"Procedure"|"Code Type"|"Revenue Code"|"Procedure Description"|"Quantity"|"Payer"|"Plan"|"Inpatient Gross Charges"|"Inpatient Expected Reimbursement"|"Inpatient Max Reimbursement"|"Inpatient Minimal Reimbursement"|"Outpatient Gross Charges"|"Outpatient Expected Reimbursement"|"Outpatient Max Reimbursement"|"Outpatient Minimal Reimbursement"
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AETNA [1015]|AETNA ACO WILCO [101532]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|512.93||||512.93|256.98|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|512.93||||512.93|180.04|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|512.93||||512.93|220.56|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|512.93||||512.93|218.51|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|512.93||||512.93|256.47|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|512.93||||512.93|333.4|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|CORESOURCE [1315]|CORESOURCE [131500]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|512.93||||512.93|189.78|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|GEHA [1415]|GEHA [141500]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HEALTHNET [1495]|HEALTHNET [149500]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|512.93||||512.93|220.56|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|512.93||||512.93|477.02|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|512.93||||512.93|307.76|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MULTIPLAN [1680]|HMA [168003]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MULTIPLAN [1680]|IHC HS [168011]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|Self-pay|Self-pay|512.93||||512.93|153.88|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|512.93||||512.93|107.72|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|TRUSTMARK [2030]|STARMARK [203000]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|512.93||||512.93|245.95|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UMR [2035]|UMR OPTIONS [203501]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|512.93||||512.93|461.64|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|512.93||||512.93|0|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|512.93||||512.93|189.78|477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|512.93||||512.93||477.02|107.72
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|512.93||||512.93|256.47|477.02|107.72
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AETNA [1015]|AETNA ACO WILCO [101532]|90||||90|0|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|90||||90|0|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|90||||90|0|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|90||||90|45.09|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|90||||90|31.59|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|90||||90|38.7|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|90||||90|38.34|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|90||||90|45|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|90||||90|58.5|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CORESOURCE [1315]|CORESOURCE [131500]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|90||||90|10.92|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|90||||90|33.3|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|GEHA [1415]|GEHA [141500]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HEALTHNET [1495]|HEALTHNET [149500]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|90||||90|38.7|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|90||||90|83.7|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90||||90|54|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|90||||90|0|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90||||90|0|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MULTIPLAN [1680]|HMA [168003]|90||||90|31.5|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MULTIPLAN [1680]|IHC HS [168011]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|90||||90|0|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|Self-pay|Self-pay|90||||90|27|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|90||||90|18.9|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|90||||90|7.27|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|TRUSTMARK [2030]|STARMARK [203000]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|90||||90|43.16|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UMR [2035]|UMR OPTIONS [203501]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|90||||90|0|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|90||||90|81|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|90||||90|0|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|90||||90|33.3|83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|90||||90||83.7|7.27
10050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|200 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|90||||90|45|83.7|7.27
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|AETNA [1015]|AETNA ACO WILCO [101532]|3164.12||||3164.12|0|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|AETNA [1015]|COVENTRY HEALTHCARE [101502]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3164.12||||3164.12|1241.34|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|3164.12||||3164.12|1470|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|3164.12||||3164.12|1470|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|3164.12||||3164.12|1585.22|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|3164.12||||3164.12|1110.61|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|3164.12||||3164.12|1360.57|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|3164.12||||3164.12|1347.92|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|3164.12||||3164.12|1582.06|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|3164.12||||3164.12|2056.68|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|CORESOURCE [1315]|CORESOURCE [131500]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|CORVEL CORP [2235]|CORVEL CORP [223500]|3164.12||||3164.12|1202.85|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|3164.12||||3164.12|1170.72|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|FIRST HEALTH [1375]|QUALCHOICE [137513]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|FMH BENEFIT SERVICES [1390]|FMH [139000]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|GEHA [1415]|GEHA [141500]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|3164.12||||3164.12|1107.44|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|HEALTHNET [1495]|HEALTHNET [149500]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|3164.12||||3164.12|1360.57|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|HEALTHSMART [1505]|HEALTHSMART [150501]|3164.12||||3164.12|2942.63|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3164.12||||3164.12|1898.47|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|3164.12||||3164.12|1338.7|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|3164.12||||3164.12|1774|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3164.12||||3164.12|1421|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|3164.12||||3164.12|1642.95|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|3164.12||||3164.12|1241.34|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MULTIPLAN [1680]|HMA [168003]|3164.12||||3164.12|1107.44|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MULTIPLAN [1680]|IHC HS [168011]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|PENDING SSI [1616]|PENDING SSI RCA [161601]|3164.12||||3164.12|1527.88|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|3164.12||||3164.12|1338.7|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|Self-pay|Self-pay|3164.12||||3164.12|949.24|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|3164.12||||3164.12|664.47|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|TRIWEST [3750]|TRIWEST TWVACCN [375000]|3164.12||||3164.12|1192.66|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|3164.12||||3164.12|1288.96|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|TRUSTMARK [2030]|STARMARK [203000]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|3164.12||||3164.12|1517.2|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|UMR [2035]|UMR OPTIONS [203501]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|3164.12||||3164.12|1353.3|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|3164.12||||3164.12|2847.71|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|3164.12||||3164.12|0|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|3164.12||||3164.12|1170.72|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|3164.12||||3164.12|1217|2942.63|664.47
100509|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 200 UNIT SOLUTION FOR INJECTION|200 Units|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|3164.12||||3164.12|1582.06|2942.63|664.47
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA [1015]|AETNA ACO WILCO [101532]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA [1015]|COVENTRY HEALTHCARE [101502]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|66.83||||66.83|33.48|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|66.83||||66.83|23.46|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|66.83||||66.83|28.74|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|66.83||||66.83|28.47|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|66.83||||66.83|33.42|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|66.83||||66.83|43.44|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CORESOURCE [1315]|CORESOURCE [131500]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CORVEL CORP [2235]|CORVEL CORP [223500]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|66.83||||66.83|24.73|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|FIRST HEALTH [1375]|QUALCHOICE [137513]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|FMH BENEFIT SERVICES [1390]|FMH [139000]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|GEHA [1415]|GEHA [141500]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HEALTHNET [1495]|HEALTHNET [149500]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|66.83||||66.83|28.74|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HEALTHSMART [1505]|HEALTHSMART [150501]|66.83||||66.83|62.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66.83||||66.83|40.1|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MULTIPLAN [1680]|HMA [168003]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MULTIPLAN [1680]|IHC HS [168011]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|Self-pay|Self-pay|66.83||||66.83|20.05|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|66.83||||66.83|14.03|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|TRIWEST [3750]|TRIWEST TWVACCN [375000]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|TRUSTMARK [2030]|STARMARK [203000]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|66.83||||66.83|32.04|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UMR [2035]|UMR OPTIONS [203501]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|66.83||||66.83|60.15|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|66.83||||66.83|0|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|66.83||||66.83|24.73|62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|66.83||||66.83||62.15|14.03
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|66.83||||66.83|33.42|62.15|14.03
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|10||||10|3|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|Self-pay|Self-pay|10||||10|3|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUVOXAMINE 50 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|AETNA [1015]|AETNA ACO WILCO [101532]|57.36||||57.36|0|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|57.36||||57.36|0|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|57.36||||57.36|0|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|57.36||||57.36|28.74|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|57.36||||57.36|20.13|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|57.36||||57.36|24.66|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|57.36||||57.36|24.44|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|57.36||||57.36|28.68|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|57.36||||57.36|37.28|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|CORESOURCE [1315]|CORESOURCE [131500]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|57.36||||57.36|17|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|57.36||||57.36|21.22|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|GEHA [1415]|GEHA [141500]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|HEALTHNET [1495]|HEALTHNET [149500]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|57.36||||57.36|24.66|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|57.36||||57.36|53.34|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|57.36||||57.36|34.42|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|57.36||||57.36|0|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57.36||||57.36|0|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MULTIPLAN [1680]|HMA [168003]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MULTIPLAN [1680]|IHC HS [168011]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|57.36||||57.36|0|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|Self-pay|Self-pay|57.36||||57.36|17.21|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|57.36||||57.36|12.05|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|TRUSTMARK [2030]|STARMARK [203000]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|57.36||||57.36|27.5|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|UMR [2035]|UMR OPTIONS [203501]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|57.36||||57.36|0|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|57.36||||57.36|51.62|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|57.36||||57.36|0|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|57.36||||57.36|21.22|53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|57.36||||57.36||53.34|12.05
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|0.25 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|57.36||||57.36|28.68|53.34|12.05
