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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 134LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13668-0135-01 0.11430 ESCITALOPRAM 5 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0135-05 0.11430 ESCITALOPRAM 5 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0135-10 0.11430 ESCITALOPRAM 5 MG TABLET 0 TORRENT PHARMAC EAGEX 16729-0168-01 0.11430 ESCITALOPRAM 5 MG TABLET 0 ACCORD HEALTHCA EAGEX 16729-0168-17 0.11430 ESCITALOPRAM 5 MG TABLET 0 ACCORD HEALTHCA EAGEX 31722-0249-90 0.11430 ESCITALOPRAM 5 MG TABLET 0 CAMBER PHARMACE EAGEX 33342-0036-11 0.11430 ESCITALOPRAM 5 MG TABLET 0 MACLEODS PHARMA EAGEX 59746-0279-01 0.11430 ESCITALOPRAM 5 MG TABLET 0 CADISTA PHARMAC EAGEX 60505-2780-01 0.11430 ESCITALOPRAM 5 MG TABLET 0 APOTEX CORP EAGEX 60505-2780-08 0.11430 ESCITALOPRAM 5 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0373-01 0.11430 ESCITALOPRAM 5 MG TABLET 0 AUROBINDO PHARM EAGEX 65862-0373-05 0.11430 ESCITALOPRAM 5 MG TABLET 0 AUROBINDO PHARM EAGEX 68180-0137-01 0.11430 ESCITALOPRAM 5 MG TABLET 0 LUPIN PHARMACEU EAGEX 76282-0249-10 0.11430 ESCITALOPRAM 5 MG TABLET 0 EXELAN PHARMACE EAGEX 76282-0249-30 0.11430 ESCITALOPRAM 5 MG TABLET 0 EXELAN PHARMACE EAGEX 76282-0249-90 0.11430 ESCITALOPRAM 5 MG TABLET 0 EXELAN PHARMACE EAGEN 00535-0012-01 0.48480 ESGIC CAPSULE 0 FOREST PHARMACE EAGEN 00535-0011-01 0.06030 ESGIC 50-325-40 MG TABLET 0 FOREST PHARMACE EABND 00430-3754-14 3.55591 ESTRACE 0.01% CREAM 0 ACTAVIS PHARMA, GMGEN 00430-0720-24 0.13896 ESTRACE 0.5 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00430-0721-24 0.08748 ESTRACE 1 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00430-0722-24 0.12137 ESTRACE 2 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00378-3349-99 11.21110 ESTRADIOL TDS 0.025 MG/DAY 0 MYLAN EAGEN 00378-3360-99 10.74000 ESTRADIOL TDS 0.0375 MG/DAY 0 MYLAN EAGEN 00378-3350-99 11.37750 ESTRADIOL TDS 0.05 MG/DAY 0 MYLAN EAGEN 00378-3361-99 11.49568 ESTRADIOL TDS 0.06 MG/DAY 0 MYLAN EAGEN 00378-3351-99 11.46550 ESTRADIOL TDS 0.075 MG/DAY 0 MYLAN EAGEN 00378-3352-99 17.36394 ESTRADIOL TDS 0.1 MG/DAY 0 MYLAN EAGEN 00574-0870-05 21.64650 ESTRADIOL VALERATE 20 MG/ML VL 0 PADDOCK LABS. MLGEN 00574-0872-05 35.90700 ESTRADIOL VALERATE 40 MG/ML VL 0 PADDOCK LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 47781-0204-04 11.21110 ESTRADIOL 0.025 MG/DAY PATCH 0 ALVOGEN INC EAGEN 47781-0205-04 10.74000 ESTRADIOL 0.0375 MG/DAY PATCH 0 ALVOGEN INC EAGEN 47781-0206-04 11.37750 ESTRADIOL 0.05 MG/DAY PATCH 0 ALVOGEN INC EAGEN 47781-0207-04 11.49568 ESTRADIOL 0.06 MG/DAY PATCH 0 ALVOGEN INC EAGEN 47781-0208-04 11.46550 ESTRADIOL 0.075 MG/DAY PATCH 0 ALVOGEN INC EAGEN 47781-0209-04 16.57500 ESTRADIOL 0.1 MG/DAY PATCH 0 ALVOGEN INC EAGEN 00378-1452-01 0.13896 ESTRADIOL 0.5 MG TABLET 0 MYLAN EAGEN 00378-1452-05 0.13896 ESTRADIOL 0.5 MG TABLET 0 MYLAN EAGEN 00555-0899-02 0.13896 ESTRADIOL 0.5 MG TABLET 0 BARR EAGEN 00591-0528-01 0.13896 ESTRADIOL 0.5 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-1454-01 0.08748 ESTRADIOL 1 MG TABLET 0 MYLAN EAGEN 00378-1454-05 0.08748 ESTRADIOL 1 MG TABLET 0 MYLAN EAGEN 00555-0886-02 0.08748 ESTRADIOL 1 MG TABLET 0 BARR EAGEN 00555-0886-04 0.08748 ESTRADIOL 1 MG TABLET 0 BARR EAGEN 00591-0487-01 0.08748 ESTRADIOL 1 MG TABLET 0 ACTAVIS PHARMA, 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: 135LIST 