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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 108LIST 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 51079-0224-01 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0224-20 0.27972 DICLOFENAC SOD EC 75 MG TAB 0 MYLAN INSTITUTI EAGEN 00093-1041-01 0.51910 DICLOFENAC SOD ER 100 MG TAB 0 TEVA USA EAGEN 00228-2717-11 0.51910 DICLOFENAC SOD ER 100 MG TAB 0 ACTAVIS PHARMA, EAGEN 00378-0355-01 0.51910 DICLOFENAC SOD ER 100 MG TAB 0 MYLAN EAGEN 00591-0676-01 0.51910 DICLOFENAC SOD ER 100 MG TAB 0 ACTAVIS PHARMA, EAGEN 00781-1381-01 0.51910 DICLOFENAC SOD ER 100 MG TAB 0 SANDOZ EAGEN 38779-2683-08 10.68750 DICLOFENAC SODIUM POWDER 0 MEDISCA INC. GMGEN 00115-1483-61 8.49210 DICLOFENAC SODIUM 3% GEL G GLOBAL PHARM GMGEN 00168-0803-01 8.84595 DICLOFENAC SODIUM 3% GEL G SANDOZ GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16571-0101-25 2.11050 DICLOFENAC 0.1% EYE DROPS 0 PACK PHARMACEUT MLGEN 16571-0101-50 2.11050 DICLOFENAC 0.1% EYE DROPS 0 PACK PHARMACEUT MLGEN 24208-0457-05 2.11050 DICLOFENAC 0.1% EYE DROPS 0 VALEANT MLGEN 24208-0457-25 2.11050 DICLOFENAC 0.1% EYE DROPS 0 VALEANT MLGEN 61314-0014-05 2.11050 DICLOFENAC 0.1% EYE DROPS 0 SANDOZ MLGEN 61314-0014-25 2.11050 DICLOFENAC 0.1% EYE DROPS 0 SANDOZ MLGEN 00591-0397-60 2.51462 DICLOFENAC-MISOPROST 50-0.2 TB G ACTAVIS PHARMA, EAGEN 59762-0028-01 2.51462 DICLOFENAC-MISOPROST 50-200 TB G GREENSTONE LLC. EAGEN 59762-0028-02 2.51442 DICLOFENAC-MISOPROST 50-200 TB G GREENSTONE LLC. EAGEN 59762-0028-04 2.51460 DICLOFENAC-MISOPROST 50-200 TB G GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-0398-60 2.51462 DICLOFENAC-MISOPROST 75-0.2 TB G ACTAVIS PHARMA, EAGEN 59762-0029-01 2.51462 DICLOFENAC-MISOPROST 75-200 TB G GREENSTONE LLC. EAGEN 59762-0029-03 2.51460 DICLOFENAC-MISOPROST 75-200 TB G GREENSTONE LLC. EAGEN 00093-3123-01 0.29363 DICLOXACILLIN 250 MG CAPSULE 0 TEVA USA EAGEN 00781-2248-01 0.29363 DICLOXACILLIN 250 MG CAPSULE 0 SANDOZ EAGEN 00093-3125-01 0.48830 DICLOXACILLIN 500 MG CAPSULE 0 TEVA USA EAGEN 00781-2258-01 0.48830 DICLOXACILLIN 500 MG CAPSULE 0 SANDOZ EAGEN 00143-3126-01 0.04266 DICYCLOMINE 10 MG CAPSULE 0 WEST-WARD,INC. EAGEN 00143-3126-10 0.04266 DICYCLOMINE 10 MG CAPSULE 0 WEST-WARD,INC. EAGEN 00378-1610-01 0.04266 DICYCLOMINE 10 MG CAPSULE 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-1610-05 0.04266 DICYCLOMINE 10 MG CAPSULE 0 MYLAN EAGEN 00527-0586-01 0.04266 DICYCLOMINE 10 MG CAPSULE 0 LANNETT CO. INC EAGEN 00527-0586-10 0.04266 DICYCLOMINE 10 MG CAPSULE 0 LANNETT CO. INC EAGEN 00591-0794-01 0.04266 DICYCLOMINE 10 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00591-0794-10 0.04266 DICYCLOMINE 10 MG CAPSULE 0 ACTAVIS PHARMA, EABND 00603-1161-58 0.07750 0.19090 DICYCLOMINE 10 MG/5 ML SOLN 0 QUALITEST MLGUL 00143-1227-01 0.04050 DICYCLOMINE 20 MG TABLET 0 WEST-WARD,INC. EAGUL 00143-1227-10 0.04050 DICYCLOMINE 20 MG TABLET 0 WEST-WARD,INC. EAGUL 00378-1620-01 0.04050 DICYCLOMINE 20 MG TABLET 0 MYLAN EAGUL 00378-1620-05 0.04050 DICYCLOMINE 20 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00527-1282-01 0.04050 DICYCLOMINE 20 MG TABLET 0 LANNETT CO. INC EAGUL 00527-1282-10 0.04050 DICYCLOMINE 20 MG TABLET 0 LANNETT CO. INC EAGUL 00591-0795-01 0.04050 DICYCLOMINE 20 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00591-0795-10 0.04050 DICYCLOMINE 20 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00904-0195-60 0.04050 DICYCLOMINE 20 MG TABLET 0 MAJOR PHARMACEU 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: 