

00677166101 GUAIFENESIN200.00 MG

00904515460 GUAIFENESIN200.00 MG

60793000604 GUAIFENESIN100.00 MG/5ML

60793000608 GUAIFENESIN100.00 MG/5ML

60432008804 GUAIFENESIN AC.000

60432008816 GUAIFENESIN AC.000

60432004816 GUAIFENESIN DM.000

60793004901 GUAIFENESIN LA600.00 MG

60793004905 GUAIFENESIN LA600.00 MG

60793004910 GUAIFENESIN LA600.00 MG

60793004952 GUAIFENESIN LA600.00 MG

57664015208 GUAIFENESIN LA600.00 MG

57664015213 GUAIFENESIN LA600.00 MG

54838012380 GUAIFENESIN NR100.00 MG/5ML

59743001801 GUAIFENESIN SR600.00 MG

59743001805 GUAIFENESIN SR600.00 MG

59743001825 GUAIFENESIN SR600.00 MG

54838012480 GUAIFENESIN-DM NR.000

00603377721 GUAIFENESIN-P-PD.000

59743002801 GUAIFENESIN-SR1200.0 MG

00603378121 GUAIFENESIN/CODEINE.000

57664036708 GUAIFENESIN/CODEINE.000

00182104201 GUAIFENESIN/DEXTROMETHORP.000

00536097085 GUAIFENESIN/DEXTROMETHORP.000

00536097097 GUAIFENESIN/DEXTROMETHORP.000

51285042002 GUAIFENESIN/DEXTROMETHORP.000

00677148601 GUAIFENESIN/DEXTROMETHORP.000

57664035508 GUAIFENESIN/DEXTROMETHORP.000

60793005001 GUAIFENESIN/DM ER.000

60793005005 GUAIFENESIN/DM ER.000

60793005010 GUAIFENESIN/DM ER.000

00677178501 GUAIFENESIN/PSEUDOEPHEDRI.000

00677148701 GUAIFENESIN/PSEUDOEPHEDRI.000

00677147601 GUAIFENESIN/PSEUDOEPHEDRI.000

00677147605 GUAIFENESIN/PSEUDOEPHEDRI.000

00677150201 GUAIFENESIN/PSEUDOEPHEDRI.000

00677150301 GUAIFENESIN/PSEUDOEPHEDRI.000

00904540440 GUAIFENESIN/PSEUDOEPHEDRI.000

00904540460 GUAIFENESIN/PSEUDOEPHEDRI.000

53489042401 GUAIFENESIN/PSEUDOEPHEDRI.000

53489042405 GUAIFENESIN/PSEUDOEPHEDRI.000

53489042501 GUAIFENESIN/PSEUDOEPHEDRI.000

00115701301 GUAIFENESIN/PSEUDOEPHEDRI.000

58521025501 GUAIFENESIN/PSEUDOEPHEDRI.000

58177021304 GUAIFENEX DM.000

58177030804 GUAIFENEX G1200.0 MG

58177037304 GUAIFENEX GP.000

58177020504 GUAIFENEX LA600.00 MG

58177020508 GUAIFENEX LA600.00 MG

58177020804 GUAIFENEX PSE 120.000

58177021404 GUAIFENEX PSE 60.000

58177027617 GUAIFENEX-RX.000

58177027717 GUAIFENEX-RX DM.000

00131205537 GUAIMAX-D.000

00172422660 GUANABENZ ACETATE4.000 MG

00172422760 GUANABENZ ACETATE8.000 MG

49884057201 GUANFACINE HCL1.000 MG

49884057301 GUANFACINE HCL2.000 MG

00603377421 GUANFACINE HCL1.000 MG

00603377521 GUANFACINE HCL2.000 MG

00378116001 GUANFACINE HCL1.000 MG

00378119001 GUANFACINE HCL2.000 MG

51991002401 GUIADRINE G-12001200.0 MG

00182025937 GUIATUSS100.00 MG/5ML

00182025940 GUIATUSS100.00 MG/5ML

00472041904 GUIATUSS100.00 MG/5ML

00472041916 GUIATUSS100.00 MG/5ML

00472041998 GUIATUSS100.00 MG/5ML

00472001204 GUIATUSS AC.000

00472001216 GUIATUSS AC.000

00472001228 GUIATUSS AC.000

00182001737 GUIATUSS AC.000

Page 45 of 125

Page 46: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00182001740 GUIATUSS AC.000

00472041594 GUIATUSS CF.000

00182615737 GUIATUSS CLEAR DM.000

00182137840 GUIATUSS DAC.000

00472001116 GUIATUSS DAC.000

00472103104 GUIATUSS DM.000

00472103116 GUIATUSS DM.000

00472103194 GUIATUSS DM.000

00182606437 GUIATUSS DM.000

00182606440 GUIATUSS DM.000

00182606441 GUIATUSS DM.000

00472103128 GUIATUSS DM.000

00472103198 GUIATUSS DM.000

00472042194 GUIATUSS PE.000

00085088709 GYNE-LOTRIMIN1.000 %

00085088711 GYNE-LOTRIMIN1.000 %

00085067004 GYNE-LOTRIMIN100.00 MG

00085110901 GYNE-LOTRIMIN 3200.00 MG

00085126001 GYNE-LOTRIMIN 32.000 %

00085110201 GYNE-LOTRIMIN 3 COMBO PAC.000

63717030101 H 9600 SR.000

00603128558 H C TUSSIVE-D.000

00254918858 H-C TUSSIVE.000

00603128454 H-C TUSSIVE.000

00603128458 H-C TUSSIVE.000

00603128460 H-C TUSSIVE.000

00904504351 HAIRVITE.000

00009001011 HALCION.125 MG

00009001032 HALCION.125 MG

00009001038 HALCION.125 MG

00009001702 HALCION.250 MG

00009001755 HALCION.250 MG

00009001759 HALCION.250 MG

51079073320 HALOPERIDOL.500 MG

51079073420 HALOPERIDOL1.000 MG

51079073520 HALOPERIDOL2.000 MG

00781139101 HALOPERIDOL.500 MG

00781139110 HALOPERIDOL.500 MG

00781139113 HALOPERIDOL.500 MG

00781139201 HALOPERIDOL1.000 MG

00781139210 HALOPERIDOL1.000 MG

00781139213 HALOPERIDOL1.000 MG

00781139301 HALOPERIDOL2.000 MG

00781139313 HALOPERIDOL2.000 MG

00781139601 HALOPERIDOL5.000 MG

00781139613 HALOPERIDOL5.000 MG

00781139701 HALOPERIDOL10.000 MG

00781139713 HALOPERIDOL10.000 MG

00781139801 HALOPERIDOL20.000 MG

00904183161 HALOPERIDOL1.000 MG

00904172920 HALOPERIDOL2.000 MG/ML

00904172935 HALOPERIDOL2.000 MG/ML

54838050115 HALOPERIDOL2.000 MG/ML

54838050140 HALOPERIDOL2.000 MG/ML

00603129054 HALOPERIDOL2.000 MG/ML

00378021401 HALOPERIDOL2.000 MG

00378021410 HALOPERIDOL2.000 MG

00378025701 HALOPERIDOL1.000 MG

00378025710 HALOPERIDOL1.000 MG

00378035101 HALOPERIDOL.500 MG

00378035110 HALOPERIDOL.500 MG

00378032701 HALOPERIDOL5.000 MG

00378032710 HALOPERIDOL5.000 MG

00182605971 HALOPERIDOL2.000 MG/ML

00093960412 HALOPERIDOL2.000 MG/ML

00093960423 HALOPERIDOL2.000 MG/ML

00093055312 HALOPERIDOL2.000 MG/ML

00144054451 HALOPERIDOL DECANOATE100.00 MG/ML

00144054456 HALOPERIDOL DECANOATE100.00 MG/ML

00144044451 HALOPERIDOL DECANOATE50.000 MG/ML

00144044456 HALOPERIDOL DECANOATE50.000 MG/ML

00144045551 HALOPERIDOL DECANOATE100.00 MG/ML

53265044451 HALOPERIDOL DECANOATE50.000 MG/ML

53265044456 HALOPERIDOL DECANOATE50.000 MG/ML

53265054451 HALOPERIDOL DECANOATE100.00 MG/ML

53265054456 HALOPERIDOL DECANOATE100.00 MG/ML

60505070201 HALOPERIDOL DECANOATE50.000 MG/ML

60505070301 HALOPERIDOL DECANOATE100.00 MG/ML

00074489402 HALOTHANE.000

00677168510 HAPONAL.000

00372003801 HAYFEBROL.000

00372003804 HAYFEBROL.000

00372003808 HAYFEBROL.000

00372003816 HAYFEBROL.000

00372003828 HAYFEBROL.000

45802028703 HC CREAM2.500 %

00016031055 HEALON10.000 MG/ML

00016031085 HEALON10.000 MG/ML

00016031440 HEALON10.000 MG/ML

00016031585 HEALON10.000 MG/ML

00904512437 HEM-PREP.000

00904530424 HEM-PREP.000

60258018001 HEMATINIC PLU VITAMINS/MI.000

60258018101 HEMATINIC/FOLIC ACID.000

00536138912 HEMORRHOIDAL.000

00603052052 HEMORRHOIDAL.000

00904518402 HEMORRHOIDAL PREP.000

00603812711 HEMORRHOIDAL-HC25.000 MG

00603812718 HEMORRHOIDAL-HC25.000 MG

00472051112 HEMORRHOIDAL-HC25.000 MG

00472051124 HEMORRHOIDAL-HC25.000 MG

00245011212 HEMRIL-3030.000 MG

00245011224 HEMRIL-3030.000 MG

00245011112 HEMRIL-HC25.000 MG

00641038725 HEP-LOCK100.00 U/ML

00641038925 HEP-LOCK100.00 U/ML

00641039225 HEP-LOCK10.000 U/ML

00641039325 HEP-LOCK10.000 U/ML

00641243641 HEP-LOCK100.00 U/ML

00641243645 HEP-LOCK100.00 U/ML

00641243841 HEP-LOCK10.000 U/ML

00641243845 HEP-LOCK10.000 U/ML

00641244241 HEP-LOCK10.000 U/ML

00641244245 HEP-LOCK10.000 U/ML

00641244341 HEP-LOCK100.00 U/ML

00641244345 HEP-LOCK100.00 U/ML

00641041125 HEP-LOCK PF100.00 U/ML

00641041425 HEP-LOCK PF10.000 U/ML

00074138902 HEP-PAK CONVENIENCE PACKA.000

00074115112 HEPARIN LOCK10.000 U/ML

00074115170 HEPARIN LOCK10.000 U/ML

00074115178 HEPARIN LOCK10.000 U/ML

00074115212 HEPARIN LOCK100.00 U/ML

00074115214 HEPARIN LOCK100.00 U/ML

00074115270 HEPARIN LOCK100.00 U/ML

00074115278 HEPARIN LOCK100.00 U/ML

00074482201 HEPARIN LOCK FLUSH10.000 U/ML

00074128002 HEPARIN LOCK FLUSH10.000 U/ML

00074128005 HEPARIN LOCK FLUSH10.000 U/ML

00074128011 HEPARIN LOCK FLUSH10.000 U/ML

00074128031 HEPARIN LOCK FLUSH10.000 U/ML

00074128032 HEPARIN LOCK FLUSH10.000 U/ML

Page 46 of 125

Page 47: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00074128033 HEPARIN LOCK FLUSH10.000 U/ML

00074128035 HEPARIN LOCK FLUSH10.000 U/ML

00074128115 HEPARIN LOCK FLUSH100.00 U/ML

00074128131 HEPARIN LOCK FLUSH100.00 U/ML

00074128132 HEPARIN LOCK FLUSH100.00 U/ML

00074128133 HEPARIN LOCK FLUSH100.00 U/ML

00074128135 HEPARIN LOCK FLUSH100.00 U/ML

08290034003 HEPARIN LOCK FLUSH10.000 U/ML

08290035005 HEPARIN LOCK FLUSH10.000 U/ML

08290036003 HEPARIN LOCK FLUSH10.000 U/ML

08290036005 HEPARIN LOCK FLUSH10.000 U/ML

08290036006 HEPARIN LOCK FLUSH10.000 U/ML

08290036105 HEPARIN LOCK FLUSH10.000 U/ML

08290037003 HEPARIN LOCK FLUSH100.00 U/ML

08290038003 HEPARIN LOCK FLUSH100.00 U/ML

08290038005 HEPARIN LOCK FLUSH100.00 U/ML

08290039003 HEPARIN LOCK FLUSH100.00 U/ML

08290039005 HEPARIN LOCK FLUSH100.00 U/ML

08290039105 HEPARIN LOCK FLUSH100.00 U/ML

08290306525 HEPARIN LOCK FLUSH FOR FL10.000 U/ML

08290306531 HEPARIN LOCK FLUSH FOR FL100.00 U/ML

08290306509 HEPARIN LOCK FLUSH/NACL F.000

08290306510 HEPARIN LOCK FLUSH/NACL F.000

08290306511 HEPARIN LOCK FLUSH/NACL F.000

08290306512 HEPARIN LOCK FLUSH/NACL F.000

08290306513 HEPARIN LOCK FLUSH/NACL F.000

08290306514 HEPARIN LOCK FLUSH/NACL F.000

08290306515 HEPARIN LOCK FLUSH/NACL F.000

08290306516 HEPARIN LOCK FLUSH/NACL F.000

08290306517 HEPARIN LOCK FLUSH/NACL F.000

00641039125 HEPARIN SODIUM1000.0 U/ML

00641040025 HEPARIN SODIUM5000.0 U/ML

00641041025 HEPARIN SODIUM10000. U/ML

00641245045 HEPARIN SODIUM1000.0 U/ML

00641246045 HEPARIN SODIUM5000.0 U/ML

00641247045 HEPARIN SODIUM10000. U/ML

00641244045 HEPARIN SODIUM1000.0 U/ML

00677027521 HEPARIN SODIUM5000.0 U/ML

00074140231 HEPARIN SODIUM5000.0 U/ML

00002721701 HEPARIN SODIUM10000. U/ML

00009026812 HEPARIN SODIUM1000.0 U/ML

00008252850 HEPARIN SODIUM LOCK FLUSH.000

08290040003 HEPARIN SODIUM LOCK FLUSH.000

08290041003 HEPARIN SODIUM LOCK FLUSH.000

08290042005 HEPARIN SODIUM LOCK FLUSH.000

00074779323 HEPARIN SODIUM/D5W.000

00074779362 HEPARIN SODIUM/D5W.000

00074779462 HEPARIN SODIUM/D5W.000

00074776003 HEPARIN SODIUM/D5W.000

00074776103 HEPARIN SODIUM/D5W.000

00074762003 HEPARIN SODIUM/SODIUM CHL.000

00074762059 HEPARIN SODIUM/SODIUM CHL.000

00074724803 HETASTARCH 6%/NACL.000

00074724861 HETASTARCH 6%/NACL.000

00074724849 HETASTARCH 6%/NACL.000

00245008201 HEXAVITAMIN.000

00245008210 HEXAVITAMIN.000

00245008211 HEXAVITAMIN.000

00182432906 HI POTENCY B COMPLEX W/C.000

00310057504 HIBICLENS4.000 %

00310057508 HIBICLENS4.000 %

00310057516 HIBICLENS4.000 %

00310057517 HIBICLENS4.000 %

00310057532 HIBICLENS4.000 %

00310057591 HIBICLENS4.000 %

00038057591 HIBICLENS4.000 %

00536598601 HIGH B COMPLEX 100.000

00182039401 HIGH POTENCY B COMPLEX/B1.000

58177022704 HISTA-VENT DA.000

58177087707 HISTINEX HC.000

58177087712 HISTINEX HC.000

58177088307 HISTINEX PV.000

00024086416 HISTUSSIN D.000

00024086016 HISTUSSIN HC.000

08881600699 HM MONOJECT INSULIN SYRIN.000

08881600798 HM MONOJECT INSULIN SYRIN.000

08881600962 HM MONOJECT INSULIN SYRIN.000

08881601689 HM MONOJECT INSULIN SYRIN.000

08881601879 HM MONOJECT INSULIN SYRIN.000

58768046705 HOMATROPINE HBR5.000 %

50383013516 HT-TUSS DM.000

00002751001 HUMALOG100.00 U/ML

00002751501 HUMALOG100.00 U/ML

00002751559 HUMALOG100.00 U/ML

00002751659 HUMALOG100.00 U/ML

00002751101 HUMALOG MIX 75/25.000

00002879459 HUMALOG MIX 75/25 PEN.000

00002872559 HUMALOG PEN100.00 U/ML

61570052910 HUMATIN250.00 MG

00002951501 HUMULIN 50/50.000

00002871501 HUMULIN 70/30.000

00002877059 HUMULIN 70/30 PEN.000

00002877001 HUMULIN 70/30 PEN.000

00002841501 HUMULIN L100.00 U/ML

00002831501 HUMULIN N100.00 U/ML

00002873059 HUMULIN N U-100 PEN100.00 U/ML

00002821501 HUMULIN R100.00 U/ML

00002850101 HUMULIN R500.00 U/ML

00002861501 HUMULIN U100.00 U/ML

08024072412 HYALGAN10.000 MG/ML

08024072420 HYALGAN10.000 MG/ML

59743002116 HYCOMAL DH.000

00078007006 HYDERGINE1.000 MG

00182055489 HYDRALAZINE HCL25.000 MG

00182055589 HYDRALAZINE HCL50.000 MG

00182090589 HYDRALAZINE HCL10.000 MG

00904334080 HYDRALAZINE HCL50.000 MG

49884002701 HYDRALAZINE HCL25.000 MG

49884002710 HYDRALAZINE HCL25.000 MG

49884002801 HYDRALAZINE HCL50.000 MG

49884002810 HYDRALAZINE HCL50.000 MG

49884002901 HYDRALAZINE HCL10.000 MG

49884002910 HYDRALAZINE HCL10.000 MG

49884012101 HYDRALAZINE HCL100.00 MG

49884012110 HYDRALAZINE HCL100.00 MG

50111039701 HYDRALAZINE HCL100.00 MG

50111039801 HYDRALAZINE HCL10.000 MG

50111039803 HYDRALAZINE HCL10.000 MG

50111032701 HYDRALAZINE HCL25.000 MG

50111032703 HYDRALAZINE HCL25.000 MG

50111032801 HYDRALAZINE HCL50.000 MG

50111032803 HYDRALAZINE HCL50.000 MG

49884014301 HYDRALAZINE/HYDROCHLOROTH.000

49884014305 HYDRALAZINE/HYDROCHLOROTH.000

49884014401 HYDRALAZINE/HYDROCHLOROTH.000

49884014405 HYDRALAZINE/HYDROCHLOROTH.000

49884014501 HYDRALAZINE/HYDROCHLOROTH.000

00182616837 HYDRAMINE12.500 MG/5ML

00182616840 HYDRAMINE12.500 MG/5ML

00003169401 HYDRASORB FOAM DRESSING.000

00003169405 HYDRASORB FOAM DRESSING.000

00003169406 HYDRASORB FOAM DRESSING.000

Page 47 of 125

Page 48: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00003169407 HYDRASORB FOAM DRESSING.000

00003169414 HYDRASORB FOAM DRESSING.000

00003083050 HYDREA500.00 MG

00904408984 HYDRO-TABS.000

58177090607 HYDRO-TUSSIN DM.000

58177089007 HYDRO-TUSSIN HD.000

00086005710 HYDROCET.000

00054338363 HYDROCHLOROTHIAZIDE50.000 MG/5ML

00228222196 HYDROCHLOROTHIAZIDE25.000 MG

00228222296 HYDROCHLOROTHIAZIDE50.000 MG

00182055689 HYDROCHLOROTHIAZIDE25.000 MG

00182055789 HYDROCHLOROTHIAZIDE50.000 MG

00172208360 HYDROCHLOROTHIAZIDE25.000 MG

00172208380 HYDROCHLOROTHIAZIDE25.000 MG

00172208960 HYDROCHLOROTHIAZIDE50.000 MG

00172208980 HYDROCHLOROTHIAZIDE50.000 MG

00172208985 HYDROCHLOROTHIAZIDE50.000 MG

00378081001 HYDROCHLOROTHIAZIDE12.500 MG

00904208380 HYDROCHLOROTHIAZIDE25.000 MG

00904208980 HYDROCHLOROTHIAZIDE50.000 MG

60429021390 HYDROCHLOROTHIAZIDE50.000 MG

00904216880 HYDROCHLOROTHIAZIDE/RESER.000

00904216960 HYDROCHLOROTHIAZIDE/RESER.000

00904216980 HYDROCHLOROTHIAZIDE/RESER.000

60432009808 HYDROCODONE CP.000

60432011208 HYDROCODONE GF.000

60432009708 HYDROCODONE HD.000

00904763060 HYDROCODONE/ACETAMINOPHEN.000

00904344061 HYDROCODONE/ACETAMINOPHEN.000

00904344260 HYDROCODONE/ACETAMINOPHEN.000

00677118401 HYDROCODONE/ACETAMINOPHEN.000

00677118405 HYDROCODONE/ACETAMINOPHEN.000

51079042020 HYDROCODONE/ACETAMINOPHEN.000

51079042021 HYDROCODONE/ACETAMINOPHEN.000

51079042099 HYDROCODONE/ACETAMINOPHEN.000

51079086721 HYDROCODONE/ACETAMINOPHEN.000

51079074821 HYDROCODONE/ACETAMINOPHEN.000

00603129558 HYDROCODONE/ACETAMINOPHEN.000

00603388021 HYDROCODONE/ACETAMINOPHEN.000

00603388102 HYDROCODONE/ACETAMINOPHEN.000

00603388116 HYDROCODONE/ACETAMINOPHEN.000

00603388119 HYDROCODONE/ACETAMINOPHEN.000

00603388120 HYDROCODONE/ACETAMINOPHEN.000

00603388121 HYDROCODONE/ACETAMINOPHEN.000

00603388122 HYDROCODONE/ACETAMINOPHEN.000

00603388128 HYDROCODONE/ACETAMINOPHEN.000

00603388221 HYDROCODONE/ACETAMINOPHEN.000

00603388228 HYDROCODONE/ACETAMINOPHEN.000

00603388232 HYDROCODONE/ACETAMINOPHEN.000

00603388321 HYDROCODONE/ACETAMINOPHEN.000

00603388328 HYDROCODONE/ACETAMINOPHEN.000

00603388421 HYDROCODONE/ACETAMINOPHEN.000

00603388428 HYDROCODONE/ACETAMINOPHEN.000

00603388521 HYDROCODONE/ACETAMINOPHEN.000

00603388528 HYDROCODONE/ACETAMINOPHEN.000

00603388621 HYDROCODONE/ACETAMINOPHEN.000

00603388628 HYDROCODONE/ACETAMINOPHEN.000

00603388721 HYDROCODONE/ACETAMINOPHEN.000

00603388728 HYDROCODONE/ACETAMINOPHEN.000

00603388821 HYDROCODONE/ACETAMINOPHEN.000

00603388828 HYDROCODONE/ACETAMINOPHEN.000

00603388832 HYDROCODONE/ACETAMINOPHEN.000

00182176589 HYDROCODONE/ACETAMINOPHEN.000

00254359435 HYDROCODONE/ACETAMINOPHEN.000

00254360128 HYDROCODONE/ACETAMINOPHEN.000

00258365801 HYDROCODONE/ACETAMINOPHEN.000

00258365805 HYDROCODONE/ACETAMINOPHEN.000

00258362201 HYDROCODONE/ACETAMINOPHEN.000

00258362205 HYDROCODONE/ACETAMINOPHEN.000

00047031930 HYDROCODONE/ACETAMINOPHEN.000

00047048630 HYDROCODONE/ACETAMINOPHEN.000

00093056710 HYDROCODONE/ACETAMINOPHEN.000

60258072016 HYDROCODONE/ACETAMINOPHEN.000

60951064185 HYDROCODONE/ACETAMINOPHEN.000

58177088107 HYDROCODONE/GUAIFENESIN.000

58177088112 HYDROCODONE/GUAIFENESIN.000

60432045516 HYDROCODONE/HOMATROPINE.000

62794008675 HYDROCOL SACRAL.000

00472132626 HYDROCORTISONE1.000 %

00472034556 HYDROCORTISONE1.000 %

00472032126 HYDROCORTISONE1.000 %

00472033720 HYDROCORTISONE2.500 %

00472033730 HYDROCORTISONE2.500 %

00414001405 HYDROCORTISONE2.500 %

00536510597 HYDROCORTISONE1.000 %

00536510795 HYDROCORTISONE1.000 %

00536510895 HYDROCORTISONE1.000 %

00603778454 HYDROCORTISONE1.000 %

00603778552 HYDROCORTISONE2.500 %

00603053550 HYDROCORTISONE1.000 %

00182095134 HYDROCORTISONE.500 %

00168028802 HYDROCORTISONE2.500 %

00168008016 HYDROCORTISONE2.500 %

00168008031 HYDROCORTISONE2.500 %

00168014616 HYDROCORTISONE2.500 %

00168014630 HYDROCORTISONE2.500 %

00168015408 HYDROCORTISONE1.000 %

00168015431 HYDROCORTISONE1.000 %

00168018131 HYDROCORTISONE1.000 %

00168001431 HYDROCORTISONE.500 %

00168001516 HYDROCORTISONE1.000 %

00168001531 HYDROCORTISONE1.000 %

00168001631 HYDROCORTISONE.500 %

00168002016 HYDROCORTISONE1.000 %

00168002031 HYDROCORTISONE1.000 %

00093916871 HYDROCORTISONE100.00 MG/60ML

00143125401 HYDROCORTISONE20.000 MG

45802027804 HYDROCORTISONE1.000 %

45802028306 HYDROCORTISONE1.000 %

00677007601 HYDROCORTISONE20.000 MG

00904267460 HYDROCORTISONE20.000 MG

00904762331 HYDROCORTISONE1.000 %

00904762427 HYDROCORTISONE1.000 %

00904762431 HYDROCORTISONE1.000 %

00904761831 HYDROCORTISONE.500 %

45802000203 HYDROCORTISONE.500 %

45802000204 HYDROCORTISONE.500 %

45802000270 HYDROCORTISONE.500 %

45802000302 HYDROCORTISONE1.000 %

45802000303 HYDROCORTISONE1.000 %

45802000305 HYDROCORTISONE1.000 %

45802000402 HYDROCORTISONE2.500 %

45802000403 HYDROCORTISONE2.500 %

45802001203 HYDROCORTISONE.500 %

45802001204 HYDROCORTISONE.500 %

45802001205 HYDROCORTISONE.500 %

45802001303 HYDROCORTISONE1.000 %

45802001304 HYDROCORTISONE1.000 %

45802001305 HYDROCORTISONE1.000 %

45802001402 HYDROCORTISONE2.500 %

00472034356 HYDROCORTISONE1.000 %

00168028704 HYDROCORTISONE1.000 %

Page 48 of 125

Page 49: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

60793031311 HYDROCORTISONE2.500 %

00904016012 HYDROCORTISONE ACETATE25.000 MG

00904016060 HYDROCORTISONE ACETATE25.000 MG

00677137712 HYDROCORTISONE ACETATE25.000 MG

45802027403 HYDROCORTISONE ACETATE1.000 %

45802072514 HYDROCORTISONE ACETATE25.000 MG

45802072530 HYDROCORTISONE ACETATE25.000 MG

45802072531 HYDROCORTISONE ACETATE25.000 MG

53265076112 HYDROCORTISONE ACETATE25.000 MG

53265076124 HYDROCORTISONE ACETATE25.000 MG

00603053450 HYDROCORTISONE ACETATE1.000 %

00574042101 HYDROCORTISONE ACETATE.000

00574042125 HYDROCORTISONE ACETATE.000

00574709012 HYDROCORTISONE ACETATE25.000 MG

00182506034 HYDROCORTISONE ACETATE MA1.000 %

00472033856 HYDROCORTISONE ACETATE/AL.000

45802019703 HYDROCORTISONE ACETATE/AL.000

45802019003 HYDROCORTISONE ACETATE/AL.000

45802019023 HYDROCORTISONE ACETATE/AL.000

46287000301 HYDROCORTISONE IN ABSORBA1.000 %

46287000304 HYDROCORTISONE IN ABSORBA1.000 %

46287000316 HYDROCORTISONE IN ABSORBA1.000 %

60258003230 HYDROCORTISONE IODOQUINOL.000

51552002001 HYDROCORTISONE MICRONIZED.000

51552002005 HYDROCORTISONE MICRONIZED.000

00574042001 HYDROCORTISONE MICRONIZED.000

00574042010 HYDROCORTISONE MICRONIZED.000

00574042025 HYDROCORTISONE MICRONIZED.000

00168029651 HYDROCORTISONE SCALP1.000 %

00168029652 HYDROCORTISONE SCALP1.000 %

45802045535 HYDROCORTISONE VALERATE.200 %

45802045537 HYDROCORTISONE VALERATE.200 %

45802045542 HYDROCORTISONE VALERATE.200 %

59772780002 HYDROCORTISONE VALERATE.200 %

59772780004 HYDROCORTISONE VALERATE.200 %

59772780007 HYDROCORTISONE VALERATE.200 %

59772810004 HYDROCORTISONE VALERATE.200 %

59772810005 HYDROCORTISONE VALERATE.200 %

59772810007 HYDROCORTISONE VALERATE.200 %

45802019603 HYDROCORTISONE/ALOE.000

00713029031 HYDROCORTISONE/ALOE.000

00472033956 HYDROCORTISONE/ALOE.000

00677072638 HYDROCORTISONE/CLIOQUINOL.000

45802000605 HYDROCORTISONE/CLIOQUINOL.000

58177080302 HYDROCORTISONE/IODOQUINOL.000

00006061968 HYDROCORTONE10.000 MG

00574005216 HYDROCREAM BASE WATER IN.000

00574005240 HYDROCREAM BASE WATER IN.000

00472103016 HYDROMET.000

00574201701 HYDROMORPHONE HCL.000

00574722406 HYDROMORPHONE HCL3.000 MG

00603392521 HYDROMORPHONE HCL2.000 MG

00603392621 HYDROMORPHONE HCL4.000 MG

00254361128 HYDROMORPHONE HCL2.000 MG

00054338750 HYDROMORPHONE HCL1.000 MG/ML

00054338758 HYDROMORPHONE HCL1.000 MG/ML

00054338763 HYDROMORPHONE HCL1.000 MG/ML

00074130431 HYDROMORPHONE HCL4.000 MG/ML

00074131230 HYDROMORPHONE HCL2.000 MG/ML

00054437025 HYDROMORPHONE HCL8.000 MG

00054439225 HYDROMORPHONE HCL2.000 MG

00054439425 HYDROMORPHONE HCL4.000 MG

00054834916 HYDROMORPHONE HCL1.000 MG/ML

00054835016 HYDROMORPHONE HCL1.000 MG/ML

00054839224 HYDROMORPHONE HCL2.000 MG

00054839424 HYDROMORPHONE HCL4.000 MG

00641234141 HYDROMORPHONE HCL2.000 MG/ML

58177029804 HYDROMORPHONE HCL2.000 MG

58177029904 HYDROMORPHONE HCL4.000 MG

60951075270 HYDROMORPHONE HCL2.000 MG

60951075770 HYDROMORPHONE HCL4.000 MG

00641012125 HYDROMORPHONE HCL DOSETTE2.000 MG/ML

60258073116 HYDRON KGS.000

60432011308 HYDROPHENE DH.000

45802009505 HYDROPHILIC.000

00168004716 HYDROPHILIC.000

00603778878 HYDROQUINONE4.000 %

58177080102 HYDROQUINONE4.000 %

00603778978 HYDROQUINONE/SUNSCREENS.000

58177080202 HYDROQUINONE/SUNSCREENS.000

58521000201 HYDROSTAT2.000 MG

58521000401 HYDROSTAT4.000 MG

00904091630 HYDROXOCOBALAMIN1000.0 MCG/ML

00781140701 HYDROXYCHLOROQUINE SULFAT200.00 MG

17236061001 HYDROXYCHLOROQUINE SULFAT200.00 MG

00904510760 HYDROXYCHLOROQUINE SULFAT200.00 MG

00955079001 HYDROXYCHLOROQUINE SULFAT200.00 MG

00955079005 HYDROXYCHLOROQUINE SULFAT200.00 MG

00378037301 HYDROXYCHLOROQUINE SULFAT200.00 MG

00093977401 HYDROXYCHLOROQUINE SULFAT200.00 MG

00093977405 HYDROXYCHLOROQUINE SULFAT200.00 MG

00054824725 HYDROXYUREA500.00 MG

00054224725 HYDROXYUREA500.00 MG

00555088202 HYDROXYUREA500.00 MG

49884072401 HYDROXYUREA500.00 MG

50383079616 HYDROXYZINE HCL10.000 MG/5ML

50111030701 HYDROXYZINE HCL10.000 MG

50111030702 HYDROXYZINE HCL10.000 MG

50111030703 HYDROXYZINE HCL10.000 MG

50111030801 HYDROXYZINE HCL25.000 MG

50111030802 HYDROXYZINE HCL25.000 MG

50111030803 HYDROXYZINE HCL25.000 MG

50111030901 HYDROXYZINE HCL50.000 MG

50111030902 HYDROXYZINE HCL50.000 MG

50111030903 HYDROXYZINE HCL50.000 MG

53489012701 HYDROXYZINE HCL25.000 MG

53489012705 HYDROXYZINE HCL25.000 MG

53489012710 HYDROXYZINE HCL25.000 MG

53489012801 HYDROXYZINE HCL50.000 MG

53489012805 HYDROXYZINE HCL50.000 MG

53489012810 HYDROXYZINE HCL50.000 MG

00641043325 HYDROXYZINE HCL50.000 MG/ML

00677060501 HYDROXYZINE HCL25.000 MG

00677060505 HYDROXYZINE HCL25.000 MG

00677060510 HYDROXYZINE HCL25.000 MG

00677060601 HYDROXYZINE HCL50.000 MG

00677060605 HYDROXYZINE HCL50.000 MG

00677060610 HYDROXYZINE HCL50.000 MG

00591552301 HYDROXYZINE HCL25.000 MG

00603131058 HYDROXYZINE HCL10.000 MG/5ML

00182137640 HYDROXYZINE HCL10.000 MG/5ML

60432015004 HYDROXYZINE HCL10.000 MG/5ML

60432015016 HYDROXYZINE HCL10.000 MG/5ML

00182109889 HYDROXYZINE PAMOATE25.000 MG

00182109989 HYDROXYZINE PAMOATE50.000 MG

00172290960 HYDROXYZINE PAMOATE50.000 MG

00172291160 HYDROXYZINE PAMOATE25.000 MG

00172291170 HYDROXYZINE PAMOATE25.000 MG

00185061301 HYDROXYZINE PAMOATE25.000 MG

00185061305 HYDROXYZINE PAMOATE25.000 MG

00185061501 HYDROXYZINE PAMOATE50.000 MG

00185061505 HYDROXYZINE PAMOATE50.000 MG

Page 49 of 125

Page 50: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00555030202 HYDROXYZINE PAMOATE50.000 MG

00555030204 HYDROXYZINE PAMOATE50.000 MG

00555032302 HYDROXYZINE PAMOATE25.000 MG

00555032304 HYDROXYZINE PAMOATE25.000 MG

00555032402 HYDROXYZINE PAMOATE100.00 MG

51079007720 HYDROXYZINE PAMOATE25.000 MG

51079007820 HYDROXYZINE PAMOATE50.000 MG

51991005601 HYFLEX-DS.000

50383021604 HYGIENOL.000

00677166501 HYOSCYAMINE SULFATE.125 MG

00904249660 HYOSCYAMINE SULFATE.125 MG

00904512060 HYOSCYAMINE SULFATE.125 MG

10267162101 HYOSCYAMINE SULFATE.125 MG

00603400221 HYOSCYAMINE SULFATE.125 MG

00603400321 HYOSCYAMINE SULFATE.125 MG

00603131473 HYOSCYAMINE SULFATE.125 MG/ML

00603131558 HYOSCYAMINE SULFATE.125 MG/5ML

00254921643 HYOSCYAMINE SULFATE.125 MG/ML

62175010101 HYOSCYAMINE SULFATE.125 MG

62175010201 HYOSCYAMINE SULFATE.125 MG

62175010416 HYOSCYAMINE SULFATE.125 MG/5ML

62175010515 HYOSCYAMINE SULFATE.125 MG/ML

60432010315 HYOSCYAMINE SULFATE.125 MG/ML

60258080116 HYOSCYAMINE SULFATE.125 MG/5ML

60258080215 HYOSCYAMINE SULFATE.125 MG/ML

58177027404 HYOSCYAMINE SULFATE.125 MG

58177025504 HYOSCYAMINE SULFATE.125 MG

59743002601 HYOSCYAMINE SULFATE.125 MG

00603400421 HYOSCYAMINE SULFATE CR.375 MG

00603400521 HYOSCYAMINE SULFATE ER.375 MG

00115702501 HYOSCYAMINE SULFATE ER.375 MG

58177023704 HYOSCYAMINE SULFATE ER.375 MG

58177001704 HYOSCYAMINE SULFATE ER.375 MG

62175010301 HYOSCYAMINE SULFATE ER.375 MG

62175010801 HYOSCYAMINE SULFATE ER.375 MG

51285093702 HYOSCYAMINE SULFATE SR.375 MG

51991069501 HYOSCYAMINE SULFATE TR.375 MG

00677171701 HYOSCYAMINE SULFATE TR.375 MG

00182199301 HYOSCYAMINE SULFATE TR.375 MG

51991013501 HYOSPAZ.150 MG

54838050615 HYOSYNE.125 MG/ML

54838051180 HYOSYNE.125 MG/5ML

00085020105 HYPERSTAT IV15.000 MG/ML

60258079016 HYPHED.000

59743001216 HYPHEN-HD.000

58768013230 HYPO TEARS PF.000

08881250206 HYPO/POLYPROP HUB/LUER LO.000

58768013015 HYPOTEARS1.000 %

58768013030 HYPOTEARS1.000 %

58768013136 HYPOTEARS.000

58768013425 HYPOTEARS SELECT.000

00024079202 HYTAKEROL.125 MG

00066009501 HYTONE2.500 %

00066009502 HYTONE2.500 %

00066009802 HYTONE2.500 %

00066804201 HYTONE1.000 %

00066804404 HYTONE1.000 %

00066999701 HYTONE2.500 %

00074380511 HYTRIN1.000 MG

00074380513 HYTRIN1.000 MG

00074380611 HYTRIN2.000 MG

00074380613 HYTRIN2.000 MG

00074380711 HYTRIN5.000 MG

00074380713 HYTRIN5.000 MG

00074380811 HYTRIN10.000 MG

00074380813 HYTRIN10.000 MG

00006071728 HYZAAR.000

00006071731 HYZAAR.000

00006071754 HYZAAR.000

00006071758 HYZAAR.000

00006071782 HYZAAR.000

00006074728 HYZAAR.000

00006074731 HYZAAR.000

00006074758 HYZAAR.000

00536509008 I-VITE.000

00482010614 I.L.X. B-12.000

00482011023 I.L.X. B-12.000

00482010714 I.L.X. B-12 SF.000

00074723530 IBERET.000

00074712530 IBERET-FOLIC-500.000

49884046701 IBU400.00 MG

49884046705 IBU400.00 MG

49884046801 IBU600.00 MG

49884046805 IBU600.00 MG

49884046901 IBU800.00 MG

49884046905 IBU800.00 MG

00904174760 IBU-200200.00 MG

00904174840 IBUPROFEN400.00 MG

00904174860 IBUPROFEN400.00 MG

00904174861 IBUPROFEN400.00 MG

00904175840 IBUPROFEN600.00 MG

00904175893 IBUPROFEN600.00 MG

00904176040 IBUPROFEN800.00 MG

00904176060 IBUPROFEN800.00 MG

00904176089 IBUPROFEN800.00 MG

00904164840 IBUPROFEN400.00 MG

00904164860 IBUPROFEN400.00 MG

00904165860 IBUPROFEN600.00 MG

00677111901 IBUPROFEN800.00 MG

00677111905 IBUPROFEN800.00 MG

00677103101 IBUPROFEN400.00 MG

00677103105 IBUPROFEN400.00 MG

00677103201 IBUPROFEN600.00 MG

00677103205 IBUPROFEN600.00 MG

00677109001 IBUPROFEN200.00 MG

00677109002 IBUPROFEN200.00 MG

00615252643 IBUPROFEN600.00 MG

00904532324 IBUPROFEN200.00 MG

00904518540 IBUPROFEN400.00 MG

00904518560 IBUPROFEN400.00 MG

00904518640 IBUPROFEN600.00 MG

00904518660 IBUPROFEN600.00 MG

00904518661 IBUPROFEN600.00 MG

00904518740 IBUPROFEN800.00 MG

00904518760 IBUPROFEN800.00 MG

00904518761 IBUPROFEN800.00 MG

00904791251 IBUPROFEN200.00 MG

00904791259 IBUPROFEN200.00 MG

00904791451 IBUPROFEN200.00 MG

00904791459 IBUPROFEN200.00 MG

00904791461 IBUPROFEN200.00 MG

00904791524 IBUPROFEN200.00 MG

00904791540 IBUPROFEN200.00 MG

00904791551 IBUPROFEN200.00 MG

00904791559 IBUPROFEN200.00 MG

00904791570 IBUPROFEN200.00 MG

17236056501 IBUPROFEN200.00 MG

17236056505 IBUPROFEN200.00 MG

17236056510 IBUPROFEN200.00 MG

17236056524 IBUPROFEN200.00 MG

17236056530 IBUPROFEN200.00 MG

17236056555 IBUPROFEN200.00 MG

Page 50 of 125

Page 51: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

17236056801 IBUPROFEN400.00 MG

17236056805 IBUPROFEN400.00 MG

17236056901 IBUPROFEN600.00 MG

17236056905 IBUPROFEN600.00 MG

17236057001 IBUPROFEN800.00 MG

17236057005 IBUPROFEN800.00 MG

49884021605 IBUPROFEN800.00 MG

51079059619 IBUPROFEN800.00 MG

51079059620 IBUPROFEN800.00 MG

51079059698 IBUPROFEN800.00 MG

51079028119 IBUPROFEN400.00 MG

51079028120 IBUPROFEN400.00 MG

51079028198 IBUPROFEN400.00 MG

51079028219 IBUPROFEN600.00 MG

51079028220 IBUPROFEN600.00 MG

51079028298 IBUPROFEN600.00 MG

51079073120 IBUPROFEN200.00 MG

53746013101 IBUPROFEN400.00 MG

53746013105 IBUPROFEN400.00 MG

53746013190 IBUPROFEN400.00 MG

53746013201 IBUPROFEN600.00 MG

53746013205 IBUPROFEN600.00 MG

53746013290 IBUPROFEN600.00 MG

53746013501 IBUPROFEN200.00 MG

53746013502 IBUPROFEN200.00 MG

53746013510 IBUPROFEN200.00 MG

53746013524 IBUPROFEN200.00 MG

53746013550 IBUPROFEN200.00 MG

53746013701 IBUPROFEN800.00 MG

53746013705 IBUPROFEN800.00 MG

53746013790 IBUPROFEN800.00 MG

53746013801 IBUPROFEN200.00 MG

53746013802 IBUPROFEN200.00 MG

53746013810 IBUPROFEN200.00 MG

53746013824 IBUPROFEN200.00 MG

53746013850 IBUPROFEN200.00 MG

00472127016 IBUPROFEN100.00 MG/5ML

00472127094 IBUPROFEN100.00 MG/5ML

00536393910 IBUPROFEN200.00 MG

00603401821 IBUPROFEN400.00 MG

00603401828 IBUPROFEN400.00 MG

00603401921 IBUPROFEN600.00 MG

00603401928 IBUPROFEN600.00 MG

00603402021 IBUPROFEN800.00 MG

00603402028 IBUPROFEN800.00 MG

00182129789 IBUPROFEN800.00 MG

00182180989 IBUPROFEN400.00 MG

00182181089 IBUPROFEN600.00 MG

00182103901 IBUPROFEN200.00 MG

00182103902 IBUPROFEN200.00 MG

00182103910 IBUPROFEN200.00 MG

00182103916 IBUPROFEN200.00 MG

00172364870 IBUPROFEN800.00 MG

00182868889 IBUPROFEN200.00 MG

00472127008 IBUPROFEN100.00 MG/5ML

60429009230 IBUPROFEN400.00 MG

60429009290 IBUPROFEN400.00 MG

60429009330 IBUPROFEN600.00 MG

60429009390 IBUPROFEN600.00 MG

60429009427 IBUPROFEN800.00 MG

60429009430 IBUPROFEN800.00 MG

60429009490 IBUPROFEN800.00 MG

59762737801 IBUPROFEN400.00 MG

59762737802 IBUPROFEN400.00 MG

59762737901 IBUPROFEN600.00 MG

59762737902 IBUPROFEN600.00 MG

59762738001 IBUPROFEN800.00 MG

59762738002 IBUPROFEN800.00 MG

63717009901 ICAR-C.000

63717010001 ICAR-C PLUS.000

00182095534 ICHTHAMMOL20.000 %

45802008003 ICHTHAMMOL10.000 %

45802008005 ICHTHAMMOL10.000 %

45802008103 ICHTHAMMOL20.000 %

00182509044 ICY RUB2.000 %

00015055605 IFEX1.000 GM

00015356415 IFEX/MESNEX COMBO PACK.000

00015355427 IFEX/MESNEX COMBO PACK.000

00015355626 IFEX/MESNEX COMBO PACK.000

00002841101 ILETIN II LENTE/PORK100.00 U/ML

00002831101 ILETIN II NPH/PORK100.00 U/ML

00002821101 ILETIN II REGULAR/PORK100.00 U/ML

00003698727 ILEX SKIN PROTECTANT49.800 %

00085411001 IMDUR60.000 MG

00085411003 IMDUR60.000 MG

00085330601 IMDUR30.000 MG

00085330603 IMDUR30.000 MG

00085115303 IMDUR120.00 MG

00085115304 IMDUR120.00 MG

00781176201 IMIPRAMINE HCL10.000 MG

00781176401 IMIPRAMINE HCL25.000 MG

00781176410 IMIPRAMINE HCL25.000 MG

00781176413 IMIPRAMINE HCL25.000 MG

00781176601 IMIPRAMINE HCL50.000 MG

00781176610 IMIPRAMINE HCL50.000 MG

00781176613 IMIPRAMINE HCL50.000 MG

00904092570 IMIPRAMINE HCL10.000 MG

00904092580 IMIPRAMINE HCL10.000 MG

00904092770 IMIPRAMINE HCL25.000 MG

00904092780 IMIPRAMINE HCL25.000 MG

00904092970 IMIPRAMINE HCL50.000 MG

00904092980 IMIPRAMINE HCL50.000 MG

00677042101 IMIPRAMINE HCL10.000 MG

00677042106 IMIPRAMINE HCL10.000 MG

00677042107 IMIPRAMINE HCL10.000 MG

00677042201 IMIPRAMINE HCL25.000 MG

00677042206 IMIPRAMINE HCL25.000 MG

00677042207 IMIPRAMINE HCL25.000 MG

00677042301 IMIPRAMINE HCL50.000 MG

00677042306 IMIPRAMINE HCL50.000 MG

00677042307 IMIPRAMINE HCL50.000 MG

53489033001 IMIPRAMINE HCL10.000 MG

53489033003 IMIPRAMINE HCL10.000 MG

53489033010 IMIPRAMINE HCL10.000 MG

53489033101 IMIPRAMINE HCL25.000 MG

53489033103 IMIPRAMINE HCL25.000 MG

53489033110 IMIPRAMINE HCL25.000 MG

53489033201 IMIPRAMINE HCL50.000 MG

53489033203 IMIPRAMINE HCL50.000 MG

53489033210 IMIPRAMINE HCL50.000 MG

49884005401 IMIPRAMINE HCL10.000 MG

49884005410 IMIPRAMINE HCL10.000 MG

49884005501 IMIPRAMINE HCL25.000 MG

49884005510 IMIPRAMINE HCL25.000 MG

49884005601 IMIPRAMINE HCL50.000 MG

49884005610 IMIPRAMINE HCL50.000 MG

45802060093 IMPROVED EXTRA CARE SKIN.000

00173059755 IMURAN50.000 MG

60976059755 IMURAN50.000 MG

60976059871 IMURAN100.00 MG

00074774501 INAMRINONE5.000 MG/ML

00378008001 INDAPAMIDE2.500 MG

Page 51 of 125

Page 52: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00378008010 INDAPAMIDE2.500 MG

00378006901 INDAPAMIDE1.250 MG

00378006905 INDAPAMIDE1.250 MG

00182820189 INDAPAMIDE1.250 MG

00228257111 INDAPAMIDE2.500 MG

00228257150 INDAPAMIDE2.500 MG

00228257196 INDAPAMIDE2.500 MG

00228259711 INDAPAMIDE1.250 MG

00228259796 INDAPAMIDE1.250 MG

00182261089 INDAPAMIDE2.500 MG

00172425960 INDAPAMIDE2.500 MG

00172425980 INDAPAMIDE2.500 MG

00172426260 INDAPAMIDE1.250 MG

00172426280 INDAPAMIDE1.250 MG

49884058901 INDAPAMIDE1.250 MG

49884058910 INDAPAMIDE1.250 MG

49884059001 INDAPAMIDE2.500 MG

49884059010 INDAPAMIDE2.500 MG

51079086820 INDAPAMIDE2.500 MG

00046042181 INDERAL10.000 MG

00046042281 INDERAL20.000 MG

00046042481 INDERAL40.000 MG

00046042681 INDERAL60.000 MG

00046042881 INDERAL80.000 MG

00046042195 INDERAL10.000 MG

00046042295 INDERAL20.000 MG

00046042495 INDERAL40.000 MG

00046047081 INDERAL LA60.000 MG

00046047181 INDERAL LA80.000 MG

00046047381 INDERAL LA120.00 MG

00046047981 INDERAL LA160.00 MG

00046048881 INDERIDE.000

00046048481 INDERIDE 40/25.000

60267062210 INDIGO CARMINE8.000 MG/ML

00006337666 INDOCIN25.000 MG/5ML

00006005068 INDOCIN50.000 MG

00006002568 INDOCIN25.000 MG

00006002582 INDOCIN25.000 MG

00006015030 INDOCIN50.000 MG

00172402960 INDOMETHACIN25.000 MG

00172402980 INDOMETHACIN25.000 MG

00172403060 INDOMETHACIN50.000 MG

00172403070 INDOMETHACIN50.000 MG

00182168189 INDOMETHACIN25.000 MG

00182168289 INDOMETHACIN50.000 MG

00378014301 INDOMETHACIN25.000 MG

00378014310 INDOMETHACIN25.000 MG

00378014701 INDOMETHACIN50.000 MG

00378014705 INDOMETHACIN50.000 MG

51079019019 INDOMETHACIN25.000 MG

51079019020 INDOMETHACIN25.000 MG

51079019120 INDOMETHACIN50.000 MG

50111040603 INDOMETHACIN25.000 MG

00677087210 INDOMETHACIN25.000 MG

00185072001 INDOMETHACIN ER75.000 MG

00185072005 INDOMETHACIN ER75.000 MG

00185072060 INDOMETHACIN ER75.000 MG

00258360701 INDOMETHACIN ER75.000 MG

00258360706 INDOMETHACIN ER75.000 MG

00904117852 INDOMETHACIN SR75.000 MG

00904117860 INDOMETHACIN SR75.000 MG

00677119706 INDOMETHACIN SR75.000 MG

00182600964 INFANTS APAP100.00 MG/ML

00904506730 INFANTS GAS RELIEF40.000 MG/0.6ML

00904525530 INFANTS MAPAP80.000 MG/0.8ML

00904525535 INFANTS MAPAP80.000 MG/0.8ML

53100021496 INFANTS PANADOL100.00 MG/ML

54838014515 INFANTS SILAPAP100.00 MG/ML

54838014530 INFANTS SILAPAP100.00 MG/ML

58768087705 INFLAMASE FORTE1.000 %

58768087710 INFLAMASE FORTE1.000 %

58768087715 INFLAMASE FORTE1.000 %

58768087505 INFLAMASE MILD.125 %

58768087510 INFLAMASE MILD.125 %

00641113131 INFUMORPH 20010.000 MG/ML

00641113231 INFUMORPH 50025.000 MG/ML

08290001172 INFUSION NEEDLE 15GX2.000

08290328245 INJECT-EASE AUTOMATIC INJ.000

00904419860 INOSITOL324.00 MG

00074789205 INPERSOL-LM/1.5% DEXTROSE.000

00074789207 INPERSOL-LM/1.5% DEXTROSE.000

00074789208 INPERSOL-LM/1.5% DEXTROSE.000

00074789227 INPERSOL-LM/1.5% DEXTROSE.000

00074789228 INPERSOL-LM/1.5% DEXTROSE.000

00074789305 INPERSOL-LM/2.5% DEXTROSE.000

00074789307 INPERSOL-LM/2.5% DEXTROSE.000

00074789308 INPERSOL-LM/2.5% DEXTROSE.000

00074789318 INPERSOL-LM/2.5% DEXTROSE.000

00074789327 INPERSOL-LM/2.5% DEXTROSE.000

00074789328 INPERSOL-LM/2.5% DEXTROSE.000

00074789407 INPERSOL-LM/4.25% DEXTROS.000

00074789408 INPERSOL-LM/4.25% DEXTROS.000

00074789418 INPERSOL-LM/4.25% DEXTROS.000

00074789427 INPERSOL-LM/4.25% DEXTROS.000

00074789428 INPERSOL-LM/4.25% DEXTROS.000

00074794305 INPERSOL/DEXTROSE.000

00074794308 INPERSOL/DEXTROSE.000

00074794313 INPERSOL/DEXTROSE.000

00074794315 INPERSOL/DEXTROSE.000

00074794317 INPERSOL/DEXTROSE.000

00074794318 INPERSOL/DEXTROSE.000

00074794327 INPERSOL/DEXTROSE.000

00074794405 INPERSOL/DEXTROSE.000

00074794407 INPERSOL/DEXTROSE.000

00074794408 INPERSOL/DEXTROSE.000

00074794413 INPERSOL/DEXTROSE.000

00074794415 INPERSOL/DEXTROSE.000

00074794427 INPERSOL/DEXTROSE.000

00074794507 INPERSOL/DEXTROSE.000

00074794508 INPERSOL/DEXTROSE.000

00074794513 INPERSOL/DEXTROSE.000

00074794515 INPERSOL/DEXTROSE.000

00074794517 INPERSOL/DEXTROSE.000

00074794518 INPERSOL/DEXTROSE.000

00074794527 INPERSOL/DEXTROSE.000

08881604188 INSULIN SYRINGE/U-100/.3C.000

08881606084 INSULIN SYRINGE/U-100/0.5.000

00603699521 INSULIN SYRINGE/U-100/0.5.000

00536991601 INSULIN SYRINGE/U-100/0.5.000

00536991501 INSULIN SYRINGE/U-100/1CC.000

00603699621 INSULIN SYRINGE/U-100/1CC.000

08881608189 INSULIN SYRINGE/U-100/1CC.000

00585067302 INTAL20.000 MG/2ML

00585067303 INTAL20.000 MG/2ML

00087436241 INTENSICAL.000

51552019404 IODINE STRONG.000

53014090471 IONAMIN-3030.000 MG

00074737103 IONOSOL-B/DEXTROSE 5%.000

00074737109 IONOSOL-B/DEXTROSE 5%.000

00074737203 IONOSOL-MB/DEXTROSE 5%.000

00074737209 IONOSOL-MB/DEXTROSE 5%.000

00074737262 IONOSOL-MB/DEXTROSE 5%.000

Page 52 of 125

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NDCNAME

STR UOM NDC NAMESTR

UOM

00074737303 IONOSOL-T/DEXTROSE 5%.000

00074737309 IONOSOL-T/DEXTROSE 5%.000

00074737362 IONOSOL-T/DEXTROSE 5%.000

00603132958 IOPHEN C-NR.000

00603133058 IOPHEN DM-NR.000

00603132858 IOPHEN-NR100.00 MG/5ML

00065066010 IOPIDINE1.000 %

00065066505 IOPIDINE.500 %

00065066510 IOPIDINE.500 %

00574001201 IPECAC.000

00172640744 IPRATROPIUM BROMIDE.020 %

00172640749 IPRATROPIUM BROMIDE.020 %

00054840211 IPRATROPIUM BROMIDE.020 %

00054840213 IPRATROPIUM BROMIDE.020 %

00054840221 IPRATROPIUM BROMIDE.020 %

00054840411 IPRATROPIUM BROMIDE.020 %

51552039301 IPRATROPIUM BROMIDE.000

00054840413 IPRATROPIUM BROMIDE.020 %

00054840421 IPRATROPIUM BROMIDE.020 %

00482062801 IRCON200.00 MG

00008077101 ISMO20.000 MG

00008077102 ISMO20.000 MG

00087035502 ISOCAL.000

00087035525 ISOCAL.000

00087035544 ISOCAL.000

00087035546 ISOCAL.000

00087035555 ISOCAL.000

00087044604 ISOCAL HN.000

00087044643 ISOCAL HN.000

00087044644 ISOCAL HN.000

00087044646 ISOCAL HN.000

00087065202 ISOCAL HN PLUS.000

00087065203 ISOCAL HN PLUS.000

00087065204 ISOCAL HN PLUS.000

00087065205 ISOCAL HN PLUS.000

00087065243 ISOCAL HN PLUS.000

00087065244 ISOCAL HN PLUS.000

00087065245 ISOCAL HN PLUS.000

00054843125 ISOETHARINE HCL.200 %

00054380440 ISOETHARINE HCL1.000 %

00054340840 ISOETHARINE HCL1.000 %

00074329201 ISOFLURANE.000

00074329202 ISOFLURANE.000

00074329249 ISOFLURANE.000

00677173901 ISOMETHEPTENE/APAP/DICHLO.000

53746014101 ISOMETHEPTENE/APAP/DICHLO.000

53746014102 ISOMETHEPTENE/APAP/DICHLO.000

53746014105 ISOMETHEPTENE/APAP/DICHLO.000

53746014150 ISOMETHEPTENE/APAP/DICHLO.000

46287000901 ISONIAZID50.000 MG/5ML

51079008220 ISONIAZID100.00 MG

51079008320 ISONIAZID300.00 MG

51079008324 ISONIAZID300.00 MG

00904209580 ISONIAZID100.00 MG

17236018001 ISONIAZID100.00 MG

17236018010 ISONIAZID100.00 MG

17236018201 ISONIAZID300.00 MG

17236018210 ISONIAZID300.00 MG

17236018230 ISONIAZID300.00 MG

17236018235 ISONIAZID300.00 MG

00143126001 ISONIAZID100.00 MG

00143126010 ISONIAZID100.00 MG

00143126101 ISONIAZID300.00 MG

00143126110 ISONIAZID300.00 MG

00143126130 ISONIAZID300.00 MG

00555006602 ISONIAZID100.00 MG

00555006605 ISONIAZID100.00 MG

00555007101 ISONIAZID300.00 MG

00555007102 ISONIAZID300.00 MG

00555007105 ISONIAZID300.00 MG

00182135610 ISONIAZID300.00 MG

00185435001 ISONIAZID300.00 MG

00185435010 ISONIAZID300.00 MG

00185435030 ISONIAZID300.00 MG

00185435101 ISONIAZID100.00 MG

00185435110 ISONIAZID100.00 MG

00185435130 ISONIAZID100.00 MG

60429011530 ISONIAZID300.00 MG

00574006610 ISOPROPYL ALCOHOL99.000 %

00574006616 ISOPROPYL ALCOHOL99.000 %

00574006710 ISOPROPYL ALCOHOL70.000 %

00574006716 ISOPROPYL ALCOHOL70.000 %

00641143835 ISOPROTERENOL HCL.200 MG/ML

00074497718 ISOPROTERENOL HCL.200 MG/ML

00074497815 ISOPROTERENOL HCL.200 MG/ML

00044181621 ISOPTIN IV2.500 MG/ML

00998030305 ISOPTO ATROPINE1.000 %

00998030315 ISOPTO ATROPINE1.000 %

00998022115 ISOPTO CARBACHOL.750 %

00998022315 ISOPTO CARBACHOL1.500 %

00998022330 ISOPTO CARBACHOL1.500 %

00998022415 ISOPTO CARBACHOL2.250 %

00998022515 ISOPTO CARBACHOL3.000 %

00998022530 ISOPTO CARBACHOL3.000 %

00998020315 ISOPTO CARPINE1.000 %

00998020415 ISOPTO CARPINE2.000 %

00998020430 ISOPTO CARPINE2.000 %

00998020615 ISOPTO CARPINE4.000 %

00998020630 ISOPTO CARPINE4.000 %

00998020815 ISOPTO CARPINE6.000 %

00998020915 ISOPTO CARPINE8.000 %

00998031105 ISOPTO HOMATROPINE2.000 %

00998031505 ISOPTO HOMATROPINE5.000 %

00998031515 ISOPTO HOMATROPINE5.000 %

00998040815 ISOPTO TEARS.500 %

00008419201 ISORDIL TITRADOSE40.000 MG

00008415201 ISORDIL TITRADOSE5.000 MG

00008415203 ISORDIL TITRADOSE5.000 MG

00677068910 ISOSORBIDE DINITRATE20.000 MG

00615157543 ISOSORBIDE DINITRATE20.000 MG

00904215061 ISOSORBIDE DINITRATE5.000 MG

00904215161 ISOSORBIDE DINITRATE10.000 MG

00904215461 ISOSORBIDE DINITRATE20.000 MG

00781155601 ISOSORBIDE DINITRATE10.000 MG

00781155610 ISOSORBIDE DINITRATE10.000 MG

00781155613 ISOSORBIDE DINITRATE10.000 MG

00781163501 ISOSORBIDE DINITRATE5.000 MG

00781163510 ISOSORBIDE DINITRATE5.000 MG

00781169501 ISOSORBIDE DINITRATE20.000 MG

00781169510 ISOSORBIDE DINITRATE20.000 MG

00781169513 ISOSORBIDE DINITRATE20.000 MG

51079008519 ISOSORBIDE DINITRATE20.000 MG

51079008520 ISOSORBIDE DINITRATE20.000 MG

51079008524 ISOSORBIDE DINITRATE20.000 MG

51079002923 ISOSORBIDE DINITRATE10.000 MG

49884000901 ISOSORBIDE DINITRATE30.000 MG

49884000910 ISOSORBIDE DINITRATE30.000 MG

49884002001 ISOSORBIDE DINITRATE5.000 MG

49884002010 ISOSORBIDE DINITRATE5.000 MG

49884002101 ISOSORBIDE DINITRATE10.000 MG

49884002110 ISOSORBIDE DINITRATE10.000 MG

49884002201 ISOSORBIDE DINITRATE20.000 MG

Page 53 of 125

Page 54: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

49884002210 ISOSORBIDE DINITRATE20.000 MG

00603412221 ISOSORBIDE DINITRATE2.500 MG

00603412321 ISOSORBIDE DINITRATE5.000 MG

00603411621 ISOSORBIDE DINITRATE5.000 MG

00603411632 ISOSORBIDE DINITRATE5.000 MG

00603411721 ISOSORBIDE DINITRATE10.000 MG

00603411732 ISOSORBIDE DINITRATE10.000 MG

00603411821 ISOSORBIDE DINITRATE20.000 MG

00603411832 ISOSORBIDE DINITRATE20.000 MG

00182086889 ISOSORBIDE DINITRATE20.000 MG

00182055089 ISOSORBIDE DINITRATE5.000 MG

00182051489 ISOSORBIDE DINITRATE10.000 MG

00143176501 ISOSORBIDE DINITRATE2.500 MG

00143176510 ISOSORBIDE DINITRATE2.500 MG

00143176701 ISOSORBIDE DINITRATE5.000 MG

00143176710 ISOSORBIDE DINITRATE5.000 MG

00143176901 ISOSORBIDE DINITRATE5.000 MG

00143176910 ISOSORBIDE DINITRATE5.000 MG

00143176925 ISOSORBIDE DINITRATE5.000 MG

00143177101 ISOSORBIDE DINITRATE10.000 MG

00143177110 ISOSORBIDE DINITRATE10.000 MG

00143177125 ISOSORBIDE DINITRATE10.000 MG

00143177201 ISOSORBIDE DINITRATE20.000 MG

00143177210 ISOSORBIDE DINITRATE20.000 MG

00143177225 ISOSORBIDE DINITRATE20.000 MG

60429010127 ISOSORBIDE DINITRATE10.000 MG

60429010136 ISOSORBIDE DINITRATE10.000 MG

60429010190 ISOSORBIDE DINITRATE10.000 MG

60429010227 ISOSORBIDE DINITRATE20.000 MG

60429010236 ISOSORBIDE DINITRATE20.000 MG

00677047310 ISOSORBIDE DINITRATE CR40.000 MG

00258361301 ISOSORBIDE DINITRATE ER40.000 MG

00228262011 ISOSORBIDE MONONITRATE20.000 MG

00228263111 ISOSORBIDE MONONITRATE10.000 MG

00143213101 ISOSORBIDE MONONITRATE20.000 MG

00143213110 ISOSORBIDE MONONITRATE20.000 MG

00143133301 ISOSORBIDE MONONITRATE20.000 MG

00143133310 ISOSORBIDE MONONITRATE20.000 MG

00093007601 ISOSORBIDE MONONITRATE20.000 MG

00093007605 ISOSORBIDE MONONITRATE20.000 MG

62175010601 ISOSORBIDE MONONITRATE10.000 MG

62175010701 ISOSORBIDE MONONITRATE20.000 MG

00228271111 ISOSORBIDE MONONITRATE ER60.000 MG

00228271150 ISOSORBIDE MONONITRATE ER60.000 MG

00228271311 ISOSORBIDE MONONITRATE ER30.000 MG

00228271350 ISOSORBIDE MONONITRATE ER30.000 MG

62175011937 ISOSORBIDE MONONITRATE ER60.000 MG

62175012837 ISOSORBIDE MONONITRATE ER30.000 MG

62175012937 ISOSORBIDE MONONITRATE ER120.00 MG

59930150201 ISOSORBIDE MONONITRATE ER30.000 MG

59930154901 ISOSORBIDE MONONITRATE ER60.000 MG

59930158701 ISOSORBIDE MONONITRATE ER120.00 MG

58177023804 ISOSORBIDE MONONITRATE ER60.000 MG

58177023811 ISOSORBIDE MONONITRATE ER60.000 MG

58177022204 ISOSORBIDE MONONITRATE ER30.000 MG

58177022211 ISOSORBIDE MONONITRATE ER30.000 MG

58177020104 ISOSORBIDE MONONITRATE ER120.00 MG

00781184201 ISOXSUPRINE HCL20.000 MG

00781184210 ISOXSUPRINE HCL20.000 MG

00781184001 ISOXSUPRINE HCL10.000 MG

00904063560 ISOXSUPRINE HCL10.000 MG

00904063580 ISOXSUPRINE HCL10.000 MG

00904063660 ISOXSUPRINE HCL20.000 MG

00904063661 ISOXSUPRINE HCL20.000 MG

00904063680 ISOXSUPRINE HCL20.000 MG

00074141001 ISUPREL.200 MG/ML

00074141005 ISUPREL.200 MG/ML

59879090106 JOINT HEALTH MINERAL FORM.000

00603417316 K+ POTASSIUM20.000 MEQ

00085026301 K-DUR10.000 MEQ

00085026381 K-DUR10.000 MEQ

00085078701 K-DUR20.000 MEQ

00085078706 K-DUR20.000 MEQ

00085078710 K-DUR20.000 MEQ

00085078781 K-DUR20.000 MEQ

00603417016 K-EFFERVESCENT25.000 MEQ

00074361101 K-LOR20.000 MEQ

00074361102 K-LOR20.000 MEQ

00074734911 K-LOR HOSPITAL PACK20.000 MEQ

00074734930 K-LOR HOSPITAL PACK20.000 MEQ

00087076001 K-LYTE25.000 MEQ

00087076043 K-LYTE25.000 MEQ

00087076101 K-LYTE25.000 MEQ

00087076102 K-LYTE25.000 MEQ

00087076143 K-LYTE25.000 MEQ

00087076641 K-LYTE/CL.000

00087076643 K-LYTE/CL.000

00087076741 K-LYTE/CL.000

00087076743 K-LYTE/CL.000

50383013108 K-PEC750.00 MG/15ML

50383013116 K-PEC750.00 MG/15ML

00486112501 K-PHOS NEUTRAL.000

00486112505 K-PHOS NEUTRAL.000

00904189946 K-SOL20.000 MEQ

00074780413 K-TABS10.000 MEQ

00074780419 K-TABS10.000 MEQ

00904534646 K-VESCENT20.000 MEQ

00904534660 K-VESCENT20.000 MEQ

00904272046 K-VESCENT25.000 MEQ

00904272060 K-VESCENT25.000 MEQ

00536231697 KALMZ ANTI-NAUSEA.000

00015350320 KANTREX333.00 MG/ML

00015350399 KANTREX333.00 MG/ML

00904524909 KAO-TIN ADVANCED FORMULA750.00 MG/15ML

00904524916 KAO-TIN ADVANCED FORMULA750.00 MG/15ML

00281310351 KAOCHLOR10.000 %

00281320351 KAON20.000 MEQ/15M

00281311351 KAON-CL20.000 %

00281313117 KAON-CL-1010.000 MEQ

00281313118 KAON-CL-1010.000 MEQ

00281313123 KAON-CL-1010.000 MEQ

00009378501 KAOPECTATE750.00 MG/15ML

00009378502 KAOPECTATE750.00 MG/15ML

00009378504 KAOPECTATE750.00 MG/15ML

00009378601 KAOPECTATE750.00 MG/15ML

00009378602 KAOPECTATE750.00 MG/15ML

00009345801 KAOPECTATE750.00 MG

00009345802 KAOPECTATE750.00 MG

00009360502 KAOPECTATE600.00 MG/15ML

00677053333 KAPECTOLIN.000

00456066104 KAY CIEL10.000 %

00456066116 KAY CIEL10.000 %

00456066270 KAY CIEL20.000 MEQ

00456066271 KAY CIEL20.000 MEQ

00024107501 KAYEXALATE.000

00074790203 KCL 0.075%/D5W/NACL 0.45%.000

00074799803 KCL 0.15%/D5W/ NACL 0.3%.000

00074799809 KCL 0.15%/D5W/ NACL 0.3%.000

00074710709 KCL 0.15%/D5W/NACL 0.9%.000

00074780609 KCL 0.224%/D5W/NACL 0.3%.000

00074799209 KCL 0.3%/D5W/NACL 0.2%.000

00777086902 KEFLEX250.00 MG

Page 54 of 125

Page 55: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00777086920 KEFLEX250.00 MG

