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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 150LIST 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 16714-0353-04 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 49884-0872-01 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 PAR PHARM. EAGEX 49884-0872-05 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 PAR PHARM. EAGEX 49884-0872-11 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 PAR PHARM. EAGEX 55111-0149-01 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 DR.REDDY'S LAB EAGEX 55111-0149-30 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 DR.REDDY'S LAB EAGEX 63304-0632-01 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 RANBAXY PHARMAC EAGEX 63304-0632-30 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 RANBAXY PHARMAC EAGEX 65862-0194-01 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0194-05 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0194-30 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0194-99 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 AUROBINDO PHARM EAGEX 68001-0129-00 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 BLUEPOINT LABOR EAGEX 68001-0129-03 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 BLUEPOINT LABOR EAGEX 68001-0129-04 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 BLUEPOINT LABOR EAGEX 68084-0101-01 0.49033 FLUOXETINE HCL 40 MG CAPSULE 0 AHP EABEX 49909-0005-30 3.28680 FLUOXETINE HCL 60 MG TABLET G EDGEMONT PHARMA EAGEX 00093-6108-12 0.03830 FLUOXETINE 20 MG/5 ML SOLUTION 0 TEVA USA MLGEX 00121-0721-04 0.03830 FLUOXETINE 20 MG/5 ML SOLUTION 0 PHARMACEU ASSOC MLGEX 00121-4721-05 0.03830 FLUOXETINE 20 MG/5 ML SOLUTION 0 PHARMACEU ASSOC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 54838-0523-40 0.03830 FLUOXETINE 20 MG/5 ML SOLUTION 0 SILARX PHARM MLGEX 60505-0352-01 0.03830 FLUOXETINE 20 MG/5 ML SOLUTION 0 APOTEX CORP MLBEX 63323-0272-05 26.84386 FLUPHENAZINE DEC 25 MG/ML VL 0 APP PHARMACEUTI MLGEX 00378-6004-01 0.13398 FLUPHENAZINE 1 MG TABLET 0 MYLAN EAGEX 00378-6004-05 0.13398 FLUPHENAZINE 1 MG TABLET 0 MYLAN EAGEX 00527-1788-01 0.13398 FLUPHENAZINE 1 MG TABLET 0 LANNETT CO. INC EAGEX 00527-1788-05 0.13398 FLUPHENAZINE 1 MG TABLET 0 LANNETT CO. INC EAGEX 00781-1436-01 0.13398 FLUPHENAZINE 1 MG TABLET 0 SANDOZ EAGEX 51079-0485-20 0.13398 FLUPHENAZINE 1 MG TABLET 0 MYLAN INSTITUTI EAGEX 00378-6097-01 0.31316 FLUPHENAZINE 10 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-6097-05 0.31316 FLUPHENAZINE 10 MG TABLET 0 MYLAN EAGEX 00527-1791-01 0.31316 FLUPHENAZINE 10 MG TABLET 0 LANNETT CO. INC EAGEX 00527-1791-05 0.31316 FLUPHENAZINE 10 MG TABLET 0 LANNETT CO. INC EAGEX 00781-1439-01 0.31316 FLUPHENAZINE 10 MG TABLET 0 SANDOZ EAGEX 51079-0488-20 0.31316 FLUPHENAZINE 10 MG TABLET 0 MYLAN INSTITUTI EAGEX 00378-6009-01 0.18900 FLUPHENAZINE 2.5 MG TABLET 0 MYLAN EAGEX 00378-6009-05 0.18900 FLUPHENAZINE 2.5 MG TABLET 0 MYLAN EAGEX 00527-1789-01 0.18900 FLUPHENAZINE 2.5 MG TABLET 0 LANNETT CO. INC EAGEX 00527-1789-05 0.18900 FLUPHENAZINE 2.5 MG TABLET 0 LANNETT CO. INC EAGEX 00781-1437-01 0.18900 FLUPHENAZINE 2.5 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0486-20 0.18900 FLUPHENAZINE 2.5 MG TABLET 0 MYLAN INSTITUTI EABEX 63323-0281-10 15.84221 FLUPHENAZINE 2.5 MG/ML VIAL 0 APP PHARMACEUTI MLBEX 00121-0654-02 0.40836 FLUPHENAZINE 2.5 MG/5 ML ELIX 0 PHARMACEU ASSOC MLBEX 00121-0654-16 0.33691 FLUPHENAZINE 2.5 MG/5 ML ELIX 0 PHARMACEU ASSOC MLGEX 00378-6074-01 0.22181 FLUPHENAZINE 5 MG TABLET 0 