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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 104LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-5191-02 7.41060 DETROL LA 4 MG CAPSULE G PHARMACIA/UPJHN EABND 00009-5191-03 7.41047 DETROL LA 4 MG CAPSULE G PHARMACIA/UPJHN EABND 00009-4541-02 1.11132 4.35999 DETROL 1 MG TABLET G PHARMACIA/UPJHN EABND 00009-4541-03 1.11132 4.36010 DETROL 1 MG TABLET G PHARMACIA/UPJHN EABND 00009-4544-02 1.14050 4.47521 DETROL 2 MG TABLET G PHARMACIA/UPJHN EABND 00009-4544-03 1.14050 4.47526 DETROL 2 MG TABLET G PHARMACIA/UPJHN EABND 00054-3176-44 0.72237 DEXAMETHASONE INTENSOL 1MG/1ML G ROXANE LABS. MLGEN 24208-0720-02 3.17850 DEXAMETHASONE 0.1% EYE DROP 0 VALEANT MLGEN 61314-0294-05 3.16500 DEXAMETHASONE 0.1% EYE DROP 0 SANDOZ MLGEN 00054-4179-25 0.06300 DEXAMETHASONE 0.5 MG TABLET 0 ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-8179-25 0.06300 DEXAMETHASONE 0.5 MG TABLET 0 ROXANE LABS. EAGEN 00603-1147-56 0.18954 DEXAMETHASONE 0.5 MG/5 ML ELX G QUALITEST MLGEN 60432-0466-08 0.18954 DEXAMETHASONE 0.5 MG/5 ML ELX G MORTON GROVE PH MLGEN 64980-0509-24 0.18954 DEXAMETHASONE 0.5 MG/5 ML ELX G RISING PHARM MLBND 00054-3177-57 0.22026 DEXAMETHASONE 0.5 MG/5 ML LIQ 0 ROXANE LABS. MLBND 00054-3177-63 0.03969 DEXAMETHASONE 0.5 MG/5 ML LIQ 0 ROXANE LABS. MLGEN 00054-4180-25 0.11360 DEXAMETHASONE 0.75 MG TABLET 0 ROXANE LABS. EAGEN 00054-8180-25 0.11360 DEXAMETHASONE 0.75 MG TABLET 0 ROXANE LABS. EABND 00054-4181-25 0.29050 DEXAMETHASONE 1 MG TABLET 0 ROXANE LABS. EABND 00054-8174-25 0.31374 DEXAMETHASONE 1 MG TABLET 0 ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-4182-25 0.07722 DEXAMETHASONE 1.5 MG TABLET 0 ROXANE LABS. EAGEN 49884-0086-01 0.07722 DEXAMETHASONE 1.5 MG TABLET 0 PAR PHARM. EAGEN 00641-0367-25 0.84308 DEXAMETHASONE 10 MG/ML VIAL 0 WEST-WARD,INC. MLBND 63323-0506-01 4.02384 DEXAMETHASONE 10 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 00069-0177-01 0.35985 DEXAMETHASONE 100 MG/10 ML VL 0 PFIZER/NOVAPLUS MLGEN 00069-0177-02 0.35985 DEXAMETHASONE 100 MG/10 ML VL 0 PFIZER/NOVAPLUS MLGEN 00069-4541-01 0.35985 DEXAMETHASONE 100 MG/10 ML VL 0 PFIZER US PHARM MLGEN 00069-0192-01 0.31500 DEXAMETHASONE 120 MG/30 ML VL 0 PFIZER/NOVAPLUS MLGEN 00069-0192-02 0.31500 DEXAMETHASONE 120 MG/30 ML VL 0 PFIZER/NOVAPLUS MLGEN 00069-4545-01 0.31500 DEXAMETHASONE 120 MG/30 ML VL 0 PFIZER US PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00517-4930-25 0.23250 DEXAMETHASONE 120 MG/30 ML VL 0 AMER. REGENT MLGEN 63323-0165-30 0.65649 DEXAMETHASONE 120 MG/30 ML VL 0 APP PHARMACEUTI MLBND 00054-4183-25 0.56888 DEXAMETHASONE 2 MG TABLET 0 ROXANE LABS. EABND 00054-8176-25 0.59303 DEXAMETHASONE 2 MG TABLET 0 ROXANE LABS. EAGEN 00069-0178-01 0.35100 DEXAMETHASONE 20 MG/5 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00069-0178-02 0.35100 DEXAMETHASONE 20 MG/5 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00069-4543-01 0.35100 DEXAMETHASONE 20 MG/5 ML VIAL 0 PFIZER US PHARM MLGEN 00517-4905-25 0.31500 DEXAMETHASONE 20 MG/5 ML VIAL 0 AMER. REGENT MLGEN 63323-0165-05 0.73080 DEXAMETHASONE 20 MG/5 ML VIAL 0 APP PHARMACEUTI MLGEN 00054-4184-25 0.12430 DEXAMETHASONE 4 MG TABLET 0 ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-8175-25 0.12430 DEXAMETHASONE 4 MG TABLET 0 ROXANE LABS. EAGEN 49884-0087-01 0.12430 DEXAMETHASONE 4 MG TABLET 0 PAR PHARM. EAGEN 00069-0179-01 0.74280 DEXAMETHASONE 4 MG/ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00069-0179-02 0.74280 DEXAMETHASONE 4 MG/ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00069-4547-01 0.74280 DEXAMETHASONE 4 MG/ML VIAL 0 PFIZER US PHARM 