00777087102 KEFLEX500.00 MG

00777087120 KEFLEX500.00 MG

00002727501 KEFUROX7.500 GM

00002727801 KEFUROX W/DILUENT750.00 MG

00002727825 KEFUROX W/DILUENT750.00 MG

00002727901 KEFUROX W/DILUENT1.500 GM

00002727910 KEFUROX W/DILUENT1.500 GM

00002727101 KEFUROX W/DILUENT750.00 MG

00002727125 KEFUROX W/DILUENT750.00 MG

00002727201 KEFUROX W/DILUENT1.500 GM

00002727210 KEFUROX W/DILUENT1.500 GM

00002727301 KEFUROX W/DILUENT750.00 MG

00002727310 KEFUROX W/DILUENT750.00 MG

00002149825 KEFZOL1.000 GM

00002701401 KEFZOL10.000 GM

00002726601 KEFZOL ADD-VANTAGE1.000 GM

00002726625 KEFZOL ADD-VANTAGE1.000 GM

00904316972 KELP.000

61570005901 KEMADRIN5.000 MG

00003017360 KENALOG.025 %

00003050270 KENALOG.100 %

00003050620 KENALOG.100 %

00003050646 KENALOG.100 %

00003050649 KENALOG.100 %

00003050820 KENALOG.100 %

00003050856 KENALOG.100 %

00003148320 KENALOG.500 %

00003049620 KENALOG IN ORABASE.100 %

00003029305 KENALOG-4040.000 MG/ML

00003029320 KENALOG-4040.000 MG/ML

00003029328 KENALOG-4040.000 MG/ML

19810053301 KERI ORIGINAL.000

19810005506 KERI ORIGINAL.000

19810005331 KERI ORIGINAL.000

19810005334 KERI ORIGINAL.000

19810005335 KERI ORIGINAL.000

19810005336 KERI ORIGINAL.000

19810000269 KERI ORIGINAL.000

19810000200 KERI SENSITIVE SKIN.000

19810005231 KERI SENSITIVE SKIN.000

19810005232 KERI SENSITIVE SKIN.000

19810005233 KERI SENSITIVE SKIN.000

19810005341 KERI SILKY SMOOTH.000

19810005342 KERI SILKY SMOOTH.000

19810005343 KERI SILKY SMOOTH.000

19810005345 KERI SILKY SMOOTH.000

19810000270 KERI SILKY SMOOTH.000

19810005771 KERICORT 101.000 %

00025520131 KERLONE20.000 MG

61570058110 KETALAR STERI-VIAL10.000 MG/ML

61570058210 KETALAR STERI-VIAL50.000 MG/ML

61570058510 KETALAR STERI-VIAL100.00 MG/ML

00074205105 KETAMINE HCL100.00 MG/ML

00074205310 KETAMINE HCL50.000 MG/ML

60793058110 KETAMINE HCL10.000 MG/ML

00093090001 KETOCONAZOLE200.00 MG

00093090005 KETOCONAZOLE200.00 MG

00093084015 KETOCONAZOLE2.000 %

00093084030 KETOCONAZOLE2.000 %

00093084092 KETOCONAZOLE2.000 %

00378026101 KETOCONAZOLE200.00 MG

00677170001 KETOCONAZOLE200.00 MG

00677170007 KETOCONAZOLE200.00 MG

50111062101 KETOCONAZOLE200.00 MG

50111062102 KETOCONAZOLE200.00 MG

53489055401 KETOCONAZOLE200.00 MG

53489055407 KETOCONAZOLE200.00 MG

55370055807 KETOCONAZOLE200.00 MG

51552030799 KETOPROFEN.000

00904771160 KETOPROFEN50.000 MG

00904771240 KETOPROFEN75.000 MG

00378575001 KETOPROFEN75.000 MG

00378407001 KETOPROFEN50.000 MG

00093319301 KETOPROFEN50.000 MG

00093319501 KETOPROFEN75.000 MG

00093319505 KETOPROFEN75.000 MG

62037052001 KETOPROFEN ER200.00 MG

00093031401 KETOROLAC TROMETHAMINE10.000 MG

00074379301 KETOROLAC TROMETHAMINE15.000 MG/ML

00074379501 KETOROLAC TROMETHAMINE30.000 MG/ML

00074379549 KETOROLAC TROMETHAMINE30.000 MG/ML

00074379601 KETOROLAC TROMETHAMINE30.000 MG/ML

00074203602 KETOROLAC TROMETHAMINE30.000 MG/ML

00074203902 KETOROLAC TROMETHAMINE30.000 MG/ML

00074202302 KETOROLAC TROMETHAMINE15.000 MG/ML

00074228731 KETOROLAC TROMETHAMINE30.000 MG/ML

00074228761 KETOROLAC TROMETHAMINE30.000 MG/ML

00074228831 KETOROLAC TROMETHAMINE15.000 MG/ML

00378113401 KETOROLAC TROMETHAMINE10.000 MG

50111060801 KETOROLAC TROMETHAMINE10.000 MG

58177030104 KETOROLAC TROMETHAMINE10.000 MG

60793003016 KG-DAL HD.000

60793003116 KG-DAL HD PLUS.000

60793002816 KG-FED EXPECTORANT.000

60793002916 KG-FED PEDIATRIC EXPECTOR.000

60793002516 KG-TUSS HD EXPECTORANT.000

60793003316 KG-TUSSIN.000

00536230375 KIDCARE DECONGESTANT7.500 MG/0.8ML

00536231097 KIDKARE COUGH/COLD.000

08881600651 KIN-RAY INSULIN SYRINGES/.000

00087060841 KINDERCAL.000

00087060842 KINDERCAL.000

00087062201 KINDERCAL.000

00087062202 KINDERCAL.000

00087062241 KINDERCAL.000

00087062242 KINDERCAL.000

00087060701 KINDERCAL TF.000

00087060741 KINDERCAL TF.000

00087069401 KINDERCAL TF/FIBER.000

00087069441 KINDERCAL TF/FIBER.000

00087061002 KINDERCAL/FIBER.000

00087061004 KINDERCAL/FIBER.000

00087061042 KINDERCAL/FIBER.000

00087061044 KINDERCAL/FIBER.000

00574200416 KIONEX.000

00004009801 KLONOPIN2.000 MG

00004005801 KLONOPIN1.000 MG

00004006801 KLONOPIN.500 MG

00245003501 KLOR-CON20.000 MEQ

00245003530 KLOR-CON20.000 MEQ

00245004101 KLOR-CON 1010.000 MEQ

00245004111 KLOR-CON 1010.000 MEQ

00245004115 KLOR-CON 1010.000 MEQ

00245004155 KLOR-CON 1010.000 MEQ

00245004001 KLOR-CON 88.000 MEQ

00245004011 KLOR-CON 88.000 MEQ

00245004015 KLOR-CON 88.000 MEQ

00245004055 KLOR-CON 88.000 MEQ

00245003901 KLOR-CON/EF25.000 MEQ

00245003930 KLOR-CON/EF25.000 MEQ

00087077041 KLOTRIX10.000 MEQ

Page 55 of 125

Page 56: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00087077042 KLOTRIX10.000 MEQ

00026062620 KONYNE 80500.00 IU

00904509151 KOREAN GINSENG500.00 MG

00496038202 KRONOFED-A.000

00496043402 KRONOFED-A-JR.000

00091412201 KU-ZYME.000

54391005009 L-CARNITINE250.00 MG

00074897518 L-CYSTEINE HCL50.000 MG/ML

00536673101 L-LYSINE ACETATE500.00 MG

00904268760 L-LYSINE HCL500.00 MG

00904424546 L-PHENYLALANINE500.00 MG

00603136558 L-TONIC.000

00536704906 L-TYROSINE500.00 MG

00185001001 LABETALOL HCL100.00 MG

00185001005 LABETALOL HCL100.00 MG

00185011701 LABETALOL HCL200.00 MG

00185011705 LABETALOL HCL200.00 MG

00185011801 LABETALOL HCL300.00 MG

00185011805 LABETALOL HCL300.00 MG

00172436460 LABETALOL HCL100.00 MG

00172436470 LABETALOL HCL100.00 MG

00172436560 LABETALOL HCL200.00 MG

00172436570 LABETALOL HCL200.00 MG

00172436660 LABETALOL HCL300.00 MG

00074233934 LABETALOL HCL5.000 MG/ML

00074226720 LABETALOL HCL5.000 MG/ML

00074226754 LABETALOL HCL5.000 MG/ML

00677170101 LABETALOL HCL100.00 MG

00677170105 LABETALOL HCL100.00 MG

00677170201 LABETALOL HCL200.00 MG

00677170205 LABETALOL HCL200.00 MG

00677170301 LABETALOL HCL300.00 MG

53489035401 LABETALOL HCL100.00 MG

53489035405 LABETALOL HCL100.00 MG

53489035501 LABETALOL HCL200.00 MG

53489035505 LABETALOL HCL200.00 MG

53489035601 LABETALOL HCL300.00 MG

53489035605 LABETALOL HCL300.00 MG

51079092820 LABETALOL HCL100.00 MG

51079092920 LABETALOL HCL200.00 MG

59930163604 LABETALOL HCL200.00 MG

59930165303 LABETALOL HCL300.00 MG

00536781106 LAC-DOSE3000.0 U

00072570801 LAC-HYDRIN12.000 %

00072571208 LAC-HYDRIN12.000 %

00072571214 LAC-HYDRIN12.000 %

00072571401 LAC-HYDRIN12.000 %

00072573028 LAC-HYDRIN12.000 %

00072573038 LAC-HYDRIN12.000 %

00072576004 LAC-HYDRIN FIVE5.000 %

00072576008 LAC-HYDRIN FIVE5.000 %

00904777460 LACTASE3300.0 U

00904522452 LACTASE ENZYME3000.0 U

00074795302 LACTATED RINGER'S.000

00074795303 LACTATED RINGER'S.000

00074795309 LACTATED RINGER'S.000

00074782808 LACTATED RINGER'S IRRIGAT.000

00087061948 LACTOFREE.000

00087061532 LACTOFREE R-T-U.000

50383079516 LACTULOSE10.000 GM/15ML

50383077908 LACTULOSE10.000 GM/15ML

50383077932 LACTULOSE10.000 GM/15ML

00054848616 LACTULOSE10.000 GM/15ML

00054348658 LACTULOSE10.000 GM/15ML

00054348663 LACTULOSE10.000 GM/15ML

00054348668 LACTULOSE10.000 GM/15ML

00603137856 LACTULOSE10.000 GM/15ML

00603137859 LACTULOSE10.000 GM/15ML

00182607240 LACTULOSE10.000 GM/15ML

00182607297 LACTULOSE10.000 GM/15ML

00182607558 LACTULOSE10.000 GM/15ML

60432003708 LACTULOSE10.000 GM/15ML

60432003732 LACTULOSE10.000 GM/15ML

00168005116 LANOLIN.000

00168005131 LANOLIN.000

45802009103 LANOLIN.000

45802009105 LANOLIN.000

00677073044 LANOLIN.000

45802009009 LANOLIN ANHYDROUS.000

45802009025 LANOLIN ANHYDROUS.000

00574004316 LANOLIN ANHYDROUS.000

00173027055 LANOXICAPS.050 MG

00173027255 LANOXICAPS.100 MG

00173027455 LANOXICAPS.200 MG

00173024255 LANOXIN.125 MG

00173024256 LANOXIN.125 MG

00173024275 LANOXIN.125 MG

00173024955 LANOXIN.250 MG

00173024956 LANOXIN.250 MG

00173024975 LANOXIN.250 MG

00173024980 LANOXIN.250 MG

00173026010 LANOXIN.250 MG/ML

00173026035 LANOXIN.250 MG/ML

00173026210 LANOXIN.100 MG/ML

00173026427 LANOXIN.050 MG/ML

00004017202 LARIAM250.00 MG

00004005601 LARODOPA500.00 MG

45802008403 LASSAR'S ZINC25.000 %

45802008405 LASSAR'S ZINC25.000 %

45802008495 LASSAR'S ZINC25.000 %

00071307123 LAVACOL70.000 %

00713042030 LAX-PILLS15.000 MG

00713042060 LAX-PILLS15.000 MG

00904423681 LECITHIN.000

00536588001 LECITHIN1200.0 MG

00904316360 LECITHIN1200.0 MG

00904316372 LECITHIN1200.0 MG

00078023405 LESCOL40.000 MG

00078023415 LESCOL40.000 MG

00078017605 LESCOL20.000 MG

00078017615 LESCOL20.000 MG

00078035405 LESCOL XL80.000 MG

00074454104 LEUCOVORIN CALCIUM10.000 MG/ML

00054849619 LEUCOVORIN CALCIUM5.000 MG

00054449613 LEUCOVORIN CALCIUM5.000 MG

00054449625 LEUCOVORIN CALCIUM5.000 MG

00054449805 LEUCOVORIN CALCIUM15.000 MG

00054449810 LEUCOVORIN CALCIUM15.000 MG

00054449911 LEUCOVORIN CALCIUM25.000 MG

00555048401 LEUCOVORIN CALCIUM5.000 MG

00555048402 LEUCOVORIN CALCIUM5.000 MG

00555048527 LEUCOVORIN CALCIUM25.000 MG

00641235441 LEUCOVORIN CALCIUM100.00 MG

51079058106 LEUCOVORIN CALCIUM5.000 MG

51079058205 LEUCOVORIN CALCIUM25.000 MG

00185740014 LEUPROLIDE ACETATE1.000 MG/0.2ML

00185740085 LEUPROLIDE ACETATE1.000 MG/0.2ML

00091450015 LEVATOL20.000 MG

00091353801 LEVBID.375 MG

00091353805 LEVBID.375 MG

50419041112 LEVLEN CONTRACT PACK.000

50419041128 LEVLEN-28.000

Page 56 of 125

Page 57: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

50419040803 LEVLITE-28.000

24208054505 LEVOBUNOLOL HCL.250 %

24208054510 LEVOBUNOLOL HCL.250 %

24208050505 LEVOBUNOLOL HCL.500 %

24208050510 LEVOBUNOLOL HCL.500 %

24208050515 LEVOBUNOLOL HCL.500 %

60505055301 LEVOBUNOLOL HCL.500 %

60505055302 LEVOBUNOLOL HCL.500 %

60505055303 LEVOBUNOLOL HCL.500 %

61314022905 LEVOBUNOLOL HCL.500 %

61314022910 LEVOBUNOLOL HCL.500 %

61314022915 LEVOBUNOLOL HCL.500 %

00074144304 LEVOPHED1.000 MG/ML

00905027928 LEVORA.000

52544027928 LEVORA 0.15/30-28.000

00456032151 LEVOTHROID50.000 MCG

00456032351 LEVOTHROID100.00 MCG

00456032551 LEVOTHROID150.00 MCG

00456032751 LEVOTHROID200.00 MCG

00677164810 LEVOTHYROXINE SODIUM25.000 MCG

00904223480 LEVOTHYROXINE SODIUM150.00 MCG

00904223580 LEVOTHYROXINE SODIUM300.00 MCG

00904223661 LEVOTHYROXINE SODIUM100.00 MCG

00904223680 LEVOTHYROXINE SODIUM100.00 MCG

00091353101 LEVSIN.125 MG

00091353105 LEVSIN.125 MG

00091453216 LEVSIN.125 MG/5ML

00091453815 LEVSIN.125 MG/ML

00091353201 LEVSIN/SL.125 MG

00091353205 LEVSIN/SL.125 MG

00091353701 LEVSINEX.375 MG

00091353705 LEVSINEX.375 MG

00186000131 LEXXEL.000

00186000168 LEXXEL.000

00186000231 LEXXEL.000

00182616799 LICE TREATMENT KIT MAXIMU.000

00182616737 LICE TREATMENT SHAMPOO MA.000

00182616743 LICE TREATMENT SHAMPOO MA.000

00904252820 LICE-AID.000

00603078554 LICE-X.000

99207050713 LIDEX.050 %

99207050714 LIDEX.050 %

99207050717 LIDEX.050 %

99207051113 LIDEX.050 %

99207051114 LIDEX.050 %

99207051117 LIDEX.050 %

99207051413 LIDEX.050 %

99207051414 LIDEX.050 %

99207051417 LIDEX.050 %

99207051746 LIDEX.050 %

99207051313 LIDEX-E.050 %

99207051314 LIDEX-E.050 %

99207051317 LIDEX-E.050 %

00548630000 LIDOCAINE HCL4.000 %

00548119000 LIDOCAINE HCL20.000 MG/ML

00548119200 LIDOCAINE HCL10.000 MG/ML

00548107800 LIDOCAINE HCL1.000 %

00548107900 LIDOCAINE HCL1.000 %

00548108000 LIDOCAINE HCL1.000 %

00548108100 LIDOCAINE HCL1.000 %

00548219000 LIDOCAINE HCL20.000 MG/ML

00548301100 LIDOCAINE HCL2.000 %

00548301200 LIDOCAINE HCL2.000 %

00548301300 LIDOCAINE HCL2.000 %

00548301500 LIDOCAINE HCL2.000 %

00168020437 LIDOCAINE HCL5.000 %

00093920031 LIDOCAINE HCL2.000 %

00074471302 LIDOCAINE HCL1.000 %

00074471332 LIDOCAINE HCL1.000 %

00074427501 LIDOCAINE HCL.500 %

00074427601 LIDOCAINE HCL1.000 %

00074427602 LIDOCAINE HCL1.000 %

00074427701 LIDOCAINE HCL2.000 %

00074427702 LIDOCAINE HCL2.000 %

00074427801 LIDOCAINE HCL.500 %

00074427902 LIDOCAINE HCL1.000 %

00074428201 LIDOCAINE HCL2.000 %

00074428202 LIDOCAINE HCL2.000 %

00074428301 LIDOCAINE HCL4.000 %

00074427001 LIDOCAINE HCL1.000 %

00074405601 LIDOCAINE HCL1.500 %

00074492315 LIDOCAINE HCL20.000 MG/ML

00074492415 LIDOCAINE HCL10.000 MG/ML

00074490315 LIDOCAINE HCL20.000 MG/ML

00074490334 LIDOCAINE HCL20.000 MG/ML

00074490415 LIDOCAINE HCL10.000 MG/ML

00074490434 LIDOCAINE HCL10.000 MG/ML

00074477601 LIDOCAINE HCL1.500 %

00074913705 LIDOCAINE HCL1.000 %

00074802601 LIDOCAINE HCL10.000 MG/ML

00074802701 LIDOCAINE HCL20.000 MG/ML

00074132305 LIDOCAINE HCL20.000 MG/ML

00074206305 LIDOCAINE HCL1.000 %

00074206605 LIDOCAINE HCL2.000 %

00054350547 LIDOCAINE HCL4.000 %

60432046550 LIDOCAINE HCL4.000 %

00074793932 LIDOCAINE HCL IN D5W.000

00074793124 LIDOCAINE HCL IN D5W.000

00074793132 LIDOCAINE HCL IN D5W.000

00074624801 LIDOCAINE HCL PTV200.00 MG/ML

00074621702 LIDOCAINE HCL PTV200.00 MG/ML

00054350049 LIDOCAINE VISCOUS2.000 %

00054850016 LIDOCAINE VISCOUS2.000 %

00472099633 LIDOCAINE VISCOUS2.000 %

50383077504 LIDOCAINE VISCOUS2.000 %

60432046400 LIDOCAINE VISCOUS2.000 %

00641241541 LIDOCAINE/EPINEPHRINE.000

00074120901 LIDOCAINE/EPINEPHRINE.000

00074317701 LIDOCAINE/EPINEPHRINE.000

00074317801 LIDOCAINE/EPINEPHRINE.000

00074317802 LIDOCAINE/EPINEPHRINE.000

00074317803 LIDOCAINE/EPINEPHRINE.000

00074317901 LIDOCAINE/EPINEPHRINE.000

00074318002 LIDOCAINE/EPINEPHRINE.000

00074318101 LIDOCAINE/EPINEPHRINE.000

00074318201 LIDOCAINE/EPINEPHRINE.000

00074318202 LIDOCAINE/EPINEPHRINE.000

00074318203 LIDOCAINE/EPINEPHRINE.000

00074318301 LIDOCAINE/EPINEPHRINE.000

00009055501 LINCOCIN300.00 MG/ML

00009055502 LINCOCIN300.00 MG/ML

00472057202 LINDANE1.000 %

60432054616 LINDANE1.000 %

60432054660 LINDANE1.000 %

60432054760 LINDANE1.000 %

00072640008 LINDORA.000

51552035401 LIOTHYRONINE SODIUM.000

00087047102 LIPISORB.000

00087047142 LIPISORB.000

00071015523 LIPITOR10.000 MG

00071015534 LIPITOR10.000 MG

00071015540 LIPITOR10.000 MG

Page 57 of 125

Page 58: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00071015623 LIPITOR20.000 MG

00071015640 LIPITOR20.000 MG

00071015723 LIPITOR40.000 MG

00071015823 LIPITOR80.000 MG

00536390808 LIPOGEN SG.000

00074979401 LIPOSYN II.000

00074978601 LIPOSYN II.000

00074978603 LIPOSYN II.000

00074978621 LIPOSYN II.000

00074978901 LIPOSYN II.000

00074978903 LIPOSYN II.000

00074979203 LIPOSYN II KIT ADMINISTRA.000

00074979301 LIPOSYN II KIT ADMINISTRA.000

00074979001 LIPOSYN III.000

00074979003 LIPOSYN III.000

00074979021 LIPOSYN III.000

00074979101 LIPOSYN III.000

00074979103 LIPOSYN III.000

00074689203 LIPOSYN III.000

00115703501 LIPRAM 4500.000

00115703505 LIPRAM 4500.000

00115703601 LIPRAM CR 10000.000

00115703605 LIPRAM CR 10000.000

00115702401 LIPRAM-CR20.000

00115702405 LIPRAM-CR20.000

00115704001 LIPRAM-PN10.000

00115702301 LIPRAM-PN16.000

00115705501 LIPRAM-PN20.000

00115704201 LIPRAM-UL12.000

00115704101 LIPRAM-UL18.000

00115704301 LIPRAM-UL20.000

00115704302 LIPRAM-UL20.000

00574192116 LIQUA-GEL.000

00496052002 LIQUI-DOSS90.000 %

00904501735 LIQUITEARS1.400 %

00054852625 LITHIUM CARBONATE150.00 MG

00054852725 LITHIUM CARBONATE300.00 MG

00054852825 LITHIUM CARBONATE300.00 MG

00054452725 LITHIUM CARBONATE300.00 MG

00054452731 LITHIUM CARBONATE300.00 MG

00054252625 LITHIUM CARBONATE150.00 MG

00054252725 LITHIUM CARBONATE300.00 MG

00054252731 LITHIUM CARBONATE300.00 MG

00182178101 LITHIUM CARBONATE300.00 MG

00182178110 LITHIUM CARBONATE300.00 MG

00054352763 LITHIUM CITRATE8.000 MEQ/5ML

00054852904 LITHIUM CITRATE8.000 MEQ/5ML

00054853004 LITHIUM CITRATE8.000 MEQ/5ML

60432061616 LITHIUM CITRATE8.000 MEQ/5ML

00032449201 LITHOBID300.00 MG

08290001118 LLX EXTENSION NEEDLE.000

00074741803 LMD 10% DEXTROSE 5%.000

00074741903 LMD 10% SODIUM CHLORIDE 0.000

00008251402 LO/OVRAL 28.000

00008251403 LO/OVRAL 28.000

00046073881 LODINE200.00 MG

00046073981 LODINE300.00 MG

00046082981 LODINE XL400.00 MG

00046083181 LODINE XL600.00 MG

00046083981 LODINE XL500.00 MG

00071091648 LOESTRIN 1.5/30-21.000

00071091548 LOESTRIN 1/20-21.000

00071091745 LOESTRIN FE.000

00071091748 LOESTRIN FE.000

00071091345 LOESTRIN FE 1/20.000

00071091348 LOESTRIN FE 1/20.000

00527117001 LOFENE.000

00527117010 LOFENE.000

00025006131 LOMOTIL.000

00025006134 LOMOTIL.000

00025006151 LOMOTIL.000

00025006152 LOMOTIL.000

00025006155 LOMOTIL.000

00025006602 LOMOTIL.000

00904766624 LONG ACTING NASAL DECONGE.000

00009012101 LONITEN2.500 MG

00009013701 LONITEN10.000 MG

00781126201 LONOX.000

00781126210 LONOX.000

00781126213 LONOX.000

00904003620 LOPERAMIDE HCL1.000 MG/5ML

00677142201 LOPERAMIDE HCL2.000 MG

50383061804 LOPERAMIDE HCL1.000 MG/5ML

51079069019 LOPERAMIDE HCL2.000 MG

51079069020 LOPERAMIDE HCL2.000 MG

00054353550 LOPERAMIDE HCL1.000 MG/5ML

00054853416 LOPERAMIDE HCL1.000 MG/5ML

00054853516 LOPERAMIDE HCL1.000 MG/5ML

00093031101 LOPERAMIDE HCL2.000 MG

00093031105 LOPERAMIDE HCL2.000 MG

00378210001 LOPERAMIDE HCL2.000 MG

00378210005 LOPERAMIDE HCL2.000 MG

00603020811 LOPERAMIDE HCL2.000 MG

00536396612 LOPERAMIDE HCL2.000 MG

00071073720 LOPID600.00 MG

00071073730 LOPID600.00 MG

00028005101 LOPRESSOR50.000 MG

00028005110 LOPRESSOR50.000 MG

00028007101 LOPRESSOR100.00 MG

00028007110 LOPRESSOR100.00 MG

00028005301 LOPRESSOR HCT.000

00028003501 LOPRESSOR HCT.000

00028007301 LOPRESSOR HCT.000

00904150061 LORAZEPAM.500 MG

00904150161 LORAZEPAM1.000 MG

00904150261 LORAZEPAM2.000 MG

00074198501 LORAZEPAM2.000 MG/ML

00074198510 LORAZEPAM2.000 MG/ML

00074153901 LORAZEPAM4.000 MG/ML

00074153910 LORAZEPAM4.000 MG/ML

00074153921 LORAZEPAM4.000 MG/ML

00074153931 LORAZEPAM4.000 MG/ML

00074677601 LORAZEPAM2.000 MG/ML

00074677701 LORAZEPAM4.000 MG/ML

00378077701 LORAZEPAM2.000 MG

00378077705 LORAZEPAM2.000 MG

00378045701 LORAZEPAM1.000 MG

00378045705 LORAZEPAM1.000 MG

00378045710 LORAZEPAM1.000 MG

00378032101 LORAZEPAM.500 MG

00378032105 LORAZEPAM.500 MG

00182180689 LORAZEPAM.500 MG

00182180889 LORAZEPAM2.000 MG

00228205710 LORAZEPAM.500 MG

00228205750 LORAZEPAM.500 MG

00228205910 LORAZEPAM1.000 MG

00228205950 LORAZEPAM1.000 MG

00228206310 LORAZEPAM2.000 MG

00228206350 LORAZEPAM2.000 MG

51079041719 LORAZEPAM.500 MG

51079041720 LORAZEPAM.500 MG

51079041721 LORAZEPAM.500 MG

Page 58 of 125

Page 59: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

51079041724 LORAZEPAM.500 MG

51079038619 LORAZEPAM1.000 MG

51079038620 LORAZEPAM1.000 MG

51079038621 LORAZEPAM1.000 MG

51079038623 LORAZEPAM1.000 MG

51079038624 LORAZEPAM1.000 MG

51079038720 LORAZEPAM2.000 MG

51079038721 LORAZEPAM2.000 MG

53489035701 LORAZEPAM.500 MG

53489035705 LORAZEPAM.500 MG

53489035801 LORAZEPAM1.000 MG

53489035805 LORAZEPAM1.000 MG

53489035810 LORAZEPAM1.000 MG

53489035901 LORAZEPAM2.000 MG

53489035905 LORAZEPAM2.000 MG

00677105601 LORAZEPAM.500 MG

00677105605 LORAZEPAM.500 MG

00677105701 LORAZEPAM1.000 MG

00677105705 LORAZEPAM1.000 MG

00677105710 LORAZEPAM1.000 MG

00677105801 LORAZEPAM2.000 MG

00677105805 LORAZEPAM2.000 MG

00781140301 LORAZEPAM.500 MG

00781140305 LORAZEPAM.500 MG

00781140401 LORAZEPAM1.000 MG

00781140405 LORAZEPAM1.000 MG

00781140501 LORAZEPAM2.000 MG

00781140505 LORAZEPAM2.000 MG

00904150040 LORAZEPAM.500 MG

00904150060 LORAZEPAM.500 MG

00904150140 LORAZEPAM1.000 MG

00904150160 LORAZEPAM1.000 MG

00904150240 LORAZEPAM2.000 MG

00904150260 LORAZEPAM2.000 MG

51079041723 LORAZEPAM.500 MG

60429051230 LORAZEPAM1.000 MG

60429051290 LORAZEPAM1.000 MG

00785635001 LORCET 10/650.000

00785635050 LORCET 10/650.000

00785635063 LORCET 10/650.000

00785112201 LORCET PLUS.000

00785112250 LORCET PLUS.000

00785112263 LORCET PLUS.000

00785112001 LORCET-HD.000

50474090916 LORTAB.000

50474091001 LORTAB 10.000

50474091050 LORTAB 10.000

50474091060 LORTAB 10.000

50474092501 LORTAB 2.5.000

50474090201 LORTAB 5.000

50474090250 LORTAB 5.000

50474090260 LORTAB 5.000

50474090701 LORTAB 7.5.000

50474090750 LORTAB 7.5.000

50474090760 LORTAB 7.5.000

00083005930 LOTENSIN5.000 MG

00083005932 LOTENSIN5.000 MG

00083005990 LOTENSIN5.000 MG

00083006330 LOTENSIN10.000 MG

00083006332 LOTENSIN10.000 MG

00083006390 LOTENSIN10.000 MG

00083007930 LOTENSIN20.000 MG

00083007932 LOTENSIN20.000 MG

00083007990 LOTENSIN20.000 MG

00083009430 LOTENSIN40.000 MG

00083009432 LOTENSIN40.000 MG

00083009490 LOTENSIN40.000 MG

00083007230 LOTENSIN HCT.000

00083007430 LOTENSIN HCT.000

00083007530 LOTENSIN HCT.000

00083005730 LOTENSIN HCT.000

00083225530 LOTREL.000

00083226030 LOTREL.000

00083226530 LOTREL.000

00085065606 LOTRIMIN AF1.000 %

00085096315 LOTRIMIN AF1.000 %

00085096317 LOTRIMIN AF1.000 %

00085092401 LOTRISONE.000

00085092402 LOTRISONE.000

00075062040 LOVENOX40.000 MG/0.4ML

00075062160 LOVENOX60.000 MG/0.6ML

00075062280 LOVENOX80.000 MG/0.8ML

00075062300 LOVENOX100.00 MG/ML

00075062430 LOVENOX30.000 MG/0.3ML

00536128083 LOW SODIUM ANTACID540.00 MG/5ML

52544084728 LOW-OGESTREL.000

00072230001 LOWILA.000

00536128583 LOWSIUM PLUS IMPROVED.000

52544036910 LOXAPINE SUCCINATE5.000 MG

52544049401 LOXITANE5.000 MG

52544049501 LOXITANE10.000 MG

52544049601 LOXITANE25.000 MG

52544049701 LOXITANE50.000 MG

00075070000 LOZOL1.250 MG

00075070099 LOZOL1.250 MG

00713026404 LUBRICATING JELLY.000

00713026458 LUBRICATING JELLY.000

45802007144 LUBRICATING JELLY.000

00603057954 LUBRICATING JELLY.000

00904516838 LUBRIFRESH P.M..000

00482011812 LUBRIN.000

00482011819 LUBRIN.000

00037073192 LUFYLLIN400.00 MG

00037073199 LUFYLLIN400.00 MG

00037051568 LUFYLLIN100.00 MG/15ML

00037052192 LUFYLLIN200.00 MG

00037052197 LUFYLLIN200.00 MG

00037052198 LUFYLLIN200.00 MG

00037054192 LUFYLLIN-GG.000

00037054196 LUFYLLIN-GG.000

00037054197 LUFYLLIN-GG.000

00037054568 LUFYLLIN-GG.000

00074154001 LUMINAL130.00 MG/ML

00074234331 LUMINAL60.000 MG/ML

00074234931 LUMINAL130.00 MG/ML

00032421010 LUVOX100.00 MG

00003164845 LYOFOAM A POLYURETHANE FO.000

00003164855 LYOFOAM A POLYURETHANE FO.000

00003164755 LYOFOAM C POLYURETHANE FO.000

00003164763 LYOFOAM C POLYURETHANE FO.000

00003165655 LYOFOAM EXTRA POLYURETHAN.000

00003165658 LYOFOAM EXTRA POLYURETHAN.000

00003165663 LYOFOAM EXTRA POLYURETHAN.000

00003165670 LYOFOAM EXTRA POLYURETHAN.000

00003164650 LYOFOAM POLYURETHANE FOAM.000

00003164655 LYOFOAM POLYURETHANE FOAM.000

00003164658 LYOFOAM POLYURETHANE FOAM.000

00003164660 LYOFOAM POLYURETHANE FOAM.000

00003164663 LYOFOAM POLYURETHANE FOAM.000

00003164670 LYOFOAM POLYURETHANE FOAM.000

00003164685 LYOFOAM POLYURETHANE FOAM.000

00003164875 LYOFOAM T POLYURETHANE FO.000

Page 59 of 125

Page 60: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00149000705 MACRODANTIN25.000 MG

00149000805 MACRODANTIN50.000 MG

00149000867 MACRODANTIN50.000 MG

00149000905 MACRODANTIN100.00 MG

00149000967 MACRODANTIN100.00 MG

00904791152 MAG-DELAY535.00 MG

60258017201 MAG-G500.00 MG

00904531118 MAG-OXIDE400.00 MG

60258017306 MAG-SR535.00 MG

00087004002 MAGNACAL RENAL.000

00087004042 MAGNACAL RENAL.000

59528102805 MAGNEBIND 200.000

59528050805 MAGNEBIND 300.000

00182438501 MAGNESIUM30.000 MG

00536668001 MAGNESIUM GLUCONATE500.00 MG

60258017101 MAGNESIUM OXIDE400.00 MG

00548103400 MAGNESIUM SULFATE50.000 %

00074407532 MAGNESIUM SULFATE50.000 %

00074491418 MAGNESIUM SULFATE50.000 %

00074216801 MAGNESIUM SULFATE50.000 %

00074216802 MAGNESIUM SULFATE50.000 %

00074216803 MAGNESIUM SULFATE50.000 %

00074175410 MAGNESIUM SULFATE50.000 %

00074491315 MAGNESIUM SULFATE ABBOJEC50.000 %

00256017201 MAGONATE500.00 MG

00256017202 MAGONATE500.00 MG

00904430816 MAJOR PEP91.000 %

00904166238 MAJOR TEARS.000

00904165335 MAJOR TEARS1.400 %

00904039280 MAJOR-GESIC.000

00904759837 MAJOR-PREP.000

00904012737 MAJOR-PREP HEMORRHOIDAL.000

00904202139 MAJOR-STAN.000

00904202196 MAJOR-STAN.000

00904154060 MAJORCON80.000 MG

00904154096 MAJORCON80.000 MG

00904258530 MAJORCON40.000 MG/0.6ML

00904783960 MAJORCON80.000 MG

00430016624 MANDELAMINE.500 GM

00430016724 MANDELAMINE1.000 GM

00074409101 MANGANESE TRACE METAL.100 MG/ML

00074403101 MANNITOL25.000 %

00074771209 MANNITOL5.000 %

00074771309 MANNITOL10.000 %

00074771403 MANNITOL15.000 %

00074771502 MANNITOL20.000 %

00074771503 MANNITOL20.000 %

00904769212 MAPAP120.00 MG

00904776812 MAPAP650.00 MG

00904525846 MAPAP80.000 MG

00904525646 MAPAP80.000 MG

00904197446 MAPAP80.000 MG

00904198146 MAPAP80.000 MG

00904198196 MAPAP80.000 MG

00904198259 MAPAP325.00 MG

00904198260 MAPAP325.00 MG

00904198261 MAPAP325.00 MG

00904198280 MAPAP325.00 MG

00904198324 MAPAP500.00 MG

00904198340 MAPAP500.00 MG

00904198351 MAPAP500.00 MG

00904198359 MAPAP500.00 MG

00904198380 MAPAP500.00 MG

00904198394 MAPAP500.00 MG

00904198500 MAPAP160.00 MG/5ML

00904198516 MAPAP160.00 MG/5ML

00904198520 MAPAP160.00 MG/5ML

00904198759 MAPAP500.00 MG

00904198760 MAPAP500.00 MG

00904198780 MAPAP500.00 MG

00904198852 MAPAP500.00 MG

00904198859 MAPAP500.00 MG

00904198860 MAPAP500.00 MG

00904198861 MAPAP500.00 MG

00904198880 MAPAP500.00 MG

00904198951 MAPAP500.00 MG

00904198959 MAPAP500.00 MG

00904518820 MAPAP CHILDRENS160.00 MG/5ML

00904511620 MAPAP CHILDRENS160.00 MG/5ML

00904525724 MAPAP COLD.000

00904765524 MAPAP COLD FORMULA.000

00904785251 MAPAP HEADACHE PLUS.000

00904534130 MAPAP INFANT100.00 MG/ML

00904758924 MAPAP JR STR160.00 MG

00904765151 MAPAP PM.000

00904795424 MAPAP SINUS MAXIMUM STREN.000

00904332361 MAPROTILINE HCL25.000 MG

00378006001 MAPROTILINE HCL25.000 MG

00378009201 MAPROTILINE HCL75.000 MG

00378008701 MAPROTILINE HCL50.000 MG

00256017101 MARBLEN.000

00074161050 MARCAINE.500 %

00074155910 MARCAINE.250 %

00074155930 MARCAINE.250 %

00074155950 MARCAINE.250 %

00074156010 MARCAINE.500 %

00074156029 MARCAINE.500 %

00074156030 MARCAINE.500 %

00074158750 MARCAINE.250 %

00074176102 MARCAINE SPINAL.000

00074158210 MARCAINE W/O EPI.750 %

00074158229 MARCAINE W/O EPI.750 %

00074158230 MARCAINE W/O EPI.750 %

00074174610 MARCAINE/EPINEPHRINE.000

00074174630 MARCAINE/EPINEPHRINE.000

00074174650 MARCAINE/EPINEPHRINE.000

00074174903 MARCAINE/EPINEPHRINE.000

00074174910 MARCAINE/EPINEPHRINE.000

00074174929 MARCAINE/EPINEPHRINE.000

00074174930 MARCAINE/EPINEPHRINE.000

00074175030 MARCAINE/EPINEPHRINE.000

00074175250 MARCAINE/EPINEPHRINE.000

00074175550 MARCAINE/EPINEPHRINE.000

53100051000 MASSENGILL.000

53100052500 MASSENGILL.000

53100052550 MASSENGILL.000

53100052570 MASSENGILL.000

53100052650 MASSENGILL.000

53100051500 MASSENGILL.000

53100051550 MASSENGILL.000

53100051590 MASSENGILL.000

53100051601 MASSENGILL.000

53100051612 MASSENGILL.000

53100051672 MASSENGILL.000

53100051700 MASSENGILL.000

53100052000 MASSENGILL.000

53100052003 MASSENGILL.000

53100052025 MASSENGILL.000

53100052050 MASSENGILL.000

53100052062 MASSENGILL.000

53100051350 MASSENGILL CONCENTRATE.000

53100000110 MASSENGILL FEMININE WASH.000

Page 60 of 125

Page 61: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

53100053000 MASSENGILL MEDICATED.300 %

53100053050 MASSENGILL MEDICATED.300 %

53100052065 MASSENGILL VINEGAR/WATER.000

00496052305 MASTISOL STERTIP.000

00496052315 MASTISOL STERTIP.000

00496052316 MASTISOL STERTIP.000

00496052348 MASTISOL STERTIP.000

00005558611 MATERNA.000

00904512660 MATERNAL VITAMIN/MINERAL.000

10267199101 MATERNITY.000

00254509828 MATERNITY-90.000

00089081521 MAXAIR AUTOHALER200.00 MCG/INH

00998061505 MAXIDEX.100 %

00998061515 MAXIDEX.100 %

00998063006 MAXITROL.000

00065063136 MAXITROL.000

00072941045 MAXIVATE.050 %

00072945045 MAXIVATE.050 %

00072949060 MAXIVATE.050 %

62794046001 MAXZIDE.000

62794046005 MAXZIDE.000

62794046401 MAXZIDE-25.000

62794046405 MAXZIDE-25.000

62794046488 MAXZIDE-25.000

00093910729 MEBENDAZOLE100.00 MG

00182057101 MECLIZINE HCL25.000 MG

00536398501 MECLIZINE HCL12.500 MG

00536399001 MECLIZINE HCL25.000 MG

00781154201 MECLIZINE HCL12.500 MG

00781154210 MECLIZINE HCL12.500 MG

00781154401 MECLIZINE HCL25.000 MG

00781154410 MECLIZINE HCL25.000 MG

00781137501 MECLIZINE HCL25.000 MG

00781134501 MECLIZINE HCL12.500 MG

49884003401 MECLIZINE HCL12.500 MG

49884003410 MECLIZINE HCL12.500 MG

49884003501 MECLIZINE HCL25.000 MG

49884003510 MECLIZINE HCL25.000 MG

51079008920 MECLIZINE HCL12.500 MG

51079009019 MECLIZINE HCL25.000 MG

51079009020 MECLIZINE HCL25.000 MG

60429060812 MECLIZINE HCL25.000 MG

60429060890 MECLIZINE HCL25.000 MG

00904141360 MECLOFENAMATE SODIUM50.000 MG

00904141440 MECLOFENAMATE SODIUM100.00 MG

00904141460 MECLOFENAMATE SODIUM100.00 MG

00378215001 MECLOFENAMATE SODIUM50.000 MG

00378300001 MECLOFENAMATE SODIUM100.00 MG

00378300005 MECLOFENAMATE SODIUM100.00 MG

08881600343 MED-FAST MONOJECT INSULIN.000

08881601382 MED-FAST MONOJECT INSULIN.000

00904505960 MEDI PADS.000

08881608202 MEDIC INSULIN SYRINGE 1/2.000

08881608203 MEDIC INSULIN SYRINGE 1/2.000

08881608211 MEDIC INSULIN SYRINGE 1/2.000

08881608302 MEDIC INSULIN SYRINGE 3/.000

08881608303 MEDIC INSULIN SYRINGE 3/.000

08881608311 MEDIC INSULIN SYRINGE 3/.000

00182508801 MEDICATED.000

00904509877 MEDICATED BODY POWDER.000

45802017772 MEDICATED CHEST RUB.000

45802017788 MEDICATED CHEST RUB.000

45802011426 MEDICATED SKIN CREAM.000

45802059991 MEDICATED SKIN CREAM.000

00009007301 MEDROL16.000 MG

00009005602 MEDROL4.000 MG

00009004902 MEDROL2.000 MG

00009002201 MEDROL8.000 MG

00009017601 MEDROL32.000 MG

00009005603 MEDROL4.000 MG

00009005605 MEDROL4.000 MG

00009005604 MEDROL DOSEPAK4.000 MG

00904522760 MEDROXYPROGESTERONE ACETA2.500 MG

00904522860 MEDROXYPROGESTERONE ACETA5.000 MG

00904269060 MEDROXYPROGESTERONE ACETA10.000 MG

00677161801 MEDROXYPROGESTERONE ACETA5.000 MG

51285054004 MEDROXYPROGESTERONE ACETA2.500 MG

51285054102 MEDROXYPROGESTERONE ACETA5.000 MG

51285054104 MEDROXYPROGESTERONE ACETA5.000 MG

51285054202 MEDROXYPROGESTERONE ACETA10.000 MG

51285054204 MEDROXYPROGESTERONE ACETA10.000 MG

00555077902 MEDROXYPROGESTERONE ACETA10.000 MG

00555077904 MEDROXYPROGESTERONE ACETA10.000 MG

00555087202 MEDROXYPROGESTERONE ACETA2.500 MG

00555087204 MEDROXYPROGESTERONE ACETA2.500 MG

00555087302 MEDROXYPROGESTERONE ACETA5.000 MG

00555087304 MEDROXYPROGESTERONE ACETA5.000 MG

59762374001 MEDROXYPROGESTERONE ACETA2.500 MG

59762374004 MEDROXYPROGESTERONE ACETA2.500 MG

59762374005 MEDROXYPROGESTERONE ACETA2.500 MG

59762374101 MEDROXYPROGESTERONE ACETA5.000 MG

59762374104 MEDROXYPROGESTERONE ACETA5.000 MG

59762374202 MEDROXYPROGESTERONE ACETA10.000 MG

59762374208 MEDROXYPROGESTERONE ACETA10.000 MG

00006336871 MEFOXIN1.000 GM

00006336973 MEFOXIN2.000 GM

00006335645 MEFOXIN1.000 GM

00006335753 MEFOXIN2.000 GM

00006338867 MEFOXIN10.000 GM

00006354845 MEFOXIN ADD-VANTAGE1.000 GM

00006354953 MEFOXIN ADD-VANTAGE2.000 GM

00015050842 MEGACE ORAL40.000 MG/ML

00054860325 MEGESTROL ACETATE20.000 MG

00054860425 MEGESTROL ACETATE40.000 MG

00054460325 MEGESTROL ACETATE20.000 MG

00054460425 MEGESTROL ACETATE40.000 MG

00555060602 MEGESTROL ACETATE20.000 MG

00555060702 MEGESTROL ACETATE40.000 MG

00555060703 MEGESTROL ACETATE40.000 MG

00555060704 MEGESTROL ACETATE40.000 MG

00182186489 MEGESTROL ACETATE40.000 MG

49884028901 MEGESTROL ACETATE20.000 MG

49884029001 MEGESTROL ACETATE40.000 MG

49884029004 MEGESTROL ACETATE40.000 MG

49884029005 MEGESTROL ACETATE40.000 MG

51079043420 MEGESTROL ACETATE20.000 MG

51079043519 MEGESTROL ACETATE40.000 MG

51079043520 MEGESTROL ACETATE40.000 MG

00677120601 MEGESTROL ACETATE40.000 MG

00904357161 MEGESTROL ACETATE40.000 MG

00904518252 MELATONIN3.000 MG

51991001406 MELATONIN3.000 MG

00536641208 MELATONIN3.000 MG

00078000505 MELLARIL100.00 MG

00078000705 MELLARIL200.00 MG

00078000805 MELLARIL15.000 MG

00078000131 MELLARIL CONCENTRATE30.000 MG/ML

61570007201 MENEST.300 MG

61570007301 MENEST.625 MG

61570007401 MENEST1.250 MG

61570007550 MENEST2.500 MG

00641113035 MEPERIDINE HCL50.000 MG/ML

Page 61 of 125

Page 62: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00641115035 MEPERIDINE HCL100.00 MG/ML

00054354563 MEPERIDINE HCL50.000 MG/5ML

00054459525 MEPERIDINE HCL50.000 MG

00054459625 MEPERIDINE HCL100.00 MG

00054859511 MEPERIDINE HCL50.000 MG

00054859611 MEPERIDINE HCL100.00 MG

00054854516 MEPERIDINE HCL50.000 MG/5ML

00074603004 MEPERIDINE HCL10.000 MG/ML

00555038102 MEPERIDINE HCL50.000 MG

00555038202 MEPERIDINE HCL100.00 MG

00641114035 MEPERIDINE HCL75.000 MG/ML

00008025901 MEPERIDINE HCL TUBEX100.00 MG/ML

58177002704 MEPERIDINE/PROMETHAZINE.000

00603441521 MEPERITAB50.000 MG

00603441621 MEPERITAB100.00 MG

00603442421 MEPROZINE.000

00015356302 MESNEX100.00 MG/ML

00015356303 MESNEX100.00 MG/ML

53014059307 METADATE ER10.000 MG

53014059407 METADATE ER20.000 MG

54838050780 METAPROTERENOL SULFATE10.000 MG/5ML

49884025801 METAPROTERENOL SULFATE10.000 MG

49884025901 METAPROTERENOL SULFATE20.000 MG

00904287861 METAPROTERENOL SULFATE10.000 MG

00603142258 METAPROTERENOL SULFATE10.000 MG/5ML

60505080701 METAPROTERENOL SULFATE.400 %

60505080801 METAPROTERENOL SULFATE.600 %

60505580209 METAPROTERENOL SULFATE10.000 MG/5ML

60432067601 METAPROTERENOL SULFATE5.000 %

60432067630 METAPROTERENOL SULFATE5.000 %

00904300305 METHADEX.000

51079089840 METHADONE HCL40.000 MG

51079069439 METHADONE HCL10.000 MG/ML

00378326001 METHADONE HCL5.000 MG

00378327201 METHADONE HCL10.000 MG

00054855324 METHADONE HCL5.000 MG

00054855424 METHADONE HCL10.000 MG

00054457025 METHADONE HCL5.000 MG

00054457125 METHADONE HCL10.000 MG

00054454725 METHADONE HCL40.000 MG

00054355344 METHADONE HCL INTENSOL10.000 MG/ML

00093941101 METHAZOLAMIDE25.000 MG

00093942401 METHAZOLAMIDE50.000 MG

00603447021 METHAZOLAMIDE25.000 MG

00603447121 METHAZOLAMIDE50.000 MG

00781107101 METHAZOLAMIDE50.000 MG

00781107201 METHAZOLAMIDE25.000 MG

00677168101 METHENAMINE MANDELATE.500 GM

00677168201 METHENAMINE MANDELATE1.000 GM

53265015910 METHENAMINE MANDELATE.500 GM

53265016010 METHENAMINE MANDELATE1.000 GM

00144050501 METHENAMINE MANDELATE.500 GM

00185020501 METHIMAZOLE5.000 MG

00185020510 METHIMAZOLE5.000 MG

00185021001 METHIMAZOLE10.000 MG

00185021010 METHIMAZOLE10.000 MG

49884064001 METHIMAZOLE5.000 MG

49884064074 METHIMAZOLE5.000 MG

49884064101 METHIMAZOLE10.000 MG

49884064174 METHIMAZOLE10.000 MG

00115703701 METHITEST10.000 MG

00143129001 METHOCARBAMOL500.00 MG

00143129005 METHOCARBAMOL500.00 MG

00143129201 METHOCARBAMOL750.00 MG

00143129205 METHOCARBAMOL750.00 MG

00364672654 METHOCARBAMOL100.00 MG/ML

00182057389 METHOCARBAMOL750.00 MG

51079009120 METHOCARBAMOL500.00 MG

51079009219 METHOCARBAMOL750.00 MG

51079009220 METHOCARBAMOL750.00 MG

00677043001 METHOCARBAMOL500.00 MG

00677043101 METHOCARBAMOL750.00 MG

00677043105 METHOCARBAMOL750.00 MG

00781175001 METHOCARBAMOL750.00 MG

00781176001 METHOCARBAMOL500.00 MG

00904236540 METHOCARBAMOL750.00 MG

00904236560 METHOCARBAMOL750.00 MG

60429011840 METHOCARBAMOL500.00 MG

00378001401 METHOTREXATE2.500 MG

00555057202 METHOTREXATE2.500 MG

00555057235 METHOTREXATE2.500 MG

00054455015 METHOTREXATE2.500 MG

00054455025 METHOTREXATE2.500 MG

00054855025 METHOTREXATE2.500 MG

00904174960 METHOTREXATE2.500 MG

00904174973 METHOTREXATE2.500 MG

51079067005 METHOTREXATE2.500 MG

51079067086 METHOTREXATE2.500 MG

00378016001 METHYCLOTHIAZIDE5.000 MG

00172298680 METHYCLOTHIAZIDE2.500 MG

51079020020 METHYLDOPA250.00 MG

51079020120 METHYLDOPA500.00 MG

00904239960 METHYLDOPA125.00 MG

00172293160 METHYLDOPA250.00 MG

00172293180 METHYLDOPA250.00 MG

00172293260 METHYLDOPA500.00 MG

00172293270 METHYLDOPA500.00 MG

00182173210 METHYLDOPA250.00 MG

00182173305 METHYLDOPA500.00 MG

00378042101 METHYLDOPA500.00 MG

00378042105 METHYLDOPA500.00 MG

00378061101 METHYLDOPA250.00 MG

00378061110 METHYLDOPA250.00 MG

00378050701 METHYLDOPA/HYDROCHLOROTHI.000

00378071101 METHYLDOPA/HYDROCHLOROTHI.000

00378071110 METHYLDOPA/HYDROCHLOROTHI.000

00904781360 METHYLDOPA/HYDROCHLOROTHI.000

00904781380 METHYLDOPA/HYDROCHLOROTHI.000

00904781480 METHYLDOPA/HYDROCHLOROTHI.000

00074303001 METHYLDOPATE HCL250.00 MG/5ML

00074303002 METHYLDOPATE HCL250.00 MG/5ML

60267040044 METHYLENE BLUE1.000 %

60267050055 METHYLENE BLUE1.000 %

00781174801 METHYLPHENIDATE HCL5.000 MG

00781174810 METHYLPHENIDATE HCL5.000 MG

00781174901 METHYLPHENIDATE HCL10.000 MG

00781174910 METHYLPHENIDATE HCL10.000 MG

00781175301 METHYLPHENIDATE HCL20.000 MG

00781175310 METHYLPHENIDATE HCL20.000 MG

53014053007 METHYLPHENIDATE HCL10.000 MG

53014053012 METHYLPHENIDATE HCL10.000 MG

53014053107 METHYLPHENIDATE HCL5.000 MG

53014053112 METHYLPHENIDATE HCL5.000 MG

53014053207 METHYLPHENIDATE HCL20.000 MG

53014053212 METHYLPHENIDATE HCL20.000 MG

00591311101 METHYLPHENIDATE HCL ER20.000 MG

00781175401 METHYLPHENIDATE HCL SR20.000 MG

00781175410 METHYLPHENIDATE HCL SR20.000 MG

00904217519 METHYLPREDNISOLONE4.000 MG

49884049059 METHYLPREDNISOLONE4.000 MG

51285030121 METHYLPREDNISOLONE4.000 MG

00603459315 METHYLPREDNISOLONE4.000 MG

Page 62 of 125

Page 63: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00603459321 METHYLPREDNISOLONE4.000 MG

00527129607 METHYLPREDNISOLONE4.000 MG

59762332701 METHYLPREDNISOLONE4.000 MG

59762332702 METHYLPREDNISOLONE4.000 MG

62269035124 METHYLPREDNISOLONE4.000 MG

62269035121 METHYLPREDNISOLONE DOSE P4.000 MG

00093610516 METOCLOPRAMIDE HCL5.000 MG/5ML

00093220301 METOCLOPRAMIDE HCL10.000 MG

00093220305 METOCLOPRAMIDE HCL10.000 MG

00093220310 METOCLOPRAMIDE HCL10.000 MG

00093220401 METOCLOPRAMIDE HCL5.000 MG

00093220405 METOCLOPRAMIDE HCL5.000 MG

00074341301 METOCLOPRAMIDE HCL5.000 MG/ML

00074341401 METOCLOPRAMIDE HCL5.000 MG/ML

00054856304 METOCLOPRAMIDE HCL5.000 MG/5ML

00054356363 METOCLOPRAMIDE HCL5.000 MG/5ML

00228226910 METOCLOPRAMIDE HCL10.000 MG

00228226950 METOCLOPRAMIDE HCL10.000 MG

00182178989 METOCLOPRAMIDE HCL10.000 MG

00182189889 METOCLOPRAMIDE HCL5.000 MG

00472045416 METOCLOPRAMIDE HCL5.000 MG/5ML

00603143558 METOCLOPRAMIDE HCL5.000 MG/5ML

50111051701 METOCLOPRAMIDE HCL5.000 MG

50111051702 METOCLOPRAMIDE HCL5.000 MG

50111043001 METOCLOPRAMIDE HCL10.000 MG

50111043002 METOCLOPRAMIDE HCL10.000 MG

50111043003 METOCLOPRAMIDE HCL10.000 MG

51079028319 METOCLOPRAMIDE HCL10.000 MG

51079028320 METOCLOPRAMIDE HCL10.000 MG

51079062920 METOCLOPRAMIDE HCL5.000 MG

54838050880 METOCLOPRAMIDE HCL5.000 MG/5ML

53489038401 METOCLOPRAMIDE HCL5.000 MG

53489038405 METOCLOPRAMIDE HCL5.000 MG

00677132301 METOCLOPRAMIDE HCL5.000 MG

00677132305 METOCLOPRAMIDE HCL5.000 MG

00904106940 METOCLOPRAMIDE HCL5.000 MG

00904106960 METOCLOPRAMIDE HCL5.000 MG

00904107040 METOCLOPRAMIDE HCL10.000 MG

00904107060 METOCLOPRAMIDE HCL10.000 MG

00904107061 METOCLOPRAMIDE HCL10.000 MG

00904107080 METOCLOPRAMIDE HCL10.000 MG

59911581501 METOCLOPRAMIDE HCL10.000 MG

59911581502 METOCLOPRAMIDE HCL10.000 MG

60432062216 METOCLOPRAMIDE HCL5.000 MG/5ML

00781122301 METOPROLOL TARTRATE50.000 MG

00781122310 METOPROLOL TARTRATE50.000 MG

00781122801 METOPROLOL TARTRATE100.00 MG

00781122810 METOPROLOL TARTRATE100.00 MG

00677148201 METOPROLOL TARTRATE50.000 MG

00677148210 METOPROLOL TARTRATE50.000 MG

00677148301 METOPROLOL TARTRATE100.00 MG

00677148310 METOPROLOL TARTRATE100.00 MG

00904777260 METOPROLOL TARTRATE50.000 MG

00904777261 METOPROLOL TARTRATE50.000 MG

00904777280 METOPROLOL TARTRATE50.000 MG

00904777360 METOPROLOL TARTRATE100.00 MG

00904777361 METOPROLOL TARTRATE100.00 MG

00904777380 METOPROLOL TARTRATE100.00 MG

00904794660 METOPROLOL TARTRATE50.000 MG

00904794680 METOPROLOL TARTRATE50.000 MG

00904794760 METOPROLOL TARTRATE100.00 MG

00904794780 METOPROLOL TARTRATE100.00 MG

53489036601 METOPROLOL TARTRATE50.000 MG

53489036610 METOPROLOL TARTRATE50.000 MG

53489036701 METOPROLOL TARTRATE100.00 MG

53489036710 METOPROLOL TARTRATE100.00 MG

51079080119 METOPROLOL TARTRATE50.000 MG

51079080120 METOPROLOL TARTRATE50.000 MG

51079080124 METOPROLOL TARTRATE50.000 MG

51079080219 METOPROLOL TARTRATE100.00 MG

51079080220 METOPROLOL TARTRATE100.00 MG

00378004701 METOPROLOL TARTRATE100.00 MG

00378004710 METOPROLOL TARTRATE100.00 MG

00378003201 METOPROLOL TARTRATE50.000 MG

00378003210 METOPROLOL TARTRATE50.000 MG

00074228505 METOPROLOL TARTRATE1.000 MG/ML

00074177835 METOPROLOL TARTRATE1.000 MG/ML

00093073301 METOPROLOL TARTRATE50.000 MG

00093073310 METOPROLOL TARTRATE50.000 MG

00093073401 METOPROLOL TARTRATE100.00 MG

00093073410 METOPROLOL TARTRATE100.00 MG

57664016608 METOPROLOL TARTRATE50.000 MG

57664016618 METOPROLOL TARTRATE50.000 MG

57664016708 METOPROLOL TARTRATE100.00 MG

57664016718 METOPROLOL TARTRATE100.00 MG

51079080123 METOPROLOL TARTRATE50.000 MG

60429012630 METOPROLOL TARTRATE50.000 MG

60429012660 METOPROLOL TARTRATE50.000 MG

60429012730 METOPROLOL TARTRATE100.00 MG

00093085101 METRONIDAZOLE250.00 MG

00093085105 METRONIDAZOLE250.00 MG

00093085152 METRONIDAZOLE250.00 MG

00093085205 METRONIDAZOLE500.00 MG

00093085253 METRONIDAZOLE500.00 MG

00182133089 METRONIDAZOLE250.00 MG

00182151789 METRONIDAZOLE500.00 MG

00172297160 METRONIDAZOLE250.00 MG

00172300760 METRONIDAZOLE500.00 MG

51079012219 METRONIDAZOLE250.00 MG

51079012220 METRONIDAZOLE250.00 MG

51079012619 METRONIDAZOLE500.00 MG

51079012620 METRONIDAZOLE500.00 MG

50111033301 METRONIDAZOLE250.00 MG

50111033302 METRONIDAZOLE250.00 MG

50111033306 METRONIDAZOLE250.00 MG

50111033401 METRONIDAZOLE500.00 MG

50111033402 METRONIDAZOLE500.00 MG

53489013501 METRONIDAZOLE250.00 MG

53489013503 METRONIDAZOLE250.00 MG

53489013601 METRONIDAZOLE500.00 MG

17236030328 METRONIDAZOLE250.00 MG

17236030404 METRONIDAZOLE500.00 MG

17236030414 METRONIDAZOLE500.00 MG

00677081601 METRONIDAZOLE500.00 MG

00677069001 METRONIDAZOLE250.00 MG

00677069003 METRONIDAZOLE250.00 MG

00904145361 METRONIDAZOLE250.00 MG

17236030308 METRONIDAZOLE250.00 MG

60429012828 METRONIDAZOLE250.00 MG

00074781124 METRONIDAZOLE IN NACL 0.7.000

00074781137 METRONIDAZOLE IN NACL 0.7.000

00006073061 MEVACOR10.000 MG

00006073128 MEVACOR20.000 MG

00006073161 MEVACOR20.000 MG

00006073182 MEVACOR20.000 MG

00006073194 MEVACOR20.000 MG

00006073261 MEVACOR40.000 MG

00006073282 MEVACOR40.000 MG

00006073294 MEVACOR40.000 MG

00093873901 MEXILETINE HCL150.00 MG

00093874001 MEXILETINE HCL200.00 MG

00093874101 MEXILETINE HCL250.00 MG

Page 63 of 125

Page 64: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00054261625 MEXILETINE HCL150.00 MG

00054261725 MEXILETINE HCL200.00 MG

00054261825 MEXILETINE HCL250.00 MG

59930168601 MEXILETINE HCL200.00 MG

00597006601 MEXITIL150.00 MG

00597006701 MEXITIL200.00 MG

00597006801 MEXITIL250.00 MG

00904000414 MI-ACID.000

00904776751 MI-ACID.000

00904791060 MI-ACID CHEW.000

00904506860 MI-ACID GAS RELIEF80.000 MG

00904000514 MI-ACID II.000

17236041201 MI-C-T.000

17236041210 MI-C-T.000

00078014923 MIACALCIN200.00 IU/ML

00597003928 MICARDIS20.000 MG

00597004028 MICARDIS40.000 MG

00597004128 MICARDIS80.000 MG

00597004328 MICARDIS HCT.000

00597004428 MICARDIS HCT.000

00009772413 MICATIN2.000 %

00009772001 MICATIN2.000 %

00009772002 MICATIN2.000 %

00009771701 MICATIN2.000 %

00009771802 MICATIN2.000 %

00009771804 MICATIN2.000 %

00009771902 MICATIN JOCK ITCH CREAM2.000 %

00009772101 MICATIN JOCK ITCH SPRAY P2.000 %

00009115102 MICATIN SPRAY POWDER ODOR2.000 %

00472173803 MICONAZOLE 3200.00 MG

00904541501 MICONAZOLE 3 COMBO PACK.000

00472173607 MICONAZOLE 7100.00 MG

00536142326 MICONAZOLE 72.000 %

00472073041 MICONAZOLE NITRATE2.000 %

00472073052 MICONAZOLE NITRATE2.000 %

00472073063 MICONAZOLE NITRATE2.000 %

00472073556 MICONAZOLE NITRATE2.000 %

00168014231 MICONAZOLE NITRATE2.000 %

00182507460 MICONAZOLE NITRATE2.000 %

00904773445 MICONAZOLE NITRATE2.000 %

00904773457 MICONAZOLE NITRATE2.000 %

00713025237 MICONAZOLE NITRATE2.000 %

00472073514 MICONAZOLE NITRATE2.000 %

00472073542 MICONAZOLE NITRATE2.000 %

53303000708 MICROKLENZ ANTISEPTIC WOU.000

00087008742 MICROLIPID.000

00009017103 MICRONASE5.000 MG

00009017105 MICRONASE5.000 MG

00009017106 MICRONASE5.000 MG

00009017107 MICRONASE5.000 MG

00009013101 MICRONASE1.250 MG

00009014101 MICRONASE2.500 MG

00009014102 MICRONASE2.500 MG

52544062201 MICROZIDE12.500 MG

00006009268 MIDAMOR5.000 MG

00074258702 MIDAZOLAM HCL1.000 MG/ML

00074258703 MIDAZOLAM HCL1.000 MG/ML

00074258705 MIDAZOLAM HCL1.000 MG/ML

00074258751 MIDAZOLAM HCL1.000 MG/ML

00074258752 MIDAZOLAM HCL1.000 MG/ML

00074258753 MIDAZOLAM HCL1.000 MG/ML

00074259602 MIDAZOLAM HCL5.000 MG/ML

00074259603 MIDAZOLAM HCL5.000 MG/ML

00074259605 MIDAZOLAM HCL5.000 MG/ML

00074259649 MIDAZOLAM HCL5.000 MG/ML

00074259651 MIDAZOLAM HCL5.000 MG/ML

00074259652 MIDAZOLAM HCL5.000 MG/ML

00074259653 MIDAZOLAM HCL5.000 MG/ML

00074229532 MIDAZOLAM HCL1.000 MG/ML

00074229632 MIDAZOLAM HCL5.000 MG/ML

60505071101 MIDAZOLAM HCL1.000 MG/ML

60505071102 MIDAZOLAM HCL1.000 MG/ML

60505071103 MIDAZOLAM HCL1.000 MG/ML

60505071201 MIDAZOLAM HCL5.000 MG/ML

60505071202 MIDAZOLAM HCL5.000 MG/ML

60505071203 MIDAZOLAM HCL5.000 MG/ML

60505071204 MIDAZOLAM HCL5.000 MG/ML

00086012025 MIDRIN.000

00713016612 MIGERGOT.000

00603466421 MIGQUIN.000

00603466424 MIGQUIN.000

00904762260 MIGRATINE.000

00904762270 MIGRATINE.000

51991039501 MIGRAZONE.000

51991039502 MIGRAZONE.000

00904078816 MILK OF MAGNESIA7.750 %

00904078814 MILK OF MAGNESIA7.750 %

00904078819 MILK OF MAGNESIA7.750 %

00904078914 MILK OF MAGNESIA7.750 %

00677081832 MILK OF MAGNESIA.000

00603078757 MILK OF MAGNESIA400.00 MG/5ML

00603078857 MILK OF MAGNESIA400.00 MG/5ML

00574001816 MILK OF MAGNESIA7.750 %

00574001832 MILK OF MAGNESIA7.750 %

00536247083 MILK OF MAGNESIA7.750 %

00536247085 MILK OF MAGNESIA7.750 %

00182608439 MILK OF MAGNESIA.000

00182608440 MILK OF MAGNESIA.000

00182083339 MILK OF MAGNESIA.000

00182083340 MILK OF MAGNESIA.000

00182083341 MILK OF MAGNESIA.000

00054356749 MILK OF MAGNESIA.000

00054356761 MILK OF MAGNESIA.000

00054357354 MILK OF MAGNESIA400.00 MG/5ML

00054856404 MILK OF MAGNESIA CASCARA.000

00037100101 MILTOWN400.00 MG

00037100102 MILTOWN400.00 MG

00037100103 MILTOWN400.00 MG

00037110101 MILTOWN200.00 MG

19810091737 MINERAL ICE2.000 %

19810011630 MINERAL ICE2.000 %

19810000344 MINERAL ICE2.000 %

00574061816 MINERAL OIL.000

00003055952 MINERAL OIL.000

00003055933 MINERAL OIL.000

00054857711 MINERAL OIL LIGHT55.000 %

00054857811 MINERAL OIL LIGHT55.000 %

00069437071 MINIPRESS2.000 MG

00069437082 MINIPRESS2.000 MG

00069438071 MINIPRESS5.000 MG

00069431041 MINIPRESS1.000 MG

00069431071 MINIPRESS1.000 MG

59743001001 MINITABS81.000 MG

00089030102 MINITRAN.100 MG/HR

00089030202 MINITRAN.200 MG/HR

00089030302 MINITRAN.400 MG/HR

00089030402 MINITRAN.600 MG/HR

00069432066 MINIZIDE.000

00069436066 MINIZIDE.000

00069430066 MINIZIDE.000

00005534323 MINOCIN50.000 MG

00005534418 MINOCIN100.00 MG

Page 64 of 125

Page 65: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00093316501 MINOCYCLINE HCL50.000 MG

