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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 168LIST 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 68645-0151-59 0.05265 GLIPIZIDE 10 MG TABLET G LEGACY PHARMACE EAGEN 00172-3649-60 0.01931 GLIPIZIDE 5 MG TABLET G IVAX PHARMACEUT EAGEN 00378-1105-01 0.01931 GLIPIZIDE 5 MG TABLET G MYLAN EAGEN 00378-1105-05 0.01931 GLIPIZIDE 5 MG TABLET G MYLAN EAGEN 00591-0460-01 0.01931 GLIPIZIDE 5 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-0460-05 0.01931 GLIPIZIDE 5 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-0460-10 0.01931 GLIPIZIDE 5 MG TABLET G ACTAVIS PHARMA, EAGEN 00781-1452-01 0.01931 GLIPIZIDE 5 MG TABLET G SANDOZ EAGEN 00781-1452-10 0.01931 GLIPIZIDE 5 MG TABLET G SANDOZ EAGEN 00904-6124-61 0.01931 GLIPIZIDE 5 MG TABLET G MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16729-0139-00 0.01931 GLIPIZIDE 5 MG TABLET G ACCORD HEALTHCA EAGEN 16729-0139-16 0.01931 GLIPIZIDE 5 MG TABLET G ACCORD HEALTHCA EAGEN 60505-0141-00 0.01931 GLIPIZIDE 5 MG TABLET G APOTEX CORP EAGEN 60505-0141-01 0.01931 GLIPIZIDE 5 MG TABLET G APOTEX CORP EAGEN 60505-0141-02 0.01931 GLIPIZIDE 5 MG TABLET G APOTEX CORP EAGEN 60505-0141-08 0.01931 GLIPIZIDE 5 MG TABLET G APOTEX CORP EAGEN 68645-0150-54 0.01931 GLIPIZIDE 5 MG TABLET G LEGACY PHARMACE EAGEN 00093-7455-01 0.41567 GLIPIZIDE-METFORMIN 2.5-250 MG 0 TEVA USA EAGEN 00378-3131-01 0.41567 GLIPIZIDE-METFORMIN 2.5-250 MG 0 MYLAN EAGEN 00591-3971-01 0.41567 GLIPIZIDE-METFORMIN 2.5-250 MG 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 23155-0115-01 0.41567 GLIPIZIDE-METFORMIN 2.5-250 MG 0 HERITAGE PHARMA EAGEN 00093-7456-01 0.41570 GLIPIZIDE-METFORMIN 2.5-500 MG 0 TEVA USA EAGEN 00378-3132-01 0.41570 GLIPIZIDE-METFORMIN 2.5-500 MG 0 MYLAN EAGEN 00591-3972-01 0.41570 GLIPIZIDE-METFORMIN 2.5-500 MG 0 ACTAVIS PHARMA, EAGEN 00093-7457-01 0.41690 GLIPIZIDE-METFORMIN 5-500 MG 0 TEVA USA EAGEN 00378-3133-01 0.41690 GLIPIZIDE-METFORMIN 5-500 MG 0 MYLAN EAGEN 00591-3973-01 0.41690 GLIPIZIDE-METFORMIN 5-500 MG 0 ACTAVIS PHARMA, EAGEN 23155-0117-01 0.41690 GLIPIZIDE-METFORMIN 5-500 MG 0 HERITAGE PHARMA EABND 00169-7065-15 164.34000 GLUCAGEN 1 MG HYPOKIT 0 NOVO NORDISK EABND 00169-7065-21 164.34000 GLUCAGEN 1 MG HYPOKIT 2-PACK 0 NOVO NORDISK EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 55390-0004-01 118.52400 GLUCAGEN 1 MG VIAL 0 BEDFORD LABS EABND 55390-0004-10 118.52400 GLUCAGEN 1 MG VIAL 0 BEDFORD LABS EABND 00002-8031-01 164.34000 GLUCAGON 1 MG EMERGENCY KIT 0 ELI LILLY & CO. EAGEN 49452-3285-01 0.59587 GLUCONOLACTONE POWDER 0 SPECTRUM GMBND 00087-6063-13 0.04185 0.94686 GLUCOPHAGE XR 500 MG TAB G BMS PRIMARYCARE EABND 00087-6064-13 0.20480 1.42046 GLUCOPHAGE XR 750 MG TAB G BMS PRIMARYCARE EABND 00087-6071-11 0.04104 1.91090 GLUCOPHAGE 1,000 MG TABLET G BMS PRIMARYCARE EABND 00087-6060-05 0.02633 0.92769 GLUCOPHAGE 500 MG TABLET G BMS PRIMARYCARE EABND 00087-6060-10 0.02633 0.92760 GLUCOPHAGE 500 MG TABLET G BMS PRIMARYCARE EABND 00087-6070-05 0.04077 1.57708 GLUCOPHAGE 850 MG TABLET G BMS PRIMARYCARE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00049-0178-07 0.36194 1.61791 GLUCOTROL XL 10 MG TABLET G PFIZER US PHARM EABND 00049-1560-66 0.36194 1.41315 GLUCOTROL XL 10 MG TABLET G PFIZER US PHARM EABND 00049-1560-73 0.36194 1.34591 GLUCOTROL XL 10 MG TABLET G PFIZER US PHARM EABND 00049-0170-01 0.28350 0.83553 GLUCOTROL XL 2.5 MG TABLET G PFIZER US PHARM EABND 00049-0174-02 0.18720 0.83572 GLUCOTROL XL 5 MG TABLET G PFIZER US PHARM 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: 