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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 14LIST 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 61748-0044-08 0.88020 3.19963 AMINOCAPROIC ACID 25% SOLUTION 0 VERSA PHARMACEU MLBND 61748-0044-16 0.88020 3.33461 AMINOCAPROIC ACID 25% SOLUTION 0 VERSA PHARMACEU MLGEN 00517-9120-25 0.07550 AMINOCAPROIC ACID 250 MG/ML 0 AMER. REGENT MLBND 61748-0045-01 1.45760 6.48877 AMINOCAPROIC ACID 500 MG TAB 0 VERSA PHARMACEU EAGEN 51672-4055-06 5.57225 AMIODARONE HCL 100 MG TABLET 0 TARO PHARM USA EAGEN 00093-9133-06 0.15390 AMIODARONE HCL 200 MG TABLET 0 TEVA USA EAGEN 00093-9133-52 0.15390 AMIODARONE HCL 200 MG TABLET 0 TEVA USA EAGEN 00185-0144-05 0.15390 AMIODARONE HCL 200 MG TABLET 0 SANDOZ EAGEN 00185-0144-09 0.15390 AMIODARONE HCL 200 MG TABLET 0 SANDOZ EAGEN 00185-0144-60 0.15390 AMIODARONE HCL 200 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0906-17 0.15390 AMIODARONE HCL 200 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0906-19 0.15390 AMIODARONE HCL 200 MG TABLET 0 MYLAN INSTITUTI EAGEN 51672-4025-04 0.15390 AMIODARONE HCL 200 MG TABLET 0 TARO PHARM USA EAGEN 63739-0387-10 0.15390 AMIODARONE HCL 200 MG TABLET 0 MCKESSON PACKAG EAGEN 68084-0371-01 0.15390 AMIODARONE HCL 200 MG TABLET 0 AHP EAGEN 68084-0371-11 0.15390 AMIODARONE HCL 200 MG TABLET 0 AHP EAGEN 68382-0227-05 0.15390 AMIODARONE HCL 200 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0227-14 0.15390 AMIODARONE HCL 200 MG TABLET 0 ZYDUS PHARMACEU EAGEN 51672-4057-06 3.96875 AMIODARONE HCL 400 MG TABLET 0 TARO PHARM USA EAGEN 51862-0156-30 5.60625 AMIODARONE HCL 400 MG TABLET 0 LIBERTAS PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 64764-0240-60 4.56223 AMITIZA 24 MCG CAPSULES G TAKEDA PHARMACE EABND 64764-0080-60 4.56223 AMITIZA 8 MCG CAPSULE G TAKEDA PHARMACE EAGEX 38779-0189-04 13.18140 AMITRIPTYLINE HCL POWDER 0 MEDISCA INC. GMGEX 38779-0189-05 13.18125 AMITRIPTYLINE HCL POWDER 0 MEDISCA INC. GMGEX 38779-0189-09 13.18125 AMITRIPTYLINE HCL POWDER 0 MEDISCA INC. GMGEX 00378-2610-01 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 MYLAN EAGEX 00378-2610-10 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 MYLAN EAGEX 00603-2212-02 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 QUALITEST EAGEX 00603-2212-16 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 QUALITEST EAGEX 00603-2212-21 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-2212-32 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 QUALITEST EAGEX 00781-1486-01 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 SANDOZ EAGEX 00781-1486-10 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 SANDOZ EAGEX 51079-0131-20 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 MYLAN INSTITUTI EAGEX 51079-0131-63 0.01980 AMITRIPTYLINE HCL 10 MG TAB 0 MYLAN INSTITUTI EAGEX 00378-2685-01 0.05520 AMITRIPTYLINE HCL 100 MG TAB 0 MYLAN EAGEX 00378-2685-93 0.05520 AMITRIPTYLINE HCL 100 MG TAB 0 MYLAN EAGEX 00603-2216-21 0.05520 AMITRIPTYLINE HCL 100 MG TAB 0 QUALITEST EAGEX 00603-2216-25 0.05520 AMITRIPTYLINE HCL 100 MG TAB 0 QUALITEST EAGEX 00781-1490-01 0.05520 AMITRIPTYLINE HCL 100 MG TAB 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0563-20 0.05520 AMITRIPTYLINE HCL 100 MG TAB 0 MYLAN INSTITUTI EAGEX 00378-2695-01 0.10840 AMITRIPTYLINE HCL 150 MG TAB 0 MYLAN EAGEX 00378-2695-93 0.10840 AMITRIPTYLINE HCL 150 MG TAB 0 MYLAN EAGEX 00603-2217-21 0.10840 AMITRIPTYLINE HCL 150 MG TAB 0 QUALITEST EAGEX 00781-1491-01 0.10840 AMITRIPTYLINE HCL 150 MG TAB 0 SANDOZ 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: 15LIST 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 00378-2625-01 