00093316753 MINOCYCLINE HCL100.00 MG

00115701701 MINOCYCLINE HCL50.000 MG

00115701806 MINOCYCLINE HCL100.00 MG

00677143501 MINOCYCLINE HCL50.000 MG

63304069401 MINOCYCLINE HCL50.000 MG

63304069501 MINOCYCLINE HCL75.000 MG

63304069650 MINOCYCLINE HCL100.00 MG

49884025601 MINOXIDIL2.500 MG

49884025701 MINOXIDIL10.000 MG

49884025705 MINOXIDIL10.000 MG

53489038601 MINOXIDIL2.500 MG

53489038701 MINOXIDIL10.000 MG

00641400386 MINOXIDIL2.500 MG

00904128060 MINOXIDIL10.000 MG

60505710105 MINOXIDIL2.000 %

60505710106 MINOXIDIL2.000 %

60505710107 MINOXIDIL2.000 %

60505710108 MINOXIDIL2.000 %

00472006673 MINOXIDIL FOR MEN2.000 %

00472006675 MINOXIDIL FOR MEN2.000 %

50383000102 MINOXIDIL FOR MEN2.000 %

57782032598 MINOXIDIL FOR MEN2.000 %

00472009473 MINOXIDIL FOR MEN5.000 %

00472009475 MINOXIDIL FOR MEN5.000 %

00904000214 MINTOX.000

00904000314 MINTOX EXTRA STRENGTH.000

00904047860 MINTOX PLUS.000

58768077353 MIOCHOL-E SYSTEM PAK20.000 MG/2ML

58768077352 MIOCHOL-E W/IOCARE STERI-1.000 :100

00065002315 MIOSTAT.010 %

57664031708 MIRAPHEN PE.000

57664022208 MIRAPHEN PSE.000

57664022213 MIRAPHEN PSE.000

00052028106 MIRCETTE.000

00597002901 MOBIC7.500 MG

00597003001 MOBIC15.000 MG

00281029817 MODANE5.000 MG

00006091768 MODURETIC 5-50.000

00072950016 MOISTUREL.000

00072910008 MOISTUREL.000

00072642008 MOISTUREL SKIN CLEANSER.000

45802061205 MOISTURIN.000

00182507945 MOISTURIN DRY SKIN.000

08881512977 MONOJECT 12CC CONTROL SYR.000

08881522000 MONOJECT 12CC SAFETY SYRI.000

08881512928 MONOJECT 12CC SYRINGE/ECC.000

08881112075 MONOJECT 12CC SYRINGE/ECC.000

08881120029 MONOJECT 12CC SYRINGE/ECC.000

08881512936 MONOJECT 12CC SYRINGE/LUE.000

08881512258 MONOJECT 12CC SYRINGE/LUE.000

08881712007 MONOJECT 12CC SYRINGE/LUE.000

08881712916 MONOJECT 12CC SYRINGE/REG.000

08881512910 MONOJECT 12CC SYRINGE/REG.000

08881120037 MONOJECT 12CC SYRINGE/REG.000

08881112059 MONOJECT 12CC SYRINGE/REG.000

08881114014 MONOJECT 140CC PISTON SYR.000

08881114055 MONOJECT 140CC PISTON SYR.000

08881520178 MONOJECT 20CC CONTROL SYR.000

08881520624 MONOJECT 20CC SYRINGE/ECC.000

08881520632 MONOJECT 20CC SYRINGE/LUE.000

08881520640 MONOJECT 20CC SYRINGE/REG.000

08881535721 MONOJECT 35CC SYRINGE/CAT.000

08881535739 MONOJECT 35CC SYRINGE/ECC.000

08881135068 MONOJECT 35CC SYRINGE/ECC.000

08881535713 MONOJECT 35CC SYRINGE/LUE.000

08881535754 MONOJECT 35CC SYRINGE/REG.000

08881135084 MONOJECT 35CC SYRINGE/REG.000

08881533908 MONOJECT 3CC SAFETY SYRIN.000

08881533130 MONOJECT 3CC SAFETY SYRIN.000

08881533155 MONOJECT 3CC SAFETY SYRIN.000

08881533239 MONOJECT 3CC SAFETY SYRIN.000

08881533254 MONOJECT 3CC SAFETY SYRIN.000

08881533338 MONOJECT 3CC SAFETY SYRIN.000

08881533510 MONOJECT 3CC SAFETY SYRIN.000

08881513934 MONOJECT 3CC SYRINGE/LUER.000

08881513025 MONOJECT 3CC SYRINGE/LUER.000

08881513033 MONOJECT 3CC SYRINGE/LUER.000

08881513058 MONOJECT 3CC SYRINGE/LUER.000

08881513132 MONOJECT 3CC SYRINGE/LUER.000

08881513157 MONOJECT 3CC SYRINGE/LUER.000

08881513231 MONOJECT 3CC SYRINGE/LUER.000

08881513249 MONOJECT 3CC SYRINGE/LUER.000

08881513256 MONOJECT 3CC SYRINGE/LUER.000

08881513330 MONOJECT 3CC SYRINGE/LUER.000

08881513512 MONOJECT 3CC SYRINGE/LUER.000

08881513538 MONOJECT 3CC SYRINGE/LUER.000

08881513546 MONOJECT 3CC SYRINGE/LUER.000

08881513744 MONOJECT 3CC SYRINGE/LUER.000

08881513918 MONOJECT 3CC SYRINGE/REG.000

08881103025 MONOJECT 3CC SYRINGE/REG.000

08881160157 MONOJECT 60CC SYRINGE/CAT.000

08881560141 MONOJECT 60CC SYRINGE/CAT.000

08881560182 MONOJECT 60CC SYRINGE/ECC.000

08881560125 MONOJECT 60CC SYRINGE/LUE.000

08881560224 MONOJECT 60CC SYRINGE/REG.000

08881560265 MONOJECT 60CC SYRINGE/TOO.000

08881516937 MONOJECT 6CC SYRINGE/LUER.000

08881516911 MONOJECT 6CC SYRINGE/REG.000

08881106028 MONOJECT 6CC SYRINGE/REG.000

08881500501 MONOJECT ALLERGIST TRAY/P.000

08881501236 MONOJECT ALLERGIST TRAY/P.000

08881241163 MONOJECT ASPIRATION-IL ST.000

08881202348 MONOJECT BLUNT NEEDLE/MET.000

08881202355 MONOJECT BLUNT NEEDLE/MET.000

08881202363 MONOJECT BLUNT NEEDLE/MET.000

08881202371 MONOJECT BLUNT NEEDLE/MET.000

08881202389 MONOJECT BLUNT NEEDLE/MET.000

08881202397 MONOJECT BLUNT NEEDLE/MET.000

08881305109 MONOJECT FILTER ASPIRATOR.000

08881305208 MONOJECT FILTER NEEDLE/IN.000

08881200110 MONOJECT HYPO/ALUM HUB/LU.000

08881200714 MONOJECT HYPO/ALUM HUB/LU.000

08881200169 MONOJECT HYPO/ALUM HUB/LU.000

08881200185 MONOJECT HYPO/ALUM HUB/LU.000

08881200326 MONOJECT HYPO/ALUM HUB/LU.000

08881200342 MONOJECT HYPO/ALUM HUB/LU.000

08881200383 MONOJECT HYPO/ALUM HUB/LU.000

08881200086 MONOJECT HYPO/ALUM HUB/LU.000

08881200136 MONOJECT HYPO/ALUM HUB/LU.000

08881200144 MONOJECT HYPO/ALUM HUB/LU.000

08881200516 MONOJECT HYPO/ALUM HUB/LU.000

08881200268 MONOJECT HYPO/ALUM HUB/LU.000

08881200292 MONOJECT HYPO/ALUM HUB/LU.000

08881200193 MONOJECT HYPO/HUB/LUER L.000

08881250057 MONOJECT HYPO/POLYPROPYLE.000

08881250107 MONOJECT HYPO/POLYPROPYLE.000

08881250024 MONOJECT HYPO/POLYPROPYLE.000

08881250065 MONOJECT HYPO/POLYPROPYLE.000

08881250073 MONOJECT HYPO/POLYPROPYLE.000

08881250081 MONOJECT HYPO/POLYPROPYLE.000

08881250099 MONOJECT HYPO/POLYPROPYLE.000

Page 65 of 125

Page 66: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

08881250115 MONOJECT HYPO/POLYPROPYLE.000

08881250362 MONOJECT HYPO/POLYPROPYLE.000

08881250545 MONOJECT HYPO/POLYPROPYLE.000

08881250149 MONOJECT HYPO/POLYPROPYLE.000

08881250172 MONOJECT HYPO/POLYPROPYLE.000

08881250180 MONOJECT HYPO/POLYPROPYLE.000

08881250198 MONOJECT HYPO/POLYPROPYLE.000

08881250214 MONOJECT HYPO/POLYPROPYLE.000

08881250222 MONOJECT HYPO/POLYPROPYLE.000

08881250230 MONOJECT HYPO/POLYPROPYLE.000

08881250255 MONOJECT HYPO/POLYPROPYLE.000

08881250289 MONOJECT HYPO/POLYPROPYLE.000

08881250032 MONOJECT HYPO/POLYPROPYLE.000

08881511110 MONOJECT INSULIN SAFETY S.000

08881511136 MONOJECT INSULIN SAFETY S.000

08881600004 MONOJECT INSULIN SYRINGE.000

08881600135 MONOJECT INSULIN SYRINGE.000

08881600800 MONOJECT INSULIN SYRINGE.000

08881600700 MONOJECT INSULIN SYRINGE.000

08881601101 MONOJECT INSULIN SYRINGE.000

08881601135 MONOJECT INSULIN SYRINGE.000

08881601600 MONOJECT INSULIN SYRINGE.000

08881601111 MONOJECT INSULIN SYRINGE.000

08881701406 MONOJECT INSULIN SYRINGE/.000

08881700408 MONOJECT INSULIN SYRINGE/.000

08881601358 MONOJECT INSULIN SYRINGE/.000

08881600350 MONOJECT INSULIN SYRINGE/.000

08881600368 MONOJECT INSULIN SYRINGE/.000

08881600145 MONOJECT INSULIN SYRINGE/.000

08881501822 MONOJECT INSULIN SYRINGE/.000

08881501210 MONOJECT INSULIN SYRINGE/.000

08881501970 MONOJECT INSULIN SYRINGE/.000

08881500014 MONOJECT INSULIN SYRINGE/.000

08881501384 MONOJECT INSULIN SYRINGE/.000

08881601366 MONOJECT INSULIN SYRINGE/.000

08881202033 MONOJECT LIFESHIELD BLUNT.000

08881204005 MONOJECT MEDICATION TRANS.000

08881260056 MONOJECT OR/ER NEEDLE 20G.000

08881260064 MONOJECT OR/ER NEEDLE 21G.000

08881260072 MONOJECT OR/ER NEEDLE 21G.000

08881260080 MONOJECT OR/ER NEEDLE 22G.000

08881260098 MONOJECT OR/ER NEEDLE 22G.000

08881260106 MONOJECT OR/ER NEEDLE 23G.000

08881260163 MONOJECT OR/ER NEEDLE 27G.000

08881260031 MONOJECT OR/ER NEEDLE/18G.000

08881520251 MONOJECT PHARMACY TRAY/20.000

08881535101 MONOJECT PHARMACY TRAY/35.000

08881513207 MONOJECT PHARMACY TRAY/3C.000

08881560232 MONOJECT PHARMACY TRAY/60.000

08881516200 MONOJECT PHARMACY TRAY/6C.000

08881501160 MONOJECT TUBERCULIN SYRIN.000

08881501368 MONOJECT TUBERCULIN SYRIN.000

08881501400 MONOJECT TUBERCULIN SYRIN.000

08881500105 MONOJECT TUBERCULINE SYRI.000

08881609004 MONOJECT ULTRA COMFORT SY.000

08881512944 MONOJECT VARI-STOP 12CC S.000

08881520087 MONOJECT VARI-STOP 20CC S.000

00091361001 MONOKET10.000 MG

00091362001 MONOKET20.000 MG

00091362011 MONOKET20.000 MG

00091362018 MONOKET20.000 MG

00087015846 MONOPRIL10.000 MG

00087015885 MONOPRIL10.000 MG

00087060942 MONOPRIL20.000 MG

00087060985 MONOPRIL20.000 MG

00087120213 MONOPRIL40.000 MG

00087149201 MONOPRIL HCT.000

00087149301 MONOPRIL HCT.000

08881600418 MOORE MED MONOJECT INSULI.000

08881600558 MOORE MED MONOJECT INSULI.000

08881601606 MOORE MED MONOJECT INSULI.000

08881601705 MOORE MED MONOJECT INSULI.000

00641016825 MORPHINE SULFATE5.000 MG/ML

00641017025 MORPHINE SULFATE8.000 MG/ML

00641018025 MORPHINE SULFATE10.000 MG/ML

00641019025 MORPHINE SULFATE15.000 MG/ML

00641117035 MORPHINE SULFATE8.000 MG/ML

00641118035 MORPHINE SULFATE10.000 MG/ML

00641119035 MORPHINE SULFATE15.000 MG/ML

00641234341 MORPHINE SULFATE10.000 MG/ML

00641234541 MORPHINE SULFATE15.000 MG/ML

00074405712 MORPHINE SULFATE.500 MG/ML

00074405812 MORPHINE SULFATE1.000 MG/ML

00074381712 MORPHINE SULFATE10.000 MG/ML

00074602804 MORPHINE SULFATE5.000 MG/ML

00074602304 MORPHINE SULFATE1.000 MG/ML

00074113403 MORPHINE SULFATE50.000 MG/ML

00074113405 MORPHINE SULFATE50.000 MG/ML

00074113502 MORPHINE SULFATE25.000 MG/ML

00074202802 MORPHINE SULFATE.500 MG/ML

00074202902 MORPHINE SULFATE1.000 MG/ML

00074176201 MORPHINE SULFATE2.000 MG/ML

00074176230 MORPHINE SULFATE2.000 MG/ML

00074125802 MORPHINE SULFATE4.000 MG/ML

00074125830 MORPHINE SULFATE4.000 MG/ML

00074126011 MORPHINE SULFATE8.000 MG/ML

00074126021 MORPHINE SULFATE8.000 MG/ML

00074126102 MORPHINE SULFATE10.000 MG/ML

00074126130 MORPHINE SULFATE10.000 MG/ML

00074126201 MORPHINE SULFATE15.000 MG/ML

00074126321 MORPHINE SULFATE10.000 MG/ML

00074126421 MORPHINE SULFATE15.000 MG/ML

00074126431 MORPHINE SULFATE15.000 MG/ML

00054858224 MORPHINE SULFATE15.000 MG

00054858324 MORPHINE SULFATE30.000 MG

00054858516 MORPHINE SULFATE10.000 MG/5ML

00054858616 MORPHINE SULFATE10.000 MG/5ML

00054378549 MORPHINE SULFATE10.000 MG/5ML

00054378563 MORPHINE SULFATE10.000 MG/5ML

00054378649 MORPHINE SULFATE20.000 MG/5ML

00054378663 MORPHINE SULFATE20.000 MG/5ML

00054458225 MORPHINE SULFATE15.000 MG

00054458325 MORPHINE SULFATE30.000 MG

00574711012 MORPHINE SULFATE5.000 MG

00574711212 MORPHINE SULFATE10.000 MG

00574711412 MORPHINE SULFATE20.000 MG

00574711612 MORPHINE SULFATE30.000 MG

00548339100 MORPHINE SULFATE1.000 MG/ML

00548193110 MORPHINE SULFATE1.000 MG/ML

00548193310 MORPHINE SULFATE1.000 MG/ML

00548191125 MORPHINE SULFATE1.000 MG/ML

00713019312 MORPHINE SULFATE5.000 MG

00713019412 MORPHINE SULFATE10.000 MG

00713019512 MORPHINE SULFATE20.000 MG

00713019612 MORPHINE SULFATE30.000 MG

00548339110 MORPHINE SULFATE1.000 MG/ML

63304070701 MORPHINE SULFATE15.000 MG

63304070801 MORPHINE SULFATE30.000 MG

60793005912 MORPHINE SULFATE5.000 MG

60793006012 MORPHINE SULFATE10.000 MG

60793006112 MORPHINE SULFATE20.000 MG

60793006212 MORPHINE SULFATE30.000 MG

Page 66 of 125

Page 67: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

60793006301 MORPHINE SULFATE10.000 MG/ML

60793006401 MORPHINE SULFATE10.000 MG/ML

60793009340 MORPHINE SULFATE25.000 MG/ML

58177031304 MORPHINE SULFATE15.000 MG

58177031404 MORPHINE SULFATE30.000 MG

58177088601 MORPHINE SULFATE20.000 MG/ML

58177088603 MORPHINE SULFATE20.000 MG/ML

58177088605 MORPHINE SULFATE20.000 MG/ML

00074617714 MORPHINE SULFATE ADD-VANT25.000 MG/ML

00074617914 MORPHINE SULFATE ADD-VANT25.000 MG/ML

00548604225 MORPHINE SULFATE DILUTE-A25.000 MG/ML

00548604325 MORPHINE SULFATE DILUTE-A25.000 MG/ML

00548604525 MORPHINE SULFATE DILUTE-A25.000 MG/ML

60951065870 MORPHINE SULFATE ER100.00 MG

60951065885 MORPHINE SULFATE ER100.00 MG

60951065270 MORPHINE SULFATE ER15.000 MG

60951065370 MORPHINE SULFATE ER30.000 MG

60951065570 MORPHINE SULFATE ER60.000 MG

00074381412 MORPHINE SULFATE FLIPTOP.500 MG/ML

00074381512 MORPHINE SULFATE FLIPTOP1.000 MG/ML

60793021101 MORPHINE SULFATE IR30.000 MG

60793021201 MORPHINE SULFATE IR15.000 MG

60793022401 MORPHINE SULFATE IR20.000 MG/ML

60793022404 MORPHINE SULFATE IR20.000 MG/ML

60793022408 MORPHINE SULFATE IR20.000 MG/ML

60793022753 MORPHINE SULFATE IR20.000 MG/5ML

60793022853 MORPHINE SULFATE IR10.000 MG/5ML

00548290100 MORPHINE SULFATE STICK-GA1.000 MG/ML

00548290125 MORPHINE SULFATE STICK-GA1.000 MG/ML

00182143711 MOTION SICKNESS50.000 MG

00009738501 MOTRIN400.00 MG

00009738502 MOTRIN400.00 MG

00009738503 MOTRIN400.00 MG

00009738504 MOTRIN400.00 MG

00009738601 MOTRIN600.00 MG

00009738602 MOTRIN600.00 MG

00009738603 MOTRIN600.00 MG

00009738604 MOTRIN600.00 MG

00009738605 MOTRIN600.00 MG

00009738701 MOTRIN800.00 MG

00009738702 MOTRIN800.00 MG

00009738703 MOTRIN800.00 MG

00009738704 MOTRIN800.00 MG

00034051310 MS CONTIN200.00 MG

00034051410 MS CONTIN15.000 MG

00034051490 MS CONTIN15.000 MG

00034051510 MS CONTIN30.000 MG

00034051545 MS CONTIN30.000 MG

00034051550 MS CONTIN30.000 MG

00034051590 MS CONTIN30.000 MG

00034051610 MS CONTIN60.000 MG

00034051690 MS CONTIN60.000 MG

00034051710 MS CONTIN100.00 MG

00034051790 MS CONTIN100.00 MG

58521011050 MS/L10.000 MG/5ML

00034051810 MSIR15.000 MG

00034051910 MSIR30.000 MG

00034052102 MSIR10.000 MG/5ML

00034052202 MSIR20.000 MG/5ML

00034052301 MSIR20.000 MG/ML

00034052302 MSIR20.000 MG/ML

00087057003 MUCOMYST20.000 %

00087057007 MUCOMYST20.000 %

00087057009 MUCOMYST20.000 %

00087057201 MUCOMYST-1010.000 %

00087057202 MUCOMYST-1010.000 %

00087057203 MUCOMYST-1010.000 %

00677099006 MULTI FERROUS FOLIC 500.000

00603471021 MULTI VIT/FL.000

00904534060 MULTI VITA-BETS/FLUORIDE.000

54838000870 MULTI-DELYN.000

54838000880 MULTI-DELYN.000

54838000970 MULTI-DELYN/IRON.000

54838000980 MULTI-DELYN/IRON.000

00603471221 MULTI-VIT/FLUORIDE.000

00603471232 MULTI-VIT/FLUORIDE.000

00603144947 MULTI-VIT/FLUORIDE.000

00603145047 MULTI-VIT/FLUORIDE.000

00603471121 MULTI-VIT/FLUORIDE 1/2 ST.000

00603471132 MULTI-VIT/FLUORIDE 1/2 ST.000

00603145347 MULTI-VIT/FLUORIDE/IRON.000

00603145247 MULTI-VIT/IRON/FLUORIDE.000

00536404401 MULTILEX.000

00536406001 MULTILEX-T&M.000

51079024830 MULTIVITAMIN.000

00536404610 MULTIVITAMINS.000

00093916601 MULTIVITAMINS/FLUORIDE.000

00093916610 MULTIVITAMINS/FLUORIDE.000

00093915801 MULTIVITAMINS/FLUORIDE.000

00093915810 MULTIVITAMINS/FLUORIDE.000

00093919701 MULTIVITAMINS/FLUORIDE/IR.000

24208027715 MURO 1285.000 %

24208027730 MURO 1285.000 %

24208038555 MURO 1285.000 %

24208038556 MURO 1285.000 %

24208028015 MUROCEL1.000 %

00015300120 MUTAMYCIN5.000 MG

00015300220 MUTAMYCIN20.000 MG

00015305920 MUTAMYCIN40.000 MG

00071033526 MYADEC.000

51479004601 MYAMBUTOL100.00 MG

51479004701 MYAMBUTOL400.00 MG

51479004704 MYAMBUTOL400.00 MG

51479004710 MYAMBUTOL400.00 MG

00093070115 MYCO-TRIACET II.000

00093070130 MYCO-TRIACET II.000

00003046630 MYCOLOG-II.000

00003046660 MYCOLOG-II.000

00003046665 MYCOLOG-II.000

00003056630 MYCOLOG-II.000

00003056660 MYCOLOG-II.000

00003056665 MYCOLOG-II.000

00003057931 MYCOSTATIN100000 U/GM

00003059320 MYCOSTATIN100000 U/GM

00065034203 MYDFRIN2.500 %

00998034205 MYDFRIN2.500 %

00998035415 MYDRIACYL.500 %

00998035515 MYDRIACYL1.000 %

00065035503 MYDRIACYL1.000 %

60432059804 MYFEDRINE PEDIATRIC30.000 MG/5ML

00603021021 MYTAB GAS80.000 MG

00603021120 MYTAB GAS MAX STR125.00 MG

00281008108 MYTREX.000

00281008115 MYTREX.000

60432004504 MYTUSSIN AC.000

60432004516 MYTUSSIN AC.000

60432004528 MYTUSSIN AC.000

60432054104 MYTUSSIN DAC.000

60432054116 MYTUSSIN DAC.000

60432003416 MYTUSSIN DM.000

60432003428 MYTUSSIN DM.000

53100085940 N'ICE3.000 MG

Page 67 of 125

Page 68: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

53100085915 N'ICE5.000 MG

53100085920 N'ICE6.000 MG

53100085961 N'ICE5.000 MG

53100085965 N'ICE5.000 MG

53100085970 N'ICE 'N CLEAR5.000 MG

53100085959 N'ICE KIDS.000

45802002611 N.T.A..000

45802002635 N.T.A..000

45802002637 N.T.A..000

38245072420 NADOLOL80.000 MG

38245072720 NADOLOL120.00 MG

51079081220 NADOLOL20.000 MG

51079081320 NADOLOL40.000 MG

51079081420 NADOLOL80.000 MG

00182263289 NADOLOL20.000 MG

00182263389 NADOLOL40.000 MG

00182263489 NADOLOL80.000 MG

00172423560 NADOLOL20.000 MG

00172423570 NADOLOL20.000 MG

00172423660 NADOLOL40.000 MG

00172423760 NADOLOL80.000 MG

00172423860 NADOLOL120.00 MG

00172423960 NADOLOL160.00 MG

00378002801 NADOLOL20.000 MG

00378117101 NADOLOL40.000 MG

00378117110 NADOLOL40.000 MG

00378113201 NADOLOL80.000 MG

00378113210 NADOLOL80.000 MG

59772246101 NADOLOL20.000 MG

59772246201 NADOLOL40.000 MG

59772246203 NADOLOL40.000 MG

59772246301 NADOLOL80.000 MG

59772246303 NADOLOL80.000 MG

59772246401 NADOLOL120.00 MG

59772246501 NADOLOL160.00 MG

00015710128 NAFCILLIN SODIUM10.000 GM

00015710198 NAFCILLIN SODIUM10.000 GM

00015722520 NAFCILLIN SODIUM1.000 GM

00015722518 NAFCILLIN SODIUM1.000 GM

00015722589 NAFCILLIN SODIUM1.000 GM

00015722599 NAFCILLIN SODIUM1.000 GM

00015722618 NAFCILLIN SODIUM2.000 GM

00015722620 NAFCILLIN SODIUM2.000 GM

00015722689 NAFCILLIN SODIUM2.000 GM

00015722699 NAFCILLIN SODIUM2.000 GM

00074146301 NALBUPHINE HCL10.000 MG/ML

00074146501 NALBUPHINE HCL20.000 MG/ML

00074146701 NALBUPHINE HCL FLIPTOP20.000 MG/ML

00074146401 NALBUPHINE HCL FLIPTOP10.000 MG/ML

00015568701 NALDECON SENIOR DX.000

00015568810 NALDECON-DX.000

63304068101 NALFON200.00 MG

63304068201 NALFON300.00 MG

00029637025 NALLPEN500.00 MG

00029637240 NALLPEN1.000 GM

00074637207 NALLPEN1.000 GM

00074178201 NALOXONE HCL.400 MG/ML

00074178221 NALOXONE HCL.400 MG/ML

00074121101 NALOXONE HCL.020 MG/ML

00074121201 NALOXONE HCL.400 MG/ML

00074121301 NALOXONE HCL.400 MG/ML

00074121501 NALOXONE HCL.400 MG/ML

00074121601 NALOXONE HCL.020 MG/ML

00074121901 NALOXONE HCL.400 MG/ML

00548146600 NALOXONE HCL.400 MG/ML

00548146900 NALOXONE HCL1.000 MG/ML

00555090201 NALTREXONE HCL50.000 MG

00555090202 NALTREXONE HCL50.000 MG

00185003901 NALTREXONE HCL50.000 MG

00185003930 NALTREXONE HCL50.000 MG

00904190635 NAPHAZOLE.100 %

24208072506 NAPHAZOLINE HCL.100 %

00998007815 NAPHCON.012 %

00065008515 NAPHCON-A.000

00086009010 NAPRELAN375.00 MG

00086009175 NAPRELAN500.00 MG

00004631014 NAPROSYN500.00 MG

00004631114 NAPROSYN375.00 MG

00004002828 NAPROSYN125.00 MG/5ML

00093014701 NAPROXEN250.00 MG

00093014705 NAPROXEN250.00 MG

00093014801 NAPROXEN375.00 MG

00093014805 NAPROXEN375.00 MG

00093014810 NAPROXEN375.00 MG

00093014901 NAPROXEN500.00 MG

00093014905 NAPROXEN500.00 MG

00093014910 NAPROXEN500.00 MG

00054363063 NAPROXEN125.00 MG/5ML

00364256201 NAPROXEN250.00 MG

00172410760 NAPROXEN250.00 MG

00172410770 NAPROXEN250.00 MG

00172410860 NAPROXEN375.00 MG

00172410870 NAPROXEN375.00 MG

00172410880 NAPROXEN375.00 MG

00172410970 NAPROXEN500.00 MG

00378055501 NAPROXEN375.00 MG

00378055505 NAPROXEN375.00 MG

00378045101 NAPROXEN500.00 MG

00378045105 NAPROXEN500.00 MG

00378037701 NAPROXEN250.00 MG

00378037705 NAPROXEN250.00 MG

17236007601 NAPROXEN250.00 MG

17236007605 NAPROXEN250.00 MG

17236007610 NAPROXEN250.00 MG

17236007701 NAPROXEN375.00 MG

17236007705 NAPROXEN375.00 MG

17236007710 NAPROXEN375.00 MG

17236007801 NAPROXEN500.00 MG

17236007805 NAPROXEN500.00 MG

17236007810 NAPROXEN500.00 MG

00781116301 NAPROXEN250.00 MG

00781116305 NAPROXEN250.00 MG

00781116401 NAPROXEN375.00 MG

00781116405 NAPROXEN375.00 MG

00781116501 NAPROXEN500.00 MG

00781116505 NAPROXEN500.00 MG

51079079319 NAPROXEN250.00 MG

51079079320 NAPROXEN250.00 MG

51079079420 NAPROXEN375.00 MG

51079079520 NAPROXEN500.00 MG

60429013312 NAPROXEN250.00 MG

60429013318 NAPROXEN250.00 MG

60429013320 NAPROXEN250.00 MG

60429013330 NAPROXEN250.00 MG

60429013360 NAPROXEN250.00 MG

60429013418 NAPROXEN375.00 MG

60429013460 NAPROXEN375.00 MG

60429013518 NAPROXEN500.00 MG

60429013520 NAPROXEN500.00 MG

60429013560 NAPROXEN500.00 MG

50111061401 NAPROXEN DR375.00 MG

50111061403 NAPROXEN DR375.00 MG

Page 68 of 125

Page 69: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

50111061501 NAPROXEN DR500.00 MG

50111061502 NAPROXEN DR500.00 MG

50111061503 NAPROXEN DR500.00 MG

00781164601 NAPROXEN DR375.00 MG

00781165301 NAPROXEN DR500.00 MG

00093100501 NAPROXEN DR375.00 MG

00093100505 NAPROXEN DR375.00 MG

00093100601 NAPROXEN DR500.00 MG

00093100605 NAPROXEN DR500.00 MG

58177030204 NAPROXEN DR375.00 MG

58177030304 NAPROXEN DR500.00 MG

00093053601 NAPROXEN SODIUM275.00 MG

00093053605 NAPROXEN SODIUM275.00 MG

00093053610 NAPROXEN SODIUM275.00 MG

00093053701 NAPROXEN SODIUM550.00 MG

00093053705 NAPROXEN SODIUM550.00 MG

00093053710 NAPROXEN SODIUM550.00 MG

00172411670 NAPROXEN SODIUM275.00 MG

00172411680 NAPROXEN SODIUM275.00 MG

00143990801 NAPROXEN SODIUM550.00 MG

00143990805 NAPROXEN SODIUM550.00 MG

00182110616 NAPROXEN SODIUM220.00 MG

00182110619 NAPROXEN SODIUM220.00 MG

00182109716 NAPROXEN SODIUM220.00 MG

00182109719 NAPROXEN SODIUM220.00 MG

00781118701 NAPROXEN SODIUM275.00 MG

00781118710 NAPROXEN SODIUM275.00 MG

00781118801 NAPROXEN SODIUM550.00 MG

00781118810 NAPROXEN SODIUM550.00 MG

00904522951 NAPROXEN SODIUM220.00 MG

00904522959 NAPROXEN SODIUM220.00 MG

00024131501 NASAL.650 %

00024131630 NASAL MOISTURIZER.650 %

45802041059 NASAL RELIEF.050 %

45802041060 NASAL RELIEF.050 %

00182613577 NASAL SPRAY.650 %

00009770901 NASALCROM5.200 MG/ACT

00009770902 NASALCROM5.200 MG/ACT

00430022723 NATACHEW.000

00430022640 NATAFORT.000

58177032220 NATALCARE CFE 60.000

58177025711 NATALCARE PIC.000

58177025811 NATALCARE PIC FORTE.000

58177022504 NATALCARE PLUS.000

58177031705 NATALCARE RX.000

58177032811 NATATAB CFE.000

58177032904 NATATAB FA.000

00904501835 NATURAL BALANCE.000

00904519965 NATURAL FIBER THERAPY48.570 %

00904519966 NATURAL FIBER THERAPY48.570 %

00904520065 NATURAL FIBER THERAPY30.900 %

00904520066 NATURAL FIBER THERAPY30.900 %

00904520177 NATURAL FIBER THERAPY SMO58.600 %

00536623772 NATURE'S TEARS.000

00003060650 NATURETIN5.000 MG

50383061604 NAUSEA CONTROL.000

00603079554 NAUSETROL.000

00049572066 NAVANE2.000 MG

00049573066 NAVANE5.000 MG

00049574066 NAVANE10.000 MG

00049577066 NAVANE20.000 MG

00173065601 NAVELBINE10.000 MG/ML

00173065644 NAVELBINE10.000 MG/ML

00002704001 NEBCIN1.200 GM

00002704016 NEBCIN1.200 GM

00002050101 NEBCIN10.000 MG/ML

00002149925 NEBCIN40.000 MG/ML

00002709001 NEBCIN MDV40.000 MG/ML

00002709016 NEBCIN MDV40.000 MG/ML

52544055028 NECON .5/35-28.000

52544055228 NECON 1/35-28.000

52544055628 NECON 1/50-28.000

52544055428 NECON 10/11-28.000

00024132103 NEGGRAM250.00 MG

00024132203 NEGGRAM500.00 MG

00024132206 NEGGRAM500.00 MG

00024134803 NEO-SYNEPHRINE.250 %

00024135105 NEO-SYNEPHRINE.500 %

00024135202 NEO-SYNEPHRINE1.000 %

00024135301 NEO-SYNEPHRINE.500 %

00024135505 NEO-SYNEPHRINE1.000 %

00024135801 NEO-SYNEPHRINE2.500 %

00024135901 NEO-SYNEPHRINE10.000 %

00024136201 NEO-SYNEPHRINE10.000 %

00074180001 NEO-SYNEPHRINE10.000 MG/ML

00024175401 NEO-SYNEPHRINE 12 HOUR EX.050 %

24208078555 NEO/POLY/BAC/HC.000

00904301610 NEOCIDIN.000

51079001520 NEOMYCIN SULFATE500.00 MG

00093117701 NEOMYCIN SULFATE500.00 MG

24208083060 NEOMYCIN-POLYMYXIN-DEXAME.000

24208079535 NEOMYCIN-POLYMYXIN-DEXAME.000

24208078055 NEOMYCIN/BACITRACIN/POLYM.000

00168022138 NEOMYCIN/POLYMIXIN/DEXAME.000

61314063136 NEOMYCIN/POLYMIXIN/DEXAME.000

60793026610 NEOMYCIN/POLYMYXIN B/GRAM.000

00904793838 NEOMYCIN/POLYMYXIN/DEXAME.000

61314063006 NEOMYCIN/POLYMYXIN/DEXAME.000

24208079062 NEOMYCIN/POLYMYXIN/GRAMIC.000

24208063110 NEOMYCIN/POLYMYXIN/HC.000

24208063562 NEOMYCIN/POLYMYXIN/HYDROC.000

61314063810 NEOMYCIN/POLYMYXIN/HYDROC.000

61314063910 NEOMYCIN/POLYMYXIN/HYDROC.000

00078027422 NEORAL100.00 MG/ML

00078024615 NEORAL25.000 MG

00078024815 NEORAL100.00 MG

00081073059 NEOSPORIN.000

00081073058 NEOSPORIN.000

00081073087 NEOSPORIN.000

00081073088 NEOSPORIN.000

61570004510 NEOSPORIN.000

61570004635 NEOSPORIN.000

61570004710 NEOSPORIN GU IRRIGANT.000

61570004750 NEOSPORIN GU IRRIGANT.000

61570004820 NEOSPORIN GU IRRIGANT.000

00081073794 NEOSPORIN PLUS MAXIMUM ST.000

00081074688 NEOSPORIN PLUS MAXIMUM ST.000

00074372201 NEOSTIGMINE METHYLSULFATE.500 MG/ML

00074372301 NEOSTIGMINE METHYLSULFATE1.000 MG/ML

00904155660 NEOTHYLLINE200.00 MG

54391002603 NEPHRO-CALCI1500.0 MG

54391000201 NEPHRO-VITE.000

54391100201 NEPHRO-VITE RX.000

00256018501 NEPHROCAPS.000

00186097266 NESACAINE2.000 %

00186099166 NESACAINE-MPF2.000 %

00186099266 NESACAINE-MPF3.000 %

00071080324 NEURONTIN100.00 MG

00071080340 NEURONTIN100.00 MG

00071080524 NEURONTIN300.00 MG

00071080540 NEURONTIN300.00 MG

00071080624 NEURONTIN400.00 MG

Page 69 of 125

Page 70: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00071080640 NEURONTIN400.00 MG

17314931102 NEUTRA-PHOS.000

00003053750 NIACIN500.00 MG

17236041801 NIACIN50.000 MG

17236041810 NIACIN50.000 MG

17236042001 NIACIN100.00 MG

17236042010 NIACIN100.00 MG

10267001201 NIACIN100.00 MG

10267001204 NIACIN100.00 MG

00904227060 NIACIN50.000 MG

00904227080 NIACIN50.000 MG

00904227160 NIACIN100.00 MG

00904227172 NIACIN100.00 MG

00904227180 NIACIN100.00 MG

00904227260 NIACIN500.00 MG

00904227280 NIACIN500.00 MG

00182440401 NIACIN250.00 MG

00182440501 NIACIN500.00 MG

00182000101 NIACIN100.00 MG

00182005301 NIACIN50.000 MG

00536407001 NIACIN50.000 MG

00536407810 NIACIN500.00 MG

00536407601 NIACIN100.00 MG

00536407610 NIACIN100.00 MG

00182081101 NIACIN CR250.00 MG

17236042101 NIACIN CR250.00 MG

00677042401 NIACIN SR125.00 MG

00677042501 NIACIN SR250.00 MG

00677042505 NIACIN SR250.00 MG

00677112601 NIACIN SR400.00 MG

00536407701 NIACIN SR500.00 MG

00536407301 NIACIN SR125.00 MG

00603473521 NIACIN TD125.00 MG

00603473621 NIACIN TD250.00 MG

00603473632 NIACIN TD250.00 MG

00182441701 NIACIN TD500.00 MG

00182441801 NIACIN TD500.00 MG

00182441810 NIACIN TD500.00 MG

00536703001 NIACIN TR500.00 MG

00536703301 NIACIN TR750.00 MG

00536703801 NIACIN TR1000.0 MG

00904062960 NIACIN TR250.00 MG

00904062970 NIACIN TR250.00 MG

00904062980 NIACIN TR250.00 MG

00904063160 NIACIN TR500.00 MG

00904063360 NIACIN TR125.00 MG

00904434260 NIACIN TR500.00 MG

00904434270 NIACIN TR500.00 MG

00904420160 NIACINAMIDE100.00 MG

00904420260 NIACINAMIDE500.00 MG

00536406801 NIACINAMIDE100.00 MG

00536406901 NIACINAMIDE500.00 MG

00245006711 NIACOR500.00 MG

60598000101 NIASPAN500.00 MG

60598000201 NIASPAN750.00 MG

60598000301 NIASPAN1000.0 MG

00172428860 NICARDIPINE HCL20.000 MG

00172428960 NICARDIPINE HCL30.000 MG

00378102005 NICARDIPINE HCL20.000 MG

00378102077 NICARDIPINE HCL20.000 MG

00378143005 NICARDIPINE HCL30.000 MG

00378143077 NICARDIPINE HCL30.000 MG

00093079301 NICARDIPINE HCL20.000 MG

00093079401 NICARDIPINE HCL30.000 MG

49884049801 NICARDIPINE HCL20.000 MG

49884049805 NICARDIPINE HCL20.000 MG

49884049901 NICARDIPINE HCL30.000 MG

49884049905 NICARDIPINE HCL30.000 MG

00766142020 NICODERM CQ21.000 MG/24HR

00766143020 NICODERM CQ14.000 MG/24HR

00766144020 NICODERM CQ7.000 MG/24HR

00766145010 NICODERM CQ21.000 MG/24HR

00766145020 NICODERM CQ21.000 MG/24HR

00766146020 NICODERM CQ14.000 MG/24HR

00766147010 NICODERM CQ7.000 MG/24HR

00766147012 NICODERM CQ7.000 MG/24HR

00766004508 NICORETTE2.000 MG

00766004548 NICORETTE2.000 MG

00766004560 NICORETTE2.000 MG

00766004708 NICORETTE4.000 MG

00766004748 NICORETTE4.000 MG

00766004760 NICORETTE4.000 MG

00766004320 NICORETTE2.000 MG

00766004330 NICORETTE2.000 MG

00766004420 NICORETTE4.000 MG

00766004430 NICORETTE4.000 MG

00766004360 NICORETTE REFILL2.000 MG

00766004460 NICORETTE REFILL4.000 MG

00766004450 NICORETTE STARTER KIT4.000 MG

00766004350 NICORETTE STARTER KIT2.000 MG

00536310643 NICOTINE POLACRILEX2.000 MG

00536310743 NICOTINE POLACRILEX4.000 MG

00536407401 NICOTINIC ACID SR250.00 MG

00536407410 NICOTINIC ACID SR250.00 MG

00536407501 NICOTINIC ACID SR400.00 MG

00093102201 NIFEDIAC CC60.000 MG

00093081901 NIFEDICAL XL30.000 MG

00093081955 NIFEDICAL XL30.000 MG

00093517301 NIFEDICAL XL60.000 MG

00093517355 NIFEDICAL XL60.000 MG

00093817101 NIFEDIPINE10.000 MG

00093817155 NIFEDIPINE10.000 MG

00228253010 NIFEDIPINE20.000 MG

00228253030 NIFEDIPINE20.000 MG

00228249710 NIFEDIPINE10.000 MG

00228249730 NIFEDIPINE10.000 MG

00904040861 NIFEDIPINE20.000 MG

00904040872 NIFEDIPINE20.000 MG

00904040961 NIFEDIPINE10.000 MG

00904769960 NIFEDIPINE20.000 MG

17236092311 NIFEDIPINE10.000 MG

57664087211 NIFEDIPINE10.000 MG

57664087218 NIFEDIPINE10.000 MG

57664087308 NIFEDIPINE20.000 MG

57664087311 NIFEDIPINE20.000 MG

57664087318 NIFEDIPINE20.000 MG

00378347501 NIFEDIPINE ER30.000 MG

00378347530 NIFEDIPINE ER30.000 MG

00378348201 NIFEDIPINE ER60.000 MG

00378348230 NIFEDIPINE ER60.000 MG

00378349501 NIFEDIPINE ER90.000 MG

00131506668 NIFEREX100.00 MG/5ML

00131220909 NIFEREX PN.000

00131230909 NIFEREX-PN FORTE.000

00904763312 NIGHT TIME.000

00182136111 NIGHTTIME COLD.000

00026285548 NIMOTOP30.000 MG

00026285570 NIMOTOP30.000 MG

00603080555 NITE TIME.000

00603080563 NITE TIME.000

00603080655 NITE TIME.000

00603080663 NITE TIME.000

Page 70 of 125

Page 71: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

50383087506 NITE-TIME COUGH MEDICINE.000

50383087510 NITE-TIME COUGH MEDICINE.000

50383087606 NITE-TIME COUGH MEDICINE.000

50383087610 NITE-TIME COUGH MEDICINE.000

00182117893 NITETIME SLEEP-AID25.000 MG

62794020293 NITREK.200 MG/HR

62794020493 NITREK.400 MG/HR

62794020693 NITREK.600 MG/HR

00085081930 NITRO-DUR.800 MG/HR

00085081935 NITRO-DUR.800 MG/HR

00085331030 NITRO-DUR.200 MG/HR

00085331035 NITRO-DUR.200 MG/HR

00085331530 NITRO-DUR.300 MG/HR

00085331535 NITRO-DUR.300 MG/HR

00085332030 NITRO-DUR.400 MG/HR

00085332035 NITRO-DUR.400 MG/HR

00085333030 NITRO-DUR.600 MG/HR

00085333035 NITRO-DUR.600 MG/HR

00085330530 NITRO-DUR.100 MG/HR

00085330535 NITRO-DUR.100 MG/HR

49483022106 NITRO-TIME2.500 MG

49483022310 NITRO-TIME9.000 MG

49483022110 NITRO-TIME2.500 MG

00168032608 NITROBID2.000 %

00168032630 NITROBID2.000 %

00168032660 NITROBID2.000 %

00677122401 NITROFURANTOIN MACROCRYST50.000 MG

00677122501 NITROFURANTOIN MACROCRYST100.00 MG

00172213060 NITROFURANTOIN MACROCRYST50.000 MG

00172213080 NITROFURANTOIN MACROCRYST50.000 MG

00172213160 NITROFURANTOIN MACROCRYST100.00 MG

00172213170 NITROFURANTOIN MACROCRYST100.00 MG

00182194489 NITROFURANTOIN MACROCRYST50.000 MG

00182194589 NITROFURANTOIN MACROCRYST100.00 MG

00456068301 NITROGARD3.000 MG

00074410401 NITROGLYCERIN5.000 MG/ML

00074410701 NITROGLYCERIN5.000 MG/ML

49483022206 NITROGLYCERIN CR6.500 MG

00603478221 NITROGLYCERIN CR2.500 MG

00603478321 NITROGLYCERIN CR6.500 MG

00603478420 NITROGLYCERIN CR9.000 MG

00185121701 NITROGLYCERIN CR9.000 MG

00185121760 NITROGLYCERIN CR9.000 MG

00185123501 NITROGLYCERIN CR6.500 MG

00185123560 NITROGLYCERIN CR6.500 MG

49483022210 NITROGLYCERIN CR6.500 MG

58177000403 NITROGLYCERIN ER2.500 MG

58177000404 NITROGLYCERIN ER2.500 MG

58177000503 NITROGLYCERIN ER6.500 MG

58177000504 NITROGLYCERIN ER6.500 MG

58177000603 NITROGLYCERIN ER9.000 MG

58177000604 NITROGLYCERIN ER9.000 MG

00074148202 NITROGLYCERIN IN 5% DEXTR.000

00074148402 NITROGLYCERIN IN 5% DEXTR.000

00074148302 NITROGLYCERIN IN DEXTROSE.000

00074148303 NITROGLYCERIN IN DEXTROSE.000

00185517401 NITROGLYCERIN SR2.500 MG

00185517460 NITROGLYCERIN SR2.500 MG

00182167089 NITROGLYCERIN TD9.000 MG

00182070289 NITROGLYCERIN TD2.500 MG

00182070389 NITROGLYCERIN TD6.500 MG

00677096706 NITROGLYCERIN TD9.000 MG

00677048501 NITROGLYCERIN TD2.500 MG

00677048601 NITROGLYCERIN TD6.500 MG

00904064352 NITROGLYCERIN TD2.500 MG

00904064360 NITROGLYCERIN TD2.500 MG

00904064452 NITROGLYCERIN TD6.500 MG

00904064460 NITROGLYCERIN TD6.500 MG

00904064752 NITROGLYCERIN TD9.000 MG

00904064760 NITROGLYCERIN TD9.000 MG

00904065246 NITROGLYCERIN TRANSDERMAL.200 MG/HR

00904065346 NITROGLYCERIN TRANSDERMAL.400 MG/HR

00904065446 NITROGLYCERIN TRANSDERMAL.600 MG/HR

00378910293 NITROGLYCERIN TRANSDERMAL.100 MG/HR

00378910493 NITROGLYCERIN TRANSDERMAL.200 MG/HR

00378911293 NITROGLYCERIN TRANSDERMAL.400 MG/HR

00378911693 NITROGLYCERIN TRANSDERMAL.600 MG/HR

00089130130 NITROGLYCERIN TRANSDERMAL.100 MG/HR

00089130230 NITROGLYCERIN TRANSDERMAL.200 MG/HR

00089130330 NITROGLYCERIN TRANSDERMAL.400 MG/HR

00089130430 NITROGLYCERIN TRANSDERMAL.600 MG/HR

00089130140 NITROGLYCERIN TRANSDERMAL.100 MG/HR

00089130240 NITROGLYCERIN TRANSDERMAL.200 MG/HR

00089130340 NITROGLYCERIN TRANSDERMAL.400 MG/HR

00089130440 NITROGLYCERIN TRANSDERMAL.600 MG/HR

00074148403 NITROGLYCERIN/IN 5% DEXTR.000

00482102501 NITROGLYN2.500 MG

00482106501 NITROGLYN6.500 MG

00482109001 NITROGLYN9.000 MG

00075022120 NITRONG2.600 MG

00075027420 NITRONG6.500 MG

00074302401 NITROPRESS25.000 MG/ML

00074325001 NITROPRESS50.000 MG

58177032304 NITROQUICK.300 MG

58177032404 NITROQUICK.400 MG

58177032418 NITROQUICK.400 MG

58177032504 NITROQUICK.600 MG

00071041724 NITROSTAT.300 MG

00071041813 NITROSTAT.400 MG

00071041824 NITROSTAT.400 MG

00071041924 NITROSTAT.600 MG

53265024910 NITROTAB.300 MG

53265025004 NITROTAB.400 MG

53265025010 NITROTAB.400 MG

53265025110 NITROTAB.600 MG

19810000623 NO DOZ100.00 MG

19810000624 NO DOZ100.00 MG

19810000625 NO DOZ100.00 MG

08290305215 NOKOR ADMIX NEEDLE THIN W.000

08290305216 NOKOR ADMIX NEEDLE THIN W.000

08290305213 NOKOR VENTED NEEDLE THIN.000

08290305214 NOKOR VENTED NEEDLE THIN.000

08290305227 NOKOR VENTED NEEDLE THIN.000

00904787720 NOLAMINE DEX SENIORS FORM.000

00310060060 NOLVADEX10.000 MG

00310060430 NOLVADEX20.000 MG

00904760520 NON ASPIRIN160.00 MG/5ML

00904764546 NON-ASPIRIN80.000 MG

00904759260 NON-ASPIRIN500.00 MG

00904759351 NON-ASPIRIN500.00 MG

00904759360 NON-ASPIRIN500.00 MG

00904759452 NON-ASPIRIN500.00 MG

00904759460 NON-ASPIRIN500.00 MG

00904759560 NON-ASPIRIN325.00 MG

00904759646 NON-ASPIRIN80.000 MG

00904517651 NON-ASPIRIN EX STR PAIN R.000

52544023528 NOR-QD.350 MG

52544072901 NORCO.000

52544053901 NORCO.000

52544053905 NORCO.000

52544091301 NORCO.000

00052044115 NORCURON10.000 MG

Page 71 of 125

Page 72: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00008007501 NORDETTE-21.000

00008007502 NORDETTE-21.000

00008253301 NORDETTE-28.000

00008253302 NORDETTE-28.000

00008253303 NORDETTE-28.000

00169776413 NORDIPEN DELIVERY SYSTEM.000

00074704101 NOREPINEPHRINE BITARTRATE1.000 MG/ML

00089054006 NORFLEX30.000 MG/ML

00089022110 NORFLEX100.00 MG

00089023110 NORGESIC.000

00089023310 NORGESIC FORTE.000

52544025928 NORINYL 1+35.000

52544026528 NORINYL 1+50.000

08290031002 NORMAL SALINE FLUSH.900 %

08290031003 NORMAL SALINE FLUSH.900 %

08290031102 NORMAL SALINE FLUSH.900 %

08290031103 NORMAL SALINE FLUSH.900 %

08290032003 NORMAL SALINE FLUSH.900 %

08290032005 NORMAL SALINE FLUSH.900 %

08290032103 NORMAL SALINE FLUSH.900 %

08290032105 NORMAL SALINE FLUSH.900 %

08290033003 NORMAL SALINE FLUSH.900 %

08290033005 NORMAL SALINE FLUSH.900 %

08290033006 NORMAL SALINE FLUSH.900 %

08290033010 NORMAL SALINE FLUSH.900 %

08290033103 NORMAL SALINE FLUSH.900 %

08290033105 NORMAL SALINE FLUSH.900 %

08290033110 NORMAL SALINE FLUSH.900 %

00085036206 NORMODYNE5.000 MG/ML

00085036207 NORMODYNE5.000 MG/ML

00085036208 NORMODYNE5.000 MG/ML

00085036209 NORMODYNE5.000 MG/ML

00074767003 NORMOSOL -R.000

00074767009 NORMOSOL -R.000

00074796703 NORMOSOL -R.000

00074796709 NORMOSOL -R.000

00074796503 NORMOSOL-M IN D5W.000

00074796509 NORMOSOL-M IN D5W.000

00074796809 NORMOSOL-R IN D5W.000

00025275231 NORPACE100.00 MG

00025275252 NORPACE100.00 MG

00025276231 NORPACE150.00 MG

00025276252 NORPACE150.00 MG

00025273231 NORPACE CR100.00 MG

00025273234 NORPACE CR100.00 MG

00025273251 NORPACE CR100.00 MG

00025274231 NORPACE CR150.00 MG

00025274234 NORPACE CR150.00 MG

00025274251 NORPACE CR150.00 MG

00093081001 NORTRIPTYLINE HCL10.000 MG

00093081005 NORTRIPTYLINE HCL10.000 MG

00093081101 NORTRIPTYLINE HCL25.000 MG

00093081105 NORTRIPTYLINE HCL25.000 MG

00093081201 NORTRIPTYLINE HCL50.000 MG

00093081205 NORTRIPTYLINE HCL50.000 MG

00093081301 NORTRIPTYLINE HCL75.000 MG

00093081305 NORTRIPTYLINE HCL75.000 MG

00378417501 NORTRIPTYLINE HCL75.000 MG

00378325001 NORTRIPTYLINE HCL50.000 MG

00378232501 NORTRIPTYLINE HCL25.000 MG

00378141001 NORTRIPTYLINE HCL10.000 MG

00904793960 NORTRIPTYLINE HCL10.000 MG

00904794060 NORTRIPTYLINE HCL25.000 MG

00904794160 NORTRIPTYLINE HCL50.000 MG

00904794260 NORTRIPTYLINE HCL75.000 MG

51079080320 NORTRIPTYLINE HCL10.000 MG

51079080419 NORTRIPTYLINE HCL25.000 MG

51079080420 NORTRIPTYLINE HCL25.000 MG

51079080520 NORTRIPTYLINE HCL50.000 MG

63304020201 NORTRIPTYLINE HCL10.000 MG/5ML

00069152068 NORVASC2.500 MG

00069153041 NORVASC5.000 MG

00069153068 NORVASC5.000 MG

00069153072 NORVASC5.000 MG

00069154041 NORVASC10.000 MG

00069154068 NORVASC10.000 MG

00149009328 NORWICH ASPIRIN325.00 MG

00904092300 NOVAGEST EXPECTORANT/CODE.000

00135010836 NOVAHISTINE DH.000

00135010842 NOVAHISTINE DH.000

00135010936 NOVAHISTINE EXPECTORANT.000

00135010942 NOVAHISTINE EXPECTORANT.000

00074180802 NOVOCAIN1.000 %

00074180806 NOVOCAIN1.000 %

00169185250 NOVOFINE 30.000

00169183711 NOVOLIN 70/30.000

00169347718 NOVOLIN 70/30 PENFILL.000

00169183511 NOVOLIN L100.00 U/ML

00169183411 NOVOLIN N100.00 U/ML

00169347418 NOVOLIN N U-100 PENFILL100.00 U/ML

00169183311 NOVOLIN R100.00 U/ML

00169347318 NOVOLIN R U-100 PENFILL100.00 U/ML

00169185290 NOVOPEN 3 INSULIN DELIVER.000

00536500572 NRS NASAL RELIEF.050 %

00536500575 NRS NASAL RELIEF.050 %

45802002711 NTA.000

45802002735 NTA.000

45802002737 NTA.000

00065920070 NUBASICS.000

00065920170 NUBASICS.000

00065920270 NUBASICS.000

00065924074 NUBASICS.000

00065924174 NUBASICS.000

00065904170 NUBASICS 2.0.000

00065925070 NUBASICS PLUS.000

00065925170 NUBASICS PLUS.000

00065925270 NUBASICS PLUS.000

00065921670 NUBASICS VHP.000

61570001716 NUCOFED.000

61570001860 NUCOFED.000

61570001616 NUCOFED EXPECTORANT.000

61570001516 NUCOFED PEDIATRIC EXPECTO.000

00091311101 NULEV.125 MG

52268030001 NULYTELY.000

52268030101 NULYTELY.000

52268030201 NULYTELY.000

52268030301 NULYTELY.000

00083581286 NUPERCAINAL1.000 %

00083581296 NUPERCAINAL1.000 %

00083584112 NUPERCAINAL.000

00083570096 NUPERCAINAL HC1.000 %

19810007672 NUPRIN200.00 MG

19810007673 NUPRIN200.00 MG

19810007674 NUPRIN200.00 MG

19810007961 NUPRIN200.00 MG

19810007962 NUPRIN200.00 MG

19810007963 NUPRIN200.00 MG

00087063212 NUTRAMENT.000

00087063312 NUTRAMENT.000

00087063412 NUTRAMENT.000

00087063512 NUTRAMENT.000

00087063612 NUTRAMENT.000

Page 72 of 125

Page 73: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00087063712 NUTRAMENT.000

00087049901 NUTRAMIGEN.000

00087026324 NUTRAMIGEN.000

00087429743 NUTRAMIGEN.000

00065902470 NUTREN 1.0.000

00065915072 NUTREN 1.0.000

00065915073 NUTREN 1.0.000

00065903070 NUTREN 1.0.000

00065903170 NUTREN 1.0/FIBER.000

00065902570 NUTREN 1.0/FIBER.000

00065915272 NUTREN 1.0/FIBER/ULTRAPAK.000

00065915273 NUTREN 1.0/FIBER/ULTRAPAK.000

00065915472 NUTREN 1.5.000

00065915473 NUTREN 1.5.000

00065903270 NUTREN 1.5.000

00065903870 NUTREN 1.5.000

00065904070 NUTREN 2.0.000

00065904370 NUTREN JUNIOR.000

00065904570 NUTREN JUNIOR/FIBER.000

00065907870 NUTRIHEP.000

58177035126 NUTRINATE.000

00065925870 NUTRIRENAL.000

00065914072 NUTRIVENT.000

00065908070 NUTRIVENT 1.5.000

00003064350 NYDRAZID100.00 MG/ML

00054860716 NYSTATIN100000 U/ML

00093036616 NYSTATIN100000 U/ML

00093098301 NYSTATIN500000 U

00472132002 NYSTATIN100000 U/ML

00472132016 NYSTATIN100000 U/ML

00472016315 NYSTATIN100000 U/GM

00472016330 NYSTATIN100000 U/GM

00472016615 NYSTATIN100000 U/GM

00472016630 NYSTATIN100000 U/GM

00168003703 NYSTATIN100000 U/ML

00168003760 NYSTATIN100000 U/ML

00168005415 NYSTATIN100000 U/GM

00168005430 NYSTATIN100000 U/GM

00168000715 NYSTATIN100000 U/GM

00168000730 NYSTATIN100000 U/GM

45802004811 NYSTATIN100000 U/GM

45802004835 NYSTATIN100000 U/GM

45802005911 NYSTATIN100000 U/GM

45802005935 NYSTATIN100000 U/GM

00904270631 NYSTATIN100000 U/GM

00904270636 NYSTATIN100000 U/GM

00904276103 NYSTATIN100000 U/ML

00677061301 NYSTATIN500000 U

53489040001 NYSTATIN500000 U

60432053716 NYSTATIN100000 U/ML

60432053760 NYSTATIN100000 U/ML

00904257431 NYSTATIN/TRIAMCINOLONE.000

00904257436 NYSTATIN/TRIAMCINOLONE.000

00168008115 NYSTATIN/TRIAMCINOLONE.000

00168008130 NYSTATIN/TRIAMCINOLONE.000

00168008160 NYSTATIN/TRIAMCINOLONE.000

00168008915 NYSTATIN/TRIAMCINOLONE.000

00168008930 NYSTATIN/TRIAMCINOLONE.000

00168008960 NYSTATIN/TRIAMCINOLONE.000

00472015015 NYSTATIN/TRIAMCINOLONE.000

00472015030 NYSTATIN/TRIAMCINOLONE.000

00472015060 NYSTATIN/TRIAMCINOLONE.000

00472015515 NYSTATIN/TRIAMCINOLONE.000

00472015530 NYSTATIN/TRIAMCINOLONE.000

00472015560 NYSTATIN/TRIAMCINOLONE.000

00574200815 NYSTOP100000 U/GM

58521056610 OBY-TRIM30.000 MG

00256015201 OCEAN NASAL SPRAY.650 %

00256015202 OCEAN NASAL SPRAY.650 %

00904424352 OCTACOSANOL.000

24208076909 OCUCOAT.000

24208076865 OCUCOAT PF.000

58768000101 OCUPRESS1.000 %

58768000102 OCUPRESS1.000 %

58768000104 OCUPRESS1.000 %

17314406403 OCUSERT20.000 MCG/HR

17314408603 OCUSERT40.000 MCG/HR

00677090621 OCUTRICIN.000

24208038760 OCUVITE.000

24208038762 OCUVITE.000

24208038819 OCUVITE EXTRA.000

24208040319 OCUVITE LUTEIN.000

00182101001 ODOR FREE GARLIC100.00 MG

00009377201 OGEN.750 MG

00009377217 OGEN.750 MG

00009377301 OGEN1.500 MG

00009377401 OGEN3.000 MG

52544084828 OGESTREL.000

17236039801 ONE DAILY.000

17236039810 ONE DAILY.000

17236040001 ONE DAILY W/IRON.000

17236040010 ONE DAILY W/IRON.000

00182442801 ONE-TABLET-DAILY NF.000

00182442810 ONE-TABLET-DAILY NF.000

00182442889 ONE-TABLET-DAILY NF.000

00182443601 ONE-TABLET-DAILY W/MINERA.000

00182443610 ONE-TABLET-DAILY W/MINERA.000

00182444001 ONE-TABLET-DAILY/IRON NF.000

00172375377 ONXOL6.000 MG/ML

00172375473 ONXOL6.000 MG/ML

00172375675 ONXOL6.000 MG/ML

63304020301 OPIUM TINCTURE10.000 %

63304020302 OPIUM TINCTURE10.000 %

00065010015 OPTI-CLEAN.000

00065010020 OPTI-CLEAN.000

00065010412 OPTI-CLEAN II CLEANER.000

00065010420 OPTI-CLEAN II CLEANER.000

00904299230 OPTI-CLEAR.050 %

00904299235 OPTI-CLEAR.050 %

00065010612 OPTI-FREE DAILY CLEANER.000

00065010620 OPTI-FREE DAILY CLEANER.000

00065213204 OPTI-FREE EXPRESS MULTI-P.000

00065213212 OPTI-FREE EXPRESS MULTI-P.000

00065013204 OPTI-FREE FOR DISINFECTIO.000

00065013208 OPTI-FREE FOR DISINFECTIO.000

00065013212 OPTI-FREE FOR DISINFECTIO.000

00065019310 OPTI-FREE REWETTING DROPS.000

00065019320 OPTI-FREE REWETTING DROPS.000

00065028503 OPTI-FREE SUPRA CLENS.000

00182441326 OPTI-GEN.000

00065008404 OPTI-ONE.000

00065008405 OPTI-ONE.000

00065008412 OPTI-ONE.000

00065008413 OPTI-ONE.000

00065008910 OPTI-ONE REWETTING.000

00065017804 OPTI-SOAK CONDITIONING.000

00065028012 OPTI-SOAK DAILY CLEANER.000

00065028115 OPTI-SOAK SOOTHING DROPS.000

00065019015 OPTI-TEARS.000

00074428722 OPTILETS-500.000

24208027507 OPTIPRANOLOL.300 %

24208027509 OPTIPRANOLOL.300 %

Page 73 of 125

Page 74: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

57599913404 OPTIUM TEST STRIPS.000

57599913505 OPTIUM TEST STRIPS.000

00574030416 ORA-SWEET.000

00904406203 ORAL PEROXIDE10.000 %

00603081155 ORALSEPTIC.000

00603081255 ORALSEPTIC.000

00536000486 ORALYTE.000

00536093586 ORALYTE.000

00536093686 ORALYTE.000

00054880524 ORAMORPH SR30.000 MG

00054879024 ORAMORPH SR15.000 MG

00054879211 ORAMORPH SR60.000 MG

00054879311 ORAMORPH SR100.00 MG

00054479025 ORAMORPH SR15.000 MG

00054479225 ORAMORPH SR60.000 MG

00054479325 ORAMORPH SR100.00 MG

00054480525 ORAMORPH SR30.000 MG

45802016850 ORASOL6.000 %

45802016863 ORASOL6.000 %

00074698502 ORETIC50.000 MG

00037421410 ORGANIDIN NR100.00 MG/5ML

00037431201 ORGANIDIN NR200.00 MG

00115201101 ORPHENADRINE CITRATE ER100.00 MG

00115201102 ORPHENADRINE CITRATE ER100.00 MG

00185002201 ORPHENADRINE CITRATE ER100.00 MG

00185002210 ORPHENADRINE CITRATE ER100.00 MG

00781164901 ORPHENADRINE CITRATE ER100.00 MG

00185071301 ORPHENADRINE COMPOUND.000

00185071305 ORPHENADRINE COMPOUND.000

00185071401 ORPHENADRINE COMPOUND DS.000

00378335401 ORPHENADRINE/ASA/CAFF.000

00378335601 ORPHENADRINE/ASA/CAFF.000

00904523860 ORPHENADRINE/ASA/CAFF.000

49884047201 ORPHENGESIC.000

49884047205 ORPHENGESIC.000

49884047301 ORPHENGESIC FORTE.000

49884047305 ORPHENGESIC FORTE.000

00008069001 ORUVAIL200.00 MG

00766165160 OS-CAL1250.0 MG

00766165460 OS-CAL 500 + D.000

10267155107 OSCAL 500/200 D-3.000

00603723873 OTICAINE OTIC20.000 %

52604021805 OTOCAIN20.000 %

00008251101 OVRAL 28.000

00008251102 OVRAL 28.000

00093415773 OXACILLIN SODIUM250.00 MG/5ML

00015710328 OXACILLIN SODIUM10.000 GM

00015797018 OXACILLIN SODIUM2.000 GM

00015798120 OXACILLIN SODIUM1.000 GM

00015710398 OXACILLIN SODIUM10.000 GM

00015797020 OXACILLIN SODIUM2.000 GM

00015797089 OXACILLIN SODIUM2.000 GM

00015797099 OXACILLIN SODIUM2.000 GM

00015798118 OXACILLIN SODIUM1.000 GM

00015798189 OXACILLIN SODIUM1.000 GM

00015798199 OXACILLIN SODIUM1.000 GM

49884072301 OXAPROZIN600.00 MG

49884072305 OXAPROZIN600.00 MG

00185014101 OXAPROZIN600.00 MG

00185014105 OXAPROZIN600.00 MG

59762500201 OXAPROZIN600.00 MG

59762500202 OXAPROZIN600.00 MG

59930150801 OXAPROZIN600.00 MG

59930150802 OXAPROZIN600.00 MG

00228206710 OXAZEPAM10.000 MG

00228206750 OXAZEPAM10.000 MG

00228206910 OXAZEPAM15.000 MG

00228206950 OXAZEPAM15.000 MG

00228207310 OXAZEPAM30.000 MG

00172480460 OXAZEPAM10.000 MG

00172480470 OXAZEPAM10.000 MG

00172480560 OXAZEPAM15.000 MG

00172480570 OXAZEPAM15.000 MG

00172480660 OXAZEPAM30.000 MG

00641450886 OXAZEPAM10.000 MG

00641450888 OXAZEPAM10.000 MG

00641451086 OXAZEPAM30.000 MG

00641451088 OXAZEPAM30.000 MG

00781280901 OXAZEPAM10.000 MG

00781281001 OXAZEPAM15.000 MG

00781281101 OXAZEPAM30.000 MG

00766750420 OXY 10 BALANCE EMERGENCY10.000 %

00766750020 OXY 10 BALANCE EMERGENCY10.000 %

00766700150 OXY 10 BALANCE MAXIMUM ME10.000 %

00766700250 OXY BALANCE.000

00766700290 OXY BALANCE.000

00766750030 OXY BALANCE EMERGENCY SPO5.000 %

00766700160 OXY BALANCE FACIAL CLEANS2.000 %

00766700350 OXY BALANCE GENTLE.000

00766700390 OXY BALANCE GENTLE.000

00766700450 OXY BALANCE MAXIMUM.000

00766700490 OXY BALANCE MAXIMUM.000

00832003800 OXYBUTYNIN CHLORIDE5.000 MG

00832003810 OXYBUTYNIN CHLORIDE5.000 MG

00832003850 OXYBUTYNIN CHLORIDE5.000 MG

00641402086 OXYBUTYNIN CHLORIDE5.000 MG

00641402089 OXYBUTYNIN CHLORIDE5.000 MG

00615351243 OXYBUTYNIN CHLORIDE5.000 MG

17236085001 OXYBUTYNIN CHLORIDE5.000 MG

17236085010 OXYBUTYNIN CHLORIDE5.000 MG

17236085011 OXYBUTYNIN CHLORIDE5.000 MG

00904522360 OXYBUTYNIN CHLORIDE5.000 MG

00904522380 OXYBUTYNIN CHLORIDE5.000 MG

00904282160 OXYBUTYNIN CHLORIDE5.000 MG

00904282161 OXYBUTYNIN CHLORIDE5.000 MG

51079062819 OXYBUTYNIN CHLORIDE5.000 MG

51079062820 OXYBUTYNIN CHLORIDE5.000 MG

50111045601 OXYBUTYNIN CHLORIDE5.000 MG

50111045602 OXYBUTYNIN CHLORIDE5.000 MG

50111045603 OXYBUTYNIN CHLORIDE5.000 MG

54838051080 OXYBUTYNIN CHLORIDE5.000 MG/5ML

00182128989 OXYBUTYNIN CHLORIDE5.000 MG

00603497502 OXYBUTYNIN CHLORIDE5.000 MG

00603497503 OXYBUTYNIN CHLORIDE5.000 MG

00603497504 OXYBUTYNIN CHLORIDE5.000 MG

00603497516 OXYBUTYNIN CHLORIDE5.000 MG

00603497520 OXYBUTYNIN CHLORIDE5.000 MG

00603497521 OXYBUTYNIN CHLORIDE5.000 MG

00603497522 OXYBUTYNIN CHLORIDE5.000 MG

00603497528 OXYBUTYNIN CHLORIDE5.000 MG

00603497532 OXYBUTYNIN CHLORIDE5.000 MG

00603149058 OXYBUTYNIN CHLORIDE5.000 MG/5ML

60258007116 OXYBUTYNIN CHLORIDE5.000 MG/5ML

60432009216 OXYBUTYNIN CHLORIDE5.000 MG/5ML

60505600809 OXYBUTYNIN CHLORIDE5.000 MG/5ML

58177004104 OXYCODONE HCL5.000 MG

58177031504 OXYCODONE HCL5.000 MG

00603499721 OXYCODONE/ACETAMINOPHEN.000

00603499821 OXYCODONE/ACETAMINOPHEN.000

00603499828 OXYCODONE/ACETAMINOPHEN.000

00254483228 OXYCODONE/ACETAMINOPHEN.000

00054279525 OXYCODONE/ACETAMINOPHEN.000

Page 74 of 125

Page 75: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

51285065802 OXYCODONE/ACETAMINOPHEN.000

59011022520 OXYFAST20.000 MG/ML

59011020110 OXYIR5.000 MG

45802031359 OXYMETAZOLINE HCL.050 %

45802031360 OXYMETAZOLINE HCL.050 %

45802031394 OXYMETAZOLINE HCL.050 %

51079021915 OXYMETAZOLINE HCL.050 %

50383067715 OXYMETAZOLINE HCL.050 %

50383067730 OXYMETAZOLINE HCL.050 %

00904270530 OXYMETAZOLINE HCL.050 %

00904270535 OXYMETAZOLINE HCL.050 %

60793041605 OXYTOCIN10.000 U/ML

00536410602 OYSCO 5001250.0 MG

00536410608 OYSCO 5001250.0 MG

00536781708 OYSCO 500/D.000

00536410301 OYSCO D.000

00536410302 OYSCO D.000

00536410310 OYSCO D.000

00182157607 OYST-CAL500.00 MG

00182157610 OYST-CAL500.00 MG

00182157626 OYST-CAL500.00 MG

00182041801 OYST-CAL D.000

00182041809 OYST-CAL D.000

00182041810 OYST-CAL D.000

00182443910 OYST-CAL-D 500.000

00182443926 OYST-CAL-D 500.000

00904188413 OYSTER1250.0 MG

00904188452 OYSTER1250.0 MG

00904188352 OYSTER CALCIUM1250.0 MG

00904188361 OYSTER CALCIUM1250.0 MG

00904188372 OYSTER CALCIUM1250.0 MG

00904188380 OYSTER CALCIUM1250.0 MG

00904188392 OYSTER CALCIUM1250.0 MG

17236043401 OYSTER SHELL1250.0 MG

17236043410 OYSTER SHELL1250.0 MG

00904546052 OYSTER SHELL CALCIUM/VITA.000

00904546072 OYSTER SHELL CALCIUM/VITA.000

00904546080 OYSTER SHELL CALCIUM/VITA.000

00904546092 OYSTER SHELL CALCIUM/VITA.000

00615457243 OYSTER SHELL CALCIUM/VITA.000

17236043501 OYSTER SHELL/VITAMIN D.000

17236043510 OYSTER SHELL/VITAMIN D.000

00904188260 OYSTER-D.000

00904188261 OYSTER-D.000

00904188272 OYSTER-D.000

00904188280 OYSTER-D.000

00575400704 P & S2.000 %

00575400708 P & S2.000 %

00245014530 PACERONE400.00 MG

00245014701 PACERONE200.00 MG

00245014715 PACERONE200.00 MG

00245014760 PACERONE200.00 MG

00245014790 PACERONE200.00 MG

00713028304 PAIN RELIEVING RUB.000

00078001633 PAMELOR10.000 MG/5ML

00078008708 PAMELOR25.000 MG

00115702901 PANCRELIPASE.000

00115702902 PANCRELIPASE.000

00904541360 PANCRELIPASE.000

00904541370 PANCRELIPASE.000

00904347240 PANCRELIPASE.000

00904347260 PANCRELIPASE.000

59743012501 PANCRELIPASE.000

59743012525 PANCRELIPASE.000

59879012201 PANCRELIPASE MST-16.000

59879050501 PANCRON 10.000

59879012601 PANCRON 20.000

00641254625 PANCURONIUM BROMIDE2.000 MG/ML

58177002904 PANGESTYME CN 10.000

58177003004 PANGESTYME CN 20.000

58177003104 PANGESTYME EC.000

58177003106 PANGESTYME EC.000

58177002804 PANGESTYME MT 16.000

58177004804 PANGESTYME UL 12.000

58177004904 PANGESTYME UL 18.000

58177005004 PANGESTYME UL 20.000

51991065501 PANOKASE.000

51991065505 PANOKASE.000

00904315360 PANTOTHENIC ACID200.00 MG

00536671701 PANTOTHENIC ACID500.00 MG

60258003130 PAPAIN-UREA-CHLOROPHYLLIN.000

60793022501 PAPAVERINE HCL30.000 MG/ML

60793022510 PAPAVERINE HCL30.000 MG/ML

00677017101 PAPAVERINE HCL CR150.00 MG

00677017110 PAPAVERINE HCL CR150.00 MG

00904218060 PAPAVERINE HCL CR150.00 MG

00603504321 PAPAVERINE HCL CR150.00 MG

00603504332 PAPAVERINE HCL CR150.00 MG

00185515601 PAPAVERINE HCL CR150.00 MG

00185515610 PAPAVERINE HCL CR150.00 MG

00536650601 PAPAYA ENZYME.000

00904135413 PAPAYA ENZYMES.000

00904424260 PARA-AMINOBENZOIC ACID500.00 MG

49483001901 PARA-TIME150.00 MG

49483001910 PARA-TIME150.00 MG

00472080216 PAREGORIC2.000 MG/5ML

60432045716 PAREGORIC2.000 MG/5ML

00078010205 PARLODEL5.000 MG

00078010215 PARLODEL5.000 MG

00078001705 PARLODEL2.500 MG

00078001715 PARLODEL2.500 MG

57664017508 PAROMOMYCIN SULFATE250.00 MG

00029321013 PAXIL10.000 MG

00029321113 PAXIL20.000 MG

00029321120 PAXIL20.000 MG

00029321121 PAXIL20.000 MG

00029321213 PAXIL30.000 MG

00029321313 PAXIL40.000 MG

00074483148 PCA INJECTOR.000

00904505020 PEDIA RELIEF COUGH/COLD.000

00009771601 PEDIACARE COUGH/COLD.000

00009771401 PEDIACARE INFANT7.500 MG/0.8ML

00009771501 PEDIACARE INFANT DECONGES.000

00009771301 PEDIACARE NIGHT REST.000

00024150906 PEDIACOF.000

00074010150 PEDIAFLOR.500 MG/ML

00074024001 PEDIALYTE.000

00074517530 PEDIALYTE.000

00074647008 PEDIALYTE.000

00074647032 PEDIALYTE.000

00074647132 PEDIALYTE.000

00074024501 PEDIALYTE FREEZER POPS.000

00074549820 PEDIALYTE SINGLES.000

53014025001 PEDIAPRED6.700 MG/5ML

54838011540 PEDIATRIC COUGH/COLD.000

00182615537 PEDIATRIC COUGH/COLD.000

00904527669 PEDIATRIC ELECTROLYTE.000

00904511869 PEDIATRIC ELECTROLYTE.000

00904785069 PEDIATRIC ELECTROLYTE.000

00904765969 PEDIATRIC ELECTROLYTE.000

00182620558 PEDIATRIC ELECTROLYTE.000

00182620658 PEDIATRIC ELECTROLYTE.000

Page 75 of 125

Page 76: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00182620758 PEDIATRIC ELECTROLYTE.000

