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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 107LIST 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 00039-0051-10 0.14877 0.89922 DIABETA 2.5 MG TABLET G SANOFI-AVENTIS EABND 00039-0052-10 0.22570 1.64896 DIABETA 5 MG TABLET G SANOFI-AVENTIS EABND 51285-0754-02 3.03510 6.86758 DIAMOX SEQUELS ER 500 MG CAP 0 DURAMED/BARR EABND 55494-0100-10 4.73100 DICLEGIS DR 10-10 MG TABLET 0 DUCHESNAY USA, EAGEN 00093-0948-01 0.43335 DICLOFENAC POT 50 MG TABLET 0 TEVA USA EAGEN 00093-0948-05 0.43335 DICLOFENAC POT 50 MG TABLET 0 TEVA USA EAGEN 00378-2474-01 0.43335 DICLOFENAC POT 50 MG TABLET 0 MYLAN EAGEN 60505-0135-00 0.43335 DICLOFENAC POT 50 MG TABLET 0 APOTEX CORP EAGEN 00378-6280-01 0.36710 DICLOFENAC SOD DR 50 MG TAB 0 MYLAN EAGEN 00378-6280-10 0.36710 DICLOFENAC SOD DR 50 MG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-1787-01 0.36710 DICLOFENAC SOD DR 50 MG TAB 0 SANDOZ EAGEN 00781-1787-10 0.36710 DICLOFENAC SOD DR 50 MG TAB 0 SANDOZ EAGEN 00781-1787-60 0.36710 DICLOFENAC SOD DR 50 MG TAB 0 SANDOZ EAGEN 00378-6281-01 0.27972 DICLOFENAC SOD DR 75 MG TAB 0 MYLAN EAGEN 00378-6281-10 0.27972 DICLOFENAC SOD DR 75 MG TAB 0 MYLAN EAGEN 61442-0103-05 0.27972 DICLOFENAC SOD DR 75 MG TAB 0 CARLSBAD TECH EAGEN 68084-0333-01 0.27972 DICLOFENAC SOD DR 75 MG TAB 0 AHP EAGEN 68084-0333-11 0.27972 DICLOFENAC SOD DR 75 MG TAB 0 AHP EAGEN 00781-1785-01 1.06635 DICLOFENAC SOD EC 25 MG TAB 0 SANDOZ EAGEN 16571-0203-10 1.04360 DICLOFENAC SOD EC 25 MG TAB 0 PACK PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-2550-06 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 ACTAVIS PHARMA, EAGEN 00228-2550-11 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 ACTAVIS PHARMA, EAGEN 00228-2550-96 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 ACTAVIS PHARMA, EAGEN 00591-0338-01 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 WATSON LABS EAGEN 00591-0338-10 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 ACTAVIS PHARMA, EAGEN 00591-0338-60 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 WATSON LABS EAGEN 16571-0202-06 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 PACK PHARMACEUT EAGEN 16571-0202-10 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 PACK PHARMACEUT EAGEN 16571-0202-11 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 PACK PHARMACEUT EAGEN 51079-0466-01 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0466-20 0.36710 DICLOFENAC SOD EC 50 MG TAB 0 MYLAN INSTITUTI EAGEN 00228-2551-06 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 ACTAVIS PHARMA, EAGEN 00228-2551-11 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 ACTAVIS PHARMA, EAGEN 00228-2551-96 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 ACTAVIS PHARMA, EAGEN 00591-0339-05 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 WATSON LABS EAGEN 00591-0339-10 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 WATSON LABS EAGEN 00591-0339-60 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 WATSON LABS EAGEN 00781-1789-01 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 SANDOZ EAGEN 00781-1789-05 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 SANDOZ EAGEN 00781-1789-10 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-1789-60 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 SANDOZ EAGEN 16571-0201-06 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 PACK PHARMACEUT EAGEN 16571-0201-10 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 PACK PHARMACEUT EAGEN 16571-0201-11 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 PACK PHARMACEUT EAGEN 16571-0201-50 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 PACK PHARMACEUT 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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