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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 148LIST 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 45802-0151-96 10.86624 FLUOCINONIDE 0.1% CREAM G PERRIGO CO. GMGEN 68682-0992-10 9.90900 FLUOCINONIDE 0.1% CREAM G OCEANSIDE PHARM GMGEN 68682-0992-30 12.10674 FLUOCINONIDE 0.1% CREAM G OCEANSIDE PHARM GMGEN 68682-0992-60 10.43037 FLUOCINONIDE 0.1% CREAM G OCEANSIDE PHARM GMGUL 00093-0263-15 0.24530 FLUOCINONIDE-E 0.05% CREAM 0 TEVA USA GMGUL 00093-0263-30 0.24530 FLUOCINONIDE-E 0.05% CREAM 0 TEVA USA GMGUL 00093-0263-92 0.24530 FLUOCINONIDE-E 0.05% CREAM 0 TEVA USA GMGUL 51672-1254-01 0.24530 FLUOCINONIDE-E 0.05% CREAM 0 TARO PHARM USA GMGUL 51672-1254-02 0.24530 FLUOCINONIDE-E 0.05% CREAM 0 TARO PHARM USA GMGUL 51672-1254-03 0.24530 FLUOCINONIDE-E 0.05% CREAM 0 TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00168-0246-15 0.24530 FLUOCINONIDE-EMOL 0.05% CREAM 0 SANDOZ GMGUL 00168-0246-30 0.24530 FLUOCINONIDE-EMOL 0.05% CREAM 0 SANDOZ GMGUL 00168-0246-60 0.24530 FLUOCINONIDE-EMOL 0.05% CREAM 0 SANDOZ GMBND 24338-0656-61 1.53218 FLUOR-A-DAY 2.5 MG/ML DROPS 0 ARBOR PHARMACEU MLGEN 51862-0171-10 0.02450 FLUORIDE 0.5 MG TABLET CHEW 0 LIBERTAS PHARMA EAGEN 51862-0171-12 0.02450 FLUORIDE 0.5 MG TABLET CHEW 0 LIBERTAS PHARMA EAGEN 60758-0880-05 7.92000 FLUOROMETHOLONE 0.1% DROPS 0 PACIFIC PHARMA MLGEN 60758-0880-10 7.92000 FLUOROMETHOLONE 0.1% DROPS 0 PACIFIC PHARMA MLGEN 60758-0880-15 7.92000 FLUOROMETHOLONE 0.1% DROPS 0 PACIFIC PHARMA MLBND 00023-0812-30 11.62000 FLUOROPLEX 1% CREAM 0 AQUA PHARMACEUT GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10139-0063-12 0.22000 FLUOROURACIL 1,000 MG/20 ML VL 0 MYLAN INSTITUTI MLGEN 10139-0063-20 0.22000 FLUOROURACIL 1,000 MG/20 ML VL 0 MYLAN INSTITUTI MLGEN 63323-0117-20 0.22000 FLUOROURACIL 1,000 MG/20 ML VL 0 APP PHARMACEUTI MLGEN 10139-0063-50 0.22950 FLUOROURACIL 2,500 MG/50 ML VL 0 MYLAN INSTITUTI MLGEN 63323-0117-51 0.23130 FLUOROURACIL 2,500 MG/50 ML VL 0 APP PHARMACEUTI MLGEN 43547-0259-01 5.18616 FLUOROURACIL 2% TOPICAL SOLN 0 SOLCO HEALTHCAR MLGEN 51672-4062-01 5.18616 FLUOROURACIL 2% TOPICAL SOLN 0 TARO PHARM USA MLGEN 63323-0117-61 0.23130 FLUOROURACIL 5,000 MG/100 ML 0 APP PHARMACEUTI MLGEN 00378-4791-06 4.63293 FLUOROURACIL 5% CREAM 0 MYLAN GMGEN 51672-4118-06 5.35250 FLUOROURACIL 5% CREAM 0 TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 66530-0249-40 4.82606 FLUOROURACIL 5% CREAM 0 SPEAR DERM PROD GMGEN 68682-0004-31 4.63293 FLUOROURACIL 5% CREAM 0 MYLAN GMGEN 43547-0258-01 7.63714 FLUOROURACIL 5% TOP SOLUTION 0 SOLCO HEALTHCAR MLGEN 51672-4063-01 7.63714 FLUOROURACIL 5% TOP SOLUTION 0 TARO PHARM USA MLGEN 10139-0063-10 0.24750 FLUOROURACIL 500 MG/10 ML VIAL 0 MYLAN INSTITUTI MLGEN 63323-0117-10 0.26400 FLUOROURACIL 500 MG/10 ML VIAL 0 APP PHARMACEUTI MLGEX 55111-0284-48 24.92000 FLUOXETINE DR 90 MG CAPSULE G DR.REDDY'S LAB EAGEX 00378-5410-28 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 MYLAN EAGEX 00781-2823-01 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 SANDOZ EAGEX 00781-2827-08 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16714-0351-01 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 16714-0351-02 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 16714-0351-03 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 50111-0647-01 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 PLIVA, INC EAGEX 50111-0647-02 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 PLIVA, INC 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: 