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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 160LIST 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 52343-0032-01 0.03540 GABAPENTIN 400 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0032-05 0.03312 GABAPENTIN 400 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0032-27 0.03650 GABAPENTIN 400 MG CAPSULE 0 GEN-SOURCE RX EAGEX 52343-0032-90 0.03650 GABAPENTIN 400 MG CAPSULE 0 GEN-SOURCE RX EAGEX 53746-0103-01 0.09977 GABAPENTIN 400 MG CAPSULE 0 AMNEAL PHARMACE EAGEX 53746-0103-05 0.09977 GABAPENTIN 400 MG CAPSULE 0 AMNEAL PHARMACE EAGEX 59762-5028-01 0.09977 GABAPENTIN 400 MG CAPSULE 0 GREENSTONE LLC. EAGEX 60505-0114-00 0.09977 GABAPENTIN 400 MG CAPSULE 0 APOTEX CORP EAGEX 60505-0114-01 0.09977 GABAPENTIN 400 MG CAPSULE 0 APOTEX CORP EAGEX 60505-0114-05 0.09977 GABAPENTIN 400 MG CAPSULE 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-0114-07 0.09977 GABAPENTIN 400 MG CAPSULE 0 APOTEX CORP EAGEX 62756-0139-02 0.09977 GABAPENTIN 400 MG CAPSULE 0 SUN PHARMACEUTI EAGEX 62756-0139-05 0.09977 GABAPENTIN 400 MG CAPSULE 0 SUN PHARMACEUTI EAGEX 63739-0376-10 0.09977 GABAPENTIN 400 MG CAPSULE 0 MCKESSON PACKAG EAGEX 65862-0200-01 0.09977 GABAPENTIN 400 MG CAPSULE 0 AUROBINDO PHARM EAGEX 65862-0200-05 0.09977 GABAPENTIN 400 MG CAPSULE 0 AUROBINDO PHARM EAGEX 67877-0224-01 0.09977 GABAPENTIN 400 MG CAPSULE 0 ASCEND LABORATO EAGEX 67877-0224-05 0.09977 GABAPENTIN 400 MG CAPSULE 0 ASCEND LABORATO EAGEX 67877-0224-10 0.09977 GABAPENTIN 400 MG CAPSULE 0 ASCEND LABORATO EAGEX 68084-0595-01 0.09977 GABAPENTIN 400 MG CAPSULE 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0595-65 0.09977 GABAPENTIN 400 MG CAPSULE 0 AHP EAGEX 76282-0323-01 0.09977 GABAPENTIN 400 MG CAPSULE 0 EXELAN PHARMACE EAGEX 00093-4443-01 0.30150 GABAPENTIN 600 MG TABLET G TEVA USA EAGEX 00093-4443-05 0.30150 GABAPENTIN 600 MG TABLET G TEVA USA EAGEX 00093-4443-10 0.30150 GABAPENTIN 600 MG TABLET G TEVA USA EAGEX 00228-2636-11 0.30150 GABAPENTIN 600 MG TABLET G ACTAVIS PHARMA, EAGEX 00228-2636-50 0.30150 GABAPENTIN 600 MG TABLET G ACTAVIS PHARMA, EAGEX 16714-0330-01 0.30150 GABAPENTIN 600 MG TABLET G NORTHSTAR RX LL EAGEX 16714-0330-02 0.30150 GABAPENTIN 600 MG TABLET G NORTHSTAR RX LL EAGEX 31722-0405-01 0.30150 GABAPENTIN 600 MG TABLET G CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 31722-0405-05 0.30150 GABAPENTIN 600 MG TABLET G CAMBER PHARMACE EAGEX 59762-5023-01 0.30150 GABAPENTIN 600 MG TABLET G GREENSTONE LLC. EAGEX 60505-2551-01 0.30150 GABAPENTIN 600 MG TABLET G APOTEX CORP EAGEX 60505-2551-05 0.30150 GABAPENTIN 600 MG TABLET G APOTEX CORP EAGEX 62756-0202-01 0.30150 GABAPENTIN 600 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0202-03 0.30150 GABAPENTIN 600 MG TABLET G SUN PHARMACEUTI EAGEX 63739-0391-10 0.30150 GABAPENTIN 600 MG TABLET G MCKESSON PACKAG EAGEX 65862-0523-01 0.30150 GABAPENTIN 600 MG TABLET G AUROBINDO PHARM EAGEX 65862-0523-05 0.30150 GABAPENTIN 600 MG TABLET G AUROBINDO PHARM EAGEX 68001-0006-00 0.30150 GABAPENTIN 600 MG TABLET G BLUEPOINT LABOR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68001-0006-03 0.30150 GABAPENTIN 600 MG TABLET G BLUEPOINT LABOR EAGEX 68084-0624-01 0.30150 GABAPENTIN 600 MG TABLET G AHP EAGEX 68084-0624-11 0.30150 GABAPENTIN 600 MG TABLET G AHP EAGEX 68382-0204-01 0.30150 GABAPENTIN 600 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0204-05 0.30150 GABAPENTIN 600 MG TABLET G ZYDUS 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 161LIST 