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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 110LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 49884-0514-10 0.21320 DIGOXIN 125 MCG TABLET 0 PAR PHARM. EAGUL 00115-9822-01 0.21320 DIGOXIN 250 MCG TABLET 0 GLOBAL PHARM EAGUL 00115-9822-03 0.21320 DIGOXIN 250 MCG TABLET 0 GLOBAL PHARM EAGEN 00143-1241-01 0.16275 DIGOXIN 250 MCG TABLET 0 WEST-WARD,INC. EAGEN 00143-1241-10 0.12618 DIGOXIN 250 MCG TABLET 0 WEST-WARD,INC. EAGEN 00143-1241-51 0.10962 DIGOXIN 250 MCG TABLET 0 WEST-WARD,INC. EAGUL 49884-0494-01 0.21320 DIGOXIN 250 MCG TABLET 0 PAR PHARM. EAGUL 49884-0494-10 0.21320 DIGOXIN 250 MCG TABLET 0 PAR PHARM. EAGEN 57664-0441-18 0.12825 DIGOXIN 250 MCG TABLET 0 CARACO PHARM EABND 00054-0057-46 0.64061 DIGOXIN 50 MCG/ML SOLUTION 0 ROXANE LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00574-0850-05 59.10750 DIHYDROERGOTAMINE 1 MG/ML AM 0 PADDOCK LABS. MLGEN 00574-0850-10 56.15250 DIHYDROERGOTAMINE 1 MG/ML AM 0 PADDOCK LABS. MLBND 55390-0013-10 27.88800 DIHYDROERGOTAMINE 1 MG/ML VL 0 BEDFORD LABS MLGEN 52544-0484-01 0.73265 DILACOR XR 240 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00071-0369-24 0.09060 DILANTIN 100 MG CAPSULE 0 PFIZER US PHARM EAGEX 00071-0369-32 0.09060 DILANTIN 100 MG CAPSULE 0 PFIZER US PHARM EABEX 00071-2214-20 0.08830 0.31568 DILANTIN 125 MG/5 ML SUSP 0 PFIZER US PHARM MLBEX 00071-3740-66 0.51742 DILANTIN 30 MG CAPSULE 0 PFIZER US PHARM EAGEX 00071-0007-24 0.40650 DILANTIN 50 MG INFATAB 0 PFIZER US PHARM EABND 52244-0920-10 2.74539 DILATRATE-SR 40 MG CAPSULE 0 AUXILIUM PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0014-06 0.53200 DILT XR 120 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0014-08 0.53200 DILT XR 120 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0015-06 0.66515 DILT XR 180 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0015-08 0.66515 DILT XR 180 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0016-06 0.73265 DILT XR 240 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0016-08 0.73265 DILT XR 240 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0010-04 0.85887 DILT-CD ER 300 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0010-08 0.85887 DILT-CD ER 300 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0007-04 0.42110 DILT-CD 120 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0007-08 0.42110 DILT-CD 120 MG CAPSULE 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0008-04 0.41240 DILT-CD 180 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0008-08 0.41240 DILT-CD 180 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0009-04 0.59454 DILT-CD 240 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0009-08 0.59454 DILT-CD 240 MG CAPSULE 0 APOTEX CORP EAGEN 62037-0548-01 0.53200 DILTIA XT 120 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0548-10 0.53200 DILTIA XT 120 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0549-01 0.66515 DILTIA XT 180 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0549-10 0.66515 DILTIA XT 180 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0550-01 0.73265 DILTIA XT 240 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0550-10 0.73265 DILTIA XT 240 MG CAPSULE 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00258-3687-90 0.62210 DILTIAZEM ER 120 MG CAPSULE 0 INWOOD LABS. EAGEN 00378-5220-01 0.53200 DILTIAZEM ER 120 MG CAPSULE 0 MYLAN EAGEN 00378-5220-05 0.53200 DILTIAZEM ER 120 MG CAPSULE 0 MYLAN EAGEN 47335-0669-13 0.62210 DILTIAZEM ER 120 MG CAPSULE 0 