Transition (Carve-Out) of the Pharmacy Benefit from Managed Care (MC) to Fee-For-Service (FFS)

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Updated February 3, 2021

NDC DRUG_LBL_NAME
00023114501 BOTOX 100 UNIT VIAL
00023392102 BOTOX 200 UNIT VIAL
00023608201 INFED 100 MG/2 ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00069005903 HEPARIN SOD 5,000 UNIT/ML VIAL
00143985625 CEFTRIAXONE 2 GM VIAL
00143985725 CEFTRIAXONE 1 GM VIAL
00143985725 CEFTRIAXONE 1 GM VIAL
00143985725 CEFTRIAXONE 1 GM VIAL
00173088101 NUCALA 100 MG VIAL
00264570510 HEPARIN SOD 5,000 UNIT/0.5 ML
00264570510 HEPARIN SOD 5,000 UNIT/0.5 ML
00310173030 FASENRA 30 MG/ML SYRINGE
00409128331 HYDROMORPHONE 1 MG/ML CARPUJC
00409141210 BUMETANIDE 2.5 MG/10 ML VIAL
00409427602 LIDOCAINE HCL 1% VIAL
00409427602 LIDOCAINE HCL 1% VIAL
00409427602 LIDOCAINE HCL 1% VIAL
00409677902 LORAZEPAM 4 MG/ML VIAL
00517300525 WATER FOR INJECTION VIAL
00548902100 KETOROLAC 30 MG/ML VIAL
00641602225 FAMOTIDINE 20 MG/2 ML VIAL
00641602225 FAMOTIDINE 20 MG/2 ML VIAL
00641602225 FAMOTIDINE 20 MG/2 ML VIAL
00641602225 FAMOTIDINE 20 MG/2 ML VIAL
00641602225 FAMOTIDINE 20 MG/2 ML VIAL
00641602225 FAMOTIDINE 20 MG/2 ML VIAL
00641602225 FAMOTIDINE 20 MG/2 ML VIAL
00641602225 FAMOTIDINE 20 MG/2 ML VIAL
00641604125 KETOROLAC 15 MG/ML VIAL
00641620410 HEPARIN SOD 5,000 UNIT/0.5 ML
00641620410 HEPARIN SOD 5,000 UNIT/0.5 ML
00641620410 HEPARIN SOD 5,000 UNIT/0.5 ML
00703701101 HALOPERIDOL DEC 50 MG/ML VIAL
00703701101 HALOPERIDOL DEC 50 MG/ML VIAL
00703701101 HALOPERIDOL DEC 50 MG/ML VIAL
00703701101 HALOPERIDOL DEC 50 MG/ML VIAL
00703701101 HALOPERIDOL DEC 50 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703702101 HALOPERIDOL DEC 100 MG/ML VIAL
00703712301 HALOPERIDOL DEC 250 MG/5 ML VL
00703712301 HALOPERIDOL DEC 250 MG/5 ML VL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00703713301 HALOPERIDOL DEC 100 MG/ML VIAL
00990799009 STERILE WATER FOR INJECTION
13925051510 PENTAMIDINE 300 MG VIAL
24338015020 TRIPTODUR 22.5 MG KIT
36000000124 METRONIDAZOLE 500 MG/100 ML
36000004624 LEVOFLOXACIN 250 MG/50 ML-D5W
36000004724 LEVOFLOXACIN 500 MG/100 ML-D5W
36000028225 FUROSEMIDE 20 MG/2 ML VIAL
36000028225 FUROSEMIDE 20 MG/2 ML VIAL
36000028325 FUROSEMIDE 40 MG/4 ML VIAL
36000028325 FUROSEMIDE 40 MG/4 ML VIAL
