25443-000NOV 2 01997
Accountant NOV 2 01997 "L�-.w Z -
t -.D
C.R
Standard Agreement for
AIDS Drug Assistance Program
July 1, 1997 = September 30, 1997
Local Health Jurisdiction
25443
CITY OF LONG BEACH
The State of California by and through the Department of Health Services (hereinafter called the
Department) and the local health jurisdiction of CITY OF LONG BEACH (hereinafter called the local
jurisdiction) in consideration of the covenants, agreements, and stipulations hereinafter expressed
or hereby agree as follows:
Article I
1. The funds allocated pursuant to this Agreement are for the cost of providing any drug
included in the AIDS Drug Assistance Program (ADAP) by the Department. This includes
drugs currently provided by ADAP and any drugs to be included in ADAP in the future. All
ADAP drugs shall be approved for use by the Food & Drug Administration (FDA) for
persons infected with human immunodeficiency virus (HIV), or included by the Department
because of the medical community's acceptance of a drug as a successful therapy used
for the management of HIV disease.
2. For the purposes of this Agreement, drugs currently provided by the ADAP are listed in
Exhibit A, "AIDS Drug Assistance Program, Drugs Currently on Formulary" and
incorporated herein, and made part hereof by this reference.
3. The term of this Agreement is for the period July 1, 1997 through September 30, 1997.
4. The maximum allocation to the local jurisdiction for the term of this Agreement shall not
exceed $249,938. Reimbursement is limited to the actual cost of drugs plus dispensing
fees.
New 5. This allocation is for a 90 -day period to allow for transition from the existing decentralized
ADAP model to a centralized administrative model of operation. It may become necessary
to extend or shorten the funding period and allocation amount based upon the transition
time line currently under development. The local health jurisdictions will receive 30 days
notice of any change to the term of the agreement or maximum allocation amount.
Revised 6. Supplemental invoices submitted by the local jurisdiction for any monthly reporting period
shall be limited to no more than one (1) per reporting period without prior authorization
from OA.
Revised 7. Eligibility criteria for individuals who participate in ADAP is based on the following: A
participant must:
a. Be a person with HIV/AIDS;
91 AIA
C
y
b. Provide a valid prescription for the drug which has been signed by:
(1) A physician licensed to practice medicine in California, or
(2) A physician's assistant or nurse practitioner acting under the supervision of
a California licensed physician or surgeon, as authorized by Section 2836.1
and 3502.1 of the Business and Professions Code);
C. Be at least 18 years of age, with the, exception of minors found to be ineligible for
both California Children Services (CCS) and Medi -Cal who have been approved
participation in ADAP by the Office of AIDS (OA). An "Exception Request"
(Exhibit B) must be submitted to OA for approval either by phone or written
correspondence;
d. Meet established medical criteria set for the use of each drug;
e. Meet the income criteria established by the Department and provide proof that
he/she meets the income criteria; and
f. The individual must not be covered for drugs under Medi -Cal, a third party
insurance company or any other private, state, or federal program or any other
contractual or legal entitlement. The exceptions are:
(1) ADAP funds may be used if the enrollee is covered by Medi -Cal and he/she
is unable to pay the share of cost identified by Medi -Cal. Once the client's
share of cost has been met, all other drug costs must be billed to Medi -Cal.
(2) ADAP funds may be used to pay for drug costs not covered by an enrollee's
insurance (i.e., no prescription coverage, prescription spending limit has
been exhausted, client's share of cost) if the enrollee meets all other
eligibility criteria.
g. Be a resident of California.
Revised 8. Financial criteria include:
a. Individuals whose federal annual adjusted gross income is less than 400 percent
of the federal poverty level guidelines will receive the drug at no cost;
b. Individual whose federal annual adjusted gross income is between 400 percent of
the federal poverty level guidelines and $50,000, will have an ADAP co -payment
obligation that is the lesser of the following:
(1) Two times the participant's annual state income tax liability, less funds
expended by the participant for health insurance premiums; or
(2) The cost of the drugs.
9. Individuals with an ADAP co -payment obligation shall not be required to pay this amount
until such time as the actual prescription costs are incurred. Clients shall not be charged
in advance for this payment obligation.
10. Drugs included on the ADAP formulary are subject to approval by the Director of the
Department.
a. If a different form of any drug on the formulary is needed, an Exception Request
must be submitted to OA for prior approval either by phone or written
correspondence. The medical necessity of the requested drug form must be
provided by the client's attending physician to the local jurisdiction. Exception
approval is given by OA on a client -by -client basis.
b. If a client requests a prescription exceeding the 30 -day supply limit, an
Exception Request must be submitted to OA for prior approval. The medical
necessity or circumstances for the excess medication must be documented by the
local jurisdiction and the client. Exception approval is given by OA on a
per -prescription basis.
Article II
1. The local jurisdiction shall adhere to all state instructions, guidelines or directives pertaining
to:
a. The provision of any drug which has been included in ADAP by the Department;
b. Allocation of funds for the cost of ADAP drugs purchased for distribution to eligible
persons; and,
C. Collection of co -payments from individuals with federal annual adjusted gross
incomes at or above 400 percent of the Federal poverty level.
2. AIDS Drug Assistance Program Guidelines, (October 1994) or any subsequent revisions
shall be adhered to in implementing the AIDS Drug Assistance Program by local
jurisdictions. Any changes and/or additions to these guidelines will be made in writing and
notification of such changes shall be made 30 days prior to implementation.
Revised 3. The local jurisdiction shall verify the enrollee's income on an annual basis. Individuals
applying for eligibility shall provide their last year's Federal tax return, Form 1040, 1040A,
or 1040EZ, "U.S. Individual Income Tax Return", or proof of income current year's
determination of their annual adjusted gross income. If an individual did not file a federal
tax return and his/her income is more that 400 percent of the Federal poverty level, the
individual shall fill out an "AIDS Drug Assistance Program Financial Eligibility and
Co -Payment Worksheet" which will be used to determine eligibility and/or obligation for
payment for drug(s). Exhibit B-3 is incorporated and made a part hereof by this reference.
3
Revised 4.
The local jurisdiction agrees that ADAP funds will be used solely for the payment of drugs
which have been included in the ADAP list of approved drugs.
Reimbursement is limited to:
"The actual cost of ADAP drugs to the county or to the county's Subcontractors, in an
amount not to exeed the lesser of the average wholesale cost minus five percent, the
California Maximum Allowable Ingredient Cost (MAIC), Federal Allowable Cost (FAC), or
Estimated Acquisition Coast (EAC), plus a $4.05 per prescription dispensing fee."
(a) Subcontractors and the county shall only be reimbursed for the actual cost of ADAP
drugs charged by the wholesaler or manufacturer in an amount not to exceed the
formula described above;
(b) ADAP drugs purchased at Public Health Service Prices, pursuant to 42 U.S.C. §
256b, shall be reimbursed at Public Health Service prices;
(c) , Actual cost does not include any mark-up in price of ADAP drugs charged by one
subsidiary of a Subcontractor to another subsidiary of the Subcontractor;
(d) The local jurisdiction may not use these funds to cover medical monitoring,
laboratory testing or other medical services for persons receiving any of the
approved drugs.
5. The maximum amount payable under this Agreement as specified in paragraph 4 of Article
I shall be subject to the conditions specified in paragraphs 5 and 6 of Article III set forth
herein. The Department reserves the sole right to amend this contract to make the
adjustments specified in paragraph 11 of Article III.
Revised 6. The local jurisdiction shall submit monthly cost/expenditure reports containing information
on the cost of drugs provided and the number of prescriptions. This information shall be
submitted in a format prescribed by the Department as displayed in Exhibit D-3, "AIDS Drug
Assistance Program Invoice Form", consisting of one page and made a part hereof by this
reference. This report shall be submitted no later than 30 calendar days after the last day
of each month.
Payment may be denied at the sole discretion of the State, for cost/expenditure reports
which are submitted later than 30 calendar days after the last day of each month, without
prior approval from the State.
Revised 7. The local jurisdiction shall provide all required monthly statistical and demographic data
described in Exhibits E-3, "AIDS Drug Assistance Program Report," and Exhibit E -3a
"AIDS Drug Assistance Copay," consisting of two pages and are made a part hereof by this
reference. This report shall be submitted no more than 30 calendar days after the last day
of each month. The Department reserves the right to require each local jurisdiction to
provide the reports on a computerized disk. The Department also reserves the right to
require each local jurisdiction to adopt a statewide computer program for compiling these
4
reports. These requirements may be made at any time during the term of the Standard
Agreement upon a 30 day notification from the Department.
Payment may be denied at the sole discretion of the State, for cost/expenditure reports
which are submitted later than 30 calendar days after the last day of each month, without
prior approval from the State.
Revised 8. The local jurisdiction shall provide, on request, a verification of the actual cost of the drug(s)
with the invoices submitted. A copy of the invoice received from the drug wholesaler or
manufacturer from which the drug was purchased shall be retained by the local jurisdiction
and surrendered to the State on request. Records shall be maintained for at least three (3)
years from the end of the State fiscal year during which this Agreement is terminated, or
from the dates the final expenditure reports to the Federal Government are submitted for
costs incurred or until the termination of all state and federal audits, whichever is later
9. Covered entities, whether local jurisdictions or their subcontractors, participating in the
federal drug pricing program, as defined in 42 U.S.C. § 256b, must invoice the State at the
reduced cost for drugs acquired under this drug discount pricing program, plus a $4.05 per
prescription dispensing fee.
10. All invoices for expenditures, statistical reports, and other official communications shall be
mailed to:
Department of Health Services
Office of AIDS
AIDS Drug Assistance Program
P.O. Box 942732
Sacramento, CA 94234-7320
11. The local jurisdiction agrees to maintain necessary program records documenting the drugs
provided, identification of persons enrolled in the program, periods of enrollment, and fiscal
expenditures made under this Agreement. Records shall be maintained for at least three
(3) years from the end of the State fiscal year during which this Agreement is terminated,
or from the dates the final expenditure reports to the Federal Government are submitted
for costs incurred or until the termination of all state and federal audits, whichever is later.
12. The local jurisdiction agrees to provide access during normal working hours to authorized
representatives of the Department and of other State and Federal agencies to all records,
files, and documentation related to this Agreement, subject to applicable state and federal
laws concerning confidentiality.
13. The local jurisdiction shall be liable for all federal and state funds allocated under this
Agreement, including but not limited to, any audit exceptions that may arise. The local
jurisdiction shall submit repayment of any funds not spent for the cost of providing any
approved drug, or for persons who did not meet the income eligibility guidelines, or for
overcharges of the drug(s), or any amount that the Department assesses the local
5
jurisdiction will not expend from their allocation within 30 days of written notification from
the State.
14. If it appears the local jurisdiction will not expend the entire amount of its allocation under
this Agreement, the State may redistribute any projected unexpended funds of the local
jurisdiction's allocation to other local jurisdictions. The Department shall notify the local
jurisdiction in writing 30 days prior to any changes in the local jurisdiction's allocation.
15. The local jurisdiction agrees to maintain the confidentiality of patients who apply for
eligibility under this program
16. The local jurisdiction agrees to the provisions as stated in the attached Exhibit C, entitled
"Nondiscrimination Clause." The local jurisdiction and its subcontractors shall not unlawfully
discriminate against any employee or applicant for employment because of race, religion,
color, national origin, ancestry, physical handicap, medical condition, marital status, age,
sex, or sexual orientation. Exhibit C, consisting of one page is incorporated and made a
part hereof by this reference.
Article III
Revised 1. The Department shall authorize payment in arrears up to the maximum allocation of this
Agreement upon the execution of this Agreement if all previous allocations pursuant to the
AIDS Drug Assistance Program have been fully expended.
2. The Department will reimburse the local jurisdiction upon receipt of invoice forms, any
amount expended by the local jurisdiction for the provision of approved formulary drugs, but
not exceeding the maximum amount reimbursable under this Agreement. Reimbursements
to the local jurisdictions will be contingent upon receipt of the AIDS Drug Assistance
Program Invoice Form.
Revised 3. The Department will reimburse the local jurisdiction for approved drugs provided at cost,
not to exceed rates specified by the Department ("AIDS Drug Assistance Program
Maximum Reimbursement Amounts", Exhibit F-3) and incorporated herein and made a part
hereof by this reference. Any new drugs approved and added to the AIDS Drug Assistance
Program shall be reimbursed at cost, not to exceed rates specified by the Department in
writing which will be made part hereof by Standard Agreement amendment.
4. The Department shall recover any funds which are not expended in accordance with this
Agreement. Recovery of funds may be accomplished by withholding payments to the local
jurisdiction, or upon written notification from the State. The local jurisdiction shall submit
repayment within 30 days of receipt of that notification.
5. It is mutually understood between the parties that this Agreement may have been written
before ascertaining the availability of Federal or State funds for the mutual benefits of both
parties in order to avoid program delays which would occur if the contract were executed
after that determination. This Agreement is valid and enforceable only to the extent that
sufficient funds are made available to the State by the United States Government and/or
N.
by the State, for the purposes of this program. If sufficient federal and/or state funds are
not made available pursuant to the Agreement, this Agreement shall be invalid and of no
further force and effect. In this event, the State shall have no liability to pay any state funds
whatsoever to the local jurisdiction, or furnish any other considerations under this
Agreement and the local jurisdiction shall not thereafter be obligated to perform any duties
of this Agreement.
6. This Agreement is subject to any additional restrictions, limitations or conditions enacted
by the Congress or the State legislature which may affect the provisions, terms or funding
of this Agreement in any manner.
7. The terms of this Agreement may be modified in writing upon mutual consent of both
parties.
8. This Agreement may be terminated at any time without cause by either party by giving 30
days prior written notice to the other. Notification shall state the effective date of the
termination.
Revised 9. Notice of the termination by the local jurisdiction shall be followed within 30 days by a final
report and a final claim for reimbursement, or repayment of funds disbursed but not
expended.
10. An adjustment may be made on the allocation to increase the amount of the payments over
the local jurisdiction's maximum allocation if more funds become available. Adjustments
may also be made to decrease the allocation if it is determined that the local jurisdiction will
not expend its full maximum allocation.
IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto.
State of California
Signatum
Title Chief, Early Intervention Section
Office of AIDS
Date_111L I I
7
Local Jurisdiction
Signature
CIM INNIUM
Title James C. Hankla EXECUTED PURSUANT
TION 301 GF
City Manager THE CITY CHARTER.
1
APPROVED AS TO FORM qq
1�_, 19. _L Z.
JOHN R. C�OtsN, C,ty Attc;ney
BY------------
DEPUTY CITY ATTORNEY
AIDS DRUG ASSISTANCE PROGRAM
Drugs Currently on Formulary
Original drug provided in
October, 1987:
zidovudine (AZT)
Drug added March 1989:
aerosolized pentamidine
Drugs added November 1991:
clindamycin
dapsone
didanosine
ganciclovir
nystatin
pyrimethamine
sulfadiazine
trimethoprim/sulfamethoxazole
Drugs added April 1992:
clotrimazole
fluconazole
ketoconazole
Drug added December 1,1993:
zalcitabine
Drugs added April 1,1994:
acyclovir
amphotericin B
atovaquone
azithromycin
clarithromycin
clofazimine
ethambutol
flucytosine
foscarnet
paromomycin
rifabutin
Drugs added March 8,1995:
alpha interferon
bleomycin sulfate
cyclophosphamide
dexamethasone
doxorubicin
dronabinol
epoetin alfa
filgrastim
itraconazole
leucovorin calcium
megestrol acetate
methotrexate
prednisone
stavudine
trimethoprim
trimetrexate glucuronate
vinblastine sulfate
vincristine sulfate
Drug added April 25,1996
lamivudine
Drugs added July 15,1996
indinavir
ritonavir
saquinavir
Drugs added April 24,1997
cidofovir
nevirapine
Drug added May 13,1997
nelfinavir
Drugs added July 3, 1997
delavirdine
liposomal daunorubicin
Exhibit A
AIDS Drug Assistance Program
Drugs Currently on Formulary
State of California
July 3, 1997
acyclovir (Zovirax)
alpha interferon (Intron -A, Roferon-A)
amphotericin (Fungizone)
atovaquone (Mepron)
azithromycin (Zithromax)
bleomycin sulfate (Blenoxane)
cidofovir (Vistide)
clarithromycin (Biaxin)
clindamycin (Cleocin)
clofazimine (Lamprene)
clotrimazole (Lotrimin, Mycelex)
cyclophosphamide (Cytoxan) 2
dapsone (Avlosulfon)
delavirdine (Rescriptor)
dexamethasone (Decadron, Hexadrol)
didanosine (ddI, Videx)
doxorubicin (Ariamycin)
dronabinol (Marinol)
epoetin alfa (Epogen, Procrit)
ethambutol (Myambutol)
filgrastim (Neupogin)
fluconazole (Diflucan)
flucytosine (5FC, Ancobon)
foscarnet (Foscavir)
ganciclovir (Cytovene)
indinavir (Crixivan)
i:klata\hi v_care\adaplsmpl_drg.lst
.10
itraconazole (Sporanox)
ketoconazole (Nizoral)
lamivudine (Epivir,.3TC)
leucovorin calcium (Leucovorin)
liposomal daunorubicin (DaunoXome)
megestrol acetate (Megace)
methotrexate (Reumatrex)
nelfinavir (Viracept)
nevirapine (Viramune)
nystatin (Mycostatin)
paromomycin (Humatin)
pentamidine (NebuPent, Pentam)
prednisone
pyrimethamine (Daraprim)
rifabutin (Mycobutin)
ritonavir (Norvir)
saquinavir (Invirase)
stavudine (d4T, Zerit)
sulfadiazine (Microsulfon)
TMP/SMX (Bactrim, Septra)
trimethoprim (Trimpex, Proloprim)
trimetrexate glucuronate (NeuTrexin)
vinblastine sulfate (Velban)
vincristine sulfate (Oncovin)
zalcitabine (ddC, HIVID)
zidovudine (AZT, Retrovir)
Client Name/ID#
AIDS Drug Assistance Program
Office of AIDS
P. o. Box 942732
Sacramento, CA 94234-7320
AIDS DRUG ASSISTANCE PROGRAM
FINANCIAL ELIGIBILITY AND CO-PAYVIENT WORKSHEET
Revised July 1. 1997
Social Security Number
(A) Federal annual adjusted gross income: $
Exhibit B-3
T4
NOTE: If using the applicant's 1996 U.S. Individual Income Tax Return, enter adjusted gross income
(Line 31 on Form 1040, Line 16 on Form 1040A, or Line 4 on Form 1040EZ} in number (1). Attach
copy of tax return to this worksheet.
(B) Is the federal adiusted gross income less than 400% of poverty ($31,560 (family of one], $42,440 (family
of two], or $50,000 [family of 3 or more])?
YES ELIGIBLE. Stop here. The applicant is eligible for ADAP with no copayment
obligation.
NO bl) ELIGIBLE - COPAYMENT REQUIRED. If the applicant's federal annual
adjusted gross income exceeds 400% of poverty for their family size, but is
less than $50,000, the applicant is eligible for ADAP but will have a
copavment obligation. Proceed to #1 to determine this amount.
b2) NOT ELIGIBLE. If the applicant's federal annual gross income exceeds
$50,000, the applicant is not eligible to receive drugs under ADAP.
COPAYMENT DETERMINATION
(1) Annual Gross Income (Monthly Gross Income X 12 = Annual Gross Income] (1) $,
NOTE: If using the applicant's 1996 California Resident Income Tax Return 540, skip
numbers (1) and (2), and enter their taxable income (Line 19 on form 540; Line 16 on forms
540A and 540EZ} iri number (3). Attach copy of tax return to worksheet.
(2) Standard California Deduction (Enter deduction.] (2) $
Filing Status
1. Single
2. Married filing joint return
3. Married filing separate return
4. Head of household
5. Qualifying widower)
Amount
$2,527
$5,054
$2,527
$5,054
$5;054
(3) Taxable Income (Subtract (2) from (1).] (3) $
(4) Tax Liability (Look up on tax table using number (3) amount and filing status.]
(5) Gross Monthly Co -payment [(4) divided by 6.]
(6) Monthly Health Insurance Premium
[Enter premium amount, if applicable.]
(7) Net Monthly Co -payment [Subtract (6) from (5).]
t (8) Cost of Drug(s)
If the cost of the drug(s) is less than number (7), then the cost of the drug(s) will be the
monthly co -payment.
Note. Figures may change each year with poverty level and tax changes.
I:IDATAIHIV_CARE\ADAP1FORMS\FWAavCL97.FR�l
1996 California Tax Table i
Use the Tax Table below if your taxable income on Form 540EZ, line 16; Form 540A, line 16; or Form 540, line 19 is $50,000 or less.
Use the Tax Rate Schedule on page 46 if your taxable income on Form 540A, line 16 or Form 540, line 19 is more than $50,000.
To Find Your Tax:
• Read down the column labeled "if Your Taxable Income Is ..." to find the range that includes your taxable income.
• Read across the columns labeled "The Tax For Fling Status" until you find the tax that applies for your taxable income and filing status.
Fillno status: 1 or 3 (Single: Married fillno
Se arate
2 or 5 Married
filina
Joint: Quallfvina
Widow(er)) 4 (Head of Household
If Your Taxable
The Tax For
If Your Taxable
The Tax For
If Your Taxable
The Tax For
Income Is
...
Filing Status
Income Is ...
Fling Status
Income Is ...
Filing Status
At But Not
1 Or 3
2 Or 5
4
Al
But Not
1 Or 3
2 Or 5
4
At
But Not
1 Or 3
2 Or 5
4
Least Over
Is
Is
Is
Least
Over
Is
Is
Is
Least
Over
Is
Is
is
1
50
0
0
0
6,451
6,550
81
65
65
12,951
13,050
238
162
162
51
150
1
1
1
6,551
6,650
83
66
66
13,051
13,150
242
164
164
151
250
2
2
2
6,651
6,750
85
67
67
13,151
13,250
246
166
166
251
350
3
3
3
6,751
6,850
87
68
68
13,251:
13,350
250
168
168
351
450
4
4
4
6,851
6,950
89
69
69
13,351
13,450
254•
170
170
451
550
5
5
5
6,951
7,050
91
70
70
13,451
13,550
258
172
172
551
650
6
6
6
7,051
7,150
93
71
71
13,551
13,650
262
174
174
651
750
7
7
7
7,151
7,250
95
72
72
13,651
13,750
266
176
176
751
850
8
8
8
7,251
7,350
97
73
73
13,751
13,850
270
178
178
851
950
9
9
9
7,351
7,450
99
74
74
13,851
13,950
274
180
180
951
1,050
10
10
10
7,451
7,550
101
75
75
13,951
14,050
278
182
182
1,051
1,150
11
11
11
7,551
7,650
103
76
76
14,051
14,150
282
184
184
1,151
1,250
12
12
12
7,651
7,750
105
77
77
14,151
14,250
286
186
186
1,251
1,350
13
13
13
7,751
.7,850
107
78
78
14,251
14,350
290
188
188
1,351
1,450
14
14
14
7,851
7,950
109
79
79
14,351
14,450
294
190
190
1,451
1,550
15
15
15
7,951
8,050
111
80
80
14,451
14,550
298
192
192
1,551
1,650
16
16
16
8,051
8,150
113
81
81'
14,551
14,650
302
194
194
1,651
1,750
17
17
17
8,151
8,250
115
82
82
14,651
14,750
306
196
196
1,751
1,850
18
18
18
8,251
8,350
117
83
83
14,751
14,850
310
198
198
1,851
1,950
19
19
19
8,351
8,450
119
84
84
14,851
14,950
314
200
200
1,951
2,050
20
20
20
8,451
8,550
121
85
85
14,951
15,050
318
202
202
2,051
2,150
21
21
21
8,551
8,650
123
86
86
15,051
15,150
322
204
204
2,151
2,250
22
22
22
8,651
8,750
125
87
87
15,151
15,250
326
206
206
2,251
2,350
23
23
23
8,751
8,850
127
88
88
15,251
15,350
330
208
208
2,351
2,450
24
24
24
8,851
8,950
129
89
89
15,351
15,450
334
210
210
2,451
2,550
25
25
25
8,951
9,050
131
90
90
15,451
15,550
338
212
212
2,551
•2,650
26
26
26
9,051
9,150
133
91
91
15,551
15,650
342
214
214
2,651
2,750
27
27
27
9,151
9,250
135
92
92
15,651
15,750
346
216
216
2,751
2,850
28
26
26
9,251
9,350
137
93
93
15,751
15,850
350
218
218
2,851
2,950
29
29
29
9,351
9,450
139
94
94
15,851
15,950
354
220
220
2,951
3,050
30
30
30
9,451
9,550
141
95
95
15,951
16,050
358
222
222
3,051
3,150
31
31
31
9,551
9,650
143
96
96
16,051
16,150
362
224
224
3,151
3,250
32
32
32
9,651
9,750
145
97
97
16,151
16,250
366
226
226
3,251
3,350
33
33
33
9,751
9,850
147
98
98
16,251
16,350
370
228
228
3,351
3,450
34
34
34
9,851
9,950
149
100
100
16,351
16,450
374
230
230
3,451
3,550
35
35
35
9,951
10,050
151
102
102
16,451
16,550
378
232
232
3,551
3,650
36
36
36
10,051
10,150
153
104
104
16,551
16,650
382
234
234
3,651
3,750
37
37
37
10,151
10,250
155
106
106
16,651
16,750
386
236
236
3,751
3,850
38
38
38
10,251
10,350
157
108
108
16,751
16,850
390
238
238
3,851
3,950
39
39
39
10,351
10,450.
159
110
110
16,851
16,950
394
240
240
3,951
4,050
40
40
40
10,451
10,550
161
112
112
16,951
17,050
398
242
242
4,051
4,150
41
41
41
10,551
10,650
163
114
114
17,051
17,150
402
244
244
4,151
4,250
42
42
42
10,651
10,750
165
116
116
17,151
17,250
406
246
246
4,251
4,350
43
43
43
-'10,751
10,850
167
118
118
17,251
17,350
410
248
248
4,351
4,450
44
44
44
10,851
10,950
169
120
120
17,351
17,450
.414
250
250
4,451
4,550
45
45
45
10,951
11,050
171
122
122
17,451
17,550
418
252
252
4,551
4,650
46
46
46
11,051
11,150
173
124
124
17,551
17,650
422
254
254
4,651
4,750
47
47
47
11,151
11,250
175
126
126
17,651
• 17,750
426
256
256
4,751
4,850
48
48
48
11,251
11,350
177
126
128
17,751
17,850
430
258
258
4,851
4,950
49
49
49
11,351.•-
11,450
179
130
130
17,851
17,950
434
260
260
4,951
5,050
51
50
50
11,451
11,550
181
132
132
17,951
18,050
438
262
262
5,051
5,150
53
51
51
11,551
11,650
183
134
134
18,051
18,150
442
264
264
5,151
5,250
55
52
52
•11,651
11,750
186
136
136
18,151
18,250
446
266
266
268
5,251
5,351
5,350
5,450
57
59
53
54
53
.54
11,751
11,851
11,850
11,950
190
194
138
140
138
140
18,251
18,351
18,350
18,450
450
455
268
270
270
5,451
5,550
61
55
55
11,951
12,050
198
142
142
18,451
18,550
461
272
272
274
5,551
5,650
63
56
56
12,051
12,150
202
144
144
18,551
18,650
467
274
5,651
5,750
65
57
57
12,151
12,250
206
146
146
18,651
18,750
473
276
276
5,751
5,850
67
58
'58
12,251
12,350
210
148
148
18,751
18,850
479
278
278
5,851
5,950
69
59
59
12,351
12,450
214
150
150
18,851
18,950
485
280
280
5,951
6,050
71
60
60
12,451
12,550
218
152
152
18,951
19,050
491
282
282
6,051
6,150
73
61
61
12,551
12,650
222
154
154
19,051
19,150
497
284
284
6,151
6,250
-75
62
62
12,651
12,750
226
156
156
19,151
19,250
503
286
286
6,251
6,350
77
63
63
12,751
12,850
230
158
158
19,251
19,350
509
288
288
6,351
6,450
79
64
64
1 12,851
12,950
234
160
160
19,351-
19,450
515
290
290
The tax table
is continugd on page 45.
Page 44 Personal Income Tax Booklet 1996
Schedule CA (540)/FTB 3885A/Schedule D Instructions 1996 Page 43
---Instructions for California Schedule D
-
California Capital Gain Or Loss Adjustment
General Informationrules.
Get form FTB 3801, Passive Activity Loss
Limitations, to see how to report capital and
Special Credits — California law authorizes special
tax
In general, California did not conform its law to
changes made to the Internal Revenue Code (IRC)
gains
losses from a passive activity.
credits not allowed under federal law or com-
puted differently under federal law. In man y
by the federal Revenue Reconciliation Act of 1993
Specific Line Instructions
ua s if you claimed special credits related to
(Public Law 103-66). California legislation during
capital
pifale�. you must reduce your basis in the
1994 and 1996 did adopt a few specific provisions of
Line 1 — List each capital asset transaction.
assets by the amount of credit.
the 1993 federal changes. All other references in
Column (a) — Description Of Property
Other adjustments may apply differently to the
these instructions are to the IRC as it existed on
Describe the asset you sold or exchanged
federal and California basis of your capital assets.
January 1, 1993. Specifically, California does not
Capital Gain Distributions. If you receive federal
Figure the original basis of your asset using the Calk
permit rollover of gain from the sale of publicly
Form 2439, Notice to Shareholder of Undistributed
forma iaw in effect when the asset was acquired,
traded securities into specialized small business
Investment companies (SSSICs). The gain is fully
Long -Term Capital Gains, from a mutual fund, do not
include the undistributed capital gain dividends an
and adjust it according to provisions of California law
in effect during the period of your ownership.
taxable to California. Use Cafifomra Schedule D to
figure the necessary adjustment.
