NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 10LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 PRICING ERRORS ARE NOT REIMBURSABLE PRICES EFFECTIVE 02/28/2014LTM BASISIND NDC CODE MRA COST COST ALTERNATE FORMULARY DESCRIPTION PA CD LABELER OF MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-2592-03 0.17861 ALENDRONATE SODIUM 5 MG TABLET 0 APOTEX CORP EAGEN 00093-5171-20 0.69530 ALENDRONATE SODIUM 70 MG TAB G TEVA USA EAGEN 00093-5171-29 0.69530 ALENDRONATE SODIUM 70 MG TAB G TEVA USA EAGEN 00093-5171-44 0.69530 ALENDRONATE SODIUM 70 MG TAB G TEVA USA EAGEN 00378-3569-99 0.69530 ALENDRONATE SODIUM 70 MG TAB G MYLAN EAGEN 16252-0601-02 0.69530 ALENDRONATE SODIUM 70 MG TAB G ACTAVIS PHARMA, EAGEN 16252-0601-44 0.69530 ALENDRONATE SODIUM 70 MG TAB G ACTAVIS PHARMA, EAGEN 16714-0633-01 0.69530 ALENDRONATE SODIUM 70 MG TAB G NORTHSTAR RX LL EAGEN 16714-0633-02 0.69530 ALENDRONATE SODIUM 70 MG TAB G NORTHSTAR RX LL EAGEN 24658-0163-71 0.69530 ALENDRONATE SODIUM 70 MG TAB G BLU PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24658-0163-73 0.69530 ALENDRONATE SODIUM 70 MG TAB G BLU PHARMACEUTI EAGEN 41616-0638-68 0.69530 ALENDRONATE SODIUM 70 MG TAB G SUN PHARMA GLOB EAGEN 51079-0942-01 0.69530 ALENDRONATE SODIUM 70 MG TAB G MYLAN INSTITUTI EAGEN 51079-0942-05 0.69530 ALENDRONATE SODIUM 70 MG TAB G MYLAN INSTITUTI EAGEN 59746-0244-02 0.69530 ALENDRONATE SODIUM 70 MG TAB G CADISTA PHARMAC EAGEN 60505-2596-02 0.69530 ALENDRONATE SODIUM 70 MG TAB G APOTEX CORP EAGEN 60505-2596-04 0.69530 ALENDRONATE SODIUM 70 MG TAB G APOTEX CORP EAGEN 60505-2596-08 0.69530 ALENDRONATE SODIUM 70 MG TAB G APOTEX CORP EAGEN 65862-0329-04 0.69530 ALENDRONATE SODIUM 70 MG TAB G AUROBINDO PHARM EAGEN 67877-0241-31 0.69530 ALENDRONATE SODIUM 70 MG TAB G ASCEND LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67877-0241-33 0.69530 ALENDRONATE SODIUM 70 MG TAB G ASCEND LABORATO EAGEN 68084-0322-11 0.69530 ALENDRONATE SODIUM 70 MG TAB G AHP EAGEN 68084-0322-94 0.69530 ALENDRONATE SODIUM 70 MG TAB G AHP EAGEN 76439-0131-04 0.69530 ALENDRONATE SODIUM 70 MG TAB G VIRTUS PHARMACE EAGEN 76439-0131-12 0.69530 ALENDRONATE SODIUM 70 MG TAB G VIRTUS PHARMACE EAGEN 76439-0131-20 0.69530 ALENDRONATE SODIUM 70 MG TAB G VIRTUS PHARMACE EABND 54746-0001-01 599.99870 ALFERON N 5 MILLION UNITS VIAL 0 HEMISPHERX BIOP MLGEN 00378-5005-05 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 MYLAN EAGEN 00378-5005-77 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 MYLAN EAGEN 13668-0021-01 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13668-0021-05 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0021-71 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 TORRENT PHARMAC EAGEN 31722-0302-01 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0302-05 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 CAMBER PHARMACE EAGEN 47335-0956-18 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 SUN PHARMA GLOB EAGEN 47335-0956-81 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 SUN PHARMA GLOB EAGEN 47335-0956-88 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 SUN PHARMA GLOB EAGEN 60505-2850-01 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 APOTEX CORP EAGEN 64679-0738-02 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0738-03 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0249-01 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 AUROBINDO PHARM EAGEN 76282-0302-01 0.25370 ALFUZOSIN HCL ER 10 MG TABLET 0 EXELAN PHARMACE EABND 27437-0106-01 2.36398 ALINIA 100 MG/5 ML SUSPENSION G LUPIN PHARMA MLBND 67546-0212-21 1.51724 ALINIA 100 MG/5 ML SUSPENSION G ROMARK PHARM MLBND 67546-0111-12 25.76320 ALINIA 500 MG TABLET G ROMARK PHARM EA** PRIOR APPROVAL CODES:PA code "0" = PA not required; PA code "N" = PA requiredPA code "G" = PA required for Non Preferred drugs OR drugs not meeting clinical criteria (FQD, STEP) OR drugs inClinical Drug Review Program, the Brand Less than Generic Program or the Mandatory Generic Program*** OTC, SUPPLY AND COMPOUND PRODUCTS LISTING AT BACK OF REPORT