DIN/PIN/NPN Detail
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
LU Criteria Text
Botox
(BOTULINUM TOXIN TYPE A)
50U/Vial Pd Inj-50U Vial Pk
DIN/PIN/NPN:
02531577
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Interchangeables:
NO
Manufacturer:
AbbVie Corporation
Formulary Listing Date:
2023-06-30
Drug Benefit Price or Unit Price:
187.4300
Amount MOH Pays:
187.4300
Coverage Status:
Limited Use Product
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