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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 126LIST 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 25010-0205-15 3.91145 EDECRIN 25 MG TABLET 0 VALEANT EABND 25010-0215-15 6.60746 EDECRIN 25 MG TABLET 0 VALEANT EABND 59676-0278-01 25.54933 EDURANT 25 MG TABLET G JANSSEN PRODUCT EAGEN 51801-0005-30 0.15110 EFFER-K 25 MEQ TABLET EFF 0 NOMAX INC EAGEN 51801-0006-30 0.15110 EFFER-K 25 MEQ TABLET EFF 0 NOMAX INC EAGEN 51801-0007-30 0.15110 EFFER-K 25 MEQ TABLET EFF 0 NOMAX INC EABEX 00008-0836-02 0.74240 7.47830 EFFEXOR XR 150 MG CAPSULE G WYETH PHARM EABEX 00008-0836-20 0.74240 7.47996 EFFEXOR XR 150 MG CAPSULE G WYETH PHARM EABEX 00008-0836-21 0.74240 7.48051 EFFEXOR XR 150 MG CAPSULE G WYETH PHARM EABEX 00008-0836-22 0.74240 7.48069 EFFEXOR XR 150 MG CAPSULE G WYETH PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00008-0837-20 0.29270 6.12761 EFFEXOR XR 37.5 MG CAPSULE G WYETH PHARM EABEX 00008-0837-21 0.29270 6.12844 EFFEXOR XR 37.5 MG CAPSULE G WYETH PHARM EABEX 00008-0837-22 0.29270 6.12890 EFFEXOR XR 37.5 MG CAPSULE G WYETH PHARM EABEX 00008-0833-20 0.34670 6.86686 EFFEXOR XR 75 MG CAPSULE G WYETH PHARM EABEX 00008-0833-21 0.34670 6.86133 EFFEXOR XR 75 MG CAPSULE G WYETH PHARM EABEX 00008-0833-22 0.34670 6.86705 EFFEXOR XR 75 MG CAPSULE G WYETH PHARM EABND 00002-5123-30 8.22696 EFFIENT 10 MG TABLET 0 ELI LILLY & CO. EABND 00002-5121-52 8.22702 EFFIENT 5 MG TABLET 0 ELI LILLY & CO. EABND 00187-3204-47 5.35250 7.23822 EFUDEX 5% CREAM 0 VALEANT GMBND 49502-0420-60 1.64150 3.31806 ELDEPRYL 5 MG CAPSULE G MYLAN SPECIALTY EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00023-9201-05 9.26440 31.82552 ELESTAT 0.05% EYE DROPS G ALLERGAN INC. MLBND 18860-0480-01 2.99789 ELESTRIN 0.06% GEL 0 MEDA PHARMACEUT GMBND 18860-0480-60 2.99789 ELESTRIN 0.06% GEL 0 MEDA PHARMACEUT GMBND 00187-5100-01 6.20867 ELIDEL 1% CREAM G VALEANT GMBND 00187-5101-02 6.20867 ELIDEL 1% CREAM G VALEANT GMBND 00187-5102-03 6.20856 ELIDEL 1% CREAM G VALEANT GMGEX 16714-0365-01 0.80097 ELINEST-28 TABLET 0 NORTHSTAR RX LL EAGEX 16714-0365-04 0.80097 ELINEST-28 TABLET 0 NORTHSTAR RX LL EAGEN 63717-0910-02 0.08200 ELIPHOS 667 MG TABLET 0 HAWTHORN PHARM EABND 00003-0893-21 4.40549 ELIQUIS 2.5 MG TABLET G BMS PRIMARYCARE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00003-0893-31 4.40547 ELIQUIS 2.5 MG TABLET G BMS PRIMARYCARE EABND 00003-0894-21 4.40549 ELIQUIS 5 MG TABLET G BMS PRIMARYCARE EABND 00003-0894-31 4.40547 ELIQUIS 5 MG TABLET G BMS PRIMARYCARE EABND 49708-0644-90 0.16012 ELIXOPHYLLIN 80 MG/15 ML ELIX 0 CARACO PHARMA I MLBEX 52544-0238-54 35.60700 ELLA 30 MG TABLET 0 ACTAVIS PHARMA, EABND 50458-0098-01 6.15494 ELMIRON 100 MG CAPSULE 0 JANSSEN PHARM. EABND 00085-0567-01 0.46670 2.97084 ELOCON 0.1% CREAM G MERCK SHARP & D GMBND 00085-0567-02 0.46670 1.81382 ELOCON 0.1% CREAM G MERCK SHARP & D GMBND 00085-3149-01 0.46670 2.97084 ELOCON 0.1% CREAM G MERCK SHARP & D GMBND 00085-3149-03 0.46670 1.63244 ELOCON 0.1% CREAM G MERCK SHARP & D GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00085-0854-01 0.23085 1.61020 ELOCON 0.1% LOTION G MERCK SHARP & D MLBND 00085-0854-02 0.23085 1.53854 ELOCON 0.1% LOTION G MERCK SHARP & D MLBND 00085-0370-01 0.26490 2.97084 ELOCON 0.1% OINTMENT G MERCK SHARP & D GMBND 00085-0370-02 0.26490 1.81382 ELOCON 0.1% OINTMENT G MERCK SHARP & D GMBND 00065-0325-05 19.22280 EMADINE 0.05% EYE DROPS G ALCON LABS. 