00074803013 PEDIAZOLE.000

00074803043 PEDIAZOLE.000

00074803053 PEDIAZOLE.000

61570003875 PEDIOTIC.000

00006489700 PEDVAX HIB.000

62175044601 PEG 3350/ELECTROLYTES.000

00093947201 PEMOLINE75.000 MG

00093952401 PEMOLINE37.500 MG

00093954101 PEMOLINE18.750 MG

00093957701 PEMOLINE37.500 MG

00603505521 PEMOLINE18.750 MG

00603505621 PEMOLINE37.500 MG

00603505628 PEMOLINE37.500 MG

00603505721 PEMOLINE75.000 MG

00781173101 PEMOLINE18.750 MG

00781174101 PEMOLINE37.500 MG

00781175101 PEMOLINE75.000 MG

00003063441 PENICILLIN G POTASSIUM1.000 MU

00003066805 PENICILLIN G SODIUM500000 U

00781165501 PENICILLIN V POTASSIUM500.00 MG

00781165510 PENICILLIN V POTASSIUM500.00 MG

00781120501 PENICILLIN V POTASSIUM250.00 MG

00781120510 PENICILLIN V POTASSIUM250.00 MG

00904245060 PENICILLIN V POTASSIUM250.00 MG

00904245080 PENICILLIN V POTASSIUM250.00 MG

00904245160 PENICILLIN V POTASSIUM500.00 MG

00904245280 PENICILLIN V POTASSIUM500.00 MG

00677010929 PENICILLIN V POTASSIUM125.00 MG/5ML

00904400104 PENICILLIN V POTASSIUM125.00 MG/5ML

00904400108 PENICILLIN V POTASSIUM125.00 MG/5ML

00904400404 PENICILLIN V POTASSIUM250.00 MG/5ML

00904400408 PENICILLIN V POTASSIUM250.00 MG/5ML

00047064824 PENICILLIN V POTASSIUM250.00 MG

00047064832 PENICILLIN V POTASSIUM250.00 MG

60429014740 PENICILLIN V POTASSIUM250.00 MG

00074454801 PENTAMIDINE ISETHIONATE300.00 MG

00074454849 PENTAMIDINE ISETHIONATE300.00 MG

63304050601 PENTAZOCINE/NALOXONE HCL.000

00074643501 PENTOTHAL1.000 GM

00074610801 PENTOTHAL5.000 GM

17236086201 PENTOXIFYLLINE CR400.00 MG

17236086205 PENTOXIFYLLINE CR400.00 MG

17236066201 PENTOXIFYLLINE CR400.00 MG

17236066210 PENTOXIFYLLINE CR400.00 MG

60429070390 PENTOXIFYLLINE CR400.00 MG

00904544840 PENTOXIFYLLINE ER400.00 MG

00904544860 PENTOXIFYLLINE ER400.00 MG

00904544861 PENTOXIFYLLINE ER400.00 MG

00615452343 PENTOXIFYLLINE ER400.00 MG

51079088919 PENTOXIFYLLINE ER400.00 MG

51079088920 PENTOXIFYLLINE ER400.00 MG

50111060901 PENTOXIFYLLINE ER400.00 MG

50111060902 PENTOXIFYLLINE ER400.00 MG

00115704401 PENTOXIFYLLINE ER400.00 MG

00115704402 PENTOXIFYLLINE ER400.00 MG

00115704403 PENTOXIFYLLINE ER400.00 MG

00093511601 PENTOXIFYLLINE ER400.00 MG

00378035701 PENTOXIFYLLINE ER400.00 MG

00378035705 PENTOXIFYLLINE ER400.00 MG

62037095101 PENTOXIFYLLINE ER400.00 MG

62037095105 PENTOXIFYLLINE ER400.00 MG

60505003306 PENTOXIFYLLINE ER400.00 MG

60505003307 PENTOXIFYLLINE ER400.00 MG

00245002701 PENTOXIL400.00 MG

00245002711 PENTOXIL400.00 MG

00245002715 PENTOXIL400.00 MG

00245002755 PENTOXIL400.00 MG

00006096328 PEPCID20.000 MG

00006096331 PEPCID20.000 MG

00006096358 PEPCID20.000 MG

00006096372 PEPCID20.000 MG

00006096382 PEPCID20.000 MG

00006096394 PEPCID20.000 MG

00006096428 PEPCID40.000 MG

00006096431 PEPCID40.000 MG

00006096458 PEPCID40.000 MG

00006096482 PEPCID40.000 MG

00006096494 PEPCID40.000 MG

00006353904 PEPCID I.V.10.000 MG/ML

00006354114 PEPCID I.V.10.000 MG/ML

00006354149 PEPCID I.V.10.000 MG/ML

00006353750 PEPCID PREMIXED.000

00065901470 PEPTAMEN.000

00065906672 PEPTAMEN.000

00065906673 PEPTAMEN.000

00065906770 PEPTAMEN.000

00065908770 PEPTAMEN 1.5.000

00065908870 PEPTAMEN 1.5.000

00065908972 PEPTAMEN 1.5.000

00065906970 PEPTAMEN JUNIOR.000

00065907070 PEPTAMEN JUNIOR.000

00065901572 PEPTAMEN JUNIOR.000

00065907170 PEPTAMEN VHP.000

00065907370 PEPTAMEN VHP.000

00065906872 PEPTAMEN VHP.000

00065906873 PEPTAMEN VHP.000

00536181059 PEPTIC RELIEF527.00 MG/30ML

00536430107 PEPTIC RELIEF300.00 MG

54092041816 PERI-COLACE.000

54092041808 PERI-COLACE.000

50383076916 PERI-DOCU.000

51284062022 PERIDEX ORAL RINSE.120 %

59075061530 PERMAX.050 MG

59075062510 PERMAX.250 MG

00472524267 PERMETHRIN1.000 %

00472524269 PERMETHRIN1.000 %

00603509021 PERPHENAZINE2.000 MG

00603509028 PERPHENAZINE2.000 MG

00603509121 PERPHENAZINE4.000 MG

00603509128 PERPHENAZINE4.000 MG

00603509221 PERPHENAZINE8.000 MG

00603509228 PERPHENAZINE8.000 MG

00603509321 PERPHENAZINE16.000 MG

00172366760 PERPHENAZINE2.000 MG

00172366860 PERPHENAZINE4.000 MG

00172366960 PERPHENAZINE8.000 MG

00172367060 PERPHENAZINE16.000 MG

00904187261 PERPHENAZINE2.000 MG

00904187340 PERPHENAZINE4.000 MG

00781104601 PERPHENAZINE2.000 MG

00781104610 PERPHENAZINE2.000 MG

00781104613 PERPHENAZINE2.000 MG

00781104701 PERPHENAZINE4.000 MG

00781104710 PERPHENAZINE4.000 MG

00781104713 PERPHENAZINE4.000 MG

00781104801 PERPHENAZINE8.000 MG

00781104810 PERPHENAZINE8.000 MG

00781104813 PERPHENAZINE8.000 MG

00781104901 PERPHENAZINE16.000 MG

00904763661 PERPHENAZINE/AMITRIPTYLIN.000

00904763761 PERPHENAZINE/AMITRIPTYLIN.000

Page 76 of 125

Page 77: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00378033001 PERPHENAZINE/AMITRIPTYLIN.000

00378033005 PERPHENAZINE/AMITRIPTYLIN.000

00378004201 PERPHENAZINE/AMITRIPTYLIN.000

00378007301 PERPHENAZINE/AMITRIPTYLIN.000

00378057401 PERPHENAZINE/AMITRIPTYLIN.000

00378057405 PERPHENAZINE/AMITRIPTYLIN.000

00378044201 PERPHENAZINE/AMITRIPTYLIN.000

00378044205 PERPHENAZINE/AMITRIPTYLIN.000

00597001701 PERSANTINE25.000 MG

00597001801 PERSANTINE50.000 MG

00597001901 PERSANTINE75.000 MG

00168005316 PETROLATUM.000

00168005321 PETROLATUM.000

00168005331 PETROLATUM.000

00168005345 PETROLATUM.000

00049052083 PFIZERPEN-G5.000 MU

00049053028 PFIZERPEN-G20.000 MU

45802017517 PH SKIN CLEANSER.000

45802017582 PH SKIN CLEANSER.000

00575101208 PHACID.000

08881600285 PHARM MONOJECT INSULIN SY.000

08881601861 PHARM MONOJECT INSULIN SY.000

00904514159 PHENAGESIC.000

00536242558 PHENASEPTIC.000

00603514121 PHENAZOPYRIDINE HCL100.00 MG

00603514132 PHENAZOPYRIDINE HCL100.00 MG

00603514221 PHENAZOPYRIDINE HCL200.00 MG

00603514232 PHENAZOPYRIDINE HCL200.00 MG

00182090401 PHENAZOPYRIDINE HCL200.00 MG

00182013801 PHENAZOPYRIDINE HCL100.00 MG

00254497128 PHENAZOPYRIDINE HCL100.00 MG

00254497228 PHENAZOPYRIDINE HCL200.00 MG

10267086001 PHENAZOPYRIDINE HCL200.00 MG

00904792260 PHENAZOPYRIDINE HCL100.00 MG

00904792360 PHENAZOPYRIDINE HCL200.00 MG

00904792380 PHENAZOPYRIDINE HCL200.00 MG

00677057501 PHENAZOPYRIDINE HCL100.00 MG

00677080401 PHENAZOPYRIDINE HCL200.00 MG

51991052001 PHENAZOPYRIDINE HCL100.00 MG

51991052501 PHENAZOPYRIDINE HCL200.00 MG

53265019610 PHENAZOPYRIDINE HCL100.00 MG

53265019611 PHENAZOPYRIDINE HCL100.00 MG

53265019710 PHENAZOPYRIDINE HCL200.00 MG

53265019711 PHENAZOPYRIDINE HCL200.00 MG

00677149901 PHENDIMETRAZINE TARTRATE35.000 MG

00677149910 PHENDIMETRAZINE TARTRATE35.000 MG

00185525401 PHENDIMETRAZINE TARTRATE105.00 MG

00185525410 PHENDIMETRAZINE TARTRATE105.00 MG

00185405701 PHENDIMETRAZINE TARTRATE35.000 MG

00185405710 PHENDIMETRAZINE TARTRATE35.000 MG

00008021201 PHENERGAN25.000 MG

00008022701 PHENERGAN50.000 MG

00008022901 PHENERGAN50.000 MG

00008001901 PHENERGAN12.500 MG

00008002702 PHENERGAN25.000 MG

00008002707 PHENERGAN25.000 MG

00008049801 PHENERGAN12.500 MG

00228202896 PHENOBARBITAL30.000 MG

00228202696 PHENOBARBITAL15.000 MG

00254501128 PHENOBARBITAL16.200 MG

00254501228 PHENOBARBITAL32.400 MG

00254501238 PHENOBARBITAL32.400 MG

00254501428 PHENOBARBITAL97.200 MG

00143144510 PHENOBARBITAL15.000 MG

00143145010 PHENOBARBITAL30.000 MG

00143145510 PHENOBARBITAL60.000 MG

00143145801 PHENOBARBITAL100.00 MG

00143145810 PHENOBARBITAL100.00 MG

00603516521 PHENOBARBITAL16.200 MG

00603516532 PHENOBARBITAL16.200 MG

00603516602 PHENOBARBITAL32.400 MG

00603516616 PHENOBARBITAL32.400 MG

00603516620 PHENOBARBITAL32.400 MG

00603516621 PHENOBARBITAL32.400 MG

00603516622 PHENOBARBITAL32.400 MG

00603516632 PHENOBARBITAL32.400 MG

00603516721 PHENOBARBITAL64.800 MG

00603516732 PHENOBARBITAL64.800 MG

00603516821 PHENOBARBITAL97.200 MG

00603516832 PHENOBARBITAL97.200 MG

00603150858 PHENOBARBITAL20.000 MG/5ML

00472101516 PHENOBARBITAL20.000 MG/5ML

00904382780 PHENOBARBITAL30.000 MG

00677169810 PHENOBARBITAL64.800 MG

00677169910 PHENOBARBITAL97.200 MG

00677173110 PHENOBARBITAL15.000 MG

00677173210 PHENOBARBITAL30.000 MG

00904101528 PHENOBARBITAL20.000 MG/5ML

51079009420 PHENOBARBITAL15.000 MG

51079009520 PHENOBARBITAL30.000 MG

63304074101 PHENOBARBITAL15.000 MG

63304074201 PHENOBARBITAL30.000 MG

63304074210 PHENOBARBITAL30.000 MG

63304074301 PHENOBARBITAL60.000 MG

63304074310 PHENOBARBITAL60.000 MG

63304074401 PHENOBARBITAL100.00 MG

00641047725 PHENOBARBITAL SODIUM130.00 MG/ML

00008030401 PHENOBARBITAL SODIUM TUBE130.00 MG/ML

51552011804 PHENOL.000

00904061480 PHENTERMINE HCL30.000 MG

00677046001 PHENTERMINE HCL30.000 MG

00677046010 PHENTERMINE HCL30.000 MG

00677082910 PHENTERMINE HCL37.500 MG

00603519032 PHENTERMINE HCL30.000 MG

00228301611 PHENTERMINE HCL37.500 MG

00228301696 PHENTERMINE HCL37.500 MG

00185500001 PHENTERMINE HCL30.000 MG

00185500010 PHENTERMINE HCL30.000 MG

00185064401 PHENTERMINE HCL15.000 MG

00185064410 PHENTERMINE HCL15.000 MG

00185064701 PHENTERMINE HCL30.000 MG

00185064710 PHENTERMINE HCL30.000 MG

60793000901 PHENTERMINE HCL30.000 MG

52604915108 PHENTRIDE30.000 MG

52604915208 PHENTRIDE30.000 MG

61314034201 PHENYLEPHRINE HCL2.500 %

61314034202 PHENYLEPHRINE HCL2.500 %

00182102701 PHENYLGESIC.000

00182102710 PHENYLGESIC.000

00603152054 PHENYLHISTINE DH MODIFIED.000

00603152058 PHENYLHISTINE DH MODIFIED.000

00603152154 PHENYLHISTINE EXPECTORANT.000

00603152158 PHENYLHISTINE EXPECTORANT.000

00472006708 PHENYTOIN125.00 MG/5ML

00074184402 PHENYTOIN SODIUM50.000 MG/ML

00074184405 PHENYTOIN SODIUM50.000 MG/ML

00074184432 PHENYTOIN SODIUM50.000 MG/ML

00074131701 PHENYTOIN SODIUM50.000 MG/ML

00074131702 PHENYTOIN SODIUM50.000 MG/ML

00641049325 PHENYTOIN SODIUM50.000 MG/ML

00641255545 PHENYTOIN SODIUM50.000 MG/ML

51079090519 PHENYTOIN SODIUM EXTENDED100.00 MG

Page 77 of 125

Page 78: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

51079090520 PHENYTOIN SODIUM EXTENDED100.00 MG

00378156001 PHENYTOIN SODIUM EXTENDED100.00 MG

00378156010 PHENYTOIN SODIUM EXTENDED100.00 MG

00172205760 PHENYTOIN SODIUM PROMPT100.00 MG

00904205780 PHENYTOIN SODIUM PROMPT100.00 MG

08024152108 PHISODERM.000

08024152124 PHISODERM.000

08024152148 PHISODERM.000

08024001005 PHISODERM FOR BABY.000

00046106505 PHOSPHOLINE IODIDE.125 %

00074614102 PHYSIOSOL IRRIGATION.000

00074614103 PHYSIOSOL IRRIGATION.000

00074614109 PHYSIOSOL IRRIGATION.000

00074614122 PHYSIOSOL IRRIGATION.000

00074701205 PHYSIOSOL IRRIGATION PH 7.000

60267060066 PHYSOSTIGMINE SALICYLATE1.000 MG/ML

00548114000 PHYTONADIONE2.000 MG/ML

58768051415 PILOCAR.500 %

58768051512 PILOCAR1.000 %

58768051515 PILOCAR1.000 %

58768051612 PILOCAR2.000 %

58768051615 PILOCAR2.000 %

58768051634 PILOCAR2.000 %

58768051812 PILOCAR4.000 %

58768051815 PILOCAR4.000 %

58768051834 PILOCAR4.000 %

58768051915 PILOCAR6.000 %

58768051934 PILOCAR6.000 %

00603724941 PILOCARPINE HCL2.000 %

00168017615 PILOCARPINE HCL6.000 %

00065072812 PILOCARPINE HCL1.000 %

00065075212 PILOCARPINE HCL2.000 %

00065075612 PILOCARPINE HCL4.000 %

00904271635 PILOCARPINE HCL3.000 %

00904271835 PILOCARPINE HCL6.000 %

24208067615 PILOCARPINE HCL1.000 %

24208067630 PILOCARPINE HCL1.000 %

24208068115 PILOCARPINE HCL2.000 %

24208068130 PILOCARPINE HCL2.000 %

24208068615 PILOCARPINE HCL4.000 %

24208068630 PILOCARPINE HCL4.000 %

24208080615 PILOCARPINE HCL.500 %

24208081115 PILOCARPINE HCL3.000 %

24208082115 PILOCARPINE HCL6.000 %

61314020315 PILOCARPINE HCL1.000 %

61314020415 PILOCARPINE HCL2.000 %

61314020615 PILOCARPINE HCL4.000 %

61314020815 PILOCARPINE HCL6.000 %

00065021535 PILOPINE HS4.000 %

55806002410 PIN-X250.00 MG/5ML

55806002411 PIN-X250.00 MG/5ML

00172421760 PINDOLOL5.000 MG

00172421860 PINDOLOL10.000 MG

00378005201 PINDOLOL5.000 MG

00378012701 PINDOLOL10.000 MG

50383062008 PINK BISMUTH527.00 MG/30ML

50383062016 PINK BISMUTH527.00 MG/30ML

00603023516 PINK BISMUTH262.00 MG

00182109117 PINK BISMUTH262.00 MG

00182181144 PINK BISMUTH527.00 MG/30ML

50383062108 PINK BISMUTH MAXIMUM STRE690.00 MG/30ML

50383062116 PINK BISMUTH MAXIMUM STRE690.00 MG/30ML

51079074220 PIROXICAM10.000 MG

51079074320 PIROXICAM20.000 MG

52555097201 PIROXICAM10.000 MG

52555097301 PIROXICAM20.000 MG

52555097305 PIROXICAM20.000 MG

00904506340 PIROXICAM20.000 MG

00904506360 PIROXICAM20.000 MG

00904769760 PIROXICAM10.000 MG

00904769840 PIROXICAM20.000 MG

00904769860 PIROXICAM20.000 MG

00904784560 PIROXICAM10.000 MG

00904781240 PIROXICAM20.000 MG

00904781260 PIROXICAM20.000 MG

00378202001 PIROXICAM20.000 MG

00378202005 PIROXICAM20.000 MG

00378101001 PIROXICAM10.000 MG

00093075601 PIROXICAM10.000 MG

00093075701 PIROXICAM20.000 MG

00093075705 PIROXICAM20.000 MG

63304069001 PIROXICAM10.000 MG

63304069101 PIROXICAM20.000 MG

63304069105 PIROXICAM20.000 MG

61570041601 PITOCIN10.000 U/ML

61570041603 PITOCIN10.000 U/ML

61570041605 PITOCIN10.000 U/ML

61570041606 PITOCIN10.000 U/ML

61570042001 PITRESSIN SYNTHETIC20.000 U/ML

61570042003 PITRESSIN SYNTHETIC20.000 U/ML

00074668510 PLACIDYL500.00 MG

00024156210 PLAQUENIL200.00 MG

00026068416 PLASBUMIN-2525.000 %

00026068420 PLASBUMIN-2525.000 %

00026068471 PLASBUMIN-2525.000 %

00026068520 PLASBUMIN-55.000 %

00026068525 PLASBUMIN-55.000 %

00053775301 PLASMA PLEX W/ADMIN SET5.000 %

00053775302 PLASMA PLEX W/ADMIN SET5.000 %

00053775303 PLASMA PLEX W/ADMIN SET5.000 %

00026061320 PLASMANATE5.000 %

00026061325 PLASMANATE5.000 %

08290008479 PLASTIC ADAPTER FOR BUSH.000

08290008499 PLASTIC ADAPTER FOR BUSH.000

00015322197 PLATINOL1.000 MG/ML

00015322022 PLATINOL AQ1.000 MG/ML

00015322122 PLATINOL AQ1.000 MG/ML

63653117101 PLAVIX75.000 MG

63653117103 PLAVIX75.000 MG

63653117105 PLAVIX75.000 MG

63653117106 PLAVIX75.000 MG

00074796905 PLEGISOL CARDIOPLEGIC SOL.000

00186045028 PLENDIL2.500 MG

00186045058 PLENDIL2.500 MG

00186045128 PLENDIL5.000 MG

00186045158 PLENDIL5.000 MG

00186045228 PLENDIL10.000 MG

00186045258 PLENDIL10.000 MG

59148000216 PLETAL100.00 MG

59148000235 PLETAL100.00 MG

59148000316 PLETAL50.000 MG

99207074106 PLEXION.000

99207074112 PLEXION.000

99207074330 PLEXION TS.000

00058012225 PLIAGEL.000

00006494300 PNEUMOVAX-23/1 DOSE25.000 MCG/0.5M

00006473900 PNEUMOVAX-23/5 DOSE25.000 MCG/0.5M

00574060115 PODOCON 25 IN BENZOIN TIN25.000 %

00186041001 POLOCAINE1.000 %

00186042001 POLOCAINE2.000 %

00186042201 POLOCAINE-MPF2.000 %

00186041201 POLOCAINE-MPF1.000 %

Page 78 of 125

Page 79: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00024164716 POLY-HISTINE.000

60258018601 POLY-IRON 150 FORTE.000

00087047202 POLY-VI-FLOR.000

00087047402 POLY-VI-FLOR.000

00087046841 POLY-VI-FLOR.000

00087045141 POLY-VI-FLOR.000

00087048741 POLY-VI-FLOR.000

00087048241 POLY-VI-FLOR/IRON.000

00087048341 POLY-VI-FLOR/IRON.000

00087040203 POLY-VI-SOL.000

00087041402 POLY-VI-SOL.000

00087041406 POLY-VI-SOL.000

00087040501 POLY-VI-SOL/IRON.000

00087045602 POLY-VI-SOL/IRON.000

00182609667 POLY-VIT DROPS W/FLUORIDE.000

50383064150 POLY-VITAMIN.000

54838000350 POLY-VITAMIN.000

50383062550 POLY-VITAMIN DROPS.000

50383064250 POLY-VITAMIN/FLUORIDE.000

54838051850 POLY-VITAMIN/FLUORIDE.000

54838051950 POLY-VITAMIN/FLUORIDE.000

50383063250 POLY-VITAMIN/IRON DROPS.000

50383063350 POLY-VITAMIN/IRON/FLUORID.000

50383063450 POLY-VITAMIN/IRON/FLUORID.000

54838052050 POLY-VITAMIN/IRON/FLUORID.000

00536845080 POLY-VITAMINS.000

00536430401 POLY-VITAMINS.000

00536853080 POLY-VITAMINS/IRON.000

54838000450 POLY-VITAMINS/IRON.000

00574030905 POLYBASE.000

00574030916 POLYBASE.000

17314932201 POLYCITRA.000

17314932101 POLYCITRA-K.000

17314932001 POLYCITRA-K CRYSTALS.000

00575022101 POLYCITRA-K CRYSTALS.000

00575022401 POLYCITRA-LC.000

17314932301 POLYCITRA-LC.000

61314062810 POLYMYXIN B SULFATE/TRIME.000

00677159701 POLYSACCHARIDE IRON COMPL150.00 MG

59879010501 POLYSACCHARIDE IRON COMPL150.00 MG

00168021702 POLYSORB HYDRATE.000

00168021716 POLYSORB HYDRATE.000

00081079858 POLYSPORIN.000

00081079888 POLYSPORIN.000

00081079887 POLYSPORIN.000

61570004935 POLYSPORIN.000

00536781601 POLYVITAMIN/IRON.000

00904098850 POLYVITE.000

00904269750 POLYVITE/IRON.000

00074186601 PONTOCAINE2.000 %

00074186602 PONTOCAINE2.000 %

00904323060 POTASSIUM75.000 MG

00074818301 POTASSIUM ACETATE2.000 MEQ/ML

00074329406 POTASSIUM ACETATE FLIPTOP2.000 MEQ/ML

00074329451 POTASSIUM ACETATE FLIPTOP2.000 MEQ/ML

44184002502 POTASSIUM BICARB/CHLORIDE.000

44184002504 POTASSIUM BICARB/CHLORIDE.000

44184002506 POTASSIUM BICARB/CHLORIDE.000

44184001602 POTASSIUM BICARBONATE25.000 MEQ

44184001604 POTASSIUM BICARBONATE25.000 MEQ

44184001606 POTASSIUM BICARBONATE25.000 MEQ

00182149717 POTASSIUM BICARBONATE25.000 MEQ

00254938458 POTASSIUM CHLORIDE20.000 %

00472100016 POTASSIUM CHLORIDE10.000 %

00472100116 POTASSIUM CHLORIDE20.000 %

00603153258 POTASSIUM CHLORIDE10.000 %

00603153458 POTASSIUM CHLORIDE10.000 %

00603153460 POTASSIUM CHLORIDE10.000 %

00603153558 POTASSIUM CHLORIDE10.000 %

00603153658 POTASSIUM CHLORIDE20.000 %

00074393402 POTASSIUM CHLORIDE2.000 MEQ/ML

00074390703 POTASSIUM CHLORIDE2.000 MEQ/ML

00074665106 POTASSIUM CHLORIDE2.000 MEQ/ML

00074665305 POTASSIUM CHLORIDE2.000 MEQ/ML

00074663501 POTASSIUM CHLORIDE2.000 MEQ/ML

00074663601 POTASSIUM CHLORIDE2.000 MEQ/ML

00074499218 POTASSIUM CHLORIDE2.000 MEQ/ML

00074499419 POTASSIUM CHLORIDE2.000 MEQ/ML

00074493101 POTASSIUM CHLORIDE2.000 MEQ/ML

00074493201 POTASSIUM CHLORIDE2.000 MEQ/ML

00074707626 POTASSIUM CHLORIDE30.000 MEQ/100

00074707714 POTASSIUM CHLORIDE20.000 MEQ/50M

00074707726 POTASSIUM CHLORIDE40.000 MEQ/100

00074707426 POTASSIUM CHLORIDE.100 MEQ/ML

00074149901 POTASSIUM CHLORIDE2.000 MEQ/ML

00074151302 POTASSIUM CHLORIDE2.000 MEQ/ML

00054871304 POTASSIUM CHLORIDE10.000 %

00054871404 POTASSIUM CHLORIDE10.000 %

00054371463 POTASSIUM CHLORIDE20.000 %

00054371663 POTASSIUM CHLORIDE10.000 %

44184001702 POTASSIUM CHLORIDE20.000 MEQ

44184001704 POTASSIUM CHLORIDE20.000 MEQ

44184001709 POTASSIUM CHLORIDE20.000 MEQ

00904100116 POTASSIUM CHLORIDE20.000 %

00904100128 POTASSIUM CHLORIDE20.000 %

00904100716 POTASSIUM CHLORIDE10.000 %

00677103507 POTASSIUM CHLORIDE20.000 MEQ

00677054033 POTASSIUM CHLORIDE10.000 %

00074799309 POTASSIUM CHLORIDE 0.075%.000

00074799709 POTASSIUM CHLORIDE 0.075%.000

00074790209 POTASSIUM CHLORIDE 0.15%/.000

00074790103 POTASSIUM CHLORIDE 0.15%/.000

00074790109 POTASSIUM CHLORIDE 0.15%/.000

00074790509 POTASSIUM CHLORIDE 0.15%/.000

00074711509 POTASSIUM CHLORIDE 0.15%/.000

00074790309 POTASSIUM CHLORIDE 0.224%.000

00074799609 POTASSIUM CHLORIDE 0.224%.000

00074799109 POTASSIUM CHLORIDE 0.224%.000

00074711609 POTASSIUM CHLORIDE 0.3%/.000

00074790409 POTASSIUM CHLORIDE 0.3%/D.000

00074790609 POTASSIUM CHLORIDE 0.3%/D.000

00074776713 POTASSIUM CHLORIDE CR8.000 MEQ

00074776719 POTASSIUM CHLORIDE CR8.000 MEQ

00677109601 POTASSIUM CHLORIDE CR8.000 MEQ

00677109610 POTASSIUM CHLORIDE CR8.000 MEQ

00781152601 POTASSIUM CHLORIDE CR10.000 MEQ

00781152610 POTASSIUM CHLORIDE CR10.000 MEQ

17236062101 POTASSIUM CHLORIDE CR8.000 MEQ

17236062110 POTASSIUM CHLORIDE CR8.000 MEQ

00904229561 POTASSIUM CHLORIDE ER10.000 MEQ

00245024210 POTASSIUM CHLORIDE ER8.000 MEQ

00245024211 POTASSIUM CHLORIDE ER8.000 MEQ

00245024310 POTASSIUM CHLORIDE ER10.000 MEQ

00245024311 POTASSIUM CHLORIDE ER10.000 MEQ

00245004200 POTASSIUM CHLORIDE ER8.000 MEQ

00245004255 POTASSIUM CHLORIDE ER8.000 MEQ

00245004285 POTASSIUM CHLORIDE ER8.000 MEQ

00245004300 POTASSIUM CHLORIDE ER10.000 MEQ

00245004355 POTASSIUM CHLORIDE ER10.000 MEQ

00074776313 POTASSIUM CHLORIDE ER10.000 MEQ

00074776353 POTASSIUM CHLORIDE ER10.000 MEQ

59911589902 POTASSIUM CHLORIDE ER10.000 MEQ

Page 79 of 125

Page 80: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

58177000104 POTASSIUM CHLORIDE ER10.000 MEQ

58177000108 POTASSIUM CHLORIDE ER10.000 MEQ

58177000109 POTASSIUM CHLORIDE ER10.000 MEQ

58177000111 POTASSIUM CHLORIDE ER10.000 MEQ

00093922501 POTASSIUM CHLORIDE SA8.000 MEQ

00093922510 POTASSIUM CHLORIDE SA8.000 MEQ

00781151601 POTASSIUM CHLORIDE SR8.000 MEQ

00781151610 POTASSIUM CHLORIDE SR8.000 MEQ

00904336040 POTASSIUM CHLORIDE SR8.000 MEQ

00904336060 POTASSIUM CHLORIDE SR8.000 MEQ

00677081907 POTASSIUM EFFERVESCENT25.000 MEQ

00904145916 POTASSIUM GLUCONATE20.000 MEQ/15M

51552023504 POTASSIUM IODIDE.000

51552008204 POTASSIUM NITRATE.000

00074729501 POTASSIUM PHOSPHATE3.000 MMOLE/M

00074729601 POTASSIUM PHOSPHATE3.000 MMOLE/M

00074420101 POTASSIUM PHOSPHATE3.000 MMOLE/M

00182076740 POVIDONE IODINE10.000 %

00603155056 POVIDONE-IODINE10.000 %

00603155058 POVIDONE-IODINE10.000 %

00603155060 POVIDONE-IODINE10.000 %

00603059950 POVIDONE-IODINE10.000 %

00904110231 POVIDONE-IODINE10.000 %

00904110309 POVIDONE-IODINE10.000 %

00904110416 POVIDONE-IODINE10.000 %

45802008255 POVIDONE-IODINE.250 %

45802005103 POVIDONE-IODINE10.000 %

45802005170 POVIDONE-IODINE10.000 %

45802005207 POVIDONE-IODINE10.000 %

45802005218 POVIDONE-IODINE10.000 %

45802005255 POVIDONE-IODINE10.000 %

99207039504 PRAMEGEL HCL1.000 %

00496071603 PRAMOSONE.000

00496071604 PRAMOSONE.000

00496072604 PRAMOSONE.000

00496072606 PRAMOSONE.000

00496072903 PRAMOSONE.000

00496072904 PRAMOSONE.000

00496072906 PRAMOSONE.000

63717040010 PRAMOTIC.000

00169008181 PRANDIN.500 MG

00169008281 PRANDIN1.000 MG

00169008481 PRANDIN2.000 MG

00003515405 PRAVACHOL10.000 MG

00003517805 PRAVACHOL20.000 MG

00003517806 PRAVACHOL20.000 MG

00003517875 PRAVACHOL20.000 MG

00003519410 PRAVACHOL40.000 MG

00005347543 PRAZOSIN HCL5.000 MG

00172406760 PRAZOSIN HCL1.000 MG

00172406765 PRAZOSIN HCL1.000 MG

00172406780 PRAZOSIN HCL1.000 MG

00172406860 PRAZOSIN HCL2.000 MG

00172406865 PRAZOSIN HCL2.000 MG

00172406880 PRAZOSIN HCL2.000 MG

00172406960 PRAZOSIN HCL5.000 MG

00172406965 PRAZOSIN HCL5.000 MG

00172406970 PRAZOSIN HCL5.000 MG

00182125589 PRAZOSIN HCL1.000 MG

00182125689 PRAZOSIN HCL2.000 MG

00182125701 PRAZOSIN HCL5.000 MG

00182125789 PRAZOSIN HCL5.000 MG

00378110101 PRAZOSIN HCL1.000 MG

00378110110 PRAZOSIN HCL1.000 MG

00378230201 PRAZOSIN HCL2.000 MG

00378230210 PRAZOSIN HCL2.000 MG

00378320501 PRAZOSIN HCL5.000 MG

00378320525 PRAZOSIN HCL5.000 MG

00904509570 PRAZOSIN HCL1.000 MG

00904509770 PRAZOSIN HCL5.000 MG

00904104080 PRAZOSIN HCL1.000 MG

00904104240 PRAZOSIN HCL5.000 MG

51079063020 PRAZOSIN HCL1.000 MG

51079063120 PRAZOSIN HCL2.000 MG

51079063220 PRAZOSIN HCL5.000 MG

00072939904 PRE SUN KIDS.000

00072937004 PRE SUN SPF15 SENSITIVE S.000

00072930004 PRE SUN SPF29 SENSITIVE S.000

08290498024 PRECISE PREGNANCY TEST.000

08290498025 PRECISE PREGNANCY TEST.000

08290498041 PRECISE PREGNANCY TEST.000

08290498042 PRECISE PREGNANCY TEST.000

08290305145 PRECISION GLIDE NEEDLES 2.000

57599875705 PRECISION PCX.000

57599833501 PRECISION QID TEST STRIPS.000

57599833601 PRECISION QID TEST STRIPS.000

57599843501 PRECISION QID TEST STRIPS.000

57599740004 PRECISION QID TEST STRIPS.000

57599740105 PRECISION QID TEST STRIPS.000

57599889401 PRECISION SURE-DOSE INSUL.000

57599889501 PRECISION SURE-DOSE INSUL.000

57599855001 PRECISION SURE-DOSE PLUS.000

57599854801 PRECISION SURE-DOSE PLUS.000

57599854901 PRECISION SURE-DOSE SYRIN.000

57599854601 PRECISION SURE-DOSE SYRIN.000

57599854701 PRECISION SURE-DOSE SYRIN.000

57599972804 PRECISION XTRA TEST STRIP.000

00026286148 PRECOSE50.000 MG

00026286151 PRECOSE50.000 MG

00026286251 PRECOSE100.00 MG

00026286351 PRECOSE25.000 MG

00527120110 PREDNISOLONE5.000 MG

00093611816 PREDNISOLONE15.000 MG/5ML

00093611887 PREDNISOLONE15.000 MG/5ML

52544052016 PREDNISOLONE15.000 MG/5ML

00527120101 PREDNISOLONE5.000 MG

00182093966 PREDNISOLONE ACETATE50.000 MG/ML

61314063705 PREDNISOLONE ACETATE1.000 %

61314063710 PREDNISOLONE ACETATE1.000 %

61314063715 PREDNISOLONE ACETATE1.000 %

24208071502 PREDNISOLONE SODIUM PHOSP1.000 %

24208071506 PREDNISOLONE SODIUM PHOSP1.000 %

24208071510 PREDNISOLONE SODIUM PHOSP1.000 %

00677069801 PREDNISONE10.000 MG

00677069805 PREDNISONE10.000 MG

00677069810 PREDNISONE10.000 MG

00677042701 PREDNISONE20.000 MG

00677042705 PREDNISONE20.000 MG

00677042710 PREDNISONE20.000 MG

00677011701 PREDNISONE5.000 MG

00677011710 PREDNISONE5.000 MG

51079003219 PREDNISONE5.000 MG

51079003220 PREDNISONE5.000 MG

51079003319 PREDNISONE10.000 MG

51079003320 PREDNISONE10.000 MG

51079002219 PREDNISONE20.000 MG

51079002220 PREDNISONE20.000 MG

53489013801 PREDNISONE5.000 MG

53489013810 PREDNISONE5.000 MG

53489013901 PREDNISONE10.000 MG

53489013905 PREDNISONE10.000 MG

53489013910 PREDNISONE10.000 MG

Page 80 of 125

Page 81: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

53489014001 PREDNISONE20.000 MG

53489014005 PREDNISONE20.000 MG

53489014010 PREDNISONE20.000 MG

00182108689 PREDNISONE20.000 MG

00182020189 PREDNISONE5.000 MG

00182133489 PREDNISONE10.000 MG

00143147301 PREDNISONE10.000 MG

00143147310 PREDNISONE10.000 MG

00143147501 PREDNISONE5.000 MG

00143147510 PREDNISONE5.000 MG

00143147701 PREDNISONE20.000 MG

00143147705 PREDNISONE20.000 MG

00143147710 PREDNISONE20.000 MG

00054372250 PREDNISONE5.000 MG/5ML

00054372263 PREDNISONE5.000 MG/5ML

00054474125 PREDNISONE1.000 MG

00054474131 PREDNISONE1.000 MG

00054474225 PREDNISONE2.500 MG

00054472825 PREDNISONE5.000 MG

00054472831 PREDNISONE5.000 MG

00054472925 PREDNISONE20.000 MG

00054472929 PREDNISONE20.000 MG

00054473025 PREDNISONE10.000 MG

00054473029 PREDNISONE10.000 MG

00054473325 PREDNISONE50.000 MG

00054872216 PREDNISONE5.000 MG/5ML

00054872425 PREDNISONE5.000 MG

00054872525 PREDNISONE10.000 MG

00054872625 PREDNISONE20.000 MG

00054872925 PREDNISONE50.000 MG

00054873925 PREDNISONE1.000 MG

00054874025 PREDNISONE2.500 MG

00054372144 PREDNISONE INTENSOL5.000 MG/ML

00065011130 PREFLEX.000

00087037943 PREGESTIMIL.000

00087033343 PREGESTIMIL 20 CAL.000

00052031510 PREGNYL W/DILUENT BENZYL10000. U

00054271925 PRELU-2 TR105.00 MG

00046086481 PREMARIN.900 MG

00046086681 PREMARIN1.250 MG

00046086691 PREMARIN1.250 MG

00046086781 PREMARIN.625 MG

00046086791 PREMARIN.625 MG

00046086799 PREMARIN.625 MG

00046086881 PREMARIN.300 MG

00046086891 PREMARIN.300 MG

00046074905 PREMARIN25.000 MG

00046087293 PREMARIN W/APPLICATOR.625 MG/GM

00046257306 PREMPHASE.000

00046257305 PREMPHASE.000

00046087506 PREMPRO.000

00046097506 PREMPRO.000

00046087505 PREMPRO.000

00046097505 PREMPRO.000

60258019590 PRENAFORT.000

60258019101 PRENATABS CBF.000

60258019001 PRENATABS FA.000

00904531360 PRENATAL.000

00904317872 PRENATAL.000

17236066801 PRENATAL 1 PLUS 1.000

17236066805 PRENATAL 1 PLUS 1.000

17236063511 PRENATAL 1+1.000

00364107690 PRENATAL FORMULA.000

10267206901 PRENATAL LOW IRON.000

58177021211 PRENATAL MR 90.000

58177031604 PRENATAL MTR/SELENIUM.000

00093722193 PRENATAL OPTIMA ADVANCE.000

00093911101 PRENATAL PLUS.000

00093911105 PRENATAL PLUS.000

00603536121 PRENATAL PLUS.000

00677168901 PRENATAL PLUS NF.000

00904533960 PRENATAL PLUS/IRON.000

58177021611 PRENATAL RX.000

00093916505 PRENATAL RX/BETA-CAROTENE.000

00093916554 PRENATAL RX/BETA-CAROTENE.000

00182403201 PRENATAL S.000

00182403901 PRENATAL S.000

58177027511 PRENATAL Z.000

00536406301 PRENAVITE.000

00536408501 PRENAVITE.000

45802035410 PREP-HEM.000

45802075230 PREP-HEM.000

45802075231 PREP-HEM.000

00072881004 PRESUN ACTIVE SUNSCREEN.000

00072883004 PRESUN ACTIVE SUNSCREEN.000

00072888035 PRESUN BLOCK.000

00072969904 PRESUN MOISTURIZING SUNSC.000

00072930111 PRESUN ULTRA/PARSOL.000

00072930210 PRESUN ULTRA/PARSOL.000

00245003623 PREVALITE4.000 GM/DOSE

00245003642 PREVALITE4.000 GM

00245003660 PREVALITE4.000 GM

00186060631 PRILOSEC10.000 MG

00186060682 PRILOSEC10.000 MG

00186074231 PRILOSEC20.000 MG

00186074282 PRILOSEC20.000 MG

00024120006 PRIMACOR1.000 MG/ML

00024120010 PRIMACOR1.000 MG/ML

00024120020 PRIMACOR1.000 MG/ML

00024120025 PRIMACOR1.000 MG/ML

00024120050 PRIMACOR1.000 MG/ML

00024120301 PRIMACOR.000

00024120302 PRIMACOR.000

00024120315 PRIMACOR.000

00024159601 PRIMAQUINE PHOSPHATE26.300 MG

53303010010 PRIMARY DRESSING TRAY.000

00603537021 PRIMIDONE250.00 MG

00527123101 PRIMIDONE250.00 MG

00527123105 PRIMIDONE250.00 MG

00527123110 PRIMIDONE250.00 MG

17236054701 PRIMIDONE250.00 MG

17236054710 PRIMIDONE250.00 MG

00677035401 PRIMIDONE250.00 MG

00904056060 PRIMIDONE250.00 MG

00904056080 PRIMIDONE250.00 MG

00003013450 PRINCIPEN500.00 MG

00003013460 PRINCIPEN500.00 MG

00003012250 PRINCIPEN250.00 MG

00003012260 PRINCIPEN250.00 MG

00003096909 PRINCIPEN125.00 MG/5ML

00003096961 PRINCIPEN125.00 MG/5ML

00003097252 PRINCIPEN250.00 MG/5ML

00003097261 PRINCIPEN250.00 MG/5ML

00006001528 PRINIVIL2.500 MG

00006001531 PRINIVIL2.500 MG

00006001558 PRINIVIL2.500 MG

00006001928 PRINIVIL5.000 MG

00006001958 PRINIVIL5.000 MG

00006001972 PRINIVIL5.000 MG

00006001982 PRINIVIL5.000 MG

00006001987 PRINIVIL5.000 MG

00006001994 PRINIVIL5.000 MG

Page 81 of 125

Page 82: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00006010628 PRINIVIL10.000 MG

00006010631 PRINIVIL10.000 MG

00006010658 PRINIVIL10.000 MG

00006010672 PRINIVIL10.000 MG

00006010682 PRINIVIL10.000 MG

00006010687 PRINIVIL10.000 MG

00006010694 PRINIVIL10.000 MG

00006020728 PRINIVIL20.000 MG

00006020731 PRINIVIL20.000 MG

00006020758 PRINIVIL20.000 MG

00006020772 PRINIVIL20.000 MG

00006020782 PRINIVIL20.000 MG

00006020787 PRINIVIL20.000 MG

00006020794 PRINIVIL20.000 MG

00006023758 PRINIVIL40.000 MG

00006014031 PRINZIDE.000

00006014058 PRINZIDE.000

00006014231 PRINZIDE.000

00006014258 PRINZIDE.000

00006014531 PRINZIDE.000

00006014558 PRINZIDE.000

00603157458 PRO-COF.000

00603157558 PRO-COF D.000

00496084202 PRO-Q SKIN PROTECTANT.000

00496084205 PRO-Q SKIN PROTECTANT.000

54092000301 PROAMATINE2.500 MG

54092000401 PROAMATINE5.000 MG

00065916270 PROBALANCE.000

00065916672 PROBALANCE.000

00065916673 PROBALANCE.000

00378015601 PROBENECID500.00 MG

00172219060 PROBENECID500.00 MG

00904219080 PROBENECID500.00 MG

00172219360 PROBENECID/COLCHICINE.000

00172234560 PROCAINAMIDE HCL250.00 MG

00172234760 PROCAINAMIDE HCL500.00 MG

00074190201 PROCAINAMIDE HCL100.00 MG/ML

00074190301 PROCAINAMIDE HCL500.00 MG/ML

00093911401 PROCAINAMIDE HCL ER750.00 MG

00093911405 PROCAINAMIDE HCL ER750.00 MG

00093911701 PROCAINAMIDE HCL ER1000.0 MG

00093918801 PROCAINAMIDE HCL SR500.00 MG

00093918805 PROCAINAMIDE HCL SR500.00 MG

00074192304 PROCAINE HCL1.000 %

00074195304 PROCAINE HCL2.000 %

61570006970 PROCANBID500.00 MG/12HR

61570007170 PROCANBID1000.0 MG/12HR

00069260066 PROCARDIA10.000 MG

00069261066 PROCARDIA20.000 MG

00069265041 PROCARDIA XL30.000 MG

00069265066 PROCARDIA XL30.000 MG

00069265072 PROCARDIA XL30.000 MG

00069266041 PROCARDIA XL60.000 MG

00069266066 PROCARDIA XL60.000 MG

00069266072 PROCARDIA XL60.000 MG

00069267041 PROCARDIA XL90.000 MG

00069267066 PROCARDIA XL90.000 MG

00713013512 PROCHLORPERAZINE25.000 MG

00641049125 PROCHLORPERAZINE EDISYLAT5.000 MG/ML

00074188032 PROCHLORPERAZINE EDISYLAT5.000 MG/ML

00093964301 PROCHLORPERAZINE MALEATE5.000 MG

00093965201 PROCHLORPERAZINE MALEATE10.000 MG

00182821089 PROCHLORPERAZINE MALEATE5.000 MG

00182821189 PROCHLORPERAZINE MALEATE10.000 MG

00172369060 PROCHLORPERAZINE MALEATE5.000 MG

00172369160 PROCHLORPERAZINE MALEATE10.000 MG

00378510501 PROCHLORPERAZINE MALEATE5.000 MG

00378511001 PROCHLORPERAZINE MALEATE10.000 MG

51285052102 PROCHLORPERAZINE MALEATE5.000 MG

51285052202 PROCHLORPERAZINE MALEATE10.000 MG

51285052204 PROCHLORPERAZINE MALEATE10.000 MG

49884054901 PROCHLORPERAZINE MALEATE5.000 MG

49884055001 PROCHLORPERAZINE MALEATE10.000 MG

51079054119 PROCHLORPERAZINE MALEATE5.000 MG

51079054120 PROCHLORPERAZINE MALEATE5.000 MG

51079054219 PROCHLORPERAZINE MALEATE10.000 MG

51079054220 PROCHLORPERAZINE MALEATE10.000 MG

63304040501 PROCTO-KIT1.000 %

63304040601 PROCTO-KIT2.500 %

61570007001 PROCTOCORT1.000 %

61570002512 PROCTOCORT30.000 MG

61570002525 PROCTOCORT30.000 MG

00091464024 PROCTOCREAM-HC2.500 %

00091475020 PROCTOFOAM1.000 %

00091069010 PROCTOFOAM HC.000

63304040812 PROCTOSOL25.000 MG

63304040824 PROCTOSOL25.000 MG

63304040701 PROCTOSOL HC2.500 %

62794005651 PRODERM.000

51991024012 PRODIUM95.000 MG

51991024030 PRODIUM95.000 MG

00009735301 PROGAINE 2 IN 1 SHAMPOO/C.000

00009735401 PROGAINE EXTRA BODY.000

00574043200 PROGESTERONE.000

00574043000 PROGESTERONE MICRONIZED.000

00574043001 PROGESTERONE MICRONIZED.000

00574043025 PROGESTERONE MICRONIZED.000

51552000510 PROGESTERONE MICRONIZED.000

51552073805 PROGESTERONE MICRONIZED.000

00574043100 PROGESTERONE WETTABLE.000

00574043101 PROGESTERONE WETTABLE.000

00574043125 PROGESTERONE WETTABLE.000

00003082030 PROLIXIN2.500 MG/5ML

00003086450 PROLIXIN2.500 MG

00003087750 PROLIXIN5.000 MG

00003080110 PROLIXIN5.000 MG/ML

00003095650 PROLIXIN10.000 MG

00003056915 PROLIXIN DECANOATE25.000 MG/ML

61570005701 PROLOPRIM100.00 MG

00074231231 PROMETHAZINE HCL25.000 MG/ML

00641149535 PROMETHAZINE HCL25.000 MG/ML

00641149635 PROMETHAZINE HCL50.000 MG/ML

00781183001 PROMETHAZINE HCL25.000 MG

00781183201 PROMETHAZINE HCL50.000 MG

00904150820 PROMETHAZINE HCL6.250 MG/5ML

00904150828 PROMETHAZINE HCL6.250 MG/5ML

00904129012 PROMETHAZINE HCL50.000 MG

60432060804 PROMETHAZINE HCL PLAIN6.250 MG/5ML

60432060816 PROMETHAZINE HCL PLAIN6.250 MG/5ML

60432060604 PROMETHAZINE PLAIN/CODEIN.000

60432060616 PROMETHAZINE PLAIN/CODEIN.000

00472162804 PROMETHAZINE VC.000

00472162816 PROMETHAZINE VC.000

00472162808 PROMETHAZINE VC.000

00472162828 PROMETHAZINE VC.000

00472162904 PROMETHAZINE VC/CODEINE.000

00472162908 PROMETHAZINE VC/CODEINE.000

00472162916 PROMETHAZINE VC/CODEINE.000

00472162704 PROMETHAZINE/CODEINE.000

00472162716 PROMETHAZINE/CODEINE.000

00472162728 PROMETHAZINE/CODEINE.000

00472162708 PROMETHAZINE/CODEINE.000

Page 82 of 125

Page 83: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00472163004 PROMETHAZINE/DEXTROMETHOR.000

00472163016 PROMETHAZINE/DEXTROMETHOR.000

50383080316 PROMETHAZINE/DEXTROMETHOR.000

00472163028 PROMETHAZINE/DEXTROMETHOR.000

60432060404 PROMETHAZINE/DEXTROMETHOR.000

60432060416 PROMETHAZINE/DEXTROMETHOR.000

00713013212 PROMETHEGAN50.000 MG

00182512334 PROMPT RELIEF HEMORRHOIDA.000

00182512343 PROMPT RELIEF HEMORRHOIDA.000

00003043150 PRONESTYL250.00 MG

00003043450 PRONESTYL375.00 MG

00003043850 PRONESTYL500.00 MG

00003075650 PRONESTYL375.00 MG

00003075850 PRONESTYL250.00 MG

00003077550 PRONESTYL SR500.00 MG

00054472125 PROPANTHELINE BROMIDE15.000 MG

00054472131 PROPANTHELINE BROMIDE15.000 MG

00054873725 PROPANTHELINE BROMIDE15.000 MG

24208073006 PROPARACAINE HCL.500 %

61314001601 PROPARACAINE HCL.500 %

00603545921 PROPOXYPHENE HCL65.000 MG

00603545928 PROPOXYPHENE HCL65.000 MG

00143323501 PROPOXYPHENE HCL65.000 MG

00143323505 PROPOXYPHENE HCL65.000 MG

00172218660 PROPOXYPHENE HCL65.000 MG

00093074101 PROPOXYPHENE HCL65.000 MG

00093074105 PROPOXYPHENE HCL65.000 MG

00093074110 PROPOXYPHENE HCL65.000 MG

00093049001 PROPOXYPHENE-N/ACETAMINOP.000

00093049005 PROPOXYPHENE-N/ACETAMINOP.000

00093089001 PROPOXYPHENE-N/ACETAMINOP.000

00093089005 PROPOXYPHENE-N/ACETAMINOP.000

00172498060 PROPOXYPHENE-N/ACETAMINOP.000

00172498070 PROPOXYPHENE-N/ACETAMINOP.000

00172498080 PROPOXYPHENE-N/ACETAMINOP.000

00182031789 PROPOXYPHENE-N/ACETAMINOP.000

00603546521 PROPOXYPHENE-N/ACETAMINOP.000

00603546621 PROPOXYPHENE-N/ACETAMINOP.000

00603546628 PROPOXYPHENE-N/ACETAMINOP.000

00603546632 PROPOXYPHENE-N/ACETAMINOP.000

00603546721 PROPOXYPHENE-N/ACETAMINOP.000

00603546728 PROPOXYPHENE-N/ACETAMINOP.000

00603546732 PROPOXYPHENE-N/ACETAMINOP.000

00603546802 PROPOXYPHENE-N/ACETAMINOP.000

00603546816 PROPOXYPHENE-N/ACETAMINOP.000

00603546819 PROPOXYPHENE-N/ACETAMINOP.000

00603546820 PROPOXYPHENE-N/ACETAMINOP.000

00603546821 PROPOXYPHENE-N/ACETAMINOP.000

00603546822 PROPOXYPHENE-N/ACETAMINOP.000

00603546828 PROPOXYPHENE-N/ACETAMINOP.000

00603546832 PROPOXYPHENE-N/ACETAMINOP.000

00378015501 PROPOXYPHENE-N/ACETAMINOP.000

00378015505 PROPOXYPHENE-N/ACETAMINOP.000

00904770240 PROPOXYPHENE-N/ACETAMINOP.000

00904770280 PROPOXYPHENE-N/ACETAMINOP.000

00904770340 PROPOXYPHENE-N/ACETAMINOP.000

51079032219 PROPOXYPHENE-N/ACETAMINOP.000

51079032220 PROPOXYPHENE-N/ACETAMINOP.000

51079032221 PROPOXYPHENE-N/ACETAMINOP.000

51079032224 PROPOXYPHENE-N/ACETAMINOP.000

51079032299 PROPOXYPHENE-N/ACETAMINOP.000

51079093420 PROPOXYPHENE-N/ACETAMINOP.000

51079093421 PROPOXYPHENE-N/ACETAMINOP.000

51079093424 PROPOXYPHENE-N/ACETAMINOP.000

51079093499 PROPOXYPHENE-N/ACETAMINOP.000

60429051830 PROPOXYPHENE-N/ACETAMINOP.000

60429051860 PROPOXYPHENE-N/ACETAMINOP.000

51079074120 PROPOXYPHENE/ACETAMINOPHE.000

00378013001 PROPOXYPHENE/ACETAMINOPHE.000

00378013005 PROPOXYPHENE/ACETAMINOPHE.000

00378018201 PROPRANOLOL HCL10.000 MG

00378018210 PROPRANOLOL HCL10.000 MG

00378018301 PROPRANOLOL HCL20.000 MG

00378018310 PROPRANOLOL HCL20.000 MG

00378018401 PROPRANOLOL HCL40.000 MG

00378018410 PROPRANOLOL HCL40.000 MG

00378018501 PROPRANOLOL HCL80.000 MG

00378018505 PROPRANOLOL HCL80.000 MG

00182181289 PROPRANOLOL HCL10.000 MG

00182181389 PROPRANOLOL HCL20.000 MG

00182181489 PROPRANOLOL HCL40.000 MG

00182181589 PROPRANOLOL HCL80.000 MG

00054372763 PROPRANOLOL HCL20.000 MG/5ML

00054373063 PROPRANOLOL HCL40.000 MG/5ML

00054876416 PROPRANOLOL HCL20.000 MG/5ML

51079027719 PROPRANOLOL HCL10.000 MG

51079027720 PROPRANOLOL HCL10.000 MG

51079027820 PROPRANOLOL HCL20.000 MG

51079027920 PROPRANOLOL HCL40.000 MG

51079028020 PROPRANOLOL HCL80.000 MG

50111046701 PROPRANOLOL HCL10.000 MG

50111046703 PROPRANOLOL HCL10.000 MG

50111046801 PROPRANOLOL HCL20.000 MG

50111046803 PROPRANOLOL HCL20.000 MG

50111046901 PROPRANOLOL HCL40.000 MG

50111046903 PROPRANOLOL HCL40.000 MG

50111047001 PROPRANOLOL HCL60.000 MG

50111047101 PROPRANOLOL HCL80.000 MG

50111047102 PROPRANOLOL HCL80.000 MG

00904041160 PROPRANOLOL HCL10.000 MG

00904041161 PROPRANOLOL HCL10.000 MG

00904041261 PROPRANOLOL HCL20.000 MG

00904041461 PROPRANOLOL HCL40.000 MG

00054372844 PROPRANOLOL HCL INTENSOL80.000 MG/ML

00904043460 PROPRANOLOL/HYDROCHLOROTH.000

00904043860 PROPRANOLOL/HYDROCHLOROTH.000

50111047301 PROPRANOLOL/HYDROCHLOROTH.000

50111047302 PROPRANOLOL/HYDROCHLOROTH.000

50111047401 PROPRANOLOL/HYDROCHLOROTH.000

00378034701 PROPRANOLOL/HYDROCHLOROTH.000

00378073101 PROPRANOLOL/HYDROCHLOROTH.000

00574007216 PROPYLENE GLYCOL.000

00228234810 PROPYLTHIOURACIL50.000 MG

00143148001 PROPYLTHIOURACIL50.000 MG

00143148010 PROPYLTHIOURACIL50.000 MG

00076010803 PROSED/DS.000

00904773518 PROSIGHT.000

00904773552 PROSIGHT.000

00087026645 PROSOBEE.000

00087030901 PROSOBEE.000

00087030908 PROSOBEE.000

00087026124 PROSOBEE.000

00074373513 PROSOM1.000 MG

00074373613 PROSOM2.000 MG

00015798540 PROSTAPHLIN250.00 MG/5ML

00009316906 PROSTIN VR PEDIATRIC500.00 MCG/ML

00087008804 PROTAIN XL.000

00087008805 PROTAIN XL.000

00087008842 PROTAIN XL.000

00087008844 PROTAIN XL.000

00904424616 PROTEIN.000

00085061402 PROVENTIL90.000 MCG/ACT

Page 83 of 125

Page 84: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00085061403 PROVENTIL90.000 MCG/ACT

