Subject: Updated and Revised Federal Upper Limits List
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- Amber Robertson
- 5 years ago
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1 P R O V I D E R B U L L E T I N BT MAY 24, 2002 To: All Pharmacy Providers Subject: Note: The information in this bulletin is not directed to those providers rendering services in the riskbased managed care (RBMC) delivery system. Overview The information provided in this bulletin contains the newly developed list of federal upper limits (FUL) for multiple source drugs that meet the criteria set forth in 42 CFR and 1927(e) of the Social Security Act, as amended by OBRA This information is in addition to the recently updated State maximum allowable cost (MAC) rates. The new rates in Table 1.1 are in effect May 11, 2002, and will apply to pharmacy claims submitted with service dates of May 11, 2002, and later. Please incorporate the list into the appropriate section in Chapter 9 of the Indiana Health Coverage Programs Provider Manual. This listing has priority over, and replaces any prior FUL listing. If there are any questions about the FUL list or the text of this bulletin, please contact the EDS Pharmacy Services Point of Service (POS)/ Prospective Drug Utilization Review (ProDUR) Help desk at EDS 1
2 Acebutolol Hydrochloride Eq 200 mg base, Capsule, Oral, /26/01 Eq 400 mg base, Capsule, Oral, /07/00 Acetaminophen; Codeine Phosphate 300mg; 15mg, Tablet, Oral, /22/02 300mg; 30mg, Tablet, Oral, /13/01 300mg; 60mg, Tablet, Oral, /13/01 Acetaminophen; Hydrocodone Bitartrate 500mg; 5mg, Capsule, Oral, /07/00 500mg; 5mg, Tablet, Oral, /26/01 500mg; 7.5mg, Tablet, Oral, /26/01 500mg; 10mg, Tablet, Oral, /26/01 500mg/15ml; 7.5 mg/15ml, Elixir, Oral, /26/01 650mg; 7.5mg, Tablet, Oral, /26/01 650mg; 10mg, Tablet, Oral, /26/01 660mg; 10mg, Tablet, Oral, /26/01 750mg; 7.5mg, Tablet, Oral, /22/02 Acetaminophen; Oxycodone Hydrochloride 325mg; 5mg, Tablet, Oral, /26/01 500mg; 5mg, Capsule, Oral, /26/01 Acetaminophen; Propoxyphene Hydrochloride 650mg; 65mg, Tablet, Oral, /7/00 Acetaminophen; Propoxyphene Napsylate 650mg; 100mg, Tablet, Oral, /26/01 Acetazolamide 250mg; Tablet, Oral, /26/01 Acetylcysteine 10%, Solution, Inhalation, 10ml /26/01 20%, Solution, Inhalation, 10ml /26/01 Acyclovir 200mg, Capsule, Oral, /26/01 400mg, Tablet, Oral, /26/01 800mg, Tablet, Oral, /22/02 EDS 2