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA ACO WILCO [101532]|39.72||||39.72|0|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|39.72||||39.72|0|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|39.72||||39.72|0|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|39.72||||39.72|19.9|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|39.72||||39.72|13.94|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|39.72||||39.72|17.08|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|39.72||||39.72|16.92|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|39.72||||39.72|19.86|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|39.72||||39.72|25.82|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CORESOURCE [1315]|CORESOURCE [131500]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|39.72||||39.72|1.97|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|39.72||||39.72|14.7|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|GEHA [1415]|GEHA [141500]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HEALTHNET [1495]|HEALTHNET [149500]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|39.72||||39.72|17.08|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|39.72||||39.72|36.94|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.72||||39.72|23.83|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|39.72||||39.72|0|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.72||||39.72|0|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MULTIPLAN [1680]|HMA [168003]|39.72||||39.72|13.9|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MULTIPLAN [1680]|IHC HS [168011]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|39.72||||39.72|0|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|39.72||||39.72|11.92|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|39.72||||39.72|8.34|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|39.72||||39.72|3.07|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|TRUSTMARK [2030]|STARMARK [203000]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|39.72||||39.72|19.05|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR OPTIONS [203501]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|39.72||||39.72|0|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|39.72||||39.72|35.75|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|39.72||||39.72|0|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|39.72||||39.72|14.7|36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|39.72||||39.72||36.94|1.97
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|39.72||||39.72|19.86|36.94|1.97
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA ACO WILCO [101532]|29||||29|0|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|29||||29|0|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|29||||29|0|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|29||||29|14.53|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|29||||29|10.18|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|29||||29|12.47|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|29||||29|12.35|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|29||||29|14.5|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|29||||29|18.85|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CORESOURCE [1315]|CORESOURCE [131500]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|29||||29|0.98|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|29||||29|10.73|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|GEHA [1415]|GEHA [141500]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHNET [1495]|HEALTHNET [149500]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|29||||29|12.47|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|29||||29|26.97|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29||||29|17.4|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|29||||29|0|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29|0|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MULTIPLAN [1680]|HMA [168003]|29||||29|10.15|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MULTIPLAN [1680]|IHC HS [168011]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29|0|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|29||||29|8.7|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|29||||29|6.09|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|29||||29|1.54|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|TRUSTMARK [2030]|STARMARK [203000]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|29||||29|13.91|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR OPTIONS [203501]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|29||||29|0|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|29||||29|26.1|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|29||||29|0|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|29||||29|10.73|26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|29||||29||26.97|0.98
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|29||||29|14.5|26.97|0.98
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|12.78||||12.78|6.4|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|12.78||||12.78|4.49|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|12.78||||12.78|5.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|12.78||||12.78|5.44|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|12.78||||12.78|6.39|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|12.78||||12.78|8.31|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|12.78||||12.78|4.73|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|12.78||||12.78|5.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|12.78||||12.78|11.89|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.78||||12.78|7.67|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|Self-pay|Self-pay|12.78||||12.78|3.83|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|12.78||||12.78|2.68|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|12.78||||12.78|6.13|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|12.78||||12.78|11.5|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|12.78||||12.78|0|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|12.78||||12.78|4.73|11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|12.78||||12.78||11.89|2.68
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|12.78||||12.78|6.39|11.89|2.68
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|10||||10|3|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|AETNA [1015]|AETNA ACO WILCO [101532]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|AETNA [1015]|COVENTRY HEALTHCARE [101502]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|238.91||||238.91|119.69|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|238.91||||238.91|83.86|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|238.91||||238.91|102.73|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|238.91||||238.91|101.78|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|238.91||||238.91|119.46|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|238.91||||238.91|155.29|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|CORESOURCE [1315]|CORESOURCE [131500]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|CORVEL CORP [2235]|CORVEL CORP [223500]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|238.91||||238.91|88.4|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|FIRST HEALTH [1375]|QUALCHOICE [137513]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|FMH BENEFIT SERVICES [1390]|FMH [139000]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|GEHA [1415]|GEHA [141500]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|HEALTHNET [1495]|HEALTHNET [149500]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|238.91||||238.91|102.73|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|HEALTHSMART [1505]|HEALTHSMART [150501]|238.91||||238.91|222.19|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|238.91||||238.91|143.35|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MULTIPLAN [1680]|HMA [168003]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MULTIPLAN [1680]|IHC HS [168011]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|Self-pay|Self-pay|238.91||||238.91|71.67|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|238.91||||238.91|50.17|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|TRIWEST [3750]|TRIWEST TWVACCN [375000]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|TRUSTMARK [2030]|STARMARK [203000]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|238.91||||238.91|114.56|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|UMR [2035]|UMR OPTIONS [203501]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|238.91||||238.91|215.02|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|238.91||||238.91|0|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|238.91||||238.91|88.4|222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|238.91||||238.91||222.19|50.17
1027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM|45 g|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|238.91||||238.91|119.46|222.19|50.17
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AETNA [1015]|AETNA ACO WILCO [101532]|128.28||||128.28|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|128.28||||128.28|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|128.28||||128.28|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|128.28||||128.28|64.27|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|128.28||||128.28|45.03|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|128.28||||128.28|55.16|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|128.28||||128.28|54.65|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|128.28||||128.28|64.14|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|128.28||||128.28|83.38|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|CORESOURCE [1315]|CORESOURCE [131500]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|128.28||||128.28|47.46|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|GEHA [1415]|GEHA [141500]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HEALTHNET [1495]|HEALTHNET [149500]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|128.28||||128.28|55.16|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|128.28||||128.28|119.3|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.28||||128.28|76.97|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|128.28||||128.28|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.28||||128.28|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MULTIPLAN [1680]|HMA [168003]|128.28||||128.28|44.9|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MULTIPLAN [1680]|IHC HS [168011]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|128.28||||128.28|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|Self-pay|Self-pay|128.28||||128.28|38.48|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|128.28||||128.28|26.94|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|128.28||||128.28|184.44|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|TRUSTMARK [2030]|STARMARK [203000]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|128.28||||128.28|61.51|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UMR [2035]|UMR OPTIONS [203501]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|128.28||||128.28|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|128.28||||128.28|115.45|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|128.28||||128.28|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|128.28||||128.28|47.46|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|128.28||||128.28||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|128.28||||128.28|64.14|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AETNA [1015]|AETNA ACO WILCO [101532]|58.46||||58.46|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|58.46||||58.46|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|58.46||||58.46|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|58.46||||58.46|29.29|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|58.46||||58.46|20.52|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|58.46||||58.46|25.14|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|58.46||||58.46|24.9|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|58.46||||58.46|29.23|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|58.46||||58.46|38|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CORESOURCE [1315]|CORESOURCE [131500]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|58.46||||58.46|52.33|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|58.46||||58.46|21.63|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|GEHA [1415]|GEHA [141500]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HEALTHNET [1495]|HEALTHNET [149500]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|58.46||||58.46|25.14|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|58.46||||58.46|54.37|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|58.46||||58.46|35.08|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|58.46||||58.46|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.46||||58.46|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MULTIPLAN [1680]|HMA [168003]|58.46||||58.46|20.46|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MULTIPLAN [1680]|IHC HS [168011]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.46||||58.46|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|Self-pay|Self-pay|58.46||||58.46|17.54|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|58.46||||58.46|12.28|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|58.46||||58.46|55.33|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|TRUSTMARK [2030]|STARMARK [203000]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|58.46||||58.46|28.03|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UMR [2035]|UMR OPTIONS [203501]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|58.46||||58.46|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|58.46||||58.46|52.61|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|58.46||||58.46|0|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|58.46||||58.46|21.63|184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|58.46||||58.46||184.44|12.28
