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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 166LIST 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 00597-0137-30 199.00080 GILOTRIF 30 MG TABLET 0 BOEHRINGER ING. EABND 00597-0138-30 199.00080 GILOTRIF 40 MG TABLET 0 BOEHRINGER ING. EABND 00944-2884-01 0.48140 GLASSIA 1 GM/50 ML VIAL 0 BAXTER BIOSCIEN EABND 00078-0401-34 70.58301 GLEEVEC 100 MG TABLET 0 NOVARTIS EABND 00078-0438-15 254.33717 GLEEVEC 400 MG TABLET 0 NOVARTIS EAGEN 00093-7254-01 0.02930 GLIMEPIRIDE 1 MG TABLET G TEVA USA EAGEN 00378-4011-01 0.02930 GLIMEPIRIDE 1 MG TABLET G MYLAN EAGEN 00603-3744-21 0.02930 GLIMEPIRIDE 1 MG TABLET G QUALITEST EAGEN 00603-3744-28 0.02930 GLIMEPIRIDE 1 MG TABLET G QUALITEST EAGEN 16729-0001-01 0.02930 GLIMEPIRIDE 1 MG TABLET G ACCORD HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42571-0100-05 0.02930 GLIMEPIRIDE 1 MG TABLET G MICRO LABS USA, EAGEN 45802-0770-78 0.02930 GLIMEPIRIDE 1 MG TABLET G PERRIGO CO. EAGEN 54458-0968-10 0.02930 GLIMEPIRIDE 1 MG TABLET G INTERNATIONAL L EAGEN 55111-0320-01 0.02930 GLIMEPIRIDE 1 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0320-05 0.02930 GLIMEPIRIDE 1 MG TABLET G DR.REDDY'S LAB EAGEN 76439-0123-10 0.02930 GLIMEPIRIDE 1 MG TABLET G VIRTUS PHARMACE EAGEN 00093-7255-01 0.04347 GLIMEPIRIDE 2 MG TABLET G TEVA USA EAGEN 00378-4012-01 0.04347 GLIMEPIRIDE 2 MG TABLET G MYLAN EAGEN 00603-3745-21 0.04347 GLIMEPIRIDE 2 MG TABLET G QUALITEST EAGEN 00603-3745-28 0.04347 GLIMEPIRIDE 2 MG TABLET G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16729-0002-01 0.04347 GLIMEPIRIDE 2 MG TABLET G ACCORD HEALTHCA EAGEN 42571-0101-05 0.04347 GLIMEPIRIDE 2 MG TABLET G MICRO LABS USA, EAGEN 45802-0822-78 0.04347 GLIMEPIRIDE 2 MG TABLET G PERRIGO CO. EAGEN 51079-0425-01 0.04347 GLIMEPIRIDE 2 MG TABLET G MYLAN INSTITUTI EAGEN 51079-0425-20 0.04347 GLIMEPIRIDE 2 MG TABLET G MYLAN INSTITUTI EAGEN 54458-0967-10 0.04347 GLIMEPIRIDE 2 MG TABLET G INTERNATIONAL L EAGEN 55111-0321-01 0.04347 GLIMEPIRIDE 2 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0321-05 0.04347 GLIMEPIRIDE 2 MG TABLET G DR.REDDY'S LAB EAGEN 66993-0163-02 0.04347 GLIMEPIRIDE 2 MG TABLET G PRASCO LABS EAGEN 68084-0326-01 0.04347 GLIMEPIRIDE 2 MG TABLET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0326-11 0.04347 GLIMEPIRIDE 2 MG TABLET G AHP EAGEN 76439-0124-10 0.04347 GLIMEPIRIDE 2 MG TABLET G VIRTUS PHARMACE EAGEN 00093-7256-01 0.06910 GLIMEPIRIDE 4 MG TABLET G TEVA USA EAGEN 00093-7256-52 0.06910 GLIMEPIRIDE 4 MG TABLET G TEVA USA EAGEN 00378-4013-01 0.06910 GLIMEPIRIDE 4 MG TABLET G MYLAN EAGEN 00603-3746-21 0.06910 GLIMEPIRIDE 4 MG TABLET G QUALITEST EAGEN 00603-3746-28 0.06910 GLIMEPIRIDE 4 MG TABLET G QUALITEST EAGEN 16729-0003-01 0.06910 GLIMEPIRIDE 4 MG TABLET G ACCORD HEALTHCA EAGEN 42571-0103-05 0.06910 GLIMEPIRIDE 4 MG TABLET G MICRO LABS USA, EAGEN 45802-0947-78 0.06910 GLIMEPIRIDE 4 MG TABLET G PERRIGO CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0426-01 0.06910 GLIMEPIRIDE 4 MG TABLET G MYLAN INSTITUTI EAGEN 51079-0426-20 0.06910 GLIMEPIRIDE 4 MG TABLET G MYLAN INSTITUTI EAGEN 54458-0966-10 0.06910 GLIMEPIRIDE 4 MG TABLET G INTERNATIONAL L EAGEN 55111-0322-01 0.06910 GLIMEPIRIDE 4 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0322-05 0.06910 GLIMEPIRIDE 4 MG TABLET G DR.REDDY'S LAB 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: 