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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 117LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00245-0182-15 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 UPSHER SMITH EAGEX 00245-0182-89 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 UPSHER SMITH EAGEX 00378-1045-01 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 MYLAN EAGEX 00603-3443-21 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 QUALITEST EAGEX 00603-3443-28 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 QUALITEST EAGEX 16714-0513-01 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 NORTHSTAR RX LL EAGEX 16714-0513-02 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 NORTHSTAR RX LL EAGEX 29300-0140-01 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 UNICHEM PHARMAC EAGEX 29300-0140-05 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 UNICHEM PHARMAC EAGEX 51079-0475-08 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-3067-01 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 APOTEX CORP EAGEX 60505-3067-05 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 APOTEX CORP EAGEX 62756-0798-13 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 SUN PHARMACEUTI EAGEX 62756-0798-88 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 SUN PHARMACEUTI EAGEX 63739-0554-10 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 MCKESSON PACKAG EAGEX 65862-0403-01 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 AUROBINDO PHARM EAGEX 68084-0315-01 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 AHP EAGEX 68084-0315-11 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 AHP EAGEX 68180-0267-01 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 LUPIN PHARMACEU EAGEX 68180-0267-02 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68382-0033-01 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 ZYDUS PHARMACEU EAGEX 68382-0033-05 0.15593 DIVALPROEX SOD DR 500 MG TAB 0 ZYDUS PHARMACEU EAGEX 00115-6911-01 1.26082 DIVALPROEX SOD ER 250 MG TAB 0 GLOBAL PHARM EAGEX 00115-6911-02 1.19778 DIVALPROEX SOD ER 250 MG TAB 0 GLOBAL PHARM EAGEX 00378-0472-01 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 MYLAN EAGEX 00378-0472-05 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 MYLAN EAGEX 00378-0472-77 1.84108 DIVALPROEX SOD ER 250 MG TAB 0 MYLAN EAGEX 00904-5990-61 1.59682 DIVALPROEX SOD ER 250 MG TAB 0 MAJOR PHARMACEU EAGEX 10370-0510-10 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 PAR PHARM. EAGEX 10370-0510-50 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0766-01 1.83750 DIVALPROEX SOD ER 250 MG TAB 0 MYLAN INSTITUTI EAGEX 51079-0766-08 1.84106 DIVALPROEX SOD ER 250 MG TAB 0 MYLAN INSTITUTI EAGEX 55111-0533-01 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 DR.REDDY'S LAB EAGEX 55111-0533-05 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 DR.REDDY'S LAB EAGEX 64679-0724-01 1.32725 DIVALPROEX SOD ER 250 MG TAB 0 WOCKHARDT USA L EAGEX 64679-0724-02 1.26082 DIVALPROEX SOD ER 250 MG TAB 0 WOCKHARDT USA L EAGEX 64679-0724-03 1.19778 DIVALPROEX SOD ER 250 MG TAB 0 WOCKHARDT USA L EAGEX 68001-0105-00 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 BLUEPOINT LABOR EAGEX 68001-0105-03 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 BLUEPOINT LABOR EAGEX 68084-0310-01 1.83525 DIVALPROEX SOD ER 250 MG TAB 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0316-01 1.79250 DIVALPROEX SOD ER 250 MG TAB 0 AHP EAGEX 68084-0316-11 1.79250 DIVALPROEX SOD ER 250 MG TAB 0 AHP EAGEX 68382-0314-01 1.84110 DIVALPROEX SOD ER 250 MG TAB 0 ZYDUS PHARMACEU EAGEX 00115-6922-01 2.21520 DIVALPROEX SOD ER 500 MG TAB 0 GLOBAL PHARM EAGEX 00115-6922-02 2.21520 DIVALPROEX SOD ER 500 MG TAB 0 GLOBAL PHARM 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