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|58.46||||58.46|29.23|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AETNA [1015]|AETNA ACO WILCO [101532]|128.28||||128.28|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|128.28||||128.28|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|128.28||||128.28|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|128.28||||128.28|64.27|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|128.28||||128.28|45.03|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|128.28||||128.28|55.16|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|128.28||||128.28|54.65|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|128.28||||128.28|64.14|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|128.28||||128.28|83.38|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|CORESOURCE [1315]|CORESOURCE [131500]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|128.28||||128.28|47.46|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|GEHA [1415]|GEHA [141500]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HEALTHNET [1495]|HEALTHNET [149500]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|128.28||||128.28|55.16|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|128.28||||128.28|119.3|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.28||||128.28|76.97|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|128.28||||128.28|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.28||||128.28|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MULTIPLAN [1680]|HMA [168003]|128.28||||128.28|44.9|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MULTIPLAN [1680]|IHC HS [168011]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|128.28||||128.28|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|Self-pay|Self-pay|128.28||||128.28|38.48|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|128.28||||128.28|26.94|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|128.28||||128.28|184.44|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|TRUSTMARK [2030]|STARMARK [203000]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|128.28||||128.28|61.51|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UMR [2035]|UMR OPTIONS [203501]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|128.28||||128.28|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|128.28||||128.28|115.45|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|128.28||||128.28|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|128.28||||128.28|47.46|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|128.28||||128.28||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|128.28||||128.28|64.14|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AETNA [1015]|AETNA ACO WILCO [101532]|58.46||||58.46|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|58.46||||58.46|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|58.46||||58.46|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|58.46||||58.46|29.29|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|58.46||||58.46|20.52|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|58.46||||58.46|25.14|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|58.46||||58.46|24.9|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|58.46||||58.46|29.23|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|58.46||||58.46|38|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CORESOURCE [1315]|CORESOURCE [131500]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|58.46||||58.46|52.33|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|58.46||||58.46|21.63|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|GEHA [1415]|GEHA [141500]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HEALTHNET [1495]|HEALTHNET [149500]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|58.46||||58.46|25.14|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|58.46||||58.46|54.37|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|58.46||||58.46|35.08|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|58.46||||58.46|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.46||||58.46|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MULTIPLAN [1680]|HMA [168003]|58.46||||58.46|20.46|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MULTIPLAN [1680]|IHC HS [168011]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.46||||58.46|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|Self-pay|Self-pay|58.46||||58.46|17.54|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|58.46||||58.46|12.28|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|58.46||||58.46|55.33|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|TRUSTMARK [2030]|STARMARK [203000]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|58.46||||58.46|28.03|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UMR [2035]|UMR OPTIONS [203501]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|58.46||||58.46|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|58.46||||58.46|52.61|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|58.46||||58.46|0|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|58.46||||58.46|21.63|184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|58.46||||58.46||184.44|12.28
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|58.46||||58.46|29.23|184.44|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AETNA [1015]|AETNA ACO WILCO [101532]|58.46||||58.46|0|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|58.46||||58.46|0|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|58.46||||58.46|0|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|58.46||||58.46|29.29|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|58.46||||58.46|20.52|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|58.46||||58.46|25.14|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|58.46||||58.46|24.9|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|58.46||||58.46|29.23|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|58.46||||58.46|38|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CORESOURCE [1315]|CORESOURCE [131500]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|58.46||||58.46|52.33|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|58.46||||58.46|21.63|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|GEHA [1415]|GEHA [141500]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HEALTHNET [1495]|HEALTHNET [149500]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|58.46||||58.46|25.14|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|58.46||||58.46|54.37|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|58.46||||58.46|35.08|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|58.46||||58.46|0|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.46||||58.46|0|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MULTIPLAN [1680]|HMA [168003]|58.46||||58.46|20.46|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MULTIPLAN [1680]|IHC HS [168011]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.46||||58.46|0|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|Self-pay|Self-pay|58.46||||58.46|17.54|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|58.46||||58.46|12.28|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|58.46||||58.46|55.33|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|TRUSTMARK [2030]|STARMARK [203000]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|58.46||||58.46|28.03|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UMR [2035]|UMR OPTIONS [203501]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|58.46||||58.46|0|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|58.46||||58.46|52.61|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|58.46||||58.46|0|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|58.46||||58.46|21.63|55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|58.46||||58.46||55.33|12.28
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|58.46||||58.46|29.23|55.33|12.28
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA ACO WILCO [101532]|209.58||||209.58|0|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|209.58||||209.58|0|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|209.58||||209.58|0|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|209.58||||209.58|105|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|209.58||||209.58|73.56|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|209.58||||209.58|90.12|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|209.58||||209.58|89.28|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|209.58||||209.58|104.79|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|209.58||||209.58|136.23|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CORESOURCE [1315]|CORESOURCE [131500]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|209.58||||209.58|5.88|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|209.58||||209.58|77.54|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|GEHA [1415]|GEHA [141500]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HEALTHNET [1495]|HEALTHNET [149500]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|209.58||||209.58|90.12|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|209.58||||209.58|194.91|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|209.58||||209.58|125.75|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|209.58||||209.58|104.79|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|209.58||||209.58|0|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MULTIPLAN [1680]|HMA [168003]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MULTIPLAN [1680]|IHC HS [168011]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|209.58||||209.58|0|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|209.58||||209.58|62.87|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|209.58||||209.58|44.01|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|209.58||||209.58|5.3|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|TRUSTMARK [2030]|STARMARK [203000]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|209.58||||209.58|100.49|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR OPTIONS [203501]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|209.58||||209.58|0|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|209.58||||209.58|188.62|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|209.58||||209.58|0|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|209.58||||209.58|77.54|194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|209.58||||209.58||194.91|5.3
10323|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|209.58||||209.58|104.79|194.91|5.3
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA ACO WILCO [101532]|343.23||||343.23|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|343.23||||343.23|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|343.23||||343.23|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|343.23||||343.23|171.96|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|343.23||||343.23|120.47|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|343.23||||343.23|147.59|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|343.23||||343.23|146.22|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|343.23||||343.23|171.62|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|343.23||||343.23|223.1|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CORESOURCE [1315]|CORESOURCE [131500]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|343.23||||343.23|11.76|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|343.23||||343.23|127|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|GEHA [1415]|GEHA [141500]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HEALTHNET [1495]|HEALTHNET [149500]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|343.23||||343.23|147.59|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|343.23||||343.23|319.2|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|343.23||||343.23|205.94|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|343.23||||343.23|171.62|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|343.23||||343.23|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MULTIPLAN [1680]|HMA [168003]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MULTIPLAN [1680]|IHC HS [168011]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|343.23||||343.23|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|343.23||||343.23|102.97|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|343.23||||343.23|72.08|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|343.23||||343.23|10.6|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|TRUSTMARK [2030]|STARMARK [203000]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|343.23||||343.23|164.58|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR OPTIONS [203501]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|343.23||||343.23|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|343.23||||343.23|308.91|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|343.23||||343.23|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|343.23||||343.23|127|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|343.23||||343.23||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|343.23||||343.23|171.62|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|AETNA [1015]|AETNA ACO WILCO [101532]|405.35||||405.35|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|405.35||||405.35|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|405.35||||405.35|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|405.35||||405.35|203.08|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|405.35||||405.35|142.28|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|405.35||||405.35|174.3|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|405.35||||405.35|172.68|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|405.35||||405.35|202.68|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|405.35||||405.35|263.48|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|CORESOURCE [1315]|CORESOURCE [131500]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|405.35||||405.35|14.7|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|405.35||||405.35|149.98|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|GEHA [1415]|GEHA [141500]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|HEALTHNET [1495]|HEALTHNET [149500]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|405.35||||405.35|174.3|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|405.35||||405.35|376.98|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|405.35||||405.35|243.21|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|405.35||||405.35|202.68|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|405.35||||405.35|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MULTIPLAN [1680]|HMA [168003]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MULTIPLAN [1680]|IHC HS [168011]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|405.35||||405.35|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|Self-pay|Self-pay|405.35||||405.35|121.6|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|405.35||||405.35|85.12|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|405.35||||405.35|13.25|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|TRUSTMARK [2030]|STARMARK [203000]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|405.35||||405.35|194.37|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|UMR [2035]|UMR OPTIONS [203501]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|405.35||||405.35|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|405.35||||405.35|364.82|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|405.35||||405.35|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|405.35||||405.35|149.98|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|405.35||||405.35||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|125 