109LIST 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 00378-8886-93 2.72370 DIDANOSINE DR 125 MG CAPSULE G MYLAN EAGEN 65862-0310-30 2.72370 DIDANOSINE DR 125 MG CAPSULE G AUROBINDO PHARM EAGEN 00378-8887-93 4.35740 DIDANOSINE DR 200 MG CAPSULE G MYLAN EAGEN 00555-0588-01 4.35740 DIDANOSINE DR 200 MG CAPSULE G BARR EAGEN 65862-0311-30 4.35740 DIDANOSINE DR 200 MG CAPSULE G AUROBINDO PHARM EAGEN 00378-8888-93 5.55240 DIDANOSINE DR 250 MG CAPSULE G MYLAN EAGEN 00555-0589-01 5.55240 DIDANOSINE DR 250 MG CAPSULE G BARR EAGEN 65862-0312-30 5.55240 DIDANOSINE DR 250 MG CAPSULE G AUROBINDO PHARM EAGEN 00378-8889-93 8.67230 DIDANOSINE DR 400 MG CAPSULE G MYLAN EAGEN 00555-0590-01 8.67230 DIDANOSINE DR 400 MG CAPSULE G BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0313-30 8.67230 DIDANOSINE DR 400 MG CAPSULE G AUROBINDO PHARM EABND 52015-0080-01 147.29595 DIFICID 200 MG TABLET G OPTIMER PHARMAC EABND 51672-1296-01 4.68175 DIFLORASONE 0.05% CREAM G TARO PHARM USA GMBND 51672-1296-02 4.68203 DIFLORASONE 0.05% CREAM G TARO PHARM USA GMBND 51672-1296-03 4.68230 DIFLORASONE 0.05% CREAM G TARO PHARM USA GMGEN 00168-0243-60 1.25199 DIFLORASONE 0.05% OINTMENT G SANDOZ GMBND 51672-1295-01 4.96727 DIFLORASONE 0.05% OINTMENT G TARO PHARM USA GMBND 51672-1295-02 4.96727 DIFLORASONE 0.05% OINTMENT G TARO PHARM USA GMBND 51672-1295-03 4.96782 DIFLORASONE 0.05% OINTMENT G TARO PHARM USA GMBND 00049-3440-19 0.30200 2.15894 DIFLUCAN 10 MG/ML SUSPENSION G PFIZER US PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00049-3420-30 0.88250 17.63611 DIFLUCAN 100 MG TABLET G PFIZER US PHARM EABND 00049-3500-79 2.74400 28.06991 DIFLUCAN 150 MG TABLET G PFIZER US PHARM EABUL 00049-3430-30 1.40750 28.86048 DIFLUCAN 200 MG TABLET G PFIZER US PHARM EABND 00049-3450-19 0.70470 7.46809 DIFLUCAN 40 MG/ML SUSPENSION G PFIZER US PHARM MLBUL 00049-3410-30 0.50000 11.22436 DIFLUCAN 50 MG TABLET G PFIZER US PHARM EABND 00049-3372-26 0.07220 0.77917 DIFLUCAN-SALINE 400 MG/200 ML G PFIZER US PHARM MLGEN 00093-0755-01 0.95500 DIFLUNISAL 500 MG TABLET G TEVA USA EAGEN 00093-0755-05 0.95500 DIFLUNISAL 500 MG TABLET G TEVA USA EAGEN 00093-0755-06 0.95500 DIFLUNISAL 500 MG TABLET G TEVA USA EAGEN 64980-0181-01 0.95500 DIFLUNISAL 500 MG TABLET G RISING PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64980-0181-05 0.95500 DIFLUNISAL 500 MG TABLET G RISING PHARM EAGEN 64980-0181-06 0.95500 DIFLUNISAL 500 MG TABLET G RISING PHARM EAGUL 00527-1324-01 0.21320 DIGOX 125 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1324-10 0.21320 DIGOX 125 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1325-01 0.21320 DIGOX 250 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1325-10 0.21320 DIGOX 250 MCG TABLET 0 LANNETT CO. INC EAGEN 00641-1410-35 1.40770 DIGOXIN 0.25 MG/ML AMPUL 0 WEST-WARD,INC. MLGEN 68094-0752-59 0.75600 DIGOXIN 0.25 MG/5 ML SOLUTION 0 PRECISION DOSE MLGEN 68094-0752-62 0.75600 DIGOXIN 0.25 MG/5 ML SOLUTION 0 PRECISION DOSE MLGUL 00115-9811-01 0.21320 DIGOXIN 125 MCG TABLET 0 GLOBAL PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00115-9811-03 0.21320 DIGOXIN 125 MCG TABLET 0 GLOBAL PHARM EAGEN 00143-1240-01 0.16275 DIGOXIN 125 MCG TABLET 0 WEST-WARD,INC. EAGEN 00143-1240-10 0.12618 DIGOXIN 125 MCG TABLET 0 WEST-WARD,INC. EAGEN 00143-1240-51 0.10962 DIGOXIN 125 MCG TABLET 0 WEST-WARD,INC. EAGUL 49884-0514-01 0.21320 DIGOXIN 125 MCG TABLET 0 PAR PHARM. 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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