169LIST 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 00049-1550-66 0.18720 0.78103 GLUCOTROL XL 5 MG TABLET G PFIZER US PHARM EABND 00049-1550-73 0.18720 0.83546 GLUCOTROL XL 5 MG TABLET G PFIZER US PHARM EABND 00049-4120-66 0.05265 1.56704 GLUCOTROL 10 MG TABLET G PFIZER US PHARM EABND 00049-4110-66 0.01931 0.83805 GLUCOTROL 5 MG TABLET G PFIZER US PHARM EABND 00087-6073-11 0.08978 1.22001 GLUCOVANCE 2.5-500 MG TABLET 0 BMS PRIMARYCARE EABND 00087-6074-11 0.08860 1.22001 GLUCOVANCE 5-500 MG TABLET 0 BMS PRIMARYCARE EABND 13913-0002-13 3.53580 GLUMETZA ER 500 MG TABLET G SANTARUS INC. EAGEN 00093-5710-01 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 TEVA USA EAGEN 00093-5710-05 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 TEVA USA EAGEN 00228-2751-11 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-2751-50 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 ACTAVIS PHARMA, EAGEN 23155-0233-01 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 HERITAGE PHARMA EAGEN 23155-0233-05 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 HERITAGE PHARMA EAGEN 55111-0695-01 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 DR.REDDY'S LAB EAGEN 65862-0080-01 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 AUROBINDO PHARM EAGEN 65862-0080-05 0.09220 GLYBURID-METFORMIN 1.25-250 MG 0 AUROBINDO PHARM EAGEN 00093-8034-01 0.03010 GLYBURIDE MICRO 1.5 MG TAB G TEVA USA EAGEN 00143-9918-01 0.03010 GLYBURIDE MICRO 1.5 MG TAB G WEST-WARD,INC. EAGEN 00378-1113-01 0.03010 GLYBURIDE MICRO 1.5 MG TAB G MYLAN EAGEN 67253-0460-10 0.03010 GLYBURIDE MICRO 1.5 MG TAB G DAVA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-8035-01 0.03092 GLYBURIDE MICRO 3 MG TABLET G TEVA USA EAGEN 00093-8035-05 0.03092 GLYBURIDE MICRO 3 MG TABLET G TEVA USA EAGEN 00143-9919-01 0.03092 GLYBURIDE MICRO 3 MG TABLET G WEST-WARD,INC. EAGEN 00143-9919-05 0.03092 GLYBURIDE MICRO 3 MG TABLET G WEST-WARD,INC. EAGEN 00378-1125-01 0.03092 GLYBURIDE MICRO 3 MG TABLET G MYLAN EAGEN 67253-0461-10 0.03092 GLYBURIDE MICRO 3 MG TABLET G DAVA PHARMACEUT EAGEN 67253-0461-11 0.03092 GLYBURIDE MICRO 3 MG TABLET G DAVA PHARMACEUT EAGEN 67253-0461-50 0.03092 GLYBURIDE MICRO 3 MG TABLET G DAVA PHARMACEUT EAGEN 00093-8036-01 0.06380 GLYBURIDE MICRO 6 MG TABLET G TEVA USA EAGEN 00143-9920-01 0.06380 GLYBURIDE MICRO 6 MG TABLET G WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00143-9920-05 0.06380 GLYBURIDE MICRO 6 MG TABLET G WEST-WARD,INC. EAGEN 00143-9920-10 0.06380 GLYBURIDE MICRO 6 MG TABLET G WEST-WARD,INC. EAGEN 00378-1142-01 0.06380 GLYBURIDE MICRO 6 MG TABLET G MYLAN EAGEN 67253-0462-10 0.06380 GLYBURIDE MICRO 6 MG TABLET G DAVA PHARMACEUT EAGEN 67253-0462-11 0.06380 GLYBURIDE MICRO 6 MG TABLET G DAVA PHARMACEUT EAGUL 00093-8342-01 0.12440 GLYBURIDE 1.25 MG TABLET G TEVA USA EAGEN 00093-9477-53 0.12440 GLYBURIDE 1.25 MG TABLET G TEVA USA EAGUL 23155-0056-01 0.12440 GLYBURIDE 1.25 MG TABLET G HERITAGE PHARMA EAGUL 59762-7020-09 0.12440 GLYBURIDE 1.25 MG TABLET G GREENSTONE LLC. EAGUL 64720-0123-10 0.12440 GLYBURIDE 1.25 MG TABLET G COREPHARMA LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 65862-0028-01 0.12440 GLYBURIDE 1.25 MG TABLET G AUROBINDO PHARM EAGEN 00093-8343-01 0.14877 GLYBURIDE 2.5 MG TABLET G TEVA USA EAGEN 00093-8343-05 0.14877 GLYBURIDE 2.5 MG TABLET G TEVA USA EAGEN 00093-8343-10 0.14877 GLYBURIDE 2.5 MG TABLET G TEVA USA EAGEN 00093-8343-98 0.14877 GLYBURIDE 2.5 MG TABLET G TEVA USA 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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