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|405.35||||405.35|202.68|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|AETNA [1015]|AETNA ACO WILCO [101532]|474.84||||474.84|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|474.84||||474.84|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|474.84||||474.84|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|474.84||||474.84|237.89|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|474.84||||474.84|166.67|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|474.84||||474.84|204.18|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|474.84||||474.84|202.28|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|474.84||||474.84|237.42|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|474.84||||474.84|308.65|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|CORESOURCE [1315]|CORESOURCE [131500]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|474.84||||474.84|17.64|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|474.84||||474.84|175.69|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|GEHA [1415]|GEHA [141500]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|HEALTHNET [1495]|HEALTHNET [149500]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|474.84||||474.84|204.18|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|474.84||||474.84|441.6|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|474.84||||474.84|284.9|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|474.84||||474.84|237.42|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|474.84||||474.84|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MULTIPLAN [1680]|HMA [168003]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MULTIPLAN [1680]|IHC HS [168011]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|474.84||||474.84|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|Self-pay|Self-pay|474.84||||474.84|142.45|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|474.84||||474.84|99.72|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|474.84||||474.84|15.9|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|TRUSTMARK [2030]|STARMARK [203000]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|474.84||||474.84|227.69|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|UMR [2035]|UMR OPTIONS [203501]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|474.84||||474.84|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|474.84||||474.84|427.36|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|474.84||||474.84|0|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|474.84||||474.84|175.69|441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|474.84||||474.84||441.6|10.6
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|150 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|474.84||||474.84|237.42|441.6|10.6
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|Self-pay|Self-pay|10||||10|3|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
1043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 10 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|AETNA [1015]|AETNA ACO WILCO [101532]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|AETNA [1015]|COVENTRY HEALTHCARE [101502]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|115.49||||115.49|57.86|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|115.49||||115.49|40.54|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|115.49||||115.49|49.66|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|115.49||||115.49|49.2|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|115.49||||115.49|57.75|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|115.49||||115.49|75.07|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|CORESOURCE [1315]|CORESOURCE [131500]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|CORVEL CORP [2235]|CORVEL CORP [223500]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|115.49||||115.49|42.73|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|FIRST HEALTH [1375]|QUALCHOICE [137513]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|FMH BENEFIT SERVICES [1390]|FMH [139000]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|GEHA [1415]|GEHA [141500]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|HEALTHNET [1495]|HEALTHNET [149500]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|115.49||||115.49|49.66|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|HEALTHSMART [1505]|HEALTHSMART [150501]|115.49||||115.49|107.41|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|115.49||||115.49|69.29|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MULTIPLAN [1680]|HMA [168003]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MULTIPLAN [1680]|IHC HS [168011]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|Self-pay|Self-pay|115.49||||115.49|34.65|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|115.49||||115.49|24.25|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|TRIWEST [3750]|TRIWEST TWVACCN [375000]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|TRUSTMARK [2030]|STARMARK [203000]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|115.49||||115.49|55.38|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|UMR [2035]|UMR OPTIONS [203501]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|115.49||||115.49|103.94|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|115.49||||115.49|0|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|115.49||||115.49|42.73|107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|115.49||||115.49||107.41|24.25
10434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM|30 g|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|115.49||||115.49|57.75|107.41|24.25
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
1044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETHANECHOL CHLORIDE 25 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AETNA [1015]|AETNA ACO WILCO [101532]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AETNA [1015]|COVENTRY HEALTHCARE [101502]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|349.29||||349.29|174.99|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|349.29||||349.29|122.6|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|349.29||||349.29|150.19|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|349.29||||349.29|148.8|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|349.29||||349.29|174.65|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|349.29||||349.29|227.04|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|CORESOURCE [1315]|CORESOURCE [131500]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|CORVEL CORP [2235]|CORVEL CORP [223500]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|349.29||||349.29|129.24|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|FIRST HEALTH [1375]|QUALCHOICE [137513]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|FMH BENEFIT SERVICES [1390]|FMH [139000]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|GEHA [1415]|GEHA [141500]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HEALTHNET [1495]|HEALTHNET [149500]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|349.29||||349.29|150.19|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HEALTHSMART [1505]|HEALTHSMART [150501]|349.29||||349.29|324.84|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|349.29||||349.29|209.57|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MULTIPLAN [1680]|HMA [168003]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MULTIPLAN [1680]|IHC HS [168011]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|Self-pay|Self-pay|349.29||||349.29|104.79|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|349.29||||349.29|73.35|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|TRIWEST [3750]|TRIWEST TWVACCN [375000]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|TRUSTMARK [2030]|STARMARK [203000]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|349.29||||349.29|167.48|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UMR [2035]|UMR OPTIONS [203501]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|349.29||||349.29|314.36|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|349.29||||349.29|0|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|349.29||||349.29|129.24|324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|349.29||||349.29||324.84|73.35
104564|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|349.29||||349.29|174.65|324.84|73.35
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|76.79||||76.79|38.47|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|76.79||||76.79|26.95|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|76.79||||76.79|33.02|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|76.79||||76.79|32.71|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|76.79||||76.79|38.4|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|76.79||||76.79|49.91|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CORESOURCE [1315]|CORESOURCE [131500]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|76.79||||76.79|28.41|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|GEHA [1415]|GEHA [141500]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HEALTHNET [1495]|HEALTHNET [149500]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|76.79||||76.79|33.02|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|76.79||||76.79|71.41|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|76.79||||76.79|46.07|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MULTIPLAN [1680]|HMA [168003]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MULTIPLAN [1680]|IHC HS [168011]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|Self-pay|Self-pay|76.79||||76.79|23.04|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|76.79||||76.79|16.13|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|TRUSTMARK [2030]|STARMARK [203000]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|76.79||||76.79|36.82|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UMR [2035]|UMR OPTIONS [203501]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|76.79||||76.79|69.11|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|76.79||||76.79|0|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|76.79||||76.79|28.41|71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|76.79||||76.79||71.41|16.13
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|76.79||||76.79|38.4|71.41|16.13
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA ACO WILCO [101532]|29||||29|0|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|29||||29|0|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|29||||29|0|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|29||||29|14.53|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|29||||29|10.18|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|29||||29|12.47|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|29||||29|12.35|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|29||||29|14.5|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|29||||29|18.85|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CORESOURCE [1315]|CORESOURCE [131500]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|29||||29|0.72|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|29||||29|10.73|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|GEHA [1415]|GEHA [141500]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHNET [1495]|HEALTHNET [149500]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|29||||29|12.47|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|29||||29|26.97|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29||||29|17.4|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|29||||29|0|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29|0|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MULTIPLAN [1680]|HMA [168003]|29||||29|10.15|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MULTIPLAN [1680]|IHC HS [168011]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29|0|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|29||||29|8.7|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|29||||29|6.09|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|29||||29|0.8|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|TRUSTMARK [2030]|STARMARK [203000]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|29||||29|13.91|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR OPTIONS [203501]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|29||||29|0|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|29||||29|26.1|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|29||||29|0|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|29||||29|10.73|26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|29||||29||26.97|0.72
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|29||||29|14.5|26.97|0.72
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|13.93||||13.93|6.98|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|13.93||||13.93|4.89|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|13.93||||13.93|5.99|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|13.93||||13.93|5.93|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|13.93||||13.93|6.97|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|13.93||||13.93|9.05|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|13.93||||13.93|5.15|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|13.93||||13.93|5.99|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|13.93||||13.93|12.95|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.93||||13.93|8.36|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|13.93||||13.93|4.18|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|13.93||||13.93|2.93|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|13.93||||13.93|6.68|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|13.93||||13.93|12.54|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|13.93||||13.93|0|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|13.93||||13.93|5.15|12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|13.93||||13.93||12.95|2.93
10531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MERCAPTOPURINE 50 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|13.93||||13.93|6.97|12.95|2.93
