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

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