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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 144LIST 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 76282-0412-05 0.18000 FINASTERIDE 5 MG TABLET 0 EXELAN PHARMACE EAGEN 76282-0412-30 0.18000 FINASTERIDE 5 MG TABLET 0 EXELAN PHARMACE EAGEN 76282-0412-90 0.18000 FINASTERIDE 5 MG TABLET 0 EXELAN PHARMACE EABND 52544-0080-01 2.26092 FIORICET 50-300-40 MG CAPSULE 0 ACTAVIS PHARMA, EABND 54092-0702-02 2657.66000 FIRAZYR 30 MG/3 ML SYRINGE 0 SHIRE US INC. MLBND 54092-0702-03 2657.66000 FIRAZYR 30 MG/3 ML SYRINGE 0 SHIRE US INC. MLBND 00025-1961-30 14.73222 FLAGYL ER 750 MG TABLET G PHARMACIA/UPJHN EABUL 00025-1831-31 0.08490 4.36613 FLAGYL 250 MG TABLET G PHARMACIA/UPJHN EABUL 00025-1831-50 0.08490 4.36646 FLAGYL 250 MG TABLET G PHARMACIA/UPJHN EABND 00025-1942-50 3.59960 6.07759 FLAGYL 375 CAPSULE G PHARMACIA/UPJHN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00025-1821-31 0.21840 7.79967 FLAGYL 500 MG TABLET G PHARMACIA/UPJHN EABUL 00025-1821-50 0.21840 7.80034 FLAGYL 500 MG TABLET G PHARMACIA/UPJHN EABND 00065-0096-05 10.14924 FLAREX 0.1% EYE DROPS 0 ALCON LABS. MLGEN 00115-1811-01 0.95400 FLAVOXATE HCL 100 MG TABLET 0 GLOBAL PHARM EAGEN 00574-0115-01 0.95400 FLAVOXATE HCL 100 MG TABLET 0 PADDOCK LABS. EAGEN 42806-0058-01 0.86550 FLAVOXATE HCL 100 MG TABLET 0 EPIC PHARMA LLC EABND 61953-0005-01 8.35444 FLEBOGAMMA DIF 10% VIAL 0 GRIFOLS MLBND 61953-0005-02 8.35444 FLEBOGAMMA DIF 10% VIAL 0 GRIFOLS MLBND 61953-0005-03 8.35444 FLEBOGAMMA DIF 10% VIAL 0 GRIFOLS MLBND 61953-0005-04 8.35444 FLEBOGAMMA DIF 10% VIAL 0 GRIFOLS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 61953-0005-05 8.35444 FLEBOGAMMA DIF 10% VIAL 0 GRIFOLS MLBND 61953-0005-06 8.35444 FLEBOGAMMA DIF 10% VIAL 0 GRIFOLS MLBND 61953-0004-00 4.17722 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLBND 61953-0004-01 4.17739 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLBND 61953-0004-02 4.17722 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLBND 61953-0004-03 4.17722 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLBND 61953-0004-04 4.17722 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLBND 61953-0004-05 4.17722 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLBND 61953-0004-06 4.17739 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLBND 61953-0004-07 4.17722 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 61953-0004-08 4.17722 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLBND 61953-0004-09 4.17722 FLEBOGAMMA DIF 5% VIAL 0 GRIFOLS MLGEN 00054-0011-21 0.29170 FLECAINIDE ACETATE 100 MG TAB 0 ROXANE LABS. EAGEN 00054-0011-25 0.29170 FLECAINIDE ACETATE 100 MG TAB 0 ROXANE LABS. EAGEN 00555-0860-02 0.29170 FLECAINIDE ACETATE 100 MG TAB 0 BARR EAGEN 65162-0642-10 0.29170 FLECAINIDE ACETATE 100 MG TAB 0 AMNEAL PHARMACE EAGEN 00054-0012-21 0.54972 FLECAINIDE ACETATE 150 MG TAB 0 ROXANE LABS. EAGEN 00054-0012-25 0.54972 FLECAINIDE ACETATE 150 MG TAB 0 ROXANE LABS. EAGEN 00555-0861-02 0.54972 FLECAINIDE ACETATE 150 MG TAB 0 BARR EAGEN 65162-0643-10 0.54972 FLECAINIDE ACETATE 150 MG TAB 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0010-21 0.19750 FLECAINIDE ACETATE 50 MG TAB 0 ROXANE LABS. EAGEN 00054-0010-25 0.19750 FLECAINIDE ACETATE 50 MG TAB 0 ROXANE LABS. EAGEN 00555-0859-02 0.19750 FLECAINIDE ACETATE 50 MG TAB 0 BARR EAGEN 65162-0641-10 0.19750 FLECAINIDE ACETATE 50 MG TAB 0 AMNEAL PHARMACE EABND 60793-0411-30 7.16483 FLECTOR 1.3% PATCH G PFIZER US PHARM 