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AETNA [1015]|AETNA ACO WILCO [101532]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|58.76||||58.76|29.44|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|58.76||||58.76|20.62|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|58.76||||58.76|25.27|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|58.76||||58.76|25.03|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|58.76||||58.76|29.38|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|58.76||||58.76|38.19|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CORESOURCE [1315]|CORESOURCE [131500]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|58.76||||58.76|21.74|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|GEHA [1415]|GEHA [141500]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HEALTHNET [1495]|HEALTHNET [149500]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|58.76||||58.76|25.27|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|58.76||||58.76|54.65|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|58.76||||58.76|35.26|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MULTIPLAN [1680]|HMA [168003]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MULTIPLAN [1680]|IHC HS [168011]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|Self-pay|Self-pay|58.76||||58.76|17.63|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|58.76||||58.76|12.34|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|TRUSTMARK [2030]|STARMARK [203000]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|58.76||||58.76|28.18|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UMR [2035]|UMR OPTIONS [203501]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|58.76||||58.76|52.88|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|58.76||||58.76|0|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|58.76||||58.76|21.74|54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|58.76||||58.76||54.65|12.34
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|58.76||||58.76|29.38|54.65|12.34
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA ACO WILCO [101532]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|29||||29|14.53|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|29||||29|10.18|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|29||||29|12.47|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|29||||29|12.35|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|29||||29|14.5|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|29||||29|18.85|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CORESOURCE [1315]|CORESOURCE [131500]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|29||||29|10.73|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|GEHA [1415]|GEHA [141500]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHNET [1495]|HEALTHNET [149500]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|29||||29|12.47|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|29||||29|26.97|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29||||29|17.4|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MULTIPLAN [1680]|HMA [168003]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MULTIPLAN [1680]|IHC HS [168011]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|Self-pay|Self-pay|29||||29|8.7|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|29||||29|6.09|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|TRUSTMARK [2030]|STARMARK [203000]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|29||||29|13.91|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UMR [2035]|UMR OPTIONS [203501]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|29||||29|26.1|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|29||||29|0|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|29||||29|10.73|26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|29||||29||26.97|6.09
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|29||||29|14.5|26.97|6.09
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA [1015]|AETNA ACO WILCO [101532]|182.52||||182.52|0|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA [1015]|COVENTRY HEALTHCARE [101502]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|182.52||||182.52|0|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|182.52||||182.52|0|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|182.52||||182.52|91.44|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|182.52||||182.52|64.06|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|182.52||||182.52|78.48|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|182.52||||182.52|77.75|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|182.52||||182.52|91.26|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|182.52||||182.52|118.64|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CORESOURCE [1315]|CORESOURCE [131500]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CORVEL CORP [2235]|CORVEL CORP [223500]|182.52||||182.52|54.32|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|182.52||||182.52|67.53|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|FIRST HEALTH [1375]|QUALCHOICE [137513]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|FMH BENEFIT SERVICES [1390]|FMH [139000]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|GEHA [1415]|GEHA [141500]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HEALTHNET [1495]|HEALTHNET [149500]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|182.52||||182.52|78.48|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HEALTHSMART [1505]|HEALTHSMART [150501]|182.52||||182.52|169.74|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|182.52||||182.52|109.51|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|182.52||||182.52|0|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182.52||||182.52|0|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MULTIPLAN [1680]|HMA [168003]|182.52||||182.52|63.88|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MULTIPLAN [1680]|IHC HS [168011]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|182.52||||182.52|0|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|Self-pay|Self-pay|182.52||||182.52|54.76|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|182.52||||182.52|38.33|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|TRIWEST [3750]|TRIWEST TWVACCN [375000]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|182.52||||182.52|47.83|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|TRUSTMARK [2030]|STARMARK [203000]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|182.52||||182.52|87.52|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UMR [2035]|UMR OPTIONS [203501]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|182.52||||182.52|0|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|182.52||||182.52|164.27|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|182.52||||182.52|0|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|182.52||||182.52|67.53|169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|182.52||||182.52||169.74|38.33
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|182.52||||182.52|91.26|169.74|38.33
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AETNA [1015]|AETNA ACO WILCO [101532]|63.64||||63.64|0|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|63.64||||63.64|0|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|63.64||||63.64|0|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|63.64||||63.64|31.88|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|63.64||||63.64|22.34|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|63.64||||63.64|27.37|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|63.64||||63.64|27.11|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|63.64||||63.64|31.82|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|63.64||||63.64|41.37|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CORESOURCE [1315]|CORESOURCE [131500]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|63.64||||63.64|6.79|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|63.64||||63.64|23.55|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|GEHA [1415]|GEHA [141500]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HEALTHNET [1495]|HEALTHNET [149500]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|63.64||||63.64|27.37|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|63.64||||63.64|59.19|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|63.64||||63.64|38.18|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|63.64||||63.64|0|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63.64||||63.64|0|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MULTIPLAN [1680]|HMA [168003]|63.64||||63.64|22.27|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MULTIPLAN [1680]|IHC HS [168011]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|63.64||||63.64|0|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|Self-pay|Self-pay|63.64||||63.64|19.09|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|63.64||||63.64|13.36|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|63.64||||63.64|5.98|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|TRUSTMARK [2030]|STARMARK [203000]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|63.64||||63.64|30.52|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UMR [2035]|UMR OPTIONS [203501]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|63.64||||63.64|0|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|63.64||||63.64|57.28|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|63.64||||63.64|0|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|63.64||||63.64|23.55|59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|63.64||||63.64||59.19|5.98
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|63.64||||63.64|31.82|59.19|5.98
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|12.03||||12.03|6.03|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|12.03||||12.03|4.22|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|12.03||||12.03|5.17|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|12.03||||12.03|5.12|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|12.03||||12.03|6.02|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|12.03||||12.03|7.82|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|12.03||||12.03|4.45|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|12.03||||12.03|5.17|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|12.03||||12.03|11.19|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.03||||12.03|7.22|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|12.03||||12.03|3.61|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|12.03||||12.03|2.53|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|12.03||||12.03|5.77|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|12.03||||12.03|10.83|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|12.03||||12.03|0|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|12.03||||12.03|4.45|11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|12.03||||12.03||11.19|2.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|12.03||||12.03|6.02|11.19|2.53
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|13.67||||13.67|6.85|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|13.67||||13.67|4.8|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|13.67||||13.67|5.88|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|13.67||||13.67|5.82|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|13.67||||13.67|6.84|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|13.67||||13.67|8.89|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|13.67||||13.67|5.06|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|13.67||||13.67|5.88|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|13.67||||13.67|12.71|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.67||||13.67|8.2|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|13.67||||13.67|4.1|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|13.67||||13.67|2.87|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|13.67||||13.67|6.55|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|13.67||||13.67|12.3|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|13.67||||13.67|0|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|13.67||||13.67|5.06|12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|13.67||||13.67||12.71|2.87
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|13.67||||13.67|6.84|12.71|2.87
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AETNA [1015]|AETNA ACO WILCO [101532]|32.62||||32.62|0|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|32.62||||32.62|0|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|32.62||||32.62|0|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|32.62||||32.62|16.34|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|32.62||||32.62|11.45|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|32.62||||32.62|14.03|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|32.62||||32.62|13.9|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|32.62||||32.62|16.31|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|32.62||||32.62|21.2|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CORESOURCE [1315]|CORESOURCE [131500]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|32.62||||32.62|2.25|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|32.62||||32.62|12.07|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|GEHA [1415]|GEHA [141500]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HEALTHNET [1495]|HEALTHNET [149500]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|32.62||||32.62|14.03|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|32.62||||32.62|30.34|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|32.62||||32.62|19.57|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|32.62||||32.62|0|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32.62||||32.62|0|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MULTIPLAN [1680]|HMA [168003]|32.62||||32.62|11.42|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MULTIPLAN [1680]|IHC HS [168011]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|32.62||||32.62|0|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|Self-pay|Self-pay|32.62||||32.62|9.79|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|32.62||||32.62|6.85|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|32.62||||32.62|2.19|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|TRUSTMARK [2030]|STARMARK [203000]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|32.62||||32.62|15.64|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UMR [2035]|UMR OPTIONS [203501]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|32.62||||32.62|0|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|32.62||||32.62|29.36|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|32.62||||32.62|0|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|32.62||||32.62|12.07|30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|32.62||||32.62||30.34|2.19
105899|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE|0.3 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|32.62||||32.62|16.31|30.34|2.19