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 151LIST 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 00378-6074-05 0.22181 FLUPHENAZINE 5 MG TABLET 0 MYLAN EAGEX 00527-1790-01 0.22181 FLUPHENAZINE 5 MG TABLET 0 LANNETT CO. INC EAGEX 00527-1790-05 0.22181 FLUPHENAZINE 5 MG TABLET 0 LANNETT CO. INC EAGEX 00781-1438-01 0.22181 FLUPHENAZINE 5 MG TABLET 0 SANDOZ EAGEX 51079-0487-20 0.22181 FLUPHENAZINE 5 MG TABLET 0 MYLAN INSTITUTI EABEX 00121-0653-04 0.96203 FLUPHENAZINE 5 MG/ML CONC 0 PHARMACEU ASSOC MLBND 58223-0684-24 0.22617 FLURA-DROPS 0.25 MG/DROP 0 KIRKMAN SALES MLGEN 24208-0314-25 1.21045 FLURBIPROFEN 0.03% EYE DROP 0 VALEANT MLGEN 60758-0910-03 1.21045 FLURBIPROFEN 0.03% EYE DROP 0 PACIFIC PHARMA MLGUL 00093-0711-01 0.24380 FLURBIPROFEN 100 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00093-0711-05 0.24380 FLURBIPROFEN 100 MG TABLET 0 TEVA USA EAGUL 00378-0093-01 0.24380 FLURBIPROFEN 100 MG TABLET 0 MYLAN EABND 00378-0076-01 0.11420 0.68674 FLURBIPROFEN 50 MG TABLET 0 MYLAN EAGEN 00172-4960-58 0.72310 FLUTAMIDE 125 MG CAPSULE 0 IVAX PHARMACEUT EAGEN 00172-4960-70 0.72310 FLUTAMIDE 125 MG CAPSULE 0 IVAX PHARMACEUT EAGEN 00591-2466-18 0.72310 FLUTAMIDE 125 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 49884-0753-13 0.72310 FLUTAMIDE 125 MG CAPSULE 0 PAR PHARM. EAGEN 00713-0632-15 0.49080 FLUTICASONE PROP 0.005% OINT G G & W LABS. GMGEN 00713-0632-31 0.49080 FLUTICASONE PROP 0.005% OINT G G & W LABS. GMGEN 00713-0632-60 0.49080 FLUTICASONE PROP 0.005% OINT G G & W LABS. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45802-0221-11 0.49080 FLUTICASONE PROP 0.005% OINT G PERRIGO CO. GMGEN 45802-0221-35 0.49080 FLUTICASONE PROP 0.005% OINT G PERRIGO CO. GMGEN 45802-0221-37 0.49080 FLUTICASONE PROP 0.005% OINT G PERRIGO CO. GMGEN 00115-1473-45 0.62890 FLUTICASONE PROP 0.05% CREAM G GLOBAL PHARM GMGEN 00115-1473-52 0.62890 FLUTICASONE PROP 0.05% CREAM G GLOBAL PHARM GMGEN 00115-1473-58 0.62890 FLUTICASONE PROP 0.05% CREAM G GLOBAL PHARM GMGEN 00168-0332-15 0.62890 FLUTICASONE PROP 0.05% CREAM G SANDOZ GMGEN 00168-0332-30 0.62890 FLUTICASONE PROP 0.05% CREAM G SANDOZ GMGEN 00168-0332-60 0.62890 FLUTICASONE PROP 0.05% CREAM G SANDOZ GMGEN 00713-0631-15 0.62890 FLUTICASONE PROP 0.05% CREAM G G & W LABS. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00713-0631-31 0.62890 FLUTICASONE PROP 0.05% CREAM G G & W LABS. GMGEN 00713-0631-60 0.62890 FLUTICASONE PROP 0.05% CREAM G G & W LABS. GMGEN 45802-0222-11 0.62890 FLUTICASONE PROP 0.05% CREAM G PERRIGO CO. GMGEN 45802-0222-35 0.62890 FLUTICASONE PROP 0.05% CREAM G PERRIGO CO. GMGEN 45802-0222-37 0.62890 FLUTICASONE PROP 0.05% CREAM G PERRIGO CO. GMGEN 00168-0434-04 5.07624 FLUTICASONE PROP 0.05% LOTION G SANDOZ MLGEN 00168-0434-60 4.87437 FLUTICASONE PROP 0.05% LOTION G SANDOZ MLGEN 45802-0441-02 4.87437 FLUTICASONE PROP 0.05% LOTION G PERRIGO CO. MLGEN 68462-0427-02 4.87437 FLUTICASONE PROP 0.05% LOTION G GLENMARK PHARMA MLGEN 00054-3270-99 1.70280 FLUTICASONE PROP 50 MCG SPRAY G ROXANE LABS. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50383-0700-16 1.70280 FLUTICASONE PROP 50 MCG SPRAY G HI-TECH PHARMAC GMGEN 60432-0264-15 1.70280 FLUTICASONE PROP 50 MCG SPRAY G MORTON GROVE PH GMGEN 60505-0829-01 1.70280 FLUTICASONE PROP 50 MCG SPRAY G APOTEX CORP GMGEN 60505-0847-03 1.70280 FLUTICASONE PROP 50 MCG SPRAY G APOTEX/NOVAPLUS GMGEN 66993-0024-52 1.70280 FLUTICASONE PROP 50 MCG SPRAY G PRASCO LABS GM** 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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