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: 127LIST 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 00013-0132-02 8.15010 EMCYT 140 MG CAPSULE 0 PHARMACIA/UPJHN EABND 00006-3862-03 134.30506 EMEND TRIFOLD PACK 0 MERCK SHARP & D EABND 00006-0462-06 177.86070 EMEND 125 MG CAPSULE 0 MERCK SHARP & D EABND 00006-0464-05 61.41336 EMEND 40 MG CAPSULE 0 MERCK SHARP & D EABND 00006-0464-10 61.41170 EMEND 40 MG CAPSULE 0 MERCK SHARP & D EABND 00006-0461-02 113.83450 EMEND 80 MG CAPSULE 0 MERCK SHARP & D EABND 00006-0461-06 113.82758 EMEND 80 MG CAPSULE 0 MERCK SHARP & D EAGEX 00603-7540-17 0.73800 EMOQUETTE 28 DAY TABLET 0 QUALITEST EAGEX 00603-7540-49 0.73800 EMOQUETTE 28 DAY TABLET 0 QUALITEST EABEX 49502-0902-30 32.94380 EMSAM 12 MG/24 HOURS PATCH 0 MYLAN SPECIALTY EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 49502-0900-30 32.94380 EMSAM 6 MG/24 HOURS PATCH 0 MYLAN SPECIALTY EABEX 49502-0901-30 32.94380 EMSAM 9 MG/24 HOURS PATCH 0 MYLAN SPECIALTY EABND 61958-0602-01 0.69436 EMTRIVA 10 MG/ML SOLUTION G GILEAD SCIENCES MLBND 61958-0601-01 16.66280 EMTRIVA 200 MG CAPSULE G GILEAD SCIENCES EABND 00078-0420-15 4.95150 ENABLEX 15 MG TABLET G WC PROF PRODS EABND 00078-0420-34 4.95141 ENABLEX 15 MG TABLET G WC PROF PRODS EABND 00430-0171-15 6.38436 ENABLEX 15 MG TABLET G ACTAVIS PHARMA, EABND 00430-0171-23 6.38436 ENABLEX 15 MG TABLET G ACTAVIS PHARMA, EABND 00078-0419-15 4.95150 ENABLEX 7.5 MG TABLET G WC PROF PRODS EABND 00078-0419-34 4.95141 ENABLEX 7.5 MG TABLET G WC PROF PRODS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00430-0170-15 6.38436 ENABLEX 7.5 MG TABLET G ACTAVIS PHARMA, EABND 00430-0170-23 6.38436 ENABLEX 7.5 MG TABLET G ACTAVIS PHARMA, EAGEN 38779-0514-04 19.45140 ENALAPRIL MALEATE POWDER 0 MEDISCA INC. GMGEN 38779-0514-05 19.45125 ENALAPRIL MALEATE POWDER 0 MEDISCA INC. GMGUL 00093-0028-01 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 TEVA USA EAGUL 00093-0028-10 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 TEVA USA EAGUL 00093-0028-50 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 TEVA USA EAGUL 00378-1053-01 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 MYLAN EAGUL 00378-1053-10 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 MYLAN EAGUL 15338-0220-30 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 APACE PACKAGING EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 49158-0502-01 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 TARO PHARM USA EAGUL 49158-0502-10 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 TARO PHARM USA EAGUL 51672-4039-01 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 TARO PHARM USA EAGUL 51672-4039-03 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 TARO PHARM USA EAGUL 60505-0051-07 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 APOTEX CORP EAGUL 60505-0051-09 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 APOTEX CORP EAGUL 64679-0925-02 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 WOCKHARDT USA L EAGUL 64679-0925-03 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 WOCKHARDT USA L EAGUL 68084-0391-01 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 AHP EAGUL 68084-0391-11 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 68645-0456-90 0.07320 ENALAPRIL MALEATE 10 MG TAB 0 LEGACY PHARMACE EAGUL 00093-0026-01 0.04730 ENALAPRIL MALEATE 2.5 MG TAB 0 TEVA USA EAGUL 00093-0026-10 0.04730 ENALAPRIL MALEATE 2.5 MG TAB 0 TEVA USA EAGUL 00378-1051-01 0.04730 ENALAPRIL MALEATE 2.5 MG TAB 0 MYLAN EAGUL 15338-0200-30 0.04730 ENALAPRIL MALEATE 2.5 MG TAB 0 APACE PACKAGING 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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