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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 100LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16714-0346-01 0.83640 DASETTA 7/7/7-28 TABLET 0 NORTHSTAR RX LL EAGEN 63323-0119-08 94.50000 DAUNORUBICIN 20 MG VIAL 0 APP PHARMACEUTI EAGEN 00703-5233-13 10.19690 DAUNORUBICIN 20 MG/4 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-5233-91 10.19690 DAUNORUBICIN 20 MG/4 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-5233-93 10.19690 DAUNORUBICIN 20 MG/4 ML VIAL 0 TEVA PARENTERAL MLGEN 55390-0108-10 10.19690 DAUNORUBICIN 20 MG/4 ML VIAL 0 BEDFORD LABS MLGEN 55390-0108-01 10.19690 DAUNORUBICIN 50 MG/10 ML VIAL 0 BEDFORD LABS MLBUL 00025-1381-31 0.67580 3.98607 DAYPRO 600 MG CAPLET G PHARMACIA/UPJHN EABND 00075-2452-01 38.60220 64.06438 DDAVP 0.01% NASAL SPRAY G SANOFI-AVENTIS MLBND 00075-2450-01 74.09576 DDAVP 0.01% SOLUTION 0 SANOFI-AVENTIS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00075-0016-00 1.27060 5.63578 DDAVP 0.1 MG TABLET G SANOFI-AVENTIS EABND 00075-0026-00 1.33760 8.11955 DDAVP 0.2 MG TABLET G SANOFI-AVENTIS EABND 00075-2451-01 6.42600 54.62147 DDAVP 4 MCG/ML AMPUL G SANOFI-AVENTIS MLBND 00075-2451-53 6.81000 55.29958 DDAVP 4 MCG/ML VIAL G SANOFI-AVENTIS MLGEN 00409-2337-25 27.88125 DEFEROXAMINE 2 GRAM VIAL 0 HOSPIRA EAGEN 00555-1131-11 41.60190 DEFEROXAMINE 2 GRAM VIAL 0 BARR EAGEN 63323-0599-30 37.08000 DEFEROXAMINE 2 GRAM VIAL 0 APP PHARMACEUTI EAGEN 00409-2336-10 7.03875 DEFEROXAMINE 500 MG VIAL 0 HOSPIRA EAGEN 00555-1132-12 11.24625 DEFEROXAMINE 500 MG VIAL 0 BARR EAGEN 55390-0263-10 12.69100 DEFEROXAMINE 500 MG VIAL 0 BEDFORD LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0597-10 11.65500 DEFEROXAMINE 500 MG VIAL 0 APP PHARMACEUTI EABND 42023-0111-01 26.61644 DELESTROGEN 20 MG/ML VIAL 0 JHP PHARMACEUTI MLBND 42023-0112-01 44.15268 DELESTROGEN 40 MG/ML VIAL G JHP PHARMACEUTI MLBND 00430-0753-27 2.20116 DELZICOL DR 400 MG CAPSULE G ACTAVIS PHARMA, EABND 00037-5010-01 0.10351 2.04113 DEMADEX 10 MG TABLET G MEDA PHARMACEUT EABND 00037-5020-01 0.12730 2.27577 DEMADEX 20 MG TABLET G MEDA PHARMACEUT EABND 00037-5005-01 0.12240 1.84168 DEMADEX 5 MG TABLET G MEDA PHARMACEUT EAGEN 00115-2111-01 5.73930 DEMECLOCYCLINE 150 MG TABLET 0 GLOBAL PHARM EAGEN 00555-0701-02 5.73930 DEMECLOCYCLINE 150 MG TABLET 0 BARR EAGEN 62584-0159-01 5.73930 DEMECLOCYCLINE 150 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62584-0159-11 5.73930 DEMECLOCYCLINE 150 MG TABLET 0 AHP EAGEN 65162-0554-10 5.73930 DEMECLOCYCLINE 150 MG TABLET 0 AMNEAL PHARMACE EAGEN 00115-2122-14 11.00010 DEMECLOCYCLINE 300 MG TABLET 0 GLOBAL PHARM EAGEN 00555-0702-84 11.00010 DEMECLOCYCLINE 300 MG TABLET 0 BARR EAGEN 61748-0113-48 11.00010 DEMECLOCYCLINE 300 MG TABLET 0 VERSA PHARMACEU EAGEN 62584-0163-11 11.00010 DEMECLOCYCLINE 300 MG TABLET 0 AHP EAGEN 62584-0163-65 11.00010 DEMECLOCYCLINE 300 MG TABLET 0 AHP EAGEN 65162-0555-48 11.00010 DEMECLOCYCLINE 300 MG TABLET 0 AMNEAL PHARMACE EABND 25010-0305-15 99.39266 DEMSER 250 MG CAPSULE 0 VALEANT EABND 40076-0624-05 85.34392 DENAVIR 1% CREAM G PRESTIUM PHARMA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50816-0624-01 63.81040 DENAVIR 1% CREAM G PRESTIUM PHARMA GMBND 50816-0624-05 64.65036 DENAVIR 1% CREAM G PRESTIUM PHARMA GMBEX 00074-1564-10 4.69995 DEPACON 500 MG VIAL G ABBVIE US LLC MLBEX 00074-5681-13 0.16830 3.68810 DEPAKENE 250 MG CAPSULE G ABBVIE US LLC EABEX 00074-5682-16 0.01660 0.78537 DEPAKENE 250 MG/5 ML SOLUTION G ABBVIE US LLC ML** 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