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 MYLAN EAGEX 00378-2625-10 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 MYLAN EAGEX 00603-2213-02 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 QUALITEST EAGEX 00603-2213-21 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 QUALITEST EAGEX 00603-2213-32 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 QUALITEST EAGEX 00781-1487-01 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 SANDOZ EAGEX 00781-1487-10 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 SANDOZ EAGEX 51079-0107-20 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 MYLAN INSTITUTI EAGEX 51079-0107-63 0.02201 AMITRIPTYLINE HCL 25 MG TAB 0 MYLAN INSTITUTI EAGEX 00378-2650-01 0.02590 AMITRIPTYLINE HCL 50 MG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-2650-10 0.02590 AMITRIPTYLINE HCL 50 MG TAB 0 MYLAN EAGEX 00603-2214-21 0.02590 AMITRIPTYLINE HCL 50 MG TAB 0 QUALITEST EAGEX 00603-2214-32 0.02590 AMITRIPTYLINE HCL 50 MG TAB 0 QUALITEST EAGEX 00781-1488-01 0.02590 AMITRIPTYLINE HCL 50 MG TAB 0 SANDOZ EAGEX 00781-1488-10 0.02590 AMITRIPTYLINE HCL 50 MG TAB 0 SANDOZ EAGEX 51079-0133-20 0.02590 AMITRIPTYLINE HCL 50 MG TAB 0 MYLAN INSTITUTI EAGEX 51079-0133-63 0.02590 AMITRIPTYLINE HCL 50 MG TAB 0 MYLAN INSTITUTI EAGEX 00378-2675-01 0.04750 AMITRIPTYLINE HCL 75 MG TAB 0 MYLAN EAGEX 00378-2675-93 0.04750 AMITRIPTYLINE HCL 75 MG TAB 0 MYLAN EAGEX 00603-2215-21 0.04750 AMITRIPTYLINE HCL 75 MG TAB 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-2215-25 0.04750 AMITRIPTYLINE HCL 75 MG TAB 0 QUALITEST EAGEX 00781-1489-01 0.04750 AMITRIPTYLINE HCL 75 MG TAB 0 SANDOZ EAGEX 51079-0147-20 0.04750 AMITRIPTYLINE HCL 75 MG TAB 0 MYLAN INSTITUTI EAGEN 00054-0102-22 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 ROXANE LABS. EAGEN 00054-0102-28 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 ROXANE LABS. EAGEN 00093-7168-98 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 TEVA USA EAGEN 00143-9961-09 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 WEST-WARD,INC. EAGEN 00378-5210-05 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MYLAN EAGEN 00378-5210-77 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MYLAN EAGEN 00603-2110-02 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-2110-16 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 QUALITEST EAGEN 00603-2110-28 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 QUALITEST EAGEN 00603-2110-32 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 QUALITEST EAGEN 00603-2110-33 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 QUALITEST EAGEN 00603-2110-60 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 QUALITEST EAGEN 00904-5993-61 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MAJOR PHARMACEU EAGEN 00904-6371-61 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MAJOR PHARMACEU EAGEN 13668-0024-05 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 TORRENT PHARMAC EAGEN 13668-0024-10 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 TORRENT PHARMAC EAGEN 31722-0239-10 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0239-90 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 CAMBER PHARMACE EAGEN 42806-0057-05 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 EPIC PHARMA LLC EAGEN 42806-0057-09 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 EPIC PHARMA LLC EAGEN 42806-0057-10 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 EPIC PHARMA LLC EAGEN 43547-0232-09 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 SOLCO HEALTHCAR 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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