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Products found: 37

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DIN/ PIN/ NPN	Generic Name	Brand Name, Strength & Dosage Form	MFR	Drug Benefit Price or Unit Price	Amount MOH Pays	Inter- change- able	Limited Use	Thera- peutic Notes
02413647	BACLOFEN	Baclofen Intrathecal (Off-Formulary Interchangeable) 2mg/mL Inj Sol (Preservative-Free)	STE	35.4500	35.4500	YES	NO	YES
02413620	BACLOFEN	Baclofen Injection (Off-Formulary Interchangeable) 0.05mg/mL Inj Sol-1mL Pk (Preservative-Free)	STE	11.2500	11.2500	YES	NO	YES
02413639	BACLOFEN	Baclofen Intrathecal (Off-Formulary Interchangeable) 0.5mg/mL Inj Sol-20mL Pk (Preservative-Free)	STE	177.2500	177.2500	YES	NO	YES
02399334	CALCITRIOL	Calcitriol Injection USP (Off-Formulary Interchangeable) 1mcg/mL Inj Sol Amp-1mL Pk	STE	9.5132	9.5132	YES	NO	NO
02437120	CEFAZOLIN SODIUM	Cefazolin for Injection (Off-Formulary Interchangeable) 10g/Vial Inj Pd-Vial Pk	STE	56.0000	56.0000	YES	NO	NO
02437112	CEFAZOLIN SODIUM	Cefazolin for Injection (Off-Formulary Interchangeable) 1g/Vial Inj Pd-Vial Pk	STE	6.0000	6.0000	YES	NO	NO
02437104	CEFAZOLIN SODIUM	Cefazolin for Injection (Off-Formulary Interchangeable) 500mg/Vial Inj Pd-Vial Pk	STE	4.0000	4.0000	YES	NO	NO
02465469	CEFAZOLIN SODIUM	Cefazolin for Injection USP (Off-Formulary Interchangeable) 1g/Vial Inj Pd-Vial Pk	STE	6.0000	6.0000	YES	NO	NO
02465477	CEFAZOLIN SODIUM	Cefazolin for Injection USP (Off-Formulary Interchangeable) 10g/Vial Inj Pd-Vial Pk	STE	56.0000	56.0000	YES	NO	NO
02325624	CEFTRIAXONE DISODIUM	Ceftriaxone Sodium For Injection BP 2g/Vial Inj Pd-1 Vial Pk	STE	34.4850	34.4850	YES	NO	NO
02325632	CEFTRIAXONE DISODIUM	Ceftriaxone Sodium For Injection BP (Off-Formulary Interchangeable) 10g/Vial Inj Pd-1 Vial Pk	STE	214.2000	214.2000	YES	NO	NO
02325616	CEFTRIAXONE DISODIUM	Ceftriaxone Sodium For Injection BP 1g/Vial Inj Pd-1 Vial Pk	STE	12.4950	12.4950	YES	NO	NO
02325594	CEFTRIAXONE DISODIUM	Ceftriaxone Sodium For Injection BP 0.25g/Vial Inj Pd-1 Vial Pk	STE	5.6430	5.6430	YES	NO	NO
01987003	CYANOCOBALAMIN	Cyanocobalamin 1mg/mL Inj Sol-10mL Pk	STE	3.0600	3.0600	YES	NO	NO
01977547	DEXAMETHASONE 21-PHOSPHATE	Dexamethasone Sodium 4mg/mL Inj Sol	STE	1.6900	1.6900	YES	NO	NO
02434571	DICLOFENAC SODIUM	Diclofenac Topical Solution (Off-Formulary Interchangeable) 1.5% W/W Top Sol	STE	0.6226	N/A	YES	NO	NO
02475391	GANCICLOVIR SODIUM	Ganciclovir for Injection USP (Temporary Benefit) 500mg/Vial Pd for Sol-10mL Vial Pk	STE	44.5480	44.5480	NO	NO	NO
