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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 102LIST 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 45963-0344-02 2.32620 DESIPRAMINE 75 MG TABLET 0 ACTAVIS PHARMA, EABND 55111-0551-31 4.83475 DESLORATADINE 2.5 MG ODT G DR.REDDY'S LAB EABND 55111-0360-31 4.83475 DESLORATADINE 5 MG ODT G DR.REDDY'S LAB EAGEN 00378-4017-01 1.04400 DESLORATADINE 5 MG TABLET G MYLAN EAGEN 00378-4017-05 1.04400 DESLORATADINE 5 MG TABLET G MYLAN EAGEN 00574-9838-01 0.45000 DESLORATADINE 5 MG TABLET G PADDOCK LABS. EAGEN 00781-5226-01 1.04400 DESLORATADINE 5 MG TABLET G SANDOZ EAGEN 00781-5226-05 1.04400 DESLORATADINE 5 MG TABLET G SANDOZ EAGEN 16714-0339-01 1.04400 DESLORATADINE 5 MG TABLET G NORTHSTAR RX LL EAGEN 16714-0339-02 1.04400 DESLORATADINE 5 MG TABLET G NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62756-0523-13 1.04400 DESLORATADINE 5 MG TABLET G SUN PHARMACEUTI EAGEN 62756-0523-88 1.04400 DESLORATADINE 5 MG TABLET G SUN PHARMACEUTI EAGEN 68180-0153-01 1.04400 DESLORATADINE 5 MG TABLET G LUPIN PHARMACEU EAGEN 68180-0153-02 1.04400 DESLORATADINE 5 MG TABLET G LUPIN PHARMACEU EAGEN 76439-0107-10 1.04400 DESLORATADINE 5 MG TABLET G VIRTUS PHARMACE EAGEN 76439-0107-50 1.04400 DESLORATADINE 5 MG TABLET G VIRTUS PHARMACE EAGEN 00409-2265-01 6.42600 DESMOPRESSIN AC 4 MCG/ML AMPUL 0 HOSPIRA MLGEN 55566-5030-01 6.42600 DESMOPRESSIN AC 4 MCG/ML AMPUL 0 FERRING PH INC MLGEN 00703-5051-03 5.53125 DESMOPRESSIN AC 4 MCG/ML VIAL 0 TEVA PARENTERAL MLGEN 00703-5054-01 5.53125 DESMOPRESSIN AC 4 MCG/ML VIAL 0 TEVA PARENTERAL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55566-5040-01 6.81000 DESMOPRESSIN AC 4 MCG/ML VIAL 0 FERRING PH INC MLGEN 00093-7316-01 1.27060 DESMOPRESSIN ACETATE 0.1 MG TB 0 TEVA USA EAGEN 00591-2464-01 1.27060 DESMOPRESSIN ACETATE 0.1 MG TB 0 ACTAVIS PHARMA, EAGEN 55566-5060-01 0.99885 DESMOPRESSIN ACETATE 0.1 MG TB 0 FERRING PH INC EAGEN 60505-0257-01 1.27060 DESMOPRESSIN ACETATE 0.1 MG TB 0 APOTEX CORP EAGEN 68084-0606-21 1.27060 DESMOPRESSIN ACETATE 0.1 MG TB 0 AHP EAGEN 00093-7317-01 1.33760 DESMOPRESSIN ACETATE 0.2 MG TB 0 TEVA USA EAGEN 00591-2465-01 1.33760 DESMOPRESSIN ACETATE 0.2 MG TB 0 ACTAVIS PHARMA, EAGEN 51079-0446-01 1.33760 DESMOPRESSIN ACETATE 0.2 MG TB 0 MYLAN INSTITUTI EAGEN 51079-0446-03 1.33760 DESMOPRESSIN ACETATE 0.2 MG TB 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55566-5061-01 1.27785 DESMOPRESSIN ACETATE 0.2 MG TB 0 FERRING PH INC EAGEN 60505-0258-01 1.33760 DESMOPRESSIN ACETATE 0.2 MG TB 0 APOTEX CORP EAGEN 68084-0604-21 1.33760 DESMOPRESSIN ACETATE 0.2 MG TB 0 AHP EAGEN 24208-0342-05 34.23910 DESMOPRESSIN 0.01% SOLUTION 0 VALEANT MLGEN 62756-0161-91 34.23910 DESMOPRESSIN 0.01% SPRAY 0 SUN PHARMACEUTI MLGEN 55566-5020-01 27.12600 DESMOPRESSIN 0.1 MG/ML SOL 0 FERRING PH INC MLGEN 60505-0815-00 36.93750 DESMOPRESSIN 0.1 MG/ML SPRAY 0 APOTEX CORP MLGEN 62756-0529-40 6.81000 DESMOPRESSIN 40 MCG/10 ML VIAL 0 SUN PHARMACEUTI MLBEX 00052-0261-06 0.73800 1.69507 DESOGEN 28 DAY TABLET G ORGANON PHARM. EAGEX 16714-0367-01 0.73800 DESOGESTREL-ETHINYL ESTRAD TAB 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16714-0367-04 0.73800 DESOGESTREL-ETHINYL ESTRAD TAB 0 NORTHSTAR RX LL EABND 10922-0828-06 6.21338 DESONATE 0.05% GEL G INTENDIS INC. GMBND 50419-0828-06 6.64830 DESONATE 0.05% GEL G BAYER,PHARM DIV GMBND 50419-0828-12 5.67056 DESONATE 0.05% GEL G BAYER,PHARM DIV GMGUL 00472-0804-15 0.23370 DESONIDE 0.05% CREAM G ACTAVIS PHARMA, GM** 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