00085113201 PROVENTIL HFA108.00 MCG/ACT

00009028603 PROVERA5.000 MG

00009006404 PROVERA2.500 MG

00009006406 PROVERA2.500 MG

00009006412 PROVERA2.500 MG

00009005002 PROVERA10.000 MG

00009005009 PROVERA10.000 MG

00009005011 PROVERA10.000 MG

00009028642 PROVERA5.000 MG

00071306620 PROXACOL3.000 %

00071306623 PROXACOL3.000 %

00002400602 PROZAC10.000 MG

00002400630 PROZAC10.000 MG

00777310402 PROZAC10.000 MG

00777310501 PROZAC20.000 MG

00777310502 PROZAC20.000 MG

00777310507 PROZAC20.000 MG

00777310530 PROZAC20.000 MG

00777310533 PROZAC20.000 MG

00777310582 PROZAC20.000 MG

00777310730 PROZAC40.000 MG

00777512058 PROZAC20.000 MG/5ML

59743006001 PSEUBROM.000

59743006101 PSEUBROM-PD.000

00904768970 PSEUDO-G/PSI.000

17714001701 PSEUDOEPHEDRINE HCL30.000 MG

17714001710 PSEUDOEPHEDRINE HCL30.000 MG

17714001801 PSEUDOEPHEDRINE HCL60.000 MG

17714001810 PSEUDOEPHEDRINE HCL60.000 MG

10267121504 PSEUDOEPHEDRINE HCL60.000 MG

17236026301 PSEUDOEPHEDRINE HCL30.000 MG

00781153301 PSEUDOEPHEDRINE HCL30.000 MG

00781153501 PSEUDOEPHEDRINE HCL60.000 MG

00677168401 PSEUDOEPHEDRINE HCL60.000 MG

00677168410 PSEUDOEPHEDRINE HCL60.000 MG

00677079701 PSEUDOEPHEDRINE HCL30.000 MG

00677079710 PSEUDOEPHEDRINE HCL30.000 MG

53746022101 PSEUDOEPHEDRINE HCL60.000 MG

53746022130 PSEUDOEPHEDRINE HCL60.000 MG

53746022150 PSEUDOEPHEDRINE HCL60.000 MG

00054474325 PSEUDOEPHEDRINE HCL30.000 MG

00054474425 PSEUDOEPHEDRINE HCL60.000 MG

00054874325 PSEUDOEPHEDRINE HCL30.000 MG

00054874425 PSEUDOEPHEDRINE HCL60.000 MG

00143148510 PSEUDOEPHEDRINE HCL60.000 MG

00536439135 PSEUDOEPHEDRINE HCL30.000 MG

00527129033 PSEUDOEPHEDRINE HCL60.000 MG

00536185085 PSEUDOEPHEDRINE HCL30.000 MG/5ML

00536185097 PSEUDOEPHEDRINE HCL30.000 MG/5ML

51285040202 PSEUDOEPHEDRINE/GG ER.000

51285040102 PSEUDOEPHEDRINE/GUAIFENES.000

00677178701 PSEUDOEPHEDRINE/GUAIFENES.000

00677178801 PSEUDOEPHEDRINE/GUAIFENES.000

00677178901 PSEUDOEPHEDRINE/GUAIFENES.000

58177004504 PSEUDOVENT.000

58177004604 PSEUDOVENT PED.000

00066007160 PSORCON.050 %

00066027217 PSORCON E.050 %

00066027231 PSORCON E.050 %

00066027260 PSORCON E.050 %

10267085814 PSYLDEX30.000 %

10267085821 PSYLDEX30.000 %

10267040714 PSYLDEX30.000 %

10267040721 PSYLDEX30.000 %

00186198804 PULMICORT.250 MG/2ML

00186198904 PULMICORT.500 MG/2ML

00186091542 PULMICORT TURBUHALER200.00 MCG/INH

00904453560 PUMPKIN SEED OIL.000

00168015011 PURALUBE.000

00168015038 PURALUBE.000

00168017715 PURALUBE TEARS1.000 %

00256017601 PURGE95.000 %

00256017602 PURGE95.000 %

00005509323 PYRAZINAMIDE500.00 MG

00005509331 PYRAZINAMIDE500.00 MG

00904252720 PYRETHINS/PIPERONYL BUTO.000

00430018024 PYRIDIUM100.00 MG

00430018124 PYRIDIUM200.00 MG

00430018215 PYRIDIUM PLUS.000

00430018224 PYRIDIUM PLUS.000

00536440601 PYRIDOXINE HCL25.000 MG

00536440801 PYRIDOXINE HCL50.000 MG

00536440810 PYRIDOXINE HCL50.000 MG

00536440901 PYRIDOXINE HCL100.00 MG

00603082354 Q-DRYL12.500 MG/5ML

00603082358 Q-DRYL12.500 MG/5ML

00603082394 Q-DRYL12.500 MG/5ML

00603023918 Q-DRYL25.000 MG

00603024018 Q-DRYL25.000 MG

00603025521 Q-GESIC.000

00603061850 Q-NAFTATE1.000 %

00603061873 Q-NAFTATE1.000 %

00603083873 Q-NOL100.00 MG/ML

00603026321 Q-NOL325.00 MG

00603026332 Q-NOL325.00 MG

00603026521 Q-NOL EX STR500.00 MG

00603026532 Q-NOL EX STR500.00 MG

00603083954 Q-PAP160.00 MG/5ML

00603083958 Q-PAP160.00 MG/5ML

00603083960 Q-PAP160.00 MG/5ML

00603083994 Q-PAP160.00 MG/5ML

00603084054 Q-PAP160.00 MG/5ML

00603084058 Q-PAP160.00 MG/5ML

00603084060 Q-PAP160.00 MG/5ML

00603084094 Q-PAP160.00 MG/5ML

00603084154 Q-PAP CHILDRENS160.00 MG/5ML

00603084254 Q-PAP CHILDRENS160.00 MG/5ML

00603084354 Q-PAP CHILDRENS160.00 MG/5ML

00603026821 Q-PAP EX STR500.00 MG

00603026832 Q-PAP EX STR500.00 MG

00603021621 Q-PROFEN200.00 MG

00603021721 Q-PROFEN200.00 MG

00603021728 Q-PROFEN200.00 MG

00603085754 Q-TUSSIN100.00 MG/5ML

00603085756 Q-TUSSIN100.00 MG/5ML

00603085758 Q-TUSSIN100.00 MG/5ML

00603085760 Q-TUSSIN100.00 MG/5ML

00603085781 Q-TUSSIN100.00 MG/5ML

00603085794 Q-TUSSIN100.00 MG/5ML

00603085554 Q-TUSSIN DM.000

00603085556 Q-TUSSIN DM.000

00603085558 Q-TUSSIN DM.000

00603085560 Q-TUSSIN DM.000

00603085581 Q-TUSSIN DM.000

00603085594 Q-TUSSIN DM.000

00603085954 Q-TUSSIN PE -AF.000

00603160958 Q-V TUSSIN.000

51991081516 QUAD TANN PEDIATRIC.000

50383080916 QUAD-TUSS TANNATE PEDIATR.000

00074662902 QUELICIN20.000 MG/ML

00074806515 QUELICIN20.000 MG/ML

Page 84 of 125

Page 85: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00074697010 QUELICIN 1000100.00 MG/ML

00603086054 QUENALIN12.500 MG/5ML

00087058005 QUESTRAN4.000 GM/DOSE

00015058011 QUESTRAN4.000 GM

00015944214 QUESTRAN LIGHT4.000 GM

54092006710 QUIBRON.000

61570002201 QUIBRON.000

54092006801 QUIBRON 300.000

61570002001 QUIBRON-T300.00 MG

54092007005 QUIBRON-T/SR300.00 MG

61570001901 QUIBRON-T/SR300.00 MG

00603557121 QUINDAL CR.000

00002140701 QUINIDINE GLUCONATE80.000 MG/ML

51079002720 QUINIDINE GLUCONATE CR324.00 MG

53489014101 QUINIDINE GLUCONATE CR324.00 MG

53489014103 QUINIDINE GLUCONATE CR324.00 MG

53489014105 QUINIDINE GLUCONATE CR324.00 MG

60429016760 QUINIDINE GLUCONATE CR324.00 MG

60429016790 QUINIDINE GLUCONATE CR324.00 MG

00677067501 QUINIDINE GLUCONATE ER324.00 MG

00677067503 QUINIDINE GLUCONATE ER324.00 MG

00677067505 QUINIDINE GLUCONATE ER324.00 MG

00185104701 QUINIDINE SULFATE300.00 MG

00185104710 QUINIDINE SULFATE300.00 MG

00185434601 QUINIDINE SULFATE200.00 MG

00185434610 QUINIDINE SULFATE200.00 MG

00677012201 QUINIDINE SULFATE200.00 MG

00677012210 QUINIDINE SULFATE200.00 MG

00677120901 QUINIDINE SULFATE300.00 MG

00904220380 QUINIDINE SULFATE300.00 MG

00904220161 QUINIDINE SULFATE200.00 MG

53489046001 QUINIDINE SULFATE300.00 MG

53489046010 QUINIDINE SULFATE300.00 MG

53489046101 QUINIDINE SULFATE200.00 MG

53489046110 QUINIDINE SULFATE200.00 MG

00093917501 QUINIDINE SULFATE ER300.00 MG

00093917552 QUINIDINE SULFATE ER300.00 MG

53489046201 QUININE SULFATE260.00 MG

53489046205 QUININE SULFATE260.00 MG

00182861589 QUININE SULFATE260.00 MG

00172300160 QUININE SULFATE260.00 MG

00172300170 QUININE SULFATE260.00 MG

00172417160 QUININE SULFATE200.00 MG

00172417260 QUININE SULFATE325.00 MG

00172417280 QUININE SULFATE325.00 MG

00904056460 QUININE SULFATE260.00 MG

00677164701 QUININE SULFATE325.00 MG

00677164705 QUININE SULFATE325.00 MG

00677164707 QUININE SULFATE325.00 MG

00677164710 QUININE SULFATE325.00 MG

53489022101 QUININE SULFATE325.00 MG

53489022105 QUININE SULFATE325.00 MG

53489022107 QUININE SULFATE325.00 MG

53489022110 QUININE SULFATE325.00 MG

60429024230 QUININE SULFATE325.00 MG

00603166154 R-TANNAMINE PEDIATRIC.000

00603166158 R-TANNAMINE PEDIATRIC.000

60258030404 R-TANNIC-S A/D.000

53303014215 RADIABLOCK LIP BALM.000

53303003041 RADIACARE POST HEALING.000

53303003042 RADIACARE POST HEALING.000

53303003043 RADIACREAM.000

53303003040 RADIACREAM.000

53303008280 RADIAKLENZ.000

53303002130 RADIGEL.000

53303002105 RADIGEL.000

51079087920 RANITIDINE HCL150.00 MG

50111089902 RANITIDINE HCL150.00 MG

49884064702 RANITIDINE HCL150.00 MG

49884064811 RANITIDINE HCL300.00 MG

49884054401 RANITIDINE HCL150.00 MG

49884054402 RANITIDINE HCL150.00 MG

49884054405 RANITIDINE HCL150.00 MG

49884054410 RANITIDINE HCL150.00 MG

49884054501 RANITIDINE HCL300.00 MG

49884054504 RANITIDINE HCL300.00 MG

49884054511 RANITIDINE HCL300.00 MG

00781188310 RANITIDINE HCL150.00 MG

00781188313 RANITIDINE HCL150.00 MG

00781188360 RANITIDINE HCL150.00 MG

00781188425 RANITIDINE HCL300.00 MG

00781188431 RANITIDINE HCL300.00 MG

00781285505 RANITIDINE HCL150.00 MG

00781285560 RANITIDINE HCL150.00 MG

00781286531 RANITIDINE HCL300.00 MG

00904526140 RANITIDINE HCL150.00 MG

00904526152 RANITIDINE HCL150.00 MG

00904526161 RANITIDINE HCL150.00 MG

00904526247 RANITIDINE HCL300.00 MG

00904526270 RANITIDINE HCL300.00 MG

17236074101 RANITIDINE HCL150.00 MG

17236074105 RANITIDINE HCL150.00 MG

17236074160 RANITIDINE HCL150.00 MG

17236074201 RANITIDINE HCL300.00 MG

17236074225 RANITIDINE HCL300.00 MG

17236074230 RANITIDINE HCL300.00 MG

00172435749 RANITIDINE HCL150.00 MG

00172435770 RANITIDINE HCL150.00 MG

00172435846 RANITIDINE HCL300.00 MG

00172435860 RANITIDINE HCL300.00 MG

00182266115 RANITIDINE HCL75.000 MG

00182266117 RANITIDINE HCL75.000 MG

00182266123 RANITIDINE HCL75.000 MG

00182266126 RANITIDINE HCL75.000 MG

00378325401 RANITIDINE HCL300.00 MG

00378325405 RANITIDINE HCL300.00 MG

00378325493 RANITIDINE HCL300.00 MG

00093854401 RANITIDINE HCL150.00 MG

00093854405 RANITIDINE HCL150.00 MG

00093854410 RANITIDINE HCL150.00 MG

00093854701 RANITIDINE HCL300.00 MG

00093854752 RANITIDINE HCL300.00 MG

00093854756 RANITIDINE HCL300.00 MG

60505016000 RANITIDINE HCL75.000 MG

60505002504 RANITIDINE HCL150.00 MG

60505002508 RANITIDINE HCL150.00 MG

60505002602 RANITIDINE HCL300.00 MG

60505002607 RANITIDINE HCL300.00 MG

55953054480 RANITIDINE HCL150.00 MG

60429070418 RANITIDINE HCL150.00 MG

00904539946 RANITIDINE HCL75.000 MG

63304074501 RANITIDINE HCL150.00 MG

63304074560 RANITIDINE HCL150.00 MG

63304074630 RANITIDINE HCL300.00 MG

57664031508 RAUWOLFIA/BENDROFLUMETHIA.000

50383001015 REDNESS RELIEVER EYE DROP.050 %

45802027016 REFLEX PAIN RELIEF7.000 %

08290408348 REGIONAL BLOCK NEEDLE SAF.000

00536187516 REGULOID50.000 %

00536187579 REGULOID50.000 %

00536188116 REGULOID50.000 %

00536188179 REGULOID50.000 %

Page 85 of 125

Page 86: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00536444454 REGULOID50.000 %

00536444489 REGULOID50.000 %

00536444554 REGULOID50.000 %

00536444589 REGULOID50.000 %

00074016201 REHYDRALYTE.000

00029485120 RELAFEN500.00 MG

00029485121 RELAFEN500.00 MG

00029485220 RELAFEN750.00 MG

00182199201 RELIABLE GENTLE LAXATIVE5.000 MG

00182199210 RELIABLE GENTLE LAXATIVE5.000 MG

00904785722 RELIEV-ALL 1-2-37.000 %

00052010530 REMERON15.000 MG

00052010930 REMERON45.000 MG

00052010730 REMERON30.000 MG

00052010790 REMERON30.000 MG

00052010830 REMERON SOLTAB30.000 MG

00052010893 REMERON SOLTAB30.000 MG

00052010630 REMERON SOLTAB15.000 MG

00052010693 REMERON SOLTAB15.000 MG

53100075003 REMIFEMIN MENOPAUSE20.000 MG

53100075201 REMIFEMIN MENOPAUSE20.000 MG

60258016001 RENA-VITE.000

60258016101 RENA-VITE RX.000

00065901370 RENALCAL.000

00904166560 RENTAMINE.000

00904166616 RENTAMINE PEDIATRIC.000

00642016210 REPAN.000

00642016610 REPAN-CF.000

00065915672 REPLETE.000

00065915673 REPLETE.000

00065902270 REPLETE.000

00065902370 REPLETE/FIBER.000

00065915872 REPLETE/FIBER/ULTRAPAK.000

00065915873 REPLETE/FIBER/ULTRAPAK.000

00007489014 REQUIP.250 MG

00007489020 REQUIP.250 MG

00007489120 REQUIP.500 MG

00007489214 REQUIP1.000 MG

00007489220 REQUIP1.000 MG

00007489314 REQUIP2.000 MG

00007489320 REQUIP2.000 MG

00007489420 REQUIP5.000 MG

00007489620 REQUIP4.000 MG

58768096105 RESCULA.150 %

00185003201 RESERPINE.100 MG

00185003210 RESERPINE.100 MG

00185013401 RESERPINE.250 MG

00185013410 RESERPINE.250 MG

00677012610 RESERPINE.250 MG

00087064403 RESPALOR.000

00087064413 RESPALOR.000

00087065105 RESPALOR.000

00087065145 RESPALOR.000

51552012001 RETINOIC ACID.000

08290001583 RETROBULBAR ANESTHESIA NE.000

08290401586 RETROBULBAR NEEDLE 25G TW.000

00173011318 RETROVIR10.000 MG/ML

08290007167 REUSABLE SYRINGE BARREL O.000

08290007178 REUSABLE SYRINGE BARREL O.000

08290007187 REUSABLE SYRINGE BARREL O.000

08290007188 REUSABLE SYRINGE BARREL O.000

08290007198 REUSABLE SYRINGE BARREL O.000

24208039407 REV-EYES.500 %

00056001130 REVIA50.000 MG

00056001170 REVIA50.000 MG

00005450791 RHEUMATREX2.500 MG

00005450704 RHEUMATREX2.500 MG

00005450705 RHEUMATREX2.500 MG

00005450707 RHEUMATREX2.500 MG

00005450709 RHEUMATREX2.500 MG

53014050013 RHINO-MIST.900 %

53014050113 RHINO-MIST.900 %

51079089019 RIFAMPIN300.00 MG

51079089020 RIFAMPIN300.00 MG

00185079901 RIFAMPIN300.00 MG

00185079905 RIFAMPIN300.00 MG

00185079930 RIFAMPIN300.00 MG

00185079960 RIFAMPIN300.00 MG

00185080101 RIFAMPIN150.00 MG

00185080130 RIFAMPIN150.00 MG

00075770060 RILUTEK50.000 MG

00074798209 RINGER'S INJECTION.000

00074798224 RINGER'S INJECTION.000

00074614009 RINGER'S IRRIGATION.000

00083003430 RITALIN20.000 MG

00083000330 RITALIN10.000 MG

00083000730 RITALIN5.000 MG

00083001630 RITALIN SR20.000 MG

00074319301 RITODRINE HCL10.000 MG/ML

00074319501 RITODRINE HCL15.000 MG/ML

00245016012 RMS5.000 MG

00245016112 RMS10.000 MG

00245016212 RMS20.000 MG

00245016312 RMS30.000 MG

00904006100 ROBAFEN100.00 MG/5ML

00904006109 ROBAFEN100.00 MG/5ML

00904006116 ROBAFEN100.00 MG/5ML

00904506500 ROBAFEN AC.000

00904506516 ROBAFEN AC.000

00904777912 ROBAFEN COLD & COUGH.000

00904005300 ROBAFEN DM.000

00904005309 ROBAFEN DM.000

00904005316 ROBAFEN DM.000

00904005320 ROBAFEN DM.000

00904005328 ROBAFEN DM.000

00904518020 ROBAFEN DM CLEAR.000

08290020003 ROBB-TYPE ANGIOGRAPHY SYR.000

60793000404 ROBISEN.000

60793000408 ROBISEN.000

00031862412 ROBITUSSIN100.00 MG/5ML

00031862418 ROBITUSSIN100.00 MG/5ML

00031862425 ROBITUSSIN100.00 MG/5ML

00031867810 ROBITUSSIN CF.000

00031867820 ROBITUSSIN CF.000

00031867830 ROBITUSSIN CF.000

00031860046 ROBITUSSIN COLD & COUGH.000

00031860246 ROBITUSSIN COLD/COUGH/FLU.000

00031866212 ROBITUSSIN COUGH/CONGESTI.000

00031868512 ROBITUSSIN DM.000

00031868518 ROBITUSSIN DM.000

00031868522 ROBITUSSIN DM.000

00031868525 ROBITUSSIN DM.000

00031868101 ROBITUSSIN DM INFANT DROP.000

00031867012 ROBITUSSIN MAXIMUM STRENG15.000 MG/5ML

00031867018 ROBITUSSIN MAXIMUM STRENG15.000 MG/5ML

00031867112 ROBITUSSIN MAXIMUM STRENG.000

00031867118 ROBITUSSIN MAXIMUM STRENG.000

00031863915 ROBITUSSIN NIGHT RELIEF.000

00031869512 ROBITUSSIN PE.000

00031869518 ROBITUSSIN PE.000

00031861012 ROBITUSSIN PEDIATRIC7.500 MG/5ML

00031860912 ROBITUSSIN PEDIATRIC COUG.000

Page 86 of 125

Page 87: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00031860918 ROBITUSSIN PEDIATRIC COUG.000

00031860812 ROBITUSSIN PEDIATRIC NIGH.000

00031860146 ROBITUSSIN SEVERE CONGEST.000

00004911500 ROCALTROL1.000 MCG/ML

00004014301 ROCALTROL.250 MCG

00004014323 ROCALTROL.250 MCG

00004014401 ROCALTROL.500 MCG

00009770001 ROGAINE EXTRA STRENGTH FO5.000 %

00009770009 ROGAINE EXTRA STRENGTH FO5.000 %

00009770013 ROGAINE EXTRA STRENGTH FO5.000 %

00009770061 ROGAINE EXTRA STRENGTH FO5.000 %

00009377901 ROGAINE FOR MEN2.000 %

00009377903 ROGAINE FOR MEN2.000 %

00009377906 ROGAINE FOR MEN2.000 %

00009377907 ROGAINE FOR MEN2.000 %

00009377908 ROGAINE FOR MEN2.000 %

00009377911 ROGAINE FOR MEN2.000 %

00009377912 ROGAINE FOR MEN2.000 %

00009378001 ROGAINE FOR WOMEN2.000 %

00009378006 ROGAINE FOR WOMEN2.000 %

00009378007 ROGAINE FOR WOMEN2.000 %

00009378008 ROGAINE FOR WOMEN2.000 %

00009378011 ROGAINE FOR WOMEN2.000 %

00009378012 ROGAINE FOR WOMEN2.000 %

00372005316 ROMILAR AC.000

00904772614 RON ACID PLUS.000

00904323514 RON-ACID540.00 MG/5ML

00904324860 RONDAMINE.000

00904325060 RONDAMINE TR.000

00054375144 ROXANOL20.000 MG/ML

00054375150 ROXANOL20.000 MG/ML

00054375158 ROXANOL20.000 MG/ML

00054377444 ROXANOL-T20.000 MG/ML

00054377450 ROXANOL-T20.000 MG/ML

00054465025 ROXICET.000

00054465029 ROXICET.000

00054865024 ROXICET.000

00054865724 ROXICODONE5.000 MG

00054465725 ROXICODONE5.000 MG

00054465825 ROXICODONE15.000 MG

00054466525 ROXICODONE30.000 MG

00054368263 ROXICODONE5.000 MG/5ML

00054878216 ROXICODONE5.000 MG/5ML

00054368344 ROXICODONE INTENSOL20.000 MG/ML

00536410501 RULETS-M 500.000

00536195083 RULOX.000

00536449601 RULOX #1.000

00536449610 RULOX #1.000

00536199083 RUOX PLUS.000

00037063866 RYNA.000

00037065504 RYNA-12 S.000

00037052266 RYNA-C.000

00037052268 RYNA-C.000

00037080166 RYNA-CX.000

00037080168 RYNA-CX.000

00037071416 RYNATAN PEDIATRIC.000

00037071792 RYNATUSS.000

00037071795 RYNATUSS.000

00037071796 RYNATUSS.000

00037071867 RYNATUSS PEDIATRIC.000

00037071868 RYNATUSS PEDIATRIC.000

00372001304 S-T FEBROL500.00 MG/15ML

00372001316 S-T FEBROL500.00 MG/15ML

00003145730 SAF-GEL.000

08290305406 SAFETY-GARD SHIELDED NEED.000

08290305407 SAFETY-GARD SHIELDED NEED.000

08290329464 SAFETY-LOK INSULIN SYRING.000

08290305554 SAFETY-LOK SAFETY SYRINGE.000

08290305559 SAFETY-LOK SYRINGE 10CC L.000

08290309606 SAFETY-LOK SYRINGE 3CC LU.000

08290305558 SAFETY-LOK SYRINGE 5CC LU.000

08290305561 SAFETY-LOK SYRINGE/DETACH.000

08290305564 SAFETY-LOK SYRINGE/DETACH.000

08290309592 SAFETY-LOK SYRINGE/NEEDLE.000

08290309593 SAFETY-LOK SYRINGE/NEEDLE.000

08290309594 SAFETY-LOK SYRINGE/NEEDLE.000

08290309595 SAFETY-LOK SYRINGE/NEEDLE.000

08290309596 SAFETY-LOK SYRINGE/NEEDLE.000

08290305553 SAFETY-LOK TB SYRINGE PER.000

60267074230 SAL-TROPINE.400 MG

00086007110 SALFLEX500.00 MG

00086007210 SALFLEX750.00 MG

00086007250 SALFLEX750.00 MG

53303002408 SALICEPT.000

50383057745 SALINE MIST.650 %

45802035758 SALINE MIST.650 %

00536250676 SALINE MIST.650 %

45802031758 SALINE NASAL SPRAY.650 %

00451450050 SALINEX.400 %

00451450085 SALINEX.400 %

00054376950 SALIVA SUBSTITUTE.000

00054880311 SALIVA SUBSTITUTE.000

00603575421 SALSALATE500.00 MG

00603575428 SALSALATE500.00 MG

00603575521 SALSALATE750.00 MG

00603575528 SALSALATE750.00 MG

00254581235 SALSALATE750.00 MG

00144130550 SALSALATE500.00 MG

00144130750 SALSALATE750.00 MG

00182180289 SALSALATE500.00 MG

00182180389 SALSALATE750.00 MG

50111039001 SALSALATE500.00 MG

50111039002 SALSALATE500.00 MG

50111039101 SALSALATE750.00 MG

50111039102 SALSALATE750.00 MG

53265018710 SALSALATE500.00 MG

53265018750 SALSALATE500.00 MG

53265018810 SALSALATE750.00 MG

53265018850 SALSALATE750.00 MG

53265013210 SALSALATE500.00 MG

53265013250 SALSALATE500.00 MG

53265013310 SALSALATE750.00 MG

53265013350 SALSALATE750.00 MG

53489046501 SALSALATE500.00 MG

53489046505 SALSALATE500.00 MG

53489046601 SALSALATE750.00 MG

53489046605 SALSALATE750.00 MG

00904507260 SALSALATE500.00 MG

00904125061 SALSALATE500.00 MG

00904125140 SALSALATE750.00 MG

00904125160 SALSALATE750.00 MG

00904125161 SALSALATE750.00 MG

00904125340 SALSALATE500.00 MG

00677102401 SALSALATE500.00 MG

00677102405 SALSALATE500.00 MG

00677102501 SALSALATE750.00 MG

00677102505 SALSALATE750.00 MG

57664010308 SALSALATE500.00 MG

57664010313 SALSALATE500.00 MG

57664010318 SALSALATE500.00 MG

57664010508 SALSALATE750.00 MG

57664010513 SALSALATE750.00 MG

Page 87 of 125

Page 88: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

57664010518 SALSALATE750.00 MG

60429020712 SALSALATE750.00 MG

60429020730 SALSALATE750.00 MG

60429020760 SALSALATE750.00 MG

54092005501 SALURON50.000 MG

54092005601 SALUTENSIN.000

54092005610 SALUTENSIN.000

54092005701 SALUTENSIN-DEMI.000

00078010901 SANDIMMUNE50.000 MG/ML

00078024015 SANDIMMUNE25.000 MG

00078024115 SANDIMMUNE100.00 MG

00603062521 SANI-CLENS.000

00713030898 SANI-PADS.000

00713010109 SANI-SUPP GLYCERIN ADULT3.000 GM

00713010150 SANI-SUPP GLYCERIN ADULT3.000 GM

00713010125 SANI-SUPP GLYCERIN ADULT3.000 GM

00713010209 SANI-SUPP INFANT1.500 GM

00713010225 SANI-SUPP INFANT1.500 GM

00904331060 SANI-WIPES.000

00002321045 SARAFEM10.000 MG

00002322045 SARAFEM20.000 MG

08290306537 SASH KIT FOR FLUSHING VAS.000

08290306538 SASH KIT FOR FLUSHING VAS.000

08290306539 SASH KIT FOR FLUSHING VAS.000

00904509360 SAW PALMETTO500.00 MG

00496081901 SBR LIPOCREAM.000

00496081930 SBR LIPOCREAM.000

00372000101 SCOT-TUSSIN.000

00372000104 SCOT-TUSSIN.000

00372000108 SCOT-TUSSIN.000

00372000116 SCOT-TUSSIN.000

00372000128 SCOT-TUSSIN.000

00372000201 SCOT-TUSSIN.000

00372000204 SCOT-TUSSIN.000

00372000208 SCOT-TUSSIN.000

00372000216 SCOT-TUSSIN.000

00372000228 SCOT-TUSSIN.000

00372004704 SCOT-TUSSIN ALLERGY RELIE12.500 MG/5ML

00372004708 SCOT-TUSSIN ALLERGY RELIE12.500 MG/5ML

00372004716 SCOT-TUSSIN ALLERGY RELIE12.500 MG/5ML

00372004728 SCOT-TUSSIN ALLERGY RELIE12.500 MG/5ML

00372003204 SCOT-TUSSIN DM.000

00372003604 SCOT-TUSSIN DM.000

00372003608 SCOT-TUSSIN DM.000

00372003616 SCOT-TUSSIN DM.000

00372003628 SCOT-TUSSIN DM.000

00372000601 SCOT-TUSSIN EXPECTORANT100.00 MG/5ML

00372000604 SCOT-TUSSIN EXPECTORANT100.00 MG/5ML

00372000608 SCOT-TUSSIN EXPECTORANT100.00 MG/5ML

00372000616 SCOT-TUSSIN EXPECTORANT100.00 MG/5ML

00372000628 SCOT-TUSSIN EXPECTORANT100.00 MG/5ML

00372005004 SCOT-TUSSIN SENIOR.000

00603038046 SEA SOFT NASAL MIST.650 %

00536718601 SEA-OMEGA300.00 MG

00536718706 SEA-OMEGA500.00 MG

00536196297 SEBEX.000

00072260007 SEBULEX.000

00072270007 SEBULEX.000

00072250007 SEBULON2.000 %

00072500007 SEBUTONE.500 %

63304067901 SECONAL100.00 MG

63304067980 SECONAL100.00 MG

00904272454 SEL-PEN BLUE1.000 %

00904526652 SELEGILINE HCL5.000 MG

49884061002 SELEGILINE HCL5.000 MG

00093078806 SELEGILINE HCL5.000 MG

59911588601 SELEGILINE HCL5.000 MG

60505343803 SELEGILINE HCL5.000 MG

60505343808 SELEGILINE HCL5.000 MG

60505005501 SELEGILINE HCL5.000 MG

60505005503 SELEGILINE HCL5.000 MG

60951062060 SELEGILINE HCL5.000 MG

60951062085 SELEGILINE HCL5.000 MG

00182113801 SELENIUM50.000 MCG

00904316260 SELENIUM50.000 MCG

00904420352 SELENIUM200.00 MCG

45802004064 SELENIUM SULFIDE2.500 %

00904153320 SELENIUM SULFIDE2.500 %

00182608837 SELENIUM SULFIDE2.500 %

00536199553 SELENIUM SULFIDE1.000 %

60432052804 SELENIUM SULFIDE2.500 %

00074266004 SELSUN SHAMPOO2.500 %

00536590401 SENEXON8.600 MG

00536590410 SENEXON8.600 MG

00904787416 SENIOR TONIC.000

00904516559 SENNA8.600 MG

00904516580 SENNA8.600 MG

00904545209 SENNA8.800 MG/5ML

17236044001 SENNA CONCENTRATE187.00 MG

17236044010 SENNA CONCENTRATE187.00 MG

00904312860 SENNA CONCENTRATE LAXATIV187.00 MG

00904312880 SENNA CONCENTRATE LAXATIV187.00 MG

00603028021 SENNA LAX8.600 MG

00904551252 SENNA PLUS.000

00182111301 SENNA S.000

00182111310 SENNA S.000

00182109301 SENNA-GEN8.600 MG

00182109310 SENNA-GEN8.600 MG

00034120020 SENOKOT8.600 MG

00034120050 SENOKOT8.600 MG

00034120080 SENOKOT8.600 MG

00034120081 SENOKOT8.600 MG

00034120091 SENOKOT8.600 MG

00034180020 SENOKOT8.800 MG/5ML

00034180080 SENOKOT8.800 MG/5ML

00034181025 SENOKOT CHILDRENS8.800 MG/5ML

00034121010 SENOKOT S.000

00034121030 SENOKOT S.000

00034121060 SENOKOT S.000

00034121081 SENOKOT S.000

00034121091 SENOKOT S.000

00003401881 SENSI-CARE MOISTURIZING.000

00003324403 SENSI-CARE MOISTURIZING.000

00003401882 SENSI-CARE PERINEAL/SKIN.000

00003401883 SENSI-CARE PERINEAL/SKIN.000

00003401884 SENSI-CARE PERINEAL/SKIN.000

00186103501 SENSORCAINE.500 %

00186103101 SENSORCAINE.250 %

00186103701 SENSORCAINE-MPF.750 %

00186103702 SENSORCAINE-MPF.750 %

00186103712 SENSORCAINE-MPF.750 %

00186103301 SENSORCAINE-MPF.500 %

00186103302 SENSORCAINE-MPF.500 %

00186103312 SENSORCAINE-MPF.500 %

00186103391 SENSORCAINE-MPF.500 %

00186103001 SENSORCAINE-MPF.250 %

00186103002 SENSORCAINE-MPF.250 %

00186103012 SENSORCAINE-MPF.250 %

00186103091 SENSORCAINE-MPF.250 %

00186102603 SENSORCAINE-MPF SPINAL.000

00186103401 SENSORCAINE-MPF/EPINEPHRI.000

00186103412 SENSORCAINE-MPF/EPINEPHRI.000

Page 88 of 125

Page 89: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00186103491 SENSORCAINE-MPF/EPINEPHRI.000

00186103801 SENSORCAINE-MPF/EPINEPHRI.000

00186103201 SENSORCAINE-MPF/EPINEPHRI.000

00186103212 SENSORCAINE-MPF/EPINEPHRI.000

00186102701 SENSORCAINE/EPINEPHRINE.000

00186102901 SENSORCAINE/EPINEPHRINE.000

00003626348 SEPTI-SOFT BODY WASH/SHAM.000

00003626393 SEPTI-SOFT BODY WASH/SHAM.000

61570005016 SEPTRA.000

61570005116 SEPTRA.000

61570005201 SEPTRA.000

61570005610 SEPTRA.000

61570005301 SEPTRA DS.000

61570005305 SEPTRA DS.000

61570005320 SEPTRA DS.000

00173046400 SEREVENT21.000 MCG/ACT

00173046500 SEREVENT21.000 MCG/ACT

00173046700 SEREVENT21.000 MCG/ACT

00173052100 SEREVENT DISKUS50.000 MCG/DOS

00173052000 SEREVENT DISKUS50.000 MCG/DOS

00904233480 SERPAZIDE.000

00087003147 SERZONE50.000 MG

00087003231 SERZONE100.00 MG

00087003331 SERZONE200.00 MG

00087003931 SERZONE150.00 MG

00087004131 SERZONE250.00 MG

60258015101 SF1.100 %

60258015001 SF 5000 PLUS1.100 %

00904343551 SHARK CARTILAGE740.00 MG

00066010566 SHEPARD'S.000

00066010574 SHEPARD'S.000

00003121222 SHUR-CLENS WOUND CLEANSER.000

00003121252 SHUR-CLENS WOUND CLEANSER.000

00003121253 SHUR-CLENS WOUND CLEANSER.000

00003187726 SIGNADRESS.000

00003401834 SIGNADRESS DUODERM.000

00003401835 SIGNADRESS DUODERM.000

54838011680 SILACE150.00 MG/15ML

54838010780 SILACE60.000 MG/15ML

54838013440 SILADRYL DAS12.500 MG/5ML

54838013500 SILADRYL SA12.500 MG/5ML

54838013540 SILADRYL SA12.500 MG/5ML

54838013570 SILADRYL SA12.500 MG/5ML

54838013580 SILADRYL SA12.500 MG/5ML

54838010140 SILAFED.000

54838010170 SILAFED.000

54838015440 SILPHEN COUGH12.500 MG/5ML

54838015470 SILPHEN COUGH12.500 MG/5ML

54838015480 SILPHEN COUGH12.500 MG/5ML

54838010540 SILPHEN DM COUGH10.000 MG/5ML

54838013040 SILTUSSIN DAS100.00 MG/5ML

54838013340 SILTUSSIN DM DAS.000

54838011740 SILTUSSIN SA100.00 MG/5ML

54838011770 SILTUSSIN SA100.00 MG/5ML

54838011780 SILTUSSIN SA100.00 MG/5ML

54838020940 SILTUSSIN-DM.000

54838020970 SILTUSSIN-DM.000

54838020980 SILTUSSIN-DM.000

61570013150 SILVADENE1.000 %

61570013198 SILVADENE1.000 %

46287050630 SIMETHICONE40.000 MG/0.6ML

17236044301 SIMETHICONE80.000 MG

17714001901 SIMETHICONE80.000 MG

00182864389 SIMETHICONE80.000 MG

00536453301 SIMETHICONE80.000 MG

00536453408 SIMETHICONE125.00 MG

00603089450 SIMETHICONE40.000 MG/0.6ML

00536222075 SIMETHICONE40.000 MG/0.6ML

00056064728 SINEMET.000

00056064768 SINEMET.000

00056065028 SINEMET.000

00056065068 SINEMET.000

00056065428 SINEMET.000

00056065468 SINEMET.000

00056052128 SINEMET CR.000

00056052168 SINEMET CR.000

00056052185 SINEMET CR.000

00056060128 SINEMET CR.000

00056060168 SINEMET CR.000

00049510047 SINEQUAN10.000 MG/ML

00049534066 SINEQUAN10.000 MG

00049535066 SINEQUAN25.000 MG

00049536066 SINEQUAN50.000 MG

00049537050 SINEQUAN150.00 MG

00049538066 SINEQUAN100.00 MG

00049539066 SINEQUAN75.000 MG

00006011728 SINGULAIR10.000 MG

00006011731 SINGULAIR10.000 MG

00006011754 SINGULAIR10.000 MG

00006027528 SINGULAIR5.000 MG

00006027531 SINGULAIR5.000 MG

00006027554 SINGULAIR5.000 MG

00006071128 SINGULAIR4.000 MG

00006071131 SINGULAIR4.000 MG

00006071154 SINGULAIR4.000 MG

59441015201 SINUMIST SR600.00 MG

00182264095 SINUS FORMULA.000

00904032159 SINUS RELIEF.000

00904032180 SINUS RELIEF.000

00086006250 SKELAXIN400.00 MG

00024180016 SKELID240.00 MG

00904427451 SLEEP TABS25.000 MG

00904432170 SLENDER FIBRE.000

00245006211 SLO-NIACIN250.00 MG

00245006311 SLO-NIACIN500.00 MG

00245006411 SLO-NIACIN750.00 MG

00083012547 SLOW FE160.00 MG

00083012574 SLOW FE160.00 MG

00083012575 SLOW FE160.00 MG

00065015204 SOACLENS.000

00074729901 SODIUM ACETATE2.000 MEQ/ML

00074329905 SODIUM ACETATE2.000 MEQ/ML

00074329906 SODIUM ACETATE2.000 MEQ/ML

00677013110 SODIUM BICARBONATE650.00 MG

00536454010 SODIUM BICARBONATE325.00 MG

00536454410 SODIUM BICARBONATE650.00 MG

00548105200 SODIUM BICARBONATE8.400 %

00548100200 SODIUM BICARBONATE7.500 %

00548200200 SODIUM BICARBONATE7.500 %

00548330200 SODIUM BICARBONATE7.500 %

00548335200 SODIUM BICARBONATE8.400 %

00548333100 SODIUM BICARBONATE4.200 %

00074663722 SODIUM BICARBONATE8.400 %

00074663734 SODIUM BICARBONATE8.400 %

00074662502 SODIUM BICARBONATE8.400 %

00074491622 SODIUM BICARBONATE7.500 %

00074491634 SODIUM BICARBONATE7.500 %

00074553418 SODIUM BICARBONATE4.200 %

00074553434 SODIUM BICARBONATE4.200 %

00074490018 SODIUM BICARBONATE8.400 %

00074490034 SODIUM BICARBONATE8.400 %

00074159403 SODIUM BICARBONATE5.000 %

Page 89 of 125

Page 90: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00002202902 SODIUM BICARBONATE650.00 MG

00548205200 SODIUM BICARBONATE STICK-8.400 %

00074149201 SODIUM CHLORIDE.900 %

00074158301 SODIUM CHLORIDE.900 %

00074158302 SODIUM CHLORIDE.900 %

00074158401 SODIUM CHLORIDE.900 %

00074158411 SODIUM CHLORIDE.900 %

00074158603 SODIUM CHLORIDE5.000 %

00074191832 SODIUM CHLORIDE.900 %

00074191833 SODIUM CHLORIDE.900 %

00074191835 SODIUM CHLORIDE.900 %

00074181205 SODIUM CHLORIDE.900 %

00074181222 SODIUM CHLORIDE.900 %

00074210202 SODIUM CHLORIDE.900 %

00074210205 SODIUM CHLORIDE.900 %

00074210230 SODIUM CHLORIDE.900 %

00074114102 SODIUM CHLORIDE4.000 MEQ/ML

00074113002 SODIUM CHLORIDE4.000 MEQ/ML

00054880925 SODIUM CHLORIDE.900 %

00054881025 SODIUM CHLORIDE.900 %

00074665773 SODIUM CHLORIDE2.500 MEQ/ML

00074666075 SODIUM CHLORIDE2.500 MEQ/ML

00074421902 SODIUM CHLORIDE2.500 MEQ/ML

00074710102 SODIUM CHLORIDE.900 %

00074710166 SODIUM CHLORIDE.900 %

00074710167 SODIUM CHLORIDE.900 %

00074798302 SODIUM CHLORIDE.900 %

00074798303 SODIUM CHLORIDE.900 %

00074798309 SODIUM CHLORIDE.900 %

00074798353 SODIUM CHLORIDE.900 %

00074798355 SODIUM CHLORIDE.900 %

00074798361 SODIUM CHLORIDE.900 %

00074798420 SODIUM CHLORIDE.900 %

00074798436 SODIUM CHLORIDE.900 %

00074798437 SODIUM CHLORIDE.900 %

00904531435 SODIUM CHLORIDE5.000 %

00904531538 SODIUM CHLORIDE5.000 %

49502082003 SODIUM CHLORIDE.450 %

49502082005 SODIUM CHLORIDE.450 %

49502083003 SODIUM CHLORIDE.900 %

49502083005 SODIUM CHLORIDE.900 %

49502083015 SODIUM CHLORIDE.900 %

49502083050 SODIUM CHLORIDE.900 %

00002202402 SODIUM CHLORIDE1.000 GM

59930160901 SODIUM CHLORIDE.900 %

59930160902 SODIUM CHLORIDE.900 %

00074614706 SODIUM CHLORIDE 0.45%.450 %

00074614736 SODIUM CHLORIDE 0.45%.450 %

00074613803 SODIUM CHLORIDE 0.9%.900 %

00074613822 SODIUM CHLORIDE 0.9%.900 %

00074797205 SODIUM CHLORIDE 0.9%.900 %

00074797207 SODIUM CHLORIDE 0.9%.900 %

00074797208 SODIUM CHLORIDE 0.9%.900 %

00074713806 SODIUM CHLORIDE 0.9%.900 %

00074713809 SODIUM CHLORIDE 0.9%.900 %

00074713836 SODIUM CHLORIDE 0.9%.900 %

00074713202 SODIUM CHLORIDE 0.45%.450 %

00074713266 SODIUM CHLORIDE 0.45%.450 %

00074713267 SODIUM CHLORIDE 0.45%.450 %

00074797507 SODIUM CHLORIDE 0.45%.450 %

00074798502 SODIUM CHLORIDE 0.45%.450 %

00074798503 SODIUM CHLORIDE 0.45%.450 %

00074798509 SODIUM CHLORIDE 0.45%.450 %

00074773020 SODIUM CHLORIDE 0.45% QUA.450 %

00074773036 SODIUM CHLORIDE 0.45% QUA.450 %

00074773037 SODIUM CHLORIDE 0.45% QUA.450 %

00074488810 SODIUM CHLORIDE 0.9%.900 %

00074488812 SODIUM CHLORIDE 0.9%.900 %

00074488820 SODIUM CHLORIDE 0.9%.900 %

00074488850 SODIUM CHLORIDE 0.9%.900 %

00074488899 SODIUM CHLORIDE 0.9%.900 %

00074196604 SODIUM CHLORIDE BACTERIOS.900 %

00074196605 SODIUM CHLORIDE BACTERIOS.900 %

00074196607 SODIUM CHLORIDE BACTERIOS.900 %

00074196612 SODIUM CHLORIDE BACTERIOS.900 %

00074196614 SODIUM CHLORIDE BACTERIOS.900 %

00641033305 SODIUM CHLORIDE BACTERIOS.900 %

00006362050 SODIUM EDECRIN50.000 MG

00677167810 SODIUM FLUORIDE2.200 MG

10267164001 SODIUM FLUORIDE1.100 MG

10267164004 SODIUM FLUORIDE1.100 MG

10267164101 SODIUM FLUORIDE2.200 MG

10267164104 SODIUM FLUORIDE2.200 MG

10267164201 SODIUM FLUORIDE2.200 MG

50383065650 SODIUM FLUORIDE1.100 MG/ML

51552014604 SODIUM FLUORIDE.000

00093965457 SODIUM FLUORIDE.500 MG/ML

00603124447 SODIUM FLUORIDE1.100 MG/ML

00074666402 SODIUM LACTATE5.000 MEQ/ML

00074739172 SODIUM PHOSPHATE3.000 MMOLE/M

00074329551 SODIUM PHOSPHATE FLIPTOP3.000 MMOLE/M

00054881611 SODIUM POLYSTYRENE SULFON15.000 GM/60ML

00054380563 SODIUM POLYSTYRENE SULFON15.000 GM/60ML

46287001216 SODIUM POLYSTYRENE SULFON.000

00677091730 SODIUM SULFACETAMIDE10.000 %

24208067004 SODIUM SULFACETAMIDE10.000 %

00904272835 SODIUM SULFACETAMIDE10.000 %

00603784478 SODIUM SULFACETAMIDE/SULF.000

60267011930 SODIUM SULFACETAMIDE/SULF.000

00009090908 SOLU-CORTEF250.00 MG

00009090916 SOLU-CORTEF250.00 MG

00009091205 SOLU-CORTEF500.00 MG

00009092003 SOLU-CORTEF1000.0 MG

00009090013 SOLU-CORTEF100.00 MG

00009090020 SOLU-CORTEF100.00 MG

00009082501 SOLU-CORTEF100.00 MG

00009069801 SOLU-MEDROL1000.0 MG

00009075801 SOLU-MEDROL500.00 MG

00009019009 SOLU-MEDROL125.00 MG

00009019016 SOLU-MEDROL125.00 MG

00009011312 SOLU-MEDROL40.000 MG

00009011319 SOLU-MEDROL40.000 MG

00009338901 SOLU-MEDROL ACT-O-VIAL1000.0 MG

00009076502 SOLU-MEDROL ACT-O-VIAL500.00 MG

00037200101 SOMA350.00 MG

00037200103 SOMA350.00 MG

00037210301 SOMA COMPOUND.000

00037210303 SOMA COMPOUND.000

00037210385 SOMA COMPOUND.000

00037240301 SOMA COMPOUND/CODEINE.000

53100012823 SOMINEX.000

53100012833 SOMINEX.000

53100012851 SOMINEX FORMULA 225.000 MG

53100012832 SOMINEX FORMULA 225.000 MG

53100012822 SOMINEX FORMULA 225.000 MG

53100012870 SOMINEX MAXIMUM STRENTH50.000 MG

53100012875 SOMINEX MAXIMUM STRENTH50.000 MG

53100012880 SOMINEX MAXIMUM STRENTH50.000 MG

51991008051 SOMNOTE500.00 MG

00904053360 SONEX-T.000

46287050001 SORBITOL70.000 %

46287050030 SORBITOL70.000 %

Page 90 of 125

Page 91: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

46287050099 SORBITOL70.000 %

00574016810 SORBITOL70.000 %

00574016816 SORBITOL70.000 %

00245002016 SORBITOL70.000 %

60258090116 SORBITOL70.000 %

00904502198 SORE THROAT LOZENGES.000

00904177021 SORE THROAT SPRAY.000

00904177121 SORE THROAT SPRAY.000

45802032782 SORE THROAT SPRAY ADVANCE1.400 %

00245001201 SORINE80.000 MG

00245001211 SORINE80.000 MG

00245001301 SORINE120.00 MG

00245001311 SORINE120.00 MG

00245001401 SORINE160.00 MG

00245001411 SORINE160.00 MG

00245001501 SORINE240.00 MG

00245001511 SORINE240.00 MG

00185017001 SOTALOL HCL120.00 MG

00185017101 SOTALOL HCL80.000 MG

00185017105 SOTALOL HCL80.000 MG

00185017401 SOTALOL HCL240.00 MG

00185017701 SOTALOL HCL160.00 MG

00378031401 SOTALOL HCL160.00 MG

00378030501 SOTALOL HCL80.000 MG

00378031001 SOTALOL HCL120.00 MG

00115271101 SOTALOL HCL80.000 MG

00115272201 SOTALOL HCL120.00 MG

00115273301 SOTALOL HCL160.00 MG

00115274401 SOTALOL HCL240.00 MG

00093106001 SOTALOL HCL120.00 MG

00093106101 SOTALOL HCL80.000 MG

00093106201 SOTALOL HCL160.00 MG

00093106301 SOTALOL HCL240.00 MG

49884058201 SOTALOL HCL80.000 MG

49884058210 SOTALOL HCL80.000 MG

49884058301 SOTALOL HCL120.00 MG

49884058310 SOTALOL HCL120.00 MG

49884058401 SOTALOL HCL160.00 MG

49884058410 SOTALOL HCL160.00 MG

49884058501 SOTALOL HCL240.00 MG

49884058510 SOTALOL HCL240.00 MG

51991004501 SPASTRIN.000

08290408360 SPINAL NEEDLE 18GX6.000

08290405161 SPINAL NEEDLE 22GX1-1/2.000

08290405073 SPINAL NEEDLE NEONATAL LU.000

00781159901 SPIRONOLACTONE25.000 MG

00781159910 SPIRONOLACTONE25.000 MG

00677170701 SPIRONOLACTONE50.000 MG

00677170705 SPIRONOLACTONE50.000 MG

00677170706 SPIRONOLACTONE50.000 MG

00677170707 SPIRONOLACTONE50.000 MG

00677170801 SPIRONOLACTONE100.00 MG

00677170805 SPIRONOLACTONE100.00 MG

00677170806 SPIRONOLACTONE100.00 MG

00677170807 SPIRONOLACTONE100.00 MG

00677062501 SPIRONOLACTONE25.000 MG

00677062505 SPIRONOLACTONE25.000 MG

00677062506 SPIRONOLACTONE25.000 MG

00677062507 SPIRONOLACTONE25.000 MG

00677062510 SPIRONOLACTONE25.000 MG

51079010319 SPIRONOLACTONE25.000 MG

51079010320 SPIRONOLACTONE25.000 MG

51552027601 SPIRONOLACTONE.000

53489032801 SPIRONOLACTONE50.000 MG

53489032805 SPIRONOLACTONE50.000 MG

53489032901 SPIRONOLACTONE100.00 MG

53489032905 SPIRONOLACTONE100.00 MG

53489014301 SPIRONOLACTONE25.000 MG

53489014305 SPIRONOLACTONE25.000 MG

53489014310 SPIRONOLACTONE25.000 MG

00378214601 SPIRONOLACTONE25.000 MG

00378214605 SPIRONOLACTONE25.000 MG

00228267211 SPIRONOLACTONE50.000 MG

00228267250 SPIRONOLACTONE50.000 MG

00228267311 SPIRONOLACTONE100.00 MG

00228267350 SPIRONOLACTONE100.00 MG

00378014101 SPIRONOLACTONE/HYDROCHLOR.000

00378014105 SPIRONOLACTONE/HYDROCHLOR.000

53489014401 SPIRONOLACTONE/HYDROCHLOR.000

53489014405 SPIRONOLACTONE/HYDROCHLOR.000

53489014410 SPIRONOLACTONE/HYDROCHLOR.000

51079010420 SPIRONOLACTONE/HYDROCHLOR.000

00677062401 SPIRONOLACTONE/HYDROCHLOR.000

00677062405 SPIRONOLACTONE/HYDROCHLOR.000

00677062407 SPIRONOLACTONE/HYDROCHLOR.000

00677062410 SPIRONOLACTONE/HYDROCHLOR.000

46287000601 SPS15.000 GM/60ML

46287000604 SPS30.000 GM/120M

46287000660 SPS15.000 GM/60ML

00054881501 SPS 30GM/120ML ENEMA30.000 GM/120M

00054881755 SPS 50GM/200ML ENEMA50.000 GM/200M

49884060036 SSD1.000 %

49884060040 SSD1.000 %

49884060057 SSD1.000 %

49884060058 SSD1.000 %

49884060085 SSD1.000 %

49884060136 SSD AF1.000 %

49884060140 SSD AF1.000 %

00245000308 SSKI1.000 GM/ML

00245000331 SSKI1.000 GM/ML

00182407926 ST JOHNS WORT EXTRACT300.00 MG

00015564420 STADOL2.000 MG/ML

00015564433 STADOL2.000 MG/ML

00015564620 STADOL2.000 MG/ML

00015564820 STADOL2.000 MG/ML

00015564897 STADOL2.000 MG/ML

00087565041 STADOL NS10.000 MG/ML

60258015201 STANNOUS FLUORIDE.400 %

60258015910 STANNOUS FLUORIDE ORAL RI.630 %

00078035105 STARLIX60.000 MG

00078035205 STARLIX120.00 MG

00072800060 STATICIN1.500 %

00904795544 STAY AWAKE200.00 MG

49502081003 STERILE WATER.000

49502081005 STERILE WATER.000

00074711807 STERILE WATER FOR INJECTI.000

00074799009 STERILE WATER INJECT.000

00074402702 STERILE WATER INJECT.000

00074402903 STERILE WATER INJECT.000

00074404402 STERILE WATER INJECT.000

00074488710 STERILE WATER INJECT.000

00074488720 STERILE WATER INJECT.000

00074488750 STERILE WATER INJECT.000

00074488799 STERILE WATER INJECT.000

00074159002 STERILE WATER INJECT.000

00074159005 STERILE WATER INJECT.000

00074613903 STERILE WATER IRRIGATION.000

00074613922 STERILE WATER IRRIGATION.000

00074797305 STERILE WATER IRRIGATION.000

00074797307 STERILE WATER IRRIGATION.000

00074797308 STERILE WATER IRRIGATION.000

00074713906 STERILE WATER IRRIGATION.000

Page 91 of 125

Page 92: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00074713909 STERILE WATER IRRIGATION.000

00074713936 STERILE WATER IRRIGATION.000

08290404201 STIMEX INSULATED NEEDLE T.000

00904026252 STRESS FORMULA.000

00904026352 STRESS FORMULA W/IRON.000

00904272752 STRESS FORMULA/ZINC.000

00182448726 STRESS TAB NF.000

00182449126 STRESS W/ZINC.000

00245013201 STRESS-600.000

00245013301 STRESS-600/ZINC.000

00182448126 STRESS/IRON.000

00642020010 STROVITE.000

00642020410 STROVITE FORTE.000

00642020110 STROVITE PLUS.000

60258024516 SU-TUSS DM.000

60258071516 SU-TUSS HD.000

00087087302 SUBDUE.000

00087087342 SUBDUE.000

00087087402 SUBDUE.000

00087087442 SUBDUE.000

00087087502 SUBDUE.000

00087087542 SUBDUE.000

00087087640 SUBDUE.000

00087100402 SUBDUE PLUS.000

00087100602 SUBDUE PLUS.000

00087100702 SUBDUE PLUS.000

00087100742 SUBDUE PLUS.000

00052044510 SUCCINYLCHOLINE CHLORIDE20.000 MG/ML

00093221001 SUCRALFATE1.000 GM

00093221005 SUCRALFATE1.000 GM

00185210001 SUCRALFATE1.000 GM

00185210005 SUCRALFATE1.000 GM

00904543840 SUCRALFATE1.000 GM

00904543860 SUCRALFATE1.000 GM

17236054601 SUCRALFATE1.000 GM

17236054605 SUCRALFATE1.000 GM

51079087119 SUCRALFATE1.000 GM

51079087120 SUCRALFATE1.000 GM

52555005701 SUCRALFATE1.000 GM

52555005705 SUCRALFATE1.000 GM

59930153201 SUCRALFATE1.000 GM

59930153202 SUCRALFATE1.000 GM

53100000851 SUCRETS2.400 MG

53100000885 SUCRETS2.000 MG

53100000904 SUCRETS2.000 MG

53100085003 SUCRETS2.000 MG

53100000917 SUCRETS ASSORTED2.000 MG

53100000902 SUCRETS CHILDRENS1.200 MG

53100000915 SUCRETS MAXIMUM STRENGTH3.000 MG

53100000916 SUCRETS MAXIMUM STRENGTH3.000 MG

00081960024 SUDAFED30.000 MG

00081086524 SUDAFED30.000 MG

00081086548 SUDAFED30.000 MG

00081067013 SUDAFED 12 HOUR120.00 MG

00081067020 SUDAFED 12 HOUR120.00 MG

00081067713 SUDAFED COLD & COUGH.000

00081067720 SUDAFED COLD & COUGH.000

00081087024 SUDAFED PLUS.000

00081960001 SUDAFED SEVERE COLD.000

00081960002 SUDAFED SEVERE COLD.000

00081960003 SUDAFED SEVERE COLD.000

00081076624 SUDAFED SINUS.000

00081076824 SUDAFED SINUS.000

00904512546 SUDOGEST60.000 MG

00904512559 SUDOGEST60.000 MG

00904505324 SUDOGEST30.000 MG

00904505359 SUDOGEST30.000 MG

00904536720 SUDOGEST CHILDRENS15.000 MG/5ML

00904505460 SUDOGEST PLUS.000

00641114133 SUFENTANIL CITRATE50.000 MCG/ML

00641114233 SUFENTANIL CITRATE50.000 MCG/ML

00641114333 SUFENTANIL CITRATE50.000 MCG/ML

00074338031 SUFENTANIL CITRATE50.000 MCG/ML

00074338032 SUFENTANIL CITRATE50.000 MCG/ML

00074338035 SUFENTANIL CITRATE50.000 MCG/ML

00074338221 SUFENTANIL CITRATE50.000 MCG/ML

00074338222 SUFENTANIL CITRATE50.000 MCG/ML

00074338225 SUFENTANIL CITRATE50.000 MCG/ML

00310089139 SULAR10.000 MG

58768073212 SULF-1010.000 %

00066002825 SULFACET-R.000

00066902825 SULFACET-R.000

00168007938 SULFACETAMIDE SODIUM10.000 %

24208031705 SULFACETAMIDE SODIUM/PRED.000

24208031710 SULFACETAMIDE SODIUM/PRED.000

00185075701 SULFADIAZINE500.00 MG

00185075710 SULFADIAZINE500.00 MG

00185011201 SULFAMETHOXAZOLE/TRIMETHO.000

00185011205 SULFAMETHOXAZOLE/TRIMETHO.000

00093008801 SULFAMETHOXAZOLE/TRIMETHO.000

00093008805 SULFAMETHOXAZOLE/TRIMETHO.000

00093008901 SULFAMETHOXAZOLE/TRIMETHO.000

00093008905 SULFAMETHOXAZOLE/TRIMETHO.000

51079012890 SULFAMETHOXAZOLE/TRIMETHO.000

50383082316 SULFAMETHOXAZOLE/TRIMETHO.000

50383082416 SULFAMETHOXAZOLE/TRIMETHO.000

53489014501 SULFAMETHOXAZOLE/TRIMETHO.000

53489014505 SULFAMETHOXAZOLE/TRIMETHO.000

53489014601 SULFAMETHOXAZOLE/TRIMETHO.000

53489014605 SULFAMETHOXAZOLE/TRIMETHO.000

00904272540 SULFAMETHOXAZOLE/TRIMETHO.000

00904272560 SULFAMETHOXAZOLE/TRIMETHO.000

00904272561 SULFAMETHOXAZOLE/TRIMETHO.000

00904272640 SULFAMETHOXAZOLE/TRIMETHO.000

00904272660 SULFAMETHOXAZOLE/TRIMETHO.000

00641276443 SULFAMETHOXAZOLE/TRIMETHO.000

00641276543 SULFAMETHOXAZOLE/TRIMETHO.000

00641276641 SULFAMETHOXAZOLE/TRIMETHO.000

00677078301 SULFAMETHOXAZOLE/TRIMETHO.000

00677078305 SULFAMETHOXAZOLE/TRIMETHO.000

00677078360 SULFAMETHOXAZOLE/TRIMETHO.000

00677078401 SULFAMETHOXAZOLE/TRIMETHO.000

00677078405 SULFAMETHOXAZOLE/TRIMETHO.000

00677078460 SULFAMETHOXAZOLE/TRIMETHO.000

60429017014 SULFAMETHOXAZOLE/TRIMETHO.000

60429017020 SULFAMETHOXAZOLE/TRIMETHO.000

53489014701 SULFASALAZINE500.00 MG

53489014705 SULFASALAZINE500.00 MG

53489014710 SULFASALAZINE500.00 MG

00904115240 SULFASALAZINE500.00 MG

00904115260 SULFASALAZINE500.00 MG

00677048301 SULFASALAZINE500.00 MG

00677048305 SULFASALAZINE500.00 MG

59762500001 SULFASALAZINE500.00 MG

59762500002 SULFASALAZINE500.00 MG

00472128416 SULFATRIM.000

00472128516 SULFATRIM.000

00472128533 SULFATRIM.000

00555027102 SULFINPYRAZONE100.00 MG

00172221860 SULFISOXAZOLE500.00 MG

00904221860 SULFISOXAZOLE500.00 MG

45802009603 SULFUR2.000 %

Page 92 of 125

Page 93: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

51552013304 SULFUR SUBLIMED.000

51079066620 SULINDAC150.00 MG

51079066720 SULINDAC200.00 MG

53489047801 SULINDAC150.00 MG

53489047805 SULINDAC150.00 MG

53489047810 SULINDAC150.00 MG

53489047901 SULINDAC200.00 MG

53489047905 SULINDAC200.00 MG

53489047910 SULINDAC200.00 MG

00677117301 SULINDAC150.00 MG

00677117305 SULINDAC150.00 MG

00677117306 SULINDAC150.00 MG

00677117401 SULINDAC200.00 MG

00677117405 SULINDAC200.00 MG

00677117406 SULINDAC200.00 MG

00904337960 SULINDAC200.00 MG

00904337961 SULINDAC200.00 MG

00378042701 SULINDAC150.00 MG

00378053101 SULINDAC200.00 MG

00047077332 SULINDAC150.00 MG

00047077432 SULINDAC200.00 MG

60429017260 SULINDAC200.00 MG

00003081550 SUMYCIN125.00 MG/5ML

00083019773 SUNKIST CHILDREN'S MULTIV.000

00083020073 SUNKIST CHILDREN'S MULTIV.000

00083019473 SUNKIST VITAMIN C250.00 MG

00083019573 SUNKIST VITAMIN C500.00 MG

00182450526 SUPER B-100.000

00536594701 SUPER HIGH VITAMINS/MINER.000

00904225360 SUPERPLEX-T.000

00603030621 SUR-Q-LAX240.00 MG

00074487813 SURBEX-T.000

00074487713 SURBEX/C.000

00074815250 SURBEX/ZINC.000

57664016106 SURELAC3000.0 U

00003650948 SUREPRESS ABSORBENT PADDI.000

00009361002 SURFAK240.00 MG

00009361003 SURFAK240.00 MG

00009361004 SURFAK240.00 MG

00009361006 SURFAK240.00 MG

00168020502 SURGILUBE.000

00168020506 SURGILUBE.000

00168020512 SURGILUBE.000

00168020536 SURGILUBE.000

00168020537 SURGILUBE.000

00168020543 SURGILUBE.000

00168020545 SURGILUBE.000

00168020555 SURGILUBE.000

00168012662 SWIM EAR.000

00168012691 SWIM EAR.000

00904365024 SYMPTOMATIC COLD RELIEF.000

53014030814 SYN-RX.000

99207050113 SYNALAR.025 %

99207050117 SYNALAR.025 %

99207050417 SYNALAR.025 %

99207050644 SYNALAR.010 %

99207050646 SYNALAR.010 %

99207050413 SYNALAR.025 %

00904098516 SYRVITE.000

00072830060 T-STAT2.000 %

00072830360 T-STAT2.000 %

00536462401 T-VITES.000

00904053046 TAB-A-VITE.000

00904053060 TAB-A-VITE.000

00904053061 TAB-A-VITE.000

00904053080 TAB-A-VITE.000

00904053160 TAB-A-VITE/IRON.000

00904053180 TAB-A-VITE/IRON.000

00108501320 TAGAMET300.00 MG

00108502618 TAGAMET400.00 MG

00108502625 TAGAMET400.00 MG

00108502725 TAGAMET800.00 MG

00766501606 TAGAMET HB200.00 MG

00766501630 TAGAMET HB200.00 MG

00766501650 TAGAMET HB200.00 MG

00766501670 TAGAMET HB200.00 MG

00024193704 TALACEN.000

00024195104 TALWIN NX.000

00089030510 TAMBOCOR50.000 MG

00089030710 TAMBOCOR100.00 MG

00089031410 TAMBOCOR150.00 MG

00555044609 TAMOXIFEN CITRATE10.000 MG

00555044663 TAMOXIFEN CITRATE10.000 MG

00555090401 TAMOXIFEN CITRATE20.000 MG

00555090414 TAMOXIFEN CITRATE20.000 MG

50383086116 TANNATE-12.000

60258030016 TANNIC-12.000

60258030101 TANNIC-12.000

60432018316 TANNIHIST-12.000

52604109401 TAPAZOLE5.000 MG

52604109501 TAPAZOLE10.000 MG

00004592001 TASMAR100.00 MG

00004592101 TASMAR200.00 MG

00043014224 TAVIST SINUS NON DROWSY M.000

00043011908 TAVIST-11.340 MG

00043011916 TAVIST-11.340 MG

00043011932 TAVIST-11.340 MG

00015347530 TAXOL6.000 MG/ML

00015347630 TAXOL6.000 MG/ML

00015347911 TAXOL6.000 MG/ML

00074509111 TAZICEF2.000 GM

00007508201 TAZICEF1.000 GM

00002723101 TAZIDIME1.000 GM

00002723125 TAZIDIME1.000 GM

00002723401 TAZIDIME2.000 GM

00002723410 TAZIDIME2.000 GM

00002723901 TAZIDIME2.000 GM

00002724101 TAZIDIME6.000 GM

00002724116 TAZIDIME6.000 GM

00002729001 TAZIDIME W/DILUENT1.000 GM

00002729025 TAZIDIME W/DILUENT1.000 GM

00002729101 TAZIDIME W/DILUENT2.000 GM

00002729110 TAZIDIME W/DILUENT2.000 GM

53706100101 TBC.000

53706100102 TBC.000

00182154364 TEARGEN1.400 %

58768072515 TEARISOL.500 %

00065041625 TEARS NATURALE.000

00065041631 TEARS NATURALE.000

00065041632 TEARS NATURALE.000

00998041315 TEARS NATURALE.000

00998041330 TEARS NATURALE.000

00065042615 TEARS NATURALE FORTE.000

00065042630 TEARS NATURALE FORTE.000

00065041815 TEARS NATURALE II.000

00065041830 TEARS NATURALE II.000

00065042005 TEARS NATURALE PM.000

00713010709 TEBAMIDE.000

00713010809 TEBAMIDE.000

00713010850 TEBAMIDE.000

00083001976 TEGRETOL100.00 MG/5ML

00083005230 TEGRETOL100.00 MG

Page 93 of 125

Page 94: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00083005232 TEGRETOL100.00 MG

