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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 13LIST 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 00832-1015-00 1.51425 AMANTADINE 100 MG CAPSULE 0 UPSHER SMITH EAGEN 00832-1015-50 1.51425 AMANTADINE 100 MG CAPSULE 0 UPSHER SMITH EAGEN 00832-2012-00 1.51425 AMANTADINE 100 MG CAPSULE 0 UPSHER SMITH EAGEN 00832-2012-50 1.51425 AMANTADINE 100 MG CAPSULE 0 UPSHER SMITH EAGEN 10888-5006-02 1.45365 AMANTADINE 100 MG CAPSULE 0 BANNER PHARMACA EAGEN 10888-5006-03 1.45368 AMANTADINE 100 MG CAPSULE 0 BANNER PHARMACA EAGEN 51079-0247-20 1.98750 AMANTADINE 100 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 68084-0611-01 1.53600 AMANTADINE 100 MG CAPSULE 0 AHP EABND 00832-0111-00 1.89513 AMANTADINE 100 MG TABLET 0 UPSHER SMITH EABND 00832-0111-50 1.89507 AMANTADINE 100 MG TABLET 0 UPSHER SMITH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00121-0646-10 0.02133 AMANTADINE 50 MG/5 ML SYRUP 0 PHARMACEU ASSOC MLGEN 00121-0646-16 0.02133 AMANTADINE 50 MG/5 ML SYRUP 0 PHARMACEU ASSOC MLGEN 50383-0807-16 0.02133 AMANTADINE 50 MG/5 ML SYRUP 0 HI-TECH PHARMAC MLGEN 60432-0093-16 0.02133 AMANTADINE 50 MG/5 ML SYRUP 0 MORTON GROVE PH MLBND 00039-0221-10 0.02930 0.82178 AMARYL 1 MG TABLET G SANOFI-AVENTIS EABND 00039-0222-10 0.04347 1.33198 AMARYL 2 MG TABLET G SANOFI-AVENTIS EABND 00039-0223-10 0.06910 2.51207 AMARYL 4 MG TABLET G SANOFI-AVENTIS EABND 00469-3051-30 162.88750 AMBISOME 50 MG VIAL 0 ASTELLAS PHARMA EAGEN 00168-0278-15 7.56000 AMCINONIDE 0.1% CREAM 0 SANDOZ GMGEN 00168-0278-30 5.67000 AMCINONIDE 0.1% CREAM 0 SANDOZ GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00168-0278-60 4.86000 AMCINONIDE 0.1% CREAM 0 SANDOZ GMGEN 51672-4054-01 1.29999 AMCINONIDE 0.1% CREAM 0 TARO PHARM USA GMGEN 51672-4054-02 0.97200 AMCINONIDE 0.1% CREAM 0 TARO PHARM USA GMGEN 51672-4054-03 0.83124 AMCINONIDE 0.1% CREAM 0 TARO PHARM USA GMBND 00168-0280-60 4.50592 AMCINONIDE 0.1% LOTION 0 SANDOZ MLBND 00168-0279-60 0.94450 5.37840 AMCINONIDE 0.1% OINTMENT 0 SANDOZ GMBND 00173-0561-00 5.72429 33.21291 AMERGE 1 MG TABLET G GLAXOSMITHKLINE EABND 00173-0562-00 4.76000 33.21291 AMERGE 2.5 MG TABLET G GLAXOSMITHKLINE EAGEX 52544-0228-29 2.21332 AMETHIA LO TABLET 0 ACTAVIS PHARMA, EAGEX 52544-0268-29 2.21332 AMETHIA 0.15-0.03-0.01 MG TAB 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 52544-0295-28 1.66320 1.76078 AMETHYST 90-20 MCG TABLET 0 ACTAVIS PHARMA, EABEX 52544-0295-31 1.66320 1.76078 AMETHYST 90-20 MCG TABLET 0 ACTAVIS PHARMA, EAGEN 55390-0226-04 3.03750 AMIKACIN SULF 1 GRAM/4 ML VIAL 0 BEDFORD LABS MLGEN 55390-0226-02 3.01500 AMIKACIN SULFATE 500 MG/2 ML 0 BEDFORD LABS MLGEN 00703-9040-03 3.67650 AMIKACIN 1,000 MG/4 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-9032-03 3.28300 AMIKACIN 500 MG/2 ML 0 TEVA PARENTERAL MLGEN 00574-0292-01 0.68189 AMILORIDE HCL 5 MG TABLET 0 PADDOCK LABS. EAGEN 49884-0117-01 0.68189 AMILORIDE HCL 5 MG TABLET 0 PAR PHARM. EAGEN 49884-0117-10 0.68189 AMILORIDE HCL 5 MG TABLET 0 PAR PHARM. EAGEN 64980-0151-01 0.68189 AMILORIDE HCL 5 MG TABLET 0 RISING PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-0577-01 0.06750 AMILORIDE HCL-HCTZ 5-50 MG TAB 0 MYLAN EAGUL 00378-0577-05 0.06750 AMILORIDE HCL-HCTZ 5-50 MG TAB 0 MYLAN EAGUL 00555-0483-02 0.06750 AMILORIDE HCL-HCTZ 5-50 MG TAB 0 BARR EAGUL 00555-0483-05 0.06750 AMILORIDE HCL-HCTZ 5-50 MG TAB 0 BARR EABND 61748-0046-01 18.61939 AMINOCAPROIC ACID 1,000 MG TAB 0 VERSA 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