Schedule D. However, if you receive federal
Fort 1099 -DIV, Dividends and Distributions,
Line 5 -1995 California Capital Loss Carryover
Pu OSe
enter
the name of the distributing corporation or mutual
Enter the amount of your 1995 California net capital
loss that was more than the loss limitation.
fund in column (a), and the amount of distributed
Use California Schedule D only if there is a differ-
capital gain dividends in column (e). Do not com-
Line 7 —Net Gain Or Loss
ence between your federal capital gains and losses
plete columns (b), (c) and (d) for these dividends.
If the amount on line 3 is more than the amount on
and your California capital gains and losses associ-
Follow the instructions for the remainder of
line 6, subtract line 6 from line 3. Enter the differ-
ated with the following:
Schedule D.
ence as a gain on Pirie 7.
• Disposition of property that was expensed or
depreciated at some time during the period you
Column (b) — Sales Price
Enter in this column either the gross sales price or
If the amount on line 6 is more than the amount on
line 3, subtract line 3 from line 6 and enter the differ -
owned it; California and federal depreciation and
property expensing methods were different before
1987
the net sales price from the safe. If you received a
Form 1099-B, 1099-S or similar statement showing
ence as a loss on line 7.
Use the worksheet on this page to figure
and after 1/1/93 and caused a difference
between the California and federal basis;
the gross safes price, enter that amount in col-
umn (b). However, if box 2 of Form 1099-B indicates
your capital
loss carryover to 1997.
• Gain or loss on stock and bond transactions;
• Installment sale gain reported on form FTS
that gross proceeds less commissions and option
were to IRS,
Line 8 — If line 7 is a net capital loss, enter the
smaller of the loss on line 7 or 53,000 ($1,500 if
3805E, Installment Sale Income; -
• Gain on the sale of personal residence where
premiums reported enter that net
amount in column (b). If you entered the net amount
in column (b), do not include the commissions and
you
are married filing a separate return).
Line 11a — Enter the difference on tine 11a and on
depreciation was allowable;
• Flow-through gain or loss from partnerships, fidu-
option premiums in column (c).
Schedule CA (540 or 540NR), line 13, column B.
nasiS corporations or limited liability compo-
ores'
Column (c) —Cost Or Other Basis
In general, the cost or other basis is the cost of the
EXAMPLES:
Gain on line 9 is more than gain on line 10.
• Distributed and undistributed capital gain
dividends;
Property plus p
purchase commissions and improve-
ments minus depreciation, amortization and de le-
p p
Federal gain on fine 9 is....... S10,000
California gain on line 10 is ...... S6,000
•Gain from involuntary conversion of capital assets
not held for business profit; and
tion. Enter the cost or adjusted basis of the asset for
Cafifomia purposes. Use your records and California
Subtract line 10 from line 9 ...... S4,000
Loss on line 9 is less than loss on line 10.
• Capital loss carryover from your 1995 California
Schedule D.
tax returns for years before 1987 to determine the
California amount to enter in column (c).
Federal loss on fine 9 is ........ 51,000
California loss on line 10 is ...... S2,000
For more information about the following, get FTB
If you used an amount other than cost as the
Subtract line 9 from line 10 ...... $1,000
Pub. 1001, Supplemental Guidelines to California
original basis, your federal basis may be different
Gain on line 9 and loss on line 10.
Adjustments:
from your California basis. Other reasons for
Federal gain on One 9 is........ $3,000
• Disposition of property inherited before 1987;
differences are:
California loss on line 10 is ...... S3,000
• Disposition of S corporation stock acquired before
Depreciation Methods and Property Expensing
Add line 9 and One 10......... 56,000
1987;
• Gain on the safe or disposition of a qualified
California law:
• Did not allow the use of ACRS before 1987;
Line 11b — Enter the difference on line t lb and on
Schedule CA (540 or 540NR), line 13, column C.
assisted housing development to low-income resi-
• Did not allow the use of an asset depredation —
EXAMPLES:
dents or to specific entities maintaining housing•
for low-income residents;
• Gain
range 20% above or below the standard rate;
Limits expensing of property under IRC
Gain on line 9 is less than gain on line 10.
Federal gain on line 9 is........ S6,000
on certain vessels transferred to and
exchanged with the Maritime Administration or
Section 179 to 510,000•
• Permitted rapid write-off of property such as solar
Californiain on One 10 is ..... $11,000
Subtract line 9 from line 10 S 5.000
realized in connection with construction of new
vessels; or
energy systems, pollution control devices and
property used in an enterprise zone, program
......
Loss on line 9 is more than loss on line 10.
• Capital loss carryback.
area, the Los Angeles Revitalization Zone (LARZ)
Federal loss on line 9 is ........ $2,000
Installment Sales
If you sold property at a gain (other than publicly
or Local Agency Military B Recovery
(LAMBRA)9 cY ry ase Recove Area
California loss on line 10 is ...... S1,C00
Subtract fine 10 from line 9 ...... S1.000
traded stocks or securities), and you will receive a
Inherited Property — The California basis of prop-
Loss on line 9 and gain on tine 10.
n a 10.
payment in a tax year after the year of sale, you
must report the sale on the installment method
erty inherited from a decedent is generally fair mar-
ket value (FMV) at the time of death. If you acquired
Federal loss line 9 is .. $2.000
California atm line
i
line 10 is ...... 55.000
9
unless you elect not to do so. Get form FTB 3805E,
community property as a surviving spouse:
Add line and line 1010
...... S7,000
Installment Sale Income. Also use that form if you
• Before January 1, 1987, generally the basis of
California Capital Loss Carryover Worksheet
received a payment in 1996 for an installment sale
made in an earlier year.
your deceased spouse's one-half interest in the
property is FMV at the time of death and the basis
1. Loss from Schedule D, line 10,
Note: You may elect not to use the installment saleof
your one-half interest is cost; or
stated as a positive number. . 1
2. Amount from Form 540 or
method for California by reporting the entire gain on
Schedule D (or Schedule D-1 for business assets) in
• On or after January 1, 1987, the entire basis of
the inherited community property is FMV at the
.
Form 540NR, line 17 ... 2
3. Amount from Form 540 or
the year of the sale and filing your return on or
before the due date.
time of death. Get FTB Pub. 1039, Basis of Prop-
erty — Decedent/Surviving Spouse for more
Form 540NR, line 18 3
4. Subtract line 3 from line 2. If less
At -Risk Rules And Passive Activity Limitations
o
If you dispose of (1) an asset used in an activity to
information.
S Corporation Stock — Prior to 1987, California law
than
an zero, enter as a neative
9
amount ............. 4
which the ase
rules apply, or (2) any part of your
e any
-activity
did not recognize S corporations. As a result, your
5. Combine line 1 and One 4. If
interest a to which the) rules apply,
and you have amounts in the activity for which you
wFormhichyou
California basis in S corporation stock may differ
from your federal basis. In general, your California
less than zero, enter -0..... 5
6. Loss from Schedule D, line 7 . 6
are not
are not at risk, get and complete federal
Limitations, using complete
California amounts to fig-
basis will be cost -adjusted for income, loss and dis-
tnbutions received after 1986, while your stock was
California S corporation Your federal
7. Enter the smaller of line 1 or
One 5 .............. 7
Are your California deductible toss under the at-riskfig-
rules. Once a loss becomes allowable under the
stock. basis will
be for income, loss and distributions
8. Subtract line 7 from line 6. This is
your capital loss carryover to
at -risk rules, it becomes subject to the"passive activ-
r
received during the time your stack qualified for fed-
....... 8
eral S corporation treatment.1997
, . , , . •
Schedule CA (540)/FTB 3885A/Schedule D Instructions 1996 Page 43
-' 1996 California Tax Table-
Continued
Fling status: 1 or 3 (Single; Married filing Separate)
2 or 5 (Married filing Joint; Qualifying Widow(er)) 4 (Head of Household)
If Your
Income
Taxable
Is ...
The Tax For
Filing Status
If Your Taxable
Income Is..
The Tax For
If Your Taxable
The Tax For
Fling Status
Income Is...
Fling Status
At
Least
But Not
Over
1 Or 3
is
2 Or 5
Is
4
At
But Not
1 Or 3
2 Or 5
4
At
But Not
1 Or 3
2 Or 5
4
Is
Least
Over
Is
Is
Is
Least
Over
Is
Is
Is
19,451
19,551
19,550
19,650
521
527
292
294
292
294
26,451
26,551
26,550
26,650
961
969
497
501
497
33,451
33,550
1,538
777
847
19,651
19,751
19,750
19,850
533
539
296
298
296
298
26,651
26,751
26,750
26,850
977
505
501
505
33,551
33,651
33,650
33,750
1,548
1,557
781
785
853
859
19,851
19,950
545
300
300
26,851
26,950
985
993
509
513
509
. 513
33,751
33,851
33,850
33,950
1,566
789
865
19,951
20,051
20,050
20,150
551
557
.302
304
302
304
26,951
27,051
27,050
27,150
1,001
1,009
517
517
33,951
34,050
1,575
793
871
1,585
797
8771,594
20,151
20,251
20,250
20,350
563
569
306
308
306
27,151
27,250
1,017
521
525
521
525
34,051
34,151
34,150
34,250
1,603
801
805
883
889
20,351
20,450
575
310
308
310
27,251
27,351
27,350
27,450
1,025
1.033
529
533
529
533
34,251
34,351
34,350
34,450
1,613
809
895
20,451
20,551
20,550
20,650
581
• 587
312
314
312
314
27,451
27,551
27,550
27,650
1,041
537
537
34,451
34,550
1,622
813
901
1,631
817
907
20,651
20,751
20,750
20,850
593
599
316
318
316
27,651
27,750
1,049
1,057
541
545
541
545
34,551
34,651
34,650
34,750
1,641
1,650
821
825
913
20,851
20,950
605
320
318
320
27,751
27,851
27,850
27,950
1,065
1.073
549
553
549
553
34,751
34,850
1,659
829
919
925
20,951
219051
21,050
21,150
611
617
322
324
322
324
27,951
28,050
1,081
557
557
34,851
34,951
34,950
35,050
1,668
833
931
1,678
837
937
21,151
21,251
21,250
21,350
623
326
326
28,051
28,151
28,150
28,250
1,089
1,097
561
565
561
565
35,051
35,151
35,150
35,250
1,687
1,696
841
943
21,351
21,450
629
635
. 328
330
328
330
28,251
28,351
28,350
28,450
1,105
1.113
569
573
569
35,251
35,350
1,706
845
849
949
955
21,451
21,551
21,550
21,650
641
647
332
334
332
334
28,451
28,550
1,121
577
573
577
35,351
35,451
35,450
35,550
1,715
853
961
1,724
857
967
21,651
21,751
21,750
653
336
336
28,551
28,651
28,650
28,750
1,129
1,137
581
585
581
585
35,551
35,651
35,650
35,750
1,734
861
973
21,851
21,850
21,950
659
665
338
340
338
340
28,751
28,851
28,850
28,950
1,145
589
589
35,751
35,850
1,743
1,752
865
869
979
985
21,951
22,050
671
342
342
28,951
29,050
1,153
1,161
593
597
593
35,851
35,950
1,761
873
991
22,051
22,151
22,150
22,250
677
683
344
346
344
346
29,051
29,151
29,150
29,250
1,169
601
597
601
35,951
36,051
36,050
36,150
1,771
1,780
877
881
997
1,003
22,251
22,351
22,350
22,450
689
695
348
350
348
29,251
29,350
1,177
1,185
605
609
605
609
36,151
36,251
36,250
36,350
1,789
1,799
885
889
1,009
1,015
22,451
22,550
701
350
29,351
29,450
1,193
613
613
36,351
36,450
.1,808
893
1,021
22,551
22,650
707
352
354
352
354
29,451
29,551
29,550
29,650
1,201
1,209
617
621
617
36,451
36,550
1,817
897
1,027
22,651
22,751
22,750
22,850
713
719
356
358
356
358
29,651
29,751
29,750
29,850
1,217
625
621
625
36,551
36,651
36,650
36,750
1,827
1,836
901
905
1,033
1,039
22,851
22,950
725
360
360
29,851
29,950
1,225
1,233
629
633
629
633
36,751
36,851
36,850
36,950
1,845
1,854
910
1,045
22,951
23,051
23,050
23,150
731
737
362
364
362
364
29,951
30,051
30,050
30,150
1,241
1,249
637
637
36,951
37,050
916
1.051
1,057
1,864
922
23,151
23,251
23,250
23,350
743
749
366
369
366
369
30,151
30,250
1,257
641
645
643
649
37,051
37,151
37,150
37,250
1,873
1,882
928
934
1,063
1,071
23,351
23,450
755
373
373
30,251
30,351
30,350
30,450
1,265
1,273
649
653
655
661
37,251
37,351
37,350
37,450
1,892
940
1,079
•23,451
23,551
23,550
23,650
761
767
377
381
377
30,451
30,550
1,281
657
667
37,451
37,550
1,901
946
1,087
1,095
1,910
952
23,651
23,751
23,750
23,850
773
779
385
381
385
30,551
30,651
30,650
30,750
1,289
1,297
661
665
673
679
37,551
37,651
37,650
37,750
1,920
1,929
958
964
1,103
1,111
23,851
23,950
785
389
393
389
393
30,751
30,851
30,850
30,950
1,305
1,313
669
673
685
691
37,751
37,850
1,938
970
1,119
23,951
24,051
24,050
24,150
791
797
397
401
397
30,951
31,050
1,321
677
697
37,851
37,951
37,950
38,050
1,947
976
1,127
1,135
1,957
982
24,151
24,251
24,250
24,350
803
405
401
405
31,051
31,151
31,150
31,250
1,329
1,337
681
685
703
709
38,051
38,151
38,150
38,250
1,966
1,975
988
994
1,143
24,351
24,450
809
815
409
413
409
413
31,251
31,351
31,350
31,450
1,345
1,353
689
715
38,251
38,350
1,985
1,000
1,151
1,159
24,451
24,550
821
417
417
31,451
31,550
1,361
693
697
721
38,351
38,450
1,994
1,006
1,167
24,551
24,651
24,650
24,750
827
833
421
425
421
425
31,551
31,651
31,650
31,750
1,369
701
727
733
38,451 •
38,551
38,550
38,650
2,003
2.013
1,012
1,018
1,175
1,183
24,751
24,851
24,850
24,950
839
845
429
433
429
31,751
31,850
1,377
1,385
705
709
739
745
38,651
38,751
38,750
38,850
2,022
2,031
1,024
1,030
1,191
1,199
24,951
25,050
851
433
31,851
31,950
1.393
713
751
38,851
38,950
2,040
1,036
1,207
25,051
25,150
857
437
441
437
441
31,951
32,051
32,050
•32,150
1,401
1,409
717
721
757
38,951
39,050
2,050
1,042
1,215
25,151
25,251
25,250
25,350
863
869
445
449
445
449
32,151
32,250
1,417
725
763
769
39,051
39,151
39,150
39,250
2,059
2,068
1,048
1,054
1,223
1,231
25,351
25,450
875
453
453
32,251
32,351
32,350
32,450
1,427
1,436
729
733
775
781
39,251
39,350
2,078
1,060
1,239
25,451
25,551
25,550
25,650
881
889
457
461
457
32,451
32,550
1,445
737
787
39,351
39,450
2,087
1,066
1,247
1,255
39,451
39,550
2,096
1,072
25,651
25,750
897
465
461
465
32,551
32,651
32,650
32,750
1,455
1,464
741
745
793
799
39,551
399650
2,106
1,078
1,263
25,751
25,851
25,850
25,950
905
913
469
473
469
473
32,751
32,850
1,473
749
805
39,651
39,751
39,750
39,850
2,115
2,124
1,084
1,090
1,271
1,279
25,951
26,050
921
32,851 .
32,950
1.482
753
811
39,851
39,950
2.133
1,096
1.287
26,051
26,150
929
477
481
477
481
32,951
33,051
33,050
33,150
1,492
1,501
757
761
817_
823
39,951
40,050
2,143
1,102
1,295
26,151
26,251
26,250
26,350
937
945
:485
489
485
489
33,151
33,251
33,250
33,350
1,510
765
40,051
829 40,151
40,150
40,250
2,152
2,161
1,108
1,114
1,303
1,311
26,351
26,450
953
493
493
33,351
33,450
1,520
1,529
769
773
835 40,251
841 40,351
40,350
2,171
1,120
1,319
40,450
2,180
1,126
1,327
The tax table is continued on page 46.
Personal Income Tax
Booklet •1996
Page 45
1996 California Tax Table- Continued
Filinq status: 1 or 3 (Single: Married filinq Separate) 2 or 5 (Married filina Joint: Oualifvina Widow(eFll a (Emgel of h-1,41
If Your Taxable
$ 0.00
The Tax For
1.0%
If Your Taxable
The Tax For
49.08
If Your Taxable
2.0%
The Tax For
11,632 18,357
Income Is ...
+
Fling Status
11,632
Income Is ...
452.56
Filing Status
6.0%
Income
is ...
880.18
Fling Status
8.0%
At
But Not
1 Or 3
2 Or 5
4
At
But Not
1 Or 3
2 Or 5
.4
At
But Not
1 Or 3
2 0r 5
4
Least
Over
Is
Is
Is
Least
Over
Is
Is
Is
Least
Over
Is
Is
Is
40,451
40,550
2,189
1,132
1,335
43,951
44,050
2,515
1,342
1,617
47,451
47,550
2,840
1,552
1,942
40,551
40,650
2,199
1,138
1,343
44,051
44,150
2,524
1,348
1,626
47,551
47,650
2,850
1,558
1,951
40,651
40,750
2,208
1,144
1,351
44,151
44,250
2,533
1,354
1,635
47,651
47,750
2,859
1,564
1,961 c
40,751
40,850
2,217
1,150
1,359
44,251
44,350
2,543
1,360
1,645
47,751
47,850
2,868
1,570
1,970
40,851
40,950
2,226
1,156
1,367
44,351
44,450
2,552
1,366
1,654
47,851
47,950
2,877
1,576
1,979
40,951
41,050
2,236
1,162
1,375
44,451
44,550
2,561
1,372
1,663
47,951
48,050
2,887
1,582-
1,989
41,051
41,150
2,245
1,168
1,383
44,551
44,650
2,571
1,378
1,672
48,051
48,150
2,896
1,588
1,998
41,151
41,250
2,254
1,174
1,391
44,651
44,750
2,580
1,384
1,682
48,151
48,250
2,905
1,594
2,007
41,251
41,350
2,264
1,180
1,399
44,751
44,850
2,589
1,390
1,691
48,251
48,350
2,915
1,600
2,017
41,351
41,450
2,273
1,186
1,407
44,851
44,950
2,598
1,396
1,700
48,351
48,450
2,924
1.606
2,026
41,451
41,550
2,282
1,192
1,415
44,951
45,050
2,608
1,402
1,710
48,451
48,550
2,933
1,612
2,035
41,551
41,650
2,292
1,198
1,423
45,051
45,150
2,617
1,408
1,719
48,551
48,650
2,943
1,618
2,044
41,651
41,750
2,301
1,204
1,431
45,151
45,250
2,626
1,414
1,728
48,651
48,750
2,952
1,624
2,054
41,751
41,850
2,310
.1,210
1,439
45,251
45,350
2,636
1,420
1,738
48,751
48,850
•2,961
1,630
2,063
41,851
41,950
2,319
1,216
1,447
45,351
45,450
2,645
1,426
1,747
48,851
48,950
2,970
1,636
2,072
41,951
42,050
2,329
1,222
1,455
45,451
45,550
2,654
1,432
1,756
48,951
49,050
2,980
1,642
2,082
42,051
42,150
2,338
1,228
1,463
45,551
45,650
2,664
1,438
1,765
49,051
49,150
2,989
1,648
2,091
42,151
42,250
2,347
1,234
1,471
45,651
45,750
2,673
1,444
1,775
49,151
49,250 -
2,998
1,654
2,100
42,251
42,350
2,357
1,240
1,479
45,751
45,850
2,682
1,450
1,784
49,251
49,350
3,008
1,660
2,110
42,351
42,450
2,366
1,246
1,487
45,851
45,950
2,691
1,456
1,793
•49,351
49,450
3,017
1,666
2,119
42,451
• 42,550
-2,375
1,252
1,495
45,951
46,050
2,701
1,462
1,803
49,451
49,550
3,026
1,672
2,128
42,551
42,650
2,385
1,258
1,503
46,051
46,150
2,710
1,468
1,812
49,551
49,650
3,036
1,678
2,137
42,651
42,750
2,394
1,264
1,511
46,151
46,250
2,719
1,474
1,821
49,651
49,750
3,045
1,684
2,147
42,751
42,850
2,403
1,270
1,519
46,251
46,350
2,729
1,480
1,831
49,751
49,850
3,054
1,690
2,156
42,851
42,950
2.412
1,276
1,527
46,351
46,450
2,738
1,486
1,840
49,851
49,950
3,063
1,696
2,165
42,951
43,050
2,422
1,282
1,535
46,451
46,550
2,747
1,492
1,849
49,951
50,000
3,070
1,701
2,172
43,051
43,151
43,150
43,250
2,431
2,440
1,288
.1,294
1,543
1,551
46,551
46,651
46,650
46,750
2,757
2,766
1,498
1,504
1,858
1,868
OVER $50,000 YOU MUST COMPUTE
43,251
43,350
2,450
1,300
1,559
46,751
46,850
2,775
1,510
1,877
YOUR
TAX USING THE TAX RATE
43,351
43,450
2,459
1,306
1,567
46,851
46,950
2,784
1,516
1,886
SCHEDULES.
43,451
43,550
2,468
1,312
1,575
46,951
47,050
2,794
1,522
1,896
43,551
43,650
2,478
1,318
1,583
47,051
47,150
2,803
1,528
1,905
43,651
43,750
2,487
1,324
1,591
47,151
47,250
2,812
1,534
1,914
43,751
43,850
2,496
1,330
1,599
47,251
47,350
2,822
1,540
1,924
43,851
43,950
2,505
1,336
1,607
47,351
47,450
2,831
1,546
1,933
1996 Tax Rate Schedules Caution: Use only if your taxable income (Form 540A, line 16 or Form 540, line 19)
is more than $50,000. If $50,000 or less, use the Tax Table.
Schedule X -
Use if your filing status is
Single or Married Filing Separate
Schedule Y -
Use if your filing status is
Married Filing Joint or Qualifying
Widower) with Dependent Child
Schedule Z -
Use if your filing status is
Head of Household
If the amount on
Form 540A, line 16
or Form 540, line 19, is:
over- But not over -
Enter on Form 540A, line 17 of the
or Form 540, line 20 amount over-
$ o $ 4,908
$ 0.00
+
1.0%
$ 0
4,908 11,632
49.08
+
2.0%
4,908
11,632 18,357
183.56
+
4.0%
11,632
18,357 25,484
452.56
+
6.0%
18,357
25,484 32,207
880.18
+
8.0%
25,484
32,207 AND OVER
1,418.02
+
9.3%
32,207
$ 0 $ 9,816
$ 0.00
+
1.0%
$ . o
9,816 23,264
98.16
+
2.0%
9,816
23,264 36,714
367.12
+
4.0%
23,264
36,714 50,968
905.12
+
6.0%
36,714
'50,968 64,414
1,760.36
+
8.0%
50,968
64,414 AND OVER
2,836.04
+
9.3%
64,414
$ o
$ 9,817
$ , 0
+
1.0%
$ 0
9,817
23,264
98.17
+
2.0%
9,817
23,264
29,988
367.11
+
4.0%
23,264
29,988
37,114
636.07
+
6.0%
29,988
37,114
43,839
1,063.63
+
8.0%
37,114
43,839
AND OVER
1,601.63
+
9.3%
43,839
Page 46 Personal Income Tax Booklet 1996
Exhibit C
NONDISCRWINI ATION CLAUSE (OCP -1)
1. During the performance of this contract, contractor and its subcontractors shall not
unlawfully discriminate, harass or allow harassment, against any employee or applicant for
employment because of sex, race, color, ancestry, religious creed, national origin, physical
disability (including HIV and AIDS), mental disability, medical condition (cancer), age
(over 40) or marital status, and denial of family care leave. Contractors and
subcontractors shall insure that the evaluation and treatment of their employees and
applicants for employment are free from such discrimination and harassment. Contractors
and subcontractors shall comply with the provisions of the Fair Employment and Housing
Act (Government Code, Section 12900 et seq.) and the applicable regulations
promulgated thereunder (California Code of Regulations, Title 2, Section 7285.0 et seq.).
The applicable regulations of the Fair Employment and Housing Commission
implementing Government Code, Section 12990 (a -f), set forth in Chapter 5 of Division 4
of Title 2 of the California Code of Regulations are incorporated into this contract by
reference and made a part hereof as if set forth in full. Contractor and its subcontractors
shall give written notice of jheir obligations under this clause to labor organizations with
which they have a collective bargaining or other agreement.
2. This contractor shall include the nondiscrimination and compliance provisions of this
clause in all subcontracts to perform work under the contract.
STD. 17A (REV.2-93)
d
State of California
Department of Health Services
Office of AIDS
P. O. Box 942732
Sacramento, CA 94234-7320
Exhibit D-3
Authorized without a supporting
Contract per HSC Sec. 188.1 (b),
AB 2251, Chapter 1246, Stat of 1989
AIDS DRUGS ASSISTANCE PROGRAM INVOICE FORM
This form must be submitted with original signatures. Copies should be retained for the local
health jurisdiction's records.
1. Name of Local Health Jurisdiction:
2. Address:
(Telephone)
I hereby certify, under penalty of perjury, that the above services have been provided in accordance with the policies,
guidelines and standards of the State Department of Health Services and that the fees do not exceed those authorized for
this program.
Signature of a Duly Authorized Health Jurisdiction Official Date
-STATE OFFICE OF AIDS USE ONLY -
:41
3.
Invoice for the month of
, 19
4.
Total number of prescriptions provided for month invoiced (excluding nebulizers and other
equipment used in administering drugs):
5.
Total cost of drugs, excluding dispensing fee:
$
6.
Total cost of dispensing fees:
$
7.
Total cost of drugs and dispensing fees:
$
(5 +6)
8.
Amount reimbursed by third -party payor:
$
9.
Amount collected for ADAP copayments:
$
10.
Net amount to be reimbursed by State
$
ADAP [7 - (8 + 9)] :
Report prepared by:
(Telephone)
I hereby certify, under penalty of perjury, that the above services have been provided in accordance with the policies,
guidelines and standards of the State Department of Health Services and that the fees do not exceed those authorized for
this program.
Signature of a Duly Authorized Health Jurisdiction Official Date
-STATE OFFICE OF AIDS USE ONLY -
:41
i
AIDS DRUG ASSISTANCE PROGRAM COPAY
MONTHNEAR
i
EXHIBIT E-30
j
JURIS
SITE
ID_SSN
Idstring
dMM
dDD
dYY
AGI
_MPO
Insur _
Overbill_-
T_Copay-_-'
w
SUBTOTALS
I:1..: W DAPILOT U S 1231C PAY9608. W K1
08/22/96
INSTRUCTIONS FOR COMPLETING THE AIDS DRUGS PROGRAM COPAY FORM
The total values shown on the ADAP Report Copay Form" must equal the corresponding totals on the ADAP Invoice Form. For additional
information or clarification call the Office of AIDS at (916) 327-6784.
Ism inctructinn
KRIS Enter your health jurisdiction number. Valid numbers range between (1-62). Check with the Office of AIDS if you are
unsure of your health jurisdiction number.
SITE Enter your site number identified within the health jurisdiction. For counties with only one site, enter 1.
ID#/SSN# Enter the client's identification number (preferably a social security number).
If the client does not have a SSN, enter 900,(your health jurisdiction's two digit number), plus four more numbers. Example:
900010001. Conon to is that number for the cnrrec nnnding client_ The next client with no SSN would be: 900-01-0002
or 900010002 on the ADAP Report form etc. The client's ID number must be unique to that patient in order to avoid
duplication.
dMM Enter the month the drug was dispensed. Enter two digits.
dDD Enter the day the drug was dispensed. Enter two digits.
dYY Enter the year the drug was dispensed. Enter two digits.
AGI This refers to the client's last reported annual gross income to determine the client's eligibility for drugs. Leave blank if
unknown.
MPO Monthly copayment obligation as calculated on the "ADAP Financial Eligibility" form. Leave blank if $0.
a
Insur Enter the total dollar amount paid by insurance. If one client has more than one drug insurance amount, they may be totaled
here and entered once. Leave blank if $0.
Overbill Enter the total dollar amount that was previously billed in error to ADAP.
T_Copay Enter the total of "MPO" and 'Insur".
I:\DATA\HIV CARBADAPIFOR.'NS\COPAYINS.096
10
AIDS DRUG ASSISTANCE REPORT
MONTKNEAR
SUBTOTALS
y•
. UoAM10 ASSAMMM YWI
EXHIBIT E3
INSTRUCTIONS FOR COMPLETING THE AIDS DRUGS PROGRAM REPORT FORM
Drug codes and maximum reimbursemait amounts are available on the "ADAP Maximum Reimbursement Amounts" list. The total values shown on
the ADAP Report Form" must equal the corresponding totals on the "ADAP Invoice Form ". If report is handwritten or typed (not generated by
computer), group data by drug code number in numerical order. For additional information or clarification call the Office of AIDS at (916) 327-6784.
Itgtn Instruction
JURIS Enter your health jurisdiction number. Check with the Office of AIDS if you are unsure of your health jurisdiction code.
SITE Enter your site number identified within the health jurisdiction. For counties with only one site, enter 1.
ID_SSN Enter the client's social security number (SS J). Do not use dashes, commas, spaces, etc. If the client does not have a SSN, enter
900, your health jurisdiction's two digit nun ber, plus four more number. (e.g. 900010001). Continue to use that number for the
gorrespondinE client. IThe client's ID SSN number must be un.que tot at patient in -order to avoid duplication.