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AETNA [1015]|AETNA ACO WILCO [101532]|43.38||||43.38|0|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|43.38||||43.38|0|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|43.38||||43.38|0|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|43.38||||43.38|21.73|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|43.38||||43.38|15.23|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|43.38||||43.38|18.65|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|43.38||||43.38|18.48|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|43.38||||43.38|21.69|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|43.38||||43.38|28.2|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CORESOURCE [1315]|CORESOURCE [131500]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|43.38||||43.38|3.01|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|43.38||||43.38|16.05|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|GEHA [1415]|GEHA [141500]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HEALTHNET [1495]|HEALTHNET [149500]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|43.38||||43.38|18.65|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|43.38||||43.38|40.34|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|43.38||||43.38|26.03|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|43.38||||43.38|0|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|43.38||||43.38|0|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MULTIPLAN [1680]|HMA [168003]|43.38||||43.38|15.18|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MULTIPLAN [1680]|IHC HS [168011]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|43.38||||43.38|0|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|Self-pay|Self-pay|43.38||||43.38|13.01|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|43.38||||43.38|9.11|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|43.38||||43.38|2.93|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|TRUSTMARK [2030]|STARMARK [203000]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|43.38||||43.38|20.8|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UMR [2035]|UMR OPTIONS [203501]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|43.38||||43.38|0|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|43.38||||43.38|39.04|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|43.38||||43.38|0|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|43.38||||43.38|16.05|40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|43.38||||43.38||40.34|2.93
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|43.38||||43.38|21.69|40.34|2.93
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA [1015]|AETNA ACO WILCO [101532]|65.17||||65.17|0|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|65.17||||65.17|0|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|65.17||||65.17|0|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|65.17||||65.17|32.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|65.17||||65.17|22.87|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|65.17||||65.17|28.02|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|65.17||||65.17|27.76|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|65.17||||65.17|32.59|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|65.17||||65.17|42.36|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CORESOURCE [1315]|CORESOURCE [131500]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|65.17||||65.17|4.51|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|65.17||||65.17|24.11|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GEHA [1415]|GEHA [141500]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHNET [1495]|HEALTHNET [149500]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|65.17||||65.17|28.02|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|65.17||||65.17|60.61|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|65.17||||65.17|39.1|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|65.17||||65.17|0|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.17||||65.17|0|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MULTIPLAN [1680]|HMA [168003]|65.17||||65.17|22.81|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MULTIPLAN [1680]|IHC HS [168011]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|65.17||||65.17|0|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|Self-pay|Self-pay|65.17||||65.17|19.55|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|65.17||||65.17|13.69|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|65.17||||65.17|4.39|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|TRUSTMARK [2030]|STARMARK [203000]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|65.17||||65.17|31.25|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UMR [2035]|UMR OPTIONS [203501]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|65.17||||65.17|0|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|65.17||||65.17|58.65|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|65.17||||65.17|0|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|65.17||||65.17|24.11|60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|65.17||||65.17||60.61|4.39
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|65.17||||65.17|32.59|60.61|4.39
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA ACO WILCO [101532]|65.55||||65.55|0|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|65.55||||65.55|0|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|65.55||||65.55|0|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|65.55||||65.55|32.84|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|65.55||||65.55|23.01|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|65.55||||65.55|28.19|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|65.55||||65.55|27.92|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|65.55||||65.55|32.78|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|65.55||||65.55|42.61|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CORESOURCE [1315]|CORESOURCE [131500]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|65.55||||65.55|6.01|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|65.55||||65.55|24.25|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GEHA [1415]|GEHA [141500]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHNET [1495]|HEALTHNET [149500]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|65.55||||65.55|28.19|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|65.55||||65.55|60.96|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|65.55||||65.55|39.33|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|65.55||||65.55|0|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.55||||65.55|0|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MULTIPLAN [1680]|HMA [168003]|65.55||||65.55|22.94|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MULTIPLAN [1680]|IHC HS [168011]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|65.55||||65.55|0|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|65.55||||65.55|19.66|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|65.55||||65.55|13.77|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|65.55||||65.55|5.85|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TRUSTMARK [2030]|STARMARK [203000]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|65.55||||65.55|31.43|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR OPTIONS [203501]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|65.55||||65.55|0|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|65.55||||65.55|59|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|65.55||||65.55|0|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|65.55||||65.55|24.25|60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|65.55||||65.55||60.96|5.85
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|65.55||||65.55|32.78|60.96|5.85
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|AETNA ACO WILCO [101532]|82.51||||82.51|0|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|82.51||||82.51|0|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|82.51||||82.51|0|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|82.51||||82.51|41.34|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|82.51||||82.51|28.96|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|82.51||||82.51|35.48|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|82.51||||82.51|35.15|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|82.51||||82.51|41.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|82.51||||82.51|53.63|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CORESOURCE [1315]|CORESOURCE [131500]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|82.51||||82.51|7.52|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|82.51||||82.51|30.53|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GEHA [1415]|GEHA [141500]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHNET [1495]|HEALTHNET [149500]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|82.51||||82.51|35.48|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|82.51||||82.51|76.73|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|82.51||||82.51|49.51|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|82.51||||82.51|0|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82.51||||82.51|0|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MULTIPLAN [1680]|HMA [168003]|82.51||||82.51|28.88|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MULTIPLAN [1680]|IHC HS [168011]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|82.51||||82.51|0|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|Self-pay|Self-pay|82.51||||82.51|24.75|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|82.51||||82.51|17.33|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|82.51||||82.51|7.31|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TRUSTMARK [2030]|STARMARK [203000]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|82.51||||82.51|39.56|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UMR [2035]|UMR OPTIONS [203501]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|82.51||||82.51|0|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|82.51||||82.51|74.26|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|82.51||||82.51|0|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|82.51||||82.51|30.53|76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|82.51||||82.51||76.73|7.31
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|82.51||||82.51|41.26|76.73|7.31
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA ACO WILCO [101532]|98.98||||98.98|0|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|98.98||||98.98|0|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|98.98||||98.98|0|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|98.98||||98.98|49.59|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|98.98||||98.98|34.74|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|98.98||||98.98|42.56|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|98.98||||98.98|42.17|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|98.98||||98.98|49.49|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|98.98||||98.98|64.34|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CORESOURCE [1315]|CORESOURCE [131500]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|98.98||||98.98|9.02|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|98.98||||98.98|36.62|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GEHA [1415]|GEHA [141500]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHNET [1495]|HEALTHNET [149500]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|98.98||||98.98|42.56|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|98.98||||98.98|92.05|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|98.98||||98.98|59.39|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|98.98||||98.98|0|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|98.98||||98.98|0|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MULTIPLAN [1680]|HMA [168003]|98.98||||98.98|34.64|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MULTIPLAN [1680]|IHC HS [168011]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|98.98||||98.98|0|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|98.98||||98.98|29.69|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|98.98||||98.98|20.79|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|98.98||||98.98|8.78|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TRUSTMARK [2030]|STARMARK [203000]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|98.98||||98.98|47.46|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR OPTIONS [203501]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|98.98||||98.98|0|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|98.98||||98.98|89.08|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|98.98||||98.98|0|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|98.98||||98.98|36.62|92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|98.98||||98.98||92.05|8.78
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|98.98||||98.98|49.49|92.05|8.78
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|Self-pay|Self-pay|10||||10|3|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 200 MG CAPSULE|1 capsule|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|AETNA [1015]|AETNA ACO WILCO [101532]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|AETNA [1015]|COVENTRY HEALTHCARE [101502]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|60.15||||60.15|30.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|60.15||||60.15|21.11|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|60.15||||60.15|25.86|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|60.15||||60.15|25.62|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|60.15||||60.15|30.08|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|60.15||||60.15|39.1|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|CORESOURCE [1315]|CORESOURCE [131500]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|CORVEL CORP [2235]|CORVEL CORP [223500]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|60.15||||60.15|22.26|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|FIRST HEALTH [1375]|QUALCHOICE [137513]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|FMH BENEFIT SERVICES [1390]|FMH [139000]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|GEHA [1415]|GEHA [141500]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|HEALTHNET [1495]|HEALTHNET [149500]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|60.15||||60.15|25.86|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|HEALTHSMART [1505]|HEALTHSMART [150501]|60.15||||60.15|55.94|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|60.15||||60.15|36.09|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MULTIPLAN [1680]|HMA [168003]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MULTIPLAN [1680]|IHC HS [168011]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|Self-pay|Self-pay|60.15||||60.15|18.04|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|60.15||||60.15|12.63|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|TRIWEST [3750]|TRIWEST TWVACCN [375000]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|TRUSTMARK [2030]|STARMARK [203000]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|60.15||||60.15|28.84|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|UMR [2035]|UMR OPTIONS [203501]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|60.15||||60.15|54.14|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|60.15||||60.15|0|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|60.15||||60.15|22.26|55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|60.15||||60.15||55.94|12.63