3 Albuterol Sulfate Eq 0.083% base, Solution, Inhalation, 3ml /22/02 Eq 0.5% base, Solution, Inhalation, 20ml /26/01 Eq 2mg base, Tablet, Oral, /5/02 Eq 4mg base, Tablet, Oral, /5/02 Allopurinol 100mg, Tablet, Oral, /5/02 300mg, Tablet, Oral, /26/01 Alprazolam 0.25mg, Tablet, Oral, /26/ mg, Tablet, Oral, /26/01 1mg, Tablet, Oral, /26/01 2mg, Tablet, Oral, /26/01 Amantadine Hydrochloride 100mg, Capsule, Oral, /07/00 50mg/5ml Syrup, Oral, 480ml /26/01 Amiloride Hydrochloride ; Hydrochlorothiazide Eq 5mg Anhydrous; 50mg, Tablet, Oral, /26/01 Aminophylline 100mg, Tablet, Oral, /07/00 200mg, Tablet, Oral, /07/00 Amiodarone Hydrochloride 200mg, Tablet, Oral, /26/01 Amitriptyline Hydrochloride 10mg, Tablet, Oral, /5/02 25mg, Tablet, Oral, /22/02 50mg, Tablet, Oral, /13/01 75mg, Tablet, Oral, /26/01 100mg, Tablet, Oral, /26/01 150mg, Tablet, Oral, /26/01 Amitriptyline Hydrochloride; Perphenazine 10mg; 2mg, Tablet, Oral, /26/01 25mg; 2mg, Tablet, Oral, /26/01 Amoxapine 50mg, Tablet, Oral, /22/02 EDS 3
4 Amoxicillin 250mg, Capsule, Oral, /07/00 500mg, Capsule, Oral, /22/02 125mg/5ml, Powder for Reconstitution, Oral, 150ml /5/02 250mg, Tablet, Chewable, Oral, /22/02 Ampicillin/Ampicillin Trihydrate 250mg, Capsule, Oral, /26/01 500mg, Capsule, Oral, /26/01 Aspirin; Carisoprodol 325mg; 200mg, Tablet, Oral, /26/01 Atenolol 25mg, Tablet, Oral, /22/02 50mg, Tablet, Oral, /22/02 100mg, Tablet, Oral, /5/02 Atenolol; Chlorthalidone 50mg; 25mg, Tablet, Oral, /26/01 100mg; 25mg, Tablet, Oral, /26/01 Atropine Sulfate; Diphenoxylate Hydrochloride 0.025mg; 2.5mg, Tablet, Oral, /07/00 Baclofen 10mg, Tablet, Oral, /26/01 20mg, Tablet, Oral, /26/01 Benzonate 100mg, Capsule, Oral, /26/01 Benztropine Mesylate 0.5mg, Tablet, Oral, /5/02 1mg, Tablet, Oral, /5/02 2mg, Tablet, Oral, /5/02 Betamethasone Dipropionate Eq 0.05% base, Cream, Topical, 15gm /26/01 Eq 0.05% base, Lotion, Topical, 60ml /26/01 Betamethasone Valerate Eq 0.1% base, Cream, Topical, 45gm /26/01 Eq 0.1% base, Lotion, Topical, 60ml /26/01 EDS 4
5 Bisoprolol Fumarate; Hydrochlorothiazide 2.5mg; 6.25mg, Tablet, Oral, /26/01 5mg; 6.25mg, Tablet, Oral, /26/01 10mg; 6.25mg, Tablet, Oral, /26/01 Bumetanide 0.5mg, Tablet, Oral, /22/02 1mg, Tablet, Oral, /26/01 2mg, Tablet, Oral, /07/00 Captopril 12.5mg, Tablet, Oral, /26/01 25mg, Tablet, Oral, /26/01 50mg, Tablet, Oral, /26/01 100mg, Tablet, Oral, /26/01 Captopril; Hydrochlorothiazide 25mg; 15mg, Tablet, Oral, /22/02 50mg; 25mg, Tablet, Oral, /22/02 Carbamazepine 200mg, Tablet, Oral, /26/01 Carbidopa; Levodopa 10mg; 100mg, Tablet, Oral, /26/01 25mg; 100mg, Tablet, Oral, /02/01 25mg; 250mg, Tablet, Oral, /02/01 Carisoprodol 350mg, Tablet, Oral, /07/00 Carteolol Hydrochloride 1%, Solution/Drops, Ophthalmic, /26/01 Cefaclor Eq 250mg base, Capsule, Oral, /26/01 Eq 500mg base, Capsule, Oral, /26/01 Eq 125mg base/5ml, Powder for Reconstitution, Oral, 150ml /26/01 Eq 187mg base/5ml, Powder for Reconstitution, Oral, 100ml /26/01 Eq 250mg base/5ml, Powder for Reconstitution, Oral, 150ml /26/01 Eq 375mg base/5ml, Powder for Reconstitution, Oral, 100ml /26/01 Cefadroxil/Cefadroxil Hemihydrate Eq 500mg base, Capsule, Oral, /26/01 EDS 5