IDSTRING This field is needed to generate an encrypted unique number. This 11 -character string is created by entering the following
characters: (1) First letter of first name; (2) Third letter of first name, if blank use middle initial, if no middle initial, use 9; (3)
First letter of last name; (4) Third letter of last name, if blank, use 9; (5-6) Month of birth as two digits, e.g. 07 for July; (7-8)
Day of birth as two digits, e.g. 01, 09; (9-10) year of birth as two digits, e.g. 45 for 1945; (11) Gender: 1=male; 2=female;
0=unknown.
Example: Joe Jones, male, born January 6, 1954 IDSTRING=J E J N 0 10 6 5 4 1
NDC Enter the National Drug Code. (See "AIDS Drug Assistance Program Formulary" or ask your local pharmacist for assistance
DRUG Enter only the code number used for each &M of ADAP drug (i.e., "1301" for zidovudine, AZT). See "AIDS Drug
(optional) Assistance Program Maximum Reimbursement Amounts" listing.
bMM Enter the client's birth month as a two digit number.
bDD Enter the client's birthday as a two digit number.
bYY Enter the last two digits of the client's year of birth as a two digit number.
RACE Enter a two digit number. Codes and definitions are as follows:
"10" White/Non Hispanic "20" Black/Non Hispanic "30" Hispanic/Latino
"40" Asian/Pacific Islander "50" Native American/Alaskan/Aleutian
"60" Other "99" Unknown
SEX Enter a one digit number. Codes and definitions are as follows.
(Gender) I = Male 2 = Female 3 = Other 6 = Refused to report 9 = Unknown
Pvt_ins Enter the one digit number to the question "Does the client have third -party, private health insurance, whether or not the
insurance covers drug prescriptions?" Codes and definitions are as follows:
1 = Yes 2 = No 9 = Unknown
MediCal Enter the one digit number response to the question "Does the client receive MediCal?" Codes and definitions are as follows:
1=Yes 2 = No 3'= MediCal approval pending spend down requirement 9 = Unknown
Pub_ins Enter the one digit number response to the question "Does the client have other public insurance?" Includes VA, Medicare,
CHAMPUS, Indian Health. Codes and definitions are as follows: 1 = Yes 2 = No 9 = Unknown
U DISP Enter the total units dispensed as noted on exhibit F-3 "AIDS Drug Assistance Program Formulary".
U—$ Enter the drug's unit price. Refer to the "AIDS Drug Assistance Program Formulary" for guidance on the allowable maximum
unit price that the Office of AIDS will reimburse local health jurisdictions
dMM Enter the month the drug was dispensed as a two digit number.
dDD Enter the day the drug was dispensed as a two digit number.
dYY Enter the year the drug was dispensed as a two digit number.
AGI This refers to the client's last reported annual gross income to determine the client's eligibility for drugs.
D Fee Enter the dispensing fee billed by the pharmacist. Note: For a prescription of a nebulizer, D Fee must = $0.
Drug Cst Enter the drug cost calculated by multiplying the unit price with the number of units of drug dispensed.
Tot Cost Enter the total of the net drug cost (Drug Cst) and the dispensing fee (D Fee).
Zipcode Five digit number for residence. If unknown use 99999.
rMM Enter the month of the invoice that this record supports.
rYY Enter the year of the invoice submitted to the Office of AIDS as a two digit number.
nMM Enter the month when the client first received ADAP service or enrolled into the program as a two digit number.
nDD Enter the day when the client first received ADAP service or enrolled into the program as a two digit number.
nYY Enter the year when the client first received ADAP service or enrolled into the program as a two digit number.
L mm Enter the most recent month of contact for which client's descriptive data was updated as a two digit number.
L dd Enter the most recent day of the month of contact for which client's descriptive data was updated as a two digit number.
1 L-yy - Enter the most recent year of contact for which client's descriptive data was updated as a two digit number.
URNj Enter a'nine-digit alphanumerical encrypted identifier generated by HRSA program using "Idstring"
(optional)
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS' EXHIBIT F-3
t -
NDC IGENERIC DRUG
DRUG LABEL
STD. PACKAGING
UNIT PRICE
'00081099341 !ACYCLOVIR
ZOVIRAX5%OINTMENT
3.0 gm OINTMENT
5.4416 per gm
000810993941ACYCLOVIR
ZOVIRAX5%OINTMENT
15.0 gmOINTMENT
2.5164 per gm
00173099341 !ACYCLOVIR
ZOVIRAX5%OINTMENT
3.0 gm OINTMENT
5.4416 per gm
00173099394 !ACYCLOVIR
ZOVIRAX 5% OINTMENT
15.0 gm OINTMENT
2.5164 per gm
00472008216 ;ACYCLOVIR
ACYCLOVIR 200MG/5ML SUSP
473.0 ml SUSP, ORAL
0.1672 per ml
00081095396 JACYCLOVIR
ZOVIRAX 200MG/5ML SUSP
480.0 ml SUSP, ORAL
0.1879 per ml
00173095396 JACYCLOVIR
ZOVIRAX 200MG/5ML SUSP
480.0 ml SUSP, ORAL
0.1879 per ml
59911583103 JACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE
0.9282 each
00054208025 JACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE
0.9282 each
00054808025 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE
0.9282 each
00081099155 JACYCLOVIR
ZOVIRAX 200MG CAPSULE.
1.0 CAPSULE
1.0314 each
00081099156 JACYCLOVIR
ZOVIRAX 200MG CAPSULE
1.0 CAPSULE
1.0314 each
00093004401 JACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE
0.9282 each
00172426660 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE
0.9075 each
00172426670 ACYCLOVIR:
- ACYCLOVIR 200MG CAPSULE-.
1.0 CAPSULE_
0.9075 each
00172426680 ACYCLOVIR - J
--c ACYCLOVIR 200MG CAPSULE,_ . , :
1:0 CAPSULE=
i 0.9075 each -
00173099155 ACYCLOVIR
ZOVIRAX 200MG CAPSULE -
1.0 CAPSULE
1:0314 each.
00173099156 ACYCLOVIR
ZOVIRAX 200MG CAPSULE-
1.0 CAPSULE
{ •"1.0314 each
00364269201 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE.
1.0 CAPSULE .=
" 0.9282 each
00378220001 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE;
_- 0.9281 each,
00378220005 JACYCLOVIR -
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE =
0:9281 each
49884046001 ACYCLOVIR-
ACYCLOVIR 200MG CAPSULE'
1.0 CAPSULE _:
0.9282 each.•.
49884046005 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE _
-:• 0.9282 each'
49884046010 ACYCLOVIRACYCLOVIR
200MG CAPSULE
1.0 CAPSULE
0.9282 each -
55370055707 ACYCLOVIR
- ACYCLOVIR 200MG CAPSULE..
1.0 CAPSULE
_ 0.8764 each -
55370055709 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE
0.8764 each
55953094040 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE.
0.9234 each
55953094041 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE
1.0 CAPSULE- -
,': 0.9234 each,
55953094070 ACYCLOVIR
ACYCLOVIR 200MG CAPSULE.
1.0 CAPSULE
0.9234 each
00081094955 ACYCLOVIR
ZOVIRAX 400MG TABLET,
1.0 TABLET
:' 2-0015 each
00172426760 ACYCLOVIR:ACYCLOVIR
400MG TABLET- _ - •=
1.0TABLET-i
l.7613 each
00172426770 ACYCLOVIR
ACYCLOVIR 400MG TABLET . - =
1:0 TABLET;
t r ':1.7613 each
00172426780 ACYCLOVIR
ACYCLOVIR 400MG TABLET. -: '
1.OTABLET i
1 ; J.. 1J613 each-:
00173094955 ACYCLOVIR'.', ... f
r3 -: ZOVIRAX400MG;TABLET)G"��=�.,,. ,,I
1:O.TABLET,"
>,7 ' x2.0015each'
00364268901 ACYCLOVIR -- "'
„ '; t - ` ' ACYCLOVIR 400MG TABLET ° _t":
1.0TABLEt `
"r + i-1.8012 each
00364268905 ACYCLOVIR
ACYCLOVIR 400MG TABLET
1.0 TABLET "
1:8012 each
00378146401 ACYCLOVIR
ACYCLOVIR 400MG TABLET
1.0 TABLET
1.8012 each
49884048701 ACYCLOVIR
ACYCLOVIR 400MG TABLET
1.0 TABLET
1.8013 each
49884048705 ACYCLOVIR
ACYCLOVIR 400MG TABLET
1.0 TABLET
1.8013 each
49884048710 ACYCLOVIR
ACYCLOVIR 400MG TABLET
1.0 TABLET
1.8013 each
55953094340 ACYCLOVIR
ACYCLOVIR 400MG TABLET
1.0 TABLET
1.7917 each
55953094341 ACYCLOVIR
ACYCLOVIR 400MG TABLET
1.0 TABLET
1.7917 each
55953094370 ACYCLOVIR
- ACYCLOVIR400MG-TABLET1.0
TABLET
1.7917 each
5991 1 31 6304 ACYCLOVIR
ACYCLOVIR 400MG TABLET
1.07ABLET
1.8013 each
59911316404 JACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET.
3.5027 each
00081094501 JACYCLOVIR
ZOVIRAX 800MG TABLET
1.0 TABLET
3.8919 each
00081094555 JACYCLOVIR
ZOVIRAX 800MG TABLET
1.0 TABLET
3.8919 each
00081094556 JACYCLOVIR
ZOVIRAX 800MG TABLET
1.0 TABLET
3.8919 each
00172426860 JACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.4249 each
00172426870 JACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.4249 1 each
00173094555 JACYCLOVIR
ZOVIRAX 800MG TABLET
1.0 TABLET-
3.8919 each
00173094556 JACYCLOVIR
ZOVIRAX 800MG TABLET
1.0 TABLET;
3.8919 each
00364269001 JACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET'
3.6637 each
00378146801 JACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.5025 each
49884047401 1ACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.5027 each
49884047405 (ACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.5027 each
49884047410 JACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.5027 each
.55953094740 JACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.4832 each
55953094741 JACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.4832 each
55953094770 1ACYCLOVIR
ACYCLOVIR 800MG TABLET
1.0 TABLET
3.4832 each
00074442701 JACYCLOVIR SODIUM
ACYCLOVIR SODIUM 500MG VIAL
1.0 VIAL EA
80.0000 each
00081099501 JACYCLOVIR SODIUM
ZOVIRAX 500MG VIAL
1.0 VIAL EA
53.7727 each
00173099501 1ACYCLOVIR SODIUM
ZOVIRAX 500MG VIAL
1.0 VIAL EA
53.7727 each
,00074445201 (ACYCLOVIR SODIUM
ACYCLOVIR SODIUM 1GM VIAL
1.0 VIAL EA
160.0000 each
100081095201 'ACYCLOVIR SODIUM
ZOVIRAX 1000MG VIAL
1.0 VIAL EA
107.5442 each
;00173095201 !ACYCLOVIR SODIUM
ZOVIRAX 1000MG VIAL
1.0 VIAL EA
107.5442 each
00003041120 1AMPHOTERICIN B
FUNGIZONE 3% CREAM
20.0 gm CREAM GM
1.2810 per gm
00003042620 IAMPHOTERICIN B
IFUNGIZONE 3% OINTMENT
120.0 gm OINTMENT
1.2315 per gm
i:\data\hiv_care\nato\adap\pricing\9706.W K1
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
'00003041230 !AMPHOTERICIN B
FUNGIZONE 3% LOTION
30.0 ml LOTION ML
1.1717 per ml
00003043730 !AMPHOTERICIN B
FUNGIZONE IV 50MG VIAL
1.0 VIAL EA
14.5600 each
;00003043732 ;AMPHOTERICIN B
FUNGIZONE IV 50MG VIAL
1.0 VIAL EA
14.5600 each
00013140544 !AMPHOTERICIN B
AMPHOCIN 50MG VIAL
1.0 VIAL EA
32.8106 each
00469233090 ,AMPHOTERICIN B
AMPHOTERICIN B 50MG VIAL
1.0 VIAL EA
30.8750 each
;00702233091 AMPHOTERICIN B
AMPHOTERICIN B 50MG VIAL
1.0 VIAL EA
30.8750 each
'00703978501 tAMPHOTERICIN B
AMPHOTERICIN B 50MG VIAL
1.0 VIAL EA
29.6400 each
39769036320 !AMPHOTERICIN B
AMPHOTERICIN B 50MG VIAL
1.0 VIAL EA
36.6225 each
39822105505 :AMPHOTERICIN B
AMPHOTERICIN B 50MG VIAL
1.0 VIAL EA
19.2375 each
100087116210 JAMPHOTERICIN B
FUNGIZONE 100MG/ML SUSPEN
24.0 ml SUSP, ORAL
1.0016 per ml
00081066518 JATOVAQUONE
MEPRON 750MG/5ML SUSPENSION
210.0 ml SUSP, ORAL
2.4369 per ml
00173066518 JATOVAQUONE
MEPRON 750MG/5ML SUSPENSION
210.0 ml SUSP, ORAL
2.4369 per ml
00081012662 IATOVAQUONE
MEPRON 250MG TABLET
1.0 TABLET
2.6314 each
00069305107 1AZITHROMYCIN
ZITHROMAX 1GM POWDER PACKET
1.0 PACKET
16.2633 each
00069305175 (AZITHROMYCIN
ZITHROMAX 1GM POWDER PACKET
1.0 PACKET
16.2633 each
00069311019 AZITHROMYCIN
ZITHROMAX 100MG/5ML SUSP
15.0 ml SUSPENSION
1.4780 per ml
00069312019 AZITHROMYCIN:
ZITHROMAX 200MG/5ML SUSP..
15.0 ml SUSPENSION
1.4780 per ml.
00069313019 AZITHROMYCIN
ZITHROMAX 200MG15ML SUSP
22.5 ml SUSPENSION
1.4780 per ml
00069314019 AZITHROMYCIN
ZITHROMAX 200MG/5ML SUSP
30.0 ml SUSPENSION
1.4780 per ml
00069305030 AZITHROMYCIN
ZITHROMAX 250MG CAPSULE
1.0 CAPSULE,
5.2372 each
00069305034 AZITHROMYCIN
ZITHROMAX 250MG Z-PAK•
1.0 CAPSULE
5.2372 each
00069305050 AZITHROMYCIN
ZITHROMAX 250MG CAPSULE ..
1.0 CAPSULE:
5.2372 each
00069305086 AZITHROMYCIN
ZITHROMAX 250MG CAPSULE
1.0 CAPSULE
5.2372 each
00069308030 AZITHROMYCIN
ZITHROMAX 600MG TABLET
1.0 TABLET -
12.5660 each
00013161678 BLEOMYCIN SULFATE
BLEOMYCIN SULFATE 15U VIAL.
1.0 VIAL EA
277.8038 each
00015301020 BLEOMYCIN SULFATE
BLENOXANE 15U VIAL
1.0 VIAL EA
277.8415 each
00015301097 BLEOMYCIN SULFATE
BLENOXANE 15U VIAL
1.0 VIAL EA
277.8415 each
00013163686 BLEOMYCIN SULFATE
BLEOMYCIN SULFATE 30U VIAL
1.0 VIAL EA
555.5838 each
00015306301 BLEOMYCIN SULFATE
BLENOXANE 30U VIAL.
1.0 VIAL EA
555.6830 each
61958010101 CIDOFOVIR
VISTIDE 75MG/ML.VIAL
5.0 ml VIAL ML
134.2920 per ml
00074316313 CLARITHROMYCIN,.:'
BIAXIN 125MG/5ML SUSPENSION
100.0 ml SUSPENSION
0.2538 per ml
00074316350 CLARITHROMYCIW is .. `.
BIAXIN 125MG/5ML SUSPENSION
50.0 ml SUSPENSION
0.2538 per ml
00074318813 CLARITHROMYCIN..:,,,-, = • - ,
BIAXIN 250MG/5MLSUSPENSION:
100.0 ml SUSPENSION :'
':: 0.4832 perml-
00074318850 CLARITHROMYCIN,:.-
BIAXIN 250MG15ML SUSPENSION ::
50.0 ml SUSPENSION -
0.4832 er ml
00074336811 CLARITHROMYCIN -.'.i .
BIAXIN 250MG TABLET _:.. , .:'- ..
1.0 -TABLET
2.7450 each
00074336860 CLARITHROMYCIN; :' :::
BIAXIN 250MG TABLET-,,:"., . -
1.0 TABLET
2.7450 each . .
00074258611 CLARITHROMYCIN
BIAXIN 500MG TABLET . -' '
1.0 TABLET
2.7450 each
00074258641 CLARITHROMYCIN.
BIAXIN 500MG TABLET
1.0 TABLET
2.7450 each
00074258660 CLARITHROMYCIN
BIAXIN 500MG TABLET
1.0 TABLET
2.7450 each
00009033102 CLINDAMYCIN HCL
CLEOCIN HCL 75MG CAPSULE
1.0 CAPSULE
0.5495 each
00332316909 1CLINDAMYCIN HCL
CLINDAMYCIN HCL 75MG CAPS
1.0 CAPSULE
0.4180 each
00677133201 CLINDAMYCIN HCL
CLINDAMYCIN HCL 75MG CAPS
1.0 CAPSULE
0.4636 each
51432091003 CLINDAMYCIN HCL
CLINDAMYCIN HCL75MG CAPS
1.0 CAPSULE
0.4228 each
00009022501 CLINDAMYCIN HCL.-
CLEOCIN HCL 150MG CAPSULE
1.0 CAPSULE
0.7043 each
00009022502 CLINDAMYCIN HCL.-
CLEOCIN HCL.150MG CAPSULE
1.0 CAPSULE
0.7043 each
00009022503 CLINDAMYCIN HCL -
CLEOCIN HCL 150MG CAPSULE
1.0 CAPSULE
0.7043 each
00182120201 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00182190601 CLINDAMYCIN HCL:
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00332317109 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00364233701 CLINDAMYCIN HCL.
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00405423301 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00536015501 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00591570801 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00603290921 1CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00615131013 1CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00677133301 (CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00719126210 (CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00781293701 (CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00839753406 1CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00904383860 1CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
'00904383861 {CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
11845046101 :CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
17236065701 :CLINDAMYCIN HCL-
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
,51079059820 ,CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
51432091103 :CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
:54274013410 1CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
56126041811 :CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
159762332801 ;CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
;61392071430 .CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
i:\data\hiy_care\nato\adap\pdcing\9706.W K1 2
`. AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS - EXHIBIT F-3
61392071431 1CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
161392071432 1CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
161392071439 iCLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
:61392071445 !CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
61392071451 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
61392071454 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
:61392071460 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
61392071490 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
62584033801 CLINDAMYCIN HCL
CLINDAMYCIN HCL 150MG CAPS
1.0 CAPSULE
0.7043 each
00009039502 CLINDAMYCIN HCL
CLEOCIN HCL 300MG CAPSULE
1.0 CAPSULE
2.0219 each
00009039513 CLINDAMYCIN HCL
CLEOCIN HCL 300MG CAPSULE
1.0 CAPSULE
2.0219 each
00009039514 CLINDAMYCIN HCL
CLEOCIN HCL 300MG CAPSULE
1.0 CAPSULE
2.0219 each
00009076004 CLINDAMYCIN PALMITATE
CLEOCIN 75MG/5ML GRANULES
100.0 ml SOLN, ORAL
0.1073
per ml
00003294211 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
2.0 ml VIAL ML
2.0900
per ml
00003294221 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL '
4.0 ml VIAL ML
1.9400
per ml
00003294222 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL,..:
6.0 MI VIAL (ML).
1.6847
per ml
00009072805 CLINDAMYCIN PHOSPHATE -
:.','i.: + i ` CLEOCIN PHOS 150MG/ML.VIAL � ":.;
60.0 mI.VIAL ML
^.2.4157
per ml
00009072809 1CLINDAMYCIN PHOSPHATE
CLEOCIN PHOS 150MG/ML VIAL -
60.0 ml VIAL ML
2.4157
per ml
00009077520 CLINDAMYCIN PHOSPHATE.
CLEOCIN PHOS 150MG/MLVIAL =
4.0 ml VIAL ML
, 2.7725
per ml
00009077526 CLINDAMYCIN PHOSPHATE.
= CLEOCIN PHOS 150MG/ML VIAL =
4.0 ml VIAL ML
2.7725
per ml
00009087021 CLINDAMYCIN PHOSPHATE
CLEOCIN PHOS 150MG/ML VIAL.::
2.0 ml VIAL ML
3.0300
per ml
00009087026 CLINDAMYCIN PHOSPHATE:
_ CLEOCIN PHOS 150MG/MC VIAL :
• 2.0 mI VIAL ML
3.0300
er ml
00009090211 CLINDAMYCIN PHOSPHATE
CLEOCIN PHOS 150MG/MLVIAL =
6.0 ml VIAL ML
2.46501perml
00009090218 CLINDAMYCIN PHOSPHATE
CLEOCIN PHOS 150MG/MLVIAL
6.0 ml VIAL ML
2.4650
per ml
00009312401 CLINDAMYCIN PHOSPHATE
CLEOCIN PHOS 150MG/ML VIAL -
4.0 ml VIAL (ML),
2.9400
er ml
00009312403 CLINDAMYCIN PHOSPHATE.
CLEOCIN PHOS 150MG/ML VIAL -
4.0 ml VIAL ML
2.9400
per ml
00009344701 CLINDAMYCIN PHOSPHATE
CLEOCIN PHOS 150MG/ML VIAL -
6.0 ml VIAL ML
2.5883
per ml
00009344703 CLINDAMYCIN PHOSPHATE
CLEOCIN PHOS 150MG/ML.VIAL
6.0 ml VIAL ML
2.5883
per ml
00074405001 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/MLVL
2.0 ml VIAL ML
5.2000
per ml
00074405101 CLINDAMYCIN PHOSPHATE.
" CLINDAMYCIN PH 150MG/ML VL : : "
4.0 ml VIAL ML
4.7625
per ml
00074405201 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH"150MG/ML VL' ('- ,
6.0 ml VIAL ML
4.2517
per ml
00074405303 CLINDAMYCIN PHOSPHATE.,.-,-.-)',..",",,,;-,:
CLINDAMYCIN PH,150MG/MLVL,',; c 2.0 ml VIAL ML
:• 5:2400
erml
00074405403 CLINDAMYCIN PHOSPHATE:•-
':. ;:' •' - CLINDAMYCIN PHm150MG/ML VL' iCU . 4.0 mI.VIAL" ML .
4.8150
er ml
00074405503 CLINDAMYCIN PHOSPHATE.
: '- CLINDAMYCIN PHl50MG/ML VL•';'•:.;
? 6.0 mI.VIAL ML °
4.2933
per ml -
00074419701 CLINDAMYCIN PHOSPHATE '
CLINDAMYCIN PH'l150MG/MLVL,-F`: 60.0"mi.VIAL'ML -.
1 - +,: 3.4868
perml
00186145004 CLINDAMYCIN PHOSPHATE: '-'.':':::':: CLINDAMYCINPH:150MG/MLVL:;:".. 2.0mI.VIAL ML
:- 0.5938
perml
00186145104 CLINDAMYCIN PHOSPHATE
: CLINDAMYCIN PH 150MG/MLVLr":'' , 4.0 mI.VIAL (ML).
0.53441per
ml
00186145204 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150M"L-VL '
6.0 ml VIAL ML .
0.47501
per ml
00186145301 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
60.0 ml VIAL ML
0.4354
per ml
00205280124 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
60.0 ml VIAL ML
2.7609
per ml
00205280147 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML.VL
6.0 ml VIAL ML
3.1785
per ml
00205280183 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL :
2.0 ml VIAL ML
3.4259
per ml
00205280193 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
4.0 ml VIAL ML
3.1172
per ml
00469282010 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL '
2.0 ml VIAL ML
1.9594
per ml
00469282070 CLINDAMYCIN PHOSPHATE.
CLINDAMYCIN PH 150MG/ML VL "
4.0 ml VIAL M
1 1.8703
per ml
00469282080 CLINDAMYCIN PHOSPHATE.
CLINDAMYCIN PH 150MG/ML VL '; •
6.0 ml VIAL ML
1.8406
per ml
00590511057 CLINDAMYCIN PHOSPHATE.
CLINDAMYCIN PH 300MG/2ML VL"' :
2.0 mI.VIAL ML
2.0781
per ml
00590511065 CLINDAMYCIN PHOSPHATE.
- CLINDAMYCIN PH 600MG/4ML VL.
4.0 ml VIAL ML
1.8703
per ml
00590511073 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 900MG/6ML VL
6.0 ml VIAL ML
1.6625
per ml
00641010625 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 300MG/2ML VL
2.0 ml VIAL ML
3.2656
per ml
00641226745 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 600MG/4ML VL"
4.0 ml VIAL ML
2.9688
per ml
00641226845 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 900MG/6ML VL
6.0 ml VIAL ML
2.63231per
ml
00641226941 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 9GW60ML VL
60.0 ml VIAL' ML
1.9792
per ml
00703910204 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
2.0 ml VIAL ML
2.8614
per ml
00703911004 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
4.0 ml VIAL ML
2.5536
per ml
00703912004 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
6.0 ml VIAL ML
2.2268
per ml
00703913801 CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
60.0 ml VIAL ML
2.7360
per ml
00703914801 1CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
I 100.0 ml VIAL ML
2.7360
per ml
00719310690 1CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 600MG14ML VL
4.0 ml VIAL ML
4.1325
per ml
100719310795 1CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 900MG/6ML VL
6.0 ml VIAL ML
3.7050
per ml
,39769022602 1CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
2.0 ml VIAL ML
5.0825
per ml
139769022604 1CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
4.0 ml VIAL ML
4.6550
per ml
39769022606 1CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
6.0 ml VIAL ML
4.1563
per ml
39769022660 JCLINDAMIYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
60.0 ml VIAL ML
3.4061
per ml
55390020025 1CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
2.0 ml VIAL ML
1.9855
per ml
;55390020125 1CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
4.0 ml VIAL ML
1.8739per
ml
155390020225 ;CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 150MG/ML VL
6.0 ml VIAL ML
1.4947
per ml
00028010801 !CLOFAZIMINE
LAMPRENE 50MG CAPSULE
1.0 CAPSULE
0.1338 each
+00028010901 CLOFAZIMINE
LAMPRENE 100MG CAPSULE
1.0 CAPSULE
0.2203 each
i:\data\hiv_care\nato\adap\pdcing\9706.WK1 3
10
AID$ DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
100026309445 1CLOTRIMAZOLE
MYCELEX-G 1% CREAM
45.0 gm CREAM W/ APP
0.2956 per gm
;00026309446 CLOTRIMAZOLE
MYCELEX-G 1% CREAM
90.0 gm CREAM W/APP
0.2580 per gm
00085088709 (CLOTRIMAZOLE
GYNE-LOTRIMIN 1% CREAM
45.0 gm CREAM W/ APP
0.2027 per gm
!00085088711 1CLOTRIMAZOLE
GYNE-LOTRIMIN 1% CREAM
45.0 gm CREAM W/ APP
0.2027 per gm
00085088713 1CLOTRIMAZOLE
GYNE-LOTRIMIN 1% CREAM
45.0 gm CREAM W/ APP
0.2027 per gm
;00085088721 !CLOTRIMAZOLE
GYNE-LOTRIMIN 1% CREAM
45.0 gm CREAM W/ APP
0.2027 er m
00085097701 CLOTRIMAZOLE
FEMCARE CREAM
45.0 gm CREAM W/ APP
0.2027 per gm
00085097720 CLOTRIMAZOLE
FEMCARE CREAM
45.0 gm CREAM W/ APP
0.2027 per gm
00168014446 CLOTRIMAZOLE
CLOTRIMAZOLE -7 CREAM
45.0 gm CREAM W/ APP
0.3040 per gm
00182503060 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.2761 per gm
00182503160 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.2761 per gm
00192250245 CLOTRIMAZOLE
MYCELEX-7 1% CREAM
45.0 gm CREAM W/ APP
0.2534 per gm
00536523026 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.2280 per gm
00839783752 CLOTRIMAZOLE
CLOTRIMAZOLE -71% CREAM
45.0 gm CREAM W/ APP
0.2238 per gm
00904777645 CLOTRIMAZOLE
CLOTRIMAZOLE I% CREAM
45.0 gm CREAM W/ APP
0.2977 per gm
10939079311 CLOTRIMAZOLE
CLOTRIMAZOLE 1%CREAM .
45.0 gm CREAM W/ APP
0.1265 pergm
11822328110 CLOTRIMAZOLE
RA CLOTRIMAZOLE. 1'/ a CREAM
45.0 gm CREAM W/ APP
0.1180 er am
12810071041 CLOTRIMAZOLE
OSCO CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.2109 per gm
15127020001 CLOTRIMAZOLE
SB CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.2109 per gm
16500002502 CLOTRIMAZOLE
MYCELEX-7 1% CREAM
45.0 gm CREAM W/ APP
0.2534 per gm
16500002508 CLOTRIMAZOLE
MYCELEX-7 1 % CREAM
45.0 gm CREAM W/ APP
0.2534 per gm
16500025020 CLOTRIMAZOLE
MYCELEX-7 1% CREAM..
45.0 gm CREAM W/ APP
0.2534 per gm
19458900901 CLOTRIMAZOLE
CLOTRIMAZOLE -1% CREAM.
45.0 gm CREAM W/ APP,
0.1898 per gm
19458901001 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.1898 per gm
23317071041 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.2280 per gm
23317071063 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.2280 per gm
34575052738 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.1898 per gm
34575052749 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.1898 per gm
37097071041 CLOTRIMAZOLE
SAV -ON CLOTRIMAZOLE 1% CRM
45.0 gm CREAM W/ APP
0.2109 per gm
37205012613 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0 gm CREAM W/ APP
0.1253 per gm
41280022918 CLOTRIMAZOLE
OSCO CLOTRIMAZOLE 1% CREAM.
