Transition (Carve-Out) of the Pharmacy Benefit from Managed Care (MC) to Fee-For-Service (FFS)
- List is also available in Portable Document Format (PDF)
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 |
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