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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 118LIST 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 00378-0473-01 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 MYLAN EAGEX 00378-0473-05 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 MYLAN EAGEX 00378-0473-77 3.05616 DIVALPROEX SOD ER 500 MG TAB 0 MYLAN EAGEX 00904-6073-61 3.30465 DIVALPROEX SOD ER 500 MG TAB 0 MAJOR PHARMACEU EAGEX 10370-0511-10 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 PAR PHARM. EAGEX 10370-0511-50 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 PAR PHARM. EAGEX 51079-0767-01 3.05250 DIVALPROEX SOD ER 500 MG TAB 0 MYLAN INSTITUTI EAGEX 51079-0767-08 3.05616 DIVALPROEX SOD ER 500 MG TAB 0 MYLAN INSTITUTI EAGEX 51079-0767-30 3.05250 DIVALPROEX SOD ER 500 MG TAB 0 MYLAN INSTITUTI EAGEX 51079-0767-56 3.05615 DIVALPROEX SOD ER 500 MG TAB 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 55111-0534-01 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 DR.REDDY'S LAB EAGEX 55111-0534-05 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 DR.REDDY'S LAB EAGEX 64679-0725-01 2.21775 DIVALPROEX SOD ER 500 MG TAB 0 WOCKHARDT USA L EAGEX 64679-0725-02 2.21775 DIVALPROEX SOD ER 500 MG TAB 0 WOCKHARDT USA L EAGEX 64679-0725-03 2.21776 DIVALPROEX SOD ER 500 MG TAB 0 WOCKHARDT USA L EAGEX 68001-0106-00 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 BLUEPOINT LABOR EAGEX 68001-0106-03 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 BLUEPOINT LABOR EAGEX 68084-0317-01 2.87400 DIVALPROEX SOD ER 500 MG TAB 0 AHP EAGEX 68084-0317-11 2.87250 DIVALPROEX SOD ER 500 MG TAB 0 AHP EAGEX 68084-0415-01 2.87400 DIVALPROEX SOD ER 500 MG TAB 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68382-0315-01 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 ZYDUS PHARMACEU EAGEX 68382-0315-05 3.05617 DIVALPROEX SOD ER 500 MG TAB 0 ZYDUS PHARMACEU EAGEX 00378-8008-01 0.67237 DIVALPROEX SODIUM 125 MG CAP G MYLAN EAGEX 00378-8008-05 0.67237 DIVALPROEX SODIUM 125 MG CAP G MYLAN EAGEX 51079-0765-01 0.67237 DIVALPROEX SODIUM 125 MG CAP G MYLAN INSTITUTI EAGEX 51079-0765-08 0.67237 DIVALPROEX SODIUM 125 MG CAP G MYLAN INSTITUTI EAGEX 51079-0765-30 0.67237 DIVALPROEX SODIUM 125 MG CAP G MYLAN INSTITUTI EAGEX 51079-0765-56 0.67237 DIVALPROEX SODIUM 125 MG CAP G MYLAN INSTITUTI EAGEX 55111-0532-01 0.67237 DIVALPROEX SODIUM 125 MG CAP G DR.REDDY'S LAB EAGEX 55111-0532-05 0.67237 DIVALPROEX SODIUM 125 MG CAP G DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0313-01 0.59595 DIVALPROEX SODIUM 125 MG CAP G AHP EAGEX 68084-0313-11 0.59595 DIVALPROEX SODIUM 125 MG CAP G AHP EAGEX 68382-0106-01 0.67207 DIVALPROEX SODIUM 125 MG CAP G ZYDUS PHARMACEU EAGEX 68382-0106-10 0.67207 DIVALPROEX SODIUM 125 MG CAP G ZYDUS PHARMACEU EABND 00245-0880-30 3.00875 DIVIGEL 0.25 MG GEL PACKET 0 UPSHER SMITH EABND 00245-0881-30 3.00875 DIVIGEL 0.5 MG GEL PACKET 0 UPSHER SMITH EABND 00245-0882-30 3.00875 DIVIGEL 1 MG GEL PACKET 0 UPSHER SMITH GMGEN 00338-1077-02 0.07387 DOBUTAMINE 1 GM-D5W 250 ML 0 BAXTER HEALTHCA MLGEN 00409-2344-02 0.19845 DOBUTAMINE 12.5 MG/ML VIAL 0 HOSPIRA MLGEN 55390-0560-90 0.17325 DOBUTAMINE 12.5 MG/ML VIAL 0 BEDFORD LABS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-1073-02 0.05396 DOBUTAMINE 250 MG-D5W 250 ML 0 BAXTER HEALTHCA MLGEN 00338-1075-02 0.05470 DOBUTAMINE 500 MG-D5W 250 ML 0 BAXTER HEALTHCA MLGEN 66758-0050-03 72.65610 DOCETAXEL 160 MG/16 ML VIAL 0 SANDOZ MLBND 16729-0267-65 303.07450 DOCETAXEL 160 MG/8 ML VIAL 0 ACCORD HEALTHCA MLGEN 16729-0267-63 112.69875 DOCETAXEL 20 MG/ML VIAL 0 ACCORD HEALTHCA 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