6 Cephalexin Eq 250mg base, Capsule, Oral, /11/02 Eq 500mg base, Capsule, Oral, /11/02 Chlordiazepoxide Hydrochloride 5mg, Capsule, Oral, /26/01 10mg, Capsule, Oral, /26/01 Chlorhexidine Gluconate 0.12%, Solution, Dental, 480ml /26/01 Chlorpheniramine Maleate 4mg, Tablet, Oral, /26/01 Chlorpropamide 100mg, Tablet, Oral, /26/01 250mg, Tablet, Oral, /26/01 Chlorthalidone 25mg, Tablet, Oral, /26/01 50mg, Tablet, Oral, /22/02 Chlorzoxazone 500mg, Tablet, Oral, /26/01 Cholestyramine Eq 4gm Resin/Packet, Powder, Oral, /26/01 Cimetidine 200mg, Tablet, Oral, /07/00 300mg, Tablet, Oral, /22/02 400mg, Tablet, Oral, /22/02 800mg, Tablet, Oral, /22/02 Cimetidine Hydrochloride Eq 300mg base/5ml, Solution, Oral, 240ml /5/02 Clindamycin Hydrochloride Eq 150mg base, Capsule, Oral, /26/01 Clindamycin Phosphate Eq 1% base, Solution, Topical, 60ml /22/02 Clobetasol Propionate 0.05%, Cream, Topical, /26/01 EDS 6
7 Clomipramine Hydrochloride 25mg, Capsule, Oral, /26/01 50mg, Capsule, Oral, /22/02 75mg, Capsule, Oral, /26/01 Clonazepam 0.5mg, Tablet, Oral, /26/01 1mg, Tablet, Oral, /26/01 2mg, Tablet, Oral, /26/01 Clonidine Hydrochloride 0.1mg, Tablet, Oral, /07/00 0.2mg, Tablet, Oral, /07/00 0.3mg, Tablet, Oral, /07/00 Clorazepate Dipotassium 3.75mg, Tablet, Oral, /26/01 7.5mg, Tablet, Oral, /07/00 15mg, Tablet, Oral, /26/01 Codeine Phosphate; Promethazine Hydrochloride 10mg/5ml; 6.25mg/5ml; Syrup, Oral, 480ml /11/02 Cromolyn Sodium 4% Solution/Drops, Opthalmic, 10ml /26/01 Cyclobenzaprine Hydrochloride 10mg, Tablet, Oral, /26/01 Desipramine Hydrochloride 10mg, Tablet, Oral, /26/01 25mg, Tablet, Oral, /07/00 50mg, Tablet, Oral, /07/00 75mg, Tablet, Oral, /07/00 100mg, Tablet, Oral, /26/01 Desonide 0.05%, Ointment, Topical, 60gm /07/00 Desoximetasone 0.25%, Cream, Topical, 60 gm /11/02 Dexamethasone 0.5mg/5ml, Elixir, Oral, 240 ml /22/02 EDS 7
8 Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate 0.1%; Eq 3.5mg base/gm; 10,000 units/gm, Ointment, Opthalmic, 3.5 gm /07/00 Diazepam 2mg, Tablet, Oral, /22/02 5mg, Tablet, Oral, /26/01 10mg, Tablet, Oral, /26/01 Diclofenac Potassium 50mg, Tablet, Oral, /26/01 Diclofenac Sodium 50mg, Tablet, Delayed Release, Oral, /07/00 75mg, Tablet, Delayed Release, Oral, /26/01 Dicyclomine Hydrochloride 10mg, Capsule, Oral, /26/01 20mg, Tablet, Oral, /26/01 Diflunisal 500mg, Tablet, Oral, /26/01 Diltiazem Hydrochloride 30mg, Tablet, Oral, /26/01 60mg, Tablet, Oral, /26/01 90mg, Tablet, Oral, /26/01 120mg, Tablet, Oral, /26/01 Diphenhydramine Hydrochloride 12.5mg/5ml, Elixir, Oral, /26/01 Dipivefrin Hydrochloride 0.1%, Solution/Drops, Ophthalmic, 5ml /07/00 Doxazosin Mesylate 1mg, Tablet, Oral, /26/01 2mg, Tablet, Oral, /26/01 4mg, Tablet, Oral, /26/01 8mg, Tablet, Oral, /26/01 EDS 8
