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

More documents

Recommendations

Info

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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 115LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00085-0575-02 3.01220 4.63693 DIPROLENE 0.05% OINTMENT G MERCK SHARP & D GMBND 00085-0575-05 3.01220 3.11167 DIPROLENE 0.05% OINTMENT G MERCK SHARP & D GMGEN 00054-0434-25 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 ROXANE LABS. EAGEN 00115-1070-01 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 GLOBAL PHARM EAGEN 00115-1070-03 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 GLOBAL PHARM EAGEN 00555-0252-02 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 BARR EAGEN 00555-0252-05 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 BARR EAGEN 64980-0133-01 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 RISING PHARM EAGEN 64980-0133-10 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 RISING PHARM EAGEN 68382-0187-01 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0187-05 0.14760 DIPYRIDAMOLE 25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00054-0435-25 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 ROXANE LABS. EAGEN 00115-1071-01 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 GLOBAL PHARM EAGEN 00115-1071-03 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 GLOBAL PHARM EAGEN 00555-0285-02 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 BARR EAGEN 00555-0285-05 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 BARR EAGEN 64980-0134-01 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 RISING PHARM EAGEN 64980-0134-10 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 RISING PHARM EAGEN 68382-0188-01 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0188-05 0.17630 DIPYRIDAMOLE 50 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0436-25 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 ROXANE LABS. EAGEN 00115-1072-01 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 GLOBAL PHARM EAGEN 00115-1072-03 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 GLOBAL PHARM EAGEN 00555-0286-02 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 BARR EAGEN 00555-0286-05 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 BARR EAGEN 64980-0135-01 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 RISING PHARM EAGEN 64980-0135-10 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 RISING PHARM EAGEN 68382-0189-01 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0189-05 0.36500 DIPYRIDAMOLE 75 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00093-3127-01 0.31000 DISOPYRAMIDE 100 MG CAPSULE 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-5560-01 0.31000 DISOPYRAMIDE 100 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00093-3129-01 0.41082 DISOPYRAMIDE 150 MG CAPSULE 0 TEVA USA EAGEN 00591-5561-01 0.41082 DISOPYRAMIDE 150 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00093-5035-01 2.46632 DISULFIRAM 250 MG TABLET 0 TEVA USA EAGEN 47781-0607-30 2.46632 DISULFIRAM 250 MG TABLET 0 ALVOGEN INC EAGEN 64980-0171-01 2.46632 DISULFIRAM 250 MG TABLET 0 RISING PHARM EAGEN 00093-5036-01 4.71117 DISULFIRAM 500 MG TABLET 0 TEVA USA EAGEN 64980-0172-01 4.71117 DISULFIRAM 500 MG TABLET 0 RISING PHARM EABND 50458-0810-01 1.29006 5.24576 DITROPAN XL 10 MG TABLET G JANSSEN PHARM. EABND 50458-0815-01 2.17500 5.37698 DITROPAN XL 15 MG TABLET G JANSSEN PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50458-0805-01 1.24956 5.24037 DITROPAN XL 5 MG TABLET G JANSSEN PHARM. EABND 65649-0311-12 0.22189 DIURIL 250 MG/5 ML ORAL SUSP 0 SALIX PHARMACEU MLGEX 00093-7439-01 0.05220 DIVALPROEX SOD DR 125 MG TAB 0 TEVA USA EAGEX 00245-0180-01 0.05220 DIVALPROEX SOD DR 125 MG TAB 0 UPSHER SMITH EAGEX 00245-0180-11 0.05220 DIVALPROEX SOD DR 125 MG TAB 0 UPSHER SMITH 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65: NEW YORK STATE DEPARTMENT OF HEALTH
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?