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

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