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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 138LIST 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 00591-3273-30 1.86530 FAMCICLOVIR 500 MG TABLET G ACTAVIS PHARMA, EAGEN 00781-5622-31 1.86530 FAMCICLOVIR 500 MG TABLET G SANDOZ EAGEN 16714-0305-01 1.86530 FAMCICLOVIR 500 MG TABLET G NORTHSTAR RX LL EAGEN 59762-2703-01 1.86530 FAMCICLOVIR 500 MG TABLET G GREENSTONE LLC. EAGEN 60505-3247-03 1.86530 FAMCICLOVIR 500 MG TABLET G APOTEX CORP EAGEN 65862-0467-30 1.86530 FAMCICLOVIR 500 MG TABLET G AUROBINDO PHARM EAGEN 63323-0738-09 0.40500 FAMOTIDINE 10 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0738-20 0.40500 FAMOTIDINE 10 MG/ML VIAL 0 APP PHARMACEUTI MLBND 00338-5197-41 0.07771 FAMOTIDINE 20 MG PIGGYBACK 0 BAXTER HEALTHCA MLGEN 00172-5728-60 0.07620 FAMOTIDINE 20 MG TABLET 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00172-5728-70 0.07620 FAMOTIDINE 20 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-5728-80 0.07620 FAMOTIDINE 20 MG TABLET 0 IVAX PHARMACEUT EAGEN 00378-3020-01 0.07620 FAMOTIDINE 20 MG TABLET 0 MYLAN EAGEN 00378-3020-05 0.07620 FAMOTIDINE 20 MG TABLET 0 MYLAN EAGEN 16714-0361-01 0.07620 FAMOTIDINE 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0361-04 0.07620 FAMOTIDINE 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0361-05 0.07620 FAMOTIDINE 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0361-06 0.07620 FAMOTIDINE 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 51079-0966-17 0.07620 FAMOTIDINE 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 55111-0119-01 0.07620 FAMOTIDINE 20 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0119-10 0.07620 FAMOTIDINE 20 MG TABLET 0 DR.REDDY'S LAB EAGEN 61442-0121-01 0.07620 FAMOTIDINE 20 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0121-10 0.07620 FAMOTIDINE 20 MG TABLET 0 CARLSBAD TECH EAGEN 64679-0936-02 0.07620 FAMOTIDINE 20 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0936-03 0.07620 FAMOTIDINE 20 MG TABLET 0 WOCKHARDT USA L EAGEN 68084-0172-01 0.07620 FAMOTIDINE 20 MG TABLET 0 AHP EAGEN 68084-0172-11 0.07620 FAMOTIDINE 20 MG TABLET 0 AHP EAGEN 68645-0140-59 0.07620 FAMOTIDINE 20 MG TABLET 0 LEGACY PHARMACE EAGEN 10019-0045-02 0.33195 FAMOTIDINE 20 MG/2 ML VIAL 0 WEST-WARD,INC. MLGEN 55390-0029-10 0.47700 FAMOTIDINE 20 MG/2 ML VIAL 0 BEDFORD LABS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0739-12 0.40500 FAMOTIDINE 20 MG/2 ML VIAL 0 APP PHARMACEUTI MLGEN 00641-6021-01 0.25875 FAMOTIDINE 200 MG/20 ML VIAL 0 WEST-WARD,INC. MLGEN 00641-6021-10 0.25875 FAMOTIDINE 200 MG/20 ML VIAL 0 WEST-WARD,INC. MLGEN 55390-0027-01 0.43030 FAMOTIDINE 200 MG/20 ML VIAL 0 BEDFORD LABS MLGEN 00172-5729-60 0.07425 FAMOTIDINE 40 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-5729-70 0.07425 FAMOTIDINE 40 MG TABLET 0 IVAX PHARMACEUT EAGEN 00378-3040-01 0.07425 FAMOTIDINE 40 MG TABLET 0 MYLAN EAGEN 16714-0362-01 0.07425 FAMOTIDINE 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0362-04 0.07425 FAMOTIDINE 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0362-05 0.07425 FAMOTIDINE 40 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0362-06 0.07425 FAMOTIDINE 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 55111-0120-01 0.07425 FAMOTIDINE 40 MG TABLET 0 DR.REDDY'S LAB EAGEN 61442-0122-01 0.07425 FAMOTIDINE 40 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0122-10 0.07425 FAMOTIDINE 40 MG TABLET 0 CARLSBAD TECH EAGEN 64679-0937-01 