106249|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT|3.5 g|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|60.15||||60.15|30.08|55.94|12.63
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA [1015]|AETNA ACO WILCO [101532]|114.31||||114.31|0|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|114.31||||114.31|0|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|114.31||||114.31|0|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|114.31||||114.31|57.27|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|114.31||||114.31|40.12|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|114.31||||114.31|49.15|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|114.31||||114.31|48.7|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|114.31||||114.31|57.16|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|114.31||||114.31|74.3|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CORESOURCE [1315]|CORESOURCE [131500]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|114.31||||114.31|13.48|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|114.31||||114.31|42.29|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|GEHA [1415]|GEHA [141500]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HEALTHNET [1495]|HEALTHNET [149500]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|114.31||||114.31|49.15|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|114.31||||114.31|106.31|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|114.31||||114.31|68.59|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|114.31||||114.31|0|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|114.31||||114.31|0|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MULTIPLAN [1680]|HMA [168003]|114.31||||114.31|40.01|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MULTIPLAN [1680]|IHC HS [168011]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|114.31||||114.31|0|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|Self-pay|Self-pay|114.31||||114.31|34.29|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|114.31||||114.31|24.01|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|114.31||||114.31|12.83|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|TRUSTMARK [2030]|STARMARK [203000]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|114.31||||114.31|54.81|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UMR [2035]|UMR OPTIONS [203501]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|114.31||||114.31|0|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|114.31||||114.31|102.88|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|114.31||||114.31|0|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|114.31||||114.31|42.29|106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|114.31||||114.31||106.31|12.83
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|114.31||||114.31|57.16|106.31|12.83
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AETNA [1015]|AETNA ACO WILCO [101532]|29||||29|0|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|29||||29|0|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|29||||29|0|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|29||||29|14.53|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|29||||29|10.18|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|29||||29|12.47|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|29||||29|12.35|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|29||||29|14.5|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|29||||29|18.85|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CORESOURCE [1315]|CORESOURCE [131500]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|29||||29|0.67|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|29||||29|10.73|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|GEHA [1415]|GEHA [141500]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HEALTHNET [1495]|HEALTHNET [149500]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|29||||29|12.47|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|29||||29|26.97|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29||||29|17.4|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|29||||29|0|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29|0|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MULTIPLAN [1680]|HMA [168003]|29||||29|10.15|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MULTIPLAN [1680]|IHC HS [168011]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29|0|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|Self-pay|Self-pay|29||||29|8.7|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|29||||29|6.09|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|29||||29|0.38|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|TRUSTMARK [2030]|STARMARK [203000]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|29||||29|13.91|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UMR [2035]|UMR OPTIONS [203501]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|29||||29|0|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|29||||29|26.1|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|29||||29|0|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|29||||29|10.73|26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|29||||29||26.97|0.38
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|29||||29|14.5|26.97|0.38
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA [1015]|AETNA ACO WILCO [101532]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA [1015]|COVENTRY HEALTHCARE [101502]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|39.52||||39.52|19.8|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|39.52||||39.52|13.87|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|39.52||||39.52|16.99|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|39.52||||39.52|16.84|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|39.52||||39.52|19.76|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|39.52||||39.52|25.69|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CORESOURCE [1315]|CORESOURCE [131500]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CORVEL CORP [2235]|CORVEL CORP [223500]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|39.52||||39.52|14.62|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|FIRST HEALTH [1375]|QUALCHOICE [137513]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|FMH BENEFIT SERVICES [1390]|FMH [139000]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|GEHA [1415]|GEHA [141500]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HEALTHNET [1495]|HEALTHNET [149500]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|39.52||||39.52|16.99|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HEALTHSMART [1505]|HEALTHSMART [150501]|39.52||||39.52|36.75|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.52||||39.52|23.71|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MULTIPLAN [1680]|HMA [168003]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MULTIPLAN [1680]|IHC HS [168011]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|Self-pay|Self-pay|39.52||||39.52|11.86|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|39.52||||39.52|8.3|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|TRIWEST [3750]|TRIWEST TWVACCN [375000]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|TRUSTMARK [2030]|STARMARK [203000]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|39.52||||39.52|18.95|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UMR [2035]|UMR OPTIONS [203501]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|39.52||||39.52|35.57|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|39.52||||39.52|0|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|39.52||||39.52|14.62|36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|39.52||||39.52||36.75|8.3
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|39.52||||39.52|19.76|36.75|8.3
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|AETNA [1015]|AETNA ACO WILCO [101532]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|60.15||||60.15|30.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|60.15||||60.15|21.11|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|60.15||||60.15|25.86|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|60.15||||60.15|25.62|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|60.15||||60.15|30.08|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|60.15||||60.15|39.1|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|CORESOURCE [1315]|CORESOURCE [131500]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|60.15||||60.15|22.26|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|GEHA [1415]|GEHA [141500]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|HEALTHNET [1495]|HEALTHNET [149500]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|60.15||||60.15|25.86|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|60.15||||60.15|55.94|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|60.15||||60.15|36.09|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MULTIPLAN [1680]|HMA [168003]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MULTIPLAN [1680]|IHC HS [168011]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|Self-pay|Self-pay|60.15||||60.15|18.04|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|60.15||||60.15|12.63|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|TRUSTMARK [2030]|STARMARK [203000]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|60.15||||60.15|28.84|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|UMR [2035]|UMR OPTIONS [203501]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|60.15||||60.15|54.14|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|60.15||||60.15|0|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|60.15||||60.15|22.26|55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|60.15||||60.15||55.94|12.63
10708|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS|5 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|60.15||||60.15|30.08|55.94|12.63
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|10||||10|3|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|Self-pay|Self-pay|10||||10|3|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
10765|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARGININE 7 GRAM-GLUTAMINE 7 GRAM-CALCIUM HMB 1.5 GRAM ORAL POWDER PACK|1 packet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|149.97||||149.97|75.13|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|149.97||||149.97|52.64|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|149.97||||149.97|64.49|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|149.97||||149.97|63.89|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|149.97||||149.97|74.99|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|149.97||||149.97|97.48|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|149.97||||149.97|55.49|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|GEHA [1415]|GEHA [141500]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|149.97||||149.97|64.49|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|149.97||||149.97|139.47|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.97||||149.97|89.98|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MULTIPLAN [1680]|HMA [168003]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|Self-pay|Self-pay|149.97||||149.97|44.99|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|149.97||||149.97|31.49|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|149.97||||149.97|71.91|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UMR [2035]|UMR OPTIONS [203501]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|149.97||||149.97|134.97|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|149.97||||149.97|0|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|149.97||||149.97|55.49|139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|149.97||||149.97||139.47|31.49
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|149.97||||149.97|74.99|139.47|31.49
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA ACO WILCO [101532]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|COVENTRY HEALTHCARE [101502]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|10||||10|5.01|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|10||||10|3.51|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|10||||10|4.3|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|10||||10|4.26|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|10||||10|5|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|10||||10|6.5|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CORESOURCE [1315]|CORESOURCE [131500]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CORVEL CORP [2235]|CORVEL CORP [223500]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|10||||10|3.7|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|FIRST HEALTH [1375]|QUALCHOICE [137513]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|FMH BENEFIT SERVICES [1390]|FMH [139000]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|GEHA [1415]|GEHA [141500]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHNET [1495]|HEALTHNET [149500]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|10||||10|4.3|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHSMART [1505]|HEALTHSMART [150501]|10||||10|9.3|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10||||10|6|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MULTIPLAN [1680]|HMA [168003]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MULTIPLAN [1680]|IHC HS [168011]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|10||||10|3|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|10||||10|2.1|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|TRIWEST [3750]|TRIWEST TWVACCN [375000]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|TRUSTMARK [2030]|STARMARK [203000]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|10||||10|4.8|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR OPTIONS [203501]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|10||||10|9|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|10||||10|0|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|10||||10|3.7|9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|10||||10||9.3|2.1