45.0 gm CREAM W/ APP
0.2109 per gm
49348079376 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM: -. -..
45.0 gm CREAM W/ APP
0.1265 per gm
51672200306 CLOTRIMAZOLE
CLOTRIM I% VAGINAL CREAM..
45.0 gm.CREAM W/ APP
0.2164 pergm
52297044413 CLOTRIMAZOLE.
HM CLOTRIMAZOLE -7 CREAM
45.0 gm CREAM W/ APP
0.1714 pergm
52297044513 CLOTRIMAZOLE.:,_ -
:.. FV CLOTRIMAZOLE -7 CREAM , -
45.0 gm CREAM W/ APP
: ,:: 0.1714 pergm
52735025228 CLOTRIMAZOLE-.
FP CLOTRIMAZOLE.1% CREAM -
: 45.0 m CREAM W/APP=
, 0.1457er. m
94441022918 CLOTRIMAZOLE
SAV -ON CLOTRIMAZOLE 1%CRM -
45.0 gm CREAM W/ APP
0.2109 per gm
00085088710 CLOTRIMAZOLE
GYNE-LOTRIMIN 1% CREAM
5.0 gm CREAM W/APPL
0.2443 per gm
00085088723 CLOTRIMAZOLE
GYNE-LOTRIMIN 1% CREAM
5.0 gm CREAM W/APPL
0.2443 1 per gm
00026309822 CLOTRIMAZOLE
MYCELEX TWIN PACK
1.0 COMBO PAK
15.5420 each
00085105001 CLOTRIMAZOLE
GYNE-LOTRIMIN COMBO PKG
1.0 COMBO PAK
8.5500 each
00085105002 CLOTRIMAZOLE
GYNE-LOTRIMIN COMBO PKG
1.0 COMBO PAK
8.5500 each
00085110201 CLOTRIMAZOLE
GYNE-LOTRIMIN 3 COMBO PKG
1.0 COMBO PAK
10.8300 each
00026309317 CLOTRIMAZOLE
MYCELEX-G VAGINAL 100MG TAB
1.0 TABLET
1.9964 each
00085067004 CLOTRIMAZOLE
GYNE-LOTRIMIN INSERT
1.0 TABLET
1.3029 each
00085067005 CLOTRIMAZOLE
GYNE-LOTRIMIN INSERT
1.0 TABLET
1.3029 each
00085098901 CLOTRIMAZOLE
FEMCARE INSERTS
1.0 TABLET
1.3029 each
00085098902 CLOTRIMAZOLE
FEMCARE INSERTS
1.0 TABLET
1.3029 each
00182703721 CLOTRIMAZOLE
CLOTRIMAZOLE INSERT
1.0 TABLET
1.4318 each
00192250107 CLOTRIMAZOLE
MYCELEX-7 100MG VAGINALTAB
1.0 TABLET
1.6292 each
00839783707 CLOTRIMAZOLE
CLOTRIMAZOLE -7 INSERT
1.0 TABLET
1.4386 each
00904784357 CLOTRIMAZOLE
CLOTRIMAZOLE -7 INSERT
1.0 TABLET--
1.4182 each
10939079411 CLOTRIMAZOLE
CLOTRIMAZOLE INSERT
1.0 TABLET!
0.8129 each
12333948702 CLOTRIMAZOLE
CLOTRIMAZOLE -7 100MG INSERT
1.0TABLETt
0.9486 each
15127020102 CLOTRIMAZOLE
SB CLOTRIMAZOLE INSERT
1.0 TABLET
1.3558 each
16500002501 CLOTRIMAZOLE
MYCELEX-7 100MG VAGINALTAB
1.0 TABLET
1.6292 each
16500025010 CLOTRIMAZOLE
MYCELEX-7 100MG VAGINAL TAB
1.0 TABLET
1.6292 each
19458900801 CLOTRIMAZOLE
CLOTRIMAZOLE INSERT
1.0 TABLET
1.2201 each
34575052736 CLOTRIMAZOLE
CLOTRIMAZOLE INSERT
1.0 TABLET
1.2201 each
49348079436 CLOTRIMAZOLE
CLOTRIMAZOLE INSERT
1.0 TABLET
0.8129 each
50428521716 CLOTRIMAZOLE
CVS CLOTRIMAZOLE -7 INSERT
1.0 TABLET
1.0029 each
00085110901 CLOTRIMAZOLE
GYNE-LOTRIMIN 3 VAG INSERT
1.0 TABLET
3.0400 each
00085110902 CLOTRIMAZOLE
GYNE-LOTRIMIN 3 VAG INSERT
1.0 TABLET
3.0400 each
100026309701 CLOTRIMAZOLE
MYCELEX-G VAGINAL 500MG TAB
1.0 TABLET
13.6705 each
'00026309159 CLOTRIMAZOLE
MYCELEX 1% CREAM
30.0 gm CREAM GM
0.5428 per m
'00026309161 CLOTRIMAZOLE
MYCELEX 1% CREAM
15.0 gm CREAM GM
0.6352 per m
00026309167 (CLOTRIMAZOLE
MYCELEX 1% CREAM
90.0 gm CREAM GM
0.3024[per gm
00067092983 1CLOTRIMAZOLE
DESENEX AF 1% CREAM
15.0 gm CREAM GM
0.3344 er m
;00083092983 1CLOTRIMAZOLE _
DESENEX AF 1% CREAM_
115.0 gm CREAM GM
0.3344 er m
1.\data\hiv_care\nato\adap\pdcing\9706.W Ki 4
.Q
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
00085061302 CLOTRIMAZOLE
LOTRIMIN 1% CREAM
15.0
gm CREAM GM
0.8145
per
gm
.00085061303 iCLOTRIMAZOLE
LOTRIMIN 1% CREAM
90.0
gm CREAM GM
0.3830
per
gm
!00085061304 iCLOTRIMAZOLE
LOTRIMIN 1% CREAM
45.0
gm CREAM GM
0.5592
per
gm
:00085061305 'CLOTRIMAZOLE
LOTRIMIN 1% CREAM
30.0
gm CREAM GM
0.6913
per
gm
00085096315 :CLOTRIMAZOLE
LOTRIMIN AF 1% CREAM
12.0
gm CREAM GM
0.4885
per
gm
,00085096317., LOTRIMAZOLE
LOTRIMIN AF 1% CREAM
24.0
gm CREAM GM
0.4885
per
gm
00182509451 ;CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
15.0
gm CREAM GM
0.5922
per
gm
00182509456 (CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.5035
per
qm
00182509460 1CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0
gm CREAM GM
0.4011
per
gm
00182509533 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
15.0
gm CREAM GM
0.5922
per
gm
00182509534 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.5035
per
gm
00536299020 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
15.0
gm CREAM GM
0.5934
per
gm
00536299026 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0
gm CREAM GM
0.4072
per
gm
00536299028 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.5038 1
per
gm
00536299520 CLOTRIMAZOLE
CLOTRIMAZOLE AF 1% CREAM
15.0
gm CREAM GM
0.5934
per
gm
00536299528 CLOTRIMAZOLE
CLOTRIMAZOLE AF 1% CREAM
30.0
gm CREAM GM
. 0.5038
per
gm
00603773074 CLOTRIMAZOLE ,
CLOTRIMAZOLE.1% CREAM :::
15.0
m CREAM GM
:.0.4972
per
gm
00603773078 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM -
30.0
gm CREAM GM
0.4243
per
gm
00603773083 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0
gm CREAM GM
: 0.3536
per
gm
00839779449 CLOTRIMAZOLE
_ CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
. : 0.5083
per
gm
00839783647 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
15.0
gm CREAM GM
..1 0.5979
per
gm
00839783649 CLOTRIMAZOLE.
CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.5083
per
gm
00839783652 CLOTRIMAZOLE'
CLOTRIMAZOLE 1% CREAM
45.0
gm CREAM GM
; 0.4102
per
gm
00904779431 CLOTRIMAZOLE
CLOTRIMAZOLE 1%CREAM
30.0
gm CREAM (GM).
0.4766
per
gm
00904779436 CLOTRIMAZOLE-
CLOTRIMAZOLE 1%CREAM
15.0
gm CREAM GM
0.5605
per
gm
00904779445 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0
gm CREAM GM
0.3958
per
gm
00904782231 CLOTRIMAZOLE
CLOTRIM ANTIFUNGAL CREAM
30.0
gm CREAM GM
0.4766
per
gm
00904782236 CLOTRIMAZOLE
CLOTRIM ANTIFUNGAL CREAM
15.0
gm CREAM GM
0.5605
per
10939082711 CLOTRIMAZOLE
CLOTRIMAZOLE AF 1% CREAM -
15.0
m CREAM GM
: 0.3667
per
11822307820 CLOTRIMAZOLE
RA CLOTRIMAZOLE AF CREAM'-
30.0
m CREAM GM
0.184612333949201
CLOTRIMAZOLE
CLOTRIMAZOLE 1%CREAM
15.0
m CREAM GM
:- .'c.0.284412333949219
CLOTRIMAZOLE•.
:_ CLOTRIMAZOLE 1% CREAM . •.. i. _
15.0
m CREAM GM
, , :•-.!:0.284412333949301
CLOTRIMAZOLE,+
".: CLOTRIMAZOLE 1%.CREAM. . ' ,
30.0
m CREAM GM
i.,<;.a:•` ,.0.2055
12333949319- CLOTRIMAZOLE-.
- CLOTRIMAZOLE:1%CREAM'•'
30.0' m.CREAM GM
°; : , -0.2055
per
gm
12810020021 CLOTRIMAZOLE
OSCO CLOTRIMAZOLEAFCREAM ; �
15:0
m.CREAM GM
:» ^ 0.3794
er
m
12810020022 CLOTRIMAZOLE
7 1 ;'- 1. _ OSCO rt: 30.0
CREAM GM,��j_
is .0.2530
er
m
16500002415 CLOTRIMAZOLE
MYCELEX 1% CREAM - , .
15.0
gm CREAM (GM),
_ 0.2965
per
gm
19458908901 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.2652
per
gm
24385020501 CLOTRIMAZOLE
ANTI -FUNGAL CREAM
15.0
gm CREAM GM
0.3414
per
gm
37205016010 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.1722
per
gm
41280020228 CLOTRIMAZOLE
OSCO CLOTRIMAZOLE AF CREAM
15.0
gm CREAM GM
0.3794
per
gm
41280020229 CLOTRIMAZOLE
OSCO CLOTRIMAZOLE AF CREAM
30.0
gm CREAM GM
0.2530
per
gm
48135926970 CLOTRIMAZOLE
TREAS CLOTRIMAZOLE 1% CRM
15.0
gm CREAM GM
0.2571
per
gm
49348082769 CLOTRIMAZOLE
CLOTRIMAZOLE AF 1% CREAM
15.0
gm CREAM GM
0.3667
per
gm
49614041505 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM . 1
15.0
gm CREAM GM
0.1944
per
gm
50428211003 CLOTRIMAZOLE
CVS CLOTRIMAZOLE 1% CREAM
15.0
gm CREAM GM
_0.2806
per
gm
50428211037 CLOTRIMAZOLE
CVS CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.1872
per
gm
51672127501 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
15.0
gm CREAM GM
0.4972
per
gm
51672127502 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.4243
per
gm
51672127506 CLOTRIMAZOLE
CLOTRIMAZOLE 1%CREAM
45.0
gm CREAM GM
0.3431
per
gm
51672127507 CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
90.0
gm CREAM GM
0.2349
per
gm
51672200201 CLOTRIMAZOLE
CLOTRIMAZOLE 1%CREAM
15.0
gm CREAM GM
0.4972
per
gm
51672200202 1CLOTRIMAZOLE
CLOTRIMAZOLE 1%CREAM
30.0
gm CREAM GM
0.4243
per
gm
52297049910 1CLOTRIMAZOLE
HM CLOTRIMAZOLE AF 1% CREAM
30.0
m CREAM GM
0.1717
per
qm
52297050010 1CLOTRIMAZOLE
FV CLOTRIMAZOLE AF 1% CREAM
30.0
m CREAM GM
0.1717
per
gm
52735025425 1CLOTRIMAZOLE
FP CLOTRIMAZOLE AF 1% CREAM
15.0
gm CREAM GM
0.5630
per
gm
59930157001 1CLOTRIMAZOLE
CLOTRIMAZOLE I% CREAM
15.0
gm CREAM GM
0.4972
per
gm
59930157002 1CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
30.0
gm CREAM GM
0.4243
per
gm
59930157003 1CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM
45.0
gm CREAM GM
0.3431
pergm
59930157009 1CLOTRIMAZOLE
CLOTRIMAZOLE 1%CREAM
90.0
gm CREAM GM
0.2349
per
gm
87701080036 CLOTRIMAZOLE
BL ANTI -FUNGAL CREAM
15.0
gm CREAM GM
0.3414
per
gm
87701080042 'CLOTRIMAZOLE
GNP ANTI -FUNGAL CREAM
15.0
gm CREAM GM
0.3414
per
gm
94441020228 iCLOTRIMAZOLE
SAV -ON CLOTRIMAZOLE AF CRM
15.0
gm CREAM GM
0.3794
per
gm
94441020229 1CLOTRIMAZOLE
SAV -ON CLOTRIMAZOLE AF CRM
30.0
gm CREAM GM
0.2530
per
gm
100026309210 (CLOTRIMAZOLE
MYCELEX 1% SOLUTION
10.0 ml SOLUTION
0.8417
per mi
i00026309230 :CLOTRIMAZOLE
MYCELEX 1% SOLUTION
30.0 ml SOLUTION
0.5887
per ml
00085018202 'CLOTRIMAZOLE
LOTRIMIN 1% SOLUTION
10.0 ml SOLUTION
1.0764
per ml
;00085018204 ;CLOTRIMAZOLE
LOTRIMIN 1% SOLUTION
30.0 ml SOLUTION
0.7461
per ml
00085065606 ;CLOTRIMAZOLE
LOTRIMIN AF 1% SOLUTION
10.0 ml SOLUTION
1.0764
per ml
i:\data\hiv_care\nato\adap\pdcing\9706.WK1 5
,*
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
00093024831 !CLOTRIMAZOLE
CLOTRIMAZOLE 1% SOLUTION
30.0 ml SOLUTION
0.4915 per ml
'00093024843 ;CLOTRIMAZOLE
CLOTRIMAZOLE 1% SOLUTION
10.0 ml SOLUTION
0.7030 per ml
00884319701 ;CLOTRIMAZOLE
FUNGOID 1% SOLUTION
30.0 ml SOLUTION
0.5130 per ml
:16500002410 1CLOTRIMAZOLE
MYCELEX 1% SOLUTION
10.0 ml SOLUTION
0.4448 per ml
;51672126003 ,CLOTRIMAZOLE
CLOTRIMAZOLE 1% SOLUTION
30.0 ml SOLUTION
0.4915 per ml
00085070702 1CLOTRIMAZOLE
LOTRIMIN 1% LOTION
30.0 ml LOTION ML
0.7809 per ml
;00085087206 (CLOTRIMAZOLE
LOTRIMIN AF 1% LOTION
20.0 ml LOTION ML
0.3848 per ml
00026309538 1CLOTRIMAZOLE
MYCELEX 10MG TROCHE
1.0 TROCHE
0.7340 each
00026309555 CLOTRIMAZOLE
MYCELEX 10MG TROCHE
1.0 TROCHE
0.7340 each
;00026309556 CLOTRIMAZOLE
MYCELEX 10MG TROCHE
1.0 TROCHE
0.7340 each
00085092401 CLOTRIMAZOLE/BETAMET DIPROP
LOTRISONE CREAM
15.0 gm CREAM GM
1.2686 per gm
00085092402 CLOTRIMAZOLE/BETAMET DIPROP
LOTRISONE CREAM
45.0 gm CREAM GM
0.9029 per gm
00013560693 CYCLOPHOSPHAMIDE
NEOSAR 100MG VIAL
1.0 VIAL EA
5.1181 each
00015050041 CYCLOPHOSPHAMIDE
CYTOXAN 100MG VIAL
1.0 VIAL EA
5.8834 each
00015053941 CYCLOPHOSPHAMIDE
CYTOXAN LYOPHILIZED 100MG
1.0 VIAL EA
5.8834 each
00087050001 CYCLOPHOSPHAMIDE
CYTOXAN 100MG VIAL
1.0 VIAL EA
4.8458 each
00641226241 CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE.100MG VIAL
1.0 VIAL EA
3.7406 each
00013561693 CYCLOPHOSPHAMIDE
NEOSAR 200MG VIAL
1.0 VIAL EA
9.7256 each
00015050141 CYCLOPHOSPHAMIDE
CYTOXAN 200MG VIAL
1.0 VIAL EA
11.1739 each
00015054641 CYCLOPHOSPHAMIDE
CYTOXAN LYOPHILIZED 200MG-.
1.0 VIAL EA
11.1739 each
00641226341 ICYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE 200MG VIAL
1.0 VIAL EA
7.1048 each
00013562693 CYCLOPHOSPHAMIDE
NEOSAR 500MG VIAL -
1.0 VIAL EA
20.4250 each
00015050241 CYCLOPHOSPHAMIDE
CYTOXAN 500MG VIAL .
1.0 VIAL EA
23.4537 each
00015054741 CYCLOPHOSPHAMIDE
CYTOXAN LYOPHILIZED 500MG
1.0 VIAL EA
23.4537 each
00641226441 CYCLOPHOSPHAMIDE:
CYCLOPHOSPHAMIDE 500MG VIAL
1.0 VIAL EA
14.9316 each
00013563670 CYCLOPHOSPHAMIDE.
NEOSAR 1GM VIAL
1.0 VIAL EA
40.8619 each
00015050541 CYCLOPHOSPHAMIDE
CYTOXAN 1 G VIAL
1.0 VIAL EA
46.9074 each
00015054841 CYCLOPHOSPHAMIDE
CYTOXAN LYOPHILIZED 1GM
1.0 VIAL EA
46.9074 each
00641226541 CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE.iGM VIAL.
1.0 VIAL EA
29.8633 each
00013564670 CYCLOPHOSPHAMIDE
NEOSAR 2GM VIAL
1.0 VIAL EA
81.7000 each
00015050641 CYCLOPHOSPHAMIDE
CYTOXAN 2GM VIAL
1.0 VIAL EA
93.8490 each
00015054941 CYCLOPHOSPHAMIDE
CYTOXAN LYOPHILIZED 2GM
1.0 VIAL EA
93.8490 each
00013567670 CYCLOPHOSPHAMIDE
NEOSAR 2GM VIAL `_: `.:_
1:0 VIAL EA
81.7000 each
00015050401 ICYCLOPHOSPHAMIDE :. -
CYTOXAN 25MG TABLET":
1.0 TABLET
1.5801 each
00015050301 CYCLOPHOSPHAMIDE:
CYTOXAN 50MG TABLET.."-
1.0 -TABLET-
2.8998 each, .
00015050302: CYCLOPHOSPHAMIDE .'
CYTOXAN 50MG TABLET.
1.0 TABLET-:
2.8998 each
00015050303 CYCLOPHOSPHAMIDE
CYTOXAN 50MG TABLET
1.0 TABLET
2.8998 each
49938010201 DAPSONE
DAPSONE 25MG TABLET
1.0 TABLET
0.1796 each
49938010101 DAPSONE
DAPSONE 100MG TABLET
1.0 TABLET
0.1876 each
00006762255 DEXAMETHASONE
DECADRON 0.5MG/5ML ELIXIR
100.0 ml ELIXIR
0.11181perml
00006762266 DEXAMETHASONE
DECADRON 0.5MG/5ML ELIXIR
240.0 ml ELIXIR
0.11181perml
00052079304 DEXAMETHASONE
HEXADROL 0.5MG/5ML ELIXIR
120.0 ml ELIXIR
0.0558 per ml
00182101344 DEXAMETHASONE.
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0594 per ml
00223649601 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
100.0 ml ELIXIR
0.0270 per ml
00223649602 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0270 per ml
00223649603 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
3840.0 ml ELIXIR
0.0270 per
00364718261 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
100.0 ml ELIXIR
0.0594
00364718276 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0594
00405262577 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0647
00426846600 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
100.0 ml ELIXIR
0.1118
00426846608 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.1118
00472097208 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.1118 per ml
00472097228 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
3840.0 ml ELIXIR
0.1118 per ml
00472097233 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
100.0 ml ELIXIR
0.1118 per ml
00536045259 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0930 per ml
00603114556 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0463 per ml
00677060142 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0623 per ml
00686097233 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
100.0 ml ELIXIR
0.0295 per ml
00719430080 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0594 per ml
;00781640008 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0505 per ml
'00832846600 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
100.0 ml ELIXIR
0.1118 per ml
00832846608 (DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.1118 per ml
;00839604466 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.1074 per ml
00839799766 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.1074 er ml
00904097204 (DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
100.0 ml ELIXIR
0.0708 per ml
.00904097209 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0708per ml
17022210204 (DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0204er ml
;17236074988 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0515 er ml
•51432056019 DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0453 per ml
i:\data\hiy_care\nato\adap\pricing\9706.W K1
I
10
AIDS` DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS. EXHIBIT F-3
52446075656 (DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.0463 per ml
60432046600 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
100.0 ml ELIXIR
0.1118 per ml
60432046608 (DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML ELX
240.0 ml ELIXIR
0.1118 perml
00054317763 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML LIQ
500.0 ml SOON, ORAL
0.0334 per ml
100054816816 (DEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML LIQ
20.0 ml SOL'N, ORAL
0.0334 per ml
,00054817716 IDEXAMETHASONE
DEXAMETHASONE 0.5MG/5ML LIQ
5.0 ml SOON, ORAL
0.0334 per ml
•00054317644 DEXAMETHASONE
DEXAMETHASONE 0.5MG/0.5ML
30.0 ml DROPS
0.4528 per ml
00006002068 DEXAMETHASONE
DECADRON 0.25MG TABLET
1.0 TABLET
0.2393 each
00302140001 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET
1.0 TABLET
0.0321 each
00364039701 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET
1.0 TABLET
0.0399 each
00364039702 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET
1.0 TABLET
0.0399 each
00405431301 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET -
1.0 TABLET. =
0.0420 each
00536358101 IDEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET %
1.0 TABLET--'
0.0494 each
00591544901 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET
1.0 TABLET
0.0399 each
00591544904 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET.
1.0 TABLET
0.0399 each
00814235814 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET.: , 1.0 TABLET_ . -
, 0.0385 each
00839601906 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET i
1.O.TABLET,_ ... _ _
T .0.0404 each
00904024260 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET =.
1.0 TABLET-=
0.0385 each
49884008301 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET.:,
1.0 TABLET _; . • ... _ -
0.0390 each
49884008310 DEXAMETHASONE
- - DEXAMETHASONE 0.25MG-TABLET: , 1.0 -TABLET- ' -.: t -
0.0390 each
51432012603 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET.
1.0 TABLET_ ' -- _ _
0.0299 each
53633008301 DEXAMETHASONE
- DEXAMETHASONE 0.25MG.TABLET,+
1.0 TABLET_
0.0462 each
53633008310 DEXAMETHASONE
- _ DEXAMETHASONE 0.25MG TABLET i;: 1.0 TABLET_
0.0462 each .
53633008311 DEXAMETHASONE
DEXAMETHASONE 0.25MG TABLET:
1.0 TABLET': -
0.0462 each
00006004168 DEXAMETHASONE.
DECADRON 0.5MG TABLET.
1.0 TABLET
0.4474 each
00032320501 DEXAMETHASONE-
DEXONE 0.5MG TABLET. _,
1.0 TABLET
0.0678 each
00054417925 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET
1.0 TABLET
0.1141 each
00054417931 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET
1.0 TABLET
0.1141 each
00054817925 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET - -
1.0 TABLET,
0.1141 each
00182161201 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET -.: , 1.0 TABLET
0.0850 each
00223079001 DEXAMETHASONE.
DEXAMETHASONE 0.5MG TABLET: , _.
1.O TABLET _ . _
0.0641 each
00302140101 DEXAMETHASONE
DEXAMETHASONE 0.5MG_TABLET.1-•.
1.O TABLET
0.0485 each
00364039801 DEXAMETHASONE:.
, ':. DEXAMETHASONE 0.5MG_TABLET:-iA
1.0_TABLET. -- -s..r_ i -
x;, 0.0774 each-
00405431401 DEXAMETHASONE:
;.'.:; DEXAMETHASONE.0.5MG.TABLET::1
1.0 -TABLET`+-%_:_ r -
? ._0.0638 each
00536358201 DEXAMETHASONE
DEXAMETHASONE 0.51VIG.TABLET•-'-�.
1.O.TABLET," .>::.
-A-.,0.0850 each
00591545001 DEXAMETHASONE
+-. DEXAMETHASONE0.5MG_TABLET.r+,.
1'.O;TABLETr_:+__:
_.0.0618 each
00603319021 DEXAMETHASONE,
DEXAMETHASONE 0.5MG TABLET, - '.
1:O TABLET L F.
" 0.0613 each -
00814236214 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET
1.0 TABLET
0.0584 each
00839602006 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET
1.0 TABLET
0.0648 each
00904024360 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET
1.0 TABLET
0.1044 each
17236037301 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET
1.0 TABLET
0.0608 each
49884008401 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET
1.0 TABLET
0.0618 each
49884008410 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET
1.0 TABLET
0.0618 each
51432012803 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET -
1.0 TABLET
0.0470 each
52446013521 DEXAMETHASONE
- DEXAMETHASONE 0.5MG TABLET _ *- 1.0 TABLET
0.0613 each
53633008401 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET:- -. 1.0 TABLET
0.0719 each
53633008410 DEXAMETHASONE
DEXAMETHASONE 0.5MG TABLET 1.0 TABLET
0.0719 each
53633008411 DEXAMETHASONE
DEXAMETHASONE 0.5MG-TABLET - --
1.0 TABLET
0.0719 each
00006006312 DEXAMETHASONE
DECADRON 0.75MG TABLET
1.0 TABLET
0.5593 each
00006006368 DEXAMETHASONE
DECADRON 0.75MG TABLET
1.0 TABLET.
0.5593 each
00032321001 DEXAMETHASONE
DEXONE 0.75MG TABLET
1.0 TABLET
0.1198 each
00054418025 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET-
0.1388 each
00054818025 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET+:
0.1388 each
00115310001 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0475 each
00115310002 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0475 each
00115310003 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET -
0.0475 each
00182048801 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.1198 each
00223079101 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0713 each
00223079102 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0713 each
00254266706 (DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET.
0.2771 each
00302140201 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0492 each
100349107801 1DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET _
0.0726 each
100349107810 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0726 each
00364009801 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET:
0.0945 each
X00364009802 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0945 each
;00405431501 ;DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0726 each
00536358301 'DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.1007 each
.00536358310 !DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.1007 each
.00556029501 (DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
11.0 TABLET
0.4199 each
1:\data\hiv_care\nato\adap\pricing\9706.WK1 • 7
`9
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMtNT AMOUNTS
EXHIBIT F-3
00556029510 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.4199 each
00591536101 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0736 each
'00591536104 ;DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0736 each
'00603319111 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0717 each
:00603319121 i DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0717 each
00615050652 iDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0572 each
00675370007 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0527 each
00675370012 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0527 each
00677034001 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0743 each
100686050621 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0337 each
00719127510 'DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0565 each
00814236014 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0641 each
00839122803 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0751 each
00839122806 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0751 each
00904024412 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.1135 each
00904024460 IDEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.1135 each
17022319902 DEXAMETHASONE,
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET._
0.0399 each
17022319906 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0399 each
17236014001 DEXAMETHASONE
DEXAMETHASONE 0.75MG-TABLET.
1.0 TABLET.
0.0684 each
49727010502 DEXAMETHASONE _
DEXAMETHASONE 0.75MG TABLET- .
1.0 TABLET
0.0594 each
49884008501 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0713 each
49884008505 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0713 each
49884008510. DEXAMETHASONE.-
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0713 each
51203017901 DEXAMETHASONE-
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0998 each
51403011701 DEXAMETHASONE
DEXAPACK 0.75MG TABLET
1.0 TABLET-
0.1049 each
51432013003 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET.
0.0570 each
52446014921 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0717 each
52555006401 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0727 each
53633008501 DEXAMETHASONE
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0814 each
53633008510 DEXAMETHASONE:
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0814 each
53633008511 DEXAMETHASONE.
DEXAMETHASONE 0.75MG TABLET
1.0 TABLET
0.0814 each
53633008527 DEXAMETHASONE..:
DEXAMETHASONE 0.75MG.TABLET .-
1.0 TABLET,
0.0814 each ..
54274021130 DEXAMETHASONEt-t: •..
DEXAMETHASONE 0.75MG.TABLET:=
1.0TABLET -.
0.0473 each.
58729008527 DEXAMETHASONE'..-
DEXAMETHASONE-0.75MG-TABLET:, 1.0 TABLET .' _
0.3919 each ,
60904008527 DEXAMETHASONE- :.
DEXAMETHASONE-0.75MG-.TABLET--' 1.0 -TABLET
0.4315 each.• -
00054418125 DEXAMETHASONE ::
DEXAMETHASONE.1MG TABLET--.:•
1.0 TABLET -
0.2424 each,
00054817425 DEXAMETHASONE •
DEXAMETHASONE 1 MG.TABLET"
1.0 TABLET
0.2424 each
00006009550 DEXAMETHASONE.
DECADRON 1.5MG TABLET
1.0 TABLET
0.9686 each
00032321501 DEXAMETHASONE
DEXONE 1.5MG TABLET
1.0 TABLET
0.2393 each
00052079091 DEXAMETHASONE
HEXADROL 1.5MG TABLET
1.0 TABLET
0.2171 each
00054418225 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.2578 each
00054818125 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.2578 each
00182161319 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.2337 each
00223079201 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1425 each
00302140301 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1048 each
00364039901 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1446 each
00405431601 DEXAMETHASONE.
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1197 each
00536358401 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.0784 each
00591545101 IDEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1378 each
00603319221 IDEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1283 each
00814236414 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.0998 each
00904024560 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET;-
0.1511 each
49884008601 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET!