0.07425 FAMOTIDINE 40 MG TABLET 0 WOCKHARDT USA L 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: 139LIST 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 64679-0937-02 0.07425 FAMOTIDINE 40 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0937-03 0.07425 FAMOTIDINE 40 MG TABLET 0 WOCKHARDT USA L EAGEN 68645-0141-54 0.07425 FAMOTIDINE 40 MG TABLET 0 LEGACY PHARMACE EAGEN 00641-6023-01 0.43030 FAMOTIDINE 40 MG/4 ML VIAL 0 WEST-WARD,INC. MLGEN 00641-6023-25 0.43030 FAMOTIDINE 40 MG/4 ML VIAL 0 WEST-WARD,INC. MLGEN 55390-0028-10 0.43030 FAMOTIDINE 40 MG/4 ML VIAL 0 BEDFORD LABS MLGEN 00574-0147-04 1.34150 FAMOTIDINE 40 MG/5 ML SUSP 0 PADDOCK LABS. MLGEN 68180-0150-01 1.34150 FAMOTIDINE 40 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68382-0444-05 1.34150 FAMOTIDINE 40 MG/5 ML SUSP 0 ZYDUS PHARMACEU MLGEN 55390-0026-01 0.43030 FAMOTIDINE 500 MG/50 ML VIAL 0 BEDFORD LABS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0366-15 2.98390 7.82219 FAMVIR 125 MG TABLET G NOVARTIS EABND 00078-0367-15 1.22175 8.50473 FAMVIR 250 MG TABLET G NOVARTIS EABND 00078-0368-15 1.86530 17.07974 FAMVIR 500 MG TABLET G NOVARTIS EABEX 00078-0602-08 12.71352 FANAPT TITRATION PACK G NOVARTIS EABEX 00078-0595-20 12.71338 FANAPT 1 MG TABLET G NOVARTIS EABEX 00078-0600-20 12.71338 FANAPT 10 MG TABLET G NOVARTIS EABEX 00078-0601-20 12.71338 FANAPT 12 MG TABLET G NOVARTIS EABEX 00078-0596-20 12.71338 FANAPT 2 MG TABLET G NOVARTIS EABEX 00078-0597-20 12.71338 FANAPT 4 MG TABLET G NOVARTIS EABEX 00078-0598-20 12.71338 FANAPT 6 MG TABLET G NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00078-0599-20 12.71338 FANAPT 8 MG TABLET G NOVARTIS EABND 11399-0005-30 25.64700 FARESTON 60 MG TABLET 0 PROSTRAKAN INC. EABND 00003-1428-11 9.60144 FARXIGA 10 MG TABLET G BMS PRIMARYCARE EABND 00003-1427-11 9.60144 FARXIGA 5 MG TABLET G BMS PRIMARYCARE EABEX 18860-0104-01 10.83737 FAZACLO 100 MG ODT G JAZZ PHARMACEUT EABEX 18860-0104-10 10.83706 FAZACLO 100 MG ODT G JAZZ PHARMACEUT EABEX 18860-0101-10 2.36242 FAZACLO 12.5 MG ODT G JAZZ PHARMACEUT EABEX 18860-0105-01 12.86915 FAZACLO 150 MG ODT G JAZZ PHARMACEUT EABEX 18860-0105-10 12.86898 FAZACLO 150 MG ODT G JAZZ PHARMACEUT EABEX 18860-0106-01 17.15852 FAZACLO 200 MG ODT G JAZZ PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 18860-0106-10 17.15867 FAZACLO 200 MG ODT G JAZZ PHARMACEUT EABEX 18860-0102-01 3.17907 FAZACLO 25 MG ODT G JAZZ PHARMACEUT EABEX 18860-0102-10 3.17856 FAZACLO 25 MG ODT G JAZZ PHARMACEUT EAGEN 64376-0802-01 0.18480 FE C PLUS TABLET 0 BOCA PHARMACAL EABND 64193-0424-02 1.58500 FEIBA NF 1,000 UNIT (NOMINAL) 0 BAXTER BIOSCIENBND 64193-0225-02 1.58500 FEIBA NF 1,750-3,250 UNIT VIAL 0 BAXTER BIOSCIENBND 64193-0425-02 1.58500 FEIBA NF 2,500 UNIT (NOMINAL) 0 BAXTER BIOSCIENBND 64193-0223-02 1.58500 FEIBA NF 400-650 UNIT VIAL 0 BAXTER BIOSCIENBND 64193-0423-02 1.58500 FEIBA NF 500 UNIT (NOMINAL) 0 BAXTER BIOSCIENBND 64193-0224-02 1.58500 FEIBA NF 651-1,200 UNIT VIAL 0 BAXTER BIOSCIEN--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 64193-0222-03 1.52500 FEIBA VH IMMUNO 400-650 UNITS 0 BAXTER BIOSCIENBND 64193-0222-04 1.52500 FEIBA VH IMMUNO 651-1,200 UNIT 0 BAXTER BIOSCIENGEX 51525-0430-01 3.87615 FELBAMATE 400 MG TABLET G WALLACE PHARMAC EAGEX 65162-0734-03 3.91524 FELBAMATE 400 MG TABLET G AMNEAL PHARMACE EAGEX 65162-0734-09 3.91524 FELBAMATE 400 MG TABLET G AMNEAL PHARMACE 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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