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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 152LIST 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 00093-7442-01 2.83020 FLUVASTATIN SODIUM 20 MG CAP G TEVA USA EAGEN 00093-7442-56 2.83500 FLUVASTATIN SODIUM 20 MG CAP G TEVA USA EAGEN 00378-8020-77 3.20544 FLUVASTATIN SODIUM 20 MG CAP G MYLAN EAGEN 00378-8020-93 3.20544 FLUVASTATIN SODIUM 20 MG CAP G MYLAN EAGEN 00093-7443-01 2.64297 FLUVASTATIN SODIUM 40 MG CAP G TEVA USA EAGEN 00093-7443-56 2.64297 FLUVASTATIN SODIUM 40 MG CAP G TEVA USA EAGEN 00378-8021-77 2.64297 FLUVASTATIN SODIUM 40 MG CAP G MYLAN EAGEN 00378-8021-93 2.64297 FLUVASTATIN SODIUM 40 MG CAP G MYLAN EAGEX 00185-0157-01 0.34570 FLUVOXAMINE MALEATE 100 MG TAB G SANDOZ EAGEX 00185-0157-05 0.34570 FLUVOXAMINE MALEATE 100 MG TAB G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-0414-01 0.34570 FLUVOXAMINE MALEATE 100 MG TAB G MYLAN EAGEX 42769-1221-00 0.34570 FLUVOXAMINE MALEATE 100 MG TAB G BAYPHARMA INC. EAGEX 51079-0993-01 0.34570 FLUVOXAMINE MALEATE 100 MG TAB G MYLAN INSTITUTI EAGEX 60505-0166-01 0.34570 FLUVOXAMINE MALEATE 100 MG TAB G APOTEX CORP EAGEX 62559-0160-01 0.34570 FLUVOXAMINE MALEATE 100 MG TAB G ANI PHARMACEUTI EAGUX 00378-0407-01 1.08830 FLUVOXAMINE MALEATE 25 MG TAB G MYLAN EAGUX 60505-0164-01 1.08830 FLUVOXAMINE MALEATE 25 MG TAB G APOTEX CORP EAGUX 62559-0158-01 1.08830 FLUVOXAMINE MALEATE 25 MG TAB G ANI PHARMACEUTI EAGEX 00185-0027-01 0.31347 FLUVOXAMINE MALEATE 50 MG TAB G SANDOZ EAGEX 00185-0027-05 0.31347 FLUVOXAMINE MALEATE 50 MG TAB G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-0412-01 0.31347 FLUVOXAMINE MALEATE 50 MG TAB G MYLAN EAGEX 42769-1225-00 0.31347 FLUVOXAMINE MALEATE 50 MG TAB G BAYPHARMA INC. EAGEX 51079-0992-01 0.31347 FLUVOXAMINE MALEATE 50 MG TAB G MYLAN INSTITUTI EAGEX 60505-0165-01 0.31347 FLUVOXAMINE MALEATE 50 MG TAB G APOTEX CORP EAGEX 62559-0159-01 0.31347 FLUVOXAMINE MALEATE 50 MG TAB G ANI PHARMACEUTI EABND 11980-0228-05 17.72880 FML FORTE 0.25% EYE DROPS 0 ALLERGAN INC. MLBND 11980-0228-10 17.72880 FML FORTE 0.25% EYE DROPS 0 ALLERGAN INC. MLBND 11980-0211-05 7.92000 17.72880 FML LIQUIFILM 0.1% EYE DROP G ALLERGAN INC. MLBND 11980-0211-10 7.92000 17.72880 FML LIQUIFILM 0.1% EYE DROP G ALLERGAN INC. MLBND 00023-0316-04 25.32686 FML S.O.P. 0.1% OINTMENT 0 ALLERGAN INC. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51991-0077-33 0.64780 FOLBECAL TABLET 0 BRECKENRIDGE EAGEN 00143-1248-01 0.01590 FOLIC ACID 1 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1248-10 0.01590 FOLIC ACID 1 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-9717-01 0.01590 FOLIC ACID 1 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-9717-10 0.01590 FOLIC ACID 1 MG TABLET 0 WEST-WARD,INC. EAGEN 00591-5216-01 0.01590 FOLIC ACID 1 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5216-10 0.01590 FOLIC ACID 1 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-3162-02 0.01590 FOLIC ACID 1 MG TABLET 0 QUALITEST EAGEN 00603-3162-21 0.01590 FOLIC ACID 1 MG TABLET 0 QUALITEST EAGEN 00603-3162-30 0.01590 FOLIC ACID 1 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-3162-32 0.01590 FOLIC ACID 1 MG TABLET 0 QUALITEST EAGEN 10267-0120-01 0.01590 FOLIC ACID 1 MG TABLET 0 CONTRACT PHARM EAGEN 10267-0120-04 0.01590 FOLIC ACID 1 MG TABLET 0 CONTRACT PHARM EAGEN 15338-0170-00 0.01590 FOLIC ACID 1 MG TABLET 0 APACE PACKAGING EAGEN 51079-0105-01 0.01590 FOLIC ACID 1 MG TABLET 0 MYLAN INSTITUTI 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: 153LIST 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 