0.1900 each
49884008603 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1900 each
49884008605 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1900 each
49884008610 DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1900 each
51432013203 IDEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.0993 each
52446013721 (DEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1283 each
53633008603 IDEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1955 each
153633008611 IDEXAMETHASONE
DEXAMETHASONE 1.5MG TABLET
1.0 TABLET
0.1955 each
!00054418325 IDEXAMETHASONE
DEXAMETHASONE 2MG TABLET
1.0 TABLET
0.4745 each
:00054817625 IDEXAMETHASONE
DEXAMETHASONE 2MG TABLET
1.0 TABLET
0.4745 each
00006009728 IDEXAMETHASONE
DECADRON 4MG TABLET
1.0 TABLET
1.6190 each
00006009750 IDEXAMETHASONE
DECADRON 4MG TABLET
1.0 TABLET
1.6190 each
;00032322001 IDEXAMETHASONE
DEXONE 4MG TABLET
1.0 TABLET
0.5141 each
;00052079890 IDEXAMETHASONE
HEXADROL 4MG TABLET
1.0 TABLET
0.4489 each
100052079891 IDEXAMETHASONE
HEXADROL 4MG TABLET
1.0 TABLET
0.4489 each
;00054418425 (DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.5549 each
;00054817525 (DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.5549 each
i:\data\hiv_carftato\adap\pdci ng\9706.W K1
a
\ AlDEfDRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS - EXHIBIT F-3
00182161401 IDEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.3531 each
00182161419 IDEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.3531 each
00302140401 !DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.2031 each
00405431701 1DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.2000 each
100536358006 ;DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.3610 each
00603319421 'DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.2142 each
00677084901 (DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.2323 each
00719127815 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.2556 each
00814236514 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.2237 each
00839673406 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.3239 each
00904024651 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.4038 each
00904024660 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
• 0.4038 each
17236014301 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.2461 each
49884008701 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET'
1.0 TABLET
0.3040 each
49884008703 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET
0.3040 each
49884008705 DEXAMETHASONE .
DEXAMETHASONE 4MG TABLET'
1.0 TABLET . _ ..
0.3040 each
49884008710 DEXAMETHASONE
r -•.:,� DEXAMETHASONE 4MG_TABLET. ! !' : 1.07ABLET.•.c_t:=
; • 0.3040 each
51432092503 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET
1.0 TABLET - .-
0.3510 each
52446014321 DEXAMETHASONE.
-+. DEXAMETHASONE4MG•TABLET, ,.� 1.O:TABLET;,o1 -_ -
:_; 0.2142 each
52555006601 DEXAMETHASONE _ : DEXAMETHASONE, 4MG -.TABLET;:!,, 1.OTABLET.= a: =
!.'.'.;0.3102 each•
53633008703 DEXAMETHASONEDEXAMETHASONE4MG_TABLET
1.0 TABLET--
; .0.3122 each
53633008711 DEXAMETHASONE
DEXAMETHASONE 4MG TABLET =
1.0.TABLET.:r _ :
0.3122 each
54274020110 DEXAMETHASONE
_ DEXAMETHASONE 4MG TABLET- :
1.0 TABLET -. -
0.2019 each -
00006014750 DEXAMETHASONE
DECADRON 6MG TABLET
1.0 TABLET
2.3098 each
00054416625 DEXAMETHASONE
DEXAMETHASONE 6MG TABLET
1.0 TABLET
0.9394 each
00054818325 DEXAMETHASONE
DEXAMETHASONE 6MG TABLET
1.0 TABLET- •
0.9394 each
00405431801 DEXAMETHASONE
DEXAMETHASONE 6MG TABLET
1.0 TABLET -
0.3316 each
49884012901 DEXAMETHASONE
DEXAMETHASONE 6MG TABLET
1.0 TABLET
0.5415 each
49884012903 DEXAMETHASONE
DEXAMETHASONE 6MG TABLET
1.0 TABLET
0.5415 each
53633012903 DEXAMETHASONE
DEXAMETHASONE 6MG TABLET
1.0 TABLET _
-0.5103 each
53633012911 DEXAMETHASONE
DEXAMETHASONE 6MG TABLET
1.0 TABLET _
r 0.5103 each
00052079514- DEXAMETHASONE . •
- , ._: HEXADROL.THERAPEUTIC PACK.::-
1.0 TABLET' ..
i, 0.3664 each
00006764401• DEXAMETHASONE ACETATE...
-,.- . 4'', DECADRON-LA 8MG/MLVIAL:, ,�?4-i:. 1.O mI VIAL ML -
7 'r. 8.1340 per ml
00006764403 DEXAMETHASONE ACETATE..
°: , DECADRON-LA 8MG/MLtV1AL. _ -:. •: ; 5.0 ml VIAL ML -
s r r 8.1340 per ml
00131102604 DEXAMETHASONE ACETATE. •: _'i '-:: DEXACEN LA -8 8MG/MLVIAL r_' :_ri •_:',- 5.0 mI.VIALQ,
o Tr:7.7520 per ml •
00182092862 DEXAMETHASONE ACETATE.-::
° . '.. _: DEXAMETHASONE BMG/ML.VIAL f ,i 5.0mI,VIAL ML ^,L. -
;-:'4.6455 per ml,
00223739005DEXAMETHASONE ACETATE
DEXAMETHASONE BMG/MENIAL", !
. 5.O ml V1AL ML
2.1850 perml
00259032805 DEXAMETHASONE ACETATE
DECAJECT-LA 8MG/ML VIAL
5.0 ml VIAL ML
6.08001per ml
00298695767 DEXAMETHASONE ACETATE
DEXSONE LA 8MG/ML VIAL
5.0 ml VIAL ML
1.8962 Der ml
00314089775 DEXAMETHASONE ACETATE
SOLUREX LA 8MG/ML VIAL
5.0 ml VIAL ML
2.3123 per ml
00364669953 DEXAMETHASONE ACETATE.
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
6.2605 per ml
00402009205 DEXAMETHASONE ACETATE
DEXAMETHASONE AC 8MG/ML VL
5.0 ml VIAL ML
6.2605 per ml
00418409131 DEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL.
5.0 ml VIAL ML
2.1033 per ml
00456107505 DEXAMETHASONE ACETATE
DALALONE L.A. 8MG/ML VIAL -
5.0 ml VIAL ML
3.3242 per ml
00463110405 DEXAMETHASONE ACETATE.
ADRENOCOT L.A. 8MG/ML VIAL..
5.0 ml VIAL ML
2.5650 per ml
00536416365 DEXAMETHASONE ACETATE.
DEXAMETHASONE 8MG/ML VIAL ..
5.0 ml VIAL (ML),
5.2972 per ml
00588534475 DEXAMETHASONE ACETATE
DEXONE LA 8MG/ML VIAL. ..
5.0 ml VIAL ML
1.8905 per ml
00677082220 DEXAMETHASONE ACETATE.
DEXAMETHASONE 8MG/MLVIAL r
5.0 ml VIAL ML
5.6867 per ml
00684015905 DEXAMETHASONE ACETATE
PRIMETHASONE LA 8MG/ML VIAL
5.0 ml VIAL ML
3.5150 per ml
00719311986 DEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML -
2.8500 per ml
00781300875 DEXAMETHASONE ACETATE.
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
5.6810 per ml
00785804505 DEXAMETHASONE ACETATE
DE -SONE LA 8MG/ML.VIAL
5.0 ml VIAL ML
2.4510 per ml
00814235538 DEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
4.5885 per ml
00839610925 IDEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
3.5378 per ml
00904090605 IDEXAMETHASONE ACETATE
DEXAMETHASONE AC 8MG/ML VL
5.0 ml VIAL ML
4.2750 per ml
17022129901 IDEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
0.8740 per ml
17236003695 IDEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
2.5840 per ml
25332001102 IDEXAMETHASONE ACETATE
DEXASONE LA 8MG/ML VIAL
5.0 ml VIAL ML
4.1705 per ml
43797011311 jDEXAMETHASONE ACETATE
DEXASONE LA 8MG/ML VIAL
5.0 ml VIAL ML
2.3655 per ml
44437009205 'DEXAMETHASONE ACETATE
DEXACORTEN-LA 8MG/ML VIAL
5.0 ml VIAL ML
3.8000 per ml
45985055505 IDEXAMETHASONE ACETATE
DEX 8MG/ML VIAL
5.0 ml VIAL ML
1.7005 per ml
49072015505 DEXAMETHASONE ACETATE
DEXAMETHASONE AC 8MG/ML VL
5.0 ml VIAL ML
2.3351 per ml
50272009205 IDEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
1.1400 per ml
51432012709 (DEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
2.9450 per ml
52349010405 IDEXAMETHASONE ACETATE
MEDIDEX-LA 8MG/ML VIAL
5.0 ml VIAL ML
1.7575 per ml
152406009205 !DEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
0.9120 per ml
152584009205 (DEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
2.3522 er ml
152604009205 iDEXAMETHASONE ACETATE
DECASONE R.P. 8MG/ML VIAL
5.0 ml VIAL ML
1.6625 per ml
54274074009 (DEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
1.91521per ml
i:\data\hiv_care\nato\adap\pricing\9706.W K1 9
AID5 DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
55726009205 DEXAMETHASONE ACETATE
CPC-CORT-D LA 8MG/ML VIAL
5.0 ml VIAL ML
1.3205
per ml
.58441011505 ,DEXAMETHASONE ACETATE
DEXAMETHASONE 8MG/ML VIAL
5.0 ml VIAL ML
2.1527
per ml
58441764403 ;DEXAMETHASONE ACETATE
DEXAMETHASONE AC 8MG/ML VL
5.0 ml VIAL ML
2.1527
per ml
59010050505 DEXAMETHASONE ACETATE
DECA-PLEX LA 8MG/ML VIAL
5.0 ml VIAL ML
2.3180
per ml
,00456109705 ;DEXAMETHASONE ACETATE
DALALONE D.P. 16MG/ML VIAL
5.0 ml VIAL ML
5.4150
per ml
:00456109741 ;DEXAMETHASONE ACETATE
DALALONE D.P. 16MG/ML VIAL
1.0 ml VIAL ML
5.4150
per ml
00785908005 'DEXAMETHASONE ACETATE
DALALONE D.P. 16MG/ML VIAL
5.0 ml VIAL ML
3.8000
per ml
00684010905 ;DEXAMETHASONE PHOSPHATE
PRIMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
2.2230
per ml
:00223740101 ;DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML AMPUL
1.0 ml AMPUL ML
0.9500
per ml
'00052079626 IDEXAMETHASONE SOD PHOSPHATE
HEXADROL 4MG/ML SYRINGE
1.0 ml SYRINGE ML
1.5417
per ml
00223740301 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML SYRING
1.0 ml SYRINGE ML
1.9950
per ml
00469908087DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML SYRN
5.0 ml SYRINGE ML
2.5413
per ml
00052079726 DEXAMETHASONE SOD PHOSPHATE
HEXADROL 10MG/ML SYRINGE
1.0 ml SYRINGE ML
2.4936
per ml
00006762803 IDEXAMETHASONE SOD PHOSPHATE
DECADRON 4MG/ML VIAL
5.0 ml VIAL ML
5.0820
per ml
00006762825 DEXAMETHASONE SOD PHOSPHATE
DECADRON 4MG/ML VIAL
25.0 ml VIAL ML
3.9456
per ml
00006762866 DEXAMETHASONE SOD PHOSPHATE
DECADRON 4MG/ML VIAL
1.0 ml VIAL ML
5.5096
per ml
00052079605 DEXAMETHASONE SOD PHOSPHATE
HEXADROL4MG/ML VIAL
5.0 ml VIAL ML
0.8930
per ml
00052079625 DEXAMETHASONE SOD PHOSPHATE
HEXADROL 4MG/ML VIAL
1.0 mi VIAL ML
0.91961perml
00052079627 DEXAMETHASONE SOD PHOSPHATE. ' HEXADROL 4MG/ML VIAL
5.0 ml VIAL ML
0.8930 1per
ml
00058080705 DEXAMETHASONE SOD PHOSPHATE:
DEXAMETHASONE 4MG/ML VIAL.
5.0 ml VIAL ML
0.6612
per ml
00131123005 DEXAMETHASONE SOD PHOSPHATE
DEXACEN 4MG/ML VIAL
10.0 ml VIAL ML
0.9025
per ml
00182300762 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML .
, 0.4655
per ml
00182300766 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.2850
per ml
00223740230 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.2660
per ml
00223740405 DEXAMETHASONE SOD PHOSPHATE.
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML _
0.5225
per ml
00223740625 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
25.0 ml VIAL ML
0.2660
per ml
00223740701 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
1.0 ml VIAL ML
1.1875
per ml
00223740810 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
10.0 ml VIAL ML
0.3800
per ml
00259029705 DEXAMETHASONE SOD PHOSPHATE
DECAJECT-5 4MG/ML VIAL
5.0 ml VIAL ML
1.4915
per ml
00259029710 DEXAMETHASONE SOD PHOSPHATE
DECAJECT-10 4MG/ML VIAL
10.0 mi VIAL ML
1.2968
per ml
00298691067 IDEXAMETHASONE SOD PHOSPHATE.
DEXSONE 4MG/MLVIAL
5.0 ml VIAL ML
0.8550
per ml
00314089605 DEXAMETHASONE:SOD PHOSPHATE.
SOLUREX 4MG/ML.VIAL... _
5.0 ml VIAL ML
0.6403
per ml
00314089610 DEXAMETHASONE SOD PHOSPHATE;- SOLUREX 4MG/ML:VIAL" :4:--•= , '
10.0 ml VIAL (ML). .
• .'.. : 0.4978
per.ml
00314089630 DEXAMETHASONE SOD PHOSPHATE -t' SOLUREX 4MG/ML..VIAL
30.0 ml VIAL (ML),
0.3851
per ml
00314089670 DEXAMETHASONE SOD PHOSPHATE:,.
SOLUREX 4MG/ML- VIAL=. . ':
10.O mI VIAL ML •_
0.4978
per ml
00314089675 DEXAMETHASONESOD PHOSPHATE.- SOLUREX 4MG/ML`VIAL .:.
5.0 ml VIAL ML
0.6403
er.ml.
00364668132 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL.
5.0 ml VIAL ML
0.5294
per ml
00364668154 DEXAMETHASONE SOD PHOSPHATE.
DEXAMETHASONE 4MG/ML VIAL
10.0 ml VIAL ML
0.4389lp2rml
00364668156 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.3170
per ml
00402058701 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE SOD PH 4MG/ML
1.0 ml VIAL ML
1.7100
per ml
00402080705 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE SOD PH 4MG/ML
5.0 ml VIAL ML
0.5301
per mi
00402080710 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE SOD PH 4MG/ML
10.0 ml VIAL ML
0.3990
per ml
00402080730 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE SOD PH 4MG/ML
30.0 ml VIAL ML
0.2882
per ml
00418192130 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 mi VIAL ML
0.33411
per ml
00418192131 DEXAMETHASONE SOD PHOSPHATE..
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
1.3870
per ml
00456107405 DEXAMETHASONE SOD PHOSPHATE.
DALALONE 4MG/ML VIAL
5.0 ml VIAL ML
1.1400
per ml
00463109005 DEXAMETHASONE SOD PHOSPHATE
ADRENOCOT 4MG/ML VIAL
5.0 ml VIAL ML
0.6650
er ml
00469165000 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
1.0 ml VIAL ML
0.7838
per ml
00469165020 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.3966
per ml
00469165050 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.3958
p2r ml
00517490125 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE SP 4MG/ML VL
1.0 ml VIAL ML
1.0331
per ml
00517490525 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE SP 4MG/ML VL
5.0 ml VIAL ML
0.4156
per ml
00517493025 !DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE SP 4MG/ML VL
30.0 ml VIAL ML
0.2482
per ml
00527018265 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.4332 1
per ml
00536415165 (DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
1.14001
per ml
00536415170 ;DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
10.0 ml VIAL ML
0.9405
per ml
00536415175 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.4313
per ml
00588534370 IDEXAMETHASONE SOD PHOSPHATE
DEXONE 4MG/ML VIAL
10.0 ml VIAL ML
0.3800
per ml
:00641037225
IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
1.0 ml VIAL ML
0.4251
per ml
,00641227341
(DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.2613
per ml
;00641227641 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.5276
per ml
'00677038520 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.6650
per ml
100703350104 1DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
1.0 ml VIAL ML
0.9348
per ml
00703351304 !DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 mi VIAL ML
0.3785
per ml
'00785804010'11DEXAMETHASONE SOD PHOSPHATE
DE -SONE 4MG/ML VIAL
10.0 ml VIAL ML
0.7363
per ml
'00814235038 !DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.4997
per ml
00814235046 'DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.1783
per ml
00839516025 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.3724
per ml
.00839516036 DEXAMETHASONE SOD PHOSPHATE
IDEXAMETHASONE 4MG/ML VIAL
130.0 ml VIAL (ML)_
1 0.1707
per ml
i.\data\hiv_care\nato\adap\pricing\9706.W K1 10
:*
t AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
00853200190 IDEXAMETHASONE SOD PHOSPHATE
MEDASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.3721 per ml
00904090505 'DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.6840 per ml
00904090510 1DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
10.0 ml VIAL ML
0.5510 per ml
00904090530 ,DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 mi VIAL ML
0.2926 per ml
17022129501 :DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.3515 per ml
17236004893 iDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.1932 per ml
•25332001002 IDEXAMETHASONE SOD PHOSPHATE
DEXASONE 4MG/ML VIAL
5.0 ml VIAL ML
1.1305 er ml
;43797000111 IDEXAMETHASONE SOD PHOSPHATE
DEXASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.6175 per ml
43797000112 IDEXAMETHASONE SOD PHOSPHATE
DEXASONE 4MG/ML VIAL
10.0 mi VIAL ML
0.5463 per ml
'43797000113 IDEXAMETHASONE SOD PHOSPHATE
DEXASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.2818 per ml
:44437080705 IDEXAMETHASONE SOD PHOSPHATE
DEXACORTEN 4MG/ML VIAL
5.0 ml VIAL ML
0.5700 per ml
45985059205 IDEXAMETHASONE SOD PHOSPHATE-
DEX-4 VIAL. -
10.0 ml VIAL ML
0.5605 per ml
49727072855 IDEXAMETHASONE SOD PHOSPHATE.
DEXAMETHASONE 4MG/ML VIAL
5.0 ml VIAL ML
0.4750 per ml
150272058705 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
5.0 mi VIAL (ML):
0.5225 per ml
52349010310 IDEXAMETHASONE SOD PHOSPHATE
MEDIDEX 4MG/ML VIAL
10.0 ml VIAL ML
0.8075 per ml
52406058705 1 DEXAMETHASONE SOD PHOSPHATE_
DEXAMETHASONE 4MG/ML VIAL .• _
5.0 ml VIAL ML :
0.4180 permi
52406058710 1 DEXAMETHASONE SOD PHOSPHATE:_
DEXAMETHASONE4MG/ML VIAL-: -
10.O mI VIAL ML i
:0.3990 per ml
52406058730 DEXAMETHASONE SOD PHOSPHATE:
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML !
0.3468 er mi
52406058781 DEXAMETHASONE SOD PHOSPHATE ' DEXAMETHASONE 4MG/ML AMPULE
1.O mi VIAL (ML)'-- ; _ .'
0.5154 er mi
52604058705 DEXAMETHASONE SOD PHOSPHATE.
DECASONE 4MG/ML VIAL = -
5.0 ml VIAL ML
0.75051perml
53268010675 DEXAMETHASONE SOD PHOSPHATE -
SPECTRO-DEX 4MG/MLVIAL - -.: _
5.0 ml VIAL ML
1:7005 per ml
54274054509 DEXAMETHASONE SOD PHOSPHATE_.:
DEXAMETHASONE4MG/ML VIAL', 5.0 ml.VIAC ML L
- OA674 per ml
55726080705 DEXAMETHASONE SOD PHOSPHATE_., CPC -CORY D 4MG/ML VIAL __ •
5.0 mI.VIAL ML
0.5225 per ml
55726080730 DEXAMETHASONE SOD PHOSPHATE':
CPC-CORT-D 4MG/ML.VIAL-
30.0 ml VIAL ML
0.2771 per ml
57706085431 DEXAMETHASONE SOD PHOSPHATE...
STORZ-DEXA 4MG/ML VIAL - =
5.0 ml VIAL ML
-: 0.3634 per ml
58441010330 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 4MG/ML VIAL
30.0 ml VIAL ML
0.0947 per ml
158441012605 DEXAMETHASONE SOD PHOSPHATE'
DEXAMETHASONE 4MG/ML VIAL.
5.0 mi VIAL ML
0.1995 per ml
59010050010 DEXAMETHASONE SOD PHOSPHATE.
DECA-PLEX 10 4MG/ML VIAL
10.0 ml VIAL ML
- 0.4750 er ml
00052079710 DEXAMETHASONE SOD PHOSPHATE
HEXADROL 10MG/ML VIAL.
10.0 ml VIAL ML
2.4890 per ml
00364236054 DEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 10MG/ML VIAL. • .:
10.O mi VIAL ML _
-: 1.1400 per mi
00402066110 DEXAMETHASONE SOD PHOSPHATE.
DEXAMETHASONE NA PH 10MG/ML,. 10.0 ml VIAL ML ..
rn•1.1400 per ml
00469061001 DEXAMETHASONE SOD PHOSPHATE_, DEXAMETHASONEIOMG/MLVIAL-;=.� 10.O mi.VIAL ML :i4:.'_ , i
c,,!-,-!1.3656 perml
00641036725 DEXAMETHASONE SOD PHOSPHAT :t DEXAMETHASONE10MG/ML:VIAL-,k*
1'.OmLVIAL ML "., "'=': :x,:.2.2121 perml
00641227741 DEXAMETHASONE SOD PHOSPHATE:'
DEXAMETHASONEIOMG/ML.VIAL:7
10.O ml.VIAL" ML i'= ` .`; t
r; r, 2.2121 per ml
00703352401 DEXAMETHASONE SOD PHOSPHATE:`: DEXAMETHASONEIOMG/ML VIALinS
10.0 mI.VIAL ML kF: .i: t f 7'10.4742 per mi.
25332011310 DEXAMETHASONE SOD PHOSPHATB::t
DEXASONEAOMG/MLsVIALi;! z"^: '..
10.0 ml,V1AL' (ML)7r,*••; 4
! ':::1.4203 per ml
00006764603 DEXAMETHASONE SOD PHOSPHATE-'! DECADRON 24MG/ML VIAL" " '' "'•
5.O mI VIALML •
-.19.58401perml
00006764610 IDEXAMETHASONE SOD PHOSPHATE
DECADRON 24MG/ML VIAL.'
10.0 ml VIAL ML
19.5840 per mi
00223740505 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 24MG/ML VIAL.
5.O mi VIAL ML
1.5675 per mi
52406022205 IDEXAMETHASONE SOD PHOSPHATE
DEXAMETHASONE 24MG/ML VIAL
5.0 ml VIAL ML
2.0805 per ml
00006763413 IDEXAMETHASONE SOD PHOSPHATE
DECADRON TURBINAIRE W/ATTAC
12.6 gm AEROSOL GM
3.3563 per grn
53014020113 DEXAMETHASONE SOD PHOSPHATE
DEXACORT PH TURBINAIRE
12.6 grn AEROSOL GM
3.3563 per grn
00087665001 DIDAWCAL CB(ALK)/MG SLT A
VIDEX 25MG TABLET CHEWABLE
1.0 TABLET
0.3848 each
00087665101 DIDAWCAL CB(ALK)/MG SLT ANT
VIDEX 50MG TABLET CHEWABLE .
1.0 TABLET .
0.7696 each
00087665201 DIDAWCAL CB(ALK)/MG SLT ANT
VIDEX 100MG TABLET CHEWABLE',-;
1.O TABLET.. -
1.5388 each
00087665301 DIDAWCAL CB(ALK)/MG SLT ANT
VIDEX 150MG-TABLET CHEWABLE..;
1.0 TABLET . =
2.3086 each
00087662843 DIDAWNACT ALK /MGA /AL NACB
VIDEX 25MG TABLET CHEWABLE_.
1.0 TABLET • _a .:
0.3682 each
00087662443 DIDAWNACT ALK /MGA /AL NACB
VIDEX 50MG TABLET CHEWABLE .-
1.0 TABLET .
0.7364 each
00087662743 DIDAWNACT ALK /MGA AL NACB
VIDEX 100MG TABLET CHEWABLE'
1.0 TABLET
1.4726 each
•00087662643 IDIDAN/NACT ALK /MGA /AL NACB
VIDEX 150MG TABLET CHEWABLE
1.0 TABLET
2.2092 each
00087663241 DIDANOSINE
VIDEX 2GM PEDIATRIC SOLN
100.0 ml SOLN, ORAL
0.3078 per ml
;00087663341 IDIDANOSINE
VIDEX 4GM PEDIATRIC SOLN
200.0 ml SOLN, ORAL
0.3078 per ml
100087661443 DIDANOSINE/NACT ALK
VIDEX 100MG PACKET
1.0 PACKET
1.5392 each
00087661543 IDIDANOSINE/NACT ALK
VIDEX 167MG PACKET
1.0 PACKET
2.5705 each
00087661643 DIDANOSINE/NACT ALK
VIDEX 250MG PACKET
1.0 PACKET
3.8476 each
00087661743 'DIDANOSINE/NACT ALK
VIDEX 375MG PACKET
1.0 PACKET
5.1311 each
00013108691 'DOXORUBICIN HCL
ADRIAMYCIN RDF 10MG VIAL
1.0 VIAL EA
43.7000 each
'00015335122 1DOXORUBICIN HCL
RUBEX 10MG VIAL
1.0 VIAL EA
39.9570 each
00186153013 ;DOXORUBICIN HCL
DOXORUBICIN 10MG VIAL
1.0 VIAL EA
15.9006 each
.00702023110 IDOXORUBICIN HCL
DOXORUBICIN 10MG VIAL
1.0 VIAL EA
37.1450 each
:53905023110 !DOXORUBICIN HCL
DOXORUBICIN 10MG VIAL
1.0 VIAL EA
42.8213 each
55390023110 IDOXORUBICIN HCL
DOXORUBICIN 10MG VIAL
1.0 VIAL EA
42.8165 each
58406051101 IDOXORUBICIN HCL
RUBEX 10MG VIAL
1.0 VIAL EA
39.9570 each
00013109691 i DOXORUBiCIN HCL
ADRIAMYCIN RDF 20MG VIAL
1.0 VIAL EA
87.4000 each
00013109694 !DOXORUBICIN HCL
ADRIAMYCIN RDF 20MG VIAL
1.0 VIAL EA
87.4000 each
00186157512 'DOXORUBICIN HCL
DOXORUBICIN 20MG VIAL
1.0 VIAL EA
38.0000 each
00702023206 :DOXORUBICIN HCL
IDOXORUBICIN 20MG VIAL
11.0 VIAL EA
74.2900 each
53905023206 ;DOXORUBICIN HCL
IDOXORUBICIN 20MG VIAL
11.0 VIAL EA
85.6544 each
53905023210 DOXORUBICIN HCL
IDOXORUBICIN 20MG VIAL
1.0 VIAL EA
85.6544 each
i.\data\hiv_care\nato\adap\pdcing\9706.W K1 11
.o
1 AID$ DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
55390023210 IDOXORUBICIN HCL
DOXORUBICIN 20MG VIAL
1.0 VIAL EA
85.6520 each
;00013110679 IDOXORUSICIN HCL
ADRIAMYCIN RDF 50MG VIAL
1.0 VIAL EA
218.5000 each
!00015335222 1DOXORUBICIN HCL
RUBEX 50MG VIAL
1.0 VIAL EA
179.8008 each
100186153101 IDOXORUBICIN HCL
DOXORUBICIN 50MG VIAL
1.0 VIAL EA
79.5031
each
:00702023301 IDOXORUBICIN HCL
DOXORUBICIN 50MG VIAL
1.0 VIAL EA
185.7250
each
:53905023301 1DOXORUBICIN HCL
DOXORUBICIN 50MG VIAL
1.0 VIAL EA
214.1300
each
155390023301 1DOXORUBICIN HCL
DOXORUBICIN 50MG VIAL
1.0 VIAL EA
214.1300 1 each
58406051201 IDOXORUBICIN HCL
RUSEX 50MG VIAL
1.0 VIAL EA
179.8008 each
00015335322 !DOXORUBICIN HCL
RUBEX 100MG VIAL
1.0 VIAL EA
359.5902 each
.58406051301 IDOXORUBICIN HCL
RUBEX 100MG VIAL
1.0 VIAL EA
359.5902 each
•00013111683 IDOXORUBICIN HCL
ADRIAMYCIN RDF 150MG VIAL
1.0 VIAL EA
642.3781 each
00013113691 DOXORUBICIN HCL
ADRIAMYCIN -PFS 2MG/ML VIAL
5.0 ml VIAL ML
9.1794
per ml
00013114691 DOXORUBICIN HCL
ADRIAMYCIN -PFS 2MG/ML VIAL
10.0 ml VIAL ML
9.1794
per ml
00013114694 DOXORUBICIN HCL
ADRIAMYCIN -PFS 2MG/ML VIAL
10.0 ml VIAL ML
9.1794
per ml
00013115679 DOXORUBICIN HCL
ADRIAMYCIN -PFS 2MG/ML VIAL
25.0 ml VIAL ML
9.1794
per ml
00013116683 DOXORUBICIN HCL
ADRIAMYCIN -PFS 2MG/ML VIAL
100.0 ml VIAL ML
8.9959
per ml
00013117687 DOXORUBICIN HCL
ADRIAMYCIN -PFS 2MG/ML VIAL
37.5 ml VIAL ML
9.0584
per ml
00186153231 IDOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
5.0 ml VIAL ML
2.37501perml
00186153241 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
10.0 ml VIAL ML
2.37501perml
00469100161 DOXORUBICIN HCL.
DOXORUBICIN 2MG/ML VIAL
100.0 ml VIAL ML
2.39881perml
00186153261 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
25.0 ml VIAL ML
9.8553
er ml
00186153281 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
100.0 ml VIAL ML
9.6706
per ml
00469883020 DOXORUBICIN HCL.
DOXORUBICIN 2MG/ML VIAL
5.0 ml VIAL ML
2.9545
per ml
00469883050 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
25.0 ml VIAL ML
2.8529per
ml
00469883130 DOXORUBICIN HCL.
DOXORUBICIN 2MG/ML VIAL.
