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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 101LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00074-6212-13 0.05220 1.31588 DEPAKOTE DR 125 MG TABLET G ABBVIE US LLC EABEX 00074-6214-13 0.08897 2.58470 DEPAKOTE DR 250 MG TABLET G ABBVIE US LLC EABEX 00074-6214-53 0.08897 2.58471 DEPAKOTE DR 250 MG TABLET G ABBVIE US LLC EABEX 00074-6215-13 0.15593 4.76644 DEPAKOTE DR 500 MG TABLET G ABBVIE US LLC EABEX 00074-6215-53 0.15593 4.76645 DEPAKOTE DR 500 MG TABLET G ABBVIE US LLC EABEX 00074-3826-13 2.35064 DEPAKOTE ER 250 MG TABLET G ABBVIE US LLC EABEX 00074-7126-13 4.13456 DEPAKOTE ER 500 MG TABLET G ABBVIE US LLC EABEX 00074-7126-53 4.13466 DEPAKOTE ER 500 MG TABLET G ABBVIE US LLC EABEX 00074-6114-13 1.25446 1.25446 DEPAKOTE 125 MG SPRINKLE CAP 0 ABBVIE US LLC EABND 00037-4401-01 22.30932 DEPEN 250 MG TITRATAB 0 MEDA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-0271-01 9.74918 DEPO-ESTRADIOL 5 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-0274-01 3.76654 DEPO-MEDROL 20 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-0280-02 3.65050 5.84984 DEPO-MEDROL 40 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-0280-03 3.65050 5.32777 DEPO-MEDROL 40 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-0280-51 3.65050 5.85050 DEPO-MEDROL 40 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-0280-52 3.65050 5.32793 DEPO-MEDROL 40 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-3073-01 3.65050 8.25020 DEPO-MEDROL 40 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-3073-03 3.65050 8.25020 DEPO-MEDROL 40 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-0306-02 6.94784 10.65554 DEPO-MEDROL 80 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-0306-12 6.94784 10.65587 DEPO-MEDROL 80 MG/ML VIAL 0 PHARMACIA/UPJHN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-3475-01 6.94784 14.30920 DEPO-MEDROL 80 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-3475-03 6.94784 14.30853 DEPO-MEDROL 80 MG/ML VIAL 0 PHARMACIA/UPJHN MLBEX 00009-7376-07 84.32800 DEPO-PROVERA 150 MG/ML SYRINGE G PFIZER US PHARM MLBEX 00009-7376-11 117.23750 DEPO-PROVERA 150 MG/ML SYRINGE G PFIZER US PHARM MLBEX 00009-0746-30 40.77000 122.52460 DEPO-PROVERA 150 MG/ML VIAL G PHARMACIA/UPJHN MLBEX 00009-0746-35 40.77000 122.53190 DEPO-PROVERA 150 MG/ML VIAL G PHARMACIA/UPJHN MLBND 00009-0626-01 105.18092 DEPO-PROVERA 400 MG/ML VIAL 0 PHARMACIA/UPJHN MLBEX 00009-4709-13 182.57446 DEPO-SUBQ PROVERA 104 SYRINGE 0 PFIZER US PHARM MLBND 00066-0507-60 0.71380 1.67577 DERMATOP 0.1% CREAM G VALEANT GMBND 00066-0508-60 1.13900 1.59594 DERMATOP 0.1% OINTMENT G VALEANT GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0467-61 12.69100 29.39030 DESFERAL MESYLATE 500 MG VL G NOVARTIS EABND 00078-0467-91 12.69100 29.38200 DESFERAL MESYLATE 500 MG VL G NOVARTIS EABND 00078-0347-51 41.60190 114.21837 DESFERAL 2 GRAM VIAL 0 NOVARTIS EABND 00078-0347-61 41.60190 114.22460 DESFERAL 2 GRAM VIAL 0 NOVARTIS EAGEX 00781-1971-01 0.84277 DESIPRAMINE 10 MG TABLET 0 SANDOZ EAGEX 45963-0341-02 0.88100 DESIPRAMINE 10 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00781-1975-01 3.18780 DESIPRAMINE 100 MG TABLET 0 SANDOZ EAGEX 45963-0345-02 3.35955 DESIPRAMINE 100 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00781-1976-50 4.61895 DESIPRAMINE 150 MG TABLET 0 SANDOZ EAGEX 45963-0346-50 4.86765 DESIPRAMINE 150 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-1972-01 0.87210 DESIPRAMINE 25 MG TABLET 0 SANDOZ EAGEX 45963-0342-02 0.87210 DESIPRAMINE 25 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00781-1973-01 1.76120 DESIPRAMINE 50 MG TABLET 0 SANDOZ EAGEX 45963-0343-02 1.76120 DESIPRAMINE 50 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00781-1974-01 2.42595 DESIPRAMINE 75 MG TABLET 0 SANDOZ 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
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