51079-0105-17 0.01590 FOLIC ACID 1 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0105-19 0.01590 FOLIC ACID 1 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0105-20 0.01590 FOLIC ACID 1 MG TABLET 0 MYLAN INSTITUTI EAGEN 59746-0012-10 0.01590 FOLIC ACID 1 MG TABLET 0 CADISTA PHARMAC EAGEN 62584-0897-11 0.01590 FOLIC ACID 1 MG TABLET 0 AHP EAGEN 63739-0537-10 0.01590 FOLIC ACID 1 MG TABLET 0 MCKESSON PACKAG EAGEN 64125-0127-01 0.01590 FOLIC ACID 1 MG TABLET 0 EXCELLIUM PHARM EAGEN 64125-0127-10 0.01590 FOLIC ACID 1 MG TABLET 0 EXCELLIUM PHARM EAGEN 65162-0361-10 0.01590 FOLIC ACID 1 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0361-11 0.01590 FOLIC ACID 1 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 76282-0210-01 0.01590 FOLIC ACID 1 MG TABLET 0 EXELAN PHARMACE EAGEN 76282-0210-10 0.01590 FOLIC ACID 1 MG TABLET 0 EXELAN PHARMACE EABND 63323-0184-10 2.65932 FOLIC ACID 5 MG/ML VIAL 0 APP PHARMACEUTI MLBND 63323-0184-11 2.65932 FOLIC ACID 5 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 13811-0535-30 0.56960 FOLIVANE-OB CAPSULE 0 TRIGEN LABORATO EABND 13811-0544-30 1.28982 FOLIVANE-PRX DHA NF CAPSULE 0 TRIGEN LABORATO EAGEN 55111-0681-02 90.25640 FONDAPARINUX 10 MG/0.8 ML SYR G DR.REDDY'S LAB MLGEN 55111-0681-10 90.25640 FONDAPARINUX 10 MG/0.8 ML SYR G DR.REDDY'S LAB MLGEN 60505-6081-00 90.25640 FONDAPARINUX 10 MG/0.8 ML SYR G APOTEX CORP MLGEN 60505-6081-04 90.25640 FONDAPARINUX 10 MG/0.8 ML SYR G APOTEX CORP ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0678-02 31.15640 FONDAPARINUX 2.5 MG/0.5 ML SYR G DR.REDDY'S LAB MLGEN 55111-0678-10 31.15640 FONDAPARINUX 2.5 MG/0.5 ML SYR G DR.REDDY'S LAB MLGEN 60505-6078-00 31.15640 FONDAPARINUX 2.5 MG/0.5 ML SYR G APOTEX CORP MLGEN 60505-6078-04 31.15640 FONDAPARINUX 2.5 MG/0.5 ML SYR G APOTEX CORP MLGEN 55111-0679-02 180.51280 FONDAPARINUX 5 MG/0.4 ML SYR G DR.REDDY'S LAB MLGEN 55111-0679-10 180.51280 FONDAPARINUX 5 MG/0.4 ML SYR G DR.REDDY'S LAB MLGEN 60505-6079-00 180.51280 FONDAPARINUX 5 MG/0.4 ML SYR G APOTEX CORP MLGEN 60505-6079-04 180.51280 FONDAPARINUX 5 MG/0.4 ML SYR G APOTEX CORP MLGEN 55111-0680-02 151.91010 FONDAPARINUX 7.5 MG/0.6 ML SYR G DR.REDDY'S LAB MLGEN 55111-0680-10 151.91010 FONDAPARINUX 7.5 MG/0.6 ML SYR G DR.REDDY'S LAB ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-6080-00 151.91010 FONDAPARINUX 7.5 MG/0.6 ML SYR G APOTEX CORP MLGEN 60505-6080-04 151.91010 FONDAPARINUX 7.5 MG/0.6 ML SYR G APOTEX CORP MLBND 00085-1401-01 3.33923 FORADIL AEROLIZER 12 MCG CAP G MERCK SHARP & D EABND 00085-1402-01 4.12510 FORADIL AEROLIZER 12 MCG CAP G MERCK SHARP & D EABND 59630-0575-60 7.32850 27.11693 FORTAMET ER 1,000 MG TABLET G SHIONOGI PHARMA EABND 59630-0574-60 4.21031 27.11693 FORTAMET ER 500 MG TABLET G SHIONOGI PHARMA EABND 00173-0434-00 12.20697 FORTAZ 1 GM ADD-VANTAGE VIAL 0 COVIS PHARMACEU EABND 24987-0434-00 12.90816 FORTAZ 1 GM TWISTVIAL 0 COVIS PHARMACEU EABND 00173-0378-10 5.08800 11.81256 FORTAZ 1 GM VIAL 0 COVIS PHARMACEU EABND 24987-0378-10 5.08800 11.81256 FORTAZ 1 GM VIAL 0 COVIS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0435-00 18.70800 24.01439 FORTAZ 2 GM ADD-VANTAGE VIAL 0 COVIS PHARMACEU EABND 24987-0435-00 18.70800 25.39800 FORTAZ 2 GM TWISTVIAL 0 COVIS PHARMACEU EABND 00173-0379-34 10.10130 23.61599 FORTAZ 2 GM VIAL 0 COVIS PHARMACEU EABND 24987-0379-34 10.10130 23.61599 FORTAZ 2 GM VIAL 0 COVIS PHARMACEU EABND 00173-0382-37 24.93817 68.72400 FORTAZ 6 GM VIAL 0 COVIS PHARMACEU 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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