10.0 ml VIAL ML
2.9545
per ml
00469883250 DOXORUSICIN HCL
DOXORUBICIN 2MG/ML VIAL
25.0 ml VIAL ML
2.8529
per ml
00702023510 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
5.0 ml VIAL ML
7.7995
per ml
00702023606 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
10.0 ml VIAL ML
7.7995
per ml
00702023610 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
10.0 mI VIAL ML
7.7995
per ml
00702023701 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
25.0 ml VIAL ML
7.7995
Fer ml
00702023801 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
100.0 ml VIAL ML
8.9868
per ml
00703504001 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
100.0 ml VIAL ML
8.2812
per ml
00703504303 DOXORUBICIN HCL .
DOXORUBICIN 2MG/ML VIAL-'.
5.0 ml -VIAL. ML
8.4497
perml,
00703504601 DOXORUBICIN HCL,
DOXORUBICIN 2MG/ML VIAL.'.,: :
25.0 ml VIAL ML
8.4501
per ml .
53905023510 DOXORUBICIN HCL,
DOXORUBICIN 2MG/ML VIAL:-,
5.0 ml VIAL ML
8.9965
per ml -
53905023606 DOXORUBICIN HCL--
DOXORUBICIN 2MG/ML VIAL_
10.0 ml VIAL ML
8.9965
per ml;
53905023610 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
10.0 ml VIAL ML
8.9965
per ml
53905023701 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
25.0 ml VIAL ML
8.9960
per ml
53905023801 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
100.0 ml VIAL ML
8.9868
per ml
55390023510 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
5.0 ml VIAL ML
8.99651perml
55390023610 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
10.0 ml VIAL ML
8.9965 1per
ml
55390023701 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
25.0 ml VIAL ML
8.9961 1per
ml
55390023801 DOXORUBICIN HCL
DOXORUBICIN 2MG/ML VIAL
100.0 ml VIAL ML
8.9868
per ml
61471029512 DOXORUBICIN HCL LIPOSOME
DOXIL 2MG/ML VIAL
10.0 ml VIAL ML
57.5938
per ml
00054260111 DRONABINOL
MARINOL 2.5MG CAPSULE
1.0 CAPSULE
2.8731 each
00054260121 DRONABINOL
MARINOL 2.5MG CAPSULE
1.0 CAPSULE
2.8731 each
00054260125 DRONABINOL
MARINOL 2.5MG CAPSULE
1.0 CAPSULE
2.8731 each
00054260211 DRONABINOL
MARINOL 5MG CAPSULE
1.0 CAPSULE
5.6836 each
00054260225 DRONABINOL
MARINOL 5MG CAPSULE
1.0 CAPSULE
5.6836 each
00054260311 1DRONABINOL
MARINOL 10MG CAPSULE
1.0 CAPSULE
12.8033 each
00054260321 1DRONABINOL
MARINOL 10MG CAPSULE
1.0 CAPSULE
12.8033 each
00062740201 IEPOETIN ALFA
PROCRIT 2000U/ML VIAL
1.0 ml VIAL ML
22.8000
per ml
55513012601 1EPOETINALFA
EPOGEN 2000U/ML VIAL
1.0 ml VIAL ML
22.8000
per ml
55513012610 1 EPOETIN ALFA
EPOGEN 2000U/ML VIAL
1.0 ml VIAL ML
22.8000
per ml
59676030201 (EPOETIN ALFA
PROCRIT 2000U/ML VIAL
1.0 ml VIAL ML
22.8000
per ml
59676030202 1 EPOETIN ALFA
PROCRIT 2000U/ML VIAL
1.0 ml VIAL ML
22.8000
per ml
100062740501 (EPOETIN ALFA
PROCRIT 3000U/ML VIAL
1.0 ml VIAL ML
34.2000
per ml
55513026701 IEPOETIN ALFA
EPOGEN 3000U/ML VIAL
1.0 ml VIAL ML
34.2000
per ml
55513026710 1 EPOETIN ALFA
EPOGEN 3000U/ML VIAL
1.0 ml VIAL ML
34.2000
per ml
i59676030301 .EPOETIN ALFA
PROCRIT 3000U/ML VIAL
1.0 ml VIAL ML
34.2000
per ml
59676030302 1 EPOETIN ALFA
PROCRIT 3000UIML VIAL
1.0 ml VIAL ML
34.2000
per ml
;00062740003 (EPOETIN ALFA
PROCRIT 4000U/ML VIAL
1.0 ml VIAL ML
45.6000
per ml
'55513014801 (EPOETIN ALFA
EPOGEN 4000U/ML VIAL
1.0 ml VIAL ML
45.6000
per ml
55513014810 1EPOETIN ALFA
EPOGEN 4000U/ML VIAL
1.0 ml VIAL ML
45.6000
per ml
159676030401 (EPOETIN ALFA
PROCRIT 4000U/ML VIAL
1.0 ml VIAL ML
45.6000
per ml
.59676030402 .EPOETIN ALFA
PROCRIT 4000U/ML VIAL
1.0 ml VIAL ML
45.6000
per ml
'00062740103 :EPOETIN ALFA
IPROCRIT 10000U/ML VIAL
1.0 ml VIAL ML
112.0620
per ml
;55513014401 JEPOETIN ALFA
IEPOGEN 10000U/ML VIAL
11.0 ml VIAL ML
114.0000
er ml
'55513014410 :EPOETIN ALFA
I EPOGEN 10000U/ML VIAL
11.0 ml VIAL ML
114.0000
er ml
1:\data\hiv_carelnato\adap\pdcing\9706.WK1 12
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS -
EXHIBIT F-3
,55513028301 1EPOETIN ALFA
EPOGEN 10000U/ML VIAL
2.0 ml VIAL ML
114:0000 per ml
.55513028310 I EPOETIN ALFA
EPOGEN 10000U/ML VIAL
2.0 ml VIAL ML
114.0000 per ml
59676031001 EPOETIN ALFA
PROCRIT 10000U/ML VIAL
1.0 ml VIAL ML
112.0620 per ml
59676031002 EPOETIN ALFA
PROCRIT 10000U/ML VIAL
1.0 ml VIAL ML
112.0620 per ml
i59676031200 I EPOETIN ALFA
PROCRIT 10000U/ML VIAL
2.0 ml VIAL ML
112.0620 per mi
59676031201 EPOETIN ALFA
PROCRIT 10000U/ML VIAL
2.0 ml VIAL ML
112.0620 per ml
55513047801 1EPOETINALFA
EPOGEN 20000U/ML VIAL
1.0 ml VIAL ML
240.5400 1 per ml
55513047810 1 EPOETIN ALFA
EPOGEN 20000U/ML VIAL
1.0 ml VIAL ML
240.5400 per ml
59676032001 JEPOETINALFA
PROCRIT 20000U/ML VIAL
1.0 ml VIAL ML
224.1240 per ml
00005501523 1 ETHAMBUTOL HCL
MYAMBUTOL 100MG TABLET
1.0 TABLET
0.4269 each
00005508434 ETHAMBUTOL HCL
MYAMBUTOL 400MG TABLET
1.0 TABLET
1.4284 each
00005508460 ETHAMBUTOL HCL
MYAMBUTOL 400MG TABLET
1.0 TABLET
:1.4284 each
00005508462 ETHAMBUTOL HCL
MYAMBUTOL 400MG TABLET
1.0 TABLET
1.4284 each
55513034701 FILGRASTIM
NEUPOGEN 300MCG/ML.VIAL
1.0 ml VIAL ML
153.2350 per ml
55513034710 FILGRASTIM
NEUPOGEN 300MCG/ML VIAL
1.0 ml VIAL ML
153.2350 per mi
55513034801 FILGRASTIM'
NEUPOGEN 300MCG/ML VIAL
1.6 ml VIAL ML
244.0550 per ml
55513034810 FILGRASTIM
NEUPOGEN 300MCG/ML.VIAL
1.6 ml VIAL ML
244.0550 per ml
55513053001 FILGRASTIM
NEUPOGEN 300MCG/ML VIAL
1.0 ml VIAL ML
.153.2350 per mi
55513053010 FILGRASTIM
NEUPOGEN 300MCGIML VIAL.
1.0 ml VIAL ML
153.2350 per mi
55513054601 FILGRASTIM
NEUPOGEN 300MCG/ML VIAL
1:6 mi VIAL ML
-244:0550 per ml
55513054610 FILGRASTIM
NEUPOGEN 300MCG/ML VIAL.
1.6 ml VIAL ML
244.0550 per ml
00049344019 FLUCONAZOLE
DIFLUCAN 10MG/MLSUSPENSION
35.0 ml SUSPENSION
0.6766 er.ml'
00049345019 FLUCONAZOLE
DIFLUCAN 40MG/ML SUSPENSION
35.0 ml SUSPENSION
2:4571 per ml
00049341030 FLUCONAZOLE
DIFLUCAN 50MG TABLET
1.0 TABLET
3.6843 each
00049342030 FLUCONAZOLE
DIFLUCAN 100MG TABLET
1.0 TABLET
-. _ 5.7893 each
00049342041 FLUCONAZOLE
DIFLUCAN 100MG TABLET
1.0 TABLET
= 5.7893 each
00049350079 FLUCONAZOLE
DIFLUCAN 150MG TABLET
1.0 TABLET
9.2158 each
00049343030 FLUCONAZOLE
DIFLUCAN 200MG TABLET
1.0 TABLET
- 9.4737 each
00049343041 FLUCONAZOLE .
DIFLUCAN 200MG TABLET
1.0 TABLET
9.4737 each
00049343726 FLUCONAZOLE/DEXTROSE-WATER
DIFLUCAN/DEXTRSE 0.2G/100ML .
100.0 ml IV. SOLN ML
0.6842 per mi
00049343826 FLUCONAZOLE/DEXTROSE-WATER
DIFLUCAN/DEXTRSE 0.4G/200ML .
200.0 ml IV SOLN ML
0.5000 per ml
00049337126 FLUCONAZOLE/SODIUM CHLORIDE:-
:. DIFLUCAN/SALINE. 0.2G/100ML. _ .;
. 100.0 mi IV SOLN ML
.:.: 0.6842 per ml
00049343526 FLUCONAZOLE/SODIUM CHLORIDE:
DIFLUCAN/SALINE 0.2G/100ML'.'. ;.
100.0 ml IV SOLN ML
,_ :0.6842 per ml.
00049337226 FLUCONAZOLE/SODIUM CHLORIDE,
DIFLUCAN/SALINE 0.4G/200ML.. -' -:
200.0 m1 IV SOLN ML ._�, 0.5000 per mi
00049343626 FLUCONAZOLE/SODIUM CHLORIDE:_'
: DIFLUCAN/SALINE 0.4G/200ML.,*!- .11.
200.0 mi IV.SOLN ML
=: - 0.5000 permi
00004007701- FLUCYTOSINE-:- �
ANCOBON 250MG CAPSULE-
1.0 CAPSULE
c _-= 1.0017 each
00004007901 FLUCYTOSINE
ANCOBON 500MG CAPSULE
1.0 CAPSULE
. 1.9279 each
00186190501 FOSCARNET SODIUM
FOSCAVIR 24MG/ML INFUS BTTL
240.0 ml BOTTLE ML
0.2785 per ml
00186190601 FOSCARNET SODIUM
FOSCAVIR 24MG/ML INFUS BTTL
500.0 ml BOTTLE ML
0.2773 per ml
61772000201 GANCICLOVIR
VITRASERT 4.5MG IMPLANT
1.0 UNIT
4750.0000 each
00004026948 GANCICLOVIR
CYTOVENE 250MG CAPSULE
1.0 CAPSULE
3.7050 each
00033291350 GANCICLOVIR
CYTOVENE 250MG CAPSULE
1.0 CAPSULE
3.7050 each
00004694003 GANCICLOVIR SODIUM
CYTOVENE 500MG VIAL
1.0 VIAL EA
33.0600 each
00033290348 GANCICLOVIR SODIUM
CYTOVENE 500MG VIAL
1.0 VIAL EA
33.0600 each
00006057142 INDINAVIR SULFATE
CRIXIVAN 200MG CAPSULE
1.0 CAPSULE
- 1.0000 each
00006057143 INDINAVIR SULFATE
CRIXIVAN 200MG CAPSULE
1.0 CAPSULE
-1.0000 each
00006057362 INDINAVIR SULFATE
CRIXIVAN 400MG CAPSULE
1.0 CAPSULE
.=2.0000 each
00004199309 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 18MMU VIAL
1.0 VIAL EA
193.3060 each
00004201009 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 9MMU/0.9ML VIAL
1.0 VIAL EA
90.7725 each
00004690009 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 9MMU/0.9ML VIAL
1.0 VIAL EA
90.7725 each
00004198709 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 3MMU/ML VIAL
1.0 ml VIALML
32.2430 per ml
00004200909 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 3MMU/ML VIAL
1.0 ml VIAL MI -
32.2430 per mi
00085116801 INTERFERON ALFA-2B,RECOMB.
INTRON A 6MMU/ML VIAL
3.0 ml VIAL ML
64.4322 per ml
00004198809 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 6MMU/ML VIAL
3.0 ml VIAL ML
64.4670 per ml
00004201109 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 6MMU/ML VIAL
3.0 mi VIAL ML
64.4670 per ml
00004690033 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 6MMU/ML VIAL
1.0 ml VIAL ML
64.4670 per ml
00004200509 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 36MMU/ML VIAL
1.0 ml VIAL ML
386.6500 per ml
00004201209 INTERFERON ALFA-2A,RECOMB.
ROFERON-A 36MMU/ML VIAL
1.0 ml VIAL ML
386.6500 per ml
00085064703 INTERFERON ALFA-2B,RECOMB.
INTRON A 3MMU VIAL
1.0 VIAL EA
32.2240 each
00085064704 (INTERFERON ALFA-213,RECOMB.
INTRON A 3MMU VIAL
1.0 VIAL EA
32.2240 each
'00085064705 JINTERFERON ALFA-2B,RECOMB.
INTRON A 3MMU VIAL
1.0 VIAL EA
32.2240 each
100085012002 IINTERFERON ALFA-26,RECOMB.
INTRON A 5MMU VIAL
1.0 VIAL EA
53.6940 each
;00085012003 (INTERFERON ALFA-2B,RECOMB.
INTRON A 5MMU VIAL
1.0 VIAL EA
53.6940 each
:00085012004 IIINTERFERON ALFA-2B,RECOMB.
INTRON A 5MMU VIAL
1.0 VIAL EA
53.6940 each
,00085012005 (INTERFERON ALFA-2B,RECOMB.
INTRON A 5MMU VIAL
1.0 VIAL EA
53.6940 each
;00085057102 (INTERFERON ALFA-2B,RECOMB.
INTRON A 10MMU VIAL
1.0 VIAL EA
107.3880 each
A0085057106 !INTERFERON ALFA-2B,RECOMB.
INTRON A 10MMU VIAL
1.0 VIAL EA
107.3880 each
0085068901 !INTERFERON ALFA-26,RECOMB.
INTRON A 18MMU VIAL
11.0 VIAL EA
193.2965 each
'00085111001 .INTERFERON ALFA-2B,RECOMB.
INTRON A 18MMU VIAL
11.0 VIAL EA
193.2965 each
i:\data\hiv_care\nato\adap\pricing\9706.WK1 13
I10
AIDS,DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
00085028502 INTERFERON ALFA-2B,RECOMB.
INTRON A 25MMU VIAL
1.0 VIAL EA
268.4890 each
00085053901 INTERFERON ALFA-2B,RECOMB.
INTRON A 50MMU VIAL
1.0 VIAL EA
536.9495 each
100085113301 JINTERFERON ALFA-2B,RECOMB.
INTRON A 10MMU/ML VIAL
2.5 ml VIAL ML
107.3880 per ml
00085117901 INTERFERON ALFA-2B,RECOMB.
INTRON A 10MMU/ML VIAL
1.0 ml VIAL ML
107.3880 per ml
Q00085118401 (INTERFERON ALFA-26,RECOMB.
INTRON A 3MMU/0.5ML VIAL
.5 ml VIAL ML
32.2240 per ml
00085076901 (INTERFERON ALFA-2B,RECOMB.
INTRON A 5MMU/ML VIAL
5.0 ml VIAL ML
53.6978 per mi
00085092301 INTERFERON ALFA-2B,RECOMB.
INTRON A 5MMU/ML VIAL
2.0 ml VIAL ML
6978 er ml
00085095301 INTERFERON ALFA-2B,RECOMB.
INTRON A 6MMU/ML VIAL
3.0 ml VIAL ML
322 per ml
00085119101 INTERFERON ALFA-28,RECOMB.
INTRON A 5MMU/0.5ML VIAL
.5 ml VIAL ML
er ml
00085117902 INTERFERON ALFA-2B,RECOMB.
INTRON A 10MMU/ML KIT
1.0 KIT
k53.6940
3565 each
00085118402 INTERFERON ALFA-2B,RECOMB.
INTRON A 3MMU/0.5ML KIT
1.0 KIT
2965 each
00085119102 INTERFERON ALFA-26,RECOMB.
INTRON A 5MMU/0.5M KIT
1.0 KIT
735 each
00034101901 INTERFERON ALFA -N3
ALFERON N 5MMU VIAL.
1.0 ml VIAL ML
151.1545 per ml
50458029515 ITRACONAZOLE
SPORANOX 10MG/ML SOLUTION
150.0 ml SOON, ORAL
0.6209 per ml
50458029001 ITRACONAZOLE
SPORANOX 100MG CAPSULE
1.0 CAPSULE
5.5313 each
50458029004 ITRACONAZOLE
SPORANOX 100MG CAPSULE
1.0 CAPSULE
5.5313 each
50458022115 KETOCONAZOLE
NIZORAL 2% CREAM
15.0 gm CREAM GM
0.9204 per gm
50458022130 KETOCONAZOLE
NIZORAL 2% CREAM
30.0 gm CREAM GM
0.7737 per gm
50458022160 KETOCONAZOLE
NIZORAL 20/6 CREAM
60.0 gm CREAM GM
0.5879 per gm
50458022001 KETOCONAZOLE' , "
NIZORAL 200MG TABLET:.
1.0 TABLET
2.7785 each
50458022010 KETOCONAZOLE •
NIZORAL 200MG TABLET -
1:0 TABLET
2.7785 each
00173047100 LAMIVUDINE.- .
EPIVIR.10MG/ML ORAL SOLN.
240.0 ml SOON, ORAL
0.2432 per ml
00173047001 LAMIVUDINE,'
EPIVIR 150MG TABLET-.= •
1.0 TABLET
3.6482 each
00205400451" LEUCOVORIN CALCIUM
LEUCOVORIN CAL 3MG/ML AMPUL
1.0 mi AMPUL ML
3.5536 per ml
00005533092 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 50MG VL
1.0 VIAL EA
78.3500 each
00081063793 LEUCOVORIN CALCIUM.
WELLCOVORIN 50MG VIAL-. -
1.0 VIAL EA
17.0658 leach
00205533019 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 50MG VL
1.0 VIAL EA
20.4488 each
00205533092 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 50MG VL
1.0 VIAL EA
20.4488 each
00469137030 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 50MG VL
1.0 VIAL EA
84.3125 each
00641236941 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 50MG VL
1.0 VIAL EA
53.4375 each
00703513001 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 50MG VL
1.0 VIAL EA
18.7530 each
51432055710 LEUCOVORIN CALCIUM.
LEUCOVORIN CALCIUM 50MG VL
1.0 VIAL EA
113.0500 each
539050051.10: LEUCOVORIN CALCIUM::
LEUCOVORIN CALCIUM 50MG.VL'
1.0 VIAL EA
'17.5156 each .
55390005110 LEUCOVORIN CALCIUM,-, 2
' LEUCOVORIN CALCIUM.50MG VL.
.'= 1.0.VIAL EA
:- 17.5180 each:
58406062105 LEUCOVORIN CALCIUM--.-.. • -.
LEUCOVORIN CALCIUM 50MG VL .
' 1.0.VIAL EA -
20:4488 each,
58406062137. LEUCOVORIN -CALCIUM:.
LEUCOVORIN CALCIUM 50MG,VL:
1.0 VIAL EA
=-20:4488 each,
00081063893 LEUCOVORIN"CALCIUM
LEUCOVORIN CALCIUM 100MG VL.' 1.0 VIAL' EA • -
-'37:8594 each
00205464694 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL
1.0 VIAL EA
37.4419 each
00641236441 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL
1.0 VIAL EA
53.4375 each
00703514001 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL.
1.0 VIAL EA
37.0500 each
51432042110 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL
1.0 VIAL EA
73.4825 each
53905005210 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL
1.0 VIAL EA
33.2500 each
55390005210 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL
1.0 VIAL EA
33.2500 each
55390081810 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL
1.0 VIAL EA
33.2500 each
58406062206 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL.
1.0 VIAL EA
37.4419 each
58406062235 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100MG VL
1.0 VIAL EA
37.4419 each
53905005301 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 200MG VL
1.0 VIAL EA
74.1000 each
55390005301 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 200MG VL
1.0 VIAL EA
74.1000 each
55390082401 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 200MG VL
1:0 VIAL EA
74.1000 each
00205464577 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 350MG VL
1.0 VIAL EA
131.0406 each
58406062307 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 350MG VL
1.0 VIAL EA
131.0406 each
58406062333 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 350MG VL
1.0 VIAL EA
131.0406 each
00005453623 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET;-
2.0993 each
00005453638 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
00005453640 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
00054449613 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
1.9255 each
00054449625 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
1.9255 each
00054849619 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
1.9255 each
00081063120 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
00081063135 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
00081063155 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
100173063135 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
,00173063155 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
00182186901 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
00182186917 ILEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
,00536414807 !LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
'00555048401 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
11.0 TABLET
2.0993 each
'00555048402 ;LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
1.0 TABLET
2.0993 each
;00603418321 LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 5MG TAB
11.0TABLET
2.0993 each
i:\data\hiv_care\nato\adap\pdcing\9706.W Ki 14
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
00182186489 1 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
!00302396001 IMEG ESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
'00304188301 IMEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
,00349876701
WEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00349876725
IMEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00364223401 IMEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00405462401 IMEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00405462404 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00536482201 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00536482202 IMEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00555060702 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00555060703 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET.
0.7793 each
00555060704 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00603439221 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00603439228 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00677120601 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
00719153610 MEGESTROL ACETATE
MEGESTROL 40MG TABLET .
1.0 TABLET.
0.7793 each
00839740606 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET.
0.7793 each -
00839740612 MEGESTROLACETATE
MEGESTROL 40MG TABLET-
1.0 TABLET
0.7793 each
00904357140 MEGESTROL ACETATE
MEGESTROL 40MG TABLET.-.
1.0 TABLET'
0.7793 each
00904357160 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET.
0.7793 each
00904357161 MEGESTROL ACETATE
MEGESTROL 40MG TABLET _
1,.0 TABLET -.
0.7793 each
00904357170 MEGESTROL ACETATE
MEGESTROL 40MG TABLET."
1.0 TABLET.
0.7793 each
11845028701 MEGESTROL ACETATE
MEGESTROL 40MG.TABLET
1.0 TABLET
0.7793 each
11845028702 MEGESTROL ACETATE.
MEGESTROL 40MG+TABLET _
1.0TABLET
0.7793 each
11845028703 MEGESTROL ACETATE.
MEGESTROL 40MG TABLET.
1.0 TABLET
0.7793 each
17236049501 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7591 each
49884029001 IMEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
49884029004 MEGESTROL ACETATE
MEGESTROL 40MGTABLET• .
1.0 TABLET
0.7793 each
49884029005 MEGESTROL ACETATE
MEGESTROL 40MG TABLET
1.0 TABLET
0.7793 each
51079043520 MEGESTROL ACETATE
MEGESTROL 40MG TABLET =
1.0 TABLET,.
0.7793 each
51432009303 MEGESTROL ACETATE
MEGESTROL40MGTABLET:=._ :_
_ 1.0 TABLET::
=0.7793 each .
51432009305 MEGESTROLACETATE
MEGESTROL 40MG TABLET._
1.0 TABLET �;
-.-.-'0.7793 each -
52555037601 MEGESTROL ACETATE .
MEGESTROL 40MGTABLET "I : -
- 1.0:TABLET_,:0.7793
each,
54274019910 IMEGESTROL ACETATE
MEGESTROL 40MG•TABLET= � , .
_ 1.0 TABLET'
0.6680 each
54274019925 MEGESTROL ACETATE
MEGESTROL 40MG•TABLETi ., "= -
1.0TABLE7r-".
0.6680 each .
54274026610 MEGESTROL ACETATE
MEGESTROL 40MG TABLET.
1.0 TABLET
0.6680 each
62584077901 MEGESTROL ACETATE
MEGESTROL 40MG TABLET. -
1.0 TABLET
1.0138 each
00005450704 METHOTREXATE
RHEUMATREX 2.5MG TABLET
1.0 TABLET
1.7993 each
00005450705 METHOTREXATE
RHEUMATREX 2.5MG TABLET
1.0 TABLET
1.7993 each
00005450707 METHOTREXATE
RHEUMATREX 2.5MG TABLET
1.0 TABLET
1.7993 each
00005450709 METHOTREXATE
RHEUMATREX 2.5MG TABLET
1.0 TABLET
1.7993 each
00005450723 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00005450791 METHOTREXATE
RHEUMATREX 2.5MG TABLET
1.0 TABLET _
1.7993 each
00054455015 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00054455025 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00054855003 METHOTREXATE
METHOTREXATE 2.5MG.TABLET
1.0 TABLET
1.7993 each
00054855005 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00054855006 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00054855007 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00054855010 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00054855025 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET--
1.7993 each
00182153901 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLETT
1.7993 each
00182153995 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET'
1.7993 each
00364249901 METHOTREXATE.
METHOTREXATE 215MG TABLET
1.0 TABLET
1.7993 each
00364249936 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
62584078201 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
3.2690 each
'00378001401 IMETHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
,00405464301 IMETHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
;00405464336 ;METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00536399801 ;METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
100536399836 ;METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
'00555057202 (METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
;00555057235 ,METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
;00555057245 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
,00555057246 (METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
'00555057247 ;METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00555057248 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
100555057249 METHOTREXATE
METHOTREXATE 2.5MG TABLET
11.0TABLET
1.7993 each
i:\data\hiv_care\nato\adap\pricing\9706.WK1 16
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
00603449921 IMETHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
'00677161001 IMETHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
100719154410 !METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00781107601 IMETHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
'00781107636 !METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
.00839790506 1 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
:00904174960 1METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
'00904174973 IMETHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET.
1.7993 each
i11845110401 IMETHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
51079067005 IMETHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
151079067086 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
.51079067087 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
51079067088 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
51079067089 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
151432052203 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
59911587401 METHOTREXATE
METHOTREXATE 2.5MG TABLET
1.0 TABLET
1.7993 each
00015305020 METHOTREXATE SODIUM
MEXATE 20MG VIAL
1.0 VIAL EA
8.0954 each
00205465490 METHOTREXATE SODIUM
METHOTREXATE 20MG VIAL
1.0 VIAL EA
2.6363 each
58406067101 METHOTREXATE SODIUM
METHOTREXATE 20MG VIAL
1.0 VIAL EA
4.7738 each
58406067301 METHOTREXATE SODIUM
METHOTREXATE 20MG VIAL
1.0 VIAL EA
4.7738 each
00015305120 METHOTREXATE SODIUM
MEXATE 50MG VIAL
1.0 VIAL EA
12.3483 each
00205933792 METHOTREXATE SODIUM
METHOTREXATE 50MG VIAL
1.0 VIAL EA
13.6390 each
58406067103 METHOTREXATE SODIUM
METHOTREXATE 50MG VIAL
1.0 VIAL EA
4.5125 each
00015305220 METHOTREXATE SODIUM
MEXATE- 100MG VIAL
1.0 VIAL EA
24.3545 each
00015305320 METHOTREXATE SODIUM
MEXATE 250MG VIAL
1.0 VIAL EA
60.1222 each
00205465302 METHOTREXATE SODIUM
METHOTREXATE. 1 GM VIAL
1.0 VIAL EA
58.3656 each
58406067105 METHOTREXATE SODIUM
METHOTREXATE 1GM VIAL
1.0 VIAL EA
58.3656 each
00469215010 METHOTREXATE SODIUM
METHOTREXATE 2.5MG/ML VIAL
2.0 ml VIAL ML
3.7406 per ml
00013226691 METHOTREXATE SODIUM
FOLEX-PFS 25MG/ML VIAL
2.0 ml VIAL ML
7.2200 per ml
00013227691 METHOTREXATE SODIUM
FOLEX-PFS 25MG/ML VIAL.