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 68462-0126-01 0.30150 GABAPENTIN 600 MG TABLET G GLENMARK PHARMA EAGEX 68462-0126-05 0.30150 GABAPENTIN 600 MG TABLET G GLENMARK PHARMA EAGEX 76282-0405-01 0.30150 GABAPENTIN 600 MG TABLET G EXELAN PHARMACE EAGEX 76282-0405-05 0.30150 GABAPENTIN 600 MG TABLET G EXELAN PHARMACE EAGEX 76282-0405-90 0.30150 GABAPENTIN 600 MG TABLET G EXELAN PHARMACE EAGEX 00093-4444-01 0.30510 GABAPENTIN 800 MG TABLET G TEVA USA EAGEX 00093-4444-05 0.30510 GABAPENTIN 800 MG TABLET G TEVA USA EAGEX 00228-2637-11 0.30510 GABAPENTIN 800 MG TABLET G ACTAVIS PHARMA, EAGEX 00228-2637-50 0.30510 GABAPENTIN 800 MG TABLET G ACTAVIS PHARMA, EAGEX 31722-0406-01 0.30510 GABAPENTIN 800 MG TABLET G CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 31722-0406-05 0.30510 GABAPENTIN 800 MG TABLET G CAMBER PHARMACE EAGEX 59762-5024-01 0.30510 GABAPENTIN 800 MG TABLET G GREENSTONE LLC. EAGEX 60505-2552-01 0.30510 GABAPENTIN 800 MG TABLET G APOTEX CORP EAGEX 60505-2552-05 0.30510 GABAPENTIN 800 MG TABLET G APOTEX CORP EAGEX 62756-0204-01 0.30510 GABAPENTIN 800 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0204-03 0.30510 GABAPENTIN 800 MG TABLET G SUN PHARMACEUTI EAGEX 65862-0524-01 0.30510 GABAPENTIN 800 MG TABLET G AUROBINDO PHARM EAGEX 65862-0524-05 0.30510 GABAPENTIN 800 MG TABLET G AUROBINDO PHARM EAGEX 68001-0007-00 0.30510 GABAPENTIN 800 MG TABLET G BLUEPOINT LABOR EAGEX 68001-0007-03 0.30510 GABAPENTIN 800 MG TABLET G BLUEPOINT LABOR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0625-01 0.30510 GABAPENTIN 800 MG TABLET G AHP EAGEX 68382-0205-01 0.30510 GABAPENTIN 800 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0205-05 0.30510 GABAPENTIN 800 MG TABLET G ZYDUS PHARMACEU EAGEX 68462-0127-01 0.30510 GABAPENTIN 800 MG TABLET G GLENMARK PHARMA EAGEX 68462-0127-05 0.30510 GABAPENTIN 800 MG TABLET G GLENMARK PHARMA EAGEX 76282-0406-01 0.30510 GABAPENTIN 800 MG TABLET G EXELAN PHARMACE EAGEX 76282-0406-05 0.30510 GABAPENTIN 800 MG TABLET G EXELAN PHARMACE EAGEX 76282-0406-90 0.30510 GABAPENTIN 800 MG TABLET G EXELAN PHARMACE EABEX 63459-0412-30 7.96800 GABITRIL 12 MG TABLET G CEPHALON,INC.-T EABEX 63459-0416-30 10.42480 GABITRIL 16 MG TABLET G CEPHALON,INC.-T EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 63459-0402-30 6.17520 6.17520 GABITRIL 2 MG TABLET 0 CEPHALON,INC.-T EABEX 63459-0404-30 6.17520 6.17520 GABITRIL 4 MG TABLET 0 CEPHALON,INC.-T EABND 45945-0155-02 10.70700 GABLOFEN 10,000 MCG/20 ML VIAL 0 CNS THERAPEUTIC MLBND 45945-0156-02 21.41400 GABLOFEN 20,000 MCG/20 ML VIAL 0 CNS THERAPEUTIC MLBND 45945-0157-01 46.06500 GABLOFEN 40,000 MCG/20 ML SYRG 0 CNS THERAPEUTIC MLBND 45945-0157-02 42.82800 GABLOFEN 40,000 MCG/20 ML VIAL 0 CNS THERAPEUTIC MLBND 45945-0151-01 79.68000 GABLOFEN 50 MCG/ML SYRINGE 0 CNS THERAPEUTIC MLGEN 00115-1121-08 2.01866 GALANTAMINE ER 16 MG CAPSULE 0 GLOBAL PHARM EAGEN 00378-8106-93 2.01866 GALANTAMINE ER 16 MG CAPSULE 0 MYLAN EAGEN 00555-1021-01 2.01866 GALANTAMINE ER 16 MG CAPSULE 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10147-0892-03 2.01866 GALANTAMINE ER 16 MG CAPSULE 0 PATRIOT PHARMAC EAGEN 47335-0836-83 2.01866 GALANTAMINE ER 16 MG CAPSULE 0 SUN PHARMA GLOB EAGEN 00115-1122-08 4.77350 GALANTAMINE ER 24 MG CAPSULE 0 GLOBAL PHARM EAGEN 00378-8107-93 4.77350 GALANTAMINE ER 24 MG CAPSULE 0 MYLAN EAGEN 10147-0893-03 4.57800 GALANTAMINE ER 24 MG CAPSULE 0 PATRIOT PHARMAC 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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