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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 122LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00093-8123-01 0.65180 DOXAZOSIN MESYLATE 8 MG TAB 0 TEVA USA EAGUL 00378-4028-01 0.65180 DOXAZOSIN MESYLATE 8 MG TAB 0 MYLAN EAGUL 60505-0096-00 0.65180 DOXAZOSIN MESYLATE 8 MG TAB 0 APOTEX CORP EAGUL 60505-0096-01 0.65180 DOXAZOSIN MESYLATE 8 MG TAB 0 APOTEX CORP EAGUL 60505-0096-08 0.65180 DOXAZOSIN MESYLATE 8 MG TAB 0 APOTEX CORP EAGUL 68645-0465-70 0.65180 DOXAZOSIN MESYLATE 8 MG TAB 0 LEGACY PHARMACE EAGUX 00378-1049-01 0.08910 DOXEPIN 10 MG CAPSULE 0 MYLAN EAGUX 00378-1049-10 0.08910 DOXEPIN 10 MG CAPSULE 0 MYLAN EAGUX 51079-0436-20 0.08910 DOXEPIN 10 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 00093-9612-12 0.06740 DOXEPIN 10 MG/ML ORAL CONC 0 TEVA USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 54838-0512-40 0.06740 DOXEPIN 10 MG/ML ORAL CONC 0 SILARX PHARM MLGEX 60432-0651-04 0.06740 DOXEPIN 10 MG/ML ORAL CONC 0 MORTON GROVE PH MLGUX 00378-6410-01 0.41740 DOXEPIN 100 MG CAPSULE 0 MYLAN EAGUX 00378-6410-10 0.41740 DOXEPIN 100 MG CAPSULE 0 MYLAN EAGUX 51079-0651-20 0.41740 DOXEPIN 100 MG CAPSULE 0 MYLAN INSTITUTI EABEX 49884-0222-01 2.76199 DOXEPIN 150 MG CAPSULE 0 PAR PHARM. EABEX 49884-0222-03 2.81834 DOXEPIN 150 MG CAPSULE 0 PAR PHARM. EABEX 49884-0222-05 2.62381 DOXEPIN 150 MG CAPSULE 0 PAR PHARM. EAGUX 00378-3125-01 0.18220 DOXEPIN 25 MG CAPSULE 0 MYLAN EAGUX 00378-3125-10 0.18220 DOXEPIN 25 MG CAPSULE 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 51079-0437-20 0.18220 DOXEPIN 25 MG CAPSULE 0 MYLAN INSTITUTI EAGUX 00378-4250-01 0.14470 DOXEPIN 50 MG CAPSULE 0 MYLAN EAGUX 00378-4250-10 0.14470 DOXEPIN 50 MG CAPSULE 0 MYLAN EAGUX 51079-0438-20 0.14470 DOXEPIN 50 MG CAPSULE 0 MYLAN INSTITUTI EABEX 00378-5375-01 0.10970 1.03160 DOXEPIN 75 MG CAPSULE 0 MYLAN EABEX 00378-5375-10 0.10970 1.00898 DOXEPIN 75 MG CAPSULE 0 MYLAN EAGEN 00781-3305-95 5.27362 DOXERCALCIFEROL 4 MCG/2 ML VL 0 SANDOZ MLBND 59676-0960-02 76.74480 107.35884 DOXIL 2 MG/ML VIAL 0 JANSSEN PRODUCT MLGEN 47335-0049-40 76.74480 DOXORUBICIN LIPOSOME 20MG/10ML 0 SUN PHARMA GLOB MLGEN 47335-0050-40 76.74480 DOXORUBICIN LIPOSOME 50MG/25ML 0 SUN PHARMA GLOB ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55390-0241-10 7.28750 DOXORUBICIN 10 MG VIAL 0 BEDFORD/NOVAPLU EAGEN 00069-4030-01 1.80000 DOXORUBICIN 10 MG/5 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00703-5043-01 2.17800 DOXORUBICIN 10 MG/5 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-5043-03 2.17800 DOXORUBICIN 10 MG/5 ML VIAL 0 TEVA PARENTERAL MLGEN 53150-0320-10 1.80000 DOXORUBICIN 10 MG/5 ML VIAL 0 AMNEAL-AGILA, L MLGEN 00069-4031-01 1.80000 DOXORUBICIN 20 MG/10 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 53150-0314-10 1.80000 DOXORUBICIN 20 MG/10 ML VIAL 0 AMNEAL-AGILA, L MLGEN 00703-5040-01 1.26735 DOXORUBICIN 200 MG/100 ML VIAL 0 TEVA PARENTERAL MLGEN 53150-0317-01 1.26000 DOXORUBICIN 200 MG/100 ML VIAL 0 AMNEAL-AGILA, L MLGEN 62756-0827-40 1.20600 DOXORUBICIN 200 MG/100 ML VIAL 0 SUN PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0101-61 1.19977 DOXORUBICIN 200 MG/100 ML VIAL 0 APP PHARMACEUTI MLGEN 55390-0243-01 19.23175 DOXORUBICIN 50 MG VIAL 0 BEDFORD/NOVAPLU EAGEN 00069-4032-01 1.26000 DOXORUBICIN 50 MG/25 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00703-5046-01 1.69200 DOXORUBICIN 50 MG/25 ML VIAL 0 TEVA PARENTERAL MLGEN 53150-0315-01 1.26000 DOXORUBICIN 50 MG/25 ML VIAL 0 AMNEAL-AGILA, L 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