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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 165LIST 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 00013-2658-02 191.16916 GENOTROPIN MINIQUICK 2 MG G PHARMACIA/UPJHN EABND 00013-2646-81 1052.35700 GENOTROPIN 12 MG CARTRIDGE G PHARMACIA/UPJHN EABND 00013-2626-81 438.47240 GENOTROPIN 5 MG CARTRIDGE G PHARMACIA/UPJHN EAGEN 17478-0284-35 4.21500 GENTAK 3 MG/GM EYE OINTMENT 0 AKORN INC. GMGUL 17478-0283-10 0.57000 GENTAK 3 MG/ML EYE DROPS 0 AKORN INC. MLBND 63323-0173-02 1.96212 GENTAMICIN PED 20 MG/2 ML VIAL 0 APP PHARMACEUTI MLBND 63323-0173-95 0.85656 GENTAMICIN PED 20 MG/2 ML VIAL 0 APP/NOVAPLUS MLBND 45802-0056-11 0.08730 1.82157 GENTAMICIN 0.1% CREAM 0 PERRIGO CO. GMBND 45802-0056-35 0.08730 1.82157 GENTAMICIN 0.1% CREAM 0 PERRIGO CO. GMBND 45802-0046-11 0.08640 1.82157 GENTAMICIN 0.1% OINTMENT 0 PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 45802-0046-35 0.08640 1.82157 GENTAMICIN 0.1% OINTMENT 0 PERRIGO CO. GMBND 00409-3401-01 0.18550 GENTAMICIN 10 MG/ML VIAL 0 HOSPIRA MLBND 00409-3402-01 0.14840 GENTAMICIN 10 MG/ML VIAL 0 HOSPIRA MLBND 63323-0513-02 2.07500 GENTAMICIN 20 MG/2 ML VIAL 0 APP PHARMACEUTI MLGEN 00574-4102-35 4.28142 GENTAMICIN 3 MG/GM EYE OINT 0 PERRIGO CO. GMGEN 48102-0102-35 4.28142 GENTAMICIN 3 MG/GM EYE OINT 0 PERRIGO CO. GMGUL 24208-0580-60 0.57000 GENTAMICIN 3 MG/ML EYE DROPS 0 VALEANT MLGUL 24208-0580-64 0.57000 GENTAMICIN 3 MG/ML EYE DROPS 0 VALEANT MLGUL 60758-0188-05 0.57000 GENTAMICIN 3 MG/ML EYE DROPS 0 PACIFIC PHARMA MLGUL 61314-0633-05 0.57000 GENTAMICIN 3 MG/ML EYE DROPS 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0010-20 0.72900 GENTAMICIN 40 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0010-95 0.44100 GENTAMICIN 40 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 00409-7879-13 0.08622 GENTAMICIN 60 MG/NS 50 ML PB 0 HOSPIRA MLGEN 00409-7883-13 0.06570 GENTAMICIN 80 MG/NS 50 ML PB 0 HOSPIRA MLGEN 00409-1207-03 0.47250 GENTAMICIN 80 MG/2 ML VIAL 0 HOSPIRA MLGEN 63323-0010-02 1.16100 GENTAMICIN 80 MG/2 ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0010-94 0.37800 GENTAMICIN 80 MG/2 ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0010-96 0.46170 GENTAMICIN 800 MG/20 ML VIAL 0 APP/NOVAPLUS MLBEX 00049-3960-60 3.37750 10.70519 GEODON 20 MG CAPSULE G PFIZER US PHARM EABEX 00049-3920-83 21.95516 GEODON 20 MG/ML VIAL G PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00049-3970-60 2.39850 10.70519 GEODON 40 MG CAPSULE G PFIZER US PHARM EABEX 00049-3980-60 3.85300 12.99130 GEODON 60 MG CAPSULE G PFIZER US PHARM EABEX 00049-3990-60 4.26398 12.99130 GEODON 80 MG CAPSULE G PFIZER US PHARM EABEX 00093-5423-28 2.04356 2.09911 GIANVI 3 MG-0.02 MG TABLET 0 TEVA USA EABEX 00093-5423-58 2.04356 2.09911 GIANVI 3 MG-0.02 MG TABLET 0 TEVA USA EABND 65649-0102-02 4.15000 GIAZO 1.1 GM TABLET G SALIX PHARMACEU EAGEX 00603-3590-17 1.12980 GILDAGIA 0.4 MG-0.035 MG TAB 0 QUALITEST EAGEX 00603-7608-17 0.72384 GILDESS FE 1.5-30 TABLET 0 QUALITEST EAGEX 00603-7609-17 0.71880 GILDESS FE 1-20 TABLET 0 QUALITEST EAGEX 00603-7607-15 1.00280 GILDESS 1 MG-20 MCG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-7607-48 1.00280 GILDESS 1 MG-20 MCG TABLET 0 QUALITEST EAGEX 00603-7606-15 1.00290 GILDESS 1.5 MG-30 MCG TABLET 0 QUALITEST EAGEX 00603-7606-48 1.00290 GILDESS 1.5 MG-30 MCG TABLET 0 QUALITEST EABND 00078-0607-51 173.12436 GILENYA 0.5 MG CAPSULE G NOVARTIS EABND 00597-0141-30 199.00080 GILOTRIF 20 MG TABLET 0 BOEHRINGER ING. 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