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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 140LIST 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 51525-0431-01 4.44232 FELBAMATE 600 MG TABLET G WALLACE PHARMAC EAGEX 65162-0735-03 4.48725 FELBAMATE 600 MG TABLET G AMNEAL PHARMACE EAGEX 65162-0735-09 4.48716 FELBAMATE 600 MG TABLET G AMNEAL PHARMACE EAGEX 65162-0735-18 4.48716 FELBAMATE 600 MG TABLET G AMNEAL PHARMACE EAGEX 51525-0442-03 1.94176 FELBAMATE 600 MG/5 ML SUSP G WALLACE PHARMAC MLGEX 51525-0442-08 2.01006 FELBAMATE 600 MG/5 ML SUSP G WALLACE PHARMAC MLGEX 65162-0686-88 2.00503 FELBAMATE 600 MG/5 ML SUSP G AMNEAL PHARMACE MLGEX 65162-0686-90 1.95942 FELBAMATE 600 MG/5 ML SUSP G AMNEAL PHARMACE MLBEX 00037-0430-01 5.85855 5.85855 FELBATOL 400 MG TABLET 0 MEDA PHARMACEUT EABEX 00037-0431-01 6.71411 6.71411 FELBATOL 600 MG TABLET 0 MEDA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00037-0442-17 2.93482 FELBATOL 600 MG/5 ML SUSP 0 MEDA PHARMACEUT MLBEX 00037-0442-67 3.03808 FELBATOL 600 MG/5 ML SUSP 0 MEDA PHARMACEUT MLBUL 00069-3220-66 0.08910 3.92631 FELDENE 10 MG CAPSULE G PFIZER US PHARM EABUL 00069-3230-66 0.11310 6.71909 FELDENE 20 MG CAPSULE G PFIZER US PHARM EAGEN 00378-5013-01 0.77004 FELODIPINE ER 10 MG TABLET 0 MYLAN EAGEN 00378-5013-05 0.77004 FELODIPINE ER 10 MG TABLET 0 MYLAN EAGEN 00603-3583-21 0.77004 FELODIPINE ER 10 MG TABLET 0 QUALITEST EAGEN 00603-3583-28 0.77004 FELODIPINE ER 10 MG TABLET 0 QUALITEST EAGEN 13668-0134-01 0.77004 FELODIPINE ER 10 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0134-05 0.77004 FELODIPINE ER 10 MG TABLET 0 TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13668-0134-10 0.77004 FELODIPINE ER 10 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0134-90 0.77004 FELODIPINE ER 10 MG TABLET 0 TORRENT PHARMAC EAGEN 51079-0468-01 0.77004 FELODIPINE ER 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0468-20 0.77004 FELODIPINE ER 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0370-01 0.77004 FELODIPINE ER 10 MG TABLET 0 MUTUAL PHARM CO EAGEN 63304-0437-01 0.77004 FELODIPINE ER 10 MG TABLET 0 RANBAXY PHARMAC EAGEN 65862-0675-01 0.77004 FELODIPINE ER 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0675-99 0.77004 FELODIPINE ER 10 MG TABLET 0 AUROBINDO PHARM EAGEN 68462-0235-01 0.77004 FELODIPINE ER 10 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-5011-01 0.56430 FELODIPINE ER 2.5 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-5011-05 0.56430 FELODIPINE ER 2.5 MG TABLET 0 MYLAN EAGEN 00603-3581-21 0.56430 FELODIPINE ER 2.5 MG TABLET 0 QUALITEST EAGEN 00603-3581-28 0.56430 FELODIPINE ER 2.5 MG TABLET 0 QUALITEST EAGEN 13668-0132-01 0.56430 FELODIPINE ER 2.5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0132-05 0.56430 FELODIPINE ER 2.5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0132-10 0.56430 FELODIPINE ER 2.5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0132-90 0.56430 FELODIPINE ER 2.5 MG TABLET 0 TORRENT PHARMAC EAGEN 53489-0368-01 0.56430 FELODIPINE ER 2.5 MG TABLET 0 MUTUAL PHARM CO EAGEN 63304-0435-01 0.56430 FELODIPINE ER 2.5 MG TABLET 0 RANBAXY PHARMAC EAGEN 65862-0673-01 0.56430 FELODIPINE ER 2.5 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0673-99 0.56430 FELODIPINE ER 2.5 MG TABLET 0 AUROBINDO PHARM EAGEN 68462-0233-01 0.56430 FELODIPINE ER 2.5 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-5012-01 0.54824 FELODIPINE ER 5 MG TABLET 0 MYLAN EAGEN 00378-5012-05 0.54824 FELODIPINE ER 5 MG TABLET 0 MYLAN EAGEN 