9 Doxepin Hydrochloride Eq 10mg base, Capsule, Oral, /26/01 Eq 25mg base, Capsule, Oral, /26/01 Eq 50mg base, Capsule, Oral /26/01 Eq 75mg base, Capsule, Oral, /26/01 Eq 100mg base, Capsule, Oral, /26/01 Eq 10mg base/ml, Concentrate, Oral, 120ml /26/01 Doxycycline Hyclate Eq 50mg base, Capsule, Oral, /22/02 Eq 100mg base, Capsule, Oral, /07/00 Eq 100mg base, Tablet, Oral, /26/01 Erythromycin 250mg, Capsule, Delayed Release Pellets, Oral, /26/01 2%, Solution, Topical, 60ml /26/01 Estazolam 1mg, Tablet, Oral, /26/01 2mg, Tablet, Oral, /26/01 Estradiol 0.5mg, Tablet, Oral, /26/01 1mg, Tablet, Oral, /26/01 2mg, Tablet, Oral, /07/00 Estropipate 0.75mg, Tablet, Oral, /26/01 1.5mg, Tablet, Oral, /26/01 3mg, Tablet, Oral, /26/01 Etodolac 200mg, Capsule, Oral, /22/02 400mg, Tablet, Oral, /07/00 500mg, Tablet, Oral, /07/00 Famotidine 20mg, Tablet, Oral, /22/02 40mg, Tablet, Oral, /22/02 Fenoprofen Calcium Eq 600mg base, Tablet, Oral, /26/01 EDS 9
10 Fluocinolone Acetonide 0.01%, Solution, Topical, 60ml /26/01 Fluocinonide 0.05%, Cream, Topical, 60gm /22/ %, Gel, Topical, /26/ %, Solution, Topical, 60ml /26/01 Fluorometholone 0.1%, Suspension/Drops, Ophthalmic, 5ml /07/00 Fluphenazine Hydrochloride 1mg, Tablet, Oral, /26/01 2.5mg, Tablet, Oral, /07/00 5mg, Tablet, Oral, /26/01 10mg, Tablet, Oral, /26/01 Flurazepam Hydrochloride 15mg, Capsule, Oral, /26/01 30mg, Capsule, Oral, /26/01 Flurbiprofen 100mg, Tablet, Oral, /22/02 Flurbiprofen Sodium 0.03%, Solution/Drops, Ophthalmic, /26/01 Folic Acid 1mg, Tablet, Oral, /26/01 Furosemide 10mg/ml, Solution, Oral, 60ml /07/00 20mg, Tablet, Oral, /5/02 40mg, Tablet, Oral, /5/02 80mg, Tablet, Oral, /22/02 Gemfibrozil 600mg, Tablet, Oral, /26/01 Gentamicin Sulfate Eq 0.3% Base, Solution/Drops, Ophthalmic, 5ml /26/01 Glipizide 5mg, Tablet, Oral, /22/02 10mg, Tablet, Oral, /26/01 EDS 10
11 Glyburide 1.5mg, Tablet, Oral, /26/01 3mg, Tablet, Oral, /26/01 Gramicidin; Neomycin Sulfate; Polymixin B Sulfate 0.025mg/ml; Eq 1.75mg base/ml; 10,000 Units/ml, Solution/Drops, Ophthalmic, 10ml /13/01 Guanfacine Hydrochloride Eq 1mg base, Tablet, Oral, /07/00 Eq 2mg base, Tablet, Oral, /07/00 Haloperidol Lactate Eq 2mg base/ml, Concentrate, Oral, 120 ml /07/00 Homatropine Methylbromide; Hydrocodone Bitartrate 1.5mg/5ml; 5mg/5ml, Syrup, Oral, 480ml /22/02 Hydralazine Hydrochloride 10mg, Tablet, Oral, /22/02 25mg, Tablet, Oral, /07/00 Hydrochlorothiazide; Propranolol Hydrochloride 25mg; 40mg, Tablet, Oral, /07/00 25mg; 80mg, Tablet, Oral, /26/01 Hydrochlorothiazide; Spironolactone 25mg; 25mg; Tablet, Oral, /26/01 Hydrochlorothiazide; Triamterene 25mg; 37.5mg, Capsule, Oral, /26/01 25mg; 50mg, Tablet, Oral, /26/01 50mg; 75mg, Tablet, Oral, /26/01 Hydrocortisone 0.5%, Cream, Topical, 30gm /26/01 1%, Cream, Topical, 30gm /26/01 2.5%, Cream, Topical, 30gm /07/00 1%, Lotion, Topical, 120ml /26/01 2.5%, Lotion, Topical, 59ml /22/02 1%, Ointment, Topical, 30gm /26/01 Hydroxychloroquine Sulfate 200mg, Tablet, Oral, /26/01 Hydroxyurea 500mg, Capsule, Oral, /22/02 EDS 11
