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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 120LIST 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 63304-0129-30 0.07398 DONEPEZIL HCL 10 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0129-90 0.07398 DONEPEZIL HCL 10 MG TABLET 0 RANBAXY PHARMAC EAGEN 63739-0668-10 0.07398 DONEPEZIL HCL 10 MG TABLET 0 MCKESSON PACKAG EAGEN 64679-0312-01 0.07398 DONEPEZIL HCL 10 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0312-03 0.07398 DONEPEZIL HCL 10 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0312-05 0.07398 DONEPEZIL HCL 10 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0326-30 0.07398 DONEPEZIL HCL 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0326-90 0.07398 DONEPEZIL HCL 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0326-99 0.07398 DONEPEZIL HCL 10 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0478-01 0.07398 DONEPEZIL HCL 10 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0478-11 0.07398 DONEPEZIL HCL 10 MG TABLET 0 AHP EAGEN 00093-0738-05 0.05940 DONEPEZIL HCL 5 MG TABLET 0 TEVA USA EAGEN 00093-0738-56 0.05940 DONEPEZIL HCL 5 MG TABLET 0 TEVA USA EAGEN 00093-0738-98 0.05940 DONEPEZIL HCL 5 MG TABLET 0 TEVA USA EAGEN 00143-9747-09 0.05940 DONEPEZIL HCL 5 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-9747-30 0.05940 DONEPEZIL HCL 5 MG TABLET 0 WEST-WARD,INC. EAGEN 00781-5274-10 0.05940 DONEPEZIL HCL 5 MG TABLET 0 SANDOZ EAGEN 00781-5274-13 0.05940 DONEPEZIL HCL 5 MG TABLET 0 SANDOZ EAGEN 00781-5274-31 0.05940 DONEPEZIL HCL 5 MG TABLET 0 SANDOZ EAGEN 00781-5274-92 0.05940 DONEPEZIL HCL 5 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-6242-61 0.05940 DONEPEZIL HCL 5 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6354-61 0.05940 DONEPEZIL HCL 5 MG TABLET 0 MAJOR PHARMACEU EAGEN 13668-0102-05 0.05940 DONEPEZIL HCL 5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0102-10 0.05940 DONEPEZIL HCL 5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0102-30 0.05940 DONEPEZIL HCL 5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0102-90 0.05940 DONEPEZIL HCL 5 MG TABLET 0 TORRENT PHARMAC EAGEN 55111-0356-05 0.05940 DONEPEZIL HCL 5 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0356-10 0.05940 DONEPEZIL HCL 5 MG TABLET 0 DR.REDDY'S LAB EAGEN 59746-0329-30 0.05940 DONEPEZIL HCL 5 MG TABLET 0 CADISTA PHARMAC EAGEN 59746-0329-90 0.05940 DONEPEZIL HCL 5 MG TABLET 0 CADISTA PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-0245-01 0.05940 DONEPEZIL HCL 5 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-0245-02 0.05940 DONEPEZIL HCL 5 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-0245-03 0.05940 DONEPEZIL HCL 5 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-0245-04 0.05940 DONEPEZIL HCL 5 MG TABLET 0 GREENSTONE LLC. EAGEN 62756-0440-18 0.05940 DONEPEZIL HCL 5 MG TABLET 0 SUN PHARMACEUTI EAGEN 62756-0440-81 0.05940 DONEPEZIL HCL 5 MG TABLET 0 SUN PHARMACEUTI EAGEN 62756-0440-83 0.05940 DONEPEZIL HCL 5 MG TABLET 0 SUN PHARMACEUTI EAGEN 63304-0128-10 0.05940 DONEPEZIL HCL 5 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0128-30 0.05940 DONEPEZIL HCL 5 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0128-90 0.05940 DONEPEZIL HCL 5 MG TABLET 0 RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63739-0667-10 0.05940 DONEPEZIL HCL 5 MG TABLET 0 MCKESSON PACKAG EAGEN 64679-0311-01 0.05940 DONEPEZIL HCL 5 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0311-03 0.05940 DONEPEZIL HCL 5 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0311-05 0.05940 DONEPEZIL HCL 5 