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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 136LIST 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 00093-0892-01 0.39230 ETODOLAC 400 MG TABLET 0 TEVA USA EAGUL 00185-0140-01 0.39230 ETODOLAC 400 MG TABLET 0 SANDOZ EAGUL 00185-0140-10 0.39230 ETODOLAC 400 MG TABLET 0 SANDOZ EAGEN 49158-0507-10 0.17377 ETODOLAC 400 MG TABLET 0 TARO PHARM USA EAGUL 51672-4018-01 0.39230 ETODOLAC 400 MG TABLET 0 TARO PHARM USA EAGUL 60505-0041-01 0.39230 ETODOLAC 400 MG TABLET 0 APOTEX CORP EAGUL 00093-1893-01 0.75000 ETODOLAC 500 MG TABLET 0 TEVA USA EAGUL 00185-0139-01 0.75000 ETODOLAC 500 MG TABLET 0 SANDOZ EAGUL 00185-0139-05 0.75000 ETODOLAC 500 MG TABLET 0 SANDOZ EAGEN 49158-0508-10 0.40305 ETODOLAC 500 MG TABLET 0 TARO PHARM USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-4036-01 0.75000 ETODOLAC 500 MG TABLET 0 TARO PHARM USA EAGUL 60505-0102-01 0.75000 ETODOLAC 500 MG TABLET 0 APOTEX CORP EABND 00015-3404-20 132.42650 ETOPOPHOS 100 MG VIAL 0 BMS ONCO/IMMUN EAGEN 55390-0293-01 1.58400 ETOPOSIDE 1,000 MG/50 ML VIAL 0 BEDFORD LABS MLGEN 63323-0104-50 2.23890 ETOPOSIDE 1,000 MG/50 ML VIAL 0 APP PHARMACEUTI MLGEN 16729-0114-31 1.70550 ETOPOSIDE 100 MG/5 ML VIAL 0 ACCORD HEALTHCA MLGEN 55390-0291-01 1.49400 ETOPOSIDE 100 MG/5 ML VIAL 0 BEDFORD LABS MLGEN 55390-0491-01 1.49400 ETOPOSIDE 100 MG/5 ML VIAL 0 BEDFORD/NOVAPLU MLGEN 63323-0104-05 2.23920 ETOPOSIDE 100 MG/5 ML VIAL 0 APP PHARMACEUTI MLBND 00378-3266-94 58.81338 ETOPOSIDE 50 MG CAPSULE 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55390-0292-01 1.58400 ETOPOSIDE 500 MG/25 ML VIAL 0 BEDFORD LABS MLGEN 63323-0104-25 2.23890 ETOPOSIDE 500 MG/25 ML VIAL 0 APP PHARMACEUTI MLBND 64011-0215-41 11.16913 EVAMIST 1.53 MG/SPRAY 0 THER-RX MLBND 00002-4165-02 6.57360 EVISTA 60 MG TABLET 0 ELI LILLY & CO. EABND 00002-4165-07 6.57360 EVISTA 60 MG TABLET 0 ELI LILLY & CO. EABND 00002-4165-30 6.57360 EVISTA 60 MG TABLET 0 ELI LILLY & CO. EABND 00145-0061-00 4.25574 EVOCLIN 1% FOAM G PRESTIUM PHARMA GMBND 00145-0061-50 5.56100 EVOCLIN 1% FOAM G PRESTIUM PHARMA GMBND 63395-0201-13 2.37510 3.81468 EVOXAC 30 MG CAPSULE 0 DAIICHI SANKYO, EABND 10631-0101-15 3.43343 EXELDERM 1% CREAM G RANBAXY LABORAT GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 10631-0101-30 4.53041 EXELDERM 1% CREAM G RANBAXY LABORAT GMBND 10631-0101-60 3.75228 EXELDERM 1% CREAM G RANBAXY LABORAT GMBND 10631-0100-04 4.53097 EXELDERM 1% SOLUTION G RANBAXY LABORAT MLBND 10631-0100-30 4.53069 EXELDERM 1% SOLUTION G RANBAXY LABORAT MLBND 00078-0323-44 2.04166 5.19469 EXELON 1.5 MG CAPSULE G NOVARTIS EABND 00078-0503-15 10.33018 EXELON 13.3 MG/24HR PATCH 0 NOVARTIS EABND 00078-0339-31 3.86607 EXELON 2 MG/ML ORAL SOLUTION 0 NOVARTIS MLBND 00078-0324-44 1.95740 5.19469 EXELON 3 MG CAPSULE G NOVARTIS EABND 00078-0325-44 2.06618 5.19469 EXELON 4.5 MG CAPSULE G NOVARTIS EABND 00078-0501-15 10.33018 EXELON 4.6 MG/24HR PATCH 0 NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0501-61 10.32520 EXELON 4.6 MG/24HR PATCH 0 NOVARTIS EABND 00078-0326-44 2.04160 5.19469 EXELON 6 MG CAPSULE G NOVARTIS EABND 00078-0502-15 10.33018 EXELON 9.5 MG/24HR PATCH 0 NOVARTIS EABND 00078-0502-61 10.32520 EXELON 9.5 MG/24HR PATCH 0 NOVARTIS EAGEN 00054-0080-13 5.23905 EXEMESTANE 25 MG TABLET 0 ROXANE LABS. 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