12 Hydroxyzine Hydrochloride 10mg/5ml, Syrup, Oral, 480ml /22/02 10mg, Tablet, Oral, /22/02 25mg, Tablet, Oral, /22/02 50mg, Tablet, Oral, /26/01 Hydroxyzine Pamoate Eq 25mg HCl, Capsule, Oral, /26/01 Eq 50mg HCl, Capsule, Oral, /26/01 Eq 100mg HCl, Capsule, Oral, /26/01 Ibuprofen 400mg, Tablet, Oral, /26/01 600mg, Tablet, Oral, /26/01 800mg, Tablet, Oral, /22/02 Imipramine Hydrochloride 10mg, Tablet, Oral, /26/01 25mg, Tablet, Oral, /26/01 50mg, Tablet, Oral, /26/01 Indapamide 1.25mg, Tablet, Oral, /22/02 2.5mg, Tablet, Oral, /26/01 Isoniazid 300mg, Tablet, Oral, /26/01 Isosorbide Dinitrate 5mg, Tablet, Oral, /26/01 2.5mg, Tablet, Sublingual, /26/01 10mg, Tablet, Oral, /26/01 20mg, Tablet, Oral, /22/02 Isosorbide Mononitrate 10mg, Tablet, Oral, /07/00 20mg, Tablet, Oral /5/02 60mg, Tablet, Extended Release, Oral, /26/01 Ketoconazole 200mg, Tablet, Oral, /22/02 EDS 12
13 Ketoprofen 50mg, Capsule, Oral, /26/01 75mg, Capsule, Oral, /26/01 Ketorolac Tromethamine 10mg, Tablet, Oral, /26/01 Labetalol Hydrochloride 100mg, Tablet, Oral, /26/01 200mg, Tablet, Oral, /26/01 300mg, Tablet, Oral, /26/01 Lactulose 10gm/15ml, Solution, Oral, 480ml /07/00 Levobunolol Hydrochloride 0.25%, Solution/Drops, Ophthalmic, 10ml /07/00 0.5%, Solution/Drops, Ophthalmic, 10ml /26/01 Lidocaine Hydrochloride 2%, Solution, Oral, 100ml /07/00 Lorazepam 0.5mg, Tablet, Oral, /07/00 1mg, Tablet, Oral, /07/00 2mg, Tablet, Oral, /26/01 Meclizine Hydrochloride 12.5mg, Tablet, Oral, /22/02 25mg, Tablet, Oral, /22/02 Medroxyprogesterone Acetate 2.5mg, Tablet, Oral, /26/01 5mg, Tablet, Oral, /22/02 10mg, Tablet, Oral, /26/01 Megestrol Acetate 20mg, Tablet, Oral, /26/01 40mg, Tablet, Oral, /26/01 Meperidine Hydrochloride 50mg, Table, Oral, /26/01 100mg, Table, Oral, /26/01 EDS 13
14 Methazolamide 25mg, Tablet, Oral, /26/01 50mg, Tablet, Oral, /26/01 Methenamine Mandelate 1gm, Tablet, Oral, /5/02 Methocarbamol 500mg, Tablet, Oral, /22/02 750mg, Tablet, Oral, /22/02 Methotrexate Sodium Eq 2.5mg base, Tablet, Oral, /07/00 Methylphenidate Hydrochloride 5mg, Tablet, Oral, /07/00 10mg, Tablet, Oral, /07/00 20mg, Tablet, Oral, /07/00 Methylprednisolone 4mg, Tablet, Oral, /26/01 Metoclopramide 10mg, Tablet, Oral, /11/02 Metoclopramide Hydrochloride Eq 5mg base/5ml, Solution, Oral, 480ml /07/00 Eq 5mg base, Tablet, Oral, /26/01 Eq 10mg base, Tablet, Oral, /26/01 Metoprolol Tartrate 50mg, Tablet, Oral, /22/02 100mg, Tablet, Oral, /22/02 Metronidazole 250mg, Tablet, Oral, /26/01 500mg, Tablet, Oral, /11/02 Mexiletine Hydrochloride 200mg, Capsule, Oral, /22/02 Minocycline Hydrochloride Eq 50mg base, Capsule, Oral, /26/01 Eq 100mg base, Capsule, Oral, /07/00 EDS 14