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0325-30 0.05940 DONEPEZIL HCL 5 MG TABLET 0 AUROBINDO 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 121LIST 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 65862-0325-90 0.05940 DONEPEZIL HCL 5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0325-99 0.05940 DONEPEZIL HCL 5 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0477-01 0.05940 DONEPEZIL HCL 5 MG TABLET 0 AHP EAGEN 68084-0477-11 0.05940 DONEPEZIL HCL 5 MG TABLET 0 AHP EAGEN 00338-1005-02 0.03240 DOPAMINE 200 MG-D5W 250 ML 0 BAXTER HEALTHCA MLGEN 00517-1805-25 0.31500 DOPAMINE 40 MG/ML VIAL 0 AMER. REGENT MLGEN 00338-1007-02 0.03589 DOPAMINE 400 MG-D5W 250 ML 0 BAXTER HEALTHCA MLGEN 00338-1005-03 0.01971 DOPAMINE 400 MG-D5W 500 ML 0 BAXTER HEALTHCA MLGEN 00338-1009-02 0.05004 DOPAMINE 800 MG-D5W 250 ML 0 BAXTER HEALTHCA MLGEN 00338-1007-03 0.03205 DOPAMINE 800 MG-D5W 500 ML 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59630-0309-01 20.99568 DORIBAX 250 MG VIAL 0 SHIONOGI PHARMA EABND 59630-0309-10 20.99568 DORIBAX 250 MG VIAL 0 SHIONOGI PHARMA EABND 50458-0401-02 38.17668 DORIBAX 500 MG VIAL 0 SHIONOGI PHARMA EABND 59630-0320-01 38.17668 DORIBAX 500 MG VIAL 0 SHIONOGI PHARMA EABND 59630-0320-10 38.17668 DORIBAX 500 MG VIAL 0 SHIONOGI PHARMA EABND 00430-0115-20 13.16703 19.02125 DORYX DR 150 MG TABLET G ACTAVIS PHARMA, EABND 00430-0114-20 25.35539 DORYX DR 200 MG TABLET G ACTAVIS PHARMA, EAGEN 00093-7618-43 2.27450 DORZOLAMIDE HCL 2% EYE DROPS 0 TEVA USA MLGEN 24208-0485-10 2.27450 DORZOLAMIDE HCL 2% EYE DROPS 0 VALEANT MLGEN 50383-0232-10 2.27450 DORZOLAMIDE HCL 2% EYE DROPS 0 HI-TECH PHARMAC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61314-0019-10 2.27450 DORZOLAMIDE HCL 2% EYE DROPS 0 SANDOZ MLGEN 66993-0175-20 2.27450 DORZOLAMIDE HCL 2% EYE DROPS 0 PRASCO LABS MLGEN 24208-0486-10 1.83465 DORZOLAMIDE-TIMOLOL EYE DROPS 0 VALEANT MLGEN 50383-0233-10 1.83465 DORZOLAMIDE-TIMOLOL EYE DROPS 0 HI-TECH PHARMAC MLGEN 61314-0030-02 1.83465 DORZOLAMIDE-TIMOLOL EYE DROPS 0 SANDOZ MLBND 50222-0260-06 7.81777 7.81777 DOVONEX 0.005% CREAM 0 LEO PHARMA INC. GMBND 50222-0260-12 7.47449 7.47449 DOVONEX 0.005% CREAM 0 LEO PHARMA INC. GMGEN 00093-8120-01 0.05170 DOXAZOSIN MESYLATE 1 MG TAB 0 TEVA USA EAGEN 00378-4021-01 0.05170 DOXAZOSIN MESYLATE 1 MG TAB 0 MYLAN EAGEN 60505-0093-00 0.05170 DOXAZOSIN MESYLATE 1 MG TAB 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0093-01 0.05170 DOXAZOSIN MESYLATE 1 MG TAB 0 APOTEX CORP EAGUL 00093-8121-01 0.59180 DOXAZOSIN MESYLATE 2 MG TAB 0 TEVA USA EAGUL 00093-8121-19 0.59180 DOXAZOSIN MESYLATE 2 MG TAB 0 TEVA USA EAGUL 00093-8121-93 0.59180 DOXAZOSIN MESYLATE 2 MG TAB 0 TEVA USA EAGUL 00378-4022-01 0.59180 DOXAZOSIN MESYLATE 2 MG TAB 0 MYLAN EAGUL 60505-0094-00 0.59180 DOXAZOSIN MESYLATE 2 MG TAB 0 APOTEX CORP EAGUL 60505-0094-01 0.59180 DOXAZOSIN MESYLATE 2 MG TAB 0 APOTEX CORP EAGUL 60505-0094-08 0.59180 DOXAZOSIN MESYLATE 2 MG TAB 0 APOTEX CORP EAGUL 68645-0463-70 0.59180 DOXAZOSIN MESYLATE 2 MG TAB 0 LEGACY PHARMACE EAGUL 00093-8122-01 0.62100 DOXAZOSIN MESYLATE 4 MG TAB 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-4024-01 0.62100 DOXAZOSIN MESYLATE 4 MG TAB 0 MYLAN EAGUL 60505-0095-00 0.62100 DOXAZOSIN MESYLATE 4 MG TAB 0 APOTEX CORP EAGUL 60505-0095-01 0.62100 DOXAZOSIN MESYLATE 4 MG TAB 0 APOTEX CORP EAGUL 60505-0095-05 0.62100 DOXAZOSIN MESYLATE 4 MG TAB 0 APOTEX CORP EAGUL 68645-0464-70 0.62100 DOXAZOSIN MESYLATE 4 MG TAB 0 LEGACY PHARMACE 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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