Wisconsin Medicaid Pharmacy Data Tables

Noncovered Drugs — Manufacturer Rebates Refused

N = NEW TO LIST
D = DELETED FROM LIST
X = DELETED NONCOVERED ITEM

PAGES: 1 | 2 | 3 | 4     Effective: 7/01/06

NEW EFFEC MANUF NDC NAME MANUF IDENTIFIED REASON
 10/1/2004 PFIZER CORPORATION 00009-0333-03 Kaopectate Suspension 236ml Manufacturer discontinued NDC 
 7/1/2000 PHARMACIA and UPJOHN 00009-0353-01 Gelfoam Compressed Sponge NDC not on CMS tape 
 7/1/2000 PHARMACIA and UPJOHN 00009-0396-01 Gelfoam Dental Packs Size 4 NDC not on CMS tape 
 10/1/2004 PFIZER CORPORATION 00009-0400-02 Kaopectate Suspension 236ml NDC not on CMS tape 
 10/1/2004 PFIZER CORPORATION 00009-0400-04 Kaopectate Suspension 355ml NDC not on CMS tape 
 10/1/2004 PFIZER CORPORATION 00009-5176-01 Somavert 10mg Vial NDC not on CMS tape 
 10/1/2004 PFIZER CORPORATION 00009-5180-01 Somavert 20mg Vial NDC not on CMS tape 
 1/1/2001 MEAD JOHNSON AND COMPANY 00015-3023-97 Amikin 250 mg/ml Vial Product not rebateable per manufacturer 
 7/1/2000 MEAD JOHNSON and COMPANY 00015-3503-99 Kantrex 1gm/3ml Vial NDC not on CMS tape 
 10/1/2004 BRISTOL MYERS SQUIBB 00015-3565-12 Mesnex 400mg Tablet NDC not on CMS tape 
 7/1/2000 MEAD JOHNSON and COMPANY 00015-7405-99 Ampicillin 2 gm Vial NDC not on CMS tape 
 1/1/2001 SANOFI SYNTHELABO 00024-0490-10 Dynabac D5-Pak 250 mg NDC not on CMS tape 
 10/1/2004 SANOFI SYNTHE LAB, INC 00024-5101-31 Kerlone 10mg Tablet NDC not on CMS tape 
 7/1/2000 HOFFMANN LAROCHE INC 00033-2501-13 Synalar 0.025% Cream NDC not on CMS tape 
 7/1/2000 HOFFMANN LAROCHE INC 00033-2906-40 Nasalide Nasal Solution NDC not on CMS tape 
 10/1/2004 WYETH 00046-0938-08 Prempro 0.3mg/1.5mg Tablet NDC not on CMS tape 
 1/1/2004 UNIMED 00051-5046-42 Teveten 600mg Tablet NDC not on CMS tape 
 1/1/2004 ORGANON 00052-0108-90 Remeron 30mg Soltab Invalid NDC per manufacturer 
 4/1/2005 ROXANNE LABS 00054-0057-46 Digoxin 50 mcg/ml Elixir NDC not on CMS tape 
 10/1/2001 ROXANE LABS 00054-4658-25 Roxicodone 15 mg Tablet NDC not on CMS tape 
 10/1/2001 ROXANE LABS 00054-8554-11 Methadone HCL 10 mg Tablet NDC not on CMS tape 
 10/1/2002 ALCON LABS 00065-0411-30 Betadine 5% Eye Solution Hospital use only 
 1/1/2001 ALCON LABS 00065-0795-15 BSS ophth soln 15ml NDC is not covered under CMS agreement 
 1/1/2004 NOVARTIS PHARMACEUTICALS 00067-6024-15 Denavir 1% Cream NDC not on CMS tape 
N 7/1/2005 ABBOTT LABORATORIES 00074-1812-22 Sodium Chloride 0.9% Syr P/F Product is a device 
N 7/1/2005 ABBOTT LABORATORIES 00074-1918-32 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 ABBOTT LABORATORIES 00074-1918-33 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 ABBOTT LABORATORIES 00074-1918-35 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 ABBOTT LABORATORIES 00074-5365-05 Sodium Chloride 0.9% Flush Product is a device 
N 7/1/2005 ABBOTT LABORATORIES 00074-5365-10 Sodium Chloride 0.9% Flush Product is a device 
 10/1/2002 NOVARTIS 00078-0369-64 Denavir 1% Cream NDC not on CMS tape 
 10/1/2000 NOVARTIS PHARMACEUTICALS 00083-6733-04 Priscoline 25 mg/ml Ampule NDC not on CMS tape 