15 Minoxidil 2.5mg, Tablet, Oral, /07/00 10mg, Tablet, Oral, /26/01 Nadolol 20mg, Tablet, Oral, /22/02 40mg, Tablet, Oral, /26/01 80mg, Tablet, Oral, /07/00 Naltrexone Hydrochloride 50mg, Tablet, Oral, /26/01 Naphazoline Hydrochloride 0.1%, Solution/Drops, Ophthalmic, 15ml /07/00 Naproxen 250mg, Tablet, Oral, /22/02 375mg, Tablet, Oral, /22/02 500mg, Tablet, Oral, /5/02 375mg, Tablet, Delayed Release, Oral, /26/01 Niacin 500mg, Tablet, Oral, /07/00 Nicardipine Hydrochloride 20mg, Capsule, Oral, /26/01 30mg, Capsule, Oral, /07/00 Nifedipine 10mg, Capsule, Oral, /26/01 Nortriptyline Hydrochloride Eq 10mg base, Capsule, Oral, /26/01 Eq 25mg base, Capsule, Oral, /26/01 Eq 50mg base, Capsule, Oral, /26/01 Eq 75mg base, Capsule, Oral, /22/02 Nystatin 100,000 units/gm, Cream, Topical, 30gm /26/01 100,000 units/ml, Suspension, Oral, 60ml /22/02 100,000 units/gm, Ointment, Topical, 15gm /07/00 Nystatin; Triamcinolone Acetonide 100,000 units/gm; 0.1%, Cream, Topical, 30gm /26/01 100,000 units/gm; 0.1%, Ointment, Topical, 30gm /07/00 EDS 15
16 Orphenadrine Citrate 100mg, Tablet, Extended Release, Oral, /26/01 Oxazepam 10mg, Capsule, Oral, /22/02 15mg, Capsule, Oral, /22/02 30mg, Capsule, Oral, /26/01 Oxybutynin Chloride 5mg, Tablet, Oral, /26/01 Penicillin V Potassium Eq 250mg base/5ml, Powder for Reconstitution, Oral, 200ml /26/01 Pentoxifylline 400mg Tablet, Extended Release, Oral, /22/02 Perphenazine 2mg, Tablet, Oral, /22/02 4mg, Tablet, Oral, /22/02 16mg, Tablet, Oral, /26/01 Pindolol 5mg, Tablet, Oral, /26/01 10mg, Tablet, Oral, /26/01 Piroxicam 10mg, Capsule, Oral, /26/01 20mg, Capsule, Oral, /26/01 Polymixin B Sulfate; Trimethoprim Sulfate 10,000 Units/ml; Eq 1mg base/ml, Solution/Drops, Ophthalmic, 10ml /07/00 Potassium Chloride 8meq, Tablet, Extended Release, Oral, /26/01 Prednisolone 15mg/5ml, Syrup, Oral, 480ml /26/01 Prednisolone Acetate 1%, Suspension/Drops, Ophthalmic, 10ml /26/01 Prednisone 5mg, Tablet, Oral, /26/01 10mg, Tablet, Oral, /26/01 20mg, Tablet, Oral, /26/01 EDS 16
17 Primidone 250mg, Tablet, Oral, /5/02 Probenecid 500mg, Tablet, Oral, /26/01 Prochlorperazine Maleate Eq 5mg base, Tablet, Oral, /07/00 Eq 10mg base, Tablet, Oral, /07/00 Promethazine Hydrochloride 6.25mg/5ml, Syrup, Oral, 120ml /26/01 Propranolol Hydrochloride 10mg, Tablet, Oral, /26/01 20mg, Tablet, Oral, /22/02 40mg, Tablet, Oral, /22/02 80mg, Tablet, Oral, /22/02 Pseudoephedrine Hydrochloride; Triprolidine Hydrochloride 60mg; 2.5mg, Tablet, Oral, /26/01 Quinidine Gluconate 324mg, Tablet, Extended Release, Oral, /11/02 Ranitidine Hydrochloride Eq 150mg base, Tablet, Oral, /26/01 Eq 300mg base, Tablet, Oral, /26/01 Selegiline Hydrochloride 5mg, Tablet, Oral, /26/01 Selenium Sulfide 2.5%, Lotion/Shampoo, Topical, 120ml /26/01 Spironolactone 25mg, Tablet, Oral, /11/02 Sucralfate 1gm, Tablet, Oral, /07/00 Sulfacetamide Sodium 10%, Solution/Drops, Ophthalmic, 15ml /22/02 Sulfamethoxazole; Trimethoprim 200mg/5ml; 40mg/5ml, Suspension, Oral, 480ml /26/01 400mg; 80mg, Tablet, Oral, /07/00 800mg; 160mg, Tablet Oral, /26/01 EDS 17