00083002730 TEGRETOL200.00 MG

00083002732 TEGRETOL200.00 MG

00083002740 TEGRETOL200.00 MG

00228207610 TEMAZEPAM15.000 MG

00228207650 TEMAZEPAM15.000 MG

00228207710 TEMAZEPAM30.000 MG

00228207750 TEMAZEPAM30.000 MG

00378401001 TEMAZEPAM15.000 MG

00378401005 TEMAZEPAM15.000 MG

00378505001 TEMAZEPAM30.000 MG

00378505005 TEMAZEPAM30.000 MG

00781220101 TEMAZEPAM15.000 MG

00781220201 TEMAZEPAM30.000 MG

00641451186 TEMAZEPAM15.000 MG

00641451188 TEMAZEPAM15.000 MG

00641451286 TEMAZEPAM30.000 MG

00641451288 TEMAZEPAM30.000 MG

51079041820 TEMAZEPAM15.000 MG

51079041821 TEMAZEPAM15.000 MG

51079041920 TEMAZEPAM30.000 MG

51079041921 TEMAZEPAM30.000 MG

00173045501 TEMOVATE.050 %

00173045502 TEMOVATE.050 %

00173045503 TEMOVATE.050 %

00173043200 TEMOVATE.050 %

00173043201 TEMOVATE.050 %

00173037501 TEMOVATE.050 %

00173037502 TEMOVATE.050 %

00173037572 TEMOVATE.050 %

00173037573 TEMOVATE.050 %

00173037601 TEMOVATE.050 %

00173037602 TEMOVATE.050 %

00173037672 TEMOVATE.050 %

00173037673 TEMOVATE.050 %

00173045401 TEMOVATE E.050 %

00173045402 TEMOVATE E.050 %

00173045403 TEMOVATE E.050 %

00087073001 TEMPRA 1100.00 MG/ML

00087073304 TEMPRA 2160.00 MG/5ML

59441015301 TENCET.000

00031890170 TENEX1.000 MG

00031890363 TENEX2.000 MG

00310011710 TENORETIC 100.000

00310011510 TENORETIC 50.000

00310010110 TENORMIN100.00 MG

00310010510 TENORMIN50.000 MG

00310010710 TENORMIN25.000 MG

00310010810 TENORMIN5.000 MG/10ML

00378226001 TERAZOSIN HCL1.000 MG

00378226401 TERAZOSIN HCL2.000 MG

00378226801 TERAZOSIN HCL5.000 MG

00378157001 TERAZOSIN HCL10.000 MG

00093076001 TERAZOSIN HCL1.000 MG

00093076101 TERAZOSIN HCL2.000 MG

00093076201 TERAZOSIN HCL5.000 MG

00093076301 TERAZOSIN HCL10.000 MG

51079093620 TERAZOSIN HCL1.000 MG

51079093720 TERAZOSIN HCL2.000 MG

51079093820 TERAZOSIN HCL5.000 MG

51079093920 TERAZOSIN HCL10.000 MG

00781205101 TERAZOSIN HCL1.000 MG

00781205105 TERAZOSIN HCL1.000 MG

00781205201 TERAZOSIN HCL2.000 MG

00781205205 TERAZOSIN HCL2.000 MG

00781205301 TERAZOSIN HCL5.000 MG

00781205305 TERAZOSIN HCL5.000 MG

00781205401 TERAZOSIN HCL10.000 MG

00781205405 TERAZOSIN HCL10.000 MG

00781154101 TERAZOSIN HCL10.000 MG

60505011500 TERAZOSIN HCL1.000 MG

60505011600 TERAZOSIN HCL2.000 MG

60505011700 TERAZOSIN HCL5.000 MG

60505011800 TERAZOSIN HCL10.000 MG

60429070790 TERAZOSIN HCL1.000 MG

60429070890 TERAZOSIN HCL2.000 MG

60429070990 TERAZOSIN HCL5.000 MG

60429071090 TERAZOSIN HCL10.000 MG

00049080108 TERRAMYCIN W/POLYMYXIN B.000

08970501021 TERUMO ALLERGY SYRINGE 1C.000

08970202531 TERUMO INSULIN SYRINGE .2.000

08970200531 TERUMO INSULIN SYRINGE .5.000

08970201021 TERUMO INSULIN SYRINGE 1C.000

08970201031 TERUMO INSULIN SYRINGE 1C.000

08970200541 TERUMO INSULIN SYRINGE U-.000

08970201041 TERUMO INSULIN SYRINGE U-.000

08970200521 TERUMO INSULIN SYRINGE/U-.000

08970721121 TERUMO SYRINGE/NEEDLE/23G.000

00456069801 TESSALON200.00 MG

00456068801 TESSALON PERLES100.00 MG

00456068802 TESSALON PERLES100.00 MG

00574046005 TESTOSTERONE.000

00574046025 TESTOSTERONE.000

00574046105 TESTOSTERONE PROPIONATE.000

00574046125 TESTOSTERONE PROPIONATE.000

60432011708 TETRA TANNATE PEDIATRIC.000

60432011716 TETRA TANNATE PEDIATRIC.000

60258010501 TETRA-MAG.000

00065074112 TETRACAINE HCL.500 %

24208092064 TETRACAINE HCL.500 %

58768078712 TETRACAINE HCL.500 %

00904240760 TETRACYCLINE HCL500.00 MG

00904240780 TETRACYCLINE HCL500.00 MG

00904241660 TETRACYCLINE HCL250.00 MG

00904241680 TETRACYCLINE HCL250.00 MG

00115140001 TETRACYCLINE HCL250.00 MG

00115140201 TETRACYCLINE HCL500.00 MG

00115140203 TETRACYCLINE HCL500.00 MG

00115140503 TETRACYCLINE HCL250.00 MG

00555001002 TETRACYCLINE HCL500.00 MG

00555001005 TETRACYCLINE HCL500.00 MG

00555001102 TETRACYCLINE HCL250.00 MG

00555001105 TETRACYCLINE HCL250.00 MG

00378010110 TETRACYCLINE HCL250.00 MG

00378010201 TETRACYCLINE HCL500.00 MG

00378010205 TETRACYCLINE HCL500.00 MG

00172240760 TETRACYCLINE HCL500.00 MG

00172240780 TETRACYCLINE HCL500.00 MG

00172241660 TETRACYCLINE HCL250.00 MG

00172241680 TETRACYCLINE HCL250.00 MG

00182011289 TETRACYCLINE HCL250.00 MG

00182067989 TETRACYCLINE HCL500.00 MG

60429020840 TETRACYCLINE HCL250.00 MG

60429020940 TETRACYCLINE HCL500.00 MG

00536094094 TETRAHYDROZOLINE HCL.050 %

61570002401 THALITONE15.000 MG

50474040001 THEO-24400.00 MG

50474010001 THEO-24100.00 MG

50474020001 THEO-24200.00 MG

50474020050 THEO-24200.00 MG

50474030001 THEO-24300.00 MG

50474030050 THEO-24300.00 MG

Page 94 of 125

Page 95: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

50474030060 THEO-24300.00 MG

50474020060 THEO-24200.00 MG

00456431001 THEOCHRON100.00 MG

00456431002 THEOCHRON100.00 MG

00456432000 THEOCHRON200.00 MG

00456432001 THEOCHRON200.00 MG

00456432002 THEOCHRON200.00 MG

00456433000 THEOCHRON300.00 MG

00456433001 THEOCHRON300.00 MG

00456433002 THEOCHRON300.00 MG

00093059901 THEOCHRON100.00 MG

00093058801 THEOCHRON SR200.00 MG

00093058901 THEOCHRON-SR300.00 MG

00054884504 THEOPHYLLINE80.000 MG/15ML

00054884816 THEOPHYLLINE80.000 MG/15ML

00054384163 THEOPHYLLINE80.000 MG/15ML

00603594421 THEOPHYLLINE CR100.00 MG

00603594428 THEOPHYLLINE CR100.00 MG

00603594521 THEOPHYLLINE CR200.00 MG

00603594528 THEOPHYLLINE CR200.00 MG

00603594532 THEOPHYLLINE CR200.00 MG

00603594621 THEOPHYLLINE CR300.00 MG

00603594628 THEOPHYLLINE CR300.00 MG

00603594632 THEOPHYLLINE CR300.00 MG

50111045901 THEOPHYLLINE CR300.00 MG

50111045902 THEOPHYLLINE CR300.00 MG

50111045903 THEOPHYLLINE CR300.00 MG

50111048201 THEOPHYLLINE CR200.00 MG

50111048202 THEOPHYLLINE CR200.00 MG

50111048203 THEOPHYLLINE CR200.00 MG

50111048301 THEOPHYLLINE CR100.00 MG

50111048302 THEOPHYLLINE CR100.00 MG

00904161060 THEOPHYLLINE CR100.00 MG

00904161061 THEOPHYLLINE CR100.00 MG

00904161160 THEOPHYLLINE CR200.00 MG

00904161161 THEOPHYLLINE CR200.00 MG

00904161180 THEOPHYLLINE CR200.00 MG

00904161240 THEOPHYLLINE CR300.00 MG

00904161260 THEOPHYLLINE CR300.00 MG

00904161261 THEOPHYLLINE CR300.00 MG

00904161280 THEOPHYLLINE CR300.00 MG

00904161360 THEOPHYLLINE CR450.00 MG

00677081701 THEOPHYLLINE CR300.00 MG

00677081705 THEOPHYLLINE CR300.00 MG

17236032401 THEOPHYLLINE CR200.00 MG

17236032410 THEOPHYLLINE CR200.00 MG

17236032501 THEOPHYLLINE CR300.00 MG

17236032510 THEOPHYLLINE CR300.00 MG

17236033501 THEOPHYLLINE CR100.00 MG

00904784760 THEOPHYLLINE ER125.00 MG

00904784960 THEOPHYLLINE ER300.00 MG

00677084601 THEOPHYLLINE ER200.00 MG

00677084605 THEOPHYLLINE ER200.00 MG

50111051801 THEOPHYLLINE ER450.00 MG

00603595021 THEOPHYLLINE ER125.00 MG

00603595121 THEOPHYLLINE ER200.00 MG

00603595221 THEOPHYLLINE ER300.00 MG

00258362501 THEOPHYLLINE ER300.00 MG

00258363401 THEOPHYLLINE ER200.00 MG

00258363801 THEOPHYLLINE ER125.00 MG

00258358101 THEOPHYLLINE ER300.00 MG

00258358105 THEOPHYLLINE ER300.00 MG

00258358110 THEOPHYLLINE ER300.00 MG

00258358301 THEOPHYLLINE ER200.00 MG

00258358305 THEOPHYLLINE ER200.00 MG

00258358310 THEOPHYLLINE ER200.00 MG

00258358401 THEOPHYLLINE ER100.00 MG

00258358405 THEOPHYLLINE ER100.00 MG

00258361401 THEOPHYLLINE ER450.00 MG

00182158989 THEOPHYLLINE TD100.00 MG

00182159089 THEOPHYLLINE TD200.00 MG

00182140089 THEOPHYLLINE TD300.00 MG

00074767713 THEOPHYLLINE/D5W.000

00074767723 THEOPHYLLINE/D5W.000

00074770562 THEOPHYLLINE/D5W.000

00074766503 THEOPHYLLINE/D5W.000

00074766509 THEOPHYLLINE/D5W.000

00074766603 THEOPHYLLINE/D5W.000

00074766662 THEOPHYLLINE/D5W.000

00074766823 THEOPHYLLINE/D5W.000

17236044801 THERA.000

17236044810 THERA.000

00904053800 THERA MULTI VIT.000

00904053820 THERA MULTI VIT.000

00904053913 THERA VITAMIN.000

00904053961 THERA VITAMIN.000

00904053980 THERA VITAMIN.000

00904429909 THERA-DERM.000

00904430309 THERA-DERM BATH OIL.000

17236045001 THERA-M.000

17236045010 THERA-M.000

45802059355 THERA-P HAND & BODY.000

50383068304 THERA-PLUS.000

00043046706 THERAFLU FLU/COLD.000

00043046606 THERAFLU FLU/COLD/COUGH.000

00043046612 THERAFLU FLU/COLD/COUGH.000

00043047106 THERAFLU MAXIMUM STRENGTH.000

00043047112 THERAFLU MAXIMUM STRENGTH.000

00043047206 THERAFLU MAXIMUM STRENGTH.000

00043013612 THERAFLU NIGHTTIME.000

00043013624 THERAFLU NIGHTTIME.000

00043047612 THERAFLU NON DROWSY FORMU.000

00043047624 THERAFLU NON DROWSY FORMU.000

00043047824 THERAFLU SINUS MAXIMUM ST.000

19810005451 THERAGRAN.000

19810005472 THERAGRAN.000

19810005492 THERAGRAN STRESS FORMULA.000

19810005365 THERAGRAN-M.000

19810005651 THERAGRAN-M.000

19810005673 THERAGRAN-M.000

00182451806 THERAPEUTIC.000

00182451810 THERAPEUTIC.000

00182451889 THERAPEUTIC.000

00245001801 THERAPEUTIC B COMPLEX W/C.000

00182602044 THERAPEUTIC BATH.000

00182601940 THERAPEUTIC BATH OIL.000

45802012647 THERAPEUTIC BATH OIL.000

45802022540 THERAPEUTIC BLUE GEL2.000 %

10267125301 THERAPEUTIC FORMULA/HEMAT.000

10267125304 THERAPEUTIC FORMULA/HEMAT.000

00482011614 THERAPEUTIC LIQUID.000

00245009001 THERAPEUTIC MULTIVITAMIN.000

00245009011 THERAPEUTIC MULTIVITAMIN.000

00245009101 THERAPEUTIC MULTIVITAMIN/.000

00245009111 THERAPEUTIC MULTIVITAMIN/.000

00904525944 THERAPEUTIC SHAMPOO.500 %

00904774923 THERAPEUTIC SHAMPOO2.000 %

10267073701 THERAPEUTIC VITAMIN & MIN.000

00182451906 THERAPEUTIC-M.000

00182451910 THERAPEUTIC-M.000

00182451989 THERAPEUTIC-M.000

99207010402 THERAPLEX Z2.000 %

Page 95 of 125

Page 96: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00182610737 THERAVITE.000

00536466010 THEREMS.000

00536466038 THEREMS.000

00536466711 THEREMS H.000

00536466110 THEREMS M.000

00536466138 THEREMS M.000

00904510850 THERMAZENE1.000 %

00603596921 THEROBEC.000

00603597021 THEROBEC PLUS.000

00536468001 THIAMINE HCL100.00 MG

00536468010 THIAMINE HCL100.00 MG

00173088025 THIOGUANINE40.000 MG

00378061201 THIORIDAZINE HCL10.000 MG

00378061210 THIORIDAZINE HCL10.000 MG

00378061401 THIORIDAZINE HCL25.000 MG

00378061410 THIORIDAZINE HCL25.000 MG

00378061601 THIORIDAZINE HCL50.000 MG

00378061610 THIORIDAZINE HCL50.000 MG

00378061801 THIORIDAZINE HCL100.00 MG

00378061810 THIORIDAZINE HCL100.00 MG

51079058020 THIORIDAZINE HCL100.00 MG

50383003804 THIORIDAZINE HCL100.00 MG/ML

50383003904 THIORIDAZINE HCL30.000 MG/ML

51079056520 THIORIDAZINE HCL10.000 MG

51079056620 THIORIDAZINE HCL25.000 MG

51079056720 THIORIDAZINE HCL50.000 MG

53489050001 THIORIDAZINE HCL100.00 MG

53489014801 THIORIDAZINE HCL10.000 MG

53489014810 THIORIDAZINE HCL10.000 MG

53489014901 THIORIDAZINE HCL25.000 MG

53489014910 THIORIDAZINE HCL25.000 MG

53489015001 THIORIDAZINE HCL50.000 MG

53489015010 THIORIDAZINE HCL50.000 MG

00677082301 THIORIDAZINE HCL10.000 MG

00677082306 THIORIDAZINE HCL10.000 MG

00677082401 THIORIDAZINE HCL25.000 MG

00677082406 THIORIDAZINE HCL25.000 MG

00677082501 THIORIDAZINE HCL50.000 MG

00677082506 THIORIDAZINE HCL50.000 MG

00677083201 THIORIDAZINE HCL100.00 MG

00677083206 THIORIDAZINE HCL100.00 MG

00904161880 THIORIDAZINE HCL100.00 MG

00904179561 THIORIDAZINE HCL25.000 MG

00781164401 THIORIDAZINE HCL100.00 MG

00781166401 THIORIDAZINE HCL150.00 MG

00781167401 THIORIDAZINE HCL200.00 MG

00781160401 THIORIDAZINE HCL10.000 MG

00781161401 THIORIDAZINE HCL15.000 MG

00781162401 THIORIDAZINE HCL25.000 MG

00781162410 THIORIDAZINE HCL25.000 MG

00781163401 THIORIDAZINE HCL50.000 MG

00781163410 THIORIDAZINE HCL50.000 MG

00054386150 THIORIDAZINE HCL INTENSOL100.00 MG/ML

00378100101 THIOTHIXENE1.000 MG

00378200201 THIOTHIXENE2.000 MG

00378200210 THIOTHIXENE2.000 MG

00378501001 THIOTHIXENE10.000 MG

00378501010 THIOTHIXENE10.000 MG

00378300501 THIOTHIXENE5.000 MG

00378300510 THIOTHIXENE5.000 MG

00904289060 THIOTHIXENE1.000 MG

00904289140 THIOTHIXENE2.000 MG

00904289160 THIOTHIXENE2.000 MG

00904289240 THIOTHIXENE5.000 MG

00904289260 THIOTHIXENE5.000 MG

00904289340 THIOTHIXENE10.000 MG

00904289360 THIOTHIXENE10.000 MG

00904295561 THIOTHIXENE1.000 MG

00904295640 THIOTHIXENE2.000 MG

00904295661 THIOTHIXENE2.000 MG

00904295761 THIOTHIXENE5.000 MG

00904295861 THIOTHIXENE10.000 MG

00781222601 THIOTHIXENE1.000 MG

00781222701 THIOTHIXENE2.000 MG

00781222710 THIOTHIXENE2.000 MG

00781222713 THIOTHIXENE2.000 MG

00781222801 THIOTHIXENE5.000 MG

00781222810 THIOTHIXENE5.000 MG

00781222813 THIOTHIXENE5.000 MG

00781222901 THIOTHIXENE10.000 MG

00781222910 THIOTHIXENE10.000 MG

51079058620 THIOTHIXENE1.000 MG

51079058720 THIOTHIXENE2.000 MG

51079058820 THIOTHIXENE5.000 MG

51079058920 THIOTHIXENE10.000 MG

00007507730 THORAZINE100.00 MG

00007507920 THORAZINE200.00 MG

00026060320 THROMBATE III W/10 ML STE500.00 IU

00904786560 THYROID30.000 MG

00904786580 THYROID30.000 MG

00904076160 THYROID65.000 MG

00904076180 THYROID65.000 MG

00904076260 THYROID130.00 MG

00904076280 THYROID130.00 MG

00904076360 THYROID180.00 MG

00904076380 THYROID180.00 MG

00677165710 THYROID30.000 MG

00677165810 THYROID60.000 MG

00677165910 THYROID120.00 MG

49483002101 THYROID30.000 MG

49483002110 THYROID30.000 MG

49483002201 THYROID60.000 MG

49483002210 THYROID60.000 MG

49483002301 THYROID120.00 MG

49483002310 THYROID120.00 MG

49483003801 THYROID195.00 MG

49483003810 THYROID195.00 MG

00456005001 THYROLAR-160.000 MG

00456004501 THYROLAR-1/230.000 MG

00456004001 THYROLAR-1/415.000 MG

00456005501 THYROLAR-2120.00 MG

00456006001 THYROLAR-3180.00 MG

00456261200 TIAZAC120.00 MG

00456261230 TIAZAC120.00 MG

00456261263 TIAZAC120.00 MG

00456261290 TIAZAC120.00 MG

00456261330 TIAZAC180.00 MG

00456261390 TIAZAC180.00 MG

00456261400 TIAZAC240.00 MG

00456261430 TIAZAC240.00 MG

00456261463 TIAZAC240.00 MG

00456261490 TIAZAC240.00 MG

00456261530 TIAZAC300.00 MG

00456261563 TIAZAC300.00 MG

00456261590 TIAZAC300.00 MG

00456261630 TIAZAC360.00 MG

00456261663 TIAZAC360.00 MG

00456261690 TIAZAC360.00 MG

00456261730 TIAZAC420.00 MG

00456261790 TIAZAC420.00 MG

00456261300 TIAZAC180.00 MG

00456261363 TIAZAC180.00 MG

Page 96 of 125

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NDCNAME

STR UOM NDC NAMESTR

UOM

00456261500 TIAZAC300.00 MG

00456261600 TIAZAC360.00 MG

00456261700 TIAZAC420.00 MG

00004001814 TICLID250.00 MG

00004001822 TICLID250.00 MG

00004001823 TICLID250.00 MG

00185011505 TICLOPIDINE HCL250.00 MG

00185011530 TICLOPIDINE HCL250.00 MG

00185011560 TICLOPIDINE HCL250.00 MG

00093015401 TICLOPIDINE HCL250.00 MG

00093015405 TICLOPIDINE HCL250.00 MG

49884059901 TICLOPIDINE HCL250.00 MG

49884059902 TICLOPIDINE HCL250.00 MG

49884059905 TICLOPIDINE HCL250.00 MG

49884059911 TICLOPIDINE HCL250.00 MG

00904537840 TICLOPIDINE HCL250.00 MG

00904537852 TICLOPIDINE HCL250.00 MG

60505002702 TICLOPIDINE HCL250.00 MG

60505002704 TICLOPIDINE HCL250.00 MG

60505002707 TICLOPIDINE HCL250.00 MG

54092054202 TIGAN100.00 MG/ML

61570050410 TIGAN.000

61570050450 TIGAN.000

61570054002 TIGAN100.00 MG/ML

00069580043 TIKOSYN125.00 MCG

00069580060 TIKOSYN125.00 MCG

00069581043 TIKOSYN250.00 MCG

00069581060 TIKOSYN250.00 MCG

00069582043 TIKOSYN500.00 MCG

00069582060 TIKOSYN500.00 MCG

00585068502 TILADE1.750 MG/ACT

00006006768 TIMOLIDE 10/25.000

00378071501 TIMOLOL MALEATE20.000 MG

00378005501 TIMOLOL MALEATE5.000 MG

00378022101 TIMOLOL MALEATE10.000 MG

00168019903 TIMOLOL MALEATE.250 %

00168019910 TIMOLOL MALEATE.250 %

00168019915 TIMOLOL MALEATE.250 %

00168019925 TIMOLOL MALEATE.250 %

00168020003 TIMOLOL MALEATE.500 %

00168020010 TIMOLOL MALEATE.500 %

00168020015 TIMOLOL MALEATE.500 %

00168020025 TIMOLOL MALEATE.500 %

51552043301 TIMOLOL MALEATE.000

00904524805 TIMOLOL MALEATE.500 %

00904524810 TIMOLOL MALEATE.500 %

00904524835 TIMOLOL MALEATE.500 %

24208032405 TIMOLOL MALEATE.500 %

24208032410 TIMOLOL MALEATE.500 %

24208032415 TIMOLOL MALEATE.500 %

24208033005 TIMOLOL MALEATE.250 %

24208033010 TIMOLOL MALEATE.250 %

24208033015 TIMOLOL MALEATE.250 %

00677162721 TIMOLOL MALEATE.500 %

00677162730 TIMOLOL MALEATE.500 %

00641403086 TIMOLOL MALEATE5.000 MG

00641403286 TIMOLOL MALEATE20.000 MG

60505055103 TIMOLOL MALEATE.500 %

60505055104 TIMOLOL MALEATE.500 %

60505055203 TIMOLOL MALEATE.250 %

60505055204 TIMOLOL MALEATE.250 %

60951078270 TIMOLOL MALEATE5.000 MG

61314022605 TIMOLOL MALEATE.250 %

61314022610 TIMOLOL MALEATE.250 %

61314022615 TIMOLOL MALEATE.250 %

61314022705 TIMOLOL MALEATE.500 %

61314022710 TIMOLOL MALEATE.500 %

61314022715 TIMOLOL MALEATE.500 %

61314022405 TIMOLOL MALEATE OPHTHALMI.250 %

61314022505 TIMOLOL MALEATE OPHTHALMI.500 %

61314022525 TIMOLOL MALEATE OPHTHALMI.500 %

00006968960 TIMOPTIC.250 %

00006969060 TIMOPTIC.500 %

00006355703 TIMOPTIC-XE.250 %

00006355732 TIMOPTIC-XE.250 %

00006355803 TIMOPTIC-XE.500 %

00006355832 TIMOPTIC-XE.500 %

00496050704 TIN-BEN.000

00496054204 TIN-CO-BEN.000

00496054206 TIN-CO-BEN.000

00085044406 TINACTIN1.000 %

00085025406 TINACTIN1.000 %

00085025407 TINACTIN1.000 %

00085033305 TINACTIN1.000 %

00085016502 TINACTIN1.000 %

00085071505 TINACTIN1.000 %

00085071507 TINACTIN1.000 %

00085007204 TINACTIN1.000 %

00085093405 TINACTIN JOCK ITCH1.000 %

00085416101 TINACTIN MAXIMUM PROTECTI1.000 %

08290001178 TITUS NEEDLE 18GX1-1/4.000

00003272510 TOBRAMYCIN SULFATE40.000 MG/ML

00003272530 TOBRAMYCIN SULFATE40.000 MG/ML

00002738216 TOBRAMYCIN SULFATE40.000 MG/ML

00904297005 TOBRAMYCIN SULFATE.300 %

24208029005 TOBRAMYCIN SULFATE.300 %

00074358201 TOBRAMYCIN SULFATE40.000 MG/ML

00074358301 TOBRAMYCIN SULFATE40.000 MG/ML

00074359002 TOBRAMYCIN SULFATE40.000 MG/ML

00603734537 TOBRAMYCIN SULFATE.300 %

61314064305 TOBRAMYCIN SULFATE.300 %

00074325403 TOBRAMYCIN SULFATE ADD-VA10.000 MG/ML

00074325503 TOBRAMYCIN SULFATE ADD-VA10.000 MG/ML

00074357701 TOBRAMYCIN SULFATE FLIPTO10.000 MG/ML

00074357801 TOBRAMYCIN SULFATE FLIPTO40.000 MG/ML

00065064305 TOBREX.300 %

00378021701 TOLAZAMIDE250.00 MG

00378055101 TOLAZAMIDE500.00 MG

00172297860 TOLAZAMIDE100.00 MG

00172297960 TOLAZAMIDE250.00 MG

00172297980 TOLAZAMIDE250.00 MG

00172298060 TOLAZAMIDE500.00 MG

51079029220 TOLAZAMIDE250.00 MG

51079029320 TOLAZAMIDE500.00 MG

51079056020 TOLBUTAMIDE500.00 MG

00378021501 TOLBUTAMIDE500.00 MG

00378021505 TOLBUTAMIDE500.00 MG

00009011404 TOLINASE250.00 MG

00009011405 TOLINASE250.00 MG

00009007002 TOLINASE100.00 MG

00378031301 TOLMETIN SODIUM600.00 MG

00378520001 TOLMETIN SODIUM400.00 MG

00093881501 TOLMETIN SODIUM400.00 MG

00093881510 TOLMETIN SODIUM400.00 MG

00677142501 TOLMETIN SODIUM200.00 MG

53489050601 TOLMETIN SODIUM200.00 MG

45802003201 TOLNAFTATE1.000 %

45802003203 TOLNAFTATE1.000 %

45802003385 TOLNAFTATE1.000 %

45802003486 TOLNAFTATE1.000 %

00904072236 TOLNAFTATE1.000 %

00904072645 TOLNAFTATE1.000 %

Page 97 of 125

Page 98: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00168000815 TOLNAFTATE1.000 %

00168000910 TOLNAFTATE1.000 %

00182503834 TOLNAFTATE1.000 %

00182166663 TOLNAFTATE1.000 %

00182166760 TOLNAFTATE1.000 %

00536513120 TOLNAFTATE1.000 %

00536515026 TOLNAFTATE1.000 %

00472190015 TOLNAFTATE1.000 %

08290001168 TONSIL NEEDLE CURVED 23GX.000

08290001169 TONSIL NEEDLE STRAIGHT 23.000

08881600863 TOPCO SYRINGE/NEEDLE U-10.000

08881600434 TOPCO SYRINGE/NEEDLE U-10.000

08881600574 TOPCO SYRINGE/NEEDLE U-10.000

08881601721 TOPCO SYRINGE/NEEDLE U-10.000

08881601622 TOPCO SYRINGE/NEEDLE U-10.000

00013733601 TOPOSAR20.000 MG/ML

00013733691 TOPOSAR20.000 MG/ML

00013734601 TOPOSAR20.000 MG/ML

00013734694 TOPOSAR20.000 MG/ML

00013735601 TOPOSAR20.000 MG/ML

00013735688 TOPOSAR20.000 MG/ML

00186108805 TOPROL XL25.000 MG

00186109005 TOPROL XL50.000 MG

00186109205 TOPROL XL100.00 MG

00186109405 TOPROL XL200.00 MG

00004692106 TORADOL15.000 MG/ML

00004027301 TORADOL ORAL10.000 MG

00029661021 TOTACILLIN-N1.000 GM

00029661025 TOTACILLIN-N1.000 GM

00029661040 TOTACILLIN-N1.000 GM

00029661222 TOTACILLIN-N2.000 GM

00029661240 TOTACILLIN-N2.000 GM

00074661007 TOTACILLIN-N1.000 GM

00074661207 TOTACILLIN-N2.000 GM

00904026013 TOTAL B/C.000

00904026060 TOTAL B/C.000

00904026080 TOTAL B/C.000

00074577901 TPN ELECTROLYTES FTV.000

00074329606 TPN ELECTROLYTES FTV.000

00074329706 TPN ELECTROLYTES II.000

00074323601 TPN ELECTROLYTES II.000

00074329806 TPN ELECTROLYTES III.000

00074588101 TPN ELECTROLYTES PTV.000

00074446810 TRACRIUM10.000 MG/ML

00074444005 TRACRIUM10.000 MG/ML

00173034743 TRANDATE200.00 MG

00173034744 TRANDATE200.00 MG

00173034844 TRANDATE300.00 MG

60976034643 TRANDATE100.00 MG

60976034644 TRANDATE100.00 MG

60976034647 TRANDATE100.00 MG

00173035057 TRANDATE IV5.000 MG/ML

00173035058 TRANDATE IV5.000 MG/ML

00047083515 TRANSDERMAL-NTG.200 MG/HR

00047083715 TRANSDERMAL-NTG.400 MG/HR

00087046404 TRAUMACAL.000

00087046444 TRAUMACAL.000

00065900191 TRAVASORB HN.000

00065026625 TRAVATAN.004 %

00093063701 TRAZODONE HCL50.000 MG

00093063710 TRAZODONE HCL50.000 MG

00093063801 TRAZODONE HCL100.00 MG

00093063810 TRAZODONE HCL100.00 MG

00555048902 TRAZODONE HCL50.000 MG

00555048904 TRAZODONE HCL50.000 MG

00555049002 TRAZODONE HCL100.00 MG

00555049004 TRAZODONE HCL100.00 MG

00555073202 TRAZODONE HCL150.00 MG

00555073204 TRAZODONE HCL150.00 MG

00555073302 TRAZODONE HCL300.00 MG

00182125989 TRAZODONE HCL50.000 MG

00182126089 TRAZODONE HCL100.00 MG

00228243910 TRAZODONE HCL50.000 MG

00228243950 TRAZODONE HCL50.000 MG

00677113301 TRAZODONE HCL50.000 MG

00677113305 TRAZODONE HCL50.000 MG

00677113401 TRAZODONE HCL100.00 MG

00677113405 TRAZODONE HCL100.00 MG

00677130201 TRAZODONE HCL150.00 MG

00677130205 TRAZODONE HCL150.00 MG

00677130207 TRAZODONE HCL150.00 MG

00641401686 TRAZODONE HCL50.000 MG

00641401688 TRAZODONE HCL50.000 MG

00641401689 TRAZODONE HCL50.000 MG

00641401786 TRAZODONE HCL100.00 MG

00641401788 TRAZODONE HCL100.00 MG

00615257843 TRAZODONE HCL50.000 MG

00904521940 TRAZODONE HCL50.000 MG

00904521960 TRAZODONE HCL50.000 MG

00904521980 TRAZODONE HCL50.000 MG

00904522040 TRAZODONE HCL100.00 MG

00904522060 TRAZODONE HCL100.00 MG

00904339270 TRAZODONE HCL150.00 MG

00904399040 TRAZODONE HCL50.000 MG

00904399061 TRAZODONE HCL50.000 MG

00904399161 TRAZODONE HCL100.00 MG

00904399270 TRAZODONE HCL150.00 MG

53489051001 TRAZODONE HCL50.000 MG

53489051005 TRAZODONE HCL50.000 MG

53489051010 TRAZODONE HCL50.000 MG

53489051101 TRAZODONE HCL100.00 MG

53489051105 TRAZODONE HCL100.00 MG

53489051110 TRAZODONE HCL100.00 MG

53489051701 TRAZODONE HCL150.00 MG

53489051705 TRAZODONE HCL150.00 MG

51079042719 TRAZODONE HCL50.000 MG

51079042720 TRAZODONE HCL50.000 MG

51079042819 TRAZODONE HCL100.00 MG

51079042820 TRAZODONE HCL100.00 MG

50111044101 TRAZODONE HCL150.00 MG

50111044102 TRAZODONE HCL150.00 MG

50111043301 TRAZODONE HCL50.000 MG

50111043302 TRAZODONE HCL50.000 MG

50111043303 TRAZODONE HCL50.000 MG

50111043401 TRAZODONE HCL100.00 MG

50111043402 TRAZODONE HCL100.00 MG

50111043403 TRAZODONE HCL100.00 MG

60429018730 TRAZODONE HCL50.000 MG

60429018760 TRAZODONE HCL50.000 MG

60429018790 TRAZODONE HCL50.000 MG

60429018830 TRAZODONE HCL100.00 MG

60429018860 TRAZODONE HCL100.00 MG

59772317101 TRAZODONE HCL DIVIDOSE150.00 MG

59772317102 TRAZODONE HCL DIVIDOSE150.00 MG

00472011720 TRETINOIN.025 %

00472011745 TRETINOIN.025 %

00555092701 TREXALL5.000 MG

00555092801 TREXALL7.500 MG

00555092901 TREXALL10.000 MG

00555094501 TREXALL15.000 MG

51991005216 TRI TANN PEDIATRIC.000

00904781060 TRI-A-VITE W/FLUORIDE.000

Page 98 of 125

Page 99: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00904201559 TRI-BUFFERED ASPIRIN.000

00904201560 TRI-BUFFERED ASPIRIN.000

00904201580 TRI-BUFFERED ASPIRIN.000

55370032912 TRI-GESTAN S.000

50419043303 TRI-LEVLEN.000

50419043306 TRI-LEVLEN.000

50419043312 TRI-LEVLEN CONTRACT PACK.000

17236029901 TRI-SUDO.000

00087045241 TRI-VI-FLOR.000

00087047841 TRI-VI-FLOR/IRON.000

00087040303 TRI-VI-SOL.000

00087045303 TRI-VI-SOL/IRON.000

00603630021 TRI-VIT/FL CHEWABLE.000

00254945148 TRI-VIT/FLUORIDE.000

00254945248 TRI-VIT/FLUORIDE.000

00603178747 TRI-VIT/FLUORIDE/IRON.000

50383063550 TRI-VITAMIN.000

50383063650 TRI-VITAMIN/FLUORIDE.000

50383063750 TRI-VITAMIN/FLUORIDE.000

54838051550 TRI-VITAMIN/FLUORIDE.000

54838051650 TRI-VITAMIN/FLUORIDE.000

54838051750 TRI-VITAMIN/IRON/FLUORIDE.000

50383062850 TRI-VITAMIN/IRON/FLUORIDE.000

00536850180 TRI-VITAMINS.000

00904523750 TRI-VITE W/FLUORIDE.000

00904261050 TRI-VITE/FLUORIDE.000

00904523650 TRI-VITE/FLUORIDE.000

00904259750 TRI-VITE/FLUORIDE.000

00785230501 TRIAD.000

00904088444 TRIAMCINOLONE4.000 MG

00904088605 TRIAMCINOLONE ACETONIDE40.000 MG/ML

45802004935 TRIAMCINOLONE ACETONIDE.500 %

45802005435 TRIAMCINOLONE ACETONIDE.025 %

45802005535 TRIAMCINOLONE ACETONIDE.100 %

45802005536 TRIAMCINOLONE ACETONIDE.100 %

45802006335 TRIAMCINOLONE ACETONIDE.025 %

45802006435 TRIAMCINOLONE ACETONIDE.100 %

45802006535 TRIAMCINOLONE ACETONIDE.500 %

00472030105 TRIAMCINOLONE ACETONIDE.100 %

00472030115 TRIAMCINOLONE ACETONIDE.100 %

00472030116 TRIAMCINOLONE ACETONIDE.100 %

00472030180 TRIAMCINOLONE ACETONIDE.100 %

00472030615 TRIAMCINOLONE ACETONIDE.100 %

00472030680 TRIAMCINOLONE ACETONIDE.100 %

00414005405 TRIAMCINOLONE ACETONIDE.025 %

00414005429 TRIAMCINOLONE ACETONIDE.025 %

00414005436 TRIAMCINOLONE ACETONIDE.025 %

00414005505 TRIAMCINOLONE ACETONIDE.100 %

00414005529 TRIAMCINOLONE ACETONIDE.100 %

00414005536 TRIAMCINOLONE ACETONIDE.100 %

00414006305 TRIAMCINOLONE ACETONIDE.025 %

00414006329 TRIAMCINOLONE ACETONIDE.025 %

00414006336 TRIAMCINOLONE ACETONIDE.025 %

00414006405 TRIAMCINOLONE ACETONIDE.100 %

00414006429 TRIAMCINOLONE ACETONIDE.100 %

00414006436 TRIAMCINOLONE ACETONIDE.100 %

00574045005 TRIAMCINOLONE ACETONIDE.000

00574045010 TRIAMCINOLONE ACETONIDE.000

00182139545 TRIAMCINOLONE ACETONIDE.100 %

00182121851 TRIAMCINOLONE ACETONIDE.500 %

00182506851 TRIAMCINOLONE ACETONIDE.500 %

00168000215 TRIAMCINOLONE ACETONIDE.500 %

00168000315 TRIAMCINOLONE ACETONIDE.025 %

00168000380 TRIAMCINOLONE ACETONIDE.025 %

00168000415 TRIAMCINOLONE ACETONIDE.100 %

00168000416 TRIAMCINOLONE ACETONIDE.100 %

00168000480 TRIAMCINOLONE ACETONIDE.100 %

00168000580 TRIAMCINOLONE ACETONIDE.025 %

00168000615 TRIAMCINOLONE ACETONIDE.100 %

00168000680 TRIAMCINOLONE ACETONIDE.100 %

60432056060 TRIAMCINOLONE ACETONIDE.025 %

60432056160 TRIAMCINOLONE ACETONIDE.100 %

46287001016 TRIAMCINOLONE ACETONIDE I.050 %

00904088505 TRIAMCINOLONE DIACETATE40.000 MG/ML

00043055804 TRIAMINIC AM COUGH/DECONG.000

00043060505 TRIAMINIC INFANT DECONGES7.500 MG/0.8ML

00043056004 TRIAMINIC NIGHT TIME MAXI.000

00043056008 TRIAMINIC NIGHT TIME MAXI.000

00043054804 TRIAMINIC NIGHT TIME MAXI.000

00043054808 TRIAMINIC NIGHT TIME MAXI.000

00043055504 TRIAMINIC SORE THROAT FOR.000

00043055508 TRIAMINIC SORE THROAT FOR.000

00172295060 TRIAMTERENE/HYDROCHLOROTH.000

00172295080 TRIAMTERENE/HYDROCHLOROTH.000

00182187289 TRIAMTERENE/HYDROCHLOROTH.000

00555064302 TRIAMTERENE/HYDROCHLOROTH.000

00555064304 TRIAMTERENE/HYDROCHLOROTH.000

00555044402 TRIAMTERENE/HYDROCHLOROTH.000

00555044404 TRIAMTERENE/HYDROCHLOROTH.000

00378253701 TRIAMTERENE/HYDROCHLOROTH.000

00378253710 TRIAMTERENE/HYDROCHLOROTH.000

00378135201 TRIAMTERENE/HYDROCHLOROTH.000

00378135205 TRIAMTERENE/HYDROCHLOROTH.000

00378135501 TRIAMTERENE/HYDROCHLOROTH.000

00378135505 TRIAMTERENE/HYDROCHLOROTH.000

00904193660 TRIAMTERENE/HYDROCHLOROTH.000

00904193680 TRIAMTERENE/HYDROCHLOROTH.000

00904196540 TRIAMTERENE/HYDROCHLOROTH.000

00904196560 TRIAMTERENE/HYDROCHLOROTH.000

00781271501 TRIAMTERENE/HYDROCHLOROTH.000

00781207401 TRIAMTERENE/HYDROCHLOROTH.000

00781207410 TRIAMTERENE/HYDROCHLOROTH.000

00781100801 TRIAMTERENE/HYDROCHLOROTH.000

00781100805 TRIAMTERENE/HYDROCHLOROTH.000

00781112301 TRIAMTERENE/HYDROCHLOROTH.000

00781112305 TRIAMTERENE/HYDROCHLOROTH.000

50111050501 TRIAMTERENE/HYDROCHLOROTH.000

50111050502 TRIAMTERENE/HYDROCHLOROTH.000

50111050503 TRIAMTERENE/HYDROCHLOROTH.000

50111053401 TRIAMTERENE/HYDROCHLOROTH.000

50111053402 TRIAMTERENE/HYDROCHLOROTH.000

51079043320 TRIAMTERENE/HYDROCHLOROTH.000

51079093520 TRIAMTERENE/HYDROCHLOROTH.000

51285048805 TRIAMTERENE/HYDROCHLOROTH.000

60429019030 TRIAMTERENE/HYDROCHLOROTH.000

60429019130 TRIAMTERENE/HYDROCHLOROTH.000

60429019190 TRIAMTERENE/HYDROCHLOROTH.000

99207005101 TRIAZ6.000 %

49884045305 TRIAZOLAM.125 MG

49884045312 TRIAZOLAM.125 MG

49884045405 TRIAZOLAM.250 MG

49884045412 TRIAZOLAM.250 MG

00054485806 TRIAZOLAM.125 MG

00054485906 TRIAZOLAM.250 MG

00054485929 TRIAZOLAM.250 MG

00054885825 TRIAZOLAM.125 MG

00054885925 TRIAZOLAM.250 MG

49884045362 TRIAZOLAM.125 MG

49884045462 TRIAZOLAM.250 MG

59762371701 TRIAZOLAM.125 MG

59762371703 TRIAZOLAM.125 MG

59762371704 TRIAZOLAM.125 MG

Page 99 of 125

Page 100: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

59762371803 TRIAZOLAM.250 MG

59762371804 TRIAZOLAM.250 MG

00603621521 TRICOSAL500.00 MG

00603621621 TRICOSAL750.00 MG

00603621721 TRICOSAL1000.0 MG

00026556161 TRIDESILON.050 %

00026556162 TRIDESILON.050 %

00026559161 TRIDESILON.050 %

00026559162 TRIDESILON.050 %

45802042435 TRIDESILON.050 %

45802042437 TRIDESILON.050 %

45802042535 TRIDESILON.050 %

45802042537 TRIDESILON.050 %

00781103201 TRIFLUOPERAZINE HCL2.000 MG

00781103401 TRIFLUOPERAZINE HCL5.000 MG

00781103601 TRIFLUOPERAZINE HCL10.000 MG

00781103610 TRIFLUOPERAZINE HCL10.000 MG

00781103613 TRIFLUOPERAZINE HCL10.000 MG

51079057220 TRIFLUOPERAZINE HCL1.000 MG

51079057320 TRIFLUOPERAZINE HCL2.000 MG

51079057420 TRIFLUOPERAZINE HCL5.000 MG

51079057520 TRIFLUOPERAZINE HCL10.000 MG

00378240101 TRIFLUOPERAZINE HCL1.000 MG

00378240201 TRIFLUOPERAZINE HCL2.000 MG

00378240501 TRIFLUOPERAZINE HCL5.000 MG

00378241001 TRIFLUOPERAZINE HCL10.000 MG

62269027824 TRIFLUOPERAZINE HCL1.000 MG

61314004475 TRIFLURIDINE1.000 %

00603624021 TRIHEXYPHENIDYL HCL2.000 MG

00603624032 TRIHEXYPHENIDYL HCL2.000 MG

00603624121 TRIHEXYPHENIDYL HCL5.000 MG

00603624132 TRIHEXYPHENIDYL HCL5.000 MG

00254597128 TRIHEXYPHENIDYL HCL2.000 MG

00143176301 TRIHEXYPHENIDYL HCL5.000 MG

00143176310 TRIHEXYPHENIDYL HCL5.000 MG

00143176401 TRIHEXYPHENIDYL HCL2.000 MG

00143176410 TRIHEXYPHENIDYL HCL2.000 MG

00677175101 TRIHEXYPHENIDYL HCL2.000 MG

00677175201 TRIHEXYPHENIDYL HCL5.000 MG

00904205061 TRIHEXYPHENIDYL HCL5.000 MG

00904273515 TRIMAZIDE100.00 MG

00904273615 TRIMETHOBENZAMIDE HCL.000

45802072332 TRIMETHOBENZAMIDE HCL.000

45802072390 TRIMETHOBENZAMIDE HCL.000

45802072432 TRIMETHOBENZAMIDE HCL.000

45802072490 TRIMETHOBENZAMIDE HCL.000

00074195202 TRIMETHOBENZAMIDE HCL100.00 MG/ML

00182139601 TRIMETHOBENZAMIDE HCL250.00 MG

00182142719 TRIMETHOBENZAMIDE HCL.000

00182142723 TRIMETHOBENZAMIDE HCL.000

00574722010 TRIMETHOBENZAMIDE HCL.000

00574722210 TRIMETHOBENZAMIDE HCL.000

00574722250 TRIMETHOBENZAMIDE HCL.000

59879011501 TRIMETHOBENZAMIDE HCL250.00 MG

58177003704 TRIMETHOBENZAMIDE HCL250.00 MG

00093215801 TRIMETHOPRIM100.00 MG

00093215901 TRIMETHOPRIM200.00 MG

00904164660 TRIMETHOPRIM100.00 MG

24208031510 TRIMETHOPRIM SULFATE/POLY.000

17236031304 TRIMETHOPRIM/SULFAMETHOXA.000

17236031308 TRIMETHOPRIM/SULFAMETHOXA.000

17236031314 TRIMETHOPRIM/SULFAMETHOXA.000

17236031320 TRIMETHOPRIM/SULFAMETHOXA.000

00003010120 TRIMOX250.00 MG

00003010150 TRIMOX250.00 MG

00003010160 TRIMOX250.00 MG

00003010920 TRIMOX500.00 MG

00003010955 TRIMOX500.00 MG

00003010960 TRIMOX500.00 MG

00003173730 TRIMOX125.00 MG/5ML

00003173740 TRIMOX125.00 MG/5ML

00003173745 TRIMOX125.00 MG/5ML

00003173830 TRIMOX250.00 MG/5ML

00003173840 TRIMOX250.00 MG/5ML

00003173845 TRIMOX250.00 MG/5ML

00004012701 TRIMPEX100.00 MG

50474036423 TRINSICON.000

50474036428 TRINSICON.000

52604521006 TRIOSTAT10.000 MCG/ML

51285074355 TRIOTANN-S PEDIATRIC.000

00008253601 TRIPHASIL 28.000

00008253603 TRIPHASIL 28.000

00008253605 TRIPHASIL 28.000

00713026831 TRIPLE ANTIBIOTIC.000

45802006101 TRIPLE ANTIBIOTIC.000

45802006103 TRIPLE ANTIBIOTIC.000

45802006110 TRIPLE ANTIBIOTIC.000

45802006170 TRIPLE ANTIBIOTIC.000

45802006195 TRIPLE ANTIBIOTIC.000

00904073431 TRIPLE ANTIBIOTIC.000

00904073436 TRIPLE ANTIBIOTIC.000

00677075230 TRIPLE ANTIBIOTIC.000

00603064450 TRIPLE ANTIBIOTIC.000

00472017909 TRIPLE ANTIBIOTIC.000

00472017956 TRIPLE ANTIBIOTIC.000

00536110095 TRIPLE ANTIBIOTIC.000

00182512233 TRIPLE ANTIBIOTIC.000

00182512234 TRIPLE ANTIBIOTIC.000

00182023230 TRIPLE ANTIBIOTIC.000

00472017916 TRIPLE ANTIBIOTIC.000

00472017934 TRIPLE ANTIBIOTIC.000

00603064550 TRIPLE ANTIBIOTIC PLUS.000

00603064573 TRIPLE ANTIBIOTIC PLUS.000

45802043101 TRIPLE ANTIBIOTIC/LIDOCAI.000

45802043105 TRIPLE ANTIBIOTIC/LIDOCAI.000

45802015645 TRIPLE SULFA.000

00904274667 TRIPLE SULFA.000

50383080804 TRIPLE TANNATE PEDIATRIC.000

50383080816 TRIPLE TANNATE PEDIATRIC.000

60432011604 TRIPLE TANNATE PEDIATRIC.000

60432011616 TRIPLE TANNATE PEDIATRIC.000

00904259050 TRIPLE VITAMIN.000

00904152320 TRIPROLIDINE/PSEUDOEPHEDR.000

53746028801 TRIPROLIDINE/PSEUDOEPHEDR.000

53746028830 TRIPROLIDINE/PSEUDOEPHEDR.000

53746028850 TRIPROLIDINE/PSEUDOEPHEDR.000

00182160937 TRIPROLIDINE/PSEUDOEPHEDR.000

00603178547 TRIVIT/FLUORIDE.000

00603178647 TRIVIT/FLUORIDE.000

52544029128 TRIVORA-28.000

00603064888 TRIXAICIN.025 %

00603064988 TRIXAICIN HP.075 %

00182510140 TROPICAL GOLD ALOE VERA100.00 %

00182510237 TROPICAL GOLD BABY SUNBLO.000

00182510744 TROPICAL GOLD DARK TANNIN.000

00182510844 TROPICAL GOLD DARK TANNIN.000

00182510338 TROPICAL GOLD SPORT SUNBL.000

00182510537 TROPICAL GOLD SUNBLOCK.000

00182510637 TROPICAL GOLD SUNSCREEN.000

24208058559 TROPICAMIDE1.000 %

24208058564 TROPICAMIDE1.000 %

24208059064 TROPICAMIDE.500 %

Page 100 of 125

Page 101: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

61314035401 TROPICAMIDE.500 %

61314035501 TROPICAMIDE1.000 %

61314035502 TROPICAMIDE1.000 %

00006351935 TRUSOPT2.000 %

00006351936 TRUSOPT2.000 %

08290005620 TUBERCULIN SYRINGE/PERMAN.000

00008914501 TUBEX INJECTOR.000

00003095015 TUBOCURARINE CHLORIDE3.000 MG/ML

00074806615 TUBOCURARINE CHLORIDE3.000 MG/ML

00074338603 TUBOCURARINE CHLORIDE3.000 MG/ML

00071170316 TUCKS.000

00071170324 TUCKS.000

00071170401 TUCKS TAKE-A-LONGS.000

00766074020 TUMS500.00 MG

00766074051 TUMS500.00 MG

00766074052 TUMS500.00 MG

00766074062 TUMS500.00 MG

00766074120 TUMS500.00 MG

00766074151 TUMS500.00 MG

00766074152 TUMS500.00 MG

00766074162 TUMS500.00 MG

00766741024 TUMS500.00 MG

00766741109 TUMS500.00 MG

00766073560 TUMS 5001250.0 MG

00766073660 TUMS 5001250.0 MG

00766074730 TUMS CALCIUM FOR LIFE BON750.00 MG

00766074710 TUMS CALCIUM FOR LIFE PMS750.00 MG

00766074720 TUMS CALCIUM FOR LIFE PMS750.00 MG

00766073919 TUMS E-X750.00 MG

00766073921 TUMS E-X750.00 MG

00766073923 TUMS E-X750.00 MG

00766073966 TUMS E-X750.00 MG

00766738808 TUMS E-X750.00 MG

00766738824 TUMS E-X750.00 MG

00766738848 TUMS E-X750.00 MG

00766738896 TUMS E-X750.00 MG

00766739148 TUMS E-X750.00 MG

00766739196 TUMS E-X750.00 MG

00766739199 TUMS E-X750.00 MG

00766739210 TUMS E-X750.00 MG

00766739305 TUMS E-X750.00 MG

00766739324 TUMS E-X750.00 MG

00766739421 TUMS E-X750.00 MG

00766739423 TUMS E-X750.00 MG

00766739466 TUMS E-X750.00 MG

00766738948 TUMS E-X SUGAR FREE750.00 MG

00766738996 TUMS E-X SUGAR FREE750.00 MG

00766074565 TUMS ULTRA1000.0 MG

00766074575 TUMS ULTRA1000.0 MG

00766074585 TUMS ULTRA1000.0 MG

00766074588 TUMS ULTRA1000.0 MG

00766074590 TUMS ULTRA1000.0 MG

00766074595 TUMS ULTRA1000.0 MG

00766074610 TUMS ULTRA1000.0 MG

00766074625 TUMS ULTRA1000.0 MG

00766074640 TUMS ULTRA1000.0 MG

00766074655 TUMS ULTRA1000.0 MG

59743005616 TUSSADUR-HD.000

00642079516 TUSSAFED.000

00642076516 TUSSAFED EX.000

00642046016 TUSSAFED HC.000

00642065010 TUSSAFED-LA.000

61570000416 TUSSEND.000

61570000516 TUSSEND EXPECTORANT.000

00472104004 TUSSEX.000

00037068110 TUSSI-12.000

00037068204 TUSSI-12 S.000

00037471401 TUSSI-ORGANIDIN DM-S NR.000

00037481410 TUSSI-ORGANIDIN NR.000

00037471410 TUSSI-ORGANIDIN NR DM.000

00037481401 TUSSI-ORGANIDIN-S NR.000

00689008201 TUSSIGON.000

00689008205 TUSSIGON.000

59743000116 TUSSIN-V.000

00904504935 TWICE-A-DAY.050 %

00904521730 TWICE-A-DAY NASAL.050 %

00904521735 TWICE-A-DAY NASAL.050 %

00074300204 TWO-WAY TRANSFER DEVICE.000

00281736339 TYMPAGESIC DROPS.000

08881609358 ULTRA COMFORT INSULIN SYR.000

08881609800 ULTRA COMFORT INSULIN SYR.000

08881608188 ULTRA COMFORT INSULIN SYR.000

08881609350 ULTRA COMFORT SYRINGE 0.5.000

08881609700 ULTRA COMFORT SYRINGE/U-1.000

00575100208 ULTRA DERM BATH OIL.000

10267004301 ULTRA NATAL.000

10267004311 ULTRA NATAL.000

58177029211 ULTRA NATALCARE.000

53303008012 ULTRA-KLENZ.000

53303008080 ULTRA-KLENZ.000

00904425418 ULTRA-MEGA.000

00904425452 ULTRA-MEGA.000

59879012301 ULTRA-NATAL.000

00087435903 ULTRACAL.000

00087435942 ULTRACAL.000

00087435943 ULTRACAL.000

00087435946 ULTRACAL.000

00087436102 ULTRACAL HN PLUS.000

00087436103 ULTRACAL HN PLUS.000

00087436104 ULTRACAL HN PLUS.000

00087436105 ULTRACAL HN PLUS.000

00087436143 ULTRACAL HN PLUS.000

00087436144 ULTRACAL HN PLUS.000

00087436145 ULTRACAL HN PLUS.000

00049001383 UNASYN.000

00049001483 UNASYN.000

00049002428 UNASYN BULK PACK.000

00677171901 UNI-CENNA8.600 MG

00677016301 UNI-DAILY.000

00677016401 UNI-DAILY/IRON.000

00677092406 UNI-EASE100.00 MG

00677048732 UNI-LAN.000

00677048832 UNI-LAN II.000

00677086490 UNI-PERR.000

00677086301 UNI-SED30.000 MG

00677041501 UNI-SERP.000

00677041510 UNI-SERP.000

00677175001 UNI-THERA M ADVANCED.000

00677086701 UNI-TREN325.00 MG

00677151233 UNI-TUSS HC.000

00009468817 UNICAP SR.000

00009468816 UNICAP-M.000

00009468818 UNICAP-T.000

00536475011 UNICOMPLEX-M.000

00008075102 UNIPEN1.000 GM

00008075103 UNIPEN2.000 GM

00008075115 UNIPEN1.000 GM

00008075118 UNIPEN10.000 GM

00034700470 UNIPHYL400.00 MG

00034700480 UNIPHYL400.00 MG

00034700680 UNIPHYL600.00 MG

00091372501 UNIRETIC.000

Page 101 of 125

Page 102: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00091371201 UNIRETIC.000

00058052527 UNISOL.000

00058052730 UNISOL 4.000

00058052744 UNISOL 4.000

00058053012 UNISOL PLUS.000

52544091201 UNITHROID300.00 MCG

00091371501 UNIVASC15.000 MG

00091371509 UNIVASC15.000 MG

00091370701 UNIVASC7.500 MG

00091370709 UNIVASC7.500 MG

51552005704 UREA.000

00006778629 URECHOLINE5.000 MG/ML

61451218301 URISED.000

00093938001 URSODIOL300.00 MG

51991002701 USEPT.000

51991064501 V-C FORTE.000

08881600566 V-R MONOJECT INSULIN SYRI.000

08881600426 V-R MONOJECT INSULIN SYRI.000

08881600830 V-R MONOJECT INSULIN SYRI.000

08881601614 V-R MONOJECT INSULIN SYRI.000

08881601713 V-R MONOJECT INSULIN SYRI.000

45802016703 VAGICAINE.000

19810000146 VAGISTAT-16.500 %

00904434951 VALERIAN ROOT493.00 MG

00004193306 VALIUM5.000 MG/ML

51079029820 VALPROIC ACID250.00 MG

00182175401 VALPROIC ACID250.00 MG

00603184058 VALPROIC ACID250.00 MG/5ML

00093963316 VALPROIC ACID250.00 MG/5ML

00832100700 VALPROIC ACID250.00 MG

00904210316 VALPROIC ACID250.00 MG/5ML

50111085201 VALPROIC ACID250.00 MG

50383079216 VALPROIC ACID250.00 MG/5ML

60432062116 VALPROIC ACID250.00 MG/5ML

00002735501 VANCOCIN HCL10.000 GM

00002729801 VANCOCIN HCL1000.0 MG

00002729810 VANCOCIN HCL1000.0 MG

00002732101 VANCOCIN HCL1000.0 MG

00002732125 VANCOCIN HCL1000.0 MG

00002144425 VANCOCIN HCL500.00 MG

00002896725 VANCOMYCIN HCL1000.0 MG

00002896925 VANCOMYCIN HCL500.00 MG

00074433201 VANCOMYCIN HCL500.00 MG

00074650901 VANCOMYCIN HCL5000.0 MG

00074653301 VANCOMYCIN HCL1000.0 MG

00074653349 VANCOMYCIN HCL1000.0 MG

00074653401 VANCOMYCIN HCL500.00 MG

00074653501 VANCOMYCIN HCL1000.0 MG

00205315405 VANCOMYCIN HCL5000.0 MG

00641277941 VANCOMYCIN HCL1000.0 MG

00074653449 VANCOMYCIN HCL500.00 MG

00074653549 VANCOMYCIN HCL1000.0 MG

00074433249 VANCOMYCIN HCL500.00 MG

00074650949 VANCOMYCIN HCL5000.0 MG

52604012701 VANEX FORTE-D.000

52604030006 VANEX-HD.000

49884072001 VANSPAR7.500 MG

49884072005 VANSPAR7.500 MG

50383067103 VAPORIZING CREAM.000

58768088705 VASOCIDIN.000

58768088710 VASOCIDIN.000

58768088115 VASOCON-A.000

00087054301 VASODILAN10.000 MG

00087054401 VASODILAN20.000 MG

00074163201 VECURONIUM BROMIDE10.000 MG

00074163401 VECURONIUM BROMIDE20.000 MG

00003068144 VEETIDS125.00 MG/5ML

00003068154 VEETIDS125.00 MG/5ML

00003068244 VEETIDS250.00 MG/5ML

00003068254 VEETIDS250.00 MG/5ML

00003011575 VEETIDS250.00 MG

00003011675 VEETIDS500.00 MG

00603098789 VEGETABLE LAXATIVE68.000 %

00603098863 VEGETABLE LAXATIVE68.000 %

00603098989 VEGETABLE LAXATIVE68.000 %

00603099063 VEGETABLE LAXATIVE68.000 %

00003011350 VELOSEF250.00 MG

00003011450 VELOSEF500.00 MG

00003119450 VELOSEF250.00 MG/5ML

00003119480 VELOSEF250.00 MG/5ML

00169007011 VELOSULIN BR100.00 U/ML

00015306120 VEPESID20.000 MG/ML

00015306220 VEPESID20.000 MG/ML

00015308420 VEPESID20.000 MG/ML

00015309145 VEPESID50.000 MG

00015309520 VEPESID20.000 MG/ML

00047032930 VERAPAMIL HCL120.00 MG

00074114315 VERAPAMIL HCL2.500 MG/ML

00074114401 VERAPAMIL HCL2.500 MG/ML

00074114402 VERAPAMIL HCL2.500 MG/ML

00074401101 VERAPAMIL HCL2.500 MG/ML

00074400001 VERAPAMIL HCL2.500 MG/ML

00074963305 VERAPAMIL HCL2.500 MG/ML

00182130089 VERAPAMIL HCL80.000 MG

00182130189 VERAPAMIL HCL120.00 MG

00378051201 VERAPAMIL HCL80.000 MG

00378051210 VERAPAMIL HCL80.000 MG

00378077201 VERAPAMIL HCL120.00 MG

00378077205 VERAPAMIL HCL120.00 MG

00781101401 VERAPAMIL HCL40.000 MG

00677113001 VERAPAMIL HCL80.000 MG

00677113005 VERAPAMIL HCL80.000 MG

00904292060 VERAPAMIL HCL80.000 MG

00904292061 VERAPAMIL HCL80.000 MG

00904292460 VERAPAMIL HCL120.00 MG

00904292461 VERAPAMIL HCL120.00 MG

00904779960 VERAPAMIL HCL40.000 MG

51079068219 VERAPAMIL HCL80.000 MG

51079068220 VERAPAMIL HCL80.000 MG

51079068320 VERAPAMIL HCL120.00 MG

52544034310 VERAPAMIL HCL80.000 MG

60429019760 VERAPAMIL HCL120.00 MG

00378041101 VERAPAMIL HCL CR240.00 MG

00378041105 VERAPAMIL HCL CR240.00 MG

00378118001 VERAPAMIL HCL ER180.00 MG

00378118005 VERAPAMIL HCL ER180.00 MG

00378112001 VERAPAMIL HCL ER120.00 MG

00378632001 VERAPAMIL HCL ER120.00 MG

00378638001 VERAPAMIL HCL ER180.00 MG

00378644001 VERAPAMIL HCL ER240.00 MG

51079089920 VERAPAMIL HCL ER180.00 MG

51079091720 VERAPAMIL HCL ER120.00 MG

51079091820 VERAPAMIL HCL ER180.00 MG

51079091908 VERAPAMIL HCL ER240.00 MG

51079089420 VERAPAMIL HCL ER120.00 MG

51079086919 VERAPAMIL HCL ER240.00 MG

51079086920 VERAPAMIL HCL ER240.00 MG

00677151801 VERAPAMIL HCL ER180.00 MG

00677145301 VERAPAMIL HCL ER240.00 MG

00677145305 VERAPAMIL HCL ER240.00 MG

00904795660 VERAPAMIL HCL SR180.00 MG

00172428060 VERAPAMIL HCL SR240.00 MG

Page 102 of 125

Page 103: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00172428070 VERAPAMIL HCL SR240.00 MG

00172428560 VERAPAMIL HCL SR120.00 MG

00172428660 VERAPAMIL HCL SR180.00 MG

00172428670 VERAPAMIL HCL SR180.00 MG

60429019830 VERAPAMIL HCL SR240.00 MG

60429019860 VERAPAMIL HCL SR240.00 MG

60429019890 VERAPAMIL HCL SR240.00 MG

60429023790 VERAPAMIL HCL SR180.00 MG

00091248923 VERELAN180.00 MG

00091249023 VERELAN120.00 MG

00091249123 VERELAN240.00 MG

00091249523 VERELAN360.00 MG

00091408501 VERELAN PM100.00 MG

00091408601 VERELAN PM200.00 MG

00091408701 VERELAN PM300.00 MG

00004194701 VERSED5.000 MG/ML

60267053104 VERSICLEAR.000

00904030460 VI-C FORTE.000

00074360602 VI-DAYLIN.000

00074360603 VI-DAYLIN.000

00074011601 VI-DAYLIN.000

00074011701 VI-DAYLIN.000

00074010304 VI-DAYLIN.000

00074699202 VI-DAYLIN + IRON.000

00074699203 VI-DAYLIN + IRON.000

00074010504 VI-DAYLIN-ADC.000

00074110450 VI-DAYLIN/F.000

00074892850 VI-DAYLIN/F + IRON.000

00074110650 VI-DAYLIN/F/ADC.000

00074892950 VI-DAYLIN/F/ADC/FE.000

00603185358 VI-Q-TUSS.000

00536475308 VI-STRESS.000

00536475408 VI-STRESS PLUS IRON.000

00536475508 VI-STRESS W/ZINC.000

00069097193 VIBRAMYCIN50.000 MG/5ML

00069095050 VIBRAMYCIN100.00 MG

00069099050 VIBRATAB100.00 MG

00603638121 VICA FORTE.000

50474031622 VICON FORTE.000

50474031624 VICON FORTE.000

50474031627 VICON FORTE.000

50474027322 VICON-C.000

00536238085 VIGORTOL.000

51991015791 VINATAL FORTE.000

51991015211 VINATE 90.000

51991015391 VINATE ADVANCED.000

51991015501 VINATE M.000

51991015411 VINATE ULTRA.000

00013745601 VINCASAR PFS1.000 MG/ML

00013745686 VINCASAR PFS1.000 MG/ML

00013746686 VINCASAR PFS1.000 MG/ML

00182094101 VIOGEN-C.000

00006007428 VIOXX12.500 MG

00006007431 VIOXX12.500 MG

00006007468 VIOXX12.500 MG

00006007482 VIOXX12.500 MG

00006011028 VIOXX25.000 MG

00006011031 VIOXX25.000 MG

00006011068 VIOXX25.000 MG

00006011082 VIOXX25.000 MG

00006011428 VIOXX50.000 MG

00006011431 VIOXX50.000 MG

00006011468 VIOXX50.000 MG

00006011474 VIOXX50.000 MG

00006378464 VIOXX12.500 MG/5ML

00006378564 VIOXX25.000 MG/5ML

61570003775 VIROPTIC1.000 %

00603039073 VISION CLEAR.050 %

00069541066 VISTARIL25.000 MG

00069542066 VISTARIL50.000 MG

00904509950 VITA DROPS.000

00904275452 VITA ZINC.000

00372002701 VITA-BOB.000

00904420813 VITA-DEC.000

00372003701 VITA-NATAL.000

00372002501 VITA-PLUS E400.00 IU

00372002001 VITA-PLUS G.000

00372002050 VITA-PLUS G.000

00372002401 VITA-PLUS H.000

00372002450 VITA-PLUS H.000

44184001804 VITA-PMS.000

44184001904 VITA-PMS PLUS.000

00536476301 VITABEE W/C.000

00642007212 VITAFOL.000

00642007416 VITAFOL.000

00642007812 VITAFOL-PN.000

00372002101 VITALIZE.000

00372002104 VITALIZE.000

00372002108 VITALIZE.000

00372002116 VITALIZE.000

00372002128 VITALIZE.000

00143233201 VITALIZE PLUS.000

00372005208 VITALIZE/GINSENG.000

00904208560 VITAMIN A10000. IU

00904421260 VITAMIN A10000. IU

45802007001 VITAMIN A & D.000

45802007005 VITAMIN A & D.000

45802007010 VITAMIN A & D.000

45802007044 VITAMIN A & D.000

45802007071 VITAMIN A & D.000

00904260802 VITAMIN A & D.000

00904260822 VITAMIN A & D.000

00168003501 VITAMIN A & D.000

00168003502 VITAMIN A & D.000

00168003504 VITAMIN A & D.000

00168003516 VITAMIN A & D.000

00168003545 VITAMIN A & D.000

00182076343 VITAMIN A & D.000

00182076345 VITAMIN A & D.000

00603041054 VITAMIN A & D.000

00085009601 VITAMIN A & D.000

00085009602 VITAMIN A & D.000

00085009604 VITAMIN A & D.000

00536478701 VITAMIN B COMPLEX.000

00536467801 VITAMIN B-150.000 MG

00182004701 VITAMIN B-1100.00 MG

00182004710 VITAMIN B-1100.00 MG

00182004789 VITAMIN B-1100.00 MG

00904054480 VITAMIN B-1100.00 MG

17236045401 VITAMIN B-150.000 MG

17236045410 VITAMIN B-150.000 MG

17236045601 VITAMIN B-1100.00 MG

17236045610 VITAMIN B-1100.00 MG

00904417760 VITAMIN B-1250.00 MG

00904421713 VITAMIN B-121000.0 MCG

00904421813 VITAMIN B-12250.00 MCG

00904320713 VITAMIN B-12500.00 MCG

17236046201 VITAMIN B-1250.000 MCG

17236046401 VITAMIN B-12100.00 MCG

00904088930 VITAMIN B-121000.0 MCG/ML

00904113160 VITAMIN B-1250.000 MCG

00904113213 VITAMIN B-12100.00 MCG

Page 103 of 125

Page 104: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00182003701 VITAMIN B-12500.00 MCG

00182004201 VITAMIN B-12100.00 MCG

00182101701 VITAMIN B-121000.0 MCG

00364665154 VITAMIN B-121000.0 MCG/ML

00536355101 VITAMIN B-12500.00 MCG

00536355601 VITAMIN B-121000.0 MCG

00536354201 VITAMIN B-12100.00 MCG

00182008601 VITAMIN B-650.000 MG

00182008701 VITAMIN B-6100.00 MG

00904051860 VITAMIN B-6100.00 MG

00904051880 VITAMIN B-6100.00 MG

00904052046 VITAMIN B-650.000 MG

00904052060 VITAMIN B-650.000 MG

00904052080 VITAMIN B-650.000 MG

17236043201 VITAMIN B-650.000 MG

17236043210 VITAMIN B-650.000 MG

17236043301 VITAMIN B-6100.00 MG

17236043310 VITAMIN B-6100.00 MG

17236016201 VITAMIN B-625.000 MG

00904417960 VITAMIN B-6250.00 MG

00904418052 VITAMIN B-6 CR500.00 MG

00904501360 VITAMIN C1000.0 MG

00904274960 VITAMIN C1000.0 MG

00904533046 VITAMIN C500.00 MG

17236037701 VITAMIN C1000.0 MG

17236037710 VITAMIN C1000.0 MG

17236036601 VITAMIN C250.00 MG

17236036610 VITAMIN C250.00 MG

17236036801 VITAMIN C500.00 MG

17236036810 VITAMIN C500.00 MG

00904052260 VITAMIN C250.00 MG

00904052272 VITAMIN C250.00 MG

00904052280 VITAMIN C250.00 MG

00904052360 VITAMIN C500.00 MG

00904052361 VITAMIN C500.00 MG

00904052372 VITAMIN C500.00 MG

00904052380 VITAMIN C500.00 MG

00904052560 VITAMIN C250.00 MG

00904052572 VITAMIN C250.00 MG

00904052660 VITAMIN C500.00 MG

00904052672 VITAMIN C500.00 MG

00677019001 VITAMIN C500.00 MG

50383016716 VITAMIN C500.00 MG/5ML

00182006801 VITAMIN C500.00 MG

00182006802 VITAMIN C500.00 MG

00182006810 VITAMIN C500.00 MG

00182006889 VITAMIN C500.00 MG

00182007501 VITAMIN C250.00 MG

00182000301 VITAMIN C250.00 MG

00182152801 VITAMIN C1000.0 MG

00182170401 VITAMIN C500.00 MG

00182411001 VITAMIN C1000.0 MG

00536329101 VITAMIN C500.00 MG

00536329201 VITAMIN C500.00 MG

00536329210 VITAMIN C500.00 MG

00536016085 VITAMIN C500.00 MG/5ML

00536016097 VITAMIN C500.00 MG/5ML

00603032521 VITAMIN C500.00 MG

60258014016 VITAMIN C500.00 MG/5ML

00904052860 VITAMIN C CR500.00 MG

00182410901 VITAMIN C TD500.00 MG

00536515501 VITAMIN C/ROSE HIPS500.00 MG

00904422725 VITAMIN D400.00 IU

60258011260 VITAMIN D8000.0 IU/ML

00677038101 VITAMIN E1000.0 IU

00677021001 VITAMIN E400.00 IU

00904027060 VITAMIN E100.00 IU

00904027072 VITAMIN E100.00 IU

00904027260 VITAMIN E200.00 IU

00904027460 VITAMIN E400.00 IU

00904027472 VITAMIN E400.00 IU

00904027746 VITAMIN E1000.0 IU

00904027760 VITAMIN E1000.0 IU

00904423046 VITAMIN E1000.0 IU

00904423060 VITAMIN E1000.0 IU

00904419360 VITAMIN E600.00 IU

00904419546 VITAMIN E1000.0 IU

00904419560 VITAMIN E1000.0 IU

00904275060 VITAMIN E100.00 IU

00904275160 VITAMIN E200.00 IU

00904275260 VITAMIN E400.00 IU

00904334660 VITAMIN E400.00 IU

00904532422 VITAMIN E1000.0 IU

17236065001 VITAMIN E400.00 IU

17236065401 VITAMIN E200.00 IU

17236065601 VITAMIN E400.00 IU

17236065610 VITAMIN E400.00 IU

17236065801 VITAMIN E1000.0 IU

00536479301 VITAMIN E100.00 IU

00536479801 VITAMIN E200.00 IU

00536479901 VITAMIN E400.00 IU

00536479910 VITAMIN E400.00 IU

00536480101 VITAMIN E1000.0 IU

00536480106 VITAMIN E1000.0 IU

00536853396 VITAMIN E14000. IU/15ML

00603033121 VITAMIN E400.00 IU

00603033132 VITAMIN E400.00 IU

00182007901 VITAMIN E200.00 IU

00182008201 VITAMIN E400.00 IU

00182008301 VITAMIN E1000.0 IU

00182079943 VITAMIN E3000.0 IU/GM

00182108134 VITAMIN E BEAUTY OIL28000. IU

00536544001 VITAMIN E/D-ALPHA400.00 IU

00074915701 VITAMIN K12.000 MG/ML

00074915801 VITAMIN K110.000 MG/ML

00182615140 VITAMIN LIQUID.000

00904504260 VITAMINS & MINERALS.000

00536854006 VITAMINS FOR HAIR.000

60258073016 VITUSSIN.000

53100000613 VIVARIN200.00 MG

53100018624 VIVARIN200.00 MG

53100018629 VIVARIN200.00 MG

53100018631 VIVARIN200.00 MG

53100018651 VIVARIN200.00 MG

53100018660 VIVARIN200.00 MG

53100018670 VIVARIN200.00 MG

00083232608 VIVELLE.050 MG/24HR

00083232808 VIVELLE.100 MG/24HR

00078034345 VIVELLE-DOT.038 MG/24HR

00078034445 VIVELLE-DOT.050 MG/24HR

00078034545 VIVELLE-DOT.075 MG/24HR

00078034645 VIVELLE-DOT.100 MG/24HR

00078034542 VIVELLE-DOT.075 MG/24HR

00028025801 VOLTAREN25.000 MG

00028026201 VOLTAREN50.000 MG

00028026401 VOLTAREN75.000 MG

58768010002 VOLTAREN.100 %

58768010005 VOLTAREN.100 %

00028020501 VOLTAREN-XR100.00 MG

00037361110 VOSOL2.000 %

00037381112 VOSOL-HC.000

00066005101 VYTONE.000

Page 104 of 125

Page 105: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00555087402 WARFARIN SODIUM4.000 MG