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|10||||10|5|9.3|2.1
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AETNA [1015]|AETNA ACO WILCO [101532]|225.43||||225.43|0|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|225.43||||225.43|0|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|225.43||||225.43|0|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|225.43||||225.43|112.94|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|225.43||||225.43|79.13|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|225.43||||225.43|96.93|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|225.43||||225.43|96.03|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|225.43||||225.43|112.72|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|225.43||||225.43|146.53|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|CORESOURCE [1315]|CORESOURCE [131500]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|225.43||||225.43|30.36|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|225.43||||225.43|83.41|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|GEHA [1415]|GEHA [141500]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HEALTHNET [1495]|HEALTHNET [149500]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|225.43||||225.43|96.93|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|225.43||||225.43|209.65|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|225.43||||225.43|135.26|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|225.43||||225.43|0|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|225.43||||225.43|0|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MULTIPLAN [1680]|HMA [168003]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MULTIPLAN [1680]|IHC HS [168011]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|225.43||||225.43|0|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|Self-pay|Self-pay|225.43||||225.43|67.63|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|225.43||||225.43|47.34|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|TRUSTMARK [2030]|STARMARK [203000]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|225.43||||225.43|108.09|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UMR [2035]|UMR OPTIONS [203501]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|225.43||||225.43|0|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|225.43||||225.43|202.89|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|225.43||||225.43|0|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|225.43||||225.43|83.41|209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|225.43||||225.43||209.65|30.36
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|225.43||||225.43|112.72|209.65|30.36
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AETNA [1015]|AETNA ACO WILCO [101532]|225.43||||225.43|0|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|225.43||||225.43|0|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|225.43||||225.43|0|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|225.43||||225.43|112.94|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|225.43||||225.43|79.13|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|225.43||||225.43|96.93|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|225.43||||225.43|96.03|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|225.43||||225.43|112.72|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|225.43||||225.43|146.53|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|CORESOURCE [1315]|CORESOURCE [131500]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|225.43||||225.43|40.47|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|225.43||||225.43|83.41|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|GEHA [1415]|GEHA [141500]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HEALTHNET [1495]|HEALTHNET [149500]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|225.43||||225.43|96.93|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|225.43||||225.43|209.65|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|225.43||||225.43|135.26|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|225.43||||225.43|0|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|225.43||||225.43|0|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MULTIPLAN [1680]|HMA [168003]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MULTIPLAN [1680]|IHC HS [168011]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|225.43||||225.43|0|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|Self-pay|Self-pay|225.43||||225.43|67.63|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|225.43||||225.43|47.34|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|TRUSTMARK [2030]|STARMARK [203000]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|225.43||||225.43|108.09|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UMR [2035]|UMR OPTIONS [203501]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|225.43||||225.43|0|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|225.43||||225.43|202.89|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|225.43||||225.43|0|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|225.43||||225.43|83.41|209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|225.43||||225.43||209.65|40.47
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|225.43||||225.43|112.72|209.65|40.47
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AETNA [1015]|AETNA ACO WILCO [101532]|493.93||||493.93|0|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|493.93||||493.93|124.08|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|493.93||||493.93|124.08|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|493.93||||493.93|247.46|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|493.93||||493.93|173.37|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|493.93||||493.93|212.39|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|493.93||||493.93|210.41|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|493.93||||493.93|246.97|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|493.93||||493.93|321.05|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|CORESOURCE [1315]|CORESOURCE [131500]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|493.93||||493.93|162.91|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|493.93||||493.93|182.75|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|GEHA [1415]|GEHA [141500]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HEALTHNET [1495]|HEALTHNET [149500]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|493.93||||493.93|212.39|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|493.93||||493.93|459.35|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|493.93||||493.93|296.36|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|493.93||||493.93|241.32|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|493.93||||493.93|119.84|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MULTIPLAN [1680]|HMA [168003]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MULTIPLAN [1680]|IHC HS [168011]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|493.93||||493.93|128.97|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|Self-pay|Self-pay|493.93||||493.93|148.18|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|493.93||||493.93|103.73|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|TRUSTMARK [2030]|STARMARK [203000]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|493.93||||493.93|236.84|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UMR [2035]|UMR OPTIONS [203501]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|493.93||||493.93|114.13|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED HEALTHCARE [2060]|GOLDEN RULE [206003]|493.93||||493.93|444.54|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC - BIND [206032]|493.93||||493.93|0|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|VA CCN OPTUM [3920]|VA CCN OPTUM [392000]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|WORKER'S COMP [2125]|CNA INSURANCE WC [2125100]|493.93||||493.93|182.75|459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|WORKER'S COMP [2125]|DEPARTMENT OF LABOR (WC) [212507]|493.93||||493.93||459.35|103.73
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|ZELIS [2385]|NEW MEXICO MEDICAL INSURANCE POOL [238502]|493.93||||493.93|246.97|459.35|103.73
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|ADMINISTRATIVE CONCEPTS [1005]|ADMINISTRATIVE CONCEPTS [100502]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA ACO WILCO [101532]|128.24||||128.24|0|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA MEDICARE SUPPLEMENT [101514]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|COVENTRY HEALTHCARE [101502]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|ALLIED BENEFIT SYSTEMS INC [1030]|ALLIED BENEFIT SYSTEMS [103000]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|ALLIED NATIONAL GLOBAL CARE [1035]|ALLIED NATIONAL [103500]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERICAN MEDICAL SECURITY [2190]|AMERICAN MEDICAL SECURITY [219000]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS IPA PAYOR [2945]|BCBS BEHAVIORAL HEALTH [294500]|128.24||||128.24|0|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BLUE CROSS CENTENNIAL CARE NEW MEXICO [116500]|128.24||||128.24|0|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BCBS TRAD/HMO/PPO/POS NM [115513]|128.24||||128.24|64.25|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS BLUE COMMUNITY HMO OF NM [115528]|128.24||||128.24|45.01|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS IMAGINE HEALTH OF NEW MEXICO [115527]|128.24||||128.24|55.14|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS NLP NEW MEXICO [115529]|128.24||||128.24|54.63|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BENEFIT MANAGEMENT [1175]|NEW MEXICO INSURANCE POOL [117501]|128.24||||128.24|64.12|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BOON-CHAPMAN [2375]|BOON-CHAPMAN [237501]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CAPROCK HEALTH PLANS [1200]|CAPROCK HEALTH PLAN [120004]|128.24||||128.24|83.36|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CHRISTUS HEALTH PLAN [2330]|CHRISTUS HP GENERATIONS HMO [233000]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CORESOURCE [1315]|CORESOURCE [131500]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CORVEL CORP [2235]|CORVEL CORP [223500]|128.24||||128.24|2.89|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|COVENTRY HEALTHCARE [1320]|COVENTRY HEALTH CARE [132000]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|EMBLEM HEALTH [2430]|EMBLEM HEALTH [243001]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|EMPLOYEE BENEFIT MANAGEMENT SERVICES [2445]|EMPLOYEE BENEFIT MANAGEMENT SERVICES [244501]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|ENABLECOMP [1350]|W/C WORK COMP ENABLECOMP [135000]|128.24||||128.24|47.45|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|FIRST HEALTH [1375]|QUALCHOICE [137513]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|FMH BENEFIT SERVICES [1390]|FMH [139000]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GEHA [1415]|GEHA [141500]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA-TLC [145007]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHCOST SOLUTIONS [2415]|HEALTHCOST SOLUTIONS [241501]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHNET [1495]|HEALTHNET [149500]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHSCOPE BENEFITS [2290]|HEALTHSCOPE BENEFITS [229000]|128.24||||128.24|55.14|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHSMART [1505]|HEALTHSMART PREFERRED CARE (HSPC) [150500]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHSMART [1505]|HEALTHSMART [150501]|128.24||||128.24|119.26|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.24||||128.24|76.94|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|INDIAN HEALTH SERVICES [1535]|WITHDRAWAL STABILIZATION-CHICKASAW [153543]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|KAISER PERMANENTE [1560]|KAISER FOUNDATION HEALTH PLAN [156001]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MAGELLAN BEHAVIORAL COMMERCIAL [2895]|MAGELLAN BEHAVORIAL COMMERCIAL [289500]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MAYO CLINIC HEALTH SOLUTIONS [2280]|MAYO CLINIC HEALTH SOLUTIONS [228000]|128.24||||128.24|0|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.24||||128.24|0|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MOLINA HEALTHCARE [1670]|MOLINA HEALTHCARE HIX [167001]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MOLINA MEDICARE REPLACEMENT [1675]|MOLINA MEDICARE ADVANTAGE [167500]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MULTIPLAN [1680]|HMA [168003]|128.24||||128.24|44.88|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MULTIPLAN [1680]|IHC HS [168011]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MUTUAL OF OMAHA [1685]|MUTUAL OF OMAHA [168500]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|NATIONAL TELEPHONE COOPERATIVE [1700]|NATIONAL TELEPHONE COOP ASSO [170000]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|NORTHAMERICA ADMINISTRATORS [1725]|NORTHAMERICA ADMINISTRATORS [172500]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PAN AMERICAN LIFE INSURANCE CO [1770]|PAN AMERICAN LIFE [177000]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PENDING COUNTY RCA [3910]|PENDING COUNTY RCA [391000]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|128.24||||128.24|0|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|GROUP HEALTH COOPERATIVE SCW [178012]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PRESBYTERIAN HEALTH PLAN [1830]|PRESBYTERIAN HIX [183001]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|128.24||||128.24|38.47|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|THE HEALTH PLAN [2915]|THE HEALTH PLAN [291500]|128.24||||128.24|26.93|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TOTAL COMMUNITY CARE [2245]|TOTAL COMM CARE MEDICARE REPL [224501]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TRIWEST [3750]|TRIWEST TWVACCN [375000]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TRUE HEALTH NEW MEXICO [2810]|TRUE HEALTH NEW MEXICO [281000]|128.24||||128.24|0.85|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TRUSTMARK [2030]|STARMARK [203000]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UMR - ARDENT EMPLOYEE [2036]|UMR - ARDENT EMPLOYEE [203601]|128.24||||128.24|61.49|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR OPTIONS [203501]|128.24||||128.24|115.42|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE CENTENNIAL CARE [2250]|UHC CENTENNIAL CARE MEDICAID REPL [225000]|128.24||||128.24|0|119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|128.24||||128.24||119.26|0.85
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/