 7/1/2000 SCHERING PLOUGH PHARMACEUTICALS 00085-0041-11 Vancenase 42 mcg Inhaler NDC not on CMS tape 
 4/1/2002 AVENTIS PHARMACEUTICALS 00088-1208-65 Anzemet 20mg/ml Amp Hospital use only 
 10/1/2004 TEVA PHARMACEUTICALS USA 00093-8111-82 Cholestyramine Light Powder Invalid NDC per manufacturer 
 10/1/2004 TEVA PHARMACEUTICALS USA 00093-8204-01 Cimetidine 400mg Tablet Invalid NDC per manufacturer 
 10/1/2004 TEVA PHARMACEUTICALS USA 00093-8204-05 Cimetidine 400mg Tablet NDC not on CMS tape 
 10/1/2004 Impax Laboratories, Inc 00115-1811-01 Flavoxate HCL 100mg Tablet NDC not on CMS tape 
 10/1/2004 Colgate Oral 00126-00126-0179-16 Prevident Dental Rinse NDC not on CMS tape 
 7/1/2000 COLGATE ORAL PHARMACEUTICALS 00126-0288-66 Prevident 5000 Plus Cream NDC not on CMS tape 
 1/1/2001 COLGATE ORAL PHARMACEUTICALS 00126-2310-68 Gel-Kam 0.63% Dental NDC not on CMS tape 
 1/1/2001 COLGATE ORAL PHARMACEUTICALS 00126-2312-68 Gel-Kam 0.63% Dental NDC not on CMS tape 
 10/1/1999 WEST WARD PHARMACEUTICALS 00143-1171-25 Captopril 12.5 Mg Tablet NDC not on CMS tape 
 1/1/2001 STIEFEL LABORATORIES 00145-2474-06 Brevoxyl-4 Creamy Wash NDC not on CMS tape 
 7/1/2000 STIEFEL LABORATORIES 00145-2484-06 Brevoxyl-8 Creamy Wash NDC not on CMS tape 
 10/1/2004 NOVO NORDISK 00169-5173-04 Vagifem 25mcg Vaginal NDC not on CMS tape 
 10/1/2004 NOVO NORDISK 00169-5174-01 Activella Tablet NDC not on CMS tape 
 10/1/2004 NOVO NORDISK 00169-5174-02 Activella Tablet NDC not on CMS tape 
N 10/1/2005 ZENITH GOLDLINE PHARMACEUTICALS 00182-1812-00 Cyclosporine 25 mg Softgel Product terminated per manufacturer 
 7/1/2000 ZENITH GOLDLINE PHARMACEUTICALS 00182-2617-89 Bumetanide 2 mg Tablets Product terminated per manufacturer 
N 10/1/2005 ZENITH GOLDLINE PHARMACEUTICALS 00182-2687-01 Isosorbide MN 60 mg Tablet NDC not valid per manufacturer 
 7/1/2001 ZENITH GOLDLINE PHARMACEUTICALS 00182-5005-34 Hydrocortisone 2.5% Cream NDC not on CMS tape 
 4/1/2002 EON LABS 00185-0027-05 Fluvoxamine Maleate 50 mg tab NDC not on CMS tape 
 10/1/2004 EON LABS MANUFACTURING 00185-0172-10 Enalapril/HCTZ 10-25mg NDC not on CMS tape 
 4/1/2003 EON LABS 00185-4400-10 Tizanidine HCl 4mg tablet NDC not on CMS tape 
 7/1/2003 EON LABS 00185-5400-33 Lisinopril 5mg Tablet NDC not on CMS tape 
 10/1/2001 ASTRAZENECA LP 00186-1033-12 Sensorcaine 0.5% Vial NDC not on CMS tape 
 4/1/2002 WYETH AYERST PHARMACEUTICLAS 00206-8454-06 Zosyn 3/0.375G Vial NDC not on CMS tape 
 10/1/2000 PUREPAC PHARM CO 00228-2183-10 Dipyridamole 50 mg Tablet NDC not on CMS tape 
 10/1/2000 PUREPAC PHARM CO 00228-2183-96 Dipyridamole 50 mg Tablet NDC not on CMS tape 
 10/1/2000 PUREPAC PHARM CO 00228-2185-10 Dipyridamole 75 mg Tablet NDC not on CMS tape 
 10/1/2000 PUREPAC PHARM INC 00228-2185-96 Dipyridamole 75 mg Tablet NDC not on CMS tape 
 10/1/2000 PUREPAC PHARM CO 00228-2193-10 Dipyridamole 25 mg Tablet NDC not on CMS tape 
 10/1/2000 PUREPAC PHARM CO 00228-2193-96 Dipyridamole 25 mg Tablet NDC not on CMS tape 