00555087405 WARFARIN SODIUM4.000 MG

00555083102 WARFARIN SODIUM1.000 MG

00555083105 WARFARIN SODIUM1.000 MG

00555083202 WARFARIN SODIUM2.500 MG

00555083205 WARFARIN SODIUM2.500 MG

00555083302 WARFARIN SODIUM5.000 MG

00555083305 WARFARIN SODIUM5.000 MG

00555083402 WARFARIN SODIUM7.500 MG

00555083405 WARFARIN SODIUM7.500 MG

00555083502 WARFARIN SODIUM10.000 MG

00555083504 WARFARIN SODIUM10.000 MG

00555086902 WARFARIN SODIUM2.000 MG

00555086905 WARFARIN SODIUM2.000 MG

00555092502 WARFARIN SODIUM3.000 MG

00555092602 WARFARIN SODIUM6.000 MG

45802023663 WART LIQUID17.000 %

00536762094 WART REMOVER12.240 %

00087026845 WATER ORAL.000

00904425684 WATER TABS.000

65597070118 WELCHOL625.00 MG

00173017755 WELLBUTRIN75.000 MG

00173017855 WELLBUTRIN100.00 MG

00173094755 WELLBUTRIN SR100.00 MG

00072810015 WESTCORT.200 %

00072810045 WESTCORT.200 %

00072810060 WESTCORT.200 %

00072780015 WESTCORT.200 %

00072780045 WESTCORT.200 %

00072780060 WESTCORT.200 %

52604750508 WESTHROID180.00 MG

52604709208 WESTHROID240.00 MG

52604709308 WESTHROID240.00 MG

52604709708 WESTHROID300.00 MG

52604707008 WESTHROID30.000 MG

52604707308 WESTHROID60.000 MG

52604707408 WESTHROID60.000 MG

52604707508 WESTHROID60.000 MG

52604707608 WESTHROID60.000 MG

52604707708 WESTHROID60.000 MG

52604708008 WESTHROID120.00 MG

52604708108 WESTHROID120.00 MG

52604708208 WESTHROID120.00 MG

52604708308 WESTHROID120.00 MG

52604708408 WESTHROID120.00 MG

52604708708 WESTHROID200.00 MG

52604708808 WESTHROID200.00 MG

52604708908 WESTHROID200.00 MG

52604709008 WESTHROID-3180.00 MG

00904425860 WHEAT GERM OIL14.000 MINIM

08290405147 WHITACRE PENCIL POINT SPI.000

08290409503 WHITE PEDIATRIC ARTERIAL.000

08290009504 WHITE PEDIATRIC ARTERIAL.000

45802009203 WHITE PETROLATUM.000

45802009225 WHITE PETROLATUM.000

45802009229 WHITE PETROLATUM.000

45802009271 WHITE PETROLATUM.000

45802009295 WHITE PETROLATUM.000

00024225304 WINSTROL2.000 MG

00034999625 X-PREP.000

00182113694 X-STR CHEW ANTACID750.00 MG

00013830304 XALATAN.005 %

00009009001 XANAX1.000 MG

00009009004 XANAX1.000 MG

00009009013 XANAX1.000 MG

00009009401 XANAX2.000 MG

00009009403 XANAX2.000 MG

00009005501 XANAX.500 MG

00009005503 XANAX.500 MG

00009005515 XANAX.500 MG

00009005546 XANAX.500 MG

00009002901 XANAX.250 MG

00009002902 XANAX.250 MG

00009002914 XANAX.250 MG

00009002946 XANAX.250 MG

00004110051 XELODA150.00 MG

00004110116 XELODA500.00 MG

63717050001 XIRAL SR.000

63402051224 XOPENEX.630 MG/3ML

63402051324 XOPENEX1.250 MG/3ML

00186024554 XYLOCAINE1.500 %

00186036001 XYLOCAINE2.000 %

00186036011 XYLOCAINE2.000 %

00186033001 XYLOCAINE2.000 %

00186033036 XYLOCAINE2.000 %

00186027512 XYLOCAINE1.000 %

00186027613 XYLOCAINE1.000 %

00186027713 XYLOCAINE1.000 %

00186027844 XYLOCAINE1.000 %

00186032001 XYLOCAINE4.000 %

00186015501 XYLOCAINE2.000 %

00186024312 XYLOCAINE2.000 %

00186025502 XYLOCAINE1.000 %

00186021003 XYLOCAINE1.000 %

00186021503 XYLOCAINE2.000 %

00186023003 XYLOCAINE1.000 %

00186023203 XYLOCAINE20.000 MG/ML

00186023503 XYLOCAINE4.000 %

00186024044 XYLOCAINE2.000 %

00186012001 XYLOCAINE2.000 %

00186013501 XYLOCAINE.500 %

00186013701 XYLOCAINE.500 %

00186014501 XYLOCAINE1.000 %

00186011001 XYLOCAINE1.000 %

00186011201 XYLOCAINE1.000 %

00186011291 XYLOCAINE1.000 %

00186024113 XYLOCAINE-MPF2.000 %

00186024213 XYLOCAINE-MPF2.000 %

00186024444 XYLOCAINE-MPF1.500 %

00186026002 XYLOCAINE-MPF/EPINEPHRINE.000

00186026092 XYLOCAINE-MPF/EPINEPHRINE.000

00186026502 XYLOCAINE-MPF/EPINEPHRINE.000

00186026503 XYLOCAINE-MPF/EPINEPHRINE.000

00186012201 XYLOCAINE-MPF/EPINEPHRINE.000

00186012212 XYLOCAINE-MPF/EPINEPHRINE.000

00186012291 XYLOCAINE-MPF/EPINEPHRINE.000

00186025002 XYLOCAINE-MPF/EPINEPHRINE.000

00186011401 XYLOCAINE-MPF/EPINEPHRINE.000

00186011412 XYLOCAINE-MPF/EPINEPHRINE.000

00186011491 XYLOCAINE-MPF/EPINEPHRINE.000

00186011701 XYLOCAINE-MPF/EPINEPHRINE.000

00186011712 XYLOCAINE-MPF/EPINEPHRINE.000

00186011791 XYLOCAINE-MPF/EPINEPHRINE.000

00186011501 XYLOCAINE/EPINEPHRINE.000

00186011512 XYLOCAINE/EPINEPHRINE.000

00186012501 XYLOCAINE/EPINEPHRINE.000

00186015001 XYLOCAINE/EPINEPHRINE.000

00186014001 XYLOCAINE/EPINEPHRINE.000

00186016001 XYLOCAINE/EPINEPHRINE.000

08290005761 YALE CLEANER.000

08290305167 YALE NEEDLE/REGULAR BEVEL.000

08290305109 YALE NEEDLE/REGULAR BEVEL.000

Page 105 of 125

Page 106: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

08290305186 YALE NEEDLE/REGULAR BEVEL.000

08290305155 YALE NEEDLES.000

08290305143 YALE NEEDLES.000

08290305195 YALE NEEDLES.000

08290305196 YALE NEEDLES.000

08290305197 YALE NEEDLES 16G X 1.000

08290305199 YALE NEEDLES 18G X 1-1/2.000

08290305176 YALE NEEDLES 20G X 1-1/2.000

08290305179 YALE NEEDLES 20G X 1-1/2.000

08290305165 YALE NEEDLES 21G X 1.000

08290305168 YALE NEEDLES 21G X 1.000

08290305169 YALE NEEDLES 21G X 1-1/2.000

08290305166 YALE NEEDLES 21G X 1-1/4.000

08290305158 YALE NEEDLES 22G X 1.000

08290305156 YALE NEEDLES 22G X 1-1/2.000

08290305159 YALE NEEDLES 22G X 1-1/2.000

08290305157 YALE NEEDLES 22G X 1-1/4.000

08290305127 YALE NEEDLES 25G X 1-1/2.000

08290305110 YALE NEEDLES 26G X 3/8.000

08290305144 YALE NEEDLES SHORT BEVEL.000

08290305106 YALE NEEDLES/REGULAR BEVE.000

08290305187 YALE NEEDLES/REGULAR BEVE.000

08290305189 YALE NEEDLES/SHORT BEVEL/.000

08290305188 YALE NEEDLES/SHORT BEVEL/.000

08290002004 YALE TUBERCULIN SYRINGE G.000

08290002027 YALE TUBERCULIN SYRINGE L.000

00904325560 YOHIMBINE HCL5.000 MG

00677141701 YOHIMBINE HCL5.400 MG

00677141705 YOHIMBINE HCL5.400 MG

00185099801 YOHIMBINE HCL5.400 MG

00185099810 YOHIMBINE HCL5.400 MG

00254637728 YOHIMBINE HCL5.400 MG

00254637738 YOHIMBINE HCL5.400 MG

00603643021 YOHIMBINE HCL5.400 MG

00603643032 YOHIMBINE HCL5.400 MG

58521090001 YOHIMBINE HCL5.400 MG

00182140726 Z-GEN.000

59075059215 ZANAFLEX2.000 MG

59075059415 ZANAFLEX4.000 MG

00173034412 ZANTAC150.00 MG

00173034414 ZANTAC150.00 MG

00173034417 ZANTAC150.00 MG

00173034442 ZANTAC150.00 MG

00173034447 ZANTAC150.00 MG

00173039306 ZANTAC300.00 MG

00173039340 ZANTAC300.00 MG

00173039347 ZANTAC300.00 MG

00071241823 ZARONTIN250.00 MG/5ML

00071023724 ZARONTIN250.00 MG

53014097571 ZAROXOLYN2.500 MG

53014097572 ZAROXOLYN2.500 MG

53014097590 ZAROXOLYN2.500 MG

53014085071 ZAROXOLYN5.000 MG

53014085072 ZAROXOLYN5.000 MG

53014085090 ZAROXOLYN5.000 MG

53014083571 ZAROXOLYN10.000 MG

53014083572 ZAROXOLYN10.000 MG

53014083590 ZAROXOLYN10.000 MG

00642010260 ZE-PLUS.000

08024253402 ZEPHIRAN17.000 %

08024253408 ZEPHIRAN17.000 %

00024252104 ZEPHIRAN1.000 :750

00024252108 ZEPHIRAN1.000 :750

00024252114 ZEPHIRAN1.000 :750

00024262401 ZEPHREX.000

00024262701 ZEPHREX LA.000

00310014110 ZESTORETIC.000

00310014210 ZESTORETIC.000

00310014510 ZESTORETIC.000

00310013010 ZESTRIL5.000 MG

00310013039 ZESTRIL5.000 MG

00310013110 ZESTRIL10.000 MG

00310013139 ZESTRIL10.000 MG

00310013210 ZESTRIL20.000 MG

00310013239 ZESTRIL20.000 MG

00310013310 ZESTRIL30.000 MG

00310013410 ZESTRIL40.000 MG

00310013510 ZESTRIL2.500 MG

00066006306 ZETAR1.000 %

51284046802 ZILACTIN10.000 %

51284057072 ZILACTIN BABY10.000 %

51284055032 ZILACTIN-B10.000 %

51284047012 ZILACTIN-L2.500 %

00173040000 ZINACEF7.500 GM

00173035231 ZINACEF750.00 MG

00173035332 ZINACEF750.00 MG

00173035435 ZINACEF1.500 GM

00173035632 ZINACEF1.500 GM

00173043600 ZINACEF750.00 MG

00173043700 ZINACEF1.500 GM

00074452605 ZINC CHLORIDE1.000 MG/ML

00182114801 ZINC GLUCONATE50.000 MG

00904319160 ZINC GLUCONATE50.000 MG

00904319172 ZINC GLUCONATE50.000 MG

00677075731 ZINC OXIDE20.000 %

00713029332 ZINC OXIDE20.000 %

45802008603 ZINC OXIDE20.000 %

45802008605 ZINC OXIDE20.000 %

45802008610 ZINC OXIDE20.000 %

45802008629 ZINC OXIDE20.000 %

45802008695 ZINC OXIDE20.000 %

00182095234 ZINC OXIDE20.000 %

00182095243 ZINC OXIDE20.000 %

00182095245 ZINC OXIDE20.000 %

00168006202 ZINC OXIDE20.000 %

00168006216 ZINC OXIDE20.000 %

00168006231 ZINC OXIDE20.000 %

00536570098 ZINC OXIDE20.000 %

00472180056 ZINC OXIDE20.000 %

00472180016 ZINC OXIDE20.000 %

00472180057 ZINC OXIDE20.000 %

00245008011 ZINC SULFATE220.00 MG

00677062201 ZINC SULFATE220.00 MG

00904533260 ZINC SULFATE220.00 MG

60258013101 ZINC SULFATE220.00 MG

00074409001 ZINC TRACE METAL1.000 MG/ML

00536718301 ZINC/VITAMIN C.000

00904428160 ZINC/VITAMIN C.000

00574916701 ZINCATE220.00 MG

00574916710 ZINCATE220.00 MG

00998051215 ZINCFRIN.000

00006072628 ZOCOR5.000 MG

00006072654 ZOCOR5.000 MG

00006072661 ZOCOR5.000 MG

00006073528 ZOCOR10.000 MG

00006073554 ZOCOR10.000 MG

00006073561 ZOCOR10.000 MG

00006073582 ZOCOR10.000 MG

00006074028 ZOCOR20.000 MG

00006074061 ZOCOR20.000 MG

00006074082 ZOCOR20.000 MG

00006074961 ZOCOR40.000 MG

Page 106 of 125

Page 107: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00785550002 ZONE-A.000

00785550202 ZONE-A FORTE.000

49884065701 ZORPRIN800.00 MG

00603749639 ZOTANE HC.000

52544038328 ZOVIA 1/35E.000

52544038428 ZOVIA 1/50E.000

00173094955 ZOVIRAX400.00 MG

00173095201 ZOVIRAX1000.0 MG

00173095396 ZOVIRAX200.00 MG/5ML

00173099155 ZOVIRAX200.00 MG

00173099156 ZOVIRAX200.00 MG

00173099501 ZOVIRAX500.00 MG

00173094555 ZOVIRAX800.00 MG

00173099870 ZYLOPRIM300.00 MG

S

08290005541 1 CC ALLERGIST TRAY SYRIN.000

08290005537 1 CC ALLERGIST TRAY SYRIN.000

08290005538 1 CC ALLERGIST TRAY SYRIN.000

08290005539 1 CC ALLERGIST TRAY SYRIN.000

08290305536 1/2 CC ALLERGIST TRAY INT.000

08290005536 1/2 CC ALLERGIST TRAY SYR.000

08290309671 10CC LUER-LOK TIP SYRINGE.000

08290305538 1CC ALLERGIST TRAY INTRAD.000

08290305539 1CC ALLERGIST TRAY INTRAD.000

08290305541 1CC ALLERGIST TRAY INTRAD.000

08290305542 1CC ALLERGIST TRAY REGULA.000

08290305537 1CC ALLERGIST TRAY REGULA.000

08290005542 1CC ALLERGIST TRAY REGULA.000

08290305500 1CC ALLERGY SYRINGE PERM.000

08290305590 1CC MEDSAVER SYRINGE/REGU.000

08290309540 1CC SYRINGE/NEEDLE SLIP T.000

08290309624 1CC TUBERCULIN SYRINGE DE.000

08290375230 3CC GLASS SYR KIT/1ML NA.000

08290375232 3CC GLASS SYR KIT/1ML NA.000

08290375234 3CC GLASS SYR KIT/1ML NA.000

08290375235 5CC GLASS SYR KIT/1ML NA500.00 U

08290375204 5CC GLASS SYR KIT/1ML NA.000

00085141001 A & D ZINC OXIDE.000

00085141002 A & D ZINC OXIDE.000

00074610905 ABBOKINASE250000 U

49502020301 ACE AEROSOL CLOUD ENHANCE.000

08290207501 ACE PAIN RELIEVING PATCH.000

08290207502 ACE PAIN RELIEVING PATCH.000

51552008604 ACETAMINOPHEN.000

00173040100 ACLOVATE.050 %

00173040101 ACLOVATE.050 %

00173040106 ACLOVATE.050 %

00173040200 ACLOVATE.050 %

00173040201 ACLOVATE.050 %

00173040206 ACLOVATE.050 %

00081009402 ACTIFED ALLERGY DAYTIME/N.000

00081008220 ACTIFED PLUS.000

00998104001 ACTIFOAM COLLAGEN SPONGE.000

00998104002 ACTIFOAM COLLAGEN SPONGE.000

50242004413 ACTIVASE50.000 MG

50242008527 ACTIVASE100.00 MG

00469087202 ADENOCARD3.000 MG/ML

00469087120 ADENOSCAN3.000 MG/ML

00469087130 ADENOSCAN3.000 MG/ML

61570030141 ADRENALIN1.000 :100

00013111601 ADRIAMYCIN RDF150.00 MG

00074482301 ADULT LUMBAR PUNCTURE TRA1.000 %

00074482320 ADULT LUMBAR PUNCTURE TRA1.000 %

00074482420 ADULT LUMBAR PUNCTURE TRA1.000 %

00074482501 ADULT LUMBAR PUNCTURE TRA1.000 %

00074482520 ADULT LUMBAR PUNCTURE TRA1.000 %

00456315467 AEROCHAMBER.000

00456074513 AEROCHAMBER MASK.000

00456074613 AEROCHAMBER/MASK-LARGE.000

00456074413 AEROCHAMBER/MASK-SMALL.000

00085047405 AFRIN MENTHOL.000

00173068700 AGENERASE15.000 MG/ML

00173067200 AGENERASE150.00 MG

00173067900 AGENERASE50.000 MG

00006371350 AGGRASTAT12.500 MG/50ML

00006373943 AGGRASTAT.000

00006373996 AGGRASTAT.000

65086071110 ALAMAST.100 %

00007550040 ALBENZA200.00 MG

00089061012 ALDARA5.000 %

00173013093 ALKERAN50.000 MG

00173004535 ALKERAN2.000 MG

08290005528 ALLERGIST PACKAGE.000

08290005529 ALLERGIST PACKAGE.000

53100061400 ALLUNA SLEEP.000

53100061410 ALLUNA SLEEP.000

00003324804 ALOE VESTA 2-N-1 SKIN CON3.000 %

00003324809 ALOE VESTA 2-N-1 SKIN CON3.000 %

00003324811 ALOE VESTA 2-N-1 SKIN CON3.000 %

00065034510 ALOMIDE.100 %

00054306844 ALPRAZOLAM INTENSOL1.000 MG/ML

24208035305 ALREX.200 %

24208035310 ALREX.200 %

00089010510 ALU-CAP400.00 MG

51552024604 ALUMINUM ACETATE.000

99207025110 ALUSTRA.000

00469305130 AMBISOME50.000 MG

00173056100 AMERGE1.000 MG

00173056200 AMERGE2.500 MG

53014037616 AMERICAINE20.000 %

53014037662 AMERICAINE20.000 %

00074436005 AMINOSYN.000

00074298905 AMINOSYN.000

00074299003 AMINOSYN.000

00074299005 AMINOSYN.000

00074299103 AMINOSYN.000

00074299105 AMINOSYN.000

00074299203 AMINOSYN.000

00074585203 AMINOSYN 7%/ELECTROLYTES.000

00074712107 AMINOSYN II.000

00074108603 AMINOSYN II.000

00074109003 AMINOSYN II.000

00074109005 AMINOSYN II.000

00074770029 AMINOSYN II 3.5%/DEXTROSE.000

00074770129 AMINOSYN II 3.5%/DEXTROSE.000

Page 107 of 125

Page 108: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00074775629 AMINOSYN II 3.5/DEXTROSE.000

00074775329 AMINOSYN II 4.25/DEXTROSE.000

00074774429 AMINOSYN II 5/DEXTROSE 25.000

00074774029 AMINOSYN II M 3.5%/DEXTRO.000

00074774229 AMINOSYN II M 4.25/DEXTRO.000

00074110803 AMINOSYN-HBC.000

00074110805 AMINOSYN-HBC.000

00074161602 AMINOSYN-PF.000

00074161603 AMINOSYN-PF.000

00074161705 AMINOSYN-PF/SODIUM HYDROS.000

00074407202 AMINOSYN-RF.000

51552054604 AMMONIATED MERCURY.000

51552033804 AMMONIUM BICARBONATE.000

51552027004 AMMONIUM CARBONATE.000

51552022604 AMMONIUM CARBONATE CHIPS.000

51552051404 AMMONIUM CHLORIDE.000

00074604301 AMMONIUM CHLORIDE5.000 MEQ/ML

00074437902 AMNIOCENTESIS TRAY1.000 %

00074437920 AMNIOCENTESIS TRAY1.000 %

00002721501 AMYTAL SODIUM500.00 MG

63304030310 AMYTAL SODIUM500.00 MG

63304030325 AMYTAL SODIUM500.00 MG

00496082904 ANALPRAM-HC.000

00496080004 ANALPRAM-HC.000

52544046960 ANDRODERM2.500 MG/24HR

52544047030 ANDRODERM5.000 MG/24HR

58177005204 ANEMAGEN OB.000

00008033204 ANTIVENIN CROTALIDAE POLY.000

00006408400 ANTIVENIN LATRODECTUS MAC.000

00008040703 ANTIVENIN MICRURUS FULVIU.000

00071108807 ANUSOL51.000 %

00071108813 ANUSOL51.000 %

00482013518 APATATE.000

00482013013 APATATE.000

00482013014 APATATE.000

61451600507 AQUACHLORAL325.00 MG

61451601007 AQUACHLORAL650.00 MG

00007440701 ARGATROBAN100.00 MG/ML

00310020130 ARIMIDEX1.000 MG

00469511705 ARISTOCORT25.000 MG/ML

00469511805 ARISTOSPAN5.000 MG/ML

00469511901 ARISTOSPAN20.000 MG/ML

00469511905 ARISTOSPAN20.000 MG/ML

00009766304 AROMASIN25.000 MG

00149075202 ASACOL400.00 MG

51552016304 ASCORBIC ACID.000

51552016404 ASCORBIC ACID.000

00182105801 ASPIRIN/ANTACID.000

00585118403 ASSESS DISPOSABLE MOUTHPI.000

00585118404 ASSESS DISPOSABLE MOUTHPI.000

49502020212 ASTECH ADAPTER/USE WITH 1.000

49502020248 ASTECH DISPOSABLE MOUTHPI.000

49502020299 ASTECH DISPOSABLE MOUTHPI.000

49502020101 ASTECH DISPOSABLE MOUTHPI.000

00037024110 ASTELIN137.00 MCG/SPR

00009722402 ATGAM50.000 MG/ML

00074789715 ATROPINE SULFATE ABBOJECT.050 MG/ML

00006470900 ATTENUVAX.000

00006458900 ATTENUVAX.000

00029608522 AUGMENTIN.000

00029608523 AUGMENTIN.000

00029608539 AUGMENTIN.000

00029609022 AUGMENTIN.000

00029609023 AUGMENTIN.000

00029609039 AUGMENTIN.000

00029607347 AUGMENTIN.000

00029607447 AUGMENTIN.000

00029607527 AUGMENTIN.000

00029607531 AUGMENTIN.000

00026858169 AVELOX400.00 MG

00026858141 AVELOX ABC PACK400.00 MG

00998101059 AVITENE FLOUR.000

08290409441 AXILLARY BLOCK NEEDLE BLO.000

08290009441 AXILLARY BLOCK NEEDLE BLO.000

00003255010 AZACTAM500.00 MG

00003257020 AZACTAM2.000 GM

00003223101 AZACTAM IN DEXTROSE.000

51479004801 AZACTAM IN DEXTROSE.000

08290309597 B-D 1CC SYRINGE/NEEDLE/SL.000

08290305903 B-D 1CC SYRINGE/SAFETYGLI.000

08290309621 B-D 1CC TUBERCULIN SYRING.000

08290375280 B-D 3CC LL SYR/PREFILL LI500.00 U

08290375283 B-D 3CC LL SYR/PREFILL LI500.00 U

08290375285 B-D 3CC LL SYR/PREFILL LI500.00 U

08290305083 B-D 3CC LL SYR/PREFILL LI500.00 U

08290309669 B-D 5CC SYRINGE LUER-LOK.000

08290309670 B-D 5CC SYRINGE LUER-LOK.000

08290305540 B-D ALLERGIST TRAY SYRING.000

08290005540 B-D ALLERGIST TRAY SYRING.000

08290550003 B-D ALLERGY/SYRINGE/NEEDL.000

08290305120 B-D DISPOSABLE NEEDLE 23G.000

08290305136 B-D DISPOSABLE NEEDLE 27G.000

08290305141 B-D DISPOSABLE NEEDLE REG.000

08290305142 B-D DISPOSABLE NEEDLE REG.000

08290305125 B-D DISPOSABLE NEEDLE REG.000

08290823000 B-D GLUCOSE300.00 MG

08290305194 B-D HYPODERMIC NEEDLE REG.000

08290305115 B-D HYPODERMIC NEEDLE REG.000

08290305101 B-D HYPODERMIC NEEDLE REG.000

08290303012 B-D HYPODERMIC NEEDLE REG.000

08290303010 B-D HYPODERMIC NEEDLE REG.000

08290005500 B-D PLASTIPAK SYRINGES.000

00574040005 BACITRACIN.000

00029152722 BACTROBAN2.000 %

00029152725 BACTROBAN2.000 %

00029152611 BACTROBAN NASAL2.000 %

08881844990 BASIC BIOPSY TRAY W/O BIO1.000 %

00087008341 BCAD 2.000

00173038879 BECONASE AQ.042 %

00071255517 BENADRYL ALLERGY & SINUS.000

58394000101 BENEFIX1000.0 IU

58394000201 BENEFIX500.00 IU

58394000301 BENEFIX250.00 IU

00066049425 BENZACLIN.000

51552015304 BENZALKONIUM CHLORIDE50.000 %

51552013004 BENZOCAINE.000

00034237230 BETADINE10.000 %

00034234505 BETADINE5.000 %

00065041130 BETADINE OPHTHALMIC PREP5.000 %

00034200202 BETADINE PLUS.000

51552062801 BETAMETHASONE ACETATE MIC.000

51552002201 BETAMETHASONE DIPROPIONAT.000

51552006401 BETAMETHASONE SODIUM PHOS.000

00074258611 BIAXIN500.00 MG

00074258660 BIAXIN500.00 MG

00074318813 BIAXIN250.00 MG/5ML

00074318850 BIAXIN250.00 MG/5ML

00074336811 BIAXIN250.00 MG

00074336860 BIAXIN250.00 MG

00074316313 BIAXIN125.00 MG/5ML

00074316350 BIAXIN125.00 MG/5ML

00074316560 BIAXIN XL500.00 MG

Page 108 of 125

Page 109: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00074316541 BIAXIN XL PAC500.00 MG

00074316514 BIAXIN XL PAC500.00 MG

00015301238 BICNU W/DILUENT ABSOLUTE100.00 MG

00043000401 BICOZENE.000

00026252106 BILTRICIDE600.00 MG

51552065401 BIOTIN.000

51552027104 BISMUTH CITRATE.000

51552045504 BISMUTH SUBCARBONATE.000

08881841202 BONE MARROW ASPIRATION TR1.000 %

08881842200 BONE MARROW ASPIRATION TR1.000 %

08881844008 BONE MARROW BIOPSY TRAY/B1.000 %

08881844016 BONE MARROW BIOPSY TRAY/B1.000 %

08881844024 BONE MARROW BIOPSY TRAY/B1.000 %

08881844081 BONE MARROW BIOPSY TRAY/B1.000 %

08881844115 BONE MARROW BIOPSY TRAY/B1.000 %

08881844131 BONE MARROW BIOPSY TRAY/B1.000 %

08881844164 BONE MARROW BIOPSY TRAY/I1.000 %

00087094303 BOOST HIGH PROTEIN.000

00087094343 BOOST HIGH PROTEIN.000

00087064541 BOOST NUTRITIONAL ENERGY.000

00087064545 BOOST NUTRITIONAL ENERGY.000

00087094503 BOOST PUDDING.000

00087094543 BOOST PUDDING.000

00087094603 BOOST PUDDING.000

00087094643 BOOST PUDDING.000

00087094703 BOOST PUDDING.000

00087094743 BOOST PUDDING.000

51552028104 BORAX.000

00074412201 BRACHIAL PLEXUS TRAY.000

00074412220 BRACHIAL PLEXUS TRAY.000

52604144605 BREVITAL SODIUM500.00 MG

00024028016 BRONCHOLATE.000

51552076501 BUPRENORPHINE HCL.000

00037011460 BUTISOL SODIUM50.000 MG

00074450601 BUTTERFLY.000

00074455002 BUTTERFLY 19G X 7/8.000

00074459001 BUTTERFLY 19G X 7/8.000

00074449201 BUTTERFLY 21G X 3/4.000

00074482101 BUTTERFLY 21GX3/4.000

00074457301 BUTTERFLY 25 GAUGE 3/8 SH.000

00074582702 BUTTERFLY INT.000

00074472102 BUTTERFLY INT 21G X 3/4.000

54391002703 CALCI-MIX CAPSULE1250.0 MG

00074255301 CALCIUM ACETATE.500 MEQ/ML

00089051006 CALCIUM DISODIUM VERSENAT200.00 MG/ML

51552039604 CAMPHOR.000

00009752901 CAMPTOSAR20.000 MG/ML

00009752902 CAMPTOSAR20.000 MG/ML

00006382210 CANCIDAS50.000 MG

00006382310 CANCIDAS70.000 MG

51552030601 CANTHARIDIN.000

51479001801 CAPASTAT SULFATE1.000 GM

00072685004 CAPITROL2.000 %

51552012901 CAPSAICIN.000

00066715030 CARAC.500 %

00074104130 CARBOCAINE1.500 %

51552010704 CARBOPOL 940 RESIN.000

51552043604 CARBOXYMETHYLCELLULOSE SO.000

00713062304 CARLESTA.000

00713062332 CARLESTA.000

53303002240 CARRAFOAM.000

53303002280 CARRAFOAM.000

53303010204 CARRAFOAM SKIN CARE KIT/4.000

53303010205 CARRAFOAM SKIN CARE KIT/8.000

53303001005 CARRASYN HYDROGEL WOUND D.000

53303001010 CARRASYN HYDROGEL WOUND D.000

53303001030 CARRASYN HYDROGEL WOUND D.000

53303001080 CARRASYN HYDROGEL WOUND D.000

53303009005 CARRINGTON DERMAL WOUND G.000

53303009010 CARRINGTON DERMAL WOUND G.000

60258095916 CASCARA SAGRADA50.000 MG/15ML

00087039040 CASEC.000

00310070510 CASODEX50.000 MG

00310070530 CASODEX50.000 MG

00310070539 CASODEX50.000 MG

51552041404 CASTOR OIL.000

00074476705 CAUDAL TRAY LIDOCAINE/EPI.000

00074476720 CAUDAL TRAY LIDOCAINE/EPI.000

00009765002 CAVERJECT20.000 MCG/ML

00009377804 CAVERJECT10.000 MCG

00009377805 CAVERJECT10.000 MCG

00009768604 CAVERJECT40.000 MCG

00009370105 CAVERJECT20.000 MCG

00009370108 CAVERJECT20.000 MCG

00074349201 CECON90.000 MG/ML

00015303020 CEENU10.000 MG

00015303120 CEENU40.000 MG

00015303220 CEENU100.00 MG

00015303410 CEENU300.00 MG

00469725101 CEFIZOX1.000 GM

00469725201 CEFIZOX1.000 GM

00469725302 CEFIZOX2.000 GM

00469725402 CEFIZOX2.000 GM

00469725510 CEFIZOX10.000 GM

00469727101 CEFIZOX ADD-VANTAGE1.000 GM

00469727202 CEFIZOX ADD-VANTAGE2.000 GM

00469722001 CEFIZOX IN DEXTROSE 5%.000

00469722102 CEFIZOX IN DEXTROSE 5%.000

00310037510 CEFOTAN10.000 GM

00310037610 CEFOTAN1.000 GM

00310037611 CEFOTAN1.000 GM

00310037631 CEFOTAN1.000 GM

00310037660 CEFOTAN1.000 GM

00310037720 CEFOTAN2.000 GM

00310037721 CEFOTAN2.000 GM

00310037732 CEFOTAN2.000 GM

00310037561 CEFOTAN10.000 GM

00310037762 CEFOTAN2.000 GM

00310037851 CEFOTAN-GALAXY.000

00310037951 CEFOTAN-GALAXY.000

00173040600 CEFTIN125.00 MG/5ML

00173055400 CEFTIN250.00 MG/5ML

00173055500 CEFTIN250.00 MG/5ML

00087771840 CEFZIL125.00 MG/5ML

00087771862 CEFZIL125.00 MG/5ML

00087771864 CEFZIL125.00 MG/5ML

00087771940 CEFZIL250.00 MG/5ML

00087771962 CEFZIL250.00 MG/5ML

00087771964 CEFZIL250.00 MG/5ML

00087772060 CEFZIL250.00 MG

00087772150 CEFZIL500.00 MG

00087772160 CEFZIL500.00 MG

00085094205 CELESTONE.600 MG/5ML

00456401001 CELEXA10.000 MG

00456402001 CELEXA20.000 MG

00456402063 CELEXA20.000 MG

00456404001 CELEXA40.000 MG

00456404063 CELEXA40.000 MG

00004025901 CELLCEPT250.00 MG

00004025905 CELLCEPT250.00 MG

00004025943 CELLCEPT250.00 MG

00004026001 CELLCEPT500.00 MG

Page 109 of 125

Page 110: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00004026043 CELLCEPT500.00 MG

00004026129 CELLCEPT200.00 MG/ML

00004029809 CELLCEPT INTRAVENOUS500.00 MG

00071052524 CELONTIN300.00 MG

00071400705 CEREBYX50.000 MG PE/M

00071400810 CEREBYX50.000 MG PE/M

58468106001 CEREDASE80.000 U/ML

58468178101 CEREDASE10.000 U/ML

58468198301 CEREZYME200.00 U

58468466301 CEREZYME400.00 U

00034549006 CERUMENEX10.000 %

00034549012 CERUMENEX10.000 %

00456412363 CERVIDIL10.000 MG

00074482620 CHILD LUMBAR PUNCTURE TRA1.000 %

59011099710 CHIROCAINE.250 %

59011099730 CHIROCAINE.250 %

59011099810 CHIROCAINE.500 %

59011099830 CHIROCAINE.500 %

59011099910 CHIROCAINE.750 %

59011099930 CHIROCAINE.750 %

00256018301 CHLOR-3.000

00087066603 CHOICE DM.000

00087066604 CHOICE DM.000

00087066642 CHOICE DM.000

00087066643 CHOICE DM.000

00087066644 CHOICE DM.000

00087066703 CHOICE DM.000

00087066704 CHOICE DM.000

00087066742 CHOICE DM.000

00087066743 CHOICE DM.000

00087066744 CHOICE DM.000

00065065435 CILOXAN.300 %

00065065605 CILOXAN.300 %

00065065610 CILOXAN.300 %

00065065625 CILOXAN.300 %

00074744716 CIMETIDINE HCL/NACL.000

00074735002 CIMETIDINE HCL/NACL.000

00074735102 CIMETIDINE HCL/NACL.000

51552042504 CINNAMON OIL.000

00026855336 CIPRO10.000 GM/100M

00026851248 CIPRO250.00 MG

00026851251 CIPRO250.00 MG

00026851348 CIPRO500.00 MG

00026851351 CIPRO500.00 MG

00026851448 CIPRO750.00 MG

00026851450 CIPRO750.00 MG

00026855136 CIPRO5.000 GM/100M

00026851106 CIPRO CYSTITIS100.00 MG

00065853110 CIPRO HC.000

00026855236 CIPRO I.V..000

00026852736 CIPRO I.V..000

00026852763 CIPRO I.V..000

00026855463 CIPRO I.V..000

00026856220 CIPRO I.V.200.00 MG

00026856464 CIPRO I.V.400.00 MG

00026856665 CIPRO I.V.10.000 MG/ML

00486113601 CITROLITH.000

00009344801 CLEOCIN2.000 %

00009033102 CLEOCIN75.000 MG

00009766701 CLEOCIN100.00 MG

00009076004 CLEOCIN PEDIATRIC GRANULE75.000 MG/5ML

00496085745 CLINAC BPO7.000 %

51552039401 CLINDAMYCIN HCL.000

51552060501 CLOBETASOL PROPIONATE.000

00327000110 CLORPACTIN WCS-902.000 GM

51552011404 COAL TAR20.000 %

00054316163 CODEINE PHOSPHATE15.000 MG/5ML

00054816016 CODEINE PHOSPHATE15.000 MG/5ML

63304074801 CODEINE PHOSPHATE30.000 MG

63304074901 CODEINE PHOSPHATE60.000 MG

00054815524 CODEINE SULFATE15.000 MG

54092049170 COLACE MICROENEMA200.00 MG/5ML

59879060525 COLD BUSTER93.000 MG

00574041701 COLISTIN SULFATE.000

00574056004 COLLODION FLEXIBLE.000

51552011704 COLLODION FLEXIBLE.000

00173059500 COMBIVIR.000

00173059502 COMBIVIR.000

00007336344 COMPAZINE5.000 MG/5ML

19810000673 COMTREX ACUTE HEAD COLD.000

19810000781 COMTREX/DAY & NIGHT/COLD.000

00006489800 COMVAX.000

17314585002 CONCERTA18.000 MG

17314585102 CONCERTA36.000 MG

17314585202 CONCERTA54.000 MG

00256017401 CONGESS JR.000

45800023530 CONTAC DAY/NIGHT ALLERGY/.000

00074480805 CONTINUOUS CAUDAL TRAY LI.000

00074480820 CONTINUOUS CAUDAL TRAY LI.000

00074481005 CONTINUOUS EPIDURAL TRAY.000

00074481020 CONTINUOUS EPIDURAL TRAY.000

00074575605 CONTINUOUS EPIDURAL TRAY.000

00074575620 CONTINUOUS EPIDURAL TRAY.000

00074403705 CONTINUOUS EPIDURAL TRAY.000

00074403720 CONTINUOUS EPIDURAL TRAY.000

00074403805 CONTINUOUS EPIDURAL TRAY.000

00074403820 CONTINUOUS EPIDURAL TRAY.000

00074264405 CONTINUOUS EPIDURAL TRAY.000

00074264420 CONTINUOUS EPIDURAL TRAY.000

00074802405 CONTINUOUS EPIDURAL TRAY.000

00074802420 CONTINUOUS EPIDURAL TRAY.000

00074828405 CONTINUOUS EPIDURAL TRAY.000

00074828420 CONTINUOUS EPIDURAL TRAY.000

00074309608 CONTINUOUS EPIDURAL TRAY/.000

00074309620 CONTINUOUS EPIDURAL TRAY/.000

00074309808 CONTINUOUS EPIDURAL TRAY/.000

00074309820 CONTINUOUS EPIDURAL TRAY/.000

00074477505 CONTINUOUS EPIDURAL TRAY/.000

00074477520 CONTINUOUS EPIDURAL TRAY/.000

51552049704 COPPER GLUCONATE.000

51552038504 COPPER SULFATE.000

00085360101 CORICIDIN COUGH & COLD.000

00085111701 CORICIDIN NIGHTTIME COLD/.000

08290002191 CORNWALL CONTROL SYRINGE.000

08290002192 CORNWALL CONTROL SYRINGE.000

08290002193 CORNWALL CONTROL SYRINGE.000

00009001201 CORTEF5.000 MG

00091069520 CORTIFOAM90.000 MG

51552003599 CORTISONE ACETATE.000

61570003275 CORTISPORIN.000

61570009010 CORTISPORIN-TC.000

00009379401 CORVERT.100 MG/ML

00006329822 COSMEGEN.500 MG

00006057062 CRIXIVAN100.00 MG

00006057143 CRIXIVAN200.00 MG

00006057318 CRIXIVAN400.00 MG

00006057340 CRIXIVAN400.00 MG

00006057342 CRIXIVAN400.00 MG

00006057354 CRIXIVAN400.00 MG

00006057362 CRIXIVAN400.00 MG

00006057465 CRIXIVAN333.00 MG

00281033010 CROFAB.000

Page 110 of 125

Page 111: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

49502018001 CUROSURF80.000 MG/ML

49502018003 CUROSURF80.000 MG/ML

00173043000 CUTIVATE.050 %

00173043001 CUTIVATE.050 %

00173043002 CUTIVATE.050 %

00173043100 CUTIVATE.005 %

00173043101 CUTIVATE.005 %

00173043102 CUTIVATE.005 %

00065035902 CYCLOMYDRIL.000

00065035905 CYCLOMYDRIL.000

00013111410 CYKLOKAPRON100.00 MG/ML

00378904001 CYSTAGON50.000 MG

00378904005 CYSTAGON50.000 MG

00378904501 CYSTAGON150.00 MG

00378904505 CYSTAGON150.00 MG

00083002430 CYTADREN250.00 MG

00004694003 CYTOVENE500.00 MG

00015054641 CYTOXAN200.00 MG

00015054741 CYTOXAN500.00 MG

00015054841 CYTOXAN1.000 GM

00015054941 CYTOXAN2.000 GM

00149003005 DANTRIUM25.000 MG

00149003105 DANTRIUM50.000 MG

00149003305 DANTRIUM100.00 MG

00149073402 DANTRIUM IV20.000 MG

00075001600 DDAVP.100 MG

00075002600 DDAVP.200 MG

00075094502 DDAVP15.000 MCG/ML

00075245201 DDAVP.010 %

00005921823 DECLOMYCIN150.00 MG

00005927029 DECLOMYCIN300.00 MG

00482018210 DECONAMINE.000

53014084261 DELSYM30.000 MG/5ML

00074712613 DEPAKOTE ER500.00 MG

00074611411 DEPAKOTE SPRINKLES125.00 MG

00074611413 DEPAKOTE SPRINKLES125.00 MG

00009074630 DEPO-PROVERA150.00 MG/ML

00009074635 DEPO-PROVERA150.00 MG/ML

00009062601 DEPO-PROVERA400.00 MG/ML

52604808107 DERMA CIDOL 2000.500 %

52604808109 DERMA CIDOL 2000.500 %

45802023303 DERMACAINE W/ALOE.000

52604808205 DERMASTAT65.000 %

51552045101 DESONIDE.000

00072200004 DESQUAM-X10.000 %

00054817425 DEXAMETHASONE1.000 MG

00054817625 DEXAMETHASONE2.000 MG

00054817716 DEXAMETHASONE.500 MG/5ML

00054418325 DEXAMETHASONE2.000 MG

00054418125 DEXAMETHASONE1.000 MG

00054317763 DEXAMETHASONE.500 MG/5ML

51552043001 DEXAMETHASONE.000

51552002401 DEXAMETHASONE ACETATE.000

00054317644 DEXAMETHASONE INTENSOL1.000 MG/ML

00574040810 DEXAMETHASONE SODIUM PHOS.000

00074150703 DEXTRAN 75.000

00074808501 DEXTRAN HM.000

00054318863 DIAZEPAM1.000 MG/ML

00054820716 DIAZEPAM1.000 MG/ML

00054820816 DIAZEPAM1.000 MG/ML

00054318544 DIAZEPAM INTENSOL5.000 MG/ML

00009002401 DIDREX50.000 MG

00009002402 DIDREX50.000 MG

51552059001 DIETHYLSTILBESTROL.000

51552059005 DIETHYLSTILBESTROL.000

51552059025 DIETHYLSTILBESTROL.000

00049341030 DIFLUCAN50.000 MG

00049342030 DIFLUCAN100.00 MG

00049342041 DIFLUCAN100.00 MG

00049343030 DIFLUCAN200.00 MG

00049343041 DIFLUCAN200.00 MG

00049344019 DIFLUCAN10.000 MG/ML

00049345019 DIFLUCAN40.000 MG/ML

00049350079 DIFLUCAN150.00 MG

00049343726 DIFLUCAN IN ISO-OSMOTIC D.000

00049343826 DIFLUCAN IN ISO-OSMOTIC D.000

00049343526 DIFLUCAN IN NACL.000

00049343626 DIFLUCAN IN NACL.000

00049337126 DIFLUCAN IN NACL.000

00049337226 DIFLUCAN IN NACL.000

00173023044 DIGIBIND38.000 MG

00071036524 DILANTIN30.000 MG

00071000724 DILANTIN INFATABS50.000 MG

00071000740 DILANTIN INFATABS50.000 MG

00054317363 DILUENT.050 %

00054817316 DILUENT.050 %

54838021733 DIMENHYDRINATE12.500 MG/5ML

00031228112 DIMETAPP COLD & FEVER.000

00031225620 DIMETAPP COLD/CONGESTION.000

00031224546 DIMETAPP DECONGESTANT30.000 MG

51552012405 DIPHENHYDRAMINE HCL.000

51552012425 DIPHENHYDRAMINE HCL.000

00008033801 DIPHTHERIA/TETANUS TOXOID.000

00008033802 DIPHTHERIA/TETANUS TOXOID.000

00085096201 DIPROLENE.050 %

00085096202 DIPROLENE.050 %

00085047506 DIPROSONE.100 %

00006325032 DIURIL IV500.00 MG

00006361932 DIURIL IV500.00 MG

00083024517 DOAN'S PM EXTRA STRENGTH.000

00037900001 DORAL7.500 MG

00037900201 DORAL15.000 MG

00037900202 DORAL15.000 MG

00013700112 DOSTINEX.500 MG

00072254006 DOVONEX.005 %

00072026006 DOVONEX.005 %

00072116006 DOVONEX.005 %

17314960001 DOXIL2.000 MG/ML

17314960002 DOXIL2.000 MG/ML

00009364301 DRAMAMINE50.000 MG

00009364302 DRAMAMINE50.000 MG

08290305374 DRIHEP ARTERIAL LINE SAMP100.00 U

08290305378 DRIHEP ARTERIAL LINE SAMP100.00 U

08290375356 DRIHEP ARTERIAL LINE SAMP100.00 U

08290375370 DRIHEP ARTERIAL LINE SAMP.000

08290375373 DRIHEP ARTERIAL LINE SAMP100.00 U

08290375376 DRIHEP ARTERIAL LINE SAMP100.00 U

08290375377 DRIHEP ARTERIAL LINE SAMP100.00 U

08290375392 DRIHEP PLUS 3CC LL PREFIL100.00 U

08290375394 DRIHEP PLUS 3CC LL PREFIL100.00 U

08290375396 DRIHEP PLUS 3CC LL PREFIL100.00 U

08290305390 DRIHEP PLUS 3CC LL PREFIL100.00 U

08290305094 DRIHEP PLUS 3CC LL PREFIL100.00 U

08290375395 DRIHEP PLUS 3CC PREFILLED100.00 U

00085026103 DRIXORAL COLD/FLU.000

00085026104 DRIXORAL COLD/FLU.000

00085193502 DRIXORAL COUGH & SORE THR.000

00085190002 DRIXORAL COUGH/CONGESTION.000

00003633517 DROXIA200.00 MG

00003633617 DROXIA300.00 MG

00003633717 DROXIA400.00 MG

00003187970 DUODERM CGF BORDER DRESSI.000

Page 111 of 125

Page 112: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00003187971 DUODERM CGF BORDER DRESSI.000

00003187972 DUODERM CGF BORDER DRESSI.000

00003187973 DUODERM CGF BORDER DRESSI.000

00003187974 DUODERM CGF BORDER DRESSI.000

00003187643 DUODERM CGF DRESSING.000

00003187644 DUODERM CGF DRESSING.000

00003187658 DUODERM CGF DRESSING.000

00003187659 DUODERM CGF DRESSING.000

00003187660 DUODERM CGF DRESSING.000

00003187661 DUODERM CGF DRESSING.000

00003187662 DUODERM CGF DRESSING.000

00003187955 DUODERM EXTRA THIN CGF DR.000

00003187957 DUODERM EXTRA THIN CGF DR.000

00003187900 DUODERM EXTRA THIN CGF DR.000

00003187901 DUODERM EXTRA-THIN CGF DR.000

00003187902 DUODERM EXTRA-THIN CGF DR.000

00003187903 DUODERM EXTRA-THIN CGF DR.000

00003187961 DUODERM EXTRA-THIN CGF DR.000

00003187987 DUODERM HYDROACTIVE GEL.000

00003187990 DUODERM HYDROACTIVE GEL.000

00003187930 DUODERM HYDROACTIVE PASTE.000

00054823301 DURACLON100.00 MCG/ML

00054823401 DURACLON500.00 MCG/ML

08290405032 DURASAFE SPINAL/EPIDURAL1.000 %

08290405033 DURASAFE SPINAL/EPIDURAL1.000 %

08290405034 DURASAFE SPINAL/EPIDURAL1.000 %

08290405035 DURASAFE SPINAL/EPIDURAL1.000 %

00451049010 DYNABAC D5-PAK250.00 MG

00451049060 DYNABAC D5-PAK250.00 MG

49502020701 EASIVENT.000

49502020725 EASIVENT.000

49502020803 EASIVENT/MASK-LARGE.000

49502020802 EASIVENT/MASK-MEDIUM.000

49502020801 EASIVENT/MASK-SMALL.000

00998063505 ECONOPRED.125 %

00998063510 ECONOPRED.125 %

00091144044 EDEX40.000 MCG

00091104006 EDEX40.000 MCG

00091101006 EDEX10.000 MCG

00091102006 EDEX20.000 MCG

00091103222 EDEX-REFILL PACK40.000 MCG

00091114011 EDEX-STARTER PACK40.000 MCG

00008078101 EFFEXOR37.500 MG

00008078102 EFFEXOR37.500 MG

00008070101 EFFEXOR25.000 MG

00008070102 EFFEXOR25.000 MG

00008070301 EFFEXOR50.000 MG

00008070401 EFFEXOR75.000 MG

00008070501 EFFEXOR100.00 MG

00008070502 EFFEXOR100.00 MG

00008083301 EFFEXOR XR75.000 MG

00008083303 EFFEXOR XR75.000 MG

00008083601 EFFEXOR XR150.00 MG

00008083603 EFFEXOR XR150.00 MG

00008083701 EFFEXOR XR37.500 MG

00008083703 EFFEXOR XR37.500 MG

59879060830 EFFICON.000

58768010705 EFLONE.100 %

58768010710 EFLONE.100 %

00009509101 ELLENCE2.000 MG/ML

00009509301 ELLENCE2.000 MG/ML

00173500001 ELLIPSE COMPACT SPACER.000

17314930001 ELMIRON100.00 MG

00085085401 ELOCON.100 %

00085085402 ELOCON.100 %

00085056701 ELOCON.100 %

00085056702 ELOCON.100 %

00006461200 ELSPAR10000. U

00065032505 EMADINE.050 %

00013013202 EMCYT140.00 MG

54092054330 EMINASE30.000 U

00186151270 EMLA ANESTHETIC DISC.000

00186151271 EMLA ANESTHETIC DISC.000

00087030001 ENFAMIL.000

00087001942 ENFAMIL 22.000

00087020144 ENFAMIL A.R..000

00087020341 ENFAMIL AR.000

00087020345 ENFAMIL AR.000

00087140144 ENFAMIL NEXT STEP.000

00087140941 ENFAMIL NEXT STEP SOY.000

00087030101 ENFAMIL/IRON.000

00087033101 ENFAMIL/IRON.000

00087033143 ENFAMIL/IRON.000

00087033163 ENFAMIL/IRON.000

00087033001 ENFAMIL/LOW IRON.000

00087033043 ENFAMIL/LOW IRON.000

00482320010 ENTSOL HYPERTONIC NASAL W.000

00065008315 ENUCLENE.000

10267129804 EPHEDRINE HCL25.000 MG

08290405022 EPIDURAL NEEDLE CRAWFORD.000

08290408272 EPIDURAL NEEDLE CRAWFORD.000

08290408280 EPIDURAL NEEDLE CRAWFORD.000

08290008272 EPIDURAL NEEDLE CRAWFORD.000

08290008280 EPIDURAL NEEDLE CRAWFORD.000

08290001304 EPIDURAL NEEDLE THIN-WALL.000

08290001300 EPIDURAL NEEDLE TUOHY THI.000

08290001219 EPIDURAL NEEDLE TUOHY THI.000

08290001284 EPIDURAL NEEDLE TUOHY THI.000

08290001285 EPIDURAL NEEDLE TUOHY THI.000

08290001209 EPIDURAL NEEDLE TUOHY THI.000

08290010038 EPIDURAL NEEDLE WEISS 17G.000

00074476905 EPIDURAL TRAY LIDOCAINE/E.000

00074476920 EPIDURAL TRAY LIDOCAINE/E.000

49502050101 EPIPEN-JR1.000 :2000

49502050102 EPIPEN-JR1.000 :2000

00173047001 EPIVIR150.00 MG

00173047100 EPIVIR10.000 MG/ML

00173066200 EPIVIR HBV100.00 MG

00173066300 EPIVIR HBV5.000 MG/ML

51552018801 ERGONOVINE MALEATE.000

51552018101 ERGOTAMINE TARTRATE.000

00074630350 ERYPED100.00 MG/2.5ML

00766112114 ESOTERICA FACIAL.000

00766044514 ESOTERICA SENSITIVE SKIN1.500 %

00071092815 ESTROSTEP FE.000

00071092847 ESTROSTEP FE.000

00281706237 ETHIODOL.000

00015340420 ETOPOPHOS100.00 MG

00072210360 EURAX10.000 %

00072220316 EURAX10.000 %

00072220360 EURAX10.000 %

00281029776 EVAC-Q-KWIK.000

00072820015 EXELDERM1.000 %

00072820030 EXELDERM1.000 %

00072820060 EXELDERM1.000 %

00072840030 EXELDERM1.000 %

00078033931 EXELON2.000 MG/ML

00078032306 EXELON1.500 MG

00078032344 EXELON1.500 MG

00078032406 EXELON3.000 MG

00078032444 EXELON3.000 MG

00078032506 EXELON4.500 MG

Page 112 of 125

Page 113: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00078032544 EXELON4.500 MG