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 00591-0487-05 0.08748 ESTRADIOL 1 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00378-1458-01 0.12137 ESTRADIOL 2 MG TABLET 0 MYLAN EAGEN 00378-1458-05 0.12137 ESTRADIOL 2 MG TABLET 0 MYLAN EAGEN 00378-1458-77 0.12137 ESTRADIOL 2 MG TABLET 0 MYLAN EAGEN 00555-0887-02 0.12137 ESTRADIOL 2 MG TABLET 0 BARR EAGEN 00555-0887-04 0.12137 ESTRADIOL 2 MG TABLET 0 BARR EAGEN 00591-0488-01 0.12137 ESTRADIOL 2 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0488-05 0.12137 ESTRADIOL 2 MG TABLET 0 ACTAVIS PHARMA, EAGEN 51991-0623-28 3.33294 ESTRADIOL-NORETH 0.5-0.1 MG TB 0 BRECKENRIDGE EAGEN 51991-0474-28 3.22934 ESTRADIOL-NORETH 1-0.5 MG TAB 0 BRECKENRIDGE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00013-2150-36 222.53960 ESTRING 2 MG VAGINAL RING 0 PHARMACIA/UPJHN EABND 00591-0414-01 0.10040 0.35814 ESTROPIPATE 0.625(0.75 MG) TAB 0 ACTAVIS PHARMA, EABND 00591-0415-01 0.11640 0.51460 ESTROPIPATE 1.25(1.5 MG) TAB 0 ACTAVIS PHARMA, EAGEN 00591-0416-01 0.50064 ESTROPIPATE 2.5(3 MG) TAB 0 ACTAVIS PHARMA, EABEX 00430-0570-45 1.51408 3.65536 ESTROSTEP FE-28 TABLET 0 ACTAVIS PHARMA, EAGEX 54879-0001-00 0.43200 ETHAMBUTOL HCL 100 MG TABLET 0 STI PHARMA, LLC EAGEX 54879-0001-01 0.34192 ETHAMBUTOL HCL 100 MG TABLET 0 STI PHARMA, LLC EAGEX 68180-0280-01 0.44400 ETHAMBUTOL HCL 100 MG TABLET 0 LUPIN PHARMACEU EAGEX 68850-0004-01 0.44377 ETHAMBUTOL HCL 100 MG TABLET 0 G & W LABS. EAGEX 00555-0923-02 1.08070 ETHAMBUTOL HCL 400 MG TABLET 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 54879-0002-00 1.08070 ETHAMBUTOL HCL 400 MG TABLET 0 STI PHARMA, LLC EAGEX 54879-0002-01 1.08070 ETHAMBUTOL HCL 400 MG TABLET 0 STI PHARMA, LLC EAGEX 68084-0280-01 1.08070 ETHAMBUTOL HCL 400 MG TABLET 0 AHP EAGEX 68084-0280-11 1.08070 ETHAMBUTOL HCL 400 MG TABLET 0 AHP EAGEX 68180-0281-01 1.08070 ETHAMBUTOL HCL 400 MG TABLET 0 LUPIN PHARMACEU EABND 00517-8575-10 7.37040 ETHANOL 98% AMPUL 0 AMER. REGENT MLGEX 50111-0901-01 0.93650 ETHOSUXIMIDE 250 MG CAPSULE 0 BARR EAGEX 61748-0025-01 0.93650 ETHOSUXIMIDE 250 MG CAPSULE 0 VERSA PHARMACEU EAGEX 00093-9660-16 0.22000 ETHOSUXIMIDE 250 MG/5 ML SOLN 0 TEVA USA MLGEX 61748-0024-16 0.30919 ETHOSUXIMIDE 250 MG/5 ML SOLN 0 VERSA PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00378-3286-91 3.58628 ETIDRONATE DISODIUM 200 MG TAB 0 MYLAN EABND 00378-3288-91 7.17092 ETIDRONATE DISODIUM 400 MG TAB 0 MYLAN EAGEN 00093-1122-01 2.17597 ETODOLAC ER 400 MG TABLET G TEVA USA EAGEN 51672-4051-01 2.17590 ETODOLAC ER 400 MG TABLET G TARO PHARM USA EAGEN 51672-4051-04 2.21949 ETODOLAC ER 400 MG TABLET G TARO PHARM USA EAGEN 00093-7172-01 2.31150 ETODOLAC ER 500 MG TABLET G TEVA USA EAGEN 51672-4052-01 2.31157 ETODOLAC ER 500 MG TABLET G TARO PHARM USA EAGEN 51672-4052-04 2.35775 ETODOLAC ER 500 MG TABLET G TARO PHARM USA EAGEN 00093-1118-01 2.45557 ETODOLAC ER 600 MG TABLET G TEVA USA EAGEN 51672-4053-01 2.45557 ETODOLAC ER 600 MG TABLET G TARO PHARM USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-4053-04 2.50475 ETODOLAC ER 600 MG TABLET G TARO PHARM USA EAGUL 51672-4016-01 0.58500 ETODOLAC 200 MG CAPSULE 0 TARO PHARM USA EAGUL 60505-0039-01 0.58500 ETODOLAC 200 MG CAPSULE 0 APOTEX CORP EAGEN 51672-4017-01 1.21260 ETODOLAC 300 MG CAPSULE 0 TARO PHARM USA EAGEN 60505-0040-01 1.21260 ETODOLAC 300 MG CAPSULE 0 APOTEX CORP 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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