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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 156LIST 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 00378-0208-10 0.01013 FUROSEMIDE 20 MG TABLET 0 MYLAN EAGEN 00378-0208-93 0.01013 FUROSEMIDE 20 MG TABLET 0 MYLAN EAGEN 00603-3739-21 0.01013 FUROSEMIDE 20 MG TABLET 0 QUALITEST EAGEN 00603-3739-32 0.01013 FUROSEMIDE 20 MG TABLET 0 QUALITEST EAGEN 00603-3739-34 0.01013 FUROSEMIDE 20 MG TABLET 0 QUALITEST EAGEN 00781-1818-01 0.01013 FUROSEMIDE 20 MG TABLET 0 SANDOZ EAGEN 00781-1818-10 0.01013 FUROSEMIDE 20 MG TABLET 0 SANDOZ EAGEN 00904-5796-61 0.01013 FUROSEMIDE 20 MG TABLET 0 MAJOR PHARMACEU EAGEN 50742-0104-01 0.01013 FUROSEMIDE 20 MG TABLET 0 INGENUS PHARMAC EAGEN 50742-0104-10 0.01013 FUROSEMIDE 20 MG TABLET 0 INGENUS PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0072-20 0.01013 FUROSEMIDE 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0072-30 0.01013 FUROSEMIDE 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0072-56 0.01013 FUROSEMIDE 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 63304-0624-01 0.01013 FUROSEMIDE 20 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0624-10 0.01013 FUROSEMIDE 20 MG TABLET 0 RANBAXY PHARMAC EAGEN 64125-0116-01 0.01013 FUROSEMIDE 20 MG TABLET 0 EXCELLIUM PHARM EAGEN 64125-0116-10 0.01013 FUROSEMIDE 20 MG TABLET 0 EXCELLIUM PHARM EAGEN 68084-0014-11 0.01013 FUROSEMIDE 20 MG TABLET 0 AHP EAGEN 00054-4299-25 0.01170 FUROSEMIDE 40 MG TABLET 0 ROXANE LABS. EAGEN 00054-4299-31 0.01170 FUROSEMIDE 40 MG TABLET 0 ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-8299-25 0.01170 FUROSEMIDE 40 MG TABLET 0 ROXANE LABS. EAGEN 00172-2907-60 0.01170 FUROSEMIDE 40 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-2907-80 0.01170 FUROSEMIDE 40 MG TABLET 0 IVAX PHARMACEUT EAGEN 00378-0216-01 0.01170 FUROSEMIDE 40 MG TABLET 0 MYLAN EAGEN 00378-0216-10 0.01170 FUROSEMIDE 40 MG TABLET 0 MYLAN EAGEN 00378-0216-93 0.01170 FUROSEMIDE 40 MG TABLET 0 MYLAN EAGEN 00603-3740-21 0.01170 FUROSEMIDE 40 MG TABLET 0 QUALITEST EAGEN 00603-3740-32 0.01170 FUROSEMIDE 40 MG TABLET 0 QUALITEST EAGEN 00603-3740-34 0.01170 FUROSEMIDE 40 MG TABLET 0 QUALITEST EAGEN 00781-1966-01 0.01170 FUROSEMIDE 40 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-1966-10 0.01170 FUROSEMIDE 40 MG TABLET 0 SANDOZ EAGEN 00904-5797-61 0.01170 FUROSEMIDE 40 MG TABLET 0 MAJOR PHARMACEU EAGEN 50742-0105-10 0.01170 FUROSEMIDE 40 MG TABLET 0 INGENUS PHARMAC EAGEN 51079-0073-20 0.01170 FUROSEMIDE 40 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0073-30 0.01170 FUROSEMIDE 40 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0073-56 0.01170 FUROSEMIDE 40 MG TABLET 0 MYLAN INSTITUTI EAGEN 58517-0400-30 0.01170 FUROSEMIDE 40 MG TABLET 0 NEW HORIZON RX EAGEN 63304-0625-01 0.01170 FUROSEMIDE 40 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0625-10 0.01170 FUROSEMIDE 40 MG TABLET 0 RANBAXY PHARMAC EAGEN 63739-0542-01 0.01170 FUROSEMIDE 40 MG TABLET 0 MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63739-0542-04 0.01170 FUROSEMIDE 40 MG TABLET 0 MCKESSON PACKAG EAGEN 63739-0542-10 0.01170 FUROSEMIDE 40 MG TABLET 0 MCKESSON PACKAG EAGEN 64125-0117-01 0.01170 FUROSEMIDE 40 MG TABLET 0 EXCELLIUM PHARM EAGEN 64125-0117-10 0.01170 FUROSEMIDE 40 MG TABLET 0 EXCELLIUM PHARM EABND 00054-3298-63 0.07242 FUROSEMIDE 40 MG/5 ML SOLN 0 ROXANE LABS. ML** 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: 157LIST 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 00054-4301-25 