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

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