SUN PHARMA GLOB EAGEN 47335-0669-81 0.62210 DILTIAZEM ER 120 MG CAPSULE 0 SUN PHARMA GLOB 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: 111LIST 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 47335-0669-83 0.62210 DILTIAZEM ER 120 MG CAPSULE 0 SUN PHARMA GLOB EAGEN 51079-0947-08 0.53200 DILTIAZEM ER 120 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 00378-6120-01 1.46812 DILTIAZEM ER 120 MG 12-HR CAP 0 MYLAN EAGEN 00258-3688-90 0.81330 DILTIAZEM ER 180 MG CAPSULE 0 INWOOD LABS. EAGEN 00378-5280-01 0.66515 DILTIAZEM ER 180 MG CAPSULE 0 MYLAN EAGEN 00378-5280-05 0.66515 DILTIAZEM ER 180 MG CAPSULE 0 MYLAN EAGEN 47335-0670-13 0.81330 DILTIAZEM ER 180 MG CAPSULE 0 SUN PHARMA GLOB EAGEN 47335-0670-81 0.81330 DILTIAZEM ER 180 MG CAPSULE 0 SUN PHARMA GLOB EAGEN 47335-0670-83 0.81330 DILTIAZEM ER 180 MG CAPSULE 0 SUN PHARMA GLOB EAGEN 00378-5340-01 0.73265 DILTIAZEM ER 240 MG CAPSULE 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-5340-05 0.73265 DILTIAZEM ER 240 MG CAPSULE 0 MYLAN EAGEN 00378-6060-01 0.80020 DILTIAZEM ER 60 MG 12-HR CAP 0 MYLAN EAGEN 00378-6090-01 0.88190 DILTIAZEM ER 90 MG 12-HR CAP 0 MYLAN EAGEN 00781-2452-05 0.62210 DILTIAZEM HCL ER 120 MG CAP 0 SANDOZ EAGEN 00781-2452-31 0.62210 DILTIAZEM HCL ER 120 MG CAP 0 SANDOZ EAGEN 00781-2452-92 0.62210 DILTIAZEM HCL ER 120 MG CAP 0 SANDOZ EAGEN 00228-1113-03 0.81330 DILTIAZEM HCL ER 180 MG CAP 0 SANDOZ EAGEN 00228-1113-09 0.81330 DILTIAZEM HCL ER 180 MG CAP 0 SANDOZ EAGEN 00781-2453-05 0.81330 DILTIAZEM HCL ER 180 MG CAP 0 SANDOZ EAGEN 00781-2453-31 0.81330 DILTIAZEM HCL ER 180 MG CAP 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-2453-92 0.81330 DILTIAZEM HCL ER 180 MG CAP 0 SANDOZ EAGEN 00258-3689-90 1.16285 DILTIAZEM HCL ER 240 MG CAP 0 INWOOD LABS. EAGEN 00781-2454-05 1.16285 DILTIAZEM HCL ER 240 MG CAP 0 SANDOZ EAGEN 00781-2454-31 1.16285 DILTIAZEM HCL ER 240 MG CAP 0 SANDOZ EAGEN 00781-2454-92 1.16285 DILTIAZEM HCL ER 240 MG CAP 0 SANDOZ EAGEN 47335-0671-13 1.16285 DILTIAZEM HCL ER 240 MG CAP 0 SUN PHARMA GLOB EAGEN 47335-0671-81 1.16285 DILTIAZEM HCL ER 240 MG CAP 0 SUN PHARMA GLOB EAGEN 47335-0671-83 1.16285 DILTIAZEM HCL ER 240 MG CAP 0 SUN PHARMA GLOB EAGEN 00258-3690-90 1.38010 DILTIAZEM HCL ER 300 MG CAP 0 INWOOD LABS. EAGEN 00781-2455-05 1.38010 DILTIAZEM HCL ER 300 MG CAP 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-2455-31 1.38010 DILTIAZEM HCL ER 300 MG CAP 0 SANDOZ EAGEN 00781-2455-92 1.38010 DILTIAZEM HCL ER 300 MG CAP 0 SANDOZ EAGEN 47335-0672-13 1.38010 DILTIAZEM HCL ER 300 MG CAP 0 SUN PHARMA GLOB EAGEN 47335-0672-81 1.38010 DILTIAZEM HCL ER 300 MG CAP 0 SUN PHARMA GLOB EAGEN 47335-0672-83 1.38010 DILTIAZEM HCL ER 300 MG CAP 0 SUN PHARMA GLOB EAGEN 00258-3691-90 1.54115 DILTIAZEM HCL ER 360 MG CAP 0 INWOOD LABS. EAGEN 00781-2456-05 1.54115 DILTIAZEM HCL ER 360 MG CAP 0 SANDOZ EAGEN 00781-2456-31 1.54115 DILTIAZEM HCL ER 360 MG CAP 0 SANDOZ EAGEN 00781-2456-92 1.54115 DILTIAZEM HCL ER 360 MG CAP 0 SANDOZ EAGEN 47335-0673-13 1.54115 DILTIAZEM HCL ER 360 MG CAP 0 SUN PHARMA GLOB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 47335-0673-81 1.54115 DILTIAZEM HCL ER 360 MG CAP 0 SUN PHARMA GLOB EAGEN 47335-0673-83 1.54115 DILTIAZEM HCL ER 360 MG CAP 0 SUN PHARMA GLOB EAGEN 00258-3692-90 1.76920 DILTIAZEM HCL ER 420 MG CAP 0 INWOOD LABS. EAGEN 00781-2457-05 1.76920 DILTIAZEM HCL ER 420 MG CAP 0 SANDOZ EAGEN 00781-2457-31 1.76920 DILTIAZEM HCL ER 420 MG CAP 0 SANDOZ 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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