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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 124LIST 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 68047-0714-01 0.36290 DOXYCYCLINE HYCLATE 20 MG TAB 0 LARKEN LABS EAGEN 68047-0714-60 0.36290 DOXYCYCLINE HYCLATE 20 MG TAB 0 LARKEN LABS EAGUL 00143-3141-50 0.13170 DOXYCYCLINE HYCLATE 50 MG CAP 0 WEST-WARD,INC. EAGUL 00591-5535-50 0.13170 DOXYCYCLINE HYCLATE 50 MG CAP 0 ACTAVIS PHARMA, EAGUL 00904-0427-51 0.13170 DOXYCYCLINE HYCLATE 50 MG CAP 0 MAJOR PHARMACEU EAGUL 53489-0118-02 0.13170 DOXYCYCLINE HYCLATE 50 MG CAP 0 MUTUAL PHARM CO EAGUL 53489-0118-05 0.13170 DOXYCYCLINE HYCLATE 50 MG CAP 0 MUTUAL PHARM CO EAGEN 00591-0411-50 1.45380 DOXYCYCLINE MONO 100 MG CAP G ACTAVIS PHARMA, EAGEN 49884-0727-03 1.77675 DOXYCYCLINE MONO 100 MG CAP G PAR PHARM. EAGEN 49884-0727-04 1.70787 DOXYCYCLINE MONO 100 MG CAP G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0216-52 1.11550 DOXYCYCLINE MONO 100 MG TABLET G SANDOZ EAGEN 00185-0216-53 1.11550 DOXYCYCLINE MONO 100 MG TABLET G SANDOZ EAGEN 00378-6023-89 1.11550 DOXYCYCLINE MONO 100 MG TABLET G MYLAN EAGEN 00527-1338-25 1.11550 DOXYCYCLINE MONO 100 MG TABLET G LANNETT CO. INC EAGEN 00527-1338-50 1.11550 DOXYCYCLINE MONO 100 MG TABLET G LANNETT CO. INC EAGEN 23155-0135-25 1.11550 DOXYCYCLINE MONO 100 MG TABLET G HERITAGE PHARMA EAGEN 49884-0093-03 1.11550 DOXYCYCLINE MONO 100 MG TABLET G PAR PHARM. EAGEN 49884-0093-04 1.11550 DOXYCYCLINE MONO 100 MG TABLET G PAR PHARM. EAGEN 63304-0132-50 1.11550 DOXYCYCLINE MONO 100 MG TABLET G RANBAXY PHARMAC EAGEN 00115-1327-13 17.82360 DOXYCYCLINE MONO 150 MG CAP G GLOBAL PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-5475-91 17.82360 DOXYCYCLINE MONO 150 MG CAP G MYLAN EAGEN 49884-0305-02 17.82360 DOXYCYCLINE MONO 150 MG CAP G PAR PHARM. EAGEN 00378-6124-93 3.88665 DOXYCYCLINE MONO 150 MG TABLET G MYLAN EAGEN 00527-1537-30 3.88665 DOXYCYCLINE MONO 150 MG TABLET G LANNETT CO. INC EAGEN 23155-0136-03 3.88665 DOXYCYCLINE MONO 150 MG TABLET G HERITAGE PHARMA EAGEN 49884-0236-11 3.88665 DOXYCYCLINE MONO 150 MG TABLET G PAR PHARM. EAGEN 63304-0173-30 3.88665 DOXYCYCLINE MONO 150 MG TABLET G RANBAXY PHARMAC EAGEN 00591-0410-01 0.89055 DOXYCYCLINE MONO 50 MG CAP G ACTAVIS PHARMA, EAGEN 49884-0726-01 1.08825 DOXYCYCLINE MONO 50 MG CAP G PAR PHARM. EAGEN 00185-0036-01 1.19760 DOXYCYCLINE MONO 50 MG TABLET G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6021-01 1.19760 DOXYCYCLINE MONO 50 MG TABLET G MYLAN EAGEN 00527-1335-01 1.19760 DOXYCYCLINE MONO 50 MG TABLET G LANNETT CO. INC EAGEN 23155-0133-01 1.19760 DOXYCYCLINE MONO 50 MG TABLET G HERITAGE PHARMA EAGEN 49884-0091-01 1.19760 DOXYCYCLINE MONO 50 MG TABLET G PAR PHARM. EAGEN 63304-0615-01 12.29827 DOXYCYCLINE MONO 75 MG CAPSULE G RANBAXY PHARMAC EAGEN 00378-6022-01 1.02938 DOXYCYCLINE MONO 75 MG TABLET G MYLAN EAGEN 00527-1535-01 1.02938 DOXYCYCLINE MONO 75 MG TABLET G LANNETT CO. INC EAGEN 23155-0134-01 1.02938 DOXYCYCLINE MONO 75 MG TABLET G HERITAGE PHARMA EAGEN 49884-0092-01 1.02938 DOXYCYCLINE MONO 75 MG TABLET G PAR PHARM. EAGEN 63304-0131-01 1.02938 DOXYCYCLINE MONO 75 MG TABLET G RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0657-01 0.28462 DOXYCYCLINE 25 MG/5 ML SUSP G LUPIN PHARMACEU MLBND 00024-0392-02 0.28026 2.56702 DRISDOL 50,000 UNITS CAPSULE G SANOFI-AVENTIS EABND 00024-0393-10 0.28026 2.89927 DRISDOL 50,000 UNITS CAPSULE G SANOFI-AVENTIS EABND 00003-6335-17 0.75378 DROXIA 200 MG CAPSULE 0 BMS ONCO/IMMUN EABND 00003-6336-17 0.75378 DROXIA 300 MG CAPSULE 0 BMS ONCO/IMMUN 