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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 142LIST 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 60505-3120-03 1.76450 FENOFIBRATE 43 MG CAPSULE G APOTEX CORP EAGEN 68180-0130-06 1.76450 FENOFIBRATE 43 MG CAPSULE G LUPIN PHARMACEU EAGEN 00093-2061-98 1.43217 FENOFIBRATE 48 MG TABLET G TEVA USA EAGEN 51079-0599-20 1.43227 FENOFIBRATE 48 MG TABLET G MYLAN INSTITUTI EAGEN 68084-0635-21 1.43225 FENOFIBRATE 48 MG TABLET G AHP EAGEN 68180-0360-09 1.43217 FENOFIBRATE 48 MG TABLET G LUPIN PHARMACEU EAGEN 68682-0525-01 1.35000 FENOFIBRATE 48 MG TABLET G PERRIGO CO. EAGEN 00115-5511-10 0.59408 FENOFIBRATE 54 MG TABLET G GLOBAL PHARM EAGEN 00378-7100-77 0.59408 FENOFIBRATE 54 MG TABLET G MYLAN EAGEN 63304-0900-90 0.59408 FENOFIBRATE 54 MG TABLET G RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00115-0511-01 0.72470 FENOFIBRATE 67 MG CAPSULE G GLOBAL PHARM EAGEN 00378-8628-77 0.72470 FENOFIBRATE 67 MG CAPSULE G MYLAN EAGEN 00115-1460-10 4.00133 FENOFIBRIC ACID DR 135 MG CAP G GLOBAL PHARM EAGEN 00378-2590-05 4.49643 FENOFIBRIC ACID DR 135 MG CAP G MYLAN EAGEN 00378-2590-77 4.49641 FENOFIBRIC ACID DR 135 MG CAP G MYLAN EAGEN 10370-0210-09 4.50117 FENOFIBRIC ACID DR 135 MG CAP G PAR PHARM. EAGEN 51079-0196-03 4.49649 FENOFIBRIC ACID DR 135 MG CAP G MYLAN INSTITUTI EAGEN 68180-0129-09 4.50133 FENOFIBRIC ACID DR 135 MG CAP G LUPIN PHARMACEU EAGEN 00115-1459-10 1.42441 FENOFIBRIC ACID DR 45 MG CAP G GLOBAL PHARM EAGEN 00378-2589-77 1.49874 FENOFIBRIC ACID DR 45 MG CAP G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10370-0209-09 1.50033 FENOFIBRIC ACID DR 45 MG CAP G PAR PHARM. EAGEN 51079-0195-03 1.49874 FENOFIBRIC ACID DR 45 MG CAP G MYLAN INSTITUTI EAGEN 68180-0128-09 1.50042 FENOFIBRIC ACID DR 45 MG CAP G LUPIN PHARMACEU EAGEN 53489-0678-07 2.25249 FENOFIBRIC ACID 105 MG TABLET G MUTUAL PHARM CO EAGEN 53489-0678-90 2.25241 FENOFIBRIC ACID 105 MG TABLET G MUTUAL PHARM CO EAGEN 53489-0677-07 0.75075 FENOFIBRIC ACID 35 MG TABLET G MUTUAL PHARM CO EABND 00378-0471-01 1.82110 FENOPROFEN 600 MG TABLET G MYLAN EABND 52609-0006-01 37.41474 FERRIPROX 500 MG TABLET 0 APOPHARMA USA I EABND 00024-2791-50 6.33456 FERRLECIT 62.5 MG/5 ML AMPUL 0 SANOFI-AVENTIS MLBND 00024-2792-10 5.15220 6.33456 FERRLECIT 62.5 MG/5 ML VIAL 0 SANOFI-AVENTIS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00456-2212-30 6.72300 FETZIMA ER 120 MG CAPSULE G FOREST PHARMACE EABEX 00456-2220-30 6.72300 FETZIMA ER 20 MG CAPSULE G FOREST PHARMACE EABEX 00456-2240-30 6.72300 FETZIMA ER 40 MG CAPSULE G FOREST PHARMACE EABEX 00456-2280-30 6.72300 FETZIMA ER 80 MG CAPSULE G FOREST PHARMACE EABEX 00456-2202-28 6.72300 FETZIMA 20-40 MG TITRATION PAK G FOREST PHARMACE EAGEN 59630-0950-10 3.07660 FEXMID 7.5 MG TABLET G SHIONOGI PHARMA EABND 13310-0102-07 2.40270 3.41849 FIBRICOR 105 MG TABLET G AR SCIENTIFIC EABND 13310-0102-90 2.40270 3.41849 FIBRICOR 105 MG TABLET G AR SCIENTIFIC EABND 13310-0101-07 0.80080 1.13931 FIBRICOR 35 MG TABLET G AR SCIENTIFIC EABND 10922-0825-02 3.85418 FINACEA 15% GEL 0 INTENDIS INC. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50419-0825-02 4.35517 FINACEA 15% GEL 0 BAYER,PHARM DIV GMGEN 38779-2410-04 317.06250 FINASTERIDE POWDER 0 MEDISCA INC. GMGEN 00093-7355-05 0.18000 FINASTERIDE 5 MG TABLET 0 TEVA USA EAGEN 00093-7355-56 0.18000 FINASTERIDE 5 MG TABLET 0 TEVA USA EAGEN 00093-7355-98 0.18000 FINASTERIDE 5 MG TABLET 0 TEVA USA 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: 143LIST 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 00378-3151-77 0.18000 FINASTERIDE 5 MG TABLET 0 MYLAN EAGEN 00378-3151-93 0.18000 FINASTERIDE 5 MG TABLET 0 MYLAN EAGEN 00603-3633-02 0.18000 FINASTERIDE 5 MG TABLET 0 QUALITEST EAGEN 00603-3633-16 0.18000 FINASTERIDE 5 MG TABLET 0 QUALITEST EAGEN 00603-3633-21 0.18000 FINASTERIDE 5 MG TABLET 0 QUALITEST EAGEN 00603-3633-28 0.18000 FINASTERIDE 5 MG TABLET 0 QUALITEST EAGEN 16714-0522-01 0.18000 FINASTERIDE 5 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0522-03 0.18000 FINASTERIDE 5 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0522-04 0.18000 FINASTERIDE 5 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0522-05 0.18000 FINASTERIDE 5 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0522-10 0.18000 FINASTERIDE 5 MG TABLET 0 NORTHSTAR RX LL EAGEN 16729-0090-01 0.18000 FINASTERIDE 5 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0090-10 0.18000 FINASTERIDE 5 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0090-15 0.18000 FINASTERIDE 5 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0090-16 0.18000 FINASTERIDE 5 MG TABLET 0 ACCORD HEALTHCA EAGEN 31722-0525-01 0.18000 FINASTERIDE 5 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0525-10 0.18000 FINASTERIDE 5 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0525-30 0.18000 FINASTERIDE 5 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0525-90 0.18000 FINASTERIDE 5 MG TABLET 0 CAMBER PHARMACE EAGEN 43598-0303-30 0.18000 FINASTERIDE 5 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 43598-0303-90 0.18000 FINASTERIDE 5 MG TABLET 0 DR.REDDY'S LAB EAGEN 45963-0500-02 0.18000 FINASTERIDE 5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 45963-0500-08 0.18000 FINASTERIDE 5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 45963-0500-30 0.18000 FINASTERIDE 5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 47335-0715-13 0.18000 FINASTERIDE 5 MG TABLET 0 SUN PHARMA GLOB EAGEN 47335-0715-81 0.18000 FINASTERIDE 5 MG TABLET 0 SUN PHARMA GLOB EAGEN 47335-0715-83 0.18000 FINASTERIDE 5 MG TABLET 0 SUN PHARMA GLOB EAGEN 50742-0123-30 0.18000 FINASTERIDE 5 MG TABLET 0 INGENUS PHARMAC EAGEN 51079-0520-01 0.18000 FINASTERIDE 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0520-20 0.18000 FINASTERIDE 5 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0520-30 0.18000 FINASTERIDE 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0520-56 0.18000 FINASTERIDE 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 55111-0172-30 0.18000 FINASTERIDE 5 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0172-90 0.18000 FINASTERIDE 5 MG TABLET 0 DR.REDDY'S LAB EAGEN 58517-0200-30 0.18000 FINASTERIDE 5 MG TABLET 0 NEW HORIZON RX EAGEN 59762-0850-02 0.18000 FINASTERIDE 5 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-0850-03 0.18000 FINASTERIDE 5 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-0850-07 0.18000 FINASTERIDE 5 MG TABLET 0 GREENSTONE LLC. EAGEN 65862-0149-01 0.18000 FINASTERIDE 5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0149-05 0.18000 FINASTERIDE 5 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0149-30 0.18000 FINASTERIDE 5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0149-90 0.18000 FINASTERIDE 5 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0399-01 0.18000 FINASTERIDE 5 MG TABLET 0 AHP EAGEN 68084-0399-11 0.18000 FINASTERIDE 5 MG TABLET 0 AHP EAGEN 68645-0446-70 0.18000 FINASTERIDE 5 MG TABLET 0 LEGACY 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93: NEW YORK STATE DEPARTMENT OF HEALTH
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?