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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 114LIST 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 60505-0211-09 0.81330 DILTZAC ER 180 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0212-03 1.16285 DILTZAC ER 240 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0212-09 1.16285 DILTZAC ER 240 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0213-03 1.38010 DILTZAC ER 300 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0213-09 1.38010 DILTZAC ER 300 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0214-03 1.54115 DILTZAC ER 360 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0214-09 1.54115 DILTZAC ER 360 MG CAPSULE 0 APOTEX CORP EAGEN 00703-9258-09 0.15750 DILUENT FOR EPOPROSTENOL VIAL 0 TEVA PARENTERAL MLBND 00173-0518-01 0.28037 DILUENT FOR FLOLAN VIAL 0 GLAXOSMITHKLINE MLGEN 38779-0614-01 1.01531 DIMETHYL SULFOXIDE LIQUID 0 MEDISCA INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0315-15 5.00102 5.00102 DIOVAN HCT 160-12.5 MG TAB G NOVARTIS EABND 00078-0315-17 3.78797 3.78797 DIOVAN HCT 160-12.5 MG TAB G NOVARTIS EABND 00078-0315-34 5.00084 5.00084 DIOVAN HCT 160-12.5 MG TAB G NOVARTIS EABND 00078-0315-67 5.00107 5.00107 DIOVAN HCT 160-12.5 MG TAB G NOVARTIS EABND 00078-0383-15 5.67111 5.67111 DIOVAN HCT 160-25 MG TABLET G NOVARTIS EABND 00078-0383-17 4.29573 4.29573 DIOVAN HCT 160-25 MG TABLET G NOVARTIS EABND 00078-0383-34 5.67129 5.67129 DIOVAN HCT 160-25 MG TABLET G NOVARTIS EABND 00078-0383-67 5.67111 5.67111 DIOVAN HCT 160-25 MG TABLET G NOVARTIS EABND 00078-0471-11 4.79901 4.79901 DIOVAN HCT 320-12.5 MG TAB G NOVARTIS EABND 00078-0471-15 6.33566 6.33566 DIOVAN HCT 320-12.5 MG TAB G NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0471-34 6.33585 6.33585 DIOVAN HCT 320-12.5 MG TAB G NOVARTIS EABND 00078-0471-67 6.33548 6.33548 DIOVAN HCT 320-12.5 MG TAB G NOVARTIS EABND 00078-0472-11 5.44457 5.44457 DIOVAN HCT 320-25 MG TABLET G NOVARTIS EABND 00078-0472-15 7.18752 7.18752 DIOVAN HCT 320-25 MG TABLET G NOVARTIS EABND 00078-0472-34 7.18798 7.18798 DIOVAN HCT 320-25 MG TABLET G NOVARTIS EABND 00078-0472-67 7.18826 7.18826 DIOVAN HCT 320-25 MG TABLET G NOVARTIS EABND 00078-0314-33 3.48153 3.48153 DIOVAN HCT 80-12.5 MG TABLET G NOVARTIS EABND 00078-0314-34 4.59617 4.59617 DIOVAN HCT 80-12.5 MG TABLET G NOVARTIS EABND 00078-0359-17 3.48060 DIOVAN 160 MG TABLET G NOVARTIS EABND 00078-0359-34 4.61480 DIOVAN 160 MG TABLET G NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0360-11 4.40301 DIOVAN 320 MG TABLET G NOVARTIS EABND 00078-0360-34 5.83803 DIOVAN 320 MG TABLET G NOVARTIS EABND 00078-0423-15 3.59002 DIOVAN 40 MG TABLET G NOVARTIS EABND 00078-0358-33 3.23690 DIOVAN 80 MG TABLET G NOVARTIS EABND 00078-0358-34 4.29165 DIOVAN 80 MG TABLET G NOVARTIS EABND 68220-0160-10 6.27189 DIPENTUM 250 MG CAPSULE 0 MEDA PHARMACEUT EAGEX 00555-0059-02 0.02660 DIPHENHYDRAMINE 50 MG CAPSULE 0 BARR EAGEX 00555-0059-05 0.02660 DIPHENHYDRAMINE 50 MG CAPSULE 0 BARR EAGEX 00641-0376-21 0.73500 DIPHENHYDRAMINE 50 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-0376-25 0.73800 DIPHENHYDRAMINE 50 MG/ML VIAL 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 63323-0664-01 0.83300 DIPHENHYDRAMINE 50 MG/ML VIAL 0 APP PHARMACEUTI MLBND 00085-0517-01 0.31320 4.63693 DIPROLENE AF 0.05% CREAM G MERCK SHARP & D GMBND 00085-0517-04 0.31320 3.11167 DIPROLENE AF 0.05% CREAM G MERCK SHARP & D GMBND 00085-0962-01 1.30980 2.66042 DIPROLENE 0.05% LOTION G MERCK SHARP & D MLBND 00085-0962-02 1.30980 2.62169 DIPROLENE 0.05% LOTION G MERCK SHARP & D ML** 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