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: 105LIST 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 00517-4901-25 0.78300 DEXAMETHASONE 4 MG/ML VIAL 0 AMER. REGENT MLGEN 63323-0165-01 0.83098 DEXAMETHASONE 4 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 67457-0423-00 0.74280 DEXAMETHASONE 4 MG/ML VIAL 0 MYLAN INSTITUTI MLGEN 67457-0423-12 0.74280 DEXAMETHASONE 4 MG/ML VIAL 0 MYLAN INSTITUTI MLGEN 00054-4186-25 0.42110 DEXAMETHASONE 6 MG TABLET 0 ROXANE LABS. EAGEN 00054-8183-25 0.42110 DEXAMETHASONE 6 MG TABLET 0 ROXANE LABS. EAGEN 49884-0129-01 0.42110 DEXAMETHASONE 6 MG TABLET 0 PAR PHARM. EABND 00517-0234-10 18.67500 DEXFERRUM 100 MG/2 ML VIAL 0 AMER. REGENT MLBND 00517-0134-10 18.67500 DEXFERRUM 50 MG/ML VIAL 0 AMER. REGENT MLBND 64764-0171-30 5.55491 DEXILANT DR 30 MG CAPSULE G TAKEDA PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 64764-0175-30 5.55491 DEXILANT DR 60 MG CAPSULE G TAKEDA PHARMACE EABND 64764-0175-90 5.55472 DEXILANT DR 60 MG CAPSULE G TAKEDA PHARMACE EABND 00095-0087-35 0.57140 1.99200 DEXPAK 10 DAY 1.5 MG TABLET G ECR PHARM. EABND 00095-0088-51 0.53180 1.99200 DEXPAK 13 DAY 1.5 MG TABLET G ECR PHARM. EABND 00095-0089-21 0.87540 1.99200 DEXPAK 6 DAY 1.5 MG TABLET G ECR PHARM. EABND 00517-0131-25 1.61850 DEXPANTHENOL 250 MG/ML VIAL 0 AMER. REGENT MLGEN 38779-0355-01 8.72850 DEXTROMETHORPHAN HBR POWDER 0 MEDISCA INC. GMGEN 38779-0355-05 8.72812 DEXTROMETHORPHAN HBR POWDER 0 MEDISCA INC. GMGEN 51927-1339-00 10.03500 DEXTROMETHORPHAN HBR POWDER 0 PROFESSIONAL CO GMBND 00264-7520-00 0.00174 DEXTROSE 10%-WATER IV SOLUTION 0 B.BRAUN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00264-7520-10 0.00340 DEXTROSE 10%-WATER IV SOLUTION 0 B.BRAUN MLGEN 00338-0023-02 0.00270 DEXTROSE 10%-WATER IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0023-03 0.00270 DEXTROSE 10%-WATER IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0023-04 0.00234 DEXTROSE 10%-WATER IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00409-7930-02 0.00270 DEXTROSE 10%-WATER IV SOLUTION 0 HOSPIRA MLBND 00409-4862-02 0.02350 DEXTROSE 10%-1/4NS IV SOLN 0 HOSPIRA MLGEN 00338-0073-04 0.00210 DEXTROSE 2.5%-1/2NS IV SOLN 0 BAXTER HEALTHCA MLGEN 00264-7751-00 0.00157 DEXTROSE 5%-LR IV SOLUTION 0 B.BRAUN MLGEN 00264-7751-10 0.00176 DEXTROSE 5%-LR IV SOLUTION 0 B.BRAUN MLGEN 00338-0125-03 0.00176 DEXTROSE 5%-LR IV SOLUTION 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0125-04 0.00169 DEXTROSE 5%-LR IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00409-7929-09 0.00172 DEXTROSE 5%-LR IV SOLUTION 0 HOSPIRA MLGEN 00264-7610-00 0.00157 DEXTROSE 5%-NS IV SOLUTION 0 B.BRAUN MLGEN 00264-7610-10 0.00189 DEXTROSE 5%-NS IV SOLUTION 0 B.BRAUN MLGEN 00264-7610-20 0.00189 DEXTROSE 5%-NS IV SOLUTION 0 B.BRAUN MLGEN 00338-0089-03 0.00189 DEXTROSE 5%-NS IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0089-04 0.00158 DEXTROSE 5%-NS IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00409-7941-02 0.00189 DEXTROSE 5%-NS IV SOLUTION 0 HOSPIRA MLGEN 00409-7941-03 0.00189 DEXTROSE 5%-NS IV SOLUTION 0 HOSPIRA MLGEN 00409-7941-09 0.00179 DEXTROSE 5%-NS IV SOLUTION 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00264-7781-00 0.00171 DEXTROSE 5%-RINGERS IV SOLN 0 B.BRAUN MLGEN 00338-0077-02 0.00210 DEXTROSE 5%-SOD CHLORIDE 0.2% 0 BAXTER HEALTHCA MLGEN 00338-0077-03 0.00210 DEXTROSE 5%-SOD CHLORIDE 0.2% 0 BAXTER HEALTHCA MLGEN 00338-0077-04 0.00192 DEXTROSE 5%-SOD CHLORIDE 0.2% 0 BAXTER HEALTHCA MLGEN 00264-1510-31 0.00190 DEXTROSE 5%-WATER IV SOLN 0 B.BRAUN 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
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