167LIST 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 61442-0117-01 0.06910 GLIMEPIRIDE 4 MG TABLET G CARLSBAD TECH EAGEN 66993-0164-02 0.06910 GLIMEPIRIDE 4 MG TABLET G PRASCO LABS EAGEN 68084-0327-01 0.06910 GLIMEPIRIDE 4 MG TABLET G AHP EAGEN 68084-0327-11 0.06910 GLIMEPIRIDE 4 MG TABLET G AHP EAGEN 76439-0125-10 0.06910 GLIMEPIRIDE 4 MG TABLET G VIRTUS PHARMACE EAGEN 00591-0845-01 0.36194 GLIPIZIDE ER 10 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-0845-10 0.36194 GLIPIZIDE ER 10 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-0845-15 0.36194 GLIPIZIDE ER 10 MG TABLET G ACTAVIS PHARMA, EAGEN 49884-0746-01 0.36194 GLIPIZIDE ER 10 MG TABLET G PAR PHARM. EAGEN 49884-0746-05 0.36194 GLIPIZIDE ER 10 MG TABLET G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0112-01 0.36194 GLIPIZIDE ER 10 MG TABLET G AHP EAGEN 68084-0112-11 0.36194 GLIPIZIDE ER 10 MG TABLET G AHP EAGEN 00591-0900-30 0.28350 GLIPIZIDE ER 2.5 MG TABLET G ACTAVIS PHARMA, EAGEN 68084-0295-11 0.28350 GLIPIZIDE ER 2.5 MG TABLET G AHP EAGEN 68084-0295-21 0.28350 GLIPIZIDE ER 2.5 MG TABLET G AHP EAGEN 00591-0844-01 0.18720 GLIPIZIDE ER 5 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-0844-10 0.18720 GLIPIZIDE ER 5 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-0844-15 0.18720 GLIPIZIDE ER 5 MG TABLET G ACTAVIS PHARMA, EAGEN 49884-0745-01 0.18720 GLIPIZIDE ER 5 MG TABLET G PAR PHARM. EAGEN 49884-0745-05 0.18720 GLIPIZIDE ER 5 MG TABLET G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0111-01 0.18720 GLIPIZIDE ER 5 MG TABLET G AHP EAGEN 68084-0111-11 0.18720 GLIPIZIDE ER 5 MG TABLET G AHP EAGEN 59762-5033-01 0.36194 GLIPIZIDE XL 10 MG TABLET G GREENSTONE LLC. EAGEN 59762-5033-02 0.36194 GLIPIZIDE XL 10 MG TABLET G GREENSTONE LLC. EAGEN 59762-5031-01 0.28350 GLIPIZIDE XL 2.5 MG TABLET G GREENSTONE LLC. EAGEN 59762-0541-01 0.18720 GLIPIZIDE XL 5 MG TABLET G GREENSTONE LLC. EAGEN 59762-0541-02 0.18720 GLIPIZIDE XL 5 MG TABLET G GREENSTONE LLC. EAGEN 59762-5032-01 0.18720 GLIPIZIDE XL 5 MG TABLET G GREENSTONE LLC. EAGEN 59762-5032-02 0.18720 GLIPIZIDE XL 5 MG TABLET G GREENSTONE LLC. EAGEN 00172-3650-60 0.05265 GLIPIZIDE 10 MG TABLET G IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00172-3650-70 0.05265 GLIPIZIDE 10 MG TABLET G IVAX PHARMACEUT EAGEN 00378-1110-01 0.05265 GLIPIZIDE 10 MG TABLET G MYLAN EAGEN 00378-1110-05 0.05265 GLIPIZIDE 10 MG TABLET G MYLAN EAGEN 00591-0461-01 0.05265 GLIPIZIDE 10 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-0461-05 0.05265 GLIPIZIDE 10 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-0461-10 0.05265 GLIPIZIDE 10 MG TABLET G ACTAVIS PHARMA, EAGEN 00781-1453-01 0.05265 GLIPIZIDE 10 MG TABLET G SANDOZ EAGEN 00781-1453-10 0.05265 GLIPIZIDE 10 MG TABLET G SANDOZ EAGEN 00904-6123-61 0.05265 GLIPIZIDE 10 MG TABLET G MAJOR PHARMACEU EAGEN 16729-0140-00 0.05265 GLIPIZIDE 10 MG TABLET G ACCORD HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16729-0140-16 0.05265 GLIPIZIDE 10 MG TABLET G ACCORD HEALTHCA EAGEN 60505-0142-00 0.05265 GLIPIZIDE 10 MG TABLET G APOTEX CORP EAGEN 60505-0142-01 0.05265 GLIPIZIDE 10 MG TABLET G APOTEX CORP EAGEN 60505-0142-02 0.05265 GLIPIZIDE 10 MG TABLET G APOTEX CORP EAGEN 60505-0142-04 0.05265 GLIPIZIDE 10 MG TABLET G APOTEX CORP 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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