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

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