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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 162LIST 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 47335-0837-83 4.77350 GALANTAMINE ER 24 MG CAPSULE 0 SUN PHARMA GLOB EAGEN 00115-1120-08 3.13700 GALANTAMINE ER 8 MG CAPSULE 0 GLOBAL PHARM EAGEN 00378-8105-93 3.13700 GALANTAMINE ER 8 MG CAPSULE 0 MYLAN EAGEN 00555-1020-01 3.13700 GALANTAMINE ER 8 MG CAPSULE 0 BARR EAGEN 00591-3496-30 3.13700 GALANTAMINE ER 8 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 10147-0891-03 3.13700 GALANTAMINE ER 8 MG CAPSULE 0 PATRIOT PHARMAC EAGEN 47335-0835-83 3.13700 GALANTAMINE ER 8 MG CAPSULE 0 SUN PHARMA GLOB EAGEN 00378-2723-91 1.87151 GALANTAMINE HBR 12 MG TABLET 0 MYLAN EAGEN 00555-0140-09 1.87151 GALANTAMINE HBR 12 MG TABLET 0 BARR EAGEN 10147-0883-06 1.87151 GALANTAMINE HBR 12 MG TABLET 0 PATRIOT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0854-01 1.87151 GALANTAMINE HBR 12 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0854-03 1.87151 GALANTAMINE HBR 12 MG TABLET 0 MYLAN INSTITUTI EAGEN 59762-0010-01 1.87151 GALANTAMINE HBR 12 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-2544-06 1.87151 GALANTAMINE HBR 12 MG TABLET 0 APOTEX CORP EAGEN 65862-0460-60 1.87151 GALANTAMINE HBR 12 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0179-14 1.87151 GALANTAMINE HBR 12 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00378-2721-91 1.87407 GALANTAMINE HBR 4 MG TABLET 0 MYLAN EAGEN 00555-0138-09 1.87407 GALANTAMINE HBR 4 MG TABLET 0 BARR EAGEN 10147-0881-06 1.87407 GALANTAMINE HBR 4 MG TABLET 0 PATRIOT PHARMAC EAGEN 51079-0852-01 1.87407 GALANTAMINE HBR 4 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0852-03 1.87407 GALANTAMINE HBR 4 MG TABLET 0 MYLAN INSTITUTI EAGEN 59762-0008-01 1.87407 GALANTAMINE HBR 4 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-2542-06 1.87407 GALANTAMINE HBR 4 MG TABLET 0 APOTEX CORP EAGEN 65862-0458-60 1.87407 GALANTAMINE HBR 4 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0492-11 1.87407 GALANTAMINE HBR 4 MG TABLET 0 AHP EAGEN 68084-0492-21 1.87407 GALANTAMINE HBR 4 MG TABLET 0 AHP EAGEN 68382-0177-14 1.87407 GALANTAMINE HBR 4 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00378-2722-91 1.86638 GALANTAMINE HBR 8 MG TABLET 0 MYLAN EAGEN 00555-0139-09 1.86638 GALANTAMINE HBR 8 MG TABLET 0 BARR EAGEN 10147-0882-06 1.86638 GALANTAMINE HBR 8 MG TABLET 0 PATRIOT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0853-01 1.86638 GALANTAMINE HBR 8 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0853-03 1.86638 GALANTAMINE HBR 8 MG TABLET 0 MYLAN INSTITUTI EAGEN 59762-0009-01 1.86638 GALANTAMINE HBR 8 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-2543-06 1.86638 GALANTAMINE HBR 8 MG TABLET 0 APOTEX CORP EAGEN 65862-0459-60 1.86638 GALANTAMINE HBR 8 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0178-14 1.86638 GALANTAMINE HBR 8 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00054-0137-49 2.20072 GALANTAMINE 4 MG/ML ORAL SOLN 0 ROXANE LABS. MLBND 57844-0215-52 1.24154 GALZIN 25 MG CAPSULE 0 GATE PHARM EABND 57844-0208-52 2.06922 GALZIN 50 MG CAPSULE 0 GATE PHARM EABND 13533-0635-12 28.36774 GAMASTAN S-D VIAL 0 GRIFOLS THERAPE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00944-2700-02 12.39107 GAMMAGARD LIQUID 10% VIAL 0 BAXTER BIOSCIEN MLBND 00944-2700-03 12.39156 GAMMAGARD LIQUID 10% VIAL 0 BAXTER BIOSCIEN MLBND 00944-2700-04 12.39123 GAMMAGARD LIQUID 10% VIAL 0 BAXTER BIOSCIEN MLBND 00944-2700-05 12.39123 GAMMAGARD LIQUID 10% VIAL 0 BAXTER BIOSCIEN MLBND 00944-2700-06 12.39123 GAMMAGARD LIQUID 10% VIAL 0 BAXTER BIOSCIEN 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: 163LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00944-2700-07 12.39123 GAMMAGARD LIQUID 10% VIAL 0 BAXTER BIOSCIEN MLBND 00944-2655-04 1411.92960 GAMMAGARD S-D 10 G (IGA
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