4.0 ml VIAL ML
7.1666 per ml
00013228691 METHOTREXATE SODIUM
FOLEX-PFS 25MG/ML VIAL
8.0 mi VIAL ML
7.0181 per ml
00013229691 METHOTREXATE SODIUM
FOLEX PFS 25MG/MLVIAL _
10.0 mi VIAL ML
6.6678 per ml
00205455626 METHOTREXATE SODIUM:
METHOTREXATE 25MG/ML VIAL.
2.0 ml VIAL ML
2.2563 perml-
00205532526 METHOTREXATE SODIUM-
METHOTREXATE LPF 25MG/ML VL .
2.0 ml VIAL ML .
2.2563 per ml
00205532618 METHOTREXATE SODIUM
METHOTREXATE LPF 25MG/ML VL :'
4.0 ml VIAL ML
2.0188 per mL
00205532730 METHOTREXATE SODIUM
METHOTREXATE LPF 25MG/ML VL
8.0 ml VIAL ML
1.9861 per ml,
00205533734 IMETHOTREXATE SODIUM
METHOTREXATE LPF 25MG/MLVL
10.0 mi VIAL ML
1.9451 per mi
00205533798 IMETHOTREXATE SODIUM
METHOTREXATE LPF 25MG/ML VL
10.0 ml VIAL ML
1.9451 per ml
00205533834 IMETHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
10.0 ml VIAL ML
1.9451 per ml
00469197010 1 METHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
2.0 ml VIAL ML
6.6203 per ml
00469197020 IMETHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
4.0 ml VIAL ML
6.5016 per ml
00469197030 METHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
8.0 ml VIAL ML
6.3977 per ml
00469216010 METHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
2.0 ml VIAL ML
6.6203 per ml
00469288030 METHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
10.0 mi VIAL ML
6.3947 per ml
53443000321 METHOTREXATE SODIUM
ABITREXATE 25MG/ML VIAL
2.0 ml VIAL ML
2.7313per ml
53443000322 METHOTREXATE SODIUM
ABITREXATE 25MG/ML VIAL
4.0 ml VIAL ML
2.5769 per ml
53443000324 METHOTREXATE SODIUM
ABITREXATE 25MG/ML VIAL
8.0 ml VIAL ML
2.4878 per ml
53443058232 METHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
2.0 ml VIAL ML
2.7313 per ml
53905003110 METHOTREXATE SODIUM
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2.0 ml VIAL ML
3.2656 per ml
53905003210 METHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
4.0 ml VIAL ML
2.0781 per ml
53905003310 METHOTREXATE SODIUM
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8.0 ml VIAL ML
2.0781 per ml
53905003410 METHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
10.0 mi VIAL ML
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55390003110 METHOTREXATE SODIUM
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2.0 ml VIAL ML
3.2680 per ml
55390003210 1 METHOTREXATE SODIUM
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4.0 ml VIAL ML
2.0781 per ml
55390003310 IMETHOTREXATE SODIUM
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8.0 ml VIAL ML
2.0781 per ml
55390003410 IMETHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
10.0 ml VIAL ML
2.5536 per ml
58406068114 IMETHOTREXATE SODIUM
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2.0 ml VIAL ML
2.2563 per ml
58406068117 IMETHOTREXATE SODIUM
METHOTREXATE 25MG/ML VIAL
10.0 ml VIAL ML
1.9451 per mi
.58406068312 iMETHOTREXATE SODIUM
METHOTREXATE LPF 25MG/ML VL
8.0 ml VIAL ML
1.9861 per ml
58406068315 IMETHOTREXATE SODIUM
METHOTREXATE LPF 25MG/ML VL
2.0 ml VIAL ML
2.2563 per ml
158406068316 (METHOTREXATE SODIUM
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10.0 ml VIAL ML
1.9451 per ml
:58406068318 IMETHOTREXATE SODIUM
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.63010001190 INELFINAVIR MESYLATE
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'63010001027 (NELFINAVIR MESYLATE
VIRACEPT 250MG TABLET
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00054464725 1NEVIRAPINE
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00003045735 ;NYSTATIN
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.00003045743 !NYSTATIN
IMYCOSTATIN VAGINAL TABLET
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00003045770 :NYSTATIN
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i:\data\hiv_care\nato\adap\pdcing\9706.W Ki 17
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1. AIDS'DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS` EXHIBIT F-3
00182098128 INYSTATIN
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00302460530 INYSTATIN
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00304020130 WYSTATIN
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00364720915 NYSTATIN
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00364720930 INYSTATIN
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00405471915 INYSTATIN
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00405471930 INYSTATIN
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00677116539 NYSTATIN
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00719163121 NYSTATIN
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17022740200 NYSTATIN-
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00302460015 NYSTATIN
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i-.\data\hiv_care\nato\adap\pricing\9706.W K1 18
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AID$ DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
117022572402 !NYSTATIN
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00003058430 NYSTATIN
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00168000715 NYSTATIN
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00132167851 NYSTATIN
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00223437915 NYSTATIN
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00223437930 NYSTATIN
NYSTATIN 100000U/GM OINT
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00281321244 INYSTATIN
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00302460115 NYSTATIN
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00302460131 NYSTATIN
NYSTATIN 100000U/GM OINT
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00536478120 NYSTATIN
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i:\data\hiv_care\nato\adap\pdcing\9706.W Ki 19
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
00574040405 INYSTATIN
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00223657266 NYSTATIN
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480.0 ml SUSP, ORAL�
0.0383
per ml'.
00281003760 NYSTATIN
NYSTEX 100000U/ML SUSP
60.0 mi SUSP; ORAL:
C ^
0.0520
per ml
00302461102 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00304095561 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00332610928 INYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00332610938 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
00349834416 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
oer ml
00349834460 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00364207516 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP. ORAL
0.0383
per ml
00364207558 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00405345016 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
00405345056 INYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00426853716 INYSTATIN
NYSTATIN t00000U/ML SUSP
480.0 ml SUSP, ORAL
0.03831perml
00426853760 INYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00472132002 INYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520.per
ml
00472132016 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
00536122061 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00536122085 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
00603148049 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00603148058 INYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
00677083625 INYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
00677083633 INYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
00719459174 (NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
;00719459183 !NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
er ml
100781610516 ;NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
;00781610561 'NYSTATIN
NYSTATIN 1000000/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
100814549050 INYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
100820011630 ;NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 1per
ml
'00832853716 :NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
!00832853760 !NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
'00839669864 ;NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
'00839669869 ;NYSTATIN
NYSTATIN 10000OUIML SUSP
480.0 ml SUSP, ORAL
0.0383
per ml
00839770364 (NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
;00904276103 -NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520
per ml
;00904276116 ;NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383
er ml
1:\data\hiv_care\nato\adap\pdcing\9706.WK1 20
AIDS'DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
.11845017301 INYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 per ml
11845017317 !NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 per ml
112939070102 (NYSTATIN
NYSTATIN ORAL SUSPENSION
60.0 ml SUSP, ORAL
0.0520 per ml
12939070116 INYSTATIN
NYSTATIN ORAL SUSPENSION
480.0 ml SUSP, ORAL
0.0383 per ml
117236079916 (NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383 per ml
117236079922 INYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 er ml
124208096060 INYSTATIN
NYSTATIN 100000U/ML SUSP
5.0 ml SUSP, ORAL
0.0383 per ml
;24208096067 jNYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 per ml
i24208096094 INYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383 per ml
49158025648 {NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 er ml
51079030710 NYSTATIN
NYSTATIN 100000U/ML SUSP
5.0 ml SUSP, ORAL
0.0383 per ml
51079073210 NYSTATIN
NYSTATIN 100000U/ML SUSP
10.0 ml SUSP, ORAL
0.0383 per ml
51079083506 NYSTATIN
NYSTATIN 100000U/ML SUSP
1.0 ml SUSP, ORAL
0.03831per ml
51079083606 NYSTATIN
NYSTATIN 100000U/ML SUSP
2.0 ml SUSP, ORAL
0.0383 per ml
51079083706 NYSTATIN
NYSTATIN 100000U/ML SUSP
5.0 ml SUSP, ORAL
0.0383 per ml
51432063720 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383 per ml
51432063723 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 per ml
52446083549 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 per ml
52446083558 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383 per ml
54274092216 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383 per ml
54274092220 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 per ml
60432053716 NYSTATIN
NYSTATIN 100000U/ML SUSP
480.0 ml SUSP, ORAL
0.0383 per ml
60432053760 NYSTATIN
NYSTATIN 100000U/ML SUSP
60.0 ml SUSP, ORAL
0.0520 per ml
00003054320 NYSTATIN
MYCOSTATIN PASTILLES
1.0 LOZENGE
0.8373 each
53191009801 NYSTATIN
BIO -STATIN 30000OU CAPSULE
1.0 CAPSULE
0.1230 each
53191000901 NYSTATIN
BIO -STATIN 50000OU CAPSULE
1.0 CAPSULE
0.2736 each
53191019201 NYSTATIN
BIO -STATIN 100000OU CAPSULE
1.0 CAPSULE
0.3990 each
00003058053 NYSTATIN
MYCOSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00003058054 NYSTATIN
MYCOSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00093098301 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00182136901 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00185075001 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00228227710 NYSTATIN
2. NYSTATIN 50000OU ORALTAB
1.0 TABLET
0.1193 each
00302461001 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00349210401 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1'.0 TABLET
0.1193 each
00349871001 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00364205101 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00405471401 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00405471402 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00536409401 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00603483021 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00677061301 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00719163010 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00781130501 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00814549514 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00832045500 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00832045510 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00839628206 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00904067260 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
11845029501 NYSTATIN
NYSTATIN 50000OU TABLET
1.0 TABLET
0.1193 each
17022611902 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1040 each
17236021901 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET-
0.1193 each
49884011901 INYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
49884011905 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
51432031403 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
52446031721 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
,52555011901 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
53489040001 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
'54274026010 NYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
55829039610 INYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.0969 each
,56126011911 INYSTATIN
NYSTATIN 50000OU ORAL TAB
1.0 TABLET
0.1193 each
00071052909 (PAROMOMYCIN SULFATE
HUMATIN 250MG KAPSEAL
1.0 CAPSULE
2.0528 each
00071052924 IPAROMOMYCIN SULFATE
HUMATIN 250MG CAPSULE
1.0 CAPSULE
2.0528 each
:00418300103 1PENTAMIDINE ISETHIONATE
PENTAMIDINE 300MG VIAL
1.0 VIAL EA
51.3000 each
00053100005 1PENTAMIDINE ISETHIONATE
PENTACARINAT 300MG VIAL
1.0 VIAL EA
88.9200 each
'00074454801 'PENTAMIDINE ISETHIONATE
PENTAMIDINE 300MG VIAL
1.0 VIAL EA
100.3900 each
00074454849 {PENTAMIDINE ISETHIONATE
1PENTAMIDINE 300MG VIAL
1.0 VIAL EA
100.3900 each
.00209856020 1PENTAMIDINE ISETHIONATE
1PENTAMIDINE 300MG VIAL
1.0 VIAL EA
94.0500 each
_00469011310 _PENTAMIDINE ISETHIONATE_
IPENTAM 300 VIAL
11.0 VIAL (EA)__93.8125
each
1:\data\hiv_care\nato\adap\pricing\9706.W K1 21
AIDS'4RUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
00469113091 1PENTAMIDINE ISETHIONATE
PENTAM 300 VIAL
1.0 VIAL EA
93.8125 each
00702454849 !PENTAMIDINE ISETHIONATE
PENTAMIDINE 300MG VIAL
1.0 VIAL EA
113.2525 each
'57317021006 (PENTAMIDINE ISETHIONATE
NEBUPENT 300MG INHAL POWDER
1.0 VIAL EA
93.8125 each
57317021103 ,PENTAMIDINE ISETHIONATE
PENTAM 300 VIAL
1.0 VIAL EA
93.8125 each
00054372263 1PREDNISONE
PREDNISONE 5MG/5ML SOLUTION
500.0 ml SOON, ORAL
0.0327per ml
00054872216 I PREDNISONE
PREDNISONE 5MG/5ML SOLUTION
5.0 ml SOON, ORAL
0.0327 per ml
00054873004 1PREDNISONE
PREDNISONE 20MG/20ML SOLN
20.0 ml SOON, ORAL
0.0327 1 per ml
00054873016 PREDNISONE
PREDNISONE 20MG/20ML SOLN
20.0 ml SOL'N, ORAL
0.0327 1per ml
00054873616 PREDNISONE
PREDNISONE 10MG/10ML SOLN
10.0 ml SOON, ORAL
0.0327 per ml
00781670516 PREDNISONE
PREDNISONE 5MG/5ML SOLUTION
480.0 ml SOON, ORAL
0.0236 per ml
51432038318 PREDNISONE
PREDNISONE 5MG/5ML SOLUTION
120.0 ml SOON, ORAL
0.0392 per ml
00451120104 PREDNISONE
LIQUID PRED 5MG/5ML SYRUP
120.0 ml SYRUP
0.1201 per ml
00451120108 PREDNISONE
LIQUID PRED 5MG/5ML SYRUP
240.0 ml SYRUP
0.1201 perml
00832864004 PREDNISONE
PREDNISONE 5MG/5ML SYRUP
120.0 ml SYRUP
0.0392 per ml
00054372144 PREDNISONE
PREDNISONE 5MG/ML SOLUTION
30.0 ml CONCENTRATE
0.4440 per ml
00032280801 PREDNISONE
ORASONE IMG TABLET
1.O TABLET
0.0339 each
00032280810 PREDNISONE
ORASONE 1MG TABLET
1.O TABLET
0.0339 each
00054474125 PREDNISONE
PREDNISONE IMG TABLET
1.0 TABLET
0.0309 each '
00054474131 1PREDNISONE,
PREDNISONE I MG TABLET
1.O TABLET
0.0309 each
00054873925 PREDNISONE
PREDNISONE I MG TABLET
1.0 TABLET:
0.0309 each
00085084303 PREDNISONE
METICORTEN I MG TABLET
1.0 TABLET-
0.0339 each
00339577512 PREDNISONE
PREDNISONE 1 MG TABLET.
1:O.TABLET 1
0.0331 each
00814280801 PREDNISONE
PREDNISONE IMG TABLET
1:O.TABLET"
0.0285 each
00009003201 PREDNISONE
DELTASONE 2.5MG.TABLET
1.0 TABLET
0.0238 each..
00054474225 PREDNISONE
PREDNISONE 2.5MG TABLET
1.0•TABLET
0.0477 each
00054874025 PREDNISONE
PREDNISONE 2.5MG TABLET
1.0 TABLET
0.0477 each
00009004501 PREDNISONE
DELTASONE 5MG TABLET
1.0 TABLET
0.0263 each
00009004502 PREDNISONE
DELTASONE 5MG TABLET
1.0 TABLET
0.0263 each
00009004504 PREDNISONE
DELTASONE 5MG TABLET
1.0 TABLET
0.0263 each
00009004505 PREDNISONE
DELTASONE 5MG TABLET
1.0 TABLET
0.0263 each
00009004516 PREDNISONE
DELTASONE 5MG TABLET
1.0 -TABLET
0.0263 each
00032281001 PREDNISONE
ORASONE 5MG TABLET.-
1.0 TABLET
0.0263 each
00032281010 PREDNISONE:-
ORASONE5MG
1.0=TABLET
: ' 0.0263 each
00054472825 PREDNISONE
PREDNISONE5MG•TABLET- = 1:0.TABLET
.,..'0.0263 each -
00054472831• PREDNISONE=:
- PREDNISONE5MG;TABLET
1.0TABLET,
0.0263 each
00054872425 PREDNISONE''
PREDNISONESMG-TABLET-.. :'; :
1'.0:TABLET
0.0263 each
00115429401 PREDNISONE
PREDNISONE 5MG TABLET
1.07ABLET-
0.0185 each
00115429402 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET "
0.0185 each
00115429403 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0185 each
00115429404 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0185 each
00131222837 PREDNISONE
PREDNICEN-M 5MG TABLET
1.0 TABLET
0.0263 each
00131222881 PREDNISONE
PREDNICEN-M 5MG TABLET
1.0 TABLET
0.0263 each
00143147501 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00143147510 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00143147525 PREDNISONE
PREDNISONE 5MG TABLET
1:0 TABLET
0.0263 each
00144150003 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET-
0.0185 each
00182020110 PREDNISONE
- PREDNISONE SMG.TABLET
1.0 TABLET
0.0263 each
00182020189 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET i
0.0263 each
00223151501 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00223151502 1PREDNISONE
PREDNISONE 5MG TABLET
1.O TABLET
0.0263 each
00228233696 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0213 each
;00254509413 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET,-
0.0263 each
00254509423 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET]
0.0263 each
00259028401 1PREDNISONE
STERAPRED 5MG TABLET UNIPAK
1.0 TABLET
0.0263 each
00259039021 1PREDNISONE
STERAPRED 5MG TABLET UNIPAK
1.0 TABLET
0.0263 each
00259039148 1PREDNISONE
STERAPRED 5MG TABLET UNIPAK
1.0 TABLET
0.0263 each
00298109811 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00302550001 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0228 each
00302550010 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0228 each
100304022900 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0177 each
'00339529312 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
i00349216201 RREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0215 each
'00349216210 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0215 each
00349893310 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0215 each
,00364021801 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
;00364021802 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
:00364021890 iPREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00405482801 i PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 1 each
'00405482803 1PREDNISONE
PREDNISONE 5MG TABLET
11.0TABLET
0.0263 1 each
i:\data\hiv_care\nato\adap\pricing\9706.W K1 22
AIDSDRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
00527120001 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0141 each
;00527120005 ;PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0141 each
00527120010 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0141 each
;00536432410 !PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
;00536432450 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
;00556012301 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00556012310 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00591505201 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
,00591505204 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00603533215 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
100603533221 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00603533231 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00603533232 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00615053613 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00615053621 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00677011701 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00677011710 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00686053613 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00719174513 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0157 each
00781149501 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00781149510 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00781149513 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00783013309 PREDNISONE-
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00814628514 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00814628530 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00839514306 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00839514316 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00839514358 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00879012901 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00879012910 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00904215719 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00904215746 PREDNISONE-
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each -
00904215752 PREDNISONE:
t PREDNISONE 5MG TABLET
1.0 TABLET:
0.0263 each
00904215760 PREDNISONE:
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00904215761 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00904215780 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
11845017801 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0240 each
11845017804 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0240 each
17022714706 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0104 each
17236025801 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0226 each
17236025810 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0226 each
38022031900 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0128 each
46703000710 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0131 each
50319050501 PREDNISONE
PRONAX 5MG TABLET
1.0 TABLET
0.0263 each
51079003220 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
51285031102 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
51285031105 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
51432036000 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
51432036006 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
52446036921 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
52446036932 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
52765125200 PREDNISONE
PREDNISONE -5 TABLET
1.0 TABLET
0.0263 each
53489013801 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
53489013810 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
53633028601 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0218 each
53633028610 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0218 each
53633028611 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0218 each
54274067010 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
54274067050 IPREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
55829042210 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
57480035101 'PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
57480035106 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
57783687001 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
57783687002 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
'58729028620 1PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
'60904028620 'PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
61392040815 ,PREDNISONE
1PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
'61392040830 ;PREDNISONE
1PREDNISONE 5MG TABLET
11.0 TABLET
0.0263 each
61392040831 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
1:\data\hiv_care\nato\adap\pricing\9706.W K1 23
`A
AIDS'ARUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
,61392040832 ;PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
:61392040839 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
61392040845 :PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
61392040851 ;PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
61392040854 PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
161392040856 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
;61392040860 (PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
;61392040890 .PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
61392040891 iPREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
62584083201 !PREDNISONE
PREDNISONE 5MG TABLET
1.0 TABLET
0.0263 each
00009019301 1PREDNISONE
DELTASONE 10MG TABLET
1.0 TABLET
0.0335 each
00009019302 1PREDNISONE
DELTASONE 10MG TABLET
1.0 TABLET
0.0335 each
00009019303 1PREDNISONE
DELTASONE 10MG TABLET
1.0 TABLET
0.0335 each
100032281201 1PREDNISONE
ORASONE 10MG TABLET
1.0 TABLET
0.0470 each
'00032281210 1PREDNISONE
ORASONE 10MG TABLET
1.0 TABLET
0.0470 each
00054473025 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00054473029 PREDNISONE.
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00054872525 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00143147301 PREDNISONE
PREDNISONE 1OMG TABLET
1.0 TABLET
0.0488 each
00143147310 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
'0.0488 each
00143147325 PREDNISONE
PREDNISONE IOMG TABLET
1.0 TABLET
0.0488 each
00182133401 1PREDNISONE
PREDNISONE 10MG TABLET
1.O TABLET 7
0.0488 each
00182133410 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00182133489 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00228233810 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
= 0.0488 each
00228233850 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00254509313 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00254509323 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00259036421 PREDNISONE
STERAPRED DS 10MG TB UNI PAK
1.0 TABLET
0.0488 each
00259036448 PREDNISONE
STERAPRED DS 10MG TB UNI PAK
1.0 TABLET
0.0488 each
00259038948 PREDNISONE
STERAPRED DS 10MG TB UNIPAK
1.0 TABLET
0.0488 each
00302550101 PREDNISONE
- PREDNISONE 10MG TABLET
1.0 TABLET
=• 0.0385 each
00302550110 PREDNISONE' _
PREDNISONE-10MG TABLET
1.O TABLET- "
= 0.0385 each
00339529512 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET-'-
0.0470 each
00349225201 PREDNISONE
PREDNISONE 10MG TABLET..
= 1.0 TABLET.
` " 0.0488 each,
00349225210 PREDNISONE-
PREDNISONE 10MG.TABLET
- 1.0 TABLET
-. 0.0488 each
00349893401 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00349893405 PREDNISONE -
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00364046101 PREDNISONE
PREDNISONE IOMG TABLET
1.0 TABLET
0.0488 each
00364046102 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00364046105 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00364046190 PREDNISONE.
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00405482901 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00405482902 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00405482903 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00536432501 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00536432510 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00555023302 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00555023305 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00591544201 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00591544203 1PREDNISONE
PREDNISONE IOMG TABLET
1.0 TABLET
0.0488 each
00591544204 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET-
0.0488 each
00603533315 !PREDNISONE
PREDNISONE IOMG TABLET
1.0 TABLET:
0.0488 each
00603533321 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00603533331 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00603533332 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
,00677069801 !PREDNISONE
PREDNISONE I OMG TABLET
1.0 TABLET
0.0488 each
00677069805 (PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
!00677069810 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
100719174610 !PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0423 each
100719174613 !PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0423 each
'00781150001 IPREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
•0078115001 O jPREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00781150013 ;PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
.00814628814 (PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
;00814628828 iPREDNISONE
PREDNISONE 10MGTABLET
1.0 TABLET
0.0488 each
00839152006 ;PREDNISONE
1PREDNISONE 10MG TABLET
1.0 TABLET
0.0488each
,00839152012 ;PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00839152016 !PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
i:\dataUhiv_care\nato\adap\pdcing\9706.WK1 24
AIDS<DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
00904214160 (PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
;00904214161 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00904214180 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
111845017901 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0392 each
11845017904 I PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0392 each
17236025901 ;PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0418 each
117236025910 ;PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0418 each
38022035601 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0361 each
51079003320 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
'51285031202 !PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0423 each
51285031205 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0423 each
51432035603 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
51432035606 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
52446037021 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
53489013901 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
53489013905 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
53489013910 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
53633028701 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
53633028710 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
53633028711 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
54274067110 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0423 each
54274067150 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0423 each
55829042310 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
57480035201 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
57480035206 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
61392041715 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
61392041730 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
61392041731 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
61392041732 1PREDNISONE
PREDNISONE 10MG TABLET.
1.0 TABLET
0.0488 each
61392041739 1PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
61392041745 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
61392041751 PREDNISONE
PREDNISONE 10MG TABLET
1.07ABLET
0.0488 each
61392041754 PREDNISONE
PREDNISONE 10MG.TABLET
1.0 TABLET
0.0488 each
61392041756 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
61392041760 PREDNISONE
PREDNISONE.10MG TABLET
1.07ABLET
. 0.0488 each
61392041790 PREDNISONE
PREDNISONE 10MG TABLET''
1.0 TABLET
0.0488 each
61392041791 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
62584083301 PREDNISONE
PREDNISONE 10MG TABLET
1.0 TABLET
0.0488 each
00009016501 PREDNISONE
DELTASONE 20MG TABLET
1.0 TABLET
0.0584 each
00009016502 PREDNISONE
DELTASONE 20MG TABLET
1.0 TABLET
0.0584 each
00009016503 1PREDNISONE
DELTASONE 20MG TABLET
1.0 TABLET
0.0584 each
00032281401 1PREDNISONE
ORASONE 20MG TABLET
1.0 TABLET
0.0743 each
00032281410 PREDNISONE
ORASONE 20MG TABLET
1.0 TABLET
0.0743 each
00054472925 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00054472929 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00054872625 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00143147701 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00143147705 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00143147710 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00143147725 JPREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00182108601 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00182108610 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET-
0.0743 each
00182108689 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00223151601 jPREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00228233710 !PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
;00228233750 !PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00302550201 !PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
100302550210 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00339577712 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00349226101 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
100349226110 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
'00349893501 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
;00364044201 ;PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
;00364044202 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
'00364044205 IPREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
;00364044290 'PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00405483001 PREDNISONE
PREDNISONE 20MG TABLET
11.0 TABLET
0.0743 each
'00405483002 ;PREDNISONE
PREDNISONE 20MG TABLET
11.0TABLET
0.0743 each
;00527126201 ;PREDNISONE
PREDNISONE 20MG TABLET
11.0TABLET
0.0471 each
i:\data\hiv_care\nato\adap\pdcing\9706.W K1 25
14
AIDS -DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
'00527126210 (PREDNISONE
PREONISONE 20MG TABLET
1.0 TABLET
0.0471 each
00536432601 'PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00536432605 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
:00536432610 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
.00591544301 iPREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
!00591544303 iPREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00603533421 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00603533432 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
'00677042701 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
'00677042705 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00677042710 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00686154213 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00719174710 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0713 each
00719174713 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0713 each
00781148501 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
;00781148513 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00814629014 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00814629028 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00839151706 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00839151712 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
- 0.0743 each
00879043801 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00879043805 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00879043810 PREDNISONE.
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00904214060 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00904214061 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
00904214080 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
11845018001 PREDNISONE.
PREDNISONE 20MG TABLET
1.0 TABLET
0.0717 each
11845018004 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
- 0.0717 each
17022715102 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0499 each
17022715106 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0499 each
17236053901 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0713 each
17236053910 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0713 each
38022035701 PREDNISONE
PREDNISONE-20MG TABLET
1.0 TABLET
0.0589 each.
51079002220 PREDNISONE:
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
51285031302 PREDNISONE-
PREDNISONE 20MG TABLET
1.0 TABLET •
= : 0.0743 each
51285031305 PREDNISONE
PREDNISONE 20MG.TABLET
1.0 TABLET
0.0743 each
51432035803 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
51432035806 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
52446037121 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
52446037132 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
53489014001 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
53489014005 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
53489014010 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
53633028801 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
53633028810 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
53633028811 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
54274067210 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
54274067250 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
55829042410 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
157480047201 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
57480047206 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
57783695001 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET-
0.0743 each
57783695002 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
61392076130 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
61392076131 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
:61392076132 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
161392076139 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
'61392076145 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
'61392076151 iPREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
61392076154 (PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
'61392076160 1PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
61392076190 iPREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
61392076191 !PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
'62584083401 PREDNISONE
PREDNISONE 20MG TABLET
1.0 TABLET
0.0743 each
100054474725 PREDNISONE
PREDNISONE 25MG TABLET
1.0 TABLET
0.1350 each
00054874725 !PREDNISONE
PREDNISONE 25MG TABLET
1.0 TABLET
0.1350 each
00009038801 'PREDNISONE
DELTASONE 50MG TABLET
11.0TABLET
0.1332 each
.00032281601 :PREDNISONE
JORASONE 50MG TABLET
1.0 TABLET
0.1753 each
00054473325 ;PREDNISONE
IPREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
i:\data\hiv_care\nato\adap\pdcing\9706.W K1 26
Y
AID& DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
100054872925 1PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
00143148101 'PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
00143148125 ,PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
:00339529612 .PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1753 each
,00536432801 ;PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
;00781145001 PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
00781145013 (PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
00814629514 1PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
00904052760 (PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1998 each
151432035903 1PREDNISONE
PREDNISONE 50MG TABLET
1.0 TABLET
0.1610 each
'00081020155 IPYRIMETHAMINE
DARAPRIM 25MG TABLET
1.0 TABLET
0.3923 each
00173020155 1PYRIMETHAMINE
DARAPRIM 25MG TABLET
1.0 TABLET
0.3923 each
00013530117 IRIFABUTIN
MYCOBUTIN 150MG CAPSULE
1.0 CAPSULE
3.7342 each
00074194063 IRITONAVIR
NORVIR 80MG/ML SOLUTION
240.0 ml SOON, ORAL
1.0935 per ml
00074949202 RITONAVIR
NORVIR 100MG CAPSULE
1.0 CAPSULE
1.5621 each
00074949254 IRITONAVIR
NORVIR 100MG CAPSULE
1.0 CAPSULE
1.5621 each
00004024515 ISAQUINAVIR MESYLATE
INVIRASE 200MG CAPSULE
1.0 CAPSULE
2.0128 each
00003196801 STAVUDINE
ZERIT 1 MG/ML SOLUTION
200.0 ml SOLN, ORAL
0.2215 per ml
00003196401 STAVUDINE
ZERIT 15MG CAPSULE
1.0 CAPSULE
3.0065 each
00003196501 STAVUDINE
ZERIT 20MG CAPSULE
1.0 CAPSULE
3.1265 each
00003196601 STAVUDINE
ZERIT 30MG CAPSULE
1.0 CAPSULE
3.2618 each
00003196701 STAVUDINE
ZERIT40MG CAPSULE
1.0 CAPSULE
3.3822 each
00115471401 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.0660 each
00115471402 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.0660 each
00115471403 SULFADIAZINE-
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.0660 each
00182199601 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.4170 each
00182199610 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.4170 each
00185075701 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.5199 each
00185075710 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.5199 each
00223189101 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.1568 each
00223189102 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.1568 each
0040549550V SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.3750 each
00527107401 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.0608 each
00527107410 SULFADIAZINE.
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.0608 each
00536565601 SULFADIAZINE:
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.4726 each
00686075701- SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.3135 each
00904254360 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.4726 each
00904787060 SULFADIAZINE
ISULFADIAZINE 500MG TABLET
1.0 TABLET
0.4726 each
00904787080 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.4726 each
51079084020 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.4275 each
51432044303 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.1515 each
51432044306 SULFADIAZINE
SULFADIAZINE 500MG TABLET
1.0 TABLET
0.1515 each
00641153233 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE W/TMP AMP.
