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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 119LIST 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 25021-0222-01 112.69875 DOCETAXEL 20 MG/ML VIAL 0 SAGENT PHARMACE MLGEN 66758-0050-01 63.90875 DOCETAXEL 20 MG/2 ML VIAL 0 SANDOZ MLGEN 16729-0267-64 112.82431 DOCETAXEL 80 MG/4 ML VIAL 0 ACCORD HEALTHCA MLGEN 25021-0222-04 112.82431 DOCETAXEL 80 MG/4 ML VIAL 0 SAGENT PHARMACE MLGEN 66758-0050-02 64.40075 DOCETAXEL 80 MG/8 ML VIAL 0 SANDOZ MLBND 59630-0074-10 5.98737 DOLGIC PLUS TABLET 0 SHIONOGI PHARMA EABND 68453-0074-10 4.33865 DOLGIC PLUS TABLET 0 SHIONOGI PHARMA EAGEN 00781-5277-64 0.28310 DONEPEZIL HCL ODT 10 MG TABLET 0 SANDOZ EAGEN 33342-0030-07 0.28310 DONEPEZIL HCL ODT 10 MG TABLET 0 MACLEODS PHARMA EAGEN 59762-0252-01 0.28310 DONEPEZIL HCL ODT 10 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63739-0653-10 0.28310 DONEPEZIL HCL ODT 10 MG TABLET 0 MCKESSON PACKAG EAGEN 68382-0347-06 0.28310 DONEPEZIL HCL ODT 10 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00781-5276-64 0.28310 DONEPEZIL HCL ODT 5 MG TABLET 0 SANDOZ EAGEN 33342-0029-07 0.28310 DONEPEZIL HCL ODT 5 MG TABLET 0 MACLEODS PHARMA EAGEN 59762-0250-01 0.28310 DONEPEZIL HCL ODT 5 MG TABLET 0 GREENSTONE LLC. EAGEN 63739-0652-10 0.28310 DONEPEZIL HCL ODT 5 MG TABLET 0 MCKESSON PACKAG EAGEN 68382-0346-06 0.28310 DONEPEZIL HCL ODT 5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00093-0739-05 0.07398 DONEPEZIL HCL 10 MG TABLET 0 TEVA USA EAGEN 00093-0739-56 0.07398 DONEPEZIL HCL 10 MG TABLET 0 TEVA USA EAGEN 00093-0739-98 0.07398 DONEPEZIL HCL 10 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00143-9748-09 0.07398 DONEPEZIL HCL 10 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-9748-30 0.07398 DONEPEZIL HCL 10 MG TABLET 0 WEST-WARD,INC. EAGEN 00781-5275-10 0.07398 DONEPEZIL HCL 10 MG TABLET 0 SANDOZ EAGEN 00781-5275-13 0.07398 DONEPEZIL HCL 10 MG TABLET 0 SANDOZ EAGEN 00781-5275-31 0.07398 DONEPEZIL HCL 10 MG TABLET 0 SANDOZ EAGEN 00781-5275-92 0.07398 DONEPEZIL HCL 10 MG TABLET 0 SANDOZ EAGEN 00904-6243-61 0.07398 DONEPEZIL HCL 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6355-61 0.07398 DONEPEZIL HCL 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 13668-0103-10 0.07398 DONEPEZIL HCL 10 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0103-26 0.07398 DONEPEZIL HCL 10 MG TABLET 0 TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13668-0103-30 0.07398 DONEPEZIL HCL 10 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0103-90 0.07398 DONEPEZIL HCL 10 MG TABLET 0 TORRENT PHARMAC EAGEN 43547-0276-11 0.07398 DONEPEZIL HCL 10 MG TABLET 0 SOLCO HEALTHCAR EAGEN 55111-0357-05 0.07398 DONEPEZIL HCL 10 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0357-10 0.07398 DONEPEZIL HCL 10 MG TABLET 0 DR.REDDY'S LAB EAGEN 59746-0330-30 0.07398 DONEPEZIL HCL 10 MG TABLET 0 CADISTA PHARMAC EAGEN 59746-0330-90 0.07398 DONEPEZIL HCL 10 MG TABLET 0 CADISTA PHARMAC EAGEN 59762-0246-01 0.07398 DONEPEZIL HCL 10 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-0246-02 0.07398 DONEPEZIL HCL 10 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-0246-03 0.07398 DONEPEZIL HCL 10 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-0246-04 0.07398 DONEPEZIL HCL 10 MG TABLET 0 GREENSTONE LLC. EAGEN 62756-0445-18 0.07398 DONEPEZIL HCL 10 MG TABLET 0 SUN PHARMACEUTI EAGEN 62756-0445-81 0.07398 DONEPEZIL HCL 10 MG TABLET 0 SUN PHARMACEUTI EAGEN 62756-0445-83 0.07398 DONEPEZIL HCL 10 MG TABLET 0 SUN PHARMACEUTI EAGEN 63304-0129-10 0.07398 DONEPEZIL HCL 10 MG TABLET 0 RANBAXY PHARMAC 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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