00603-3582-21 0.54824 FELODIPINE ER 5 MG TABLET 0 QUALITEST 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: 141LIST 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 00603-3582-28 0.54824 FELODIPINE ER 5 MG TABLET 0 QUALITEST EAGEN 13668-0133-01 0.54824 FELODIPINE ER 5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0133-05 0.54824 FELODIPINE ER 5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0133-10 0.54824 FELODIPINE ER 5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0133-90 0.54824 FELODIPINE ER 5 MG TABLET 0 TORRENT PHARMAC EAGEN 51079-0467-01 0.54824 FELODIPINE ER 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0467-20 0.54824 FELODIPINE ER 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0369-01 0.54824 FELODIPINE ER 5 MG TABLET 0 MUTUAL PHARM CO EAGEN 63304-0436-01 0.54824 FELODIPINE ER 5 MG TABLET 0 RANBAXY PHARMAC EAGEN 65862-0674-01 0.54824 FELODIPINE ER 5 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0674-99 0.54824 FELODIPINE ER 5 MG TABLET 0 AUROBINDO PHARM EAGEN 68462-0234-01 0.54824 FELODIPINE ER 5 MG TABLET 0 GLENMARK PHARMA EABND 00078-0249-15 0.15300 20.19943 FEMARA 2.5 MG TABLET 0 NOVARTIS EABEX 00430-0482-14 3.18720 FEMCON FE TABLET 0 ACTAVIS PHARMA, EABND 00430-0145-14 2.87844 FEMHRT 0.5 MG-2.5 MCG TABLET 0 ACTAVIS PHARMA, EABND 00430-6201-40 227.76860 FEMRING 0.05 MG VAGINAL RING 0 ACTAVIS PHARMA, EABND 00430-6202-40 242.71690 FEMRING 0.10 MG VAGINAL RING 0 ACTAVIS PHARMA, EAGEN 00378-6089-77 5.18900 FENOFIBRATE 130 MG CAPSULE G MYLAN EAGEN 00378-6089-93 5.18900 FENOFIBRATE 130 MG CAPSULE G MYLAN EAGEN 60505-3121-03 5.19474 FENOFIBRATE 130 MG CAPSULE G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-3121-09 5.19474 FENOFIBRATE 130 MG CAPSULE G APOTEX CORP EAGEN 68180-0131-06 5.19474 FENOFIBRATE 130 MG CAPSULE G LUPIN PHARMACEU EAGEN 00115-0522-01 1.34388 FENOFIBRATE 134 MG CAPSULE G GLOBAL PHARM EAGEN 00115-0522-02 1.34388 FENOFIBRATE 134 MG CAPSULE G GLOBAL PHARM EAGEN 00378-8629-05 1.34388 FENOFIBRATE 134 MG CAPSULE G MYLAN EAGEN 00378-8629-77 1.34388 FENOFIBRATE 134 MG CAPSULE G MYLAN EAGEN 00093-2060-98 4.29650 FENOFIBRATE 145 MG TABLET G TEVA USA EAGEN 00378-3066-77 4.29650 FENOFIBRATE 145 MG TABLET G MYLAN EAGEN 51079-0608-20 3.86250 FENOFIBRATE 145 MG TABLET G MYLAN INSTITUTI EAGEN 68084-0636-25 3.86250 FENOFIBRATE 145 MG TABLET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0361-02 4.29648 FENOFIBRATE 145 MG TABLET G LUPIN PHARMACEU EAGEN 68180-0361-09 4.29650 FENOFIBRATE 145 MG TABLET G LUPIN PHARMACEU EAGEN 68682-0528-01 4.10000 FENOFIBRATE 145 MG TABLET G PERRIGO CO. EAGEN 00115-5522-02 1.34973 FENOFIBRATE 160 MG TABLET G GLOBAL PHARM EAGEN 00115-5522-10 1.34973 FENOFIBRATE 160 MG TABLET G GLOBAL PHARM EAGEN 00378-7101-77 1.34973 FENOFIBRATE 160 MG TABLET G MYLAN EAGEN 63304-0901-90 1.34973 FENOFIBRATE 160 MG TABLET G RANBAXY PHARMAC EAGEN 68084-0328-11 1.34973 FENOFIBRATE 160 MG TABLET G AHP EAGEN 68084-0328-21 1.34973 FENOFIBRATE 160 MG TABLET G AHP EAGEN 00115-0533-01 2.17020 FENOFIBRATE 200 MG CAPSULE G GLOBAL PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00115-0533-02 2.17020 FENOFIBRATE 200 MG CAPSULE G GLOBAL PHARM EAGEN 00378-8630-05 2.17020 FENOFIBRATE 200 MG CAPSULE G MYLAN EAGEN 00378-8630-77 2.17020 FENOFIBRATE 200 MG CAPSULE G MYLAN EAGEN 68084-0329-21 2.17020 FENOFIBRATE 200 MG CAPSULE G AHP EAGEN 00378-6088-93 1.76250 FENOFIBRATE 43 MG CAPSULE G MYLAN 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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