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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 112LIST 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 00781-2457-92 1.76920 DILTIAZEM HCL ER 420 MG CAP 0 SANDOZ EAGEN 38779-0227-05 9.66330 DILTIAZEM HCL POWDER 0 MEDISCA INC. GMGEN 00093-0321-01 0.13690 DILTIAZEM 120 MG TABLET 0 TEVA USA EAGEN 00378-0525-01 0.13690 DILTIAZEM 120 MG TABLET 0 MYLAN EAGEN 00228-2588-03 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 ACTAVIS PHARMA, EAGEN 00228-2588-09 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 ACTAVIS PHARMA, EAGEN 00228-2588-50 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 ACTAVIS PHARMA, EAGEN 49884-0829-05 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 PAR PHARM. EAGEN 49884-0829-09 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 PAR PHARM. EAGEN 49884-0829-11 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63739-0283-10 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 MCKESSON PACKAG EAGEN 63739-0283-31 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 MCKESSON PACKAG EAGEN 68084-0052-01 0.32452 DILTIAZEM 24HR CD 120 MG CAP 0 AHP EAGEN 68084-0052-30 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 AHP EAGEN 68084-0052-90 0.42110 DILTIAZEM 24HR CD 120 MG CAP 0 AHP EAGEN 00228-2577-03 0.41240 DILTIAZEM 24HR CD 180 MG CAP 0 ACTAVIS PHARMA, EAGEN 00228-2577-09 0.41240 DILTIAZEM 24HR CD 180 MG CAP 0 ACTAVIS PHARMA, EAGEN 00228-2577-50 0.41240 DILTIAZEM 24HR CD 180 MG CAP 0 ACTAVIS PHARMA, EAGEN 49884-0830-05 0.41240 DILTIAZEM 24HR CD 180 MG CAP 0 PAR PHARM. EAGEN 49884-0830-09 0.41240 DILTIAZEM 24HR CD 180 MG CAP 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0830-11 0.41240 DILTIAZEM 24HR CD 180 MG CAP 0 PAR PHARM. EAGEN 63739-0284-10 0.41240 DILTIAZEM 24HR CD 180 MG CAP 0 MCKESSON PACKAG EAGEN 63739-0284-31 0.41240 DILTIAZEM 24HR CD 180 MG CAP 0 MCKESSON PACKAG EAGEN 68084-0053-01 0.38220 DILTIAZEM 24HR CD 180 MG CAP 0 AHP EAGEN 00228-2578-03 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 ACTAVIS PHARMA, EAGEN 00228-2578-09 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 ACTAVIS PHARMA, EAGEN 00228-2578-50 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 ACTAVIS PHARMA, EAGEN 49884-0831-05 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 PAR PHARM. EAGEN 49884-0831-09 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 PAR PHARM. EAGEN 49884-0831-11 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63739-0285-10 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 MCKESSON PACKAG EAGEN 63739-0285-31 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 MCKESSON PACKAG EAGEN 68084-0054-30 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 AHP EAGEN 68084-0054-90 0.59454 DILTIAZEM 24HR CD 240 MG CAP 0 AHP EAGEN 00228-2579-03 0.85887 DILTIAZEM 24HR CD 300 MG CAP 0 ACTAVIS PHARMA, EAGEN 00228-2579-09 0.85887 DILTIAZEM 24HR CD 300 MG CAP 0 ACTAVIS PHARMA, EAGEN 00228-2579-50 0.85887 DILTIAZEM 24HR CD 300 MG CAP 0 ACTAVIS PHARMA, EAGEN 49884-0832-05 0.85887 DILTIAZEM 24HR CD 300 MG CAP 0 PAR PHARM. EAGEN 49884-0832-09 0.85887 DILTIAZEM 24HR CD 300 MG CAP 0 PAR PHARM. EAGEN 49884-0832-11 0.85887 DILTIAZEM 24HR CD 300 MG CAP 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0055-30 0.85887 DILTIAZEM 24HR CD 300 MG CAP 0 AHP EAGEN 68084-0055-90 0.85887 DILTIAZEM 24HR CD 300 MG CAP 0 AHP EAGEN 68682-0521-01 7.36883 DILTIAZEM 24HR CD 360 MG CAP 0 OCEANSIDE PHARM EAGEN 00093-5112-98 0.42110 DILTIAZEM 24HR ER 120 MG CAP 0 TEVA USA EAGEN 47335-0675-13 0.42110 DILTIAZEM 24HR ER 120 MG CAP 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