00078032606 EXELON6.000 MG

00078032644 EXELON6.000 MG

58768010330 EYESCRUB.000

54092017030 FARESTON60.000 MG

54092017001 FARESTON60.000 MG

00372001204 FEBROL325.00 MG/5ML

00037043001 FELBATOL400.00 MG

00037043011 FELBATOL400.00 MG

00037043101 FELBATOL600.00 MG

00037043111 FELBATOL600.00 MG

00037044217 FELBATOL600.00 MG/5ML

00037044267 FELBATOL600.00 MG/5ML

00078024915 FEMARA2.500 MG

49692094113 FEOSOL45.000 MG

49692094122 FEOSOL45.000 MG

49692094160 FEOSOL45.000 MG

00456037263 FEOSTAT100.00 MG

00456037308 FEOSTAT100.00 MG/ML

00074723830 FERO-GRAD-500.000

51552029604 FERRIC SUBSULFATE.000

00904067860 FERRO-CAPS.000

08881305117 FILTER NEEDLE 18GX1-1/2.000

08290305201 FILTER NEEDLE THIN WALL 5.000

00065009605 FLAREX.100 %

00173051900 FLOLAN1.500 MG

00173051700 FLOLAN.500 MG

00597005801 FLOMAX.400 MG

00173045301 FLONASE50.000 MCG/ACT

00456052708 FLUMADINE50.000 MG/5ML

51552013401 FLUOCINOLONE ACETONIDE.000

51552005601 FLUOCINONIDE.000

00245001760 FOLGARD.000

00052030631 FOLLISTIM75.000 IU

00173041300 FORTAZ.000

00173041200 FORTAZ GALAXY.000

00004024648 FORTOVASE200.00 MG

00186190501 FOSCAVIR24.000 MG/ML

00186190601 FOSCAVIR24.000 MG/ML

19810005831 FOSTEX BPO10.000 %

19810005801 FOSTEX MEDICATED CLEANSIN.000

00013240691 FRAGMIN2500.0 IU/0.2ML

00013242691 FRAGMIN5000.0 IU/0.2ML

00013243606 FRAGMIN10000. IU/ML

51479002947 FURADANTIN25.000 MG/5ML

54092013001 FUROXONE100.00 MG

54092013020 FUROXONE100.00 MG

54092043016 FUROXONE50.000 MG/15ML

63459040201 GABITRIL2.000 MG

63459040401 GABITRIL4.000 MG

63459041201 GABITRIL12.000 MG

63459041601 GABITRIL16.000 MG

57844020852 GALZIN50.000 MG

57844021552 GALZIN25.000 MG

00004100328 GANTRISIN PEDIATRIC500.00 MG/5ML

00043055610 GAS-X EXTRA STRENGTH50.000 MG/5ML

00043055710 GAS-X EXTRA STRENGTH50.000 MG/5ML

53014067870 GASTROCROM100.00 MG/5ML

51552009504 GELATIN.000

00002240702 GELATIN CAPSULE EMPTY SZ.000

00002240704 GELATIN CAPSULE EMPTY SZ.000

00002240802 GELATIN CAPSULE EMPTY SZ.000

00002240804 GELATIN CAPSULE EMPTY SZ.000

00002240902 GELATIN CAPSULE EMPTY SZ.000

00002240904 GELATIN CAPSULE EMPTY SZ.000

00002241002 GELATIN CAPSULE EMPTY SZ.000

00002241102 GELATIN CAPSULE EMPTY SZ.000

00002241302 GELATIN CAPSULE EMPTY SZ.000

00002241304 GELATIN CAPSULE EMPTY SZ.000

00009028301 GELFILM ENVELOPE.000

00009029701 GELFILM OP.000

00009037101 GELFOAM.000

00009039601 GELFOAM DENTAL PACK.000

00009045701 GELFOAM PROSTATECTOMY CON.000

00009031503 GELFOAM SPONGE.000

00009032301 GELFOAM SPONGE.000

00009034201 GELFOAM SPONGE.000

00009034901 GELFOAM SPONGE.000

00009035301 GELFOAM SPONGE COMPRESSED.000

00013262681 GENOTROPIN5.800 MG

00013262694 GENOTROPIN5.800 MG

00013264681 GENOTROPIN13.800 MG

00013264694 GENOTROPIN13.800 MG

00013261694 GENOTROPIN INTRA-MIX5.800 MG

00013260694 GENOTROPIN INTRA-MIX1.500 MG

00013261681 GENOTROPIN INTRA-MIX5.800 MG

00013265202 GENOTROPIN MINIQUICK.800 MG

00013265402 GENOTROPIN MINIQUICK1.200 MG

00013264902 GENOTROPIN MINIQUICK.200 MG

00013265002 GENOTROPIN MINIQUICK.400 MG

00013265102 GENOTROPIN MINIQUICK.600 MG

00013265302 GENOTROPIN MINIQUICK1.000 MG

00013265602 GENOTROPIN MINIQUICK1.600 MG

00013265702 GENOTROPIN MINIQUICK1.800 MG

00013265802 GENOTROPIN MINIQUICK2.000 MG

51552077501 GENTAMICIN SULFATE.000

00074788623 GENTAMICIN SULFATE/0.9% S.000

00074788113 GENTAMICIN SULFATE/0.9% S.000

00049143066 GEOCILLIN382.00 MG

00049396060 GEODON20.000 MG

00049397060 GEODON40.000 MG

00049398060 GEODON60.000 MG

00049399060 GEODON80.000 MG

60258016916 GERIATRIC VITAMIN.000

00904526360 GINGER ROOT470.00 MG

00002808501 GLUCAGON1.000 MG

00002803101 GLUCAGON EMERGENCY KIT1.000 MG

00904547352 GLUCOSAMINE MSM COMPLEX.000

00087022045 GLUCOSE NURSETTE5.000 %

00087022944 GLUCOSE NURSETTE10.000 %

00574195906 GLUTOL.000

51552004201 GLYCOPYRROLATE.000

08290001328 GREENE POINT SPINAL NEEDL.000

00085049201 GUANIDINE HCL125.00 MG

00007419518 HALFAN250.00 MG

00003148215 HALOG.100 %

00003148220 HALOG.100 %

00003148230 HALOG.100 %

00003148240 HALOG.100 %

00003024815 HALOG.100 %

00003024820 HALOG.100 %

00003024830 HALOG.100 %

00003024840 HALOG.100 %

00003024915 HALOG.100 %

00003024920 HALOG.100 %

00003149421 HALOG-E.100 %

00003149431 HALOG-E.100 %

51552051901 HALOPERIDOL.000

00904526460 HAWTHORN BERRY550.00 MG

00016031955 HEALON GV14.000 MG/ML

00016031985 HEALON GV14.000 MG/ML

00053813001 HELIXATE FS250.00 IU

Page 113 of 125

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NDCNAME

STR UOM NDC NAMESTR

UOM

00053813002 HELIXATE FS500.00 IU

00053813004 HELIXATE FS1000.0 IU

00009085608 HEMABATE250.00 MCG/ML

00074258102 HEPARIN SODIUM2000.0 U/ML

00074258402 HEPARIN SODIUM25000. U/ML

00074765062 HEPARIN SODIUM/NACL 0.45%.000

00074765103 HEPARIN SODIUM/NACL 0.45%.000

00074765162 HEPARIN SODIUM/NACL 0.45%.000

50242013460 HERCEPTIN440.00 MG

58063000170 HEXALEN50.000 MG

00074155554 HEXTEND.000

00310057717 HIBICLENS.000

00005010432 HIBTITER.000

00005020110 HIBTITER.000

00087408041 HIST 1.000

00087408141 HIST 2.000

00071449903 HISTOPLASMIN1.000 :100

00004022001 HIVID.375 MG

00004022101 HIVID.750 MG

00087406541 HOM 1.000

00087406641 HOM 2.000

00053762010 HUMATE-P1000.0 IU

00053762005 HUMATE-P500.00 IU

00053762020 HUMATE-P2000.0 IU

00002808901 HUMATROPE6.000 MG

00002809001 HUMATROPE12.000 MG

00002809101 HUMATROPE24.000 MG

00002733501 HUMATROPE COMBO PACK5.000 MG

00002733516 HUMATROPE COMBO PACK5.000 MG

00007420105 HYCAMTIN4.000 MG

00496085904 HYDROCORTISONE ACETATE2.500 %

45802027603 HYDROCORTISONE ACETATE.000

45802027605 HYDROCORTISONE ACETATE.000

51552006604 HYDROQUINONE.000

00482010514 I.L.X..000

63717010204 ICAR PEDIACTRIC15.000 MG/1.25M

51552031404 ICHTHAMMOL.000

00015055741 IFEX3.000 GM

00173044902 IMITREX6.000 MG/0.5ML

00173045003 IMITREX100.00 MG

00173045900 IMITREX50.000 MG

00173046002 IMITREX25.000 MG

00173052300 IMITREX20.000 MG/ACT

00173052400 IMITREX5.000 MG/ACT

00173047900 IMITREX STATDOSE PEN6.000 MG/0.5ML

00173047800 IMITREX STATDOSE REFILL6.000 MG/0.5ML

00006340617 INDOCIN IV SDV1.000 MG

00074496301 INFANT LUMBAR PUNCTURE TR1.000 %

00074496320 INFANT LUMBAR PUNCTURE TR1.000 %

00074482701 INFANT/CHILD LUMBAR PUNCT1.000 %

00074482720 INFANT/CHILD LUMBAR PUNCT1.000 %

00456460006 INFASURF.000

00536398401 INOSITOL500.00 MG

00085460270 INSPIREASE BAGS 144'S.000

00085460202 INSPIREASE DRUG DELIVERY.000

00085460401 INSPIREASE MOUTHPIECE 144.000

00085460402 INSPIREASE REPLACEMENT MO.000

00085460203 INSPIREASE RESERVOIR BAGS.000

00085117701 INTEGRILIN2.000 MG/ML

00085117702 INTEGRILIN2.000 MG/ML

00085113601 INTEGRILIN.750 MG/ML

00085124201 INTRON-A3.000 MU/0.2ML

00085116801 INTRON-A600000 U/ML

00085123501 INTRON-A5.000 MU/0.2ML

00085125401 INTRON-A10.000 MU/0.2ML

00085117901 INTRON-A10.000 MU/ML

00085117902 INTRON-A10.000 MU/ML

00085118401 INTRON-A300000 U/0.5ML

00085118402 INTRON-A3.000 MU/0.5ML

00085113301 INTRON-A10.000 MU/ML

00085057102 INTRON-A W/DILUENT10.000 MU

00085053901 INTRON-A W/DILUENT50.000 MU

00085028502 INTRON-A W/DILUENT25.000 MU

00085111001 INTRON-A W/DILUENT18.000 MU

00085012002 INTRON-A W/DILUENT5.000 MU

00004024515 INVIRASE200.00 MG

53014090371 IONAMIN-1515.000 MG

00482093201 IRCON-FA.000

00065003408 ISMOTIC100.00 GM/220M

00998033105 ISOPTO HYOSCINE.250 %

00998033115 ISOPTO HYOSCINE.250 %

00087077141 K-LYTE DS50.000 MEQ

00087077142 K-LYTE DS50.000 MEQ

00087075841 K-LYTE/CL 50.000

00486111101 K-PHOS500.00 MG

00486111105 K-PHOS500.00 MG

00486113501 K-PHOS MF.000

00486113505 K-PHOS MF.000

00486113401 K-PHOS NO 2.000

00486113405 K-PHOS NO 2.000

00074395646 KALETRA.000

00074395977 KALETRA.000

00074711109 KCL 0.15%/D5W/LR.000

00074711309 KCL 0.3%/D5W/LR IV LAC RI.000

00074710509 KCL 0.3%/D5W/NACL 0.3%.000

00074710909 KCL 0.3%/D5W/NACL 0.9%.000

00003050162 KENALOG.000

00003049420 KENALOG-1010.000 MG/ML

50474059140 KEPPRA250.00 MG

50474059240 KEPPRA500.00 MG

50474059340 KEPPRA750.00 MG

19810005001 KERI ANTI-BACTERIAL.000

19810005204 KERI ANTI-BACTERIAL.000

19810005205 KERI ANTI-BACTERIAL.000

19810000280 KERI ANTI-BACTERIAL.000

51552069725 KETAMINE HCL.000

00245003730 KLOR-CON 2525.000 MEQ

00245003701 KLOR-CON 2525.000 MEQ

00026066520 KOATE-DVI250.00 IU

00026066530 KOATE-DVI500.00 IU

00026066550 KOATE-DVI1000.0 IU

00026066420 KOATE-HP250.00 IU

00026066430 KOATE-HP500.00 IU

00026066450 KOATE-HP1000.0 IU

00026066460 KOATE-HP1500.0 AHFU

00026067020 KOGENATE250.00 IU

00026067030 KOGENATE500.00 IU

00026067050 KOGENATE1000.0 IU

00026037220 KOGENATE FS250.00 IU

00026037230 KOGENATE FS500.00 IU

00026037250 KOGENATE FS1000.0 IU

00026062650 KONYNE 801000.0 U

62794050217 KRISTALOSE20.000 GM

62794050117 KRISTALOSE10.000 GM

62794050193 KRISTALOSE10.000 GM

62794050293 KRISTALOSE20.000 GM

00091352501 KU-ZYME HP.000

00091417501 KUTRASE.000

51552052201 L-TRYPTOPHAN.000

51552052225 L-TRYPTOPHAN.000

51552052250 L-TRYPTOPHAN.000

00006338060 LACRISERT5.000 MG

Page 114 of 125

Page 115: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

51552011604 LACTIC ACID85.000 %

00087061614 LACTOFREE.000

00087061663 LACTOFREE.000

00087061413 LACTOFREE.000

00091350501 LACTRASE250.00 MG

00173064255 LAMICTAL100.00 MG

00173064360 LAMICTAL150.00 MG

00173064460 LAMICTAL200.00 MG

00173063302 LAMICTAL25.000 MG

00173052600 LAMICTAL CHEWABLE DISPERS5.000 MG

00173052700 LAMICTAL CHEWABLE DISPERS25.000 MG

00078017905 LAMISIL250.00 MG

00078017915 LAMISIL250.00 MG

00078032882 LAMISIL1.000 %

00028010801 LAMPRENE50.000 MG

00054849706 LEUCOVORIN CALCIUM10.000 MG

00054449705 LEUCOVORIN CALCIUM10.000 MG

00054449710 LEUCOVORIN CALCIUM10.000 MG

00173063535 LEUKERAN2.000 MG

58406005014 LEUKINE500.00 MCG/ML

00004191106 LEVO DROMORAN2.000 MG/ML

00054449425 LEVORPHANOL TARTRATE2.000 MG

00091153605 LEVSIN.500 MG/ML

00074625401 LIDOCAINE HCL100.00 MG/ML

00074471201 LIDOCAINE HCL/DEXTROSE.000

08290375240 LIQUIHEP B-D 3CC PREFIL S500.00 U

08290375243 LIQUIHEP B-D 3CC PREFILLE500.00 U

08290375696 LIQUIHEP B-D 3CC PREFILLE500.00 U

08290305089 LIQUIHEP II B-D 3CC LL SY500.00 U

08290375381 LIQUIHEP II B-D 3CC PREFI500.00 U

08290375384 LIQUIHEP II B-D 3CC PREFI500.00 U

08290375385 LIQUIHEP II B-D 3CC PREFI500.00 U

08290375387 LIQUIHEP II B-D 3CC PREFI500.00 U

00054853125 LITHIUM CARBONATE600.00 MG

00054253125 LITHIUM CARBONATE600.00 MG

58768061005 LIVOSTIN.050 %

58768061010 LIVOSTIN.050 %

08290001359 LOCAL ANESTHESIA SECURITY.000

08290001360 LOCAL ANESTHESIA SECURITY.000

08290001362 LOCAL ANESTHESIA SECURITY.000

08290001364 LOCAL ANESTHESIA SECURITY.000

08290001369 LOCAL ANESTHESIA SECURITY.000

00074478601 LOCAL INFILTRATION TRAY 21.000 %

00074478620 LOCAL INFILTRATION TRAY 21.000 %

00496080215 LOCOID.100 %

00496080245 LOCOID.100 %

00496080315 LOCOID.100 %

00496080345 LOCOID.100 %

00496080420 LOCOID.000

00496080460 LOCOID.000

00496082115 LOCOID LIPOCREAM.100 %

00496082145 LOCOID LIPOCREAM.100 %

00056051168 LODOSYN25.000 MG

00087034042 LOFENALAC.000

99207000915 LOPROX.770 %

99207001330 LOPROX.770 %

99207001345 LOPROX.770 %

00002317030 LORABID200.00 MG

00002317130 LORABID400.00 MG

00002513587 LORABID100.00 MG/5ML

00002513618 LORABID200.00 MG/5ML

00002513687 LORABID200.00 MG/5ML

51552072901 LORAZEPAM.000

00054353244 LORAZEPAM INTENSOL2.000 MG/ML

24208029905 LOTEMAX.500 %

24208029910 LOTEMAX.500 %

24208029915 LOTEMAX.500 %

24208029925 LOTEMAX.500 %

00085087206 LOTRIMIN AF1.000 %

00085080901 LOTRISONE.000

00205538534 LOXITANE50.000 MG/ML

00074100101 LTA II KIT4.000 %

00482012001 LUBRIN DUO.000

00009348404 LUNELLE.000

00009348405 LUNELLE.000

63032002100 LUXIQ.120 %

00087407541 LYS 1.000

00087407641 LYS 2.000

00015308060 LYSODREN500.00 MG

00006474900 M-M-R II W/DILUENT 1 DOSE.000

00006468100 M-M-R II W/DILUENT 10 DOS.000

00006467700 M-R-VAX II.000

00006475100 M-R-VAX II.000

00149071001 MACROBID100.00 MG

00281412117 MAGAN545.00 MG

63717020006 MAGGEL600.00 MG

59528041605 MAGNEBIND 400.000

00904423960 MAGNESIUM500.00 MG

51552047204 MAGNESIUM CITRATE DIBASIC.000

00074672903 MAGNESIUM SULFATE40.000 MG/ML

00074672909 MAGNESIUM SULFATE40.000 MG/ML

00074672923 MAGNESIUM SULFATE40.000 MG/ML

00074673013 MAGNESIUM SULFATE80.000 MG/ML

00074672709 MAGNESIUM SULFATE IN D5W.000

00074672723 MAGNESIUM SULFATE IN D5W.000

00074672809 MAGNESIUM SULFATE IN D5W.000

50419018801 MAGNEVIST469.01 MG/ML

50419018802 MAGNEVIST469.01 MG/ML

50419018805 MAGNEVIST469.01 MG/ML

50419018810 MAGNEVIST469.01 MG/ML

50419018815 MAGNEVIST469.01 MG/ML

50419018836 MAGNEVIST469.01 MG/ML

50419018837 MAGNEVIST469.01 MG/ML

50419018838 MAGNEVIST469.01 MG/ML

00256018401 MAGONATE1000.0 MG/5ML

00256019101 MAGONATE NATAL65.200 MG/ML

00173067501 MALARONE.000

00173067601 MALARONE.000

00037905108 MALTSUPEX16.000 GM/15ML

00037905112 MALTSUPEX16.000 GM/15ML

00037910108 MALTSUPEX.000

00037910112 MALTSUPEX.000

00037920101 MALTSUPEX750.00 MG

00002706101 MANDOL1.000 GM

00002706125 MANDOL1.000 GM

00002706401 MANDOL2.000 GM

00002706410 MANDOL2.000 GM

61570004415 MANTADIL.000

00256016501 MARBLEN.000

53100051250 MASSENGILL.000

53100054300 MASSENGILL SOFT CLOTH MED.500 %

53100054000 MASSENGILL SOFT CLOTH TOW.000

00006026606 MAXALT5.000 MG

00006026706 MAXALT10.000 MG

00006380006 MAXALT-MLT5.000 MG

00006380106 MAXALT-MLT10.000 MG

52544063401 MAXIDONE.000

00003773199 MAXIPIME500.00 MG

00003773295 MAXIPIME1.000 GM

51479005410 MAXIPIME1.000 GM

51479005420 MAXIPIME1.000 GM

51479005430 MAXIPIME1.000 GM

Page 115 of 125

Page 116: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

51479005510 MAXIPIME2.000 GM

51479005520 MAXIPIME2.000 GM

51479005530 MAXIPIME2.000 GM

00087036503 MCT OIL.000

08290305605 MEDSAVER SYRINGE/NEEDLE/.000

00006354725 MEFOXIN IN DEXTROSE 2.2%.000

00006354524 MEFOXIN IN DEXTROSE 3.9%.000

51552066701 MEGESTROL ACETATE.000

62794015102 MENTAX1.000 %

62794015103 MENTAX1.000 %

00006004368 MEPHYTON5.000 MG

00173066518 MEPRON750.00 MG/5ML

00173054700 MEPRON750.00 MG/5ML

00310032130 MERREM1.000 GM

00310032520 MERREM500.00 MG

00006474700 MERUVAX II W/DILUENT 1 DO.000

00006467300 MERUVAX II W/DILUENT 10 D.000

51552030101 METHACHOLINE CHLORIDE CRY.000

51079068155 METHADONE HCL.000

00054355563 METHADONE HCL5.000 MG/5ML

00054355663 METHADONE HCL10.000 MG/5ML

00054975085 METHADONE HCL.000

00054975088 METHADONE HCL.000

00078005303 METHERGINE.200 MG/ML

00078005405 METHERGINE.200 MG

51552021204 METHYLCELLULOSE.000

51552021004 METHYLCELLULOSE.000

51552010104 METHYLPARABEN.000

00054356444 METOCLOPRAMIDE HCL INTENS10.000 MG/ML

00083013311 METOPIRONE250.00 MG

00089020025 METROGEL VAGINAL.750 %

00904511571 MI-ACID.000

00904432425 MILK DIGESTANT.000

00904532152 MILK THISTLE150.00 MG

00205530594 MINOCIN100.00 MG

00006333160 MINTEZOL500.00 MG/5ML

00006090736 MINTEZOL500.00 MG

52268080002 MIRALAX.000

52268080003 MIRALAX.000

50419042101 MIRENA20.000 MCG/24H

00026816115 MITHRACIN2500.0 MCG

00074436505 MIVACRON2.000 MG/ML

00074436510 MIVACRON2.000 MG/ML

00074437520 MIVACRON2.000 MG/ML

00087048041 MODUCAL.000

00053765601 MONOCLATE-P250.00 IU

00053765602 MONOCLATE-P500.00 IU

00053765604 MONOCLATE-P HUMAN1000.0 IU

08881522026 MONOJECT 12CC SAFETY SYRI.000

08881522018 MONOJECT 12CC SAFETY SYRI.000

08881512720 MONOJECT 12CC SYRINGE/LUE.000

08881512837 MONOJECT 12CC SYRINGE/LUE.000

08881512589 MONOJECT 12CC SYRINGE/LUE.000

08881512654 MONOJECT 12CC SYRINGE/LUE.000

08881512712 MONOJECT 12CC SYRINGE/LUE.000

08881516051 MONOJECT 6CC SYRINGE/LUER.000

08881516135 MONOJECT 6CC SYRINGE/LUER.000

08881516150 MONOJECT 6CC SYRINGE/LUER.000

08881516259 MONOJECT 6CC SYRINGE/LUER.000

08881501962 MONOJECT ALLERGIST TRAY/P.000

08881501558 MONOJECT ALLERGIST TRAY/P.000

08881500493 MONOJECT ALLERGIST TRAY/P.000

08881202314 MONOJECT BLUNT NEEDLE/MET.000

08881202322 MONOJECT BLUNT NEEDLE/MET.000

08881202330 MONOJECT BLUNT NEEDLE/MET.000

08881240009 MONOJECT BONE MARROW ASPI.000

08881240017 MONOJECT BONE MARROW ASPI.000

08881242088 MONOJECT BONE MARROW BIOP.000

08881242112 MONOJECT BONE MARROW BIOP.000

08881242120 MONOJECT BONE MARROW BIOP.000

08881242138 MONOJECT BONE MARROW BIOP.000

08881305018 MONOJECT FILTER NEEDLE/20.000

08881200755 MONOJECT HYPO/ALUM HUB/LU.000

08881200805 MONOJECT HYPO/ALUM HUB/LU.000

08881200573 MONOJECT HYPO/ALUM HUB/LU.000

08881200011 MONOJECT HYPO/ALUM HUB/LU.000

08881200029 MONOJECT HYPO/ALUM HUB/LU.000

08881200037 MONOJECT HYPO/ALUM HUB/LU.000

08881200045 MONOJECT HYPO/ALUM HUB/LU.000

08881200060 MONOJECT HYPO/ALUM HUB/LU.000

08881200508 MONOJECT HYPO/ALUM HUB/LU.000

08881200151 MONOJECT HYPO/ALUM HUB/LU.000

08881200219 MONOJECT HYPO/ALUM HUB/LU.000

08881200227 MONOJECT HYPO/ALUM HUB/LU.000

08881200235 MONOJECT HYPO/ALUM HUB/LU.000

08881200433 MONOJECT HYPO/ALUM HUB/LU.000

08881200441 MONOJECT HYPO/ALUM HUB/LU.000

08881200318 MONOJECT HYPO/ALUM HUB/LU.000

08881200466 MONOJECT HYPO/ALUM/LUER L.000

08881250123 MONOJECT HYPO/POLYPROPYLE.000

08881250131 MONOJECT HYPO/POLYPROPYLE.000

08881251188 MONOJECT HYPO/POLYPROPYLE.000

08881250305 MONOJECT HYPO/POLYPROPYLE.000

08881250313 MONOJECT HYPO/POLYPROPYLE.000

08881250321 MONOJECT HYPO/POLYPROPYLE.000

08881750510 MONOJECT HYPODERMIC NEEDL.000

08881260114 MONOJECT OR/ER NEEDLE 25G.000

08881260148 MONOJECT OR/ER NEEDLE 27G.000

08881260130 MONOJECT OR/ER NEEDLE/26G.000

08881511201 MONOJECT TUBERCULIN SAFET.000

08881501608 MONOJECT TUBERCULIN SYRIN.000

08881501178 MONOJECT TUBERCULIN SYRIN.000

00053766801 MONONINE250.00 IU

00053766802 MONONINE500.00 IU

00053766804 MONONINE1000.0 IU

00456430008 MONUROL5.631 GM

00574200625 MORPHINE SULFATE.000

63304070601 MORPHINE SULFATE10.000 MG

60793006701 MORPHINE SULFATE15.000 MG/ML

00074606202 MORPHINE SULFATE IN DEXTR.000

00074606203 MORPHINE SULFATE IN DEXTR.000

00074606211 MORPHINE SULFATE IN DEXTR.000

00086007405 MOTOFEN.000

00087406041 MSUD 1.000

00087406141 MSUD 2.000

00087041842 MSUD DIET POWDER.000

08290002900 MULTIFIT REUSABLE CONTROL.000

08290002901 MULTIFIT REUSABLE CONTROL.000

08290002902 MULTIFIT REUSABLE CONTROL.000

08290002903 MULTIFIT REUSABLE CONTROL.000

08290002904 MULTIFIT REUSABLE CONTROL.000

08290002905 MULTIFIT REUSABLE CONTROL.000

08290002906 MULTIFIT REUSABLE CONTROL.000

08290002907 MULTIFIT REUSABLE CONTROL.000

08290002908 MULTIFIT REUSABLE CONTROL.000

08290002134 MULTIFIT REUSABLE SYRINGE.000

08290002135 MULTIFIT REUSABLE SYRINGE.000

08290002144 MULTIFIT REUSABLE SYRINGE.000

08290002145 MULTIFIT REUSABLE SYRINGE.000

08290002401 MULTIFIT REUSABLE SYRINGE.000

08290002402 MULTIFIT REUSABLE SYRINGE.000

08290002404 MULTIFIT REUSABLE SYRINGE.000

Page 116 of 125

Page 117: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

08290002412 MULTIFIT REUSABLE SYRINGE.000

08290002421 MULTIFIT REUSABLE SYRINGE.000

08290002430 MULTIFIT REUSABLE SYRINGE.000

08290002431 MULTIFIT REUSABLE SYRINGE.000

08290002432 MULTIFIT REUSABLE SYRINGE.000

08290002433 MULTIFIT REUSABLE SYRINGE.000

08290002434 MULTIFIT REUSABLE SYRINGE.000

08290002435 MULTIFIT REUSABLE SYRINGE.000

08290002440 MULTIFIT REUSABLE SYRINGE.000

08290002441 MULTIFIT REUSABLE SYRINGE.000

08290002442 MULTIFIT REUSABLE SYRINGE.000

08290002443 MULTIFIT REUSABLE SYRINGE.000

08290002444 MULTIFIT REUSABLE SYRINGE.000

08290002445 MULTIFIT REUSABLE SYRINGE.000

08290002450 MULTIFIT REUSABLE SYRINGE.000

08290002451 MULTIFIT REUSABLE SYRINGE.000

08290002452 MULTIFIT REUSABLE SYRINGE.000

08290002453 MULTIFIT REUSABLE SYRINGE.000

08290002454 MULTIFIT REUSABLE SYRINGE.000

08290002455 MULTIFIT REUSABLE SYRINGE.000

08290002460 MULTIFIT REUSABLE SYRINGE.000

08290002461 MULTIFIT REUSABLE SYRINGE.000

08290002462 MULTIFIT REUSABLE SYRINGE.000

08290002463 MULTIFIT REUSABLE SYRINGE.000

08290002464 MULTIFIT REUSABLE SYRINGE.000

08290002465 MULTIFIT REUSABLE SYRINGE.000

08290002470 MULTIFIT REUSABLE SYRINGE.000

08290002471 MULTIFIT REUSABLE SYRINGE.000

08290002472 MULTIFIT REUSABLE SYRINGE.000

08290002473 MULTIFIT REUSABLE SYRINGE.000

08290002474 MULTIFIT REUSABLE SYRINGE.000

08290002475 MULTIFIT REUSABLE SYRINGE.000

08290002480 MULTIFIT REUSABLE SYRINGE.000

08290002481 MULTIFIT REUSABLE SYRINGE.000

08290002482 MULTIFIT REUSABLE SYRINGE.000

08290002483 MULTIFIT REUSABLE SYRINGE.000

08290002484 MULTIFIT REUSABLE SYRINGE.000

08290002485 MULTIFIT REUSABLE SYRINGE.000

08290002154 MULTIFIT REUSABLE SYRINGE.000

08290002155 MULTIFIT REUSABLE SYRINGE.000

08290002156 MULTIFIT REUSABLE TB SYRI.000

08290002146 MULTIFIT REUSABLE TB SYRI.000

08290002150 MULTIFIT REUSABLE TB SYRI.000

08290002151 MULTIFIT REUSABLE TB SYRI.000

08290002152 MULTIFIT REUSABLE TB SYRI.000

08290002153 MULTIFIT REUSABLE TB SYRI.000

08290002136 MULTIFIT REUSABLE TB SYRI.000

08290002140 MULTIFIT REUSABLE TB SYRI.000

08290002141 MULTIFIT REUSABLE TB SYRI.000

08290002142 MULTIFIT REUSABLE TB SYRI.000

08290002143 MULTIFIT REUSABLE TB SYRI.000

08290002130 MULTIFIT REUSABLE TB SYRI.000

08290002131 MULTIFIT REUSABLE TB SYRI.000

08290002132 MULTIFIT REUSABLE TB SYRI.000

08290002133 MULTIFIT REUSABLE TB SYRI.000

00006475300 MUMPSVAX W/DILUENT 1 DOSE.000

00006458400 MUMPSVAX W/DILUENT 10 DOS.000

24208027615 MURO 1282.000 %

24208027805 MUROCOLL-2.000

62541011001 MUSE125.00 MCG

62541011006 MUSE125.00 MCG

62541012006 MUSE250.00 MCG

62541013006 MUSE500.00 MCG

62541014006 MUSE1000.0 MCG

00006775331 MUSTARGEN10.000 MG

17314940001 MYCELEX10.000 MG

17314940002 MYCELEX10.000 MG

17314940003 MYCELEX10.000 MG

00026309822 MYCELEX-G.000

00013530117 MYCOBUTIN150.00 MG

00173071325 MYLERAN2.000 MG

58063097909 MYLOCEL1000.0 MG

00008451001 MYLOTARG5.000 MG

59075071010 MYOBLOC2500.0 U/0.5ML

59075071110 MYOBLOC5000.0 U/ML

59075071210 MYOBLOC10000. U/2ML

00024128704 MYTELASE10.000 MG

53100085935 N'ICE 'N CLEAR7.000 MG

00015565801 NALDECON SENIOR200.00 MG/5ML

00186085944 NAROPIN2.000 MG/ML

00186085954 NAROPIN2.000 MG/ML

00186085981 NAROPIN2.000 MG/ML

00186085991 NAROPIN2.000 MG/ML

00186086354 NAROPIN5.000 MG/ML

00186086361 NAROPIN5.000 MG/ML

00186086369 NAROPIN5.000 MG/ML

00186086754 NAROPIN7.500 MG/ML

00186086844 NAROPIN10.000 MG/ML

00186086854 NAROPIN10.000 MG/ML

00186086857 NAROPIN10.000 MG/ML

00186086357 NAROPIN5.000 MG/ML

00075150616 NASACORT AQ55.000 MCG/ACT

00085119701 NASONEX50.000 MCG/ACT

00065064515 NATACYN5.000 %

00002729301 NEBCIN60.000 MG

00013560601 NEOSAR100.00 MG

00013561601 NEOSAR200.00 MG

00013562601 NEOSAR500.00 MG

00013563601 NEOSAR1.000 GM

00013564601 NEOSAR2.000 GM

59528031701 NEPHPLEX RX.000

54391001308 NEPHRO-FER350.00 MG

59528445601 NEPHRON FA.000

00256016101 NEPHROX.000

00074478220 NERVE BLOCK TRAY/LIDOCAIN.000

00186097166 NESACAINE1.000 %

58394000401 NEUMEGA5.000 MG

58394000402 NEUMEGA5.000 MG

00482001306 NEUROCHOL210.00 MG

00074660902 NEUT FTV4.000 %

00575023101 NEUTRA-PHOS.000

00575022801 NEUTRA-PHOS-K.000

17314931201 NEUTRA-PHOS-K.000

17314931302 NEUTRA-PHOS-K.000

58178002010 NEUTREXIN25.000 MG

58178002101 NEUTREXIN200.00 MG

00186502031 NEXIUM20.000 MG

00186502228 NEXIUM20.000 MG

00186504031 NEXIUM40.000 MG

00186504228 NEXIUM40.000 MG

00256012301 NICOTINEX50.000 MG/5ML

00074437805 NIMBEX2.000 MG/ML

00074438010 NIMBEX2.000 MG/ML

00074438220 NIMBEX10.000 MG/ML

00081054050 NIMBEX2.000 MG/ML

00081054301 NIMBEX10.000 MG/ML

00003052620 NITRATEST PAPER.000

00003052650 NITRATEST PAPER.000

00169777411 NORDITROPIN4.000 MG

00169777011 NORDITROPIN CARTRIDGE15.000 MG/1.5ML

00006070520 NOROXIN400.00 MG

00006070528 NOROXIN400.00 MG

Page 117 of 125

Page 118: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00006070568 NOROXIN400.00 MG

00074194063 NORVIR80.000 MG/ML

00074663322 NORVIR100.00 MG

00074181002 NOVOCAIN10.000 %

00169706001 NOVOSEVEN1200.0 MCG

00169706201 NOVOSEVEN4800.0 MCG

00065923081 NUBASICS COMPLETE NUTRITI.000

00065923181 NUBASICS COMPLETE NUTRITI.000

00065925581 NUBASICS COMPLETE NUTRITI.000

00074443705 NUROMAX MDV1.000 MG/ML

00087033801 NUTRAMIGEN.000

00087049801 NUTRAMIGEN.000

50242003235 NUTROPIN DEPOT13.500 MG

50242003441 NUTROPIN DEPOT18.000 MG

50242003654 NUTROPIN DEPOT22.500 MG

00574040402 NYSTATIN.000

00574040405 NYSTATIN.000

00574040415 NYSTATIN.000

00574040450 NYSTATIN.000

00256020001 OBEGYN LIQUID PRENATAL VI.000

00074909916 OCL.000

00085036109 OCUCLEAR.025 %

63032003100 OLUX.050 %

00074376930 OMNICEF300.00 MG

00074376960 OMNICEF300.00 MG

00074377113 OMNICEF125.00 MG/5ML

00074377160 OMNICEF125.00 MG/5ML

00065010706 OPTI-FREE ENZYMATIC CLEAN.000

00065010712 OPTI-FREE ENZYMATIC CLEAN.000

00065010718 OPTI-FREE ENZYMATIC CLEAN.000

00998012008 OPTI-ZYME WEEKLY ENZYME C.000

00998012024 OPTI-ZYME WEEKLY ENZYME C.000

00998012036 OPTI-ZYME WEEKLY ENZYME C.000

00998012056 OPTI-ZYME WEEKLY ENZYME C.000

00451702506 OPTIVAR.050 %

00574030316 ORA-PLUS.000

00574030216 ORA-SWEET SF.000

46287001401 ORACIT.000

46287001415 ORACIT.000

46287001430 ORACIT.000

46287001499 ORACIT.000

57844015101 ORAP1.000 MG

57844018701 ORAP2.000 MG

00087409041 OS 1.000

00087409141 OS 2.000

00065003508 OSMOGLYN50.000 %

00430058311 OVCON-35/21.000

00430058214 OVCON-35/28.000

00430058514 OVCON-50 28.000

00008006201 OVRETTE 28.075 MG

00173044801 OXISTAT1.000 %

00173042300 OXISTAT1.000 %

00173042301 OXISTAT1.000 %

00173042304 OXISTAT1.000 %

00766700166 OXY BALANCE DEEP PORE CLE.500 %

00766700130 OXY BALANCE FACIAL CLEANS1.000 %

08290375846 OXYCEL ABSORBANT COTTON-T.000

08290375847 OXYCEL ABSORBANT GAUZE-TY.000

08290375848 OXYCEL ABSORBANT GAUZE-TY.000

08290379301 OXYCEL ABSORBANT GAUZE-TY.000

08290379361 OXYCEL ABSORBANT GAUZE-TY.000

59011010010 OXYCONTIN10.000 MG

59011010025 OXYCONTIN10.000 MG

59011010310 OXYCONTIN20.000 MG

59011010325 OXYCONTIN20.000 MG

59011010510 OXYCONTIN40.000 MG

59011010525 OXYCONTIN40.000 MG

59011010710 OXYCONTIN80.000 MG

59011010725 OXYCONTIN80.000 MG

59011010910 OXYCONTIN160.00 MG

59011010925 OXYCONTIN160.00 MG

00575400104 P & S.000

00575400108 P & S.000

00482006101 PAMINE2.500 MG

00281015315 PANDEL.100 %

00281015346 PANDEL.100 %

00281015380 PANDEL.100 %

00074200043 PANHEMATIN313.00 MG

52604050601 PANTHODERM2.000 %

52604050602 PANTHODERM2.000 %

51552009704 PARA-AMINOBENZOIC ACID.000

00015321330 PARAPLATIN50.000 MG

00015321430 PARAPLATIN150.00 MG

00015321530 PARAPLATIN450.00 MG

08290001319 PARASYMPATHETIC NERVE NEE.000

00007447120 PARNATE10.000 MG

00065027105 PATANOL.100 %

00029321548 PAXIL10.000 MG/5ML

00085025104 PAXIPAM20.000 MG

00085053804 PAXIPAM40.000 MG

19810000241 PAZO.000

00074338913 PCE500.00 MG

00074629060 PCE333.00 MG

00456103916 PEDAMETH75.000 MG/5ML

00074558801 PEDIATRIC BUTTERFLY 25GX3.000

00074499501 PEDIATRIC BUTTERFLY 27GX3.000

00085127901 PEG-INTRON150.00 MCG/0.5M

00085129101 PEG-INTRON80.000 MCG/0.5M

00085130401 PEG-INTRON120.00 MCG/0.5M

00085136801 PEG-INTRON50.000 MCG/0.5M

00066800802 PENLAC NAIL LACQUER8.000 %

54092018980 PENTASA250.00 MG

54092018981 PENTASA250.00 MG

00074641801 PENTOTHAL250.00 MG

00074641901 PENTOTHAL400.00 MG

00074643102 PENTOTHAL1.000 GM

00074332901 PENTOTHAL500.00 MG

00074335101 PENTOTHAL250.00 MG

00074335201 PENTOTHAL400.00 MG

00074335301 PENTOTHAL500.00 MG

00006353892 PEPCID40.000 MG/5ML

00006355331 PEPCID RPD20.000 MG

00006355348 PEPCID RPD20.000 MG

00072790005 PERNOX.000

00072520002 PERNOX.000

00072520004 PERNOX.000

00072530002 PERNOX.000

00072530004 PERNOX.000

51552031704 PERUVIAN BALSAM.000

46287050816 PETROLATUM.000

00087007941 PFD 2.000

00641047625 PHENOBARBITAL SODIUM65.000 MG/ML

51552013104 PHENOL.000

00074397105 PHENURONE500.00 MG

00087036842 PHENYL-FREE.000

00087008041 PHENYL-FREE 2.000

00087008141 PHENYL-FREE 2HP.000

24208074002 PHENYLEPHRINE HCL2.500 %

24208074006 PHENYLEPHRINE HCL2.500 %

24208074059 PHENYLEPHRINE HCL2.500 %

00024153502 PHISOHEX3.000 %

00024153506 PHISOHEX3.000 %

Page 118 of 125

Page 119: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00024153508 PHISOHEX3.000 %

00024153524 PHISOHEX3.000 %

00024153548 PHISOHEX3.000 %

51552047701 PILOCARPINE HCL.000

00256013901 PIMA325.00 MG/5ML

00087405541 PKU 1.000

00087405641 PKU 2.000

00087405741 PKU 3.000

00026069102 PLASBUMIN-2020.000 %

00003012880 PLASTIBASE.000

00085026805 POLARAMINE.000

00186041801 POLOCAINE-MPF1.500 %

00087048841 POLY-VI-FLOR/IRON.000

00074200701 PONTOCAINE.500 %

00074184602 PONTOCAINE1.000 %

00074184906 PONTOCAINE NIPHANOID20.000 MG

00087038701 PORTAGEN.000

00904535352 POTASSIUM95.000 MG

51552014404 POTASSIUM BROMIDE.000

00074707514 POTASSIUM CHLORIDE10.000 MEQ/50M

00074707526 POTASSIUM CHLORIDE20.000 MEQ/100

51552004004 POTASSIUM PERMANGANATE.000

51552021404 POTASSIUM SORBATE.000

00496071703 PRAMOSONE.000

00496071704 PRAMOSONE.000

00496076304 PRAMOSONE.000

00496077704 PRAMOSONE.000

00496074803 PRAX1.000 %

00496074804 PRAX1.000 %

00496074815 PRAX1.000 %

00074163802 PRECEDEX100.00 MCG/ML

57599881508 PRECISION XTRA.000

00087036701 PREGESTIMIL.000

00009335902 PREPIDIL.500 MG/3GM

08290375410 PRESET 1CC LS SYR/PREFILL70.000 U

08290375413 PRESET 1CC LS SYR/PREFILL70.000 U

08290375420 PRESET 1CC LS SYR/PREFILL70.000 U

08290375423 PRESET 1CC LS SYR/PREFILL70.000 U

08290305416 PRESET 1CC LS SYR/PREFILL70.000 U

08290305421 PRESET 1CC LS SYR/PREFILL70.000 U

08290305350 PRESET 1CC LS SYR/PREFILL70.000 U

08290305352 PRESET 3CC LL SYR/PREFILL100.00 U

08290305355 PRESET 3CC LL SYR/PREFILL100.00 U

08290305306 PRESET 3CC LL SYR/PREFILL100.00 U

08290305326 PRESET 3CC LL SYR/PREFILL100.00 U

08290375320 PRESET 3CC LL SYR/PREFILL100.00 U

08290375323 PRESET 3CC LL SYR/PREFILL100.00 U

08290375310 PRESET 3CC LL SYR/PREFILL100.00 U

08290375313 PRESET 3CC LL SYR/PREFILL100.00 U

08290375315 PRESET 3CC SYR/PREFILL LY100.00 U

08290375325 PRESET 3CC SYR/PREFILL LY100.00 U

08290305332 PRESET 3CC SYR/PREFILL LY100.00 U

08290305342 PRESET 3CC SYR/PREFILL LY100.00 U

08290305333 PRESET 3CC SYR/PREFILLED100.00 U

08290375316 PRESET 3CC SYR/PREFILLED100.00 U

00072979906 PRESUN FOR KIDS SPRAY.000

00072972006 PRESUN SPRAY SUNSCREEN.000

00005197067 PREVNAR16.000 MCG/0.5M

00186074331 PRILOSEC40.000 MG

00186074368 PRILOSEC40.000 MG

00186074382 PRILOSEC40.000 MG

00006358275 PRIMAXIN I.M..000

00006358376 PRIMAXIN I.M..000

00006366659 PRIMAXIN IV.000

00006351458 PRIMAXIN IV.000

00006351659 PRIMAXIN IV.000

00006351775 PRIMAXIN IV.000

00006355158 PRIMAXIN IV ADD-VANTAGE.000

00006355259 PRIMAXIN IV ADD-VANTAGE.000

54092007301 PRO-BANTHINE7.500 MG

00087042441 PRODUCT 3200AB.000

00087042541 PRODUCT 3232A.000

00087042042 PRODUCT 80056.000

00575620030 PROGLYCEM50.000 MG/ML

00469061710 PROGRAF1.000 MG

00469301601 PROGRAF5.000 MG/ML

00026060130 PROLASTIN500.00 MG

00026060135 PROLASTIN1000.0 MG

51552014701 PROMETHAZINE HCL.000

00032170801 PROMETRIUM100.00 MG

00032171101 PROMETRIUM200.00 MG

00006007131 PROPECIA1.000 MG

00006007161 PROPECIA PRO-PAK1.000 MG

51552010204 PROPYLPARABEN.000

00006007228 PROSCAR5.000 MG

00006007231 PROSCAR5.000 MG

00006007258 PROSCAR5.000 MG

00087030801 PROSOBEE.000

00087310121 PROSOBEE.000

00087310122 PROSOBEE.000

00087310163 PROSOBEE.000

51552049801 PROSTAGLANDIN E1.000

00009082703 PROSTIN E220.000 MG

00008084181 PROTONIX40.000 MG

00008084199 PROTONIX40.000 MG

00008092303 PROTONIX40.000 MG

00469520130 PROTOPIC.030 %

00469520160 PROTOPIC.030 %

00469520230 PROTOPIC.100 %

00469520260 PROTOPIC.100 %

50242001502 PROTROPIN5.000 MG

50242001620 PROTROPIN10.000 MG

63459010001 PROVIGIL100.00 MG

63459020001 PROVIGIL200.00 MG

00002300475 PROZAC WEEKLY90.000 MG

00066027517 PSORCON E.050 %

00066027531 PSORCON E.050 %

00066027560 PSORCON E.050 %

08290409403 PUDENDAL/LOCAL BLOCK TRAY1.000 %

50242010039 PULMOZYME1.000 MG/ML

50242010040 PULMOZYME1.000 MG/ML

65086013505 QUIXIN.500 %

00009043624 R-GENE 1010.000 %

53303014141 RADIADRES GEL SHEET.000

00008103004 RAPAMUNE1.000 MG/ML

00008103006 RAPAMUNE1.000 MG/ML

00085125801 REBETRON.000

00085125802 REBETRON.000

00085125803 REBETRON.000

00085123601 REBETRON.000

00085123602 REBETRON.000

00085123603 REBETRON.000

00085124101 REBETRON.000

00085124102 REBETRON.000

00085124103 REBETRON.000

00006498000 RECOMBIVAX HB5.000 MCG/0.5M

00006498100 RECOMBIVAX HB5.000 MCG/0.5M

00006477300 RECOMBIVAX HB10.000 MCG/ML

00006477500 RECOMBIVAX HB10.000 MCG/ML

00006477600 RECOMBIVAX HB40.000 MCG/ML

00006487200 RECOMBIVAX HB10.000 MCG/ML

00006487300 RECOMBIVAX HB10.000 MCG/ML

Page 119 of 125

Page 120: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00006487600 RECOMBIVAX HB5.000 MCG/0.5M

58394000501 REFACTO1000.0 IU

58394000601 REFACTO500.00 IU

58394000701 REFACTO250.00 IU

00173068101 RELENZA DISKHALER5.000 MG/BLIST

00052011030 REMERON SOLTAB45.000 MG

00327001105 RENACIDIN.000

58468002001 RENAGEL400.00 MG

58468002101 RENAGEL800.00 MG

58468470901 RENAGEL403.00 MG

00002714001 REOPRO2.000 MG/ML

00173050100 RETROVIR300.00 MG

00173010855 RETROVIR100.00 MG

00173010856 RETROVIR100.00 MG

00173010793 RETROVIR IV INFUSION10.000 MG/ML

51817007102 RHINARIS.000

51817007202 RHINARIS.000

51817007205 RHINARIS.000

00186107008 RHINOCORT AQUA32.000 MCG/ACT

50242005121 RITUXAN10.000 MG/ML

50242005306 RITUXAN10.000 MG/ML

08290020013 ROBB INFUSION SYRINGE 100.000

00031862155 ROBITUSSIN COUGH DROPS10.000 MG

00031862252 ROBITUSSIN COUGH DROPS7.400 MG

00031862255 ROBITUSSIN COUGH DROPS7.400 MG

00031862352 ROBITUSSIN COUGH DROPS7.400 MG

00031861851 ROBITUSSIN COUGHDROPS10.000 MG

00031861951 ROBITUSSIN COUGHDROPS10.000 MG

00031862552 ROBITUSSIN LIQUID CENTER10.000 %

00031862652 ROBITUSSIN LIQUID CENTER10.000 MG

00031862752 ROBITUSSIN LIQUID CENTER8.000 MG

00031860346 ROBITUSSIN NIGHT-TIME COL.000

00031860352 ROBITUSSIN NIGHT-TIME COL.000

00031867901 ROBITUSSIN PEDIATRIC.000

00004196201 ROCEPHIN250.00 MG

00004196202 ROCEPHIN250.00 MG

00004196301 ROCEPHIN500.00 MG

00004196302 ROCEPHIN500.00 MG

00004196401 ROCEPHIN1.000 GM

00004196402 ROCEPHIN1.000 GM

00004196404 ROCEPHIN1.000 GM

00004196405 ROCEPHIN1.000 GM

00004196501 ROCEPHIN2.000 GM

00004196505 ROCEPHIN2.000 GM

00004197101 ROCEPHIN10.000 GM

00004196502 ROCEPHIN2.000 GM

00004200278 ROCEPHIN IN ISO-OSMOTIC D.000

00004200378 ROCEPHIN IN ISO-OSMOTIC D.000

00004201507 ROFERON-A3.000 MU/0.5ML

00004201509 ROFERON-A3.000 MU/0.5ML

00004201607 ROFERON-A6.000 MU/0.5ML

00004201609 ROFERON-A6.000 MU/0.5ML

00004201707 ROFERON-A9.000 MU/0.5ML

00004201709 ROFERON-A9.000 MU/0.5ML

00004691106 ROMAZICON.100 MG/ML

00004691206 ROMAZICON.100 MG/ML

00032192482 ROWASA4.000 GM

00054878424 ROXICET.000

00054368663 ROXICET.000

00054478425 ROXICET.000

00054864816 ROXICET.000

00256016001 RUM-K15.000 %

00372004804 S-T FORTE 2.000

00372004808 S-T FORTE 2.000

00372004816 S-T FORTE 2.000

00372004828 S-T FORTE 2.000

51552035604 SACCHARIN.000

00074479203 SADDLE BLOCK-22 LIDOCAINE.000

00074479220 SADDLE BLOCK-22 LIDOCAINE.000

00074479503 SADDLE BLOCK-25 LIDOCAINE.000

00074479520 SADDLE BLOCK-25 LIDOCAINE.000

00074479521 SADDLE BLOCK-25 LIDOCAINE.000

00074474503 SADDLE BLOCK-26.000

00074474520 SADDLE BLOCK-26 TETRACAIN.000

58063070510 SALAGEN5.000 MG

51552005304 SALICYLIC ACID.000

08290002290 SANA-LOK CONTROL SYRINGE.000

08290002292 SANA-LOK CONTROL SYRINGE.000

08290002507 SANA-LOK CONTROL SYRINGE.000

00078011022 SANDIMMUNE100.00 MG/ML

00078018325 SANDOSTATIN.200 MG/ML

00078018425 SANDOSTATIN1.000 MG/ML

00078034084 SANDOSTATIN LAR DEPOT10.000 MG

00078034184 SANDOSTATIN LAR DEPOT20.000 MG

00078034284 SANDOSTATIN LAR DEPOT30.000 MG

00904522599 SCALP AID3.000 %

60267030100 SCOPACE.400 MG

51552044401 SCOPOLAMINE HBR.000

00372004304 SCOT-TUSSIN DIABETES CF10.000 MG/5ML

00372004316 SCOT-TUSSIN DIABETES CF10.000 MG/5ML

00372004328 SCOT-TUSSIN DIABETES CF10.000 MG/5ML

00372004420 SCOT-TUSSIN DM COUGH CHAS2.500 MG

53100086150 SCOTT'S EMULSION.000

53100086152 SCOTT'S EMULSION.000

53100086156 SCOTT'S EMULSION.000

53100086160 SCOTT'S EMULSION.000

00085060005 SEBIZON10.000 %

00072480004 SEBUCARE1.800 %

53014040410 SEMPREX-D.000

51079085820 SENNA CONCENTRATE217.00 MG

00034110020 SENOKOT326.00 MG/TSP

00034110060 SENOKOT326.00 MG/TSP

00034110084 SENOKOT326.00 MG/TSP

00034120112 SENOKOT XTRA374.00 MG

00034120163 SENOKOT XTRA374.00 MG

51479001901 SEROMYCIN250.00 MG

00310027110 SEROQUEL100.00 MG

00310027139 SEROQUEL100.00 MG

00310027210 SEROQUEL200.00 MG

00310027239 SEROQUEL200.00 MG

00310027439 SEROQUEL300.00 MG

00310027460 SEROQUEL300.00 MG

00310027510 SEROQUEL25.000 MG

00310027539 SEROQUEL25.000 MG

00093961413 SILVER NITRATE.500 %

51552011904 SIMETHICONE.000

00904345960 SIMPLET.000

00078033184 SIMULECT20.000 MG

00074198601 SINGLE-SHOT EPIDURAL TRAY.000

00074198620 SINGLE-SHOT EPIDURAL TRAY.000

00083012417 SLOW FE/FOLIC ACID.000

51552033799 SODIUM ASCORBATE.000

49502064015 SODIUM CHLORIDE DEY-PAK3.000 %

49502064115 SODIUM CHLORIDE DEY-PAK10.000 %

51552026304 SODIUM LAURYL SULFATE.000

60267007910 SODIUM NITRITE30.000 MG/ML

51552010504 SODIUM PERBORATE.000

51552050116 SODIUM PROPIONATE.000

00009079601 SOLU-MEDROL2.000 GM

00008092581 SONATA5.000 MG

00008092681 SONATA10.000 MG

51552044104 SORBIC ACID.000

Page 120 of 125

Page 121: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00074798108 SORBITOL-MANNITOL.000

00074614406 SORBITOL-MANNITOL.000

00074614436 SORBITOL-MANNITOL.000

08290005160 SPINAL INTRODUCER 20GX1-1.000

08290405174 SPINAL NEEDLE 18GX3.000

08290405184 SPINAL NEEDLE 18GX3-1/2.000

08290405173 SPINAL NEEDLE 19GX3.000

08290005173 SPINAL NEEDLE 19GX3.000

08290005183 SPINAL NEEDLE 19GX3-1/2.000

08290405183 SPINAL NEEDLE 19GX3-1/2.000

08290405162 SPINAL NEEDLE 20GX1-1/2.000

08290405071 SPINAL NEEDLE 20GX2-1/2.000

08290005071 SPINAL NEEDLE 20GX2-1/2.000

08290005172 SPINAL NEEDLE 20GX3.000

08290405172 SPINAL NEEDLE 20GX3.000

08290405182 SPINAL NEEDLE 20GX3-1/2.000

08290405211 SPINAL NEEDLE 20GX6.000

08290005211 SPINAL NEEDLE 20GX6.000

08290405074 SPINAL NEEDLE 22GX2-1/2.000

08290405171 SPINAL NEEDLE 22GX3.000

08290405181 SPINAL NEEDLE 22GX3-1/2.000

08290405148 SPINAL NEEDLE 22GX5.000

08290405149 SPINAL NEEDLE 22GX7.000

08290005149 SPINAL NEEDLE 22GX7.000

08290400106 SPINAL NEEDLE 23GX3-1/2.000

08290405170 SPINAL NEEDLE 25GX3.000

08290405180 SPINAL NEEDLE 25GX3-1/2.000

08290405234 SPINAL NEEDLE 25GX4-11/16.000

08290405164 SPINAL NEEDLE 26GX3-1/2.000

08290405081 SPINAL NEEDLE 27GX3-1/2.000

08290405235 SPINAL NEEDLE 27GX4-11/16.000

08290405236 SPINAL NEEDLE 29GX3-1/2.000

08290405237 SPINAL NEEDLE 29GX4-11/16.000

08290405078 SPINAL NEEDLE NEONATAL LU.000

08290405070 SPINAL NEEDLE THIN-WALL 1.000

08290409444 SPINAL NEEDLE THIN-WALL 1.000

08290005070 SPINAL NEEDLE THIN-WALL 1.000

08290001293 SPINAL NEEDLE WITH FITTED.000

08290001295 SPINAL NEEDLE WITH FITTED.000

08290001296 SPINAL NEEDLE WITH FITTED.000

08290001310 SPINAL NEEDLE WITH FITTED.000

00074371620 SPINAL-22 BUPIVACAINE/DEX.000

00074122420 SPINAL-22 BUPIVACAINE/DEX.000

00074477303 SPINAL-22 TETRACAINE/DEX/.000

00074478803 SPINAL-22 TETRACAINE/DEX/.000

00074478820 SPINAL-22 TETRACAINE/DEXT.000

00074477320 SPINAL-22 TETRACAINE/DEXT.000

00074477321 SPINAL-22 TETRACAINE/DEXT.000

00074473320 SPINAL-22 TETRACAINE/DEXT.000

00074480420 SPINAL-22 WHITACRE LIDO/D.000

00074480403 SPINAL-22 WHITACRE LIDOCA.000

00074371720 SPINAL-25 BUPIVACAINE/DEX.000

00074122503 SPINAL-25 BUPIVACAINE/DEX.000

00074122520 SPINAL-25 BUPIVACAINE/DEX.000

00074371703 SPINAL-25 QUINCKE BUPIVAC.000

00074479003 SPINAL-25 QUINCKE TETRACA.000

00074477403 SPINAL-25 QUINCKE TETRACA.000

00074477420 SPINAL-25 TETRACAINE/DEXT.000

00074477421 SPINAL-25 TETRACAINE/DEXT.000

00074479002 SPINAL-25 TETRACAINE/DEXT.000

00074479020 SPINAL-25 TETRACAINE/DEXT.000

00074473520 SPINAL-25 TETRACAINE/DEXT.000

00074309903 SPINAL-26 BUPIVACAINE/DEX.000

00074309920 SPINAL-26 BUPIVACAINE/DEX.000

00074479620 SPINAL-26 TETRACAINE/DEXT.000

00074480520 SPINAL-WHITACRE TETRACAIN.000

51552071201 SQUARIC ACID DI-N-BUTYL E.000

00173051800 STERILE DILUENT FOR FLOLA.000

00026813120 STILPHOSTROL50.000 MG/ML

00053245300 STIMATE1.500 MG/ML

08290015150 STIMEX INSULATED NEEDLE T.000

08290404204 STIMEX INSULATED NEEDLE T.000

08290404246 STIMEX INSULATED NEEDLE T.000

60267091160 STOMAX400.00 MG

00006003220 STROMECTOL3.000 MG

00006013910 STROMECTOL6.000 MG

00642020316 STROVITE FORTE.000

53100001100 SUCRETS 4-HOUR COUGH DROP15.000 MG

53100001120 SUCRETS 4-HOUR COUGH DROP15.000 MG

00081087582 SUDAFED.000

62794010150 SULFAMYLON85.000 MG/GM

62794010151 SULFAMYLON85.000 MG/GM

62794010154 SULFAMYLON85.000 MG/GM

62794011117 SULFAMYLON50.000 GM

62794011198 SULFAMYLON50.000 GM

51552041904 SULFURATED POTASH.000

00083019377 SUNKIST VITAMIN C60.000 MG

54092063875 SUPPRELIN500.00 MCG/ML

54092063975 SUPPRELIN1000.0 MCG/ML

00074104004 SURVANTA INTRATRACHEAL.000

00074104008 SURVANTA INTRATRACHEAL.000

00574030716 SUSPENDOL-S.000

00056047030 SUSTIVA50.000 MG

00056047330 SUSTIVA100.00 MG

00056047492 SUSTIVA200.00 MG

08290001317 SYMPATHETIC NERVE NEEDLE.000

08290001318 SYMPATHETIC NERVE NEEDLE.000

08290001320 SYMPATHETIC NERVE NEEDLE.000

00025016608 SYNAREL2.000 MG/ML

00008914901 SYNVISC8.000 MG/ML

00006066168 SYPRINE250.00 MG

00173045701 T.R.U.E. TEST.000

00766501512 TAGAMET200.00 MG/20ML

00074192010 TALWIN30.000 MG/ML

00074194101 TALWIN30.000 MG/ML

00074194111 TALWIN30.000 MG/ML

00074204202 TALWIN30.000 MG/ML

00004080085 TAMIFLU75.000 MG

51552012704 TANNIC ACID.000

51552026804 TARTARIC ACID.000

00075800120 TAXOTERE20.000 MG/0.5ML

00075800180 TAXOTERE80.000 MG/2ML

00007508804 TAZICEF.000

00007508904 TAZICEF.000

00182708264 TEARGEN II.400 %

00083006030 TEGRETOL-XR400.00 MG

00083006130 TEGRETOL-XR100.00 MG

00083006230 TEGRETOL-XR200.00 MG

00085124401 TEMODAR20.000 MG

00085124402 TEMODAR20.000 MG

00085125901 TEMODAR100.00 MG

00085125902 TEMODAR100.00 MG

00085124801 TEMODAR5.000 MG

00085125201 TEMODAR250.00 MG

00085125202 TEMODAR250.00 MG

00085124802 TEMODAR5.000 MG

19810000228 TEMPRA QUICKLETS80.000 MG

00015111750 TEQUIN200.00 MG

00015111780 TEQUIN200.00 MG

00015117760 TEQUIN400.00 MG

00015117780 TEQUIN400.00 MG

00015117980 TEQUIN10.000 MG/ML

Page 121 of 125

Page 122: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

51552031904 TERPIN HYDRATE.000

00003069050 TESLAC50.000 MG

00008034101 TETANUS/DIPHTHERIA TOXOID.000

00008034102 TETANUS/DIPHTHERIA TOXOID.000

00074159304 THAM30.000 MEQ/100

00074766209 THEOPHYLLINE/D5W.000

00043047906 THERAFLU FLU & COLD SORE.000

99207010302 THERAPLEX T1.000 %

58790000032 THERATEARS.250 %

00007507103 THORAZINE100.00 MG

00026060330 THROMBATE III W/20 ML STE1000.0 IU

52604710201 THROMBIN-JMI DILUENT5000.0 U

52604710601 THROMBIN-JMI DILUENT50000. U

52604710503 THROMBIN-JMI DILUENT20000. U

52604735502 THROMBIN-JMI SYRINGE SPRA20000. U

52604710502 THROMBIN-JMI W/DIL SPRAY20000. U

62053053425 THYMOGLOBULIN25.000 MG

58468184904 THYROGEN1.100 MG

00029655226 TICAR3.000 GM

00074655207 TICAR3.000 GM

00052060202 TICE BCG50.000 MG

00052060302 TICE BCG50.000 MG

00029657126 TIMENTIN.000

00029657131 TIMENTIN.000

00029657140 TIMENTIN.000

00029657921 TIMENTIN.000

50242003861 TNKASE50.000 MG

00065064705 TOBRADEX.000

00065064710 TOBRADEX.000

00065064725 TOBRADEX.000

00065064835 TOBRADEX.000

00074346913 TOBRAMYCIN SULFATE/SODIUM.000

00074347023 TOBRAMYCIN SULFATE/SODIUM.000

00065064435 TOBREX.300 %

00004692006 TORADOL15.000 MG/ML

00004692206 TORADOL30.000 MG/ML

00074459210 TRACE METALS ADDITIVE FTV.000

00074459250 TRACE METALS ADDITIVE FTV.000

00074400801 TRACE METALS ADDITIVE PTV.000

51552035204 TRAGACANTH.000

00074269913 TRANXENE-SD11.250 MG

00026819636 TRASYLOL10000. KIU/ML

00026819763 TRASYLOL10000. KIU/ML

00008413001 TRECATOR-SC250.00 MG

00451505015 TRI-NASAL50.000 MCG/SPR

52544027428 TRI-NORINYL 28.000

51552027801 TRIAMCINOLONE DIACETATE M.000

00043020218 TRIAMINIC.000

99207020901 TRIAZ3.000 %

99207011609 TRIAZ CLEANSER6.000 %

99207011612 TRIAZ CLEANSER6.000 %

99207020609 TRIAZ CLEANSER3.000 %

99207020612 TRIAZ CLEANSER3.000 %

51552004904 TRICHLOROACETIC ACID.000

00091080105 TRICHOTINE POWDER VAGINAL.000

00091080112 TRICHOTINE POWDER VAGINAL.000

00078033605 TRILEPTAL150.00 MG

00078033606 TRILEPTAL150.00 MG

00078033705 TRILEPTAL300.00 MG

00078033706 TRILEPTAL300.00 MG

00078033805 TRILEPTAL600.00 MG

00078033806 TRILEPTAL600.00 MG

00085070304 TRINALIN REPETABS.000

00173069100 TRIZIVIR.000

00009056601 TROBICIN W/DILUENT2.000 GM

00766739260 TUMS PLUS.000

08290405018 TUOHY EPIDURAL NEEDLE THI.000

08290405025 TUOHY EPIDURAL NEEDLE THI.000

08290405028 TUOHY EPIDURAL NEEDLE THI.000

08290405092 TUOHY EPIDURAL NEEDLE THI.000

61570001101 TUSSEND.000

53014054867 TUSSIONEX PENNKINETIC EXT.000

00372001704 TUSSIREX.000

00372001708 TUSSIREX.000

00372001716 TUSSIREX.000

00372001728 TUSSIREX.000

00372001804 TUSSIREX.000

00372001808 TUSSIREX.000

00372001816 TUSSIREX.000

00372001828 TUSSIREX.000

00087408541 TYR 1.000

00087408641 TYR 2.000

00087008241 TYROS 2.000

00482476015 TYZINE.100 %

00482476030 TYZINE.100 %

00482477015 TYZINE PEDIATRIC NASAL DR.050 %

00087407041 UCD 1.000

00087407141 UCD 2.000

00074445602 ULTANE.000

00074449803 ULTIVA1.000 MG

00074450405 ULTIVA2.000 MG

00575402008 ULTRA MIDE 2525.000 %

00998041215 ULTRA TEARS1.000 %

00072140015 ULTRAVATE.050 %

00072140050 ULTRAVATE.050 %

00072145015 ULTRAVATE.050 %

00072145050 ULTRAVATE.050 %

50419034005 ULTRAVIST31.000 %

50419034205 ULTRAVIST50.000 %

50419034210 ULTRAVIST50.000 %

50419034220 ULTRAVIST50.000 %

50419034405 ULTRAVIST62.000 %

50419034410 ULTRAVIST62.000 %

50419034415 ULTRAVIST62.000 %

50419034605 ULTRAVIST77.000 %

50419034610 ULTRAVIST77.000 %

50419034615 ULTRAVIST77.000 %

50419034620 ULTRAVIST77.000 %

00049003183 UNASYN ADD-VANTAGE.000

00049003283 UNASYN ADD-VANTAGE.000

00049002283 UNASYN PIGGYBACK UNIT.000

00049002383 UNASYN PIGGYBACK UNIT.000

00076010903 URO-KP-NEUTRAL.000

00076050103 UROLENE BLUE65.000 MG

00486111401 UROQID #2.000

00004003822 VALCYTE450.00 MG

00173093356 VALTREX500.00 MG

00002312542 VANCOCIN HCL125.00 MG

00002312642 VANCOCIN HCL250.00 MG

00072150030 VANIQA13.900 %

00009353101 VANTIN50.000 MG/5ML

00009353103 VANTIN50.000 MG/5ML

00009361501 VANTIN100.00 MG/5ML

00009361503 VANTIN100.00 MG/5ML

00009361701 VANTIN100.00 MG

00009361702 VANTIN100.00 MG

00009361801 VANTIN200.00 MG

00009361802 VANTIN200.00 MG

00006484400 VAQTA50.000 U/ML

00006484438 VAQTA50.000 U/ML

00006484500 VAQTA25.000 U/0.5ML

00006484538 VAQTA25.000 U/0.5ML

Page 122 of 125

Page 123: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

00006483100 VAQTA25.000 U/0.5ML

00006483138 VAQTA25.000 U/0.5ML

00006484100 VAQTA50.000 U/ML

00006484138 VAQTA50.000 U/ML

00006482600 VARIVAX1350.0 PFU/0.5M

00006482700 VARIVAX1350.0 PFU/0.5M

58768089015 VASOCLEAR.020 %

58768089515 VASOCLEAR A.000

00004025001 VESANOID10.000 MG

00003092020 VESPRIN20.000 MG/ML

00026971101 VIADUR120.00 MCG/24H

00069420030 VIAGRA25.000 MG

00069421030 VIAGRA50.000 MG

00069421066 VIAGRA50.000 MG

00069422030 VIAGRA100.00 MG

00069422066 VIAGRA100.00 MG

00069097065 VIBRAMYCIN25.000 MG/5ML

00087661443 VIDEX100.00 MG

00087663241 VIDEX2.000 GM

00087663341 VIDEX4.000 GM

00087665001 VIDEX25.000 MG

00087665101 VIDEX50.000 MG

00087665201 VIDEX100.00 MG

00087665301 VIDEX150.00 MG

00087666515 VIDEX200.00 MG

00087667117 VIDEX EC125.00 MG

00087667217 VIDEX EC200.00 MG

00087667317 VIDEX EC250.00 MG

00087667417 VIDEX EC400.00 MG

00065012316 VISION CARE ENZYMATIC CLE.000

00069544093 VISTARIL25.000 MG/5ML

00069544097 VISTARIL25.000 MG/5ML

58768015015 VISUDYNE15.000 MG

00904762960 VITAMIN A 7500 IU FISH7500.0 IU

60258016716 VITONIC.000

58768090235 VITRAVENE6.600 MG/ML

00015307519 VUMON.000

00015307597 VUMON.000

08290405093 WEISS EPIDURAL NEEDLE THI.000

08290405094 WEISS EPIDURAL NEEDLE THI.000

08290405091 WEISS EPIDURAL NEEDLE THI.000

08290405026 WEISS EPIDURAL NEEDLE THI.000

08290405024 WEISS EPIDURAL NEEDLE THI.000

08290405017 WEISS EPIDURAL NEEDLE THI.000

08290405516 WEISS EPIDURAL NEEDLE THI.000

08290405517 WEISS EPIDURAL NEEDLE THI.000

08290405023 WEISS EPIDURAL NEEDLE TUO.000

00173013555 WELLBUTRIN SR150.00 MG

08290405010 WHITACRE PENCIL POINT SPI.000

08290405012 WHITACRE PENCIL POINT SPI.000

08290405145 WHITACRE PENCIL POINT SPI.000

08290405146 WHITACRE PENCIL POINT SPI.000

08290405079 WHITACRE PENCIL POINT SPI.000

08290409442 WHITACRE PENCIL POINT SPI.000

08290409443 WHITACRE PENCIL POINT SPI.000

08290001336 WHITACRE SPINAL NEEDLE 22.000

00003037405 WOUND MANAGER STERILE DRA.000

00003037406 WOUND MANAGER STERILE DRA.000

00003037407 WOUND MANAGER STERILE DRA.000

00034999700 X-PREP187.00 MG

00575101504 X-SEB T PLUS.000

00004025652 XENICAL120.00 MG

00186021203 XYLOCAINE.000

08290305124 YALE NEEDLE/REGULAR BEVEL.000

08290001252 YALE NEEDLES.000

08290001256 YALE NEEDLES.000

08290001258 YALE NEEDLES.000

08290001108 YALE NEEDLES.000

08290001110 YALE NEEDLES.000

08290001015 YALE NEEDLES.000

08290001017 YALE NEEDLES.000

08290001000 YALE NEEDLES.000

08290001001 YALE NEEDLES.000

08290001002 YALE NEEDLES.000

08290001005 YALE NEEDLES.000

08290001011 YALE NEEDLES.000

08290001012 YALE NEEDLES.000

08290001013 YALE NEEDLES.000

08290305122 YALE NEEDLES.000

08290305129 YALE NEEDLES.000

08290305175 YALE NEEDLES.000

08290001021 YALE NEEDLES.000

08290001022 YALE NEEDLES.000

08290001023 YALE NEEDLES.000

08290001025 YALE NEEDLES.000

08290001027 YALE NEEDLES.000

08290001028 YALE NEEDLES.000

08290001032 YALE NEEDLES.000

08290001034 YALE NEEDLES.000

08290001035 YALE NEEDLES.000

08290001037 YALE NEEDLES.000

08290001042 YALE NEEDLES.000

08290001045 YALE NEEDLES.000

08290001047 YALE NEEDLES.000

08290001048 YALE NEEDLES.000

08290001055 YALE NEEDLES.000

08290001057 YALE NEEDLES.000

08290001058 YALE NEEDLES.000

08290001059 YALE NEEDLES.000

08290001065 YALE NEEDLES.000

08290001067 YALE NEEDLES.000

08290001075 YALE NEEDLES.000

08290001077 YALE NEEDLES.000

08290001078 YALE NEEDLES.000

08290001087 YALE NEEDLES.000

08290001089 YALE NEEDLES.000

08290001095 YALE NEEDLES.000

08290001097 YALE NEEDLES.000

08290001098 YALE NEEDLES.000

08290001100 YALE NEEDLES.000

08290001101 YALE NEEDLES.000

08290305198 YALE NEEDLES 16G X 1-1/2.000

08290305178 YALE NEEDLES 20G X 1.000

08290305111 YALE NEEDLES 26G X 1/2.000

08290001211 YALE NEEDLES/HUBER BEVEL.000

08290001014 YALE REUSABLE NEEDLE 26G.000

08290001019 YALE REUSABLE NEEDLE INTR.000

08290001109 YALE REUSABLE NEEDLE SHOR.000

08290001103 YALE REUSABLE NEEDLE SHOR.000

08290001104 YALE REUSABLE NEEDLE SHOR.000

08290001106 YALE REUSABLE NEEDLE SHOR.000

08290001107 YALE REUSABLE NEEDLE SHOR.000

08290002300 YALE REUSABLE SYRINGE GLA.000

08290002301 YALE REUSABLE SYRINGE GLA.000

08290002302 YALE REUSABLE SYRINGE GLA.000

08290002303 YALE REUSABLE SYRINGE GLA.000

08290002304 YALE REUSABLE SYRINGE GLA.000

08290002305 YALE REUSABLE SYRINGE GLA.000

08290002306 YALE REUSABLE SYRINGE GLA.000

08290002310 YALE REUSABLE SYRINGE LUE.000

08290002311 YALE REUSABLE SYRINGE LUE.000

08290002312 YALE REUSABLE SYRINGE LUE.000

Page 123 of 125

Page 124: Low Cost Drugs for the Elderly or Disabled Benefit ... · Low Cost Drugs for the Elderly or Disabled Benefit Catastrophic Cap "Qualifying" NDC numbers. Alpha listing by drug name

NDCNAME

STR UOM NDC NAMESTR

UOM

08290002313 YALE REUSABLE SYRINGE LUE.000

08290002314 YALE REUSABLE SYRINGE LUE.000

08290002315 YALE REUSABLE SYRINGE LUE.000

08290002316 YALE REUSABLE SYRINGE LUE.000

08290002317 YALE REUSABLE SYRINGE LUE.000

08290001114 YALE SPINAL NEEDLE QUINCK.000

08290001120 YALE SPINAL NEEDLE QUINCK.000

08290001135 YALE SPINAL NEEDLE QUINCK.000

08290001136 YALE SPINAL NEEDLE QUINCK.000

08290001137 YALE SPINAL NEEDLE QUINCK.000

08290001138 YALE SPINAL NEEDLE QUINCK.000

08290001139 YALE SPINAL NEEDLE QUINCK.000

08290001140 YALE SPINAL NEEDLE QUINCK.000

08290001141 YALE SPINAL NEEDLE QUINCK.000

08290001142 YALE SPINAL NEEDLE QUINCK.000

08290001143 YALE SPINAL NEEDLE QUINCK.000

08290001147 YALE SPINAL NEEDLE QUINCK.000

08290001148 YALE SPINAL NEEDLE QUINCK.000

08290001150 YALE SPINAL NEEDLE QUINCK.000

08290001316 YALE SPINAL NEEDLE QUINCK.000

08290002019 YALE TUBERCULIN SYRINGE G.000

08290002001 YALE TUBERCULIN SYRINGE G.000

08290002002 YALE TUBERCULIN SYRINGE G.000

58768010205 ZADITOR.025 %

62794001111 ZAGAM200.00 MG

62794001155 ZAGAM200.00 MG

00173036238 ZANTAC25.000 MG/ML

00173036300 ZANTAC25.000 MG/ML

00173036301 ZANTAC25.000 MG/ML

00173038354 ZANTAC75.000 MG/5ML

00173042702 ZANTAC150.00 MG

00173045101 ZANTAC150.00 MG

00173044100 ZANTAC.000

00074165801 ZEMPLAR5.000 MCG/ML

00074165802 ZEMPLAR5.000 MCG/ML

00052045015 ZEMURON10.000 MG/ML

00052045016 ZEMURON10.000 MG/ML

00004050109 ZENAPAX25.000 MG/5ML

00003196401 ZERIT15.000 MG

00003196501 ZERIT20.000 MG

00003196601 ZERIT30.000 MG

00003196701 ZERIT40.000 MG

00003196801 ZERIT1.000 MG/ML

00173066400 ZIAGEN20.000 MG/ML

00173066100 ZIAGEN300.00 MG

00173066101 ZIAGEN300.00 MG

00173042400 ZINACEF.000

00173042500 ZINACEF.000

00904319560 ZINC GLUCONATE78.000 MG

00904319572 ZINC GLUCONATE78.000 MG

51552050004 ZINC STEARATE.000

00013871562 ZINECARD250.00 MG

00013872589 ZINECARD500.00 MG

00069306086 ZITHROMAX250.00 MG

00069308030 ZITHROMAX600.00 MG

00069311019 ZITHROMAX100.00 MG/5ML

00069312019 ZITHROMAX200.00 MG/5ML

00069313019 ZITHROMAX200.00 MG/5ML

00069314019 ZITHROMAX200.00 MG/5ML

00069315083 ZITHROMAX500.00 MG

00069305107 ZITHROMAX1.000 GM

00069305175 ZITHROMAX1.000 GM

00069306030 ZITHROMAX250.00 MG

00069306075 ZITHROMAX Z-PAK250.00 MG

00173044200 ZOFRAN2.000 MG/ML

00173044202 ZOFRAN2.000 MG/ML

00173044600 ZOFRAN4.000 MG

00173044602 ZOFRAN4.000 MG

00173044604 ZOFRAN4.000 MG

00173044700 ZOFRAN8.000 MG

00173044702 ZOFRAN8.000 MG

00173044704 ZOFRAN8.000 MG

00173048900 ZOFRAN4.000 MG/5ML

00173046100 ZOFRAN32.000 MG/50ML

00173068000 ZOFRAN24.000 MG

00173056900 ZOFRAN ODT4.000 MG

00173057000 ZOFRAN ODT8.000 MG

00173057004 ZOFRAN ODT8.000 MG

00049490041 ZOLOFT50.000 MG

00049490066 ZOLOFT50.000 MG

00049490073 ZOLOFT50.000 MG

00049491041 ZOLOFT100.00 MG

00049491066 ZOLOFT100.00 MG

00049491073 ZOLOFT100.00 MG

00049494023 ZOLOFT20.000 MG/ML

00049496050 ZOLOFT25.000 MG

00310021020 ZOMIG2.500 MG

00310021125 ZOMIG5.000 MG

00310020920 ZOMIG ZMT2.500 MG

59075068010 ZONEGRAN100.00 MG

00206845216 ZOSYN.000

00206845217 ZOSYN.000

00206845417 ZOSYN.000

00206845455 ZOSYN.000

00206845517 ZOSYN.000

00206845525 ZOSYN.000

00206862011 ZOSYN.000

00206882002 ZOSYN.000

00206882102 ZOSYN.000

00206882202 ZOSYN.000

00173055601 ZYBAN150.00 MG

00173055602 ZYBAN150.00 MG

00002411204 ZYPREXA2.500 MG

00002411233 ZYPREXA2.500 MG

00002411260 ZYPREXA2.500 MG

00002411504 ZYPREXA5.000 MG

00002411533 ZYPREXA5.000 MG

00002411560 ZYPREXA5.000 MG

00002411633 ZYPREXA7.500 MG

00002411660 ZYPREXA7.500 MG

00002411704 ZYPREXA10.000 MG

00002411733 ZYPREXA10.000 MG

00002411760 ZYPREXA10.000 MG

00002441533 ZYPREXA15.000 MG

00002441560 ZYPREXA15.000 MG

00002442033 ZYPREXA20.000 MG

00002442060 ZYPREXA20.000 MG

00002445385 ZYPREXA ZYDIS5.000 MG

00002445485 ZYPREXA ZYDIS10.000 MG

00069550066 ZYRTEC5.000 MG

00069551066 ZYRTEC10.000 MG

00069553047 ZYRTEC5.000 MG/5ML

00069553093 ZYRTEC5.000 MG/5ML

00009513502 ZYVOX600.00 MG

00009513503 ZYVOX600.00 MG

00009513601 ZYVOX100.00 MG/5ML

00009513701 ZYVOX2.000 MG/ML

00009514001 ZYVOX2.000 MG/ML

Page 124 of 125

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NDCNAME

STR UOM NDC NAMESTR

UOM

Page 125 of 125