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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 16LIST 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 51079-0452-01 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0452-17 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0452-19 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0452-20 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0452-56 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 MYLAN INSTITUTI EAGEN 54458-0895-02 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 INTERNATIONAL L EAGEN 57664-0057-13 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 CARACO PHARM EAGEN 57664-0057-18 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 CARACO PHARM EAGEN 57664-0057-99 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 CARACO PHARM EAGEN 57664-0570-13 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 CARACO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 57664-0570-18 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 CARACO PHARM EAGEN 57664-0570-99 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 CARACO PHARM EAGEN 58517-0120-30 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 NEW HORIZON RX EAGEN 59762-1540-01 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 GREENSTONE LLC. EAGEN 59762-1540-02 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 GREENSTONE LLC. EAGEN 59762-1540-03 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 GREENSTONE LLC. EAGEN 60505-0195-02 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 APOTEX CORP EAGEN 60505-0195-03 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 APOTEX CORP EAGEN 64679-0423-01 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 WOCKHARDT USA L EAGEN 64679-0423-02 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65162-0008-09 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AMNEAL PHARMACE EAGEN 65162-0008-50 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AMNEAL PHARMACE EAGEN 65862-0103-05 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0103-90 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0103-99 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AUROBINDO PHARM EAGEN 67877-0199-05 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 ASCEND LABORATO EAGEN 67877-0199-10 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 ASCEND LABORATO EAGEN 67877-0199-90 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 ASCEND LABORATO EAGEN 68084-0260-01 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AHP EAGEN 68084-0260-11 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0506-01 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AHP EAGEN 68084-0506-11 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 AHP EAGEN 68180-0752-03 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 LUPIN PHARMACEU EAGEN 68180-0752-09 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 LUPIN PHARMACEU EAGEN 68382-0123-05 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 ZYDUS PHARMACEU EAGEN 68382-0123-16 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 ZYDUS PHARMACEU EAGEN 68645-0445-70 0.02550 AMLODIPINE BESYLATE 10 MG TAB 0 LEGACY PHARMACE EAGEN 00054-0100-22 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 ROXANE LABS. EAGEN 00093-0083-98 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 TEVA USA EAGEN 00143-9959-09 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-5208-05 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 MYLAN EAGEN 00378-5208-77 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 MYLAN EAGEN 00603-2108-02 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 QUALITEST EAGEN 00603-2108-25 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 QUALITEST EAGEN 00603-2108-28 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 QUALITEST 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: 17LIST 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 00603-2108-32 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 QUALITEST EAGEN 00904-5991-61 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 MAJOR PHARMACEU EAGEN 00904-6369-61 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 MAJOR PHARMACEU EAGEN 13668-0022-03 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 TORRENT PHARMAC EAGEN 13668-0022-05 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 TORRENT PHARMAC EAGEN 31722-0237-10 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 CAMBER PHARMACE EAGEN 31722-0237-90 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 CAMBER PHARMACE EAGEN 42806-0055-05 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 EPIC PHARMA LLC EAGEN 42806-0055-09 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 EPIC PHARMA LLC EAGEN 42806-0055-10 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 EPIC PHARMA LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0450-01 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0450-20 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0450-63 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0450-66 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 MYLAN INSTITUTI EAGEN 57664-0055-18 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 CARACO PHARM EAGEN 57664-0055-99 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 CARACO PHARM EAGEN 57664-0568-13 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 CARACO PHARM EAGEN 57664-0568-18 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 CARACO PHARM EAGEN 57664-0568-99 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 CARACO PHARM EAGEN 59762-1520-01 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-1520-02 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 GREENSTONE LLC. EAGEN 60505-0193-02 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 APOTEX CORP EAGEN 60505-0193-03 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 APOTEX CORP EAGEN 64679-0421-01 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 WOCKHARDT USA L EAGEN 65162-0006-09 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AMNEAL PHARMACE EAGEN 65162-0006-50 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AMNEAL PHARMACE EAGEN 65862-0101-05 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0101-90 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0101-99 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AUROBINDO PHARM EAGEN 67877-0197-05 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 ASCEND LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67877-0197-10 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 ASCEND LABORATO EAGEN 67877-0197-90 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 ASCEND LABORATO EAGEN 68084-0258-01 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AHP EAGEN 68084-0258-11 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AHP EAGEN 68084-0498-01 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AHP EAGEN 68084-0498-11 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 AHP EAGEN 68180-0750-09 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 LUPIN PHARMACEU EAGEN 68382-0121-05 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 ZYDUS PHARMACEU EAGEN 68382-0121-16 0.03540 AMLODIPINE BESYLATE 2.5 MG TAB 0 ZYDUS PHARMACEU EAGEN 00054-0101-22 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0101-28 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 ROXANE LABS. EAGEN 00093-7167-55 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 TEVA USA EAGEN 00093-7167-98 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 TEVA USA EAGEN 00143-9960-09 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 WEST-WARD,INC. EAGEN 00378-5209-05 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MYLAN 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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