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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 158LIST 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 53746-0101-05 0.05090 GABAPENTIN 100 MG CAPSULE 0 AMNEAL PHARMACE EAGEX 53746-0101-10 0.05090 GABAPENTIN 100 MG CAPSULE 0 AMNEAL PHARMACE EAGUX 59762-5026-01 0.08250 GABAPENTIN 100 MG CAPSULE 0 GREENSTONE LLC. EAGEX 60505-0112-00 0.05090 GABAPENTIN 100 MG CAPSULE 0 APOTEX CORP EAGEX 60505-0112-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 APOTEX CORP EAGEX 60505-0112-07 0.05090 GABAPENTIN 100 MG CAPSULE 0 APOTEX CORP EAGEX 60505-0112-08 0.05090 GABAPENTIN 100 MG CAPSULE 0 APOTEX CORP EAGEX 62756-0137-02 0.05090 GABAPENTIN 100 MG CAPSULE 0 SUN PHARMACEUTI EAGEX 62756-0137-05 0.05090 GABAPENTIN 100 MG CAPSULE 0 SUN PHARMACEUTI EAGEX 63739-0374-10 0.05090 GABAPENTIN 100 MG CAPSULE 0 MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0198-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0198-05 0.05090 GABAPENTIN 100 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0198-99 0.05090 GABAPENTIN 100 MG CAPSULE 0 AUROBINDO PHARM EAGEX 67877-0222-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 ASCEND LABORATO EAGEX 67877-0222-05 0.05090 GABAPENTIN 100 MG CAPSULE 0 ASCEND LABORATO EAGEX 67877-0222-10 0.05090 GABAPENTIN 100 MG CAPSULE 0 ASCEND LABORATO EAGEX 68084-0594-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 AHP EAGEX 76282-0321-01 0.05090 GABAPENTIN 100 MG CAPSULE 0 EXELAN PHARMACE EAGEX 50383-0311-47 0.23260 GABAPENTIN 250 MG/5 ML SOLN 0 HI-TECH PHARMAC MLGEX 59762-5025-01 0.23260 GABAPENTIN 250 MG/5 ML SOLN 0 GREENSTONE LLC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00143-9993-01 0.06642 GABAPENTIN 300 MG CAPSULE 0 WEST-WARD,INC. EAGEX 00228-2666-11 0.06642 GABAPENTIN 300 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00228-2666-50 0.06642 GABAPENTIN 300 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00378-5427-01 0.06642 GABAPENTIN 300 MG CAPSULE 0 MYLAN EAGEX 00378-5427-05 0.06642 GABAPENTIN 300 MG CAPSULE 0 MYLAN EAGEX 00904-5632-40 0.06642 GABAPENTIN 300 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5632-46 0.06642 GABAPENTIN 300 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5632-52 0.06642 GABAPENTIN 300 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5632-53 0.06642 GABAPENTIN 300 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5632-61 0.06642 GABAPENTIN 300 MG CAPSULE 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-5632-89 0.06642 GABAPENTIN 300 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5632-93 0.06642 GABAPENTIN 300 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-6079-61 0.06642 GABAPENTIN 300 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 14550-0512-02 0.06642 GABAPENTIN 300 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 14550-0512-04 0.06642 GABAPENTIN 300 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 16714-0662-01 0.06642 GABAPENTIN 300 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 16714-0662-02 0.06642 GABAPENTIN 300 MG CAPSULE 0 NORTHSTAR RX LL EAGEX 31722-0222-01 0.06642 GABAPENTIN 300 MG CAPSULE 0 CAMBER PHARMACE EAGEX 31722-0222-05 0.06642 GABAPENTIN 300 MG CAPSULE 0 CAMBER PHARMACE EAGEX 51991-0338-01 0.06642 GABAPENTIN 300 MG CAPSULE 0 BRECKENRIDGE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 52343-0031-01 0.02985 GABAPENTIN 300 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0031-18 0.02854 GABAPENTIN 300 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0031-27 0.02980 GABAPENTIN 300 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0031-30 0.03399 GABAPENTIN 300 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0031-60 0.04074 GABAPENTIN 300 MG CAPSULE 0 GEN-SOURCE RX 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