36000029624 LEVOFLOXACIN 750 MG/150 ML-D5W
39822110001 FOLIC ACID 50 MG/10 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
42023011001 DELESTROGEN 50 MG/5 ML VIAL
43547054325 GLYCOPYRROLATE 0.2 MG/ML VIAL
49401008847 BENLYSTA 200 MG/ML SYRINGE
49401010101 BENLYSTA 120 MG VIAL
49401010201 BENLYSTA 400 MG VIAL
50242004062 XOLAIR 150 MG VIAL
50242021401 XOLAIR 75 MG/0.5 ML SYRINGE
50242021501 XOLAIR 150 MG/ML SYRINGE
55150011310 AMPICILLIN 1 GM VIAL
55150011310 AMPICILLIN 1 GM VIAL
55150016205 LIDOCAINE HCL 1% 50 MG/5 ML VL
55150016205 LIDOCAINE HCL 1% 50 MG/5 ML VL
55513071001 PROLIA 60 MG/ML SYRINGE
55513088001 EVENITY 105 MG/1.17 ML SYRINGE
55513088002 EVENITY 210 MG DOSE-2 SYRINGES
59148001970 ABILIFY MAINTENA ER 400 MG VL
59148001970 ABILIFY MAINTENA ER 400 MG VL
59148002985 ABILIFY MYCITE 2 MG KIT
59310061031 CINQAIR 100 MG/10 ML VIAL
60505619600 ERTAPENEM 1 GRAM VIAL
60505619600 ERTAPENEM 1 GRAM VIAL
60505619604 ERTAPENEM 1 GRAM VIAL
60505619604 ERTAPENEM 1 GRAM VIAL
60505619604 ERTAPENEM 1 GRAM VIAL
60505619604 ERTAPENEM 1 GRAM VIAL
60505619604 ERTAPENEM 1 GRAM VIAL
60505619604 ERTAPENEM 1 GRAM VIAL
60505619604 ERTAPENEM 1 GRAM VIAL
60793013010 PENICILLIN G 600,000 UNIT/1 ML
60793070001 BICILLIN L-A 600,000 UNIT/ML
60793070102 BICILLIN L-A 1,200,000 UNITS
60793070102 BICILLIN L-A 1,200,000 UNITS
60793070204 BICILLIN L-A 2,400,000 UNITS
60793070204 BICILLIN L-A 2,400,000 UNITS
60793070204 BICILLIN L-A 2,400,000 UNITS
60793070204 BICILLIN L-A 2,400,000 UNITS
60793070204 BICILLIN L-A 2,400,000 UNITS
63323016214 KETOROLAC 60 MG/2 ML VIAL
63323018505 WATER FOR INJECTION VIAL
63323018550 WATER FOR INJECTION VIAL
63323018730 SODIUM CHLORIDE 4 MEQ/ML VL
63323018730 SODIUM CHLORIDE 4 MEQ/ML VL
63323018730 SODIUM CHLORIDE 4 MEQ/ML VL
63323018730 SODIUM CHLORIDE 4 MEQ/ML VL
63323018730 SODIUM CHLORIDE 4 MEQ/ML VL
63323018730 SODIUM CHLORIDE 4 MEQ/ML VL
63323025803 METHYLPREDNISOLONE SS 125 MG
63323025803 METHYLPREDNISOLONE SS 125 MG
63323025803 METHYLPREDNISOLONE SS 125 MG
63323025803 METHYLPREDNISOLONE SS 125 MG
63323025803 METHYLPREDNISOLONE SS 125 MG
63323030474 PIPERACIL-TAZOBACT 40.5 GRAM
63323051610 DEXAMETHASONE 100 MG/10 ML VL
63323064810 LEVOTHYROXINE 500 MCG VIAL
63323064907 LEVOTHYROXINE 100 MCG VIAL
63323072910 MICAFUNGIN 100 MG VIAL