18 Sulfasalazine 500mg, Tablet, Oral, /26/01 Sulindac 150mg, Tablet, Oral, /26/01 200mg, Tablet, Oral, /26/01 Temazepam 15mg, Capsule, Oral, /26/01 30mg, Capsule, Oral, /07/00 Terazosin Hydrochloride Eq 1mg base, Capsule, Oral, /26/01 Eq 2mg base, Capsule, Oral, /26/01 Eq 5mg base, Capsule, Oral, /26/01 Eq 10mg base, Capsule, Oral, /26/01 Tetracycline Hydrochloride 500mg, Capsule, Oral, /26/01 Theophylline 100mg, Tablet, Extended Release, Oral, /22/02 200mg, Tablet, Extended Release, Oral, /26/01 300mg, Tablet, Extended Release, Oral, /26/01 Thioridazine Hydrochloride 10mg, Tablet, Oral, /26/01 25mg, Tablet, Oral, /26/01 50mg, Tablet, Oral, /2/02 100mg, Tablet, Oral, /26/01 Thiothixene 1mg, Capsule, Oral, /26/01 2mg, Capsule, Oral, /26/01 5mg, Capsule, Oral, /26/01 10mg, Capsule, Oral, /22/02 Ticlopidine Hydrochloride 250mg, Tablet, Oral, /26/01 Timolol Maleate Eq 0.25% base, Solution/Drops, Ophthalmic, 10ml /26/01 Eq 0.5% base, Solution/Drops, Ophthalmic, 15ml /26/01 EDS 18
19 Tobramycin 0.3%, Solution/Drops, Ophthalmic, 5ml /26/01 Tolazamide 250mg, Tablet, Oral, /26/01 Trazodone Hydrochloride 50mg, Tablet, Oral, /22/02 100mg, Tablet, Oral, /07/00 150mg, Tablet, Oral, /26/01 Triamcinolone Acetonide 0.025%, Cream, Topical, 80gm /26/01 0.1%, Cream, Topical, 80gm /22/02 0.5%, Cream, Topical, /07/00 0.1%, Lotion, Topical, 60ml /07/00 0.1%, Ointment, Topical, 80gm /07/00 0.1%, Paste, Dental, 5gm /26/01 Triazolam 0.125mg, Tablet, Oral, /26/01 Trifluoperazine Hydrochloride Eq 1mg base, Tablet, Oral, /07/00 Eq 2mg base, Tablet, Oral, /07/00 Eq 5mg base, Tablet, Oral, /07/00 Eq 10mg base, Tablet, Oral, /26/01 Trihexyphenidyl Hydrochloride 2mg, Tablet, Oral, /26/01 5mg, Tablet, Oral, /26/01 Tropicamide 0.5%, Solution/Drops, Ophthalmic, 15ml /07/00 1%, Solution/Drops, Ophthalmic, 15ml /07/00 Valproic Acid 250mg, Capsule, Oral, /26/01 250mg/5ml, Syrup, Oral, 480ml /26/01 EDS 19
20 Verapamil Hydrochloride 120mg, Capsule, Extended Release, Oral, /07/00 180mg, Capsule, Extended Release, Oral, /07/00 240mg, Capsule, Extended Release, Oral, /07/00 40mg, Tablet, Oral, /26/01 80mg, Tablet, Oral, /26/01 120mg, Tablet, Oral, /26/01 180mg, Tablet, Extended Release, Oral, /26/01 240mg, Tablet, Extended Release, Oral, /13/01 CDT-3/2000 (including procedure codes, definitions (descriptions) and other data) is copyrighted by the American Dental Association American Dental Association. All rights reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) Apply. CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply. EDS 20
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