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: 125LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00003-6337-17 0.80661 DROXIA 400 MG CAPSULE 0 BMS ONCO/IMMUN EABND 00145-2371-05 5.64326 DUAC 1.2-5% GEL G STIEFEL LABS. GMBND 64764-0302-30 13.12064 DUETACT 30-2 MG TABLET G TAKEDA PHARMACE EABND 64764-0304-30 13.12064 DUETACT 30-4 MG TABLET G TAKEDA PHARMACE EABND 75987-0010-03 8.84448 DUEXIS 800-26.6 MG TABLET G HORIZON PHARMA EABND 00085-7206-01 18.36470 DULERA 100 MCG/5 MCG INHALER G MERCK SHARP & D GMBND 00085-7206-07 18.36375 DULERA 100 MCG/5 MCG INHALER G MERCK SHARP & D GMBND 00085-4610-01 18.36470 DULERA 200 MCG/5 MCG INHALER G MERCK SHARP & D GMBND 00085-4610-05 18.36375 DULERA 200 MCG/5 MCG INHALER G MERCK SHARP & D GMBND 49502-0672-30 0.09666 0.74589 DUONEB 0.5 MG-3 MG/3 ML SOLN G MYLAN SPECIALTY ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 49502-0672-60 0.09666 0.74584 DUONEB 0.5 MG-3 MG/3 ML SOLN G MYLAN SPECIALTY MLBND 67457-0218-10 2.77330 4.38240 DURACLON 100 MCG/ML VIAL 0 MYLAN INSTITUTI MLBND 67457-0219-10 11.66660 21.91200 DURACLON 500 MCG/ML VIAL 0 MYLAN INSTITUTI MLBND 00065-9240-05 21.35424 DUREZOL 0.05% EYE DROPS 0 ALCON LABS. MLBND 00065-9240-07 23.98368 DUREZOL 0.05% EYE DROPS 0 ALCON LABS. MLBND 00310-1097-30 0.52788 DUTOPROL 100-12.5 MG TABLET G ASTRAZENECA EABND 00310-1087-30 0.52788 DUTOPROL 25-12.5 MG TABLET G ASTRAZENECA EABND 00310-1095-30 0.52788 DUTOPROL 50-12.5 MG TABLET G ASTRAZENECA EABUL 00007-3650-22 0.31770 1.26301 DYAZIDE 37.5-25 CAPSULE G GLAXOSMITHKLINE EABUL 00007-3650-30 0.31770 1.21350 DYAZIDE 37.5-25 CAPSULE G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00037-0245-23 6.27011 DYMISTA NASAL SPRAY G MEDA PHARMACEUT GMGEN 49884-0098-03 3.06288 DYNACIN 100 MG TABLET G PAR PHARM. EABND 24338-0134-02 1.34709 E.E.S. 200 MG/5 ML GRANULES 0 ARBOR PHARMACEU MLBND 24338-0136-10 0.81937 E.E.S. 200 MG/5 ML GRANULES 0 ARBOR PHARMACEU MLBND 24338-0100-13 3.24911 E.E.S. 400 FILMTAB 0 ARBOR PHARMACEU EAGEN 00168-0312-15 0.22015 ECONAZOLE NITRATE 1% CREAM G SANDOZ GMGEN 00168-0312-30 0.22015 ECONAZOLE NITRATE 1% CREAM G SANDOZ GMGEN 00168-0312-85 0.22015 ECONAZOLE NITRATE 1% CREAM G SANDOZ GMGEN 45802-0466-11 0.22015 ECONAZOLE NITRATE 1% CREAM G PERRIGO CO. GMGEN 45802-0466-35 0.22015 ECONAZOLE NITRATE 1% CREAM G PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45802-0466-53 0.22015 ECONAZOLE NITRATE 1% CREAM G PERRIGO CO. GMGEN 51672-1303-01 0.22015 ECONAZOLE NITRATE 1% CREAM G TARO PHARM USA GMGEN 51672-1303-02 0.22015 ECONAZOLE NITRATE 1% CREAM G TARO PHARM USA GMGEN 51672-1303-08 0.22015 ECONAZOLE NITRATE 1% CREAM G TARO PHARM USA GMGEN 52565-0022-15 0.22015 ECONAZOLE NITRATE 1% CREAM G IGI LABS, INC. GMGEN 52565-0022-30 0.22015 ECONAZOLE NITRATE 1% CREAM G IGI LABS, INC. GMGEN 52565-0022-85 0.22015 ECONAZOLE NITRATE 1% CREAM G IGI LABS, INC. GMGEN 66993-0879-15 0.22015 ECONAZOLE NITRATE 1% CREAM G PRASCO LABS GMGEN 66993-0879-31 0.22015 ECONAZOLE NITRATE 1% CREAM G PRASCO LABS GMGEN 66993-0879-85 0.22015 ECONAZOLE NITRATE 1% CREAM G PRASCO LABS GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00485-0082-01 0.40950 ED-SPAZ 0.125 MG ODT 0 EDWARDS PHARMAC EABND 64764-0844-30 3.13269 EDARBI 40 MG TABLET G ARBOR PHARMACEU EABND 64764-0884-30 3.13269 EDARBI 80 MG TABLET G ARBOR PHARMACEU EABND 64764-0944-30 3.21403 EDARBYCLOR 40-12.5 MG TABLET G ARBOR PHARMACEU EABND 64764-0994-30 3.21403 EDARBYCLOR 40-25 MG TABLET G ARBOR PHARMACEU 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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