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: 145LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51672-1338-03 3.45197 FLO-PRED 16.7(15) MG/5 ML SUSP G TARO PHARM USA MLBND 00173-0517-00 18.61690 FLOLAN 0.5 MG VIAL 0 GLAXOSMITHKLINE EABND 00173-0519-00 44.96110 FLOLAN 1.5 MG VIAL 0 GLAXOSMITHKLINE EABND 00597-0058-01 0.17210 5.69048 FLOMAX 0.4 MG CAPSULE G BOEHRINGER ING. EABND 00173-0453-01 1.70280 5.56618 FLONASE 0.05% NASAL SPRAY G GLAXOSMITHKLINE GMBND 00173-0719-20 15.09493 FLOVENT HFA 110 MCG INHALER G GLAXOSMITHKLINE GMBND 00173-0720-20 23.44611 FLOVENT HFA 220 MCG INHALER G GLAXOSMITHKLINE GMBND 00173-0718-20 12.76398 FLOVENT HFA 44 MCG INHALER G GLAXOSMITHKLINE GMBND 00173-0602-00 2.98236 FLOVENT 100 MCG DISKUS G GLAXOSMITHKLINE EABND 00173-0602-02 2.25496 FLOVENT 100 MCG DISKUS G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0601-00 3.99318 FLOVENT 250 MCG DISKUS G GLAXOSMITHKLINE EABND 00173-0601-02 3.01898 FLOVENT 250 MCG DISKUS G GLAXOSMITHKLINE EABND 00173-0600-02 2.13835 FLOVENT 50 MCG DISKUS G GLAXOSMITHKLINE EAGEN 63323-0145-07 107.10000 FLOXURIDINE 500 MG VIAL 0 APP PHARMACEUTI EAGEN 38779-2442-09 52.72500 FLUCONAZOLE POWDER 0 MEDISCA INC. GMGEN 00054-0002-85 0.30200 FLUCONAZOLE 10 MG/ML SUSP 0 ROXANE LABS. MLGEN 00093-5414-95 0.30200 FLUCONAZOLE 10 MG/ML SUSP 0 TEVA USA MLGEN 16714-0695-01 0.30200 FLUCONAZOLE 10 MG/ML SUSP 0 NORTHSTAR RX LL MLGEN 59762-5029-01 0.30200 FLUCONAZOLE 10 MG/ML SUSP 0 GREENSTONE LLC. MLGUL 00172-5411-46 0.88250 FLUCONAZOLE 100 MG TABLET 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00172-5411-60 0.88250 FLUCONAZOLE 100 MG TABLET 0 IVAX PHARMACEUT EAGUL 00378-2516-93 0.88250 FLUCONAZOLE 100 MG TABLET 0 MYLAN EAGUL 57237-0004-30 0.88250 FLUCONAZOLE 100 MG TABLET 0 CITRON PHARMA L EAGUL 59762-5016-01 0.88250 FLUCONAZOLE 100 MG TABLET 0 GREENSTONE LLC. EAGUL 65862-0059-30 0.88250 FLUCONAZOLE 100 MG TABLET 0 AUROBINDO PHARM EAGUL 68462-0102-30 0.88250 FLUCONAZOLE 100 MG TABLET 0 GLENMARK PHARMA EAGEN 00172-5412-11 2.74400 FLUCONAZOLE 150 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-5412-79 2.74400 FLUCONAZOLE 150 MG TABLET 0 IVAX PHARMACEUT EAGEN 16714-0692-11 2.74400 FLUCONAZOLE 150 MG TABLET 0 NORTHSTAR RX LL EAGEN 57237-0005-11 2.74400 FLUCONAZOLE 150 MG TABLET 0 CITRON PHARMA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-5017-01 2.74400 FLUCONAZOLE 150 MG TABLET 0 GREENSTONE LLC. EAGEN 65862-0060-11 2.74400 FLUCONAZOLE 150 MG TABLET 0 AUROBINDO PHARM EAGEN 68462-0103-40 2.74400 FLUCONAZOLE 150 MG TABLET 0 GLENMARK PHARMA EAGUL 00172-5413-46 1.40750 FLUCONAZOLE 200 MG TABLET 0 IVAX PHARMACEUT EAGUL 00172-5413-60 1.40750 FLUCONAZOLE 200 MG TABLET 0 IVAX PHARMACEUT EAGUL 00378-2520-93 1.40750 FLUCONAZOLE 200 MG TABLET 0 MYLAN EAGUL 57237-0006-30 1.40750 FLUCONAZOLE 200 MG TABLET 0 CITRON PHARMA L EAGUL 59762-5018-01 1.40750 FLUCONAZOLE 200 MG TABLET 0 GREENSTONE LLC. EAGUL 65862-0061-30 1.40750 FLUCONAZOLE 200 MG TABLET 0 AUROBINDO PHARM EAGUL 68462-0104-30 1.40750 FLUCONAZOLE 200 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0003-85 0.70470 FLUCONAZOLE 40 MG/ML SUSP 0 ROXANE LABS. MLGEN 00093-5415-95 0.70470 FLUCONAZOLE 40 MG/ML SUSP 0 TEVA USA MLGEN 59762-5030-01 0.70470 FLUCONAZOLE 40 MG/ML SUSP 0 GREENSTONE LLC. MLGUL 00172-5410-46 0.50000 FLUCONAZOLE 50 MG TABLET 0 IVAX PHARMACEUT EAGUL 00172-5410-60 0.50000 FLUCONAZOLE 50 MG TABLET 0 IVAX PHARMACEUT 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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