02473879	GLYCOPYRROLATE	Glycopyrrolate Injection USP 0.2mg/mL Inj Sol	STE	2.7825	2.7825	YES	YES	NO
02473895	GLYCOPYRROLATE	Glycopyrrolate Injection USP 0.4mg/2mL Inj Sol (Preservative Free)	STE	2.7825	2.7825	YES	YES	NO
02473887	GLYCOPYRROLATE	Glycopyrrolate Injection USP 4mg/20mL Inj Sol (With Preservative)	STE	2.7825	2.7825	YES	YES	NO
00723754	HYDRALAZINE HCL	Apresoline 20mg/mL Inj Sol-1mL Vial Pk	STE	11.6500	8.7375	YES	NO	NO
00005533	HYDRALAZINE HCL	Apresoline (Not a Benefit) 25mg Tab	STE	N/A	N/A	YES	NO	NO
02400871	KETOTIFEN	Ketotifen Ophthalmic Solution (Off-Formulary Interchangeable) 0.25mg/mL Oph Sol-5mL Pk	STE	21.1700	N/A	YES	NO	NO
02415275	MERCAPTOPURINE	Mercaptopurine Tablets USP 50mg Tab	STE	2.8610	2.8610	YES	NO	YES
02493349	MEROPENEM	Meropenem for Injection (Off-Formulary Interchangeable) 1g/Vial Pd for Inj Sol	STE	47.9900	47.9900	YES	NO	NO
02493330	MEROPENEM	Meropenem for Injection (Off-Formulary Interchangeable) 500mg/Vial Pd for Inj Sol	STE	23.9950	23.9950	YES	NO	NO
02464578	ONDANSETRON HCL DIHYDRATE	Ondansetron Injection USP (Off-Formulary Interchangeable) 2mg/mL Inj Sol-2mL Pk	STE	13.2180	N/A	YES	NO	NO
09857602	ONDANSETRON HCL DIHYDRATE	Ondansetron Injection USP (Off-Formulary Interchangeable) 2mg/mL Inj Sol-4mL Pk	STE	26.4360	N/A	YES	NO	NO
02362619	PIPERACILLIN SODIUM & TAZOBACTAM SODIUM	Piperacillin & Tazobactam for Injection (Off-Formulary Interchangeable) 2g & 250mg Inj Pd-2.25g Vial Pk	STE	10.1300	10.1300	YES	NO	NO
02362627	PIPERACILLIN SODIUM & TAZOBACTAM SODIUM	Piperacillin & Tazobactam for Injection (Off-Formulary Interchangeable) 3g & 375mg Inj Pd-3.375g Vial Pk	STE	15.2000	15.2000	YES	NO	NO
02362635	PIPERACILLIN SODIUM & TAZOBACTAM SODIUM	Piperacillin & Tazobactam for Injection (Off-Formulary Interchangeable) 4g & 500mg Inj Pd-4.5g Vial Pk	STE	20.2700	20.2700	YES	NO	NO
09858283	PRAZOSIN HCL	Prazosin Hydrochloride Capsules, USP (Temporary Benefit) 5mg Cap	STE	0.5121	0.5121	NO	NO	NO
09858282	PRAZOSIN HCL	Prazosin Hydrochloride Capsules, USP (Temporary Benefit) 2mg Cap	STE	0.3725	0.3725	NO	NO	NO
09858281	PRAZOSIN HCL	Prazosin Hydrochloride Capsules, USP (Temporary Benefit) 1mg Cap	STE	0.2743	0.2743	NO	NO	NO
02410338	TETRABENAZINE	Tetrabenazine Tablets (Off-Formulary Interchangeable) 25mg Tab	STE	4.8551	4.8551	YES	NO	NO
02502372	TOBRAMYCIN SULFATE	Tobramycin Injection USP 80mg/2mL Inj Sol-2mL Pk	STE	3.1500	3.1500	YES	NO	YES
02401231	TRANEXAMIC ACID	Tranexamic Acid Tablets (Off-Formulary Interchangeable) 500mg Tab	STE	0.8071	0.8071	YES	NO	NO

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