Drug Generic Name
Olanzapine short acting intramuscular injection
Sodium Chloride, Hypertonic (3% - 5% infusion)
Coagulation Factor IX, Recombinant (Ixinity)
Coagulation Factor IX (Recombinant) (Ixinity)

Manufacturer Name
Fresenius Kabi USA, LLC (APP Auth Import)

Drug Name (Brand Name or Generic Name)
Olanzapine long acting intramuscular injection
Propofol Injectable Emulsion (Fresenius Propoven)
Human Immune Globulin Intravenous (Gammaplex)
Neonatal SurgiMend, 6x12 cm x 2.0 mm; 1 each
Neonatal SurgiMend, 10x15 cm x 2.0 mm; 1 each
Neonatal SurgiMend, 13x25 cm x 2.0 mm; 1 each
Neonatal SurgiMend, 25x40 cm x 2.0 mm; 1 each
Neonatal SurgiMend, 20x30 cm x 2.0 mm; 1 each
Neonatal SurgiMend, 6x12 cm x 3.0 mm; 1 each
Neonatal SurgiMend, 10x15 cm x 3.0 mm; 1 each
Neonatal SurgiMend, 13x25 cm x 3.0 mm; 1 each
Neonatal SurgiMend, 25x40 cm x 3.0 mm; 1 each
Neonatal SurgiMend, 20x30 cm x 3.0 mm; 1 each
Neonatal SurgiMend, 6x12 cm x 4.0 mm; 1 each
Neonatal SurgiMend, 10x15 cm x 4.0 mm; 1 each
Neonatal SurgiMend, 13x25 cm x 4.0 mm; 1 each
Neonatal SurgiMend, 25x40 cm x 4.0 mm; 1 each
Neonatal SurgiMend, 20x30 cm x 4.0 mm; 1 each

Dosage descriptor assigned to the HCPCS code
lidocaine 70 mg/tetracaine 70 mg, per patch