63323082301 ERTAPENEM 1 GRAM VIAL
63323082320 ERTAPENEM 1 GRAM VIAL
67457019602 THIAMINE 200 MG/2 ML VIAL
67979000201 SUPPRELIN LA 50 MG KIT
68001033862 VANCOMYCIN 500 MG VIAL
68001033862 VANCOMYCIN 500 MG VIAL
68001033862 VANCOMYCIN 500 MG VIAL
68001040831 ERTAPENEM 1 GRAM VIAL
68001040831 ERTAPENEM 1 GRAM VIAL
68001040831 ERTAPENEM 1 GRAM VIAL
68001040831 ERTAPENEM 1 GRAM VIAL
68001040831 ERTAPENEM 1 GRAM VIAL
68001040831 ERTAPENEM 1 GRAM VIAL
68001040831 ERTAPENEM 1 GRAM VIAL
68001040831 ERTAPENEM 1 GRAM VIAL
68180061110 CEFTRIAXONE 250 MG VIAL
68180062201 CEFTRIAXONE 500 MG VIAL
68180062201 CEFTRIAXONE 500 MG VIAL
68180063301 CEFTRIAXONE 1 GM VIAL
68180063301 CEFTRIAXONE 1 GM VIAL
68180063301 CEFTRIAXONE 1 GM VIAL
68180063310 CEFTRIAXONE 1 GM VIAL
68180063310 CEFTRIAXONE 1 GM VIAL
68180063310 CEFTRIAXONE 1 GM VIAL
68180063310 CEFTRIAXONE 1 GM VIAL
68180064410 CEFTRIAXONE 2 GM VIAL
70069007210 NALOXONE 4 MG/10 ML VIAL
70121165101 TRIAMCINOLONE ACET 40 MG/ML VL
70121165701 TRIAMCINOLONE ACET 40 MG/ML VL
70860010541 VANCOMYCIN 1 GM VIAL
70860012620 PENICILLIN GK 5 MILLION UNIT
70860012620 PENICILLIN GK 5 MILLION UNIT
70860012751 PENICILLIN GK 20 MILLION UNIT
70860012751 PENICILLIN GK 20 MILLION UNIT
70860070141 KETOROLAC 30 MG/ML VIAL
71288000630 AMPICILLIN-SULBACTAM 3 GM VIAL
71288000630 AMPICILLIN-SULBACTAM 3 GM VIAL
71288000630 AMPICILLIN-SULBACTAM 3 GM VIAL
71288000630 AMPICILLIN-SULBACTAM 3 GM VIAL
71288000631 AMPICILLIN-SULBACTAM 3 GM VIAL
71288040301 HEPARIN SOD 5,000 UNIT/ML VIAL
71288040301 HEPARIN SOD 5,000 UNIT/ML VIAL
71773005012 XERAVA 50 MG VIAL
72485010125 DIPHENHYDRAMINE 50 MG/ML VIAL
72485010125 DIPHENHYDRAMINE 50 MG/ML VIAL
72485010125 DIPHENHYDRAMINE 50 MG/ML VIAL
72485010125 DIPHENHYDRAMINE 50 MG/ML VIAL
72611072225 KETOROLAC 30 MG/ML VIAL
72611072225 KETOROLAC 30 MG/ML VIAL
72611072225 KETOROLAC 30 MG/ML VIAL
72611072225 KETOROLAC 30 MG/ML VIAL
72611072225 KETOROLAC 30 MG/ML VIAL
72611072225 KETOROLAC 30 MG/ML VIAL
72611072225 KETOROLAC 30 MG/ML VIAL
72611072525 KETOROLAC 60 MG/2 ML VIAL
76329336901 NALOXONE 2 MG/2 ML SYRINGE
76329336901 NALOXONE 2 MG/2 ML SYRINGE
76329336901 NALOXONE 2 MG/2 ML SYRINGE
76329336901 NALOXONE 2 MG/2 ML SYRINGE
76329336901 NALOXONE 2 MG/2 ML SYRINGE
76329336901 NALOXONE 2 MG/2 ML SYRINGE