5.0 ml AMPUL ML
1.1189 er ml
00004195501 SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM IV INFUSION VIAL
10.0 ml VIAL ML
1.5219 per ml
00004195601 SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM IV INFUSION VIAL
5.0 ml VIAL ML
1.4070 per ml
00004195801 SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM VIAL
30.0 ml VIAL ML
1.4146 per ml
00081085601 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA I.V. INFUSION VIAL
20.0 ml VIAL ML
0.6884 per ml
00081085602 SULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA I.V. INFUSION VIAL
50.0 ml VIAL ML
0.4884 per ml
00081085644 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA I.V. INFUSION VIAL
5.0 ml VIAL ML
0.7567 per ml
00081085647 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA I.V. INFUSION VIAL
10.0 ml VIAL ML
0.7569 per ml
00081085695 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA I.V. INFUSION VIAL
10.0 ml VIAL ML
0.7569 per ml
00173085601 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA I.V. INFUSION VIAL
20.0 ml VIAL ML
0.6884 per ml
00173085644 SULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA I.V. INFUSION VIAL
5.0 ml VIAL ML
0.7567 per ml
00173085695 SULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA I.V. INFUSION VIAL
10.0 ml VIAL ML
0.7415 per ml
00469161020 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE WJ TMP VIAL
5.0 ml VIAL ML
0.5819 per ml
00469161030 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE W/TMP VIAL
10.0 ml VIAL ML
0.5166 per ml
'00469161050 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP VIAL
30.0 ml VIAL ML
0.5126 per ml
00641276443 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP VIAL
5.0 ml VIAL ML
1.2303 per ml
'00641276543 11SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP VIAL
10.0 ml VIAL ML
1.2057 per ml
00641276641 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE W/TMP VIAL
30.0 ml VIAL ML
1.1194 per ml
1100703950303 ISULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP VIAL
5.0 ml VIAL ML
0.5084 per ml
;00703951403 'SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP VIAL
10.0 ml VIAL ML
0.5654 per ml
00703952601 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP VIAL
30.0 ml VIAL ML
0.4606 per ml
,00003120110 ISULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158 per ml
'00004103301 ISULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM SUSPENSION
100.0 ml SUSP, ORAL
0.0243 per ml
'00004103328 1SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158 per ml
00005312465 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.01581perml
00047290323 iSULFAMETHOXAZOLE/TRIMETHOPRIM TRISULFAM SUSPENSION
480.0 ml SUSP, ORAL
0.0158 er ml
00081085496 ISULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA SUSPENSION
480.0 ml SUSP, ORALI
0.0158 er ml
i:\data\hiv_care\nato\adap\pdcing\9706.W K1 27
:q
AID&DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
00081085501 1SULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA SUSPENSION
150.0 ml SUSP, ORAL
0.0158
per ml
'00081085502 ISULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA SUSPENSION
200.0 ml SUSP, ORAL
0.0158
per ml
00081085503 SULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA SUSPENSION
100.0 ml SUSP, ORAL
0.0243
per mi
'00081085593 ISULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA SUSPENSION
20.0 ml SUSP, ORAL
0.0158
per mi
00081085596SULFAMETHOXAZOLE/rRiMETHOPRIM SEPTRA SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
00093019016 ISULFAMETHOXAZOLE/TRIMETHOPRIM COTRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
;00093056216 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
00093610016 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
.00173085496 SULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
;00173085503 SULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA SUSPENSION
100.0 ml SUSP, ORAL
0.0243
per ml
00173085596 SULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
00182155840 SULFAMETHOXAZOLE/T-RIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
100182155940 SULFAMETHOXAZOLE/rRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
X00223661201 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 mi SUSP, ORAL
0.0158
per ml
!00223661301 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per mi
00228239416 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 mi SUSP, ORAL
0.0158
per ml
00304096098 SULFAMETHOXAZOLE/TRIMETHOPRIM. SULFAPRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per mi
00332610032 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
100.0 ml SUSP, ORAL
0.0243
per mi
00332610038 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
00349834316 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 mi SUSP, ORAL
0.0158
per ml.
00364207616 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per mi
00364207716 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-W/TMP SUSP
480.0 mi SUSP, ORAL
0.0158
per mi..
00405367516 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE.W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml.
00472128416 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 MI SUSP, ORAL
0.0158
per mi
00472128516 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
00472128533 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
100.0 ml SUSP, ORAL
0.0243
per ml
00536171585 SULFAMETHOXAZOLE/rRiMETHOPRIM SULFAMETHOXAZOLE.W/rMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
00536172585 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
00603168758 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
00603168858 SULFAMETHOXAZOLE/TRIMETHOPRIM. SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL -
0.0158
per ml.
00677084033 SULFAMETHOXAZOLE/TRIMETHOPRIM. SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per mi
00677084133 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP. SUSP
480.0 ml SUSP, ORAL..-.
0.0158
per mi
00719476083 SULFAMETHOXAZOLE/TRIMETHOPRV SULFATRIM SUSPENSION -
480.0 ml SUSP, ORAL.
0.01581permi.
00719476183 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL : r
0.0158
er mi
00781606216 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE.W/TMP SUSP-
480.0 ml SUSP, ORAL.-.--.- -
0.0158
perml,.
00781606316 SULFAMETHOXAZOLE/TRIMETHOPRIM. SULFAMETHOXAZOLE W/TMP SUSP
480.0 mi SUSP, ORAL_' • :
0.0158
per mi:.
00814724282 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-W/TMP SUSP
480.0 mi SUSP, ORAL
0.0158
per ml
00814724382 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per mi,
00839669969 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
perml
00839671869 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
00839770969 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/rMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
00904040516 SULFAMETHOXAZOLE/TRIMETHOPRIM BETHAPRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
00904040616 SULFAMETHOXAZOLE/TRIMETHOPRIM BETHAPRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
11845012507 ISULFAMETHOXAZOLEfrRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.01581perml
11845044213 SULFAMETHOXAZOLE/TRIMETHOPRIM, SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
permi
11845044313 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
17236084816 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
17236084916 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 ml SUSP, ORAL
0.0158
per ml
51079063810 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
20.0 ml SUSP, ORAL
0.0158
per ml
51079083806 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
5.0 ml SUSP, ORAL
0.0158
per ml
51079083906 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/rMP SUSP
2.5 ml SUSP, ORAL
0.0158
per ml
51432067120ISULFAMETHOXAZOLE/TRIMETHOPRIM SULFATRIM SUSPENSION
480.0 mi SUSP, ORAL
0.0158
per mi
52446088758ISULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE W/TMP SUSP
480.0 ml SUSP, ORAL
0.0158
per ml
58173002916 ISULFAMETHOXAZOLEITRIMETHOPRIM SULTREX SUSPENSION
480.0 mi SUSP, ORAL
0.0158
per ml
100003013850 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
'00003013860 11SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
00004005001 SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM 400-80MG TABLET -
1.0 TABLET
0.0711 each
00004005034 SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM 400-80MG TABLET
1.0 TABLET
0.0711 each
.00004005049 ISULFAMETHOXAZOLEITRIMETHOPRIM BACTRIM 400-80MG TABLET
1.0 TABLET
0.0711 each
00005311731 ISULFAMETHOXAZOLEITRIMETHOPRIM SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
:00054480025 ;SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
00054880025 ISULFAMETHOXAZOLEJTRIMETHOPRIM SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
.00081085255ISULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA 80/400 TABLET
1.0 TABLET
0.0711 each
,00081085256 ISULFAMETHOXAZOLEITRIMETHOPRIM SEPTRA 80/400 TABLET
1.0 TABLET
0.0711 each
100081085270 iSULFAMETHOXAZOLE/TRIMETHOPRIM SEPTRA 80/400 TABLET
1.0 TABLET
0.0711 each
'00093008801 'SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
00093008805 !SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
'00093018801 !SULFAMETHOXAZOLE/TRIMETHOPRIM COTRIM 400-80MG TABLET
1.0 TABLET
0.0711 each
.00093018805 !SULFAMETHOXAZOLE/TRIMETHOPRIM COTRIM 400-80MG TABLET
1.0 TABLET
0.0711 each
i:\data\hiv_care\nato\adap\pdcing\9706.W K1 28
I
AIDS•DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
00093018893 1SULFAMETHOXAZOLE/TRIMETHOPRIM
COTRIM 400-80MG TABLET
1.0 TABLET
0.0711 each
100173085255 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA 80/400 TABLET
1.0 TABLET
0.0711 each
X00182147801 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
:00182147805 ISULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
:00182884389 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00185011101 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00185011105 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLElrMP SS TAB
1.0 TABLET
0.0711 each
100302665001 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
100302665005 ISULFAMETHOXAZOLEfrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
;00332213009 ISULFAMETHOXAZOLEIrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
00332213013 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00349236401 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00349236405 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
00364206801 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00364206805 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00364206890 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00405492801 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00405492802 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00527100701 SULFAMETHOXAZOLE/rRIMETHOPRIM
TRIAZOLE 400/80MG TABLET
1.0 TABLET
0.0711 each
00527100705 SULFAMETHOXAZOLE/TRIMETHOPRIM TRIAZOLE 400/80MG TABLET
1.0 TABLET
0.0711 each
00536469201 SULFAMETHOXAZOLElrRIMETHOPRIM
SULFAMETHOXAZOLEITMP SS TAB
1.0 TABLET
0.0711 each
00536469205 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00555032102 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00555032104 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00591554601 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00591554603 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
00603577821 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00615017113 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00677078301 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00677078305 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
00686213010 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLElrMP SS TAB
1.0 TABLET
0.0711 each
00719188510 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFOXAPRIM SS TABLET
1.0 TABLET
0.0711 each
00781106201 SULFAMETHOXAZOLE/TRIMETHOPR
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00781106213 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00814723914 ISULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB .
1.0 TABLET
0.0711 each
00814723928 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00839648706 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00839648712 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
00904272640 SULFAMETHOXAZOLE/TRIMETHOPRIM
BETHAPRIM SS 400-80MG TAB
1.0 TABLET
0.0711 each
00904272660 SULFAMETHOXAZOLE/TRIMETHOPRIM
BETHAPRIM 400-80MG TAB
1.0 TABLET
0.0711 each
00904272661 SULFAMETHOXAZOLE/TRIMETHOPRIM
BETHAPRIM 400-80MG TAB
1.0 TABLET
0.0711 each
11845019001 ISULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
11845019003 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
17236030001 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
17236030005 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
38022033101 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
45809051011 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS SS 400/80 TABLET
1.0 TABLET
0.0711 each
45809051012 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS SS 400/80 TABLET
1.0 TABLET
0.0711 each
45809051013 ISULFAMETHOXAZOLEfrRIMETHOPRIM
UROPLUS SS 400/80 TABLET
1.0 TABLET
0.0711 each
45809091011 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS SS TABLET
1.0 TABLET
0.0711 each
45809091012 ISULFAMETHOXAZOLEfrRIMETHOPRIM
UROPLUS SS TABLET
1.0 TABLET
0.0711 each
49727004602 ISULFAMETHOXAZOLEITRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET--
0.0711 leach
50111034101 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
50111034102 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
51203020901 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
51432042003 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
52446044721 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
152555034101 IS ULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
52555034105 ISULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
53489014501 1SULFAMETHOXAZOLErFRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
153489014505 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
:53633013901 1SULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
53633013905 1SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
53633013911 ISULFAMETHOXAZOLEfrRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
53746027101 ISULFAMETHOXAZOLEfrRIMETHOPRIM
SULFAMETHOXAZOLElrMP SS TAB
1.0 TABLET
0.0711 each
'53746027105 ISULFAMETHOXAZOLEfTRIMETHOPRIM
SULFAMETHOXAZOLEIrMP SS TAB
1.0 TABLET
0.0711 each
;54274048110 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
54274048130 ;SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
155829048510 ;SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLEITMP SS TAB
1.0 TABLET
0.0711 each
i:\data\hiv_care\nato\adap\pdcing\9706.W K1 29
t . X
AIDS DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
;56126013911 !SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP SS TAB
1.0 TABLET
0.0711 each
57480043601 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLEITMP SS TAB
1.0 TABLET
0.0711 each
:57480043606 •SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
61392078230 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
61392078231 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
;61392078232 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
61392078239 iSULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
61392078245 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLErrMP SS TAB
1.0 TABLET
0.0711 each
61392078251 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
;61392078254 ,SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
61392078260 iSULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
61392078290 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
61392078291 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.0711 each
62584085601 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP SS TAB
1.0 TABLET
0.2987 each
00003017150 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00003017160 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00004011701 SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM DS TABLET
1.0 TABLET
0.0893 each
00004011704 SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM DS TABLET
1.0 TABLET
0.0893 each
00004011714 SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM DS TABLET
1.0 TABLET
0.0893 each
00004011749 SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM DS TABLET
1.0 TABLET
0.0893 each
00004011754 SULFAMETHOXAZOLE/TRIMETHOPRIM
BACTRIM DS TABLET
1.0 TABLET
0.0893 each
00005311831 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLEfTMP DS TAB
1.0 TABLET
0.0893 each
00054480125 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00054880125 SULFAMETHOXAZOLE/TRIMETHOPRIM,
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00081085352 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA DS TABLET
1.0 TABLET
0.0893 each
00081085355 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA DS TABLET
1.0 TABLET
0.0893 each
00081085356 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA DS TABLET
1.0 TABLET
0.0893 each
00081085365 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRA DS TABLET
1.0 TABLET
0.0893 each
00093008901 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00093008905 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00093018901 SULFAMETHOXAZOLE/TRIMETHOPRIM COTRIM DS TABLET
1.0 TABLET
0.0893 each
00093018905 SULFAMETHOXAZOLE/TRIMETHOPRIM COTRIM DS TABLET
1.0 TABLET
0.0893 each
00093018993 SULFAMETHOXAZOLE/TRIMETHOPR •
COTRIM DS.TABLET
1.0TABLET
0.0893 each
00143162525 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00173085365 SULFAMETHOXAZOLE/TRIMETHOPRIM
SEPTRADSTABLET. -
1.0 -TABLET
0.0893 each
00182140801 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS.TAB .
1.0 TABLET -
0.0893 each.
00182140805 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00182140810 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00182884489 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00185011201 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLEITMP DS TAB
1.0 TABLET
0.0893 each.
00185011205 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00228239510 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00228239550 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00302665201 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00302665205 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00304029605 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAPRIM DS TABLET
1.0 TABLET
0.0893 each
00332213209 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00332213213 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00349233601 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00349233605 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00364206901 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00364206905 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET-
0.0893 each
00364206990 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET'
0.0893 each
00405492901 1SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET.
0.0893 each
00405492902 ISULFAMETHOXAZOLE/TRIMETHOPRIM'
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00527111001 ISULFAMETHOXAZOLEITRIMETHOPRIM
TRIAZOLE 800/160 TABLET
1.0 TABLET
0.0893 each
00527111005 ISULFAMETHOXAZOLE/TRIMETHOPRIM TRIAZOLE 800/160 TABLET
1.0 TABLET
0.0893 each
00536469301 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00536469305 !SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00555032202 ISULFAMETHOXAZOLEfTRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00555032204 1SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00556032001 ;SULFAMETHOXAZOLE/TRIMETHOPRIM
CHERAGAN W/TMP TABLET
1.0 TABLET
0.0893 each
;00556032005 ;SULFAMETHOXAZOLE/TRIMETHOPRIM
CHERAGAN W/TMP TABLET
1.0 TABLET
0.0893 each
00591554701 SULFAMETHOXAZOLEITRIMETHOPRIM SULFAMETHOXAZOLEITMP DS TAB
1.0 TABLET
0.0893 each
;00591554703 :SULFAMETHOXAZOLEITRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00603577921 ''SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
100603577928 :SULFAMETHOXAZOLE/TRIMETHOPRIM
ISULFAMETHOXAZOLE/TMP DS TAB
11.0 TABLET
0.0893 each
'00615017013 :SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
11.0 TABLET
I 0.0893 each
00677078401 ISULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TMP DS TAB
11.0 TABLET
I 0.0893 each
1:\data\hiv_care\nato\adap\pricing\9706.W K1 30
e0
c 3
ill D& DRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
'00677078405 iSULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00686213210 iSULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00686213212 !SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP DS TAB
1.0 TABLET
0.0893 each
00719188610 ISULFAMETHOXAZOLE/rRIMETHOPRIM
SULFOXAPRIM DS TABLET
1.0 TABLET
0.0893 each
00719188612 ISULFAMETHOXAZOLE/rRIMETHOPRIM
SULFOXAPRIM DS TABLET
1.0 TABLET
0.0893 each
00781106301 1SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00781106305 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
;00781106313 ISULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00814724014 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00814724028 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
,00839640606 SULFA METHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP DS TAB
1.0 TABLET
0.0893 each
'90839640612 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
00839769412 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
'00904272540 SULFAMETHOXAZOLE/TRIMETHOPRIM
BETHAPRIM DS TABLET
1.0 TABLET
0.0893 each
;00904272560 ISULFAMETHOXAZOLErrRIMETHOPRIM
BETHAPRIM DS TABLET
1.0 TABLET
0.0893 each
00904272561 ISULFAMETHOXAZOLE/TRIMETHOPRIM
BETHAPRIM DS TABLET
1.0 TABLET
0.0893 each
00904272595 SULFAMETHOXAZOLE/TRIMETHOPRIM
BETHAPRIM DS TABLET
1.0 TABLET
0.0893 each
11845018801 ISULFAMETHOXAZOLEfrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
11845018803 ISULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
12939066950 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
17236031301 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
17236031305 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
38022033201 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
45809051121 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS DS.TABLET
1.0 TABLET
0.0893 each
45809051122 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS DS TABLET
1.0 TABLET
0.0893 each
45809051123 SULFAMETHOXAZOLEITRIMETHOPRIM
UROPLUS DS TABLET
1.0 TABLET
0.0893 each
45809051124 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS DS TABLET
1.0 TABLET
0.0893 each
45809051125 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS DS TABLET
1.0 TABLET
0.0893 each
45809091121 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS DS TABLET
1.0 TABLET
0.0893 each
45809091122 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS DS TABLET
1.0 TABLET
0.0893 each
45809091124 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS DS TABLET
1.0 TABLET
0.0893 each
45809091126 SULFAMETHOXAZOLE/TRIMETHOPRIM
UROPLUS DS TABLET
1.0 TABLET
0.0893 each
49727004702 SULFAMETHOXAZOLEfrRIMETHOPRV
SULFAMETHOXAZOLErrMP DS TAB
1.0 TABLET
0.0893 each
49727004704 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
50111034201 SULFAMETHOXAZOLE/TRIMETHOPRIM,
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
50111034202 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
51079012890 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
51203021001 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
51432042203 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
51432042205 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
52555034201 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
52555034205 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
52765130505 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAPRIM D.S. TABLET
1.0 TABLET
0.0893 each
52999054701 SULFAMETHOXAZOLE/TRIMETHOPRIM
KIDTRIM DS TABLET
1.0 TABLET
0.0893 each
53489014601 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
53489014605 SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
53633014001 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
53633014005 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
53633014011 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
153746027201 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP DS TAB
1.0 TABLET
0.0893 each
53746027205 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP DS TAB
1.0 TABLET
0.0893 each
;53746027210 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/rMP DS TAB
1.0 TABLET-
0.0893 each
154274024730 ISULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
i54274049810 ISULFAMETHOXAZOLEfTRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
54274049830 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP. DS TAB
1.0 TABLET
0.0893 each
;55649045901 ISULFAMETHOXAZOLEITRIMETHOPRIM
COFATRIM DS CAPLET
1.0 TABLET
0.0893 each
'55829048610 ISULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
56126014011 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
57480038701 ISULFAMETHOXAZOLEfTRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
57480038706 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
:58345080265 !SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
60429017014 +SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
60429017020 1SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
61392078330 1SULFAMETHOXAZOLE/rRIMETHOPRIM
SULFAMETHOXAZOLE/rMP DS TAB
1.0 TABLET
0.0893 each
61392078331 ;SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
61392078332 !SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
61392078339 :SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
61392078345 'SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
11.0 TABLET
0.0893 each
61392078351 ,SULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
i:\data\hiv_care\nato\adap\pdcing\9706.W K1 31
14 � R
P 11),%DRUG ASSISTA(JCE'PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS
EXHIBIT F-3
61392078354 !SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMP DS TAB
1.0 TABLET
0.0893 each
61392078360 !SULFAMETHOXAZOLErrRIMETHOPRIM
SULFAMETHOXAZOLErrMP DS TAB
1.0 TABLET
0.0893 each
:61392078390 iSULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLEIrMP DS TAB
1.0 TABLET
0.0893 each
:61392078391 ISULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE)TMP DS TAB
1.0 TABLET
0.0893 each
62584085701 SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TMPDSTAB
1.0 TABLET
0.3525 each
00004012701 TRIMETHOPRIM.
TRIMPEX 100MG TABLET
1.0 TABLET
0.1643 each
;00004012749 ,TRIMETHOPRIM
TRI MPEX 100MG TABLET
1.0 TABLET
0.1643 each
'00081082055 iTRIMETHOPRIM
PROLOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
:00173082055 iTRIMETHOPRIM
PROLOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
'00182153601 iTRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
;00332215809 iTRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00349831701 ITRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00364064901 ITRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00536468601 ITRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00555042902 ITRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00591557101 ITRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00603626421 ITRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00719197910 ITRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00839728406 TRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00904164660 TRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00904164661 TRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
17236088701 TRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1:0 TABLET
0.1643 each
51432097803 TRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
52446043721 TRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
54274051510 ITRIMETHOPRIM,
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
56126040911 ITRIMETHOPRIM
TRIMETHOPRIM 100MG TABLET
1.0 TABLET
0.1643 each
00081082555 ITRIMETHOPRIM
PROLOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
00173082555 TRIMETHOPRIM
PROLOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
00332215909 TRIMETHOPRIM
TRIMETHOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
00536468301 TRIMETHOPRIM
TRIMETHOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
00603626521 TRIMETHOPRIM
TRIMETHOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
00839743306 TRIMETHOPRIM
TRIMETHOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
00904164760 TRIMETHOPRIM
TRIMETHOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
00904164761 TRIMETHOPRIM
TRIMETHOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
51432097603 TRIMETHOPRIM
TRIMETHOPRIM 200MG TABLET
1.0 TABLET
0.2438 each
52446043821 TRIMETHOPRIM
TRIMETHOPRIM 200MG TABLET .
1.0 TABLET
0.2438 each
58178002010 TRIMETREXATE GLUCURONATE
NEUTREXIN 25MG VIAL
1.0 VIAL EA
60.2063 each
58178002050 TRIMETREXATE GLUCURONATE
NEUTREXIN 25MG VIAL
1.0 VIAL EA
60.2063 each
00002145201 VINBLASTINE SULFATE
VELBAN 10MG VIAL
1.0 VIAL EA
38.5130 each
00013737686 VINBLASTINE SULFATE
VELSAR 10MG VIAL
1.0 VIAL EA
33.6063 each
0364244754 VINBLASTINE SULFATE
VINBLASTINE SULF 10MG VIAL
1.0 VIAL EA
35.6250 each
00402102710 VINBLASTINE SULFATE
VINBLASTINE SULF 10MG VIAL
1.0 VIAL EA
35.6250 each
53905009110 VINBLASTINE SULFATE
VINBLASTINE SULF 10MG VIAL
1.0 VIAL EA
20.1875 each
55390009110 VINBLASTINE SULFATE
VINBLASTINE SULF 10MG VIAL
1.0 VIAL EA
20.1875 each
61703031018 VINBLASTINE SULFATE
VINBLASTINE SULF 10MG VIAL
1.0 VIAL EA
35.6250 each
00469278030 IVINBLASTINE SULFATE
VINBLASTINE 1 MG/ML VIAL
10.0 ml VIAL ML
3.1473 per ml
51432041910 IVINSLASTINE SULFATE
VINBLASTINE SULF 1MG/ML VL
10.0 ml VIAL ML
20.1875 per ml
51432047810 IVINBLASTINE SULFATE
VINBLASTINE SULF 1MG/ML VL
25.0 ml VIAL ML
2.0140 per ml
00002719809 JVINCRISTINE SULFATE.
ONCOVIN 1 MG/ML SYRINGE
1.0 ml SYRINGE ML
35.3875 er ml
00002719909 JVINCRISTINE SULFATE
ONCOVIN 1MG/ML SYRINGE
2.0 ml SYRINGE ML
34.8112 per ml
00002719401 IVINCRISTINE SULFATE
ONCOVIN 1 MG/ML VIAL
1.0 ml VIAL ML
34.2570 per ml
00002719501 IVINCRISTINE SULFATE
ONCOVIN 1 MG/ML VIAL
2.0 ml VIAL ML
34.2475 per ml
00002719601 IVINCRISTINE SULFATE
ONCOVIN IMG/ML VIAL
5.0 ml VIAL ML
30.9149per ml
00013745686 IVINCRISTINE SULFATE
VINCASAR PFS 1MG/ML VIAL
1.0 ml VIAL ML
35.2213 per ml
00013746686 IVINCRISTINE SULFATE
VINCASAR PFS 1 MG/ML VIAL
2.0 ml VIAL ML
35.2213 per ml
00364244851 IVINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
1.0 ml VIAL ML
28.6520 per ml
00364244852 IVINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
2.0 ml VIAL ML
18.1688 per ml
;00402102801 IVINCRISTINE SULFATE
VINCRISTINE SU 1 MG/ML VIAL
1.0 ml VIAL ML
28.6520 per ml
'00402102802 IVINCRISTINE SULFATE
VINCRISTINE SU 1MG/ML VIAL
2.0 ml VIAL ML
18.1688 perml
:00469352000 'VINCRISTINE SULFATE
VINCRISTINE 1 MG/ML VIAL
1.0 ml VIAL ML
30.1744 per ml
00469352010 IVINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
2.0 ml VIAL ML
29.5509 per ml
;00469352020 IVINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
5.0 ml VIAL ML
26.6333 per ml
;51432047505 IVINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
5.0 ml VIAL ML
13.8947 per ml
.51432047601 IVINCRISTINE SULFATE
VINCRISTINE 1 MG/ML VIAL
1.0 ml VIAL ML
14.2500 per ml
;51432047702 IVINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
2.0 ml VIAL ML
14.2500 per ml
:53443000740 ;VINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
1.0 ml VIAL ML
17.1000 per ml
;53443000741 ;VINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
2.0 ml VIAL ML
17.1000 per ml
.53443000743 IVINCRISTINE SULFATE
IVINCRISTINE 1MG/ML VIAL
5.0 ml VIAL ML
15.1050 per ml
.61703030906 IVINCRISTINE SULFATE
IVINCRISTINE 1 MG/ML VIAL
1.0 ml VIAL ML
30.1625 per ml
i:\data\hiv_care\nato\adap\pdcing\9706.WKI 32
-�p
A As f
ti AIDSsDRUG ASSISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS EXHIBIT F-3
J
61703030916 ;VINCRISTINE SULFATE
VINCRISTINE 1MG/ML VIAL
2.0 ml VIAL ML
18.1688 per ml
00004022001 :ZALCITABINE
HIVID 0.375MG TABLET
1.0 TABLET
1.7425 each
00004022101 iZALCITABINE
HIVID 0.750MG TABLET
1.0 TABLET
2.1842 each
00081010793 !ZIDOVUDINE
RETROVIR IV INFUSION VIAL
20.0 ml VIAL ML
0.8184 per ml
00173010793 iZIDOVUDINE
RETROVIR IV INFUSION VIAL
20.0 ml VIAL ML
0.8184 verml
00081011318 ZIDOVUDINE
RETROVIR 10MG/ML SYRUP
240.0 ml SYRUP
0.1513 per ml
00173011318 iZIDOVUDINE
RETROVIR 10MG/ML SYRUP
240.0 ml SYRUP
0.1513 perml
00081010855 (ZIDOVUDINE
RETROVIR 100MG CAPSULE
1.0 CAPSULE
1.5132 each
00081010856 21DOVUDINE
RETROVIR 100MG CAPSULE
1.0 CAPSULE
1.5132 each
00173010855 (ZIDOVUDINE
RETROVIR 100MG CAPSULE
1.0 CAPSULE
1.5132 each
00173010856 !ZIDOVUDINE
RETROVIR 100MG CAPSULE
1.0 CAPSULE.
1.5132 each
'00173050100 (ZIDOVUDINE
RETROVIR 300MG TABLET
1.0 TABLET
4.5397 each
99999900902 IINHALER
PENTAMIDINE NEBULIZER
1.0 UNIT
15.0000 EACH
I
i
Note: There id no corresponding National Drug
Code for It a nebulizer, thepseudo-NDC was assigr
ed by the Office of AIDS.
i:\data\hiv--care\nato\adap\pdcing\9706.WK1 33
le