 10/1/2002 B BRAUN MEDICAL 00264-9361-55 Trophamine 6% IV Soln NDC not on CMS tape 
 10/1/2002 B BRAUN MEDICAL 00264-9371-55 Hepatamine 8% IV Solution NDC not on CMS tape 
 7/1/2000 BAXTER HEALTH CARE 00338-0033-13 Dextrose 70% Water IV Solution NDC not on CMS tape 
 10/1/2002 BAXTER HEALTHCARE 00338-0071-04 Dextrose 2.5%-1/2NS IV Soln NDC not on CMS tape 
 10/1/2001 BAXTER HEALTHCARE 00338-2015-48 Penicillin GK 3mmu/100ml D5W NDC not on CMS tape 
 7/1/2000 BAXTER HEALTH CARE 00338-2689-75 Morphine 1 mg/ml Syringe NDC not on CMS tape 
N 4/1/2005 BAXTER HEALTH 00338-38017-77 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8017-77 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8019-70 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8019-70 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8020-72 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8020-72 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8021-79 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8021-79 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8302-69 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8303-70 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8303-70 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8303-72 Sodium Chloride 0.9% Syringe Product is a device 
N 7/1/2005 BAXTER HEALTH 00338-8303-72 Sodium Chloride 0.9% Syringe Product is a device 
 10/1/2000 SCHEIN PHARMACEUTICAL INC 00364-2491-01 Dipyridamole 25 mg Tablet NDC not on CMS tape 
 10/1/2000 SCHEIN PHARMACEUTICAL INC 00364-2491-02 Dipyridamole 25 mg Tablet NDC not on CMS tape 
 10/1/2000 SCHEIN PHARMACEUTICAL INC 00364-2492-01 Dipyridamole 50 mg Tablet NDC not on CMS tape 
N 7/1/2005 HOSPIRA 00409-1918-33 Sodium Chloride 0.9% Syringe Product is a device 
 10/1/2004 PHARMADERM 00462-0395-30 Apexicon E 0.05% Cream NDC not on CMS tape 
 10/1/2001 ALPHARMA USPD 00472-0342-56 Hydrocortisone 0.5% Cream NDC not on CMS tape 
 10/1/2001 ALPHARMA USPD 00472-0345-56 Hydrocortisone 1% Ointment NDC not on CMS tape 
 10/1/2000 ALPHARMA USPD 00472-0709-16 Brondelate Elixir NDC not on CMS tape 
 10/1/2000 ALPHARMA USPD 00472-1540-16 Theolate Elixir NDC not on CMS tape 
 10/1/2001 PFIZER 00501-2003-99 Benadryl Allergy Ultratab NDC not on CMS tape 
N 4/1/2005 AMERICAN REGENT LABS 00517-2802-25 Sodium Chloride Injection, USP 0.9% Product is a device 
N 4/1/2005 AMERICAN REGENT LABS 00517-2810-02 Sodium Chloride Injection, USP 0.9% Product is a device 
 4/1/2003 LANNETT COMPANY 00527-1170-10 Diphenoxylate/Atropine tablet NDC not on CMS tape 
N 10/1/2005 BARR 00555-0696-02 Ciprofloxacin HCL 750 mg NDC is not valid per manufacturer 
 10/1/2004 WATSON PHARMA, INC 00591-0363-01 Clozepate 3.75mg Tablet NDC not on CMS tape 
 10/1/2004 WATSON PHARMA, INC 00591-0364-01 Clozepate 7.5mg Tablet NDC not on CMS tape 
 10/1/2000 QUALITEST PRODUCTS INC 00603-3383-21 Dipyridamole 25 mg Tablet NDC not on CMS tape 

N = NEW TO LIST
D = DELETED FROM LIST
X = DELETED NONCOVERED ITEM

PAGES: 1 | 2 | 3 | 4

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