149LIST 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 50111-0647-03 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 PLIVA, INC EAGEX 55111-0147-01 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 DR.REDDY'S LAB EAGEX 65862-0192-01 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0192-05 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0192-99 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 AUROBINDO PHARM EAGEX 68645-0131-54 0.03250 FLUOXETINE HCL 10 MG CAPSULE 0 LEGACY PHARMACE EAGEX 00093-7188-56 0.05170 FLUOXETINE HCL 10 MG TABLET 0 TEVA USA EAGEX 00378-0734-01 0.05170 FLUOXETINE HCL 10 MG TABLET 0 MYLAN EAGEX 00378-0734-93 0.05170 FLUOXETINE HCL 10 MG TABLET 0 MYLAN EAGEX 49884-0734-01 0.05170 FLUOXETINE HCL 10 MG TABLET 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 49884-0734-10 0.05170 FLUOXETINE HCL 10 MG TABLET 0 PAR PHARM. EAGEX 49884-0734-11 0.05170 FLUOXETINE HCL 10 MG TABLET 0 PAR PHARM. EAGEX 00093-4356-19 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 TEVA USA EAGEX 00093-4356-93 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 TEVA USA EAGEX 00378-5420-28 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 MYLAN EAGEX 00781-2822-01 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 SANDOZ EAGEX 00781-2822-10 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 SANDOZ EAGEX 16714-0352-01 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 16714-0352-02 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 16714-0352-03 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 50111-0648-01 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 PLIVA, INC EAGEX 50111-0648-02 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 TEVA USA EAGEX 50111-0648-03 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 PLIVA, INC EAGEX 50111-0648-44 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 PLIVA, INC EAGEX 55111-0148-01 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 DR.REDDY'S LAB EAGEX 55111-0148-10 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 DR.REDDY'S LAB EAGEX 65862-0193-01 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0193-05 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0193-99 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 AUROBINDO PHARM EAGEX 68084-0605-01 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68645-0130-54 0.02500 FLUOXETINE HCL 20 MG CAPSULE 0 LEGACY PHARMACE EAGEX 00378-0735-01 0.72553 FLUOXETINE HCL 20 MG TABLET 0 MYLAN EAGEX 00378-0735-93 0.72553 FLUOXETINE HCL 20 MG TABLET 0 MYLAN EAGEX 49884-0735-01 0.72553 FLUOXETINE HCL 20 MG TABLET 0 PAR PHARM. EAGEX 49884-0735-10 0.72553 FLUOXETINE HCL 20 MG TABLET 0 PAR PHARM. EAGEX 49884-0735-11 0.72553 FLUOXETINE HCL 20 MG TABLET 0 PAR PHARM. EAGEX 00093-4346-56 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 TEVA USA EAGEX 00093-7198-01 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 TEVA USA EAGEX 00093-7198-56 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 TEVA USA EAGEX 00781-2824-01 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-2824-10 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 SANDOZ EAGEX 00781-2824-31 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 SANDOZ EAGEX 16714-0353-01 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 16714-0353-02 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 16714-0353-03 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 NORTHSTAR RX LL 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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