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

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