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Subject to change at anytime without notice key for symbol codes For Questions, call the Pharmacy Resolution number, 1-800-435-4165 Drug Name Description VANTIN 200 MG TABLET NDC 00009361802 PDL Prior Authorization Required Yes Generic Dispensing Incentive Applies No Clinical Therapeutic Edit PA No PDL Therapeutic Class List others in this class PA Effective Date 04 28 2004 Package Size 100 Units EA OTC Compound Only: Medicaid Compound Only: CHIP Compound Only: KHC Compound Only: CSHCN Medicaid Effective Date 03 01 2002 Medicaid End Date 00 00 0000 CHIP Effective Date 03 01 2002 CHIP End Date 00 00 0000 KHC Effective Date KHC End Date CSHCN Effective Date 03 01 2002 CSHCN End Date 00 00 0000 Maximum Allowable Cost .00000 MAC Date Wholesale estimated acquisition cost 5.83261 Direct estimated acquisition cost .00000 Warehouse Cost 5.76400 Return to search VDP Home Page DUR Home Page This page is maintained by the HHSC Medicaid CHIP: Vendor Drug Program. Comments and suggestions may be addressed to: contact@hhsc.state.tx.us. Some documents are in Adobe Acrobat (PDF) format. You will need to download the free Acrobat Reader to view these files. Access.adobe.com provides a set of free tools that may allow visually disabled users to read documents in Adobe PDF format. Last Update: 04 2003. Home About HHSC Contact Us HHSC Council HHSC Programs (Medicaid CHIP) HHSC Projects Research Stats News & Events Business Opportunities Site Search Services Search Site Map © Health and Human Services Commission webmaster@hhsc.state.tx.us Privacy & Disclaimer Statement Software links pa vantin 200


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