0.02730 FUROSEMIDE 80 MG TABLET 0 ROXANE LABS. EAGEN 00054-4301-29 0.02730 FUROSEMIDE 80 MG TABLET 0 ROXANE LABS. EAGEN 00054-8301-25 0.02730 FUROSEMIDE 80 MG TABLET 0 ROXANE LABS. EAGEN 00378-0232-01 0.02730 FUROSEMIDE 80 MG TABLET 0 MYLAN EAGEN 00378-0232-05 0.02730 FUROSEMIDE 80 MG TABLET 0 MYLAN EAGEN 00378-0232-93 0.02730 FUROSEMIDE 80 MG TABLET 0 MYLAN EAGEN 00603-3741-02 0.02730 FUROSEMIDE 80 MG TABLET 0 QUALITEST EAGEN 00603-3741-04 0.02730 FUROSEMIDE 80 MG TABLET 0 QUALITEST EAGEN 00603-3741-21 0.02730 FUROSEMIDE 80 MG TABLET 0 QUALITEST EAGEN 00603-3741-28 0.02730 FUROSEMIDE 80 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-3741-32 0.02730 FUROSEMIDE 80 MG TABLET 0 QUALITEST EAGEN 00781-1446-01 0.02730 FUROSEMIDE 80 MG TABLET 0 SANDOZ EAGEN 00781-1446-05 0.02730 FUROSEMIDE 80 MG TABLET 0 SANDOZ EAGEN 00904-5798-61 0.02730 FUROSEMIDE 80 MG TABLET 0 MAJOR PHARMACEU EAGEN 50742-0106-01 0.02730 FUROSEMIDE 80 MG TABLET 0 INGENUS PHARMAC EAGEN 50742-0106-05 0.02730 FUROSEMIDE 80 MG TABLET 0 INGENUS PHARMAC EAGEN 51079-0527-20 0.02730 FUROSEMIDE 80 MG TABLET 0 MYLAN INSTITUTI EAGEN 63304-0626-01 0.02730 FUROSEMIDE 80 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0626-05 0.02730 FUROSEMIDE 80 MG TABLET 0 RANBAXY PHARMAC EAGEN 64125-0118-01 0.02730 FUROSEMIDE 80 MG TABLET 0 EXCELLIUM PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64125-0118-05 0.02730 FUROSEMIDE 80 MG TABLET 0 EXCELLIUM PHARM EAGEN 68084-0017-11 0.02730 FUROSEMIDE 80 MG TABLET 0 AHP EABND 00004-0381-40 48.60328 FUZEON 90 MG VIAL G GENENTECH, INC. EAGEX 38779-2461-08 39.18750 GABAPENTIN POWDER 0 MEDISCA INC. GMGEX 00143-9992-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 WEST-WARD,INC. EAGEX 00228-2665-11 0.05090 GABAPENTIN 100 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00228-2665-50 0.05090 GABAPENTIN 100 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00378-5426-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 MYLAN EAGEX 00378-5426-05 0.05090 GABAPENTIN 100 MG CAPSULE 0 MYLAN EAGEX 00904-5631-61 0.05090 GABAPENTIN 100 MG CAPSULE 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-5631-93 0.05090 GABAPENTIN 100 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-6078-61 0.05090 GABAPENTIN 100 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 14550-0511-02 0.05090 GABAPENTIN 100 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 14550-0511-04 0.05090 GABAPENTIN 100 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 16714-0661-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 16714-0661-02 0.05090 GABAPENTIN 100 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 31722-0221-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 CAMBER PHARMACE EAGEX 31722-0221-05 0.05090 GABAPENTIN 100 MG CAPSULE 0 CAMBER PHARMACE EAGEX 51991-0337-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 BRECKENRIDGE EAGEX 52343-0030-01 0.02257 GABAPENTIN 100 MG CAPSULE 0 GEN-SOURCE RX EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 52343-0030-18 0.02545 GABAPENTIN 100 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0030-27 0.02347 GABAPENTIN 100 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0030-90 0.02283 GABAPENTIN 100 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0030-99 0.01974 GABAPENTIN 100 MG CAPSULE 0 GEN-SOURCE RX EAGEX 53746-0101-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 AMNEAL PHARMACE 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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