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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 106LIST 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 00264-1510-32 0.00190 DEXTROSE 5%-WATER IV SOLN 0 B.BRAUN MLGEN 00264-1510-36 0.00190 DEXTROSE 5%-WATER IV SOLN 0 B.BRAUN MLGEN 00264-7510-00 0.00157 DEXTROSE 5%-WATER IV SOLN 0 B.BRAUN MLGEN 00264-7510-10 0.00190 DEXTROSE 5%-WATER IV SOLN 0 B.BRAUN MLGEN 00264-7510-20 0.00190 DEXTROSE 5%-WATER IV SOLN 0 B.BRAUN MLGEN 00338-0017-01 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-02 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-03 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-04 0.00156 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-10 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0017-11 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-18 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-31 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-38 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-41 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-0017-48 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLBND 00338-0551-11 0.09900 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLBND 00338-0551-18 0.02371 0.04950 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLGEN 00338-6346-02 0.00190 DEXTROSE 5%-WATER IV SOLN 0 BAXTER HEALTHCA MLBND 00409-7100-66 0.02390 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00409-7100-67 0.01822 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00409-7922-02 0.00190 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00409-7922-03 0.00190 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00409-7922-09 0.00162 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00409-7922-53 0.00190 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00409-7922-55 0.00190 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00409-7922-61 0.00190 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00409-7923-36 0.00190 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00409-7923-37 0.00190 DEXTROSE 5%-WATER IV SOLN 0 HOSPIRA MLGEN 00264-7612-00 0.00157 DEXTROSE 5%-1/2NS IV SOLUTION 0 B.BRAUN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0085-03 0.00189 DEXTROSE 5%-1/2NS IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0085-04 0.00168 DEXTROSE 5%-1/2NS IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00409-7926-02 0.00189 DEXTROSE 5%-1/2NS IV SOLUTION 0 HOSPIRA MLGEN 00409-7926-03 0.00189 DEXTROSE 5%-1/2NS IV SOLUTION 0 HOSPIRA MLGEN 00409-7926-09 0.00152 DEXTROSE 5%-1/2NS IV SOLUTION 0 HOSPIRA MLGEN 00338-0081-03 0.00190 DEXTROSE 5%-1/3NS IV SOLUTION 0 BAXTER HEALTHCA MLGEN 00409-7925-03 0.00190 DEXTROSE 5%-1/3NS IV SOLUTION 0 HOSPIRA MLGEN 00409-7925-09 0.00168 DEXTROSE 5%-1/3NS IV SOLUTION 0 HOSPIRA MLGEN 00409-7924-02 0.00210 DEXTROSE 5%-1/4NS IV SOLUTION 0 HOSPIRA MLGEN 00409-7924-09 0.00160 DEXTROSE 5%-1/4NS IV SOLUTION 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00264-1280-55 0.00580 DEXTROSE 50%-WATER IV SOLN 0 B.BRAUN MLGEN 00409-7517-16 0.09640 DEXTROSE 50%-WATER SYRINGE 0 HOSPIRA MLGEN 76329-3301-01 0.09640 DEXTROSE 50%-WATER SYRINGE 0 INTERNATIONAL M MLBND 00409-6648-02 0.02020 0.04083 DEXTROSE 50%-WATER VIAL 0 HOSPIRA MLBND 00039-0053-05 0.12440 0